Published online by Cambridge University Press: 12 October 2009
The post-mortem examination in cases of dementia
It has been said, with a good deal of truth, that the answer to every question in medicine is in three parts: first, take a history, second, make a physical examination, and third, perform the relevant special tests and investigations. For the pathologist, the first two parts of this rubric are fulfilled by reading the patient's chart. The third is the performance of what, in at least one sense, is the ultimate diagnostic test, the post-mortem examination.
History and examination
The clinical information available to the pathologist called upon to perform an autopsy examination on a case of dementia is extraordinarily variable. At one extreme is the patient who has been studied over an extended period where the quality and extent of cognitive failure has been documented and, often, a presumptive pathological diagnosis is made. This type of history is often supplemented by more or less objective tests of intellectual function and the results of numerous investigations. Patients submitted to this degree of investigative rigour are often in centres that have a particular interest or active research programme into dementia. In these circumstances it can (we hope) be assumed that there is good liaison between the clinical service and the pathology department and the cases will be dealt with according to protocol.
The opposite end of this particular spectrum is the patient coming to autopsy examination who is reported to have an unspecified degree of cognitive decline, variously described in imprecise terms. In such cases recourse to considerable ingenuity is required to form an idea of the nature and severity of the decline. Clues can sometimes be gleaned from the nursing notes or even from the patient's address.