Principles of history-taking and etiology identification
Due to the multi-etiological nature of emotional and behavioral disturbances, the foundation of diagnosis is laid during the medical history-taking stage. The interview is conducted not only with the patient but also with their close relatives to obtain an objective history.
The physician must identify potential triggers and causes of the disorders:
- Genetic factor.
- Impact of acute or chronic emotional stress.
- Body intoxications.
- Presence of comorbid somatic or neurological conditions.
Specialized scales are used for quantitative and qualitative objectification of symptoms: rating scales for anxiety, depression, and apathy. The evaluation of such patients requires a mandatory multidisciplinary approach involving a psychiatrist and a medical psychologist.
Basic cognitive screening
Assessment of cognitive status begins with a series of simple functional tests. Writing function is tested by asking the patient to write their full name and any extended sentence.
Evaluation of executive functions, attention, and memory:
- Simple tests: counting up to 10 and backward, reciting the months or days of the week in forward and reverse order.
- Serial calculation (the "100 minus 7" test): sequentially subtracting seven from one hundred. Before the test, it is important to ensure that basic arithmetic skills are intact.
- Memory: learning unrelated words or digits with subsequent recall.
Assessment of planning, organization, and control:
- Verbal fluency: listing the maximum number of animals, plants, or words starting with a given letter in 1 minute (norm — at least 10 words).
- Constructional tasks: copying a complex geometric figure or continuing an alternating sequence (e.g., triangle-quadrilateral).
- Trail making test: connecting randomly scattered numbers from 1 to 20.
- Alternating test: alternately connecting numbers and letters (1-A, 2-B, 3-C).
- Go/No-Go task (conflicting response test): the patient must tap the table twice in response to a single tap by the examiner, and refrain from tapping in response to two taps.
Montreal Cognitive Assessment (MoCA)
For a more precise and standardized assessment of cognitive impairment (including over time), the MoCA scale is used. The duration of the test is 10–15 minutes, with a maximum score of 30. A score below 26 points indicates clinically significant pathology.
The scale assesses several domains:
- Visuospatial and executive skills (up to 5 points): trail-making test (numbers and letters in ascending order), accurate copy of a cube, and drawing a clock set to "11:10" (contour, numbers, and hands are evaluated).
- Naming (up to 3 points): identification of depicted animals (lion, rhinoceros, camel).
- Attention (up to 6 points): forward and backward digit span, vigilance test (tapping to every letter "A" in a sequence of letters), and serial subtraction of 7 from 100 (scoring depends on the number of correct subtractions).
- Language (up to 3 points): accurate repetition of two complex sentences and a verbal fluency test (naming the maximum number of words starting with the letter "L" in a minute, norm $\ge 11$ words).
- Abstraction (up to 2 points): identifying a categorical generalization (e.g., what a train and a bicycle, or a watch and a ruler, have in common).
- Delayed recall (up to 5 points): the patient is read 5 words (FACE, VELVET, CHURCH, DAISY, RED), warned to remember them, and asked to recall them after 5 minutes. Points are awarded only for unprompted responses.
- Orientation (up to 6 points): naming the current date, day of the week, month, year, location, and city.
Note: If the patient has 12 years of education or less, 1 point is added to their total score (up to a maximum total of 30).
Briefly: answers to topical questions
Which specific scales are used for the quantitative assessment of anxiety and depression in neurological patients?
Specialized clinical scales based on patient self-assessment or physician rating are used for the quantitative assessment of anxiety and depression.
- The Hospital Anxiety and Depression Scale (HADS) is used for rapid screening in general medical practice.
- The State-Trait Anxiety Inventory (Spielberger-Hanin scale) is used to assess anxiety symptoms.
- The Beck Depression Inventory is used to assess depressive symptoms.
- The Hamilton Anxiety Rating Scale (HARS) is recommended for in-depth diagnosis.
- The Hamilton Depression Rating Scale (HDRS) is used for in-depth diagnosis of emotional state.
Which medication classes are used to treat behavioral disorders in patients with cognitive decline?
The following medication classes are used to treat psychotic and behavioral disorders in patients with cognitive decline:
- Cholinesterase inhibitors — prescribed prior to antipsychotics.
- Memantine — used prior to prescribing antipsychotics.
- Antipsychotics — prescribed only when cholinesterase inhibitors, memantine, and non-pharmacological methods are ineffective. For managing acute agitation, the drug of choice is low-dose quetiapine; for baseline therapy of psychotic disorders, it is recommended to start with minimal doses of clozapine or quetiapine.
- If cognitive impairment is confirmed, cerebroprotectants may be used.
Class and exam questions
What should be done if clinical symptoms are present, but screening shows no impairments?
The detection of any signs of higher cortical function impairment, even with normal screening results, is a direct indication for referring the patient for a specialized neuropsychological examination using advanced tests.
Are prompts allowed during memory testing in the MoCA test?
Yes, if difficulties arise, the examiner may use a "category cue" or "multiple choice" to qualitatively analyze the deficit. However, points in the delayed recall section are awarded exclusively for words recalled independently by the patient.
Which specialists should manage a patient with emotional disorders?
Due to the multi-etiological nature of these conditions, the evaluation must be multidisciplinary. A medical psychologist and a psychiatrist are strictly required to be involved in the process.
What else to study on this topic
- Differential diagnosis between dementia and non-dementia cognitive disorders
- Specific rating scales for anxiety, depression, and apathy
- Methodology for conducting an in-depth neuropsychological examination
- Clinical features associated with concomitant hallucinations and illusions
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