Health Assessments And Tests
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Everyone should familiarise themselves with the full details of the FAST test for strokes, so that in an emergency you're completely sure of the details. Please read the description below, even if you think you already know all about it.
FAST stroke test
Important clarifications regarding symptoms
Before we repeat the standard F.A.S.T. test below, it's very important to be clear on four additional things:
- you only need any ONE of the three symptoms described for it to be essential to call for an ambulance immediately (think of it as F or A or S = T)
- strokes can have other symptoms at the same time
- occasionally a stroke will not display as any of the three symptoms in the standard test, so if you think there's been any kind of sudden impairment of brain function you should treat it as a suspected stroke and call for an ambulance immediately
- in a 'mini-stroke' (see below) symptoms can last just a few minutes or a few hours before disappearing again completely - DO NOT treat this as a false alarm, because a full stroke may be on its way and needs to be prevented - call for an ambulance immediately.
In addition to the above clarifications, we're also going to break with convention and note that vomiting can potentially be a symptom of a stroke - obviously vomiting is nearly always caused by something else and that's why it isn't usually mentioned, in order to avoid false alarms. However, we feel that it's best to have the information so that you know at least to look for other signs that may point to a stroke. In the absence of other signs a stroke should not be assumed. Vomiting occurs in approximately one in seven strokes (statistic taken from the Emergency Medicine Journal 2013;30:728-731 (BMJ website)) - but of course a far smaller proportion of cases of vomiting are caused by a stroke.
The F.A.S.T test
| Face | Has their mouth or eye drooped on one side? Are they no longer able to make a smile that is even, comparing one side to the other? |
| or | |
| Arms | Are they no longer able to raise both arms (to shoulder level) and keep them there? |
| or | |
| Speech | Have they stopped being able to speak clearly (i.e. making sense and not slurred), when they could before? Have they stopped being able to understand what you're saying? |
| = | |
| Time to act | Call for an emergency ambulance immediately (999 in the UK) if the answer to any of these questions is yes. |
Ambulance not car
The advice is to call for an ambulance rather than to drive the patient to hospital, as the ambulance crew will be able to do tests and start appropriate treatment straight away. Someone suffering a stroke should never attempt to drive themselves, as there'll be an accident.
See also
See our section on how to reduce the risk of getting a stroke.
See our section on strokes for more information about them.
Pain assessment
Depending on their stage of dementia, the person may not be able to communicate in words that they have pain or where it is, even when they're capable of speech. They may not even know within their own mind what part of their body is hurting or what that means. In these cases pain can come out as upset behaviour such as agitation, irritability or shouting, or alternatively it may come out as withdrawing into their shell and not wanting to move. Distraction caused by the pain may be confused by others as simply part of the symptoms of dementia.
For these reasons it's believed that sedatives are often given when what's really needed is an assessment for pain, and then appropriate steps taken to address the cause of pain or to manage it using techniques including (but not only) pain relief medication.
There are several alternative tools used by health professionals for assessment of pain in those with dementia, and we'll mention two of them here:
- The Abbey Pain Scale - see the NHS Wales website's document of the Abbey Pain Scale.
- The Pain Assessment IN Advanced Dementia (PAINAD) Tool - see the GeriatricPain.org website, under family caregivers - pain assessment.
When examining for the cause of pain by gently touching or slightly moving part of their body to see if there's a pain response, it's recommended that you hold one of their hands (preferably their right hand if they're right handed), since when the painful area or movement is reached there may be a squeezing of your hand that's a useful indicator. Also watch their expression, and note other behaviour.
If the assessment indicates a likelihood of pain but the cause can't be identified, then pain relief medication might be trialled and the effect on behaviour noted, together with a follow-up assessment using the original pain assessment tool to see whether there's been an improvement. Obviously, if it appears that pain relief does help then a greater search for the cause of the pain may be appropriate, but equally it should be recognised that it may not be possible to identify the specific cause.
Depression assessment
Diagnosis of depression, especially for someone with dementia, requires a clinical specialist. There's otherwise too great a scope for misassessment based on the effects of other medical conditions including the symptoms of dementia, or unassessed pain.
In case you come across it, we mention here the Cornell Scale for Depression in Dementia (CSDD) - but we do not regard it as a valid or useful tool when used by non-specialist staff.
To justify this bold statement we quote below in its entirety the summary conclusion given in the abstract of the scientific paper Jeon YH et al, The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes. Am J Geriatr Psychiatry. 2015 Aug;23(8):784-93 (US National Library of Medicine website):
"Conclusion: When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes."
Other studies have compared CSDD scores obtained from interviews with the residents themselves and with nursing home staff, and found very poor agreement.
One factor in the poor results might be the aforementioned scope for scores to be assigned based on other medical conditions or unassessed pain.
Cognitive assessment
Several alternative tools have been developed for use by health professionals for assessment of cognitive impairment in those with dementia, and we'll mention here the two you're likely to come across in the UK. These tools are used as part of initial diagnosis, in addition to physical investigations and a review of the medications being taken which may also affect cognitive ability, and are also re-used periodically in assessment of progression of the disease over time.
