Assessing Cognitive Impairment in Older Patients
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As a primary care practitioner, you likely have long-established relationships with some of your patients and are in an ideal position to observe potential signs of a cognitive problem. You and your staff are often the first to address a patient’s or family’s concerns about cognitive as well as behavioral and functional changes that may have already affected their lives and resulted in, for example, a motor vehicle accident or being the victim of identity theft or financial fraud.(1, 2) It’s important to take concerns seriously and to assess the person as early as possible to determine the potential cause of impairment. This quick guide features information about assessing cognitive, behavioral, and functional changes in older adults.
Why is it important to assess cognitive impairment in older adults?
It’s important to address any changes in an older person’s memory, language abilities, or personality as these may reflect a neurodegenerative disease process that may either be due to a reversible cause or become more serious. Whether memory or other cognition concerns are reported by the patient or a family member, or directly observed by you, the issues should be noted in the patient’s chart and followed up with a cognitive, behavioral and/or functional assessment.
Cognitive impairment in older adults has a variety of possible causes, including medication side effects; metabolic and/or endocrine dysfunction; delirium due to illness (such as a urinary tract or COVID-19 infection); depression; and dementia, including Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal disorders. 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 may be treatable for a period of time. It is important to help prepare patients and their families for additional changes that come as cognitive impairment progresses.
Many people who are developing dementia or already have it do not receive a diagnosis. One study found that more than 50% of patients with dementia had not received a clinical cognitive evaluation by a physician.(3) Another study showed that physicians were unaware of cognitive impairment in more than 40% of their cognitively impaired patients.(4) Yet another analysis looking at undetected dementia globally found the U.S. rate to be 61%.(5) The problem of underdiagnosis is even more pronounced in underserved populations and in those with lower educational attainment.(6, 7) The failure to evaluate memory or cognitive complaints is likely to hinder treatment of underlying disease and comorbid conditions, and may present safety issues for the patient and others.(8, 9) In many cases, the cognitive problem will worsen over time and may lead to preventable hospitalizations.(2, 8, 10, 11)
Some older people have mild cognitive impairment (MCI). People living with MCI have more memory problems than is normal for their age, but their symptoms do not interfere significantly with their everyday lives. Older people with MCI are at greater risk for developing Alzheimer’s, but not all of them do. Some may even go back to normal cognition. It is important to determine the cause of the impairment to anticipate future needs, address any reversible causes, and try to mediate modifiable risk factors.
Most people with memory, other cognitive, or behavioral complaints want a diagnosis to understand the nature of their problem and to know what to expect.(10, 12, 13, 14, 15) In a survey conducted by the Alzheimer’s Association of 2,434 U.S. adults age 18 and older, 85% of respondents said they would want to know early if they had Alzheimer’s. Reasons for wanting to know included planning for the future, allowing for earlier treatment of symptoms, taking steps to preserve existing cognitive function, and being able to understand what is happening.(16)
Some people are reluctant to mention concerns about memory or other cognitive or behavioral issues because they fear a diagnosis of dementia and how the disease will impact their lives in the future. In these cases, a primary care provider can explain the benefits of finding out what may be causing the person’s health concerns.
While pharmacological treatment options for Alzheimer’s-related memory loss and other cognitive symptoms are limited, there are medicines approved by the U.S. Food and Drug Administration to help manage symptoms, as well as newer medicines granted Accelerated Approval to treat Alzheimer’s. Learn more about these medications in NIA’s How Is Alzheimer’s Disease Treated?
In addition, there are non-drug strategies that can promote physical and emotional comfort. Assessing cognitive impairment and identifying its cause, particularly at an early stage, is beneficial so patients and families can learn about these strategies and develop a care plan in concert with their health care providers.
Clinical trials or other research studies are also an option for people with cognitive impairment. Patients may be interested in participating in clinical trials not only for themselves but also because of the potential to help future generations. Visit Alzheimers.gov for more information.
Benefits of early assessment
If assessment is negative, meaning there is no evidence of cognitive impairment: Concerns may be alleviated, at least at that point in time, and it is useful for both the person with concerns as well as the clinician to have a baseline for future assessments.
If assessment is positive and further evaluation is warranted: The patient and physician can take the next step of identifying the cause of impairment because medical conditions such as tumors, vitamin deficiencies, or medication side effects can also cause serious memory problems that resemble dementia. The results of an evaluation may lead to:
- Treating the underlying disease or health condition
- Managing comorbid conditions and medications more effectively and appropriately for the diagnosis
- Averting or addressing potential safety issues
- Allowing the patient to create or update advance directives and plan long-term care
- Ensuring the patient has support services and a care network to help with medical, legal, and financial concerns
- Working with the patient and their caregiver to develop strategies to improve quality of life, modify the patient’s lifestyle, make home safety modifications, and manage emotions related to the dementia diagnosis
- Referring the patient to a geriatrician, neurologist, geriatric psychiatrist, neuropsychologist, geriatric social worker, geriatric counselor, mental health counselor, or substance abuse professional for a more specific diagnosis or help with care management
- Ensuring the caregiver receives appropriate information, referrals, and support for coping with a dementia diagnosis, managing stress, and preparing for expected changes as well as making the best use of intact abilities
- Encouraging participation in clinical research, including clinical trials and studies
When is assessment 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.”(17)
Other risk factors that could indicate the need for dementia screening include: history of type 2 diabetes, stroke, depression, trouble managing money or medications, and being older than 80.(18) 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.(18)
How can physicians and staff find time for assessment?
