Clinical question
Who should I assess for cognitive impairment and what screening tools should I use?
Bottom line
The Canadian Task Force on Preventive Health Care
recommend[s] not screening asymptomatic adults 65 years of age or older for cognitive impairment. (Strong recommendation, low-quality evidence) .... The recommendation does not apply to [patients with] symptoms suggestive of cognitive impairment ... or who are suspected of having cognitive impairment by clinicians, family or friends.1
But if family and friends do not report cognitive impairment (because they do not notice it or incorrectly label it “normal aging”), what signs should alert clinicians to its subtler forms? Once suspected, what screening tools should clinicians employ? This is especially pertinent given changes in access to the Montreal Cognitive Assessment (MoCA).
The Mini-Mental State Examination used to be most commonly used until the rights owners began to charge for use. Many FPs then began using MoCA. Recently, one of the MoCA developers announced he will be charging for training, certification, and access to the full website resources. What other tools have been validated in primary care?
Evidence
Six reasonably brief cognitive screening tests have been validated in primary care: Mini-Cog, Memory Impairment Screen, General Practitioner Assessment of Cognition, Short Portable Mental Status Questionnaire, Free and Cued Selective Reminding Test, and 6 Item Cognitive Impairment Test.2–9 To learn more visit www.dementiascreen.ca.
Approach
Patients do not always come to you with cognitive concerns (in fact, patients might lose awareness of their impairment). Some caregivers incorrectly dismiss cognitive changes as “normal aging” and do not raise the issue. Paying attention to subtler signs (Box 1) might flag those needing screening.
Box 1. Behavioural flags suggestive of dementia.
Frequent calls to the office or visits to the doctor or emergency department
Poor historian, vague, seems “off,” repetitive
New nonadherence with medications or instructions (loss of ability to manage concurrent medical conditions that they could manage in the past)
Changes in appearance, mood, personality, behaviour
Word-finding problems, decreased social interaction
Missing appointments, coming on the wrong day
Confusion: postoperative delirium or with illness or new medications
Weight loss in the older person living alone
Driving: accidents, problems, tickets, family concerns
Head-turning sign (turning to caregiver for answers)
Developed by Dr W. Dalziel and printed with permission.
When patients or families raise concerns, do not assume it is normal aging; always consider formal assessment. Guidelines can help guide the overall approach to initial assessment (www.cfp.ca/content/60/5/433), which should include cognitive screening, medication review, and investigations for remediable factors.10
Implementation
Use a screening tool in addition to reviewing functional effects of deficits, with corroboration from family if possible. No cutoff score on any test definitively diagnoses dementia; your knowledge of the patient and their function is key. Screening score is relevant but one of many factors. How the patient approaches tasks—which they do well; what is challenging—provides useful information particularly compared with past ability. As decline progresses, repeat testing with the same tool might provide objective information.
Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.
Footnotes
Competing interests
None declared
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de janvier 2020 à la page e12.
References
- 1.Canadian Task Force on Preventive Health Care. Pottie K, Rahal R, Jaramillo A, Birtwhistle R, Thombs BD, et al. Recommendations on screening for cognitive impairment in older adults. CMAJ. 2016;188(1):37–46. doi: 10.1503/cmaj.141165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Lorentz WJ, Scanlan JM, Borson S. Brief screening tests for dementia. Can J Psychiatry. 2002;47(8):723–33. doi: 10.1177/070674370204700803. [DOI] [PubMed] [Google Scholar]
- 3.Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia screening instrument for general practitioners to use? Am J Geriatr Psychiatry. 2006;14(5):391–9. doi: 10.1097/01.JGP.0000216181.20416.b2. [DOI] [PubMed] [Google Scholar]
- 4.Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriat. 2008;20(5):911–26. doi: 10.1017/S1041610208007394. [DOI] [PubMed] [Google Scholar]
- 5.Ismail Z, Rajji TK, Shulman KI. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry. 2010;25(2):111–20. doi: 10.1002/gps.2306. [DOI] [PubMed] [Google Scholar]
- 6.Lin JS, O’Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;159(9):601–12. doi: 10.7326/0003-4819-159-9-201311050-00730. Erratum in: Ann Intern Med 2014;160(1):72. [DOI] [PubMed] [Google Scholar]
- 7.Yokomizo JE, Simon SS, Machado de Campos Bottino C. Cognitive screening for dementia in primary care: a systematic review. Int Psychogeriatr. 2014;26(11):1783–804. doi: 10.1017/S1041610214001082. Epub 2014 Jul 15. [DOI] [PubMed] [Google Scholar]
- 8.Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Internal Med. 2015;175(9):1450–8. doi: 10.1001/jamainternmed.2015.2152. [DOI] [PubMed] [Google Scholar]
- 9.Abd Razak MA, Ahmad NA, Chan YY, Mohamad Kasim N, Yusof M, Abdul Ghani MKA, et al. Validity of screening tools for dementia and mild cognitive impairment among the elderly in primary health care: a systematic review. Public Health. 2019;169:84–92. doi: 10.1016/j.puhe.2019.01.001. Epub 2019 Mar 1. [DOI] [PubMed] [Google Scholar]
- 10.Moore A, Patterson C, Lee L, Vedel I, Bergman H. Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. Recommendations for family physicians. Can Fam Physician. 2014;60:433–8. (Eng), e244–50 (Fr). [PMC free article] [PubMed] [Google Scholar]