Dementia

Dementia is a large-scale problem in the elderly. It has been estimated that 5-8% of patients aged 65 yr and older suffer from dementia to an appreciable degree, with the proportion probably exceeding 20% in 80-yr-olds (98). However, in many of these patients, dementia is not recognized until there is some form of crisis in their lives. Such a crisis may be precipitated by sudden illness, bereavement, or police arrest. Individuals seem able to develop strategies to cope with their daily tasks and thus appear to function normally until the crisis disrupts the status quo and exposes the degree of their dementia (99).

Although there are many different causes of dementia, the clinical picture remains broadly similar, with any variation depending mainly on the age of onset of the illness, premorbid personality, and intelligence. In the custodial situation, the doctor is likely to encounter only those at an early stage of the disease. This is characterized by impaired memory, loss of the sense of time, and spatial disorientation, all of which can distort a suspect's recollection of events. This distortion may be compounded by the lack of judgment that is frequently displayed by those with dementia and that can cause the suspect to misjudge the importance of providing reliable testimony (88). Therefore, it is important that the doctor be aware of the possibility that an elderly suspect may be suffering from dementia, even when there are reports of apparently normal social functioning before arrest. In such circumstances, recognition of the dementia can be facilitated by using a standard test of cognitive function, such as the Mini-Mental State Examination Score (see Appendix 4).

This test of cognitive function has been thoroughly validated (100). It is called "mini" because it concentrates only on the cognitive aspects of mental functioning and excludes questions concerning mood, abnormal mental experiences, and the form of thinking. A score of 24 out of 30 was originally suggested as the lower limit of normal, but it has been repeatedly shown that performance on even this simple test is influenced considerably by age and by educational attainment. Hence, a well-educated young adult should perform flawlessly, whereas a normal elderly subject who left school at age 14 may score as low as 22 or 23. Given this proviso, the Mini-Mental State Examination is useful in quantifying cognitive impairment and is particularly useful for grading and monitoring the severity of dementia.

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