Trained staff need only 10 minutes or less to initially assess a patient for cognitive impairment. While results alone are insufficient to diagnose dementia, they are an important first step. The AD8, QDRS, and Mini-Cog are among many possible tools and some can be filled out by the person or the caregiver while in the waiting room.
Disclaimer: NIA does not endorse any specific cognitive assessment tools. The selection of an assessment tool depends on a variety of factors, including the setting, target population age and demographics, language, and expertise of the administrator. Research is underway to create and validate new tools for cognitive assessment in primary care settings. For more information, visit Cognitive Assessment Considerations: Understanding the Evidence.
How to assess for cognitive impairment
Assessment for cognitive impairment can be performed at any visit but is a required component of the Medicare Annual Wellness Visit.(8, 19) Coverage for yearly wellness visits, and importantly, for follow-up visits for cognitive assessment and care plan services, is available to patients with Medicare Part B coverage.
Visit the Centers for Medicare & Medicaid Services (CMS) 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. The Alzheimer’s Association also offers information on cognitive assessment and care planning services.
Positive results from a brief assessment warrant further evaluation. A combination of neuropsychological evaluation, including self- and informant-reports from a person who has frequent contact with the person being evaluated, such as a spouse or other care provider, is the best way to assess cognitive impairment more fully.(20)
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 an NIA-funded Alzheimer’s Disease Research Center may also accept referrals.
Genetic testing, neuroimaging, and biomarker testing have been recommended for limited clinical uses.(2, 21) 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. In addition, some new Alzheimer’s medications may require or warrant the confirmation of beta-amyloid plaques before prescribing, as well as brain imaging during treatment to evaluate for amyloid-related imaging abnormalities (ARIA).
Interviews to assess memory, behavior, mood, and functional status of the patient are best conducted without family members or companions present who may prompt the person’s responses. However, family members or close companions can also be good sources of information. It can be beneficial to speak with them while the patient is in the room, as well as privately to allow for a more candid discussion. Per HIPAA regulations, the patient should give permission in advance. Brief, easy-to-administer tools, such as the Short IQCODE (PDF, 1.9M), the AD8, or the QDRS for the caregiver are available.
Note that people who are only mildly impaired may be adept at covering up their cognitive decline 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.
Additional resources are available to help health care teams in their detection of cognitive impairment and support of patients. For example, the American Academy of Family Physicians developed a Cognitive Care Kit, and the Gerontological Society of America developed the GSA KAER Toolkit for Primary Care Teams.
For more information on cognitive assessment tools, and other resources for health professionals, visit Alzheimer’s and Related Dementias Resources for Professionals.
What to do after assessment
After assessment for cognitive impairment is complete, take time to reflect on your relationship with the person to determine the best way to deliver the results.
Some people may prefer a cautious, reserved explanation. Other patients may prefer more precise language and appreciate when specific words, such as “Alzheimer’s disease,” are referenced.
The American College of Physicians Foundation and Alzheimer’s Association have produced an 11-minute video, Disclosing an Alzheimer’s Diagnosis, that may be helpful. Written materials can also be helpful: NIA’s Alzheimer’s and related Dementias Education and Referral Center has free tools and publications you can give to your patients, including Next Steps After an Alzheimer’s Diagnosis. Local resources can also be found using the Eldercare Locator.
Communicating with older patients
If possible, schedule additional time for the appointment or a follow-up, so that you can listen and respond to the patient’s and caregiver’s concerns. Ask the patient if there is a family member or friend who can help with medical, legal, and financial concerns going forward. Suggest making these arrangements as early as possible and ensure that the patient has given you formal authorization to include the caregiver in the conversation about your patient’s care. Keep that person’s name and contact information in your notes for future reference.
Informing family members or others that the patient may have Alzheimer’s, or any cognitive impairment, may be done in a telephone conference or group meeting, which should be arranged with the consent of the patient. It is the patient’s choice on how, whether, and with whom they want to share this information. Let everyone know that you will continue to be available for care, information, guidance, and support. And provide them with resources, such as the 24/7 helpline, in writing. Make them aware that there are support groups and other ways to get help.
