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screening for dementia; screening for cognitive impairment; screening for Alzheimer's disease

Indications: - no obvious benefits or harms of screening for dememtia in primary care [21] * also see cognitive assessment Procedure: - simple cognitive assessment tools - executive function assessment - clock drawing test - time & change test - mental status examination - Folstein mini-mental status examination (MMSE) - modified mini-mental status examination (MMMSE)# [11] - of no benefit in assessing risk of MCI progressing to dementia [14] - MiniCog* - Montreal Cognitive Assessment (MoCA)* [9] - MoCA-B useful for illiterate or low-education elderly - precedence over screening for depression [24] - others - visuospatial function assessment (language-independent) - visual association test improves predictive value of the MMSE score for development of dementia [19] - clock drawing test (also falls in this category) - somewhat more complex cognitive assessment* [5] - consisting of: - mini mental status examination - neuropsychological testing - episodic/recall ability - verbal fluency - visuospatial skills - detects 18% of early-stage Alzheimer's disease developing within 3 years - 100% predictive value for development of early Alzheimer's disease - screening for depression - QuoCo tool (cognitive chart) - cognitive screening by telephone 10-CS [22] - 10-point cognitive screen - 1 point each for correct year, month, & date - 1 point for each of 3 named objects that are remembered several minutes later - points for naming animals - 4 points for >= 15 animals for fewer animals - instructions for administering & scoring the 10-CS are available free of charge in the online supplement of [22] * free tools validated in primary care populations [10] # MMSE may be better than MoCA for cognitive screening in African American patients # MoCA is better than MMSE for detecting MCI in the elderly, particularly in the oldest old population [12,13] Diagnostic criteria: - clinical diagnosis of dementia requires cognitive impairment that interferes with activities of daily living [25] - also see diagnostic criteria for dementia Clinical significance: - cognitive decline begins 6 years prior to onset of dementia [26] - intact olfaction & intact global cognition together predict a no progression to dementia [23] - race & apoE4 genotype may influence odor identification screening & global cognitive screening & their association with risk of dementia [23] Laboratory: - CSF tau increases 10 years before onset of dementia [26] - CSF Abeta42 decreases 18 years before onset of dementia [26] Radiology: - PET scan with Pittsburg compound B for amyloid* - brain MRI for hippocampal atrophy* & white matter lesions* - shrinkage of hippocampal volume 8 years before onset of dementia [26] * presence of 2 of 3 predicts dementia * hippocampal atrophy associated with 5-fold risk * white matter lesions associated with ~3-fold risk [8] Management: - insufficient evidence to recommend for or against screening [1] - screening best postponed until effective therapy available [4] - consider screening for all older adults, despite lack of effective treatment [2] - actually 2-5% of cases are due to reversible causes [3] - early warnings could avoid problems with a) driving b) financial mismanagement c) social isolation - screening of nursing home residents for dementia does not reduce emergency department transfers [20] - a healthy diet, adequate sleep, & exercise should be part of recommendations for every patient, regardless of cognitive complaints [6]

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cognitive assessment

General

screening

References

  1. US Preventive Services Task Force Screening for Dementia June 2003 http://www.uspreventiveservicestaskforce.org/3rduspstf/dementia/dementrr.htm - updated Sept, 2014 - Owens DK et al. Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. JAMA 2020 Feb 25; 323:757. PMID: 32096858 https://jamanetwork.com/journals/jama/fullarticle/2761651 - Patnode CD et al. Screening for cognitive impairment in older adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2020 Feb 25; 323:764. PMID: 32096857 https://jamanetwork.com/journals/jama/fullarticle/2761650 - Petersen RC. Yaffe K. Issues and questions surrounding screening for cognitive impairment in older patients. JAMA 2020 Feb 25; 323:722. PMID: 32096831 https://jamanetwork.com/journals/jama/fullarticle/2761621
  2. McCarten JR et al Screening for Cognitive Impairment in an Elderly Veteran Population: Acceptability and Results Using Different Versions of the Mini-Cog Journal of the American Geriatrics Society, 59: 309-313 PMID: 21314650 http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03249.x/abstract
  3. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  4. Journal Watch 23(6):48, 2003 Palmer K et al Detection of Alzheimer's disease and dementia in the preclinical phase: population based cohort study. BMJ 326:245, 2003 PMID: 12560271 http://bmj.com/cgi/content/full/326/7383/245
  5. Journal Watch 23(12):93, 2003 Tan ZS, Seshadri S, Beiser A, Wilson PW, Kiel DP, Tocco M, D'Agostino RB, Wolf PA. Plasma total cholesterol level as a risk factor for Alzheimer disease: the Framingham Study. Arch Intern Med. 2003 May 12;163(9):1053-7. PMID: 12742802
  6. Le Couteur DG et al. Political drive to screen for pre-dementia: Not evidence based and ignores the harms of diagnosis. BMJ 2013 Sep 9; 347:f5125 PMID: 24018000 http://www.bmj.com/content/347/bmj.f5125
  7. Moyer VA; U.S. Preventive Services Task Force Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Jun 3;160(11):791-7 PMID: 24663815
  8. Lopez OL et al. Amyloid, neurodegeneration, and small vessel disease as predictors of dementia in the oldest-old. Neurology 2014 Nov 11; 83:1804 http://www.neurology.org/content/83/20/1804
  9. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  10. Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
  11. Sink KM, Craft S, Smith SC et al Montreal Cognitive Assessment and Modified Mini Mental State Examination in African Americans. J Aging Res. 2015;2015:872018. Epub 2015 Nov 4. PMID: 26618003 Free PMC Article
  12. Tan JP, Li N, Gao J et al Optimal cutoff scores for dementia and mild cognitive impairment of the Montreal Cognitive Assessment among elderly and oldest-old Chinese population. J Alzheimers Dis. 2015;43(4):1403-12. PMID: 25147113
  13. Trzepacz PT, Hochstetler H, Wang S et al Relationship between the Montreal Cognitive Assessment and Mini-mental State Examination for assessment of mild cognitive impairment in older adults. BMC Geriatr. 2015 Sep 7;15:107. PMID: 26346644 Free PMC Article
  14. Arevalo-Rodriguez I, Smailagic N et al Mini-Mental State Examination (MMSE) for the detection of Alzheimer's disease and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev. 2015 Mar 5;(3):CD010783 Review. PMID: 25740785
  15. Dong Y, Lee WY, Basri NA et al The Montreal Cognitive Assessment is superior to the Mini- Mental State Examination in detecting patients at higher risk of dementia. Int Psychogeriatr. 2012 Nov;24(11):1749-55. PMID: 22687278
  16. Velayudhan L, Ryu SH, Raczek M et al Review of brief cognitive tests for patients with suspected dementia.. Int Psychogeriatr. 2014 Aug;26(8):1247-62. Review. PMID: 24685119 Free PMC Article
  17. Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2015 Sep;175(9):1450-8. Review. PMID: 26052687
  18. Newman JC. Copyright and bedside cognitive testing: why we need alternatives to the Mini-Mental State Examination. JAMA