"Oh, I can do a test right now. You don't need a referral, and we'll have the results right away," your mother's doctor says when you ask if it makes sense to have your mother see a specialist for testing because you have observed some lapses in her thinking.
Don't be misled by this offer. The doctor is most likely referring to the Mini-Mental State Exam (MMSE), a test that takes 5-10 minutes and is widely used by doctors, nurses and social workers to screen for cognitive impairment (mental decline). It includes questions such as, "What day of the week is it?" and "What town are we in?" In some versions of the test, the test-giver points to an object such as a wristwatch or a standard wooden pencil and asks the patient what it is called. The patient is asked to complete basic tasks such as copying a simple drawing, spelling a given 5-letter word backwards, and/or remembering three words.
The problem with this test is that it's a little too simple. Your mother may know what day of the week it is even though she's forgotten how to pay the bills. Your father may know the name of the town he's in even though he gets mixed up about his medicines and often takes too many or too few pills. And if your parents are very intelligent and highly educated, they may continue to earn high scores on the MMSE long after it is obvious to you that something is seriously wrong. Looking at the results, the doctor may say, "Your mother got a perfectly good score on this test. There's nothing wrong with her."
One way to get the attention needed is to give facts using the lingo that professionals use. Consider "instrumental activities of daily living" or IADLs, a term that healthcare professionals use among themselves. IADLs are the multi-step tasks that most people manage routinely: using the telephone, shopping, planning and preparing meals, keeping house, doing laundry, driving or taking public transportation, taking medicines, and managing money.
Often, the first sign of cognitive impairment is a decrease in the individual's ability to handle IADLs. As an example, for money management one source lists the following activity levels, in decreasing order of mental functioning: "Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income," "Manages day-to-day purchases, but needs help with banking, major purchases, etc.," and "Incapable of handling money."
For using the telephone, activity levels include, "Operates telephone on own initiative, looks up and dials numbers." "Dials a few well-known numbers," "Answers telephone, but does not dial," and "Does not use telephone at all."
For a description of the reduced functioning seen in each of eight IADLs as mental abilities decline, see http://www.sfaetc.ucsf.edu/docs/iadl.pdf. If you are concerned about a loved one, you might try estimating for each IADL which of the levels of activity described best matches their current behavior. For most people, I think that the value in doing so is not in coming up with a score. (The scoring is simplistic and doesn't imply any specific diagnoses.)
Instead, the value is that it captures on one page a snapshot of the decline in the individual's abilities to date. Seeing the results in this format may help you get a sense for whether there really is a problem that needs attention. Additionally, if you give your parent's doctor a copy of the page with your parent's activity levels circled, it will help the doctor quickly understand the situation - because you will be using a framework and language familiar to her.
If you want even more information about IADLs, go to http://tuftshealthplans.com/providers/pdf/lawton_iadl.pdf. This document is written for nurses. It offers stories to make its points clear. While it does use medical jargon in places, most of its explanations can be understood by people without medical training.
If the Mini-Mental State Exam isn't the best way to come up with a diagnosis if you have concerns about a loved one's inability to handle IADLs (instrumental activities of daily living), what is? Next week's column will address this point.