Consider how your practice can coordinate and integrate care for the patient and caregiver across the many specialists and services that will be involved. Nonprofit support and community organizations can provide information about planning, social services, and care.
Learn more in Caring for Older Patients With Cognitive Impairment.
Communicating with caregivers
All caregivers face challenges, but these challenges are compounded for people caring for patients with Alzheimer’s or other forms of cognitive impairment. Here are some approaches that can be especially useful when communicating with caregivers:
- Explain that much can be done to improve the patient’s quality of life. Measures such as modifications in daily routine and medications may help. If the patient is in the later stages of dementia, consider bringing in a palliative care consultant to help with symptom management.
- Provide information about the consumer resources and services available from local organizations, as well as support groups.
- Encourage caregivers to get regular respite, especially when patients require constant attention. Ask if the caregiver, who is at considerable risk for stress-related disorders, is receiving adequate support. Encourage the caregiver to speak with their own health care provider. They may have trouble recognizing their own needs when they are so focused on their loved one; assure them that it is crucial to take care of themselves in order to best support their loved one.
Points to remember
- People should be assessed for cognitive impairment if:
- The individual, family members, or others express concerns about changes in the person’s memory, thinking, or behavior
- As the health care provider, you observe problems/changes in the patient’s memory, thinking, or behavior
- Brief assessments are available and can be used in an office visit.
- Assessment for cognitive impairment is a required component of the Medicare Annual Wellness Visit.
- People, particularly those who express a concern, likely want to know what the underlying problem is. It is important to emphasize that, no matter what the diagnosis is, there are options for support and care for the person and their caregivers.
- It's important to talk with the patient and caregiver about potential challenges and how to cope with their results.
- Bunn F, 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. doi: 10.1371/journal.pmed.1001331.
- Galvin JE and Sadowsky CH. Practical guidelines for the recognition and diagnosis of dementia. J Am Board Family Med. 2012;25(3):367-382. doi: 10.3122/jabfm.2012.03.100181.
- Kotagal V, et al. Factors associated with cognitive evaluations in the United States. Neurology. 2015;84(1):64-71. doi: 10.1212/WNL.0000000000001096.
- Chodosh J, et al. Physician recognition of cognitive impairment: Evaluating the need for improvement. J Am Geriatr Soc. 2004;52(7):1051-1059. doi: 10.1111/j.1532-5415.2004.52301.x.
- Lang L, et al. Prevalence and determinants of undetected dementia in the community: A systematic literature review and a meta-analysis. BMJ Open. 2017;7(2):e011146. doi: 10.1136/bmjopen-2016-011146.
- Amjad H, et al. Underdiagnosis of dementia: An observational study of patterns in diagnosis and awareness in US older adults. J Gen Intern Med. 2018;33(7):1131-1138. doi: 10.1007/s11606-018-4377-y.
- Lin PJ, et al. Dementia diagnosis disparities by race and ethnicity. Med Care. 2021;59(8):679-686. doi: 10.1097/MLR.0000000000001577.
- McPherson S and Schoephoester G. Screening for dementia in a primary care practice. Minn Med. 2012;95(1):36-40.
- Bradford A, et al. Missed and delayed diagnosis of dementia in primary care: Prevalence and contributing factors. Alzheimer Dis Assoc Disord. 2009;23(4):306-313. doi: 10.1097/WAD.0b013e3181a6bebc.
- Boustani M, 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. doi: 10.7326/0003-4819-138-11-200306030-00015.
- Phelan EA, et al. Association of incident dementia with hospitalizations. JAMA. 2012;307(2):165-72. doi: 10.1001/jama.2011.1964.
- Weimer DL and Sager MA. Early identification and treatment of Alzheimer disease: social and fiscal outcomes. Alzheimers Dement. 2009;5(3):215-226. doi: 10.1016/j.jalz.2009.01.028.
- Connell CM, et al. Black and white adult family members’ attitudes toward a dementia diagnosis. J Am Geriatr Soc. 2009;57(9):1562-1568. doi: 10.1111/j.1532-5415.2009.02395.
- 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. doi: 10.1002/gps.1485.
- Turnbull Q, et al. Attitudes of elderly subjects toward “truth telling” for the diagnosis of Alzheimer’s disease. J Geriatr Psychiatry Neurol. 2003;16(2):90-93. doi: 10.1177/0891988703016002005.
- 2022 Alzheimer's disease facts and figures. Alzheimers Dement. 2022;18(4):700-789. doi: 10.1002/alz.12638.
- 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. doi: 10.1001/jama.2020.0435.
- Barnes DE, 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, 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. doi: 10.1016/j.jalz.2012.09.011.
- Holsinger T, et al. Does this patient have dementia? JAMA. 2007;297(21):2391-2404. doi: 10.1001/jama.297.21.2391.
- McKhann GM, 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. doi: 10.1016/j.jalz.2011.03.005.
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April 16, 2023