What is the recommended approach to documenting a psychiatric evaluation on a patient with dementia?

Documentation of Psychiatric Evaluation in Dementia Patients

Document a comprehensive psychiatric evaluation in dementia patients using validated structured assessment tools across three mandatory domains: neuropsychiatric symptoms (using NPI-Q or MBI-C), functional status (using FAQ or DAD), and cognitive performance (using MMSE or MoCA), combined with corroborative informant history. 1

Essential Components to Document

Neuropsychiatric Symptom Assessment

Use the Neuropsychiatric Inventory-Questionnaire (NPI-Q) or Mild Behavioural Impairment Checklist (MBI-C) to systematically document behavioral and psychological symptoms. 1 These tools assess:

• Delusions, hallucinations, and psychotic symptoms 2
• Mood disturbances including depression, anxiety, and dysphoria 2
• Behavioral symptoms including agitation, aggression, disinhibition, and irritability 2
• Apathy, euphoria, and aberrant motor activity 2
• Sleep and appetite changes 3

The NPI evaluates both frequency and severity of each behavioral domain, which is critical for tracking treatment response and disease progression. 2 Document specific examples of behaviors rather than general statements, as neuropsychiatric symptoms affect up to 90% of dementia patients and strongly correlate with caregiver burden and functional decline. 3

Cognitive Assessment Documentation

Document objective cognitive performance using validated instruments, preferably the Montreal Cognitive Assessment (MoCA) for mild dementia or the Mini-Mental State Examination (MMSE) for moderate dementia. 1

• For rapid screening (5-10 minutes): Use Mini-Cog, AD8, or four-item MoCA (Clock-drawing, Tap-at-letter-A, Orientation, Delayed-recall) 1
• For comprehensive assessment (15-30 minutes): Use full MoCA (preferred for mild cognitive impairment) or MMSE (widely used, high specificity for moderate dementia) 1
• Document specific domain impairments: Memory, executive function, visuospatial abilities, language, attention, and orientation 4

The MoCA is more sensitive than MMSE for detecting mild cognitive impairment and should be used when MMSE scores are in the "normal" range (24+ out of 30) but clinical suspicion remains. 1

Functional Status Documentation

Assess and document functional impairment using the Pfeffer Functional Activities Questionnaire (FAQ) or Disability Assessment for Dementia (DAD) with input from both patient and informant. 1

Document specific deficits in:

• Financial management and bill paying 5
• Medication management and adherence 5
• Transportation abilities and driving safety 5
• Household management tasks 5
• Cooking and meal preparation 5
• Shopping and errands 5

The distinction between mild cognitive impairment and dementia rests primarily on whether cognitive deficits significantly interfere with daily functioning. 5, 4

Informant-Based History

Obtain and document corroborative history from a reliable informant using standardized tools such as the AD8, IQCODE, or ECog. 1

• Informant report is essential because patients with dementia often lack insight into their cognitive, functional, and behavioral changes 1
• Document the informant's relationship to the patient and frequency of contact to establish reliability 1
• Use informant-based tools that cover cognitive, functional, and behavioral aspects to increase diagnostic accuracy when combined with patient-related measures 1

Combining cognitive tests with functional screens and informant reports significantly improves case-finding accuracy. 1

Structured Documentation Format

History Section

• Chief complaint and presenting symptoms (from both patient and informant) 4
• Timeline of cognitive and behavioral decline with specific examples 4
• Impact on work, social activities, and usual functioning 4
• Risk factors: stroke/TIA, depression, sleep apnea, metabolic disorders, delirium, head injury, Parkinson's disease 1

Mental Status Examination

• Appearance, behavior, and cooperation 4
• Mood and affect (document specific observations, not just patient's self-report) 4
• Thought process and content (delusions, hallucinations, paranoia) 2
• Cognitive domain-specific findings from standardized testing 4

Behavioral Assessment Results

• NPI-Q or MBI-C scores with specific symptom frequencies and severities 1, 2
• Specific behavioral examples that illustrate functional impact 3
• Temporal patterns (time of day, triggers, duration) 3

Functional Assessment Results

• FAQ or DAD scores with specific activity limitations 1
• Comparison to baseline functioning 5
• Safety concerns (wandering, falls, medication errors, financial exploitation) 5

Caregiver Burden Assessment

• Document caregiver stress, burden, and available support systems 6
• Caregiver burden is a major determinant of hospitalization and nursing home placement and must be evaluated at least annually 7, 6

Follow-Up Documentation

Schedule reassessment every 6-12 months using the same validated instruments to track disease progression, with more frequent visits (every 3-6 months) for patients with prominent behavioral symptoms. 7, 5

Document changes in:

• Cognitive scores (using same instrument for consistency) 5
• Functional abilities (progression of ADL/IADL impairment) 5
• Behavioral symptoms (emergence of new symptoms or worsening of existing ones) 5
• Caregiver burden (increasing stress, need for additional support) 7

Common Pitfalls to Avoid

• Relying solely on patient self-report without informant corroboration leads to missed diagnoses due to lack of insight 1
• Using only cognitive testing without assessing function and behavior provides incomplete severity assessment 6
• Failing to use standardized, validated instruments reduces diagnostic accuracy and makes longitudinal tracking unreliable 1
• Neglecting to document caregiver burden misses a critical factor in patient outcomes and care planning 7, 6
• Not documenting specific behavioral examples makes it difficult to track treatment response and communicate with other providers 3
• Delaying specialist referral for atypical presentations (early onset, rapid progression, prominent neuropsychiatric symptoms, or atypical cognitive patterns) can lead to worse outcomes 7