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• W2089946219 abstract "To the Editor: It is generally acknowledged that an accurate description of a patient's behavioral changes by an informant is essential for making the diagnosis of dementia. Information provided by family members or other caregivers, however, is subject to bias, and this may affect the clinical diagnosis. We report two cases in which the diagnosis was changed after interviewing a “second witness.” A systematic study to assess the validity of caregiver reports may be valuable. A 72-year-old retired teacher was referred by her general practitioner for evaluation of progressive forgetfulness. She admitted to being slightly forgetful, but she did not consider it abnormal at her age. “Nervousness” was her main complaint. She said that she could still keep house well. Her husband reported only that her memory had deteriorated. Nothing went wrong according to him. On examination she was cooperative but nervous. She was not fully orientated in time and place. A memory disorder was clearly present on neurological examination whereas other tasks, involving language, visuoconstruction, visuoperception, and abstract reasoning, were all performed normally. An Amnestic Syndrome (DSM-III-R) was diagnosed.1 Her husband disclosed that the referral had been initiated by his children. Denial by him was suspected. Interviewing the children was revealing. The patient had become quick tempered - causing painful situations - and less affectionate. Previously she had been an able needlewoman and a good cook, but she had lost these skills. The situation had gradually become a heavy burden for her husband, but he seemed to close his eyes to the changes other people observed clearly. On the basis of the amnesia (neurological examination) in combination with clear personality changes and loss of skills - denied by her husband but revealed by her children - we reached a diagnosis of Dementia (DSM-III-R). A 75-year-old retired clerk was referred by his general practitioner for evaluation of his behavior. On questioning, he admitted only that his memory had become worse, which made it difficult for him to follow serial programs on television. He said that his wife accused him of being snappy. His wife reported that his behavior had changed dramatically during the last 6 years. He behaved disgracefully, and he was shunned in the home where they lived; his memory had gone. On examination he was cooperative but a bit slow, and, except for the date, fully orientated in time. Assessment of the mental status showed failures only on memory tasks. Although the available information was strongly suggestive for dementia (DSM-III-R) his wife also mentioned that she had never been happy with him. Aggravation was suspected. Information from the team at the day center - based on several months’ observations - indicated that he behaved more like a volunteer than a patient in that setting. He was not demented, in their opinion, and he was kind and helpful to others. It became obvious that his personality had not altered but that his wife was tired of him. His diagnosis was then changed from Dementia to a mild Amnestic Syndrome (DSM-III-R). The cases presented here illustrate an important clinical practice problem that is often not investigated systematically: the validity of family members’ reports about older people in whom dementia is suspected. In the first case our initial informant denied the changes that other people observed. Denial often occurs in mild cases of dementia and may lead to “false negative” conclusions with respect to the diagnosis. The second case illustrates bias in the opposite direction (aggravation) that may lead to “false positive” conclusions. Currently, determination of the validity of information about the patient is dependent on clinical judgement. At our memory clinic, interviews with informants are always performed in the absence of the patient to allow for a more free discussion. If important bias is suspected, a “second witness” may improve diagnostic accuracy, particularly in detecting mild dementia and in differentiating normal aging from pathological decline. This approach may not only be valuable from a clinical perspective, but it may also be important to research inasmuch the earliest detection of decline currently rests on clinical methods using informant reports rather than test performance.2" @default.
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• W2089946219 date "1995-10-01" @default.
• W2089946219 modified "2023-09-25" @default.
• W2089946219 title "THE NEED FOR A “SECOND WITNESS” IN DIAGNOSING DEMENTIA" @default.
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• W2089946219 doi "https://doi.org/10.1111/j.1532-5415.1995.tb07029.x" @default.
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