Assessing Cognitive Impairment in Older Patients
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As a primary care practitioner, you and your staff are often the first to address a patient’s complaints — or a family’s concerns — about memory loss or possible dementia.(1,2) This quick guide provides information about assessing cognitive impairment in older adults.
With this information, you can identify emerging cognitive deficits and possible causes, following up with treatment for what may be a reversible health condition. Or, if Alzheimer’s disease or another dementia is suspected, you can help patients and their caregivers prepare for the future. Brief, nonproprietary risk assessment and screening tools are available.(2)
Why Is It Important to Assess Cognitive Impairment in Older Adults?
Cognitive impairment in older adults has a variety of possible causes, including medication side effects; metabolic and/or endocrine derangements; delirium due to illness (such as a urinary tract or COVID-19 infection); depression; and dementia, with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed or improved with treatment. Others, such as Alzheimer’s, cannot be reversed but symptoms can be treated for a period of time, and importantly, families can be prepared for predictable changes and address safety concerns.
Most people with memory, other cognitive, or behavior complaints want a diagnosis to understand the nature of their problem and what to expect.(6-10) Some people (or their families) are reluctant to mention such concerns because they fear a diagnosis of dementia and the future it foreshadows. In these cases, a primary care provider can explain the benefits of finding out what may be causing the person’s health concerns.
Read tips on Talking with Older Patients About Cognitive Problems.
Pharmacological treatment options for Alzheimer’s-related memory loss and other cognitive symptoms are limited, and none can stop or reverse the course of the disease. However, assessing cognitive impairment and identifying its cause, particularly at an early stage, offers several benefits.
When Is Screening Indicated?
In its 2020 review and recommendation regarding routine screening for cognitive impairment in adults 65 years old and older, the U.S. Preventive Services Task Force noted that “although there is insufficient evidence to recommend for or against screening for cognitive impairment, there may be important reasons to identify cognitive impairment early. Clinicians should remain alert to early signs or symptoms of cognitive impairment (e.g., problems with memory or language) and evaluate the individual as appropriate.”(11) Tools such as the Dementia Screening Indicator can help guide clinician decisions about when it may be appropriate to screen for cognitive impairment in the primary care setting.(12)
How Can Physicians and Staff Find Time for Screening?
Trained staff using readily available screening tools need only 10 minutes or less to initially assess a patient for cognitive impairment. While screening results alone are insufficient to diagnose dementia, they are an important first step. The AD8 (PDF, 1.2M), QDRS (PDF, 239KB), and Mini-Cog (PDF, 86K) are among many possible tools. (NIA does not endorse any specific screening tools. The selection of a screening tool depends on a variety of factors, including the setting, target population age and demographics, language, expertise of the administrator, etc. Research is currently underway to create and validate new tools for cognitive screening in primary care settings.)
Assessment for cognitive impairment can be performed at any visit but is now a required component of the Medicare Annual Wellness Visit.(4),(13) Coverage for yearly wellness visits, and importantly, for follow-up visits for cognitive assessment and care plan services, is available to patients who have had Medicare Part B coverage for at least 12 months. Visit the Centers for Medicare & Medicaid Services (CMS) webpage for more information on cognitive assessment and care plan services (code 99483), including what it covers and how to bill for it. CMS also created a related educational video for health care providers.
How Is Cognitive Impairment Evaluated?
Positive screening results warrant further evaluation. A combination of cognitive testing and information from a person who has frequent contact with the person, such as a spouse or other care provider, is the best way to more fully assess cognitive impairment.(14)
A primary care provider may conduct an evaluation or refer to a specialist such as a geriatrician, neurologist, geriatric psychiatrist, or neuropsychologist. If available, a local memory disorders clinic or Alzheimer’s Disease Research Center may also accept referrals.
Genetic testing, neuroimaging, and biomarker testing are recommended for limited clinical uses at this time.(2),(15) These tests are primarily conducted in research settings and may require consultation with the medical provider, a counselor, and the family and caregivers, as there are complex ethical, legal, and social implications that should be considered.
Interviews to assess memory, behavior, mood and functional status (especially complex actions such as driving and managing money(16)) are best conducted with the patient alone, so that family members or companions cannot prompt the person. Information can also be gleaned from the person’s behavior on arrival in the doctor’s office and interactions with staff.
