Assessing Cognitive Impairment in Older Patients
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As a primary care practice, 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 found, you can help patients and their caregivers prepare for the future. Brief, nonproprietary risk assessment and screening tools are available.(2)
Cognitive impairment in older adults has a variety of possible causes, including medication side effects, metabolic and/or endocrine derangements, delirium due to intercurrent illness, depression, and dementia, with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed with treatment. Others, such as Alzheimer’s disease, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for predictable changes.
Most patients with memory, other cognitive, or behavior complaints want a diagnosis to understand the nature of their problem and what to expect.(6-10) Some patients (or families) are reluctant to mention such complaints because they fear a diagnosis of dementia and the future it portends. In these cases, a primary care provider can explain the benefits of finding out what may be causing the patient’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.
The U.S. Preventive Services Task Force, in its 2014 review and recommendation regarding routine screening for cognitive impairment, noted that “although the overall evidence on routine screening is insufficient, clinicians should remain alert to early signs or symptoms of cognitive impairment (for example, problems with memory or language) and evaluate as appropriate.”(11) A 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)
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) and Mini-Cog (PDF, 86K) are among many possible tools.
Assessment for cognitive impairment can be performed at any visit but is now a required component of the Medicare Annual Wellness Visit (PDF, 565K).(4),(13) Coverage for wellness and, importantly, for follow-up visits is available to any patient who has had Medicare Part B coverage for at least 12 months.
Positive screening results warrant further evaluation. A combination of cognitive testing and information from a person who has frequent contact with the patient, 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 Center may also accept referrals.
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 patient. Information can also be gleaned from the patient’s behavior on arrival in the doctor’s office and interactions with staff.
Note that patients who are only mildly impaired may be adept at covering up their cognitive deficits and reluctant to address the problem.
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 patient’s interview and contribute additional information after the patient has spoken.
- Recommendations for operationalizing the detection of cognitive impairment during the Medicare annual wellness visit in a primary care setting (Alzheimer's & Dementia)
- Cognitive Impairment in Older Adults: Screening (U.S. Preventive Services Task Force)
1. 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. www.ncbi.nlm.nih.gov/pmc/articles/PMC3484131/
2. Galvin JE and Sadowsky CH. Practical guidelines for the recognition and diagnosis of dementia. J Am Board Family Med. 2012;25(3):367-382. www.ncbi.nlm.nih.gov/pubmed/22570400
3. 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. www.ncbi.nlm.nih.gov/pubmed/15209641
4. McPherson S and Schoephoester G. Screening for dementia in a primary care practice. Minn Med. 2012 Jan;95(1):36-40. www.ncbi.nlm.nih.gov/pubmed/22355911
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. www.ncbi.nlm.nih.gov/pmc/articles/PMC2787842/
6. 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. www.ncbi.nlm.nih.gov/pubmed/12779304
7. Weimer DL and Sager MA. Early identification and treatment of Alzheimer disease: social and fiscal outcomes. Alzheimers Dement. 2009;5(3):215-226. www.ncbi.nlm.nih.gov/pmc/articles/PMC2785909/
8. 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. www.ncbi.nlm.nih.gov/pubmed/19682136
9. 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. www.ncbi.nlm.nih.gov/pubmed/16676286
10. 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. www.ncbi.nlm.nih.gov/pubmed/12801158
11. U.S. Preventive Services Task Force. Cognitive impairment in older adults: screeening. 2014. Retrieved 10/9/14 from www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cognitive-impairment-in-older-adults-screening#clinical-considerations
12. Barnes DE, Beiser AS, Lee A, et al. Development and validation of a brief dementia screening indicator for primary care. Alzheimers Dement. 2014 Feb 1. pii: S1552-5260(13)02940-3. doi: 10.1016/j.jalz.2013.11.006. [Epub ahead of print] www.ncbi.nlm.nih.gov/pubmed/24491321
13. 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 March;9(2):141-150. www.ncbi.nlm.nih.gov/pubmed/23265826
14. Holsinger T, Deveau J, Boustani M, et al. Does this patient have dementia? JAMA. 2007;297(21):2391-2404. www.ncbi.nlm.nih.gov/pubmed/17551132
15. 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. www.ncbi.nlm.nih.gov/pmc/articles/PMC3312024/
16. Marson DC. Clinical and ethical aspects of financial capacity in dementia: a commentary. Am J Geriatr Psychiatry. 2013;21(4)382-390. www.ncbi.nlm.nih.gov/pmc/articles/PMC3784311/
17. Kotagal V, Langa KM, Plassman BL, et al. Factors associated with cognitive evaluations in the United States. Neurology. 2014 Nov 26. pii: 10.1212/WNL.0000000000001096. [Epub ahead of print] www.ncbi.nlm.nih.gov/pubmed/25428689
For More Information About Alzheimer's and Dementia
NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center
The National Institute on Aging’s ADEAR Center offers information and free print publications about Alzheimer’s disease 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.
Content reviewed: September 26, 2014