Assessing Cognitive Impairment in Older Patients

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)

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 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.

When Is Screening Indicated?
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)

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) 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.

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 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.

Genetic testing, neuroimaging, and biomarker testing are not generally recommended for clinical use at this time.(2),(15) These tests are primarily conducted in research settings.

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.

Brief, easy-to-administer informant screening tools, such as the short IQCODE or the AD8 (PDF, 1.2M), are available.