Note that people who are only mildly impaired may be adept at covering up their cognitive deficits and reluctant to address the problem. In some cases, patients may not have insight into their cognitive and functional problems due to the nature of their illness.
Family members or close companions can also be good sources of information. Inviting them to speak privately may allow for a more candid discussion. Per HIPAA regulations, the patient should give permission in advance. An alternative would be to invite the family member or close companion to be in the examining room during the interview and contribute additional information after the person has spoken.
Brief, easy-to-administer informant screening tools, such as the short IQCODE (PDF, 1.9M), the AD8 (PDF, 1.2M) or the QDRS (PDF, 239KB) are available. For more information on screening tools, cognitive assessments, and other resources for health professionals, visit Alzheimer’s and Dementia Resources for Professionals.
- Bunn F, Goodman C, Sworm L, et al. Psychosocial factors that shape patient and carer experiences of dementia diagnosis and treatment: a systematic review of qualitative studies. PLOS Med. 2012;9(10):e1001331.
- Galvin JE and Sadowsky CH. Practical guidelines for the recognition and diagnosis of dementia. J Am Board Family Med. 2012;25(3):367-382.
- Chodosh J, Petitti DB, Elliott M, et al. Physician recognition of cognitive impairment: evaluating the need for improvement. J Am Geriatr Soc. 2004;52(7):1051-1059.
- McPherson S and Schoephoester G. Screening for dementia in a primary care practice. Minn Med. 2012;95(1):36-40.
- 5. Bradford A, Kunik M, Schulz P, et al. Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors. Alzheimer Dis Assoc Disord. 2009;23(4):306-313.
- Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2003;138(11):927-937.
- Weimer DL and Sager MA. Early identification and treatment of Alzheimer disease: social and fiscal outcomes. Alzheimers Dement. 2009;5(3):215-226.
- Connell CM, Roberts JS, McLaughlin SJ, et al. Black and white adult family members’ attitudes toward a dementia diagnosis. J Am Geriatr Soc. 2009;57(9):1562-1568.
- Elson P. Do older adults presenting with memory complaints wish to be told if later diagnosed with Alzheimer’s disease? Int J Geriatr Psychiatry. 2006;21(5):419-425.
- Turnbull Q, Wolf AMD, Holroyd S. Attitudes of elderly subjects toward “truth telling” for the diagnosis of Alzheimer’s disease. J Geriatr Psychiatry Neurol. 2003;16(2):90-93.
- U.S. Preventive Services Task Force. Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. JAMA. 2020;323(8):757-763.
- Barnes DE, Beiser AS, Lee A, et al. Development and validation of a brief dementia screening indicator for primary care. Alzheimers Dement. 2014;10(6):656-665.e1. doi: 10.1016/j.jalz.2013.11.006.
- Cordell CB, Borson S, Boustani M, et al. Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141-150.
- Holsinger T, Deveau J, Boustani M, et al. Does this patient have dementia? JAMA. 2007;297(21):2391-2404.
- McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging–Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7(3):263-269.
- Marson DC. Clinical and ethical aspects of financial capacity in dementia: a commentary. Am J Geriatr Psychiatry. 2013;21(4)382-390.
- Kotagal V, Langa KM, Plassman BL, et al. Factors associated with cognitive evaluations in the United States. Neurology. 2015;84(1):64-71. doi: 10.1212/WNL.0000000000001096.
- Amjad, H., Roth, D. L., Sheehan, O. C., Lyketsos, C. G., Wolff, J. L., & Samus, Q. M. (2018). Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awareness in US Older Adults. Journal of general internal medicine. 33(7), 1131–1138. https://doi.org/10.1007/s11606-018-4377-y
For More Information About Alzheimer's and Dementia
NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center
The NIA ADEAR Center offers information and free print publications about Alzheimer’s and related dementias for families, caregivers, and health professionals. ADEAR Center staff answer telephone, email, and written requests and make referrals to local and national resources.
Explore the Alzheimers.gov portal for information and resources on Alzheimer’s and related dementias from across the federal government.
This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.
March 23, 2021