For a discussion of the context of these assessment tools see the NHS website, for 'tests for diagnosing dementia' and the Patient.info website, for 'screening for cognitive impairment'. This latter regards the GPCOG tool as the most reliable, compared to the well-established MMSE tool. Both of these tools are referenced below.
The General Practitioner Assessment of Cognition (GPCOG) tool is a series of questions and tasks for the patient, together with questions for their relative or carer. The questions are available on the Patient.info website, for 'GPCOG'.
The Mini Mental State Examination (MMSE) tool is a series of questions and tasks for the patient. A version can be found on the British Columbia government website, for 'SMMSE'.
Urine test strips
A care home or a nurse can use a urine test strip to assess a number of different aspects of the body's functioning, as an aid to diagnosis of problems such as a urinary tract infection (UTI). (These strips can also be purchased, but are reliant on the correct interpretation of a number of coloured indicators.) This test may indicate a referral to a doctor is required, who may carry out other tests.
For more information see our section on urinary tract infections.
Temperature
An ear thermometer can potentially be very useful in helping to look for something being wrong, particularly given that someone with dementia may be unable to indicate that there's a problem.
Follow the thermometer's instructions, and get an idea of what the normal temperature reading is for your loved one in the absence of any issues.
Ear temperature isn't a good indicator of whether the person feels slightly too cold or hot in the room.
Blood oxygen
A pulse oximeter is a small device that clips onto the end of your finger and measures the oxygen content in your blood, together with your pulse rate. Most of them also show a graph of the pulse, when the display mode is set to that.
Normally only used by medical staff, their home use became more common during the covid-19 pandemic, when people recovering from covid were lent them to monitor changes in blood oxygen levels. The 'consumer' versions for home use, and available for purchase, are not as accurate as those used in a hospital setting (for example, they may read too high with dark skin), although this is less of an issue when comparing a current reading to the person's usual reading with the same device).
During the covid-19 pandemic the NHS' advice for monitoring at home was to look for a drop from the patient's usual blood oxygen level. A guideline was also given that a level of 95% or more was satisfactory; 92% or less should prompt you to seek urgent medical attention; and in between you should seek non-urgent medical advice. (For further information see the NHS website Health A-Z for coronavirus self-care.)
If you wish to buy a pulse oximeter for home use, then use it as a supplement to other observations, and in particular pay most attention to changes from the person's usual level. Follow the instructions (including no nail polish or false nails), otherwise there's a danger of false alarms. In the UK, you should buy one with the CE mark, UKCA mark or CE UKNI mark. Follow the instructions regarding finger and device cleaning, and try different fingers (you may find one's more accurate than another, for example according to its size compared to the curved hole in the device). Also note that the device takes a few seconds to calibrate itself to the strength of your pulse, before it can give a reading.
Eye test
An annual eye test is recommended, both from the point of view of ensuring that eyesight is corrected by glasses if necessary, to reduce the risk of falls amongst other benefits; and from the point of view of checking eye health.
For people with dementia who can't recognise letters or can't communicate what they see, specialists have a form of test that uses pictures with different levels of contrast and allows them to observe how these levels of contrast affect the patient's study of them.
In the UK an annual eye test is free on the NHS for over 60s.
Many opticians can do eye tests at home if dementia or physical issues make visiting the optician impractical.
In the UK, eyes tests at home can be carried out by the national chain Specsavers (see the Specsavers website home visits menu) amongst others. However, if it's practical to go to the optician we'd recommend you do so, as they'll have a better level of equipment available there.
Tell the optician your loved one has dementia, and between you explain to your loved one what's going to happen before things like the puff of air that tests for eye pressure.
If you use a wheelchair to help with a visit to the optician, it may be worth mentioning this when you make the appointment, to make sure the wheelchair will fit with their equipment when you have to use the equipment's chin rest. You may want to try to ensure the cushion you use with the wheelchair gives a suitable chin height. If you have to remove wheelchair arms to fit under the equipment then make sure your loved one doesn't topple sideways out of the chair.
Hearing test
Poor hearing can reduce communication ability, increase a sense of isolation, cause confusion, and prevent enjoyment of music and so on.
If you think your loved one may have hearing loss then consult your GP, who'll be able to check for issues such as earwax buildup and will refer you to a specialist for a test if appropriate. In the UK this is free on the NHS.
Diabetes tests and assessments
As an overview, in the UK diabetics will have a number of different tests:
- the 'finger prick' test where a drop of blood is put against a test strip in a small device that measures the current blood sugar level. The doctor or care team will determine when such tests need to be done - this may be several times a day for a short period in order to determine the correct dosage of medicine, with tests carried out much less frequently otherwise.
- a periodical blood test known as HbA1C, which provides information about excess blood sugar levels over the previous 3 months (this being the lifetime of blood cells that show a 'coating' of any excess sugar). This test may be carried out at 3 or 6 month intervals.
- an annual foot test, looking for loss of sensitivity to touch due to nerve damage
- periodically foot checks should be carried out by carers, to look for any signs of problems that have gone unnoticed by the person because of loss of feeling, or which they've not been able to communicate, before the problems develop into skin ulcers and worse
- an annual eye test to check for diabetic retinopathy, which is a potential form of damage to the eye
- an annual check-up by a GP or diabetic nurse.
For more information see the NHS website Health A-Z for type 2 diabetes check-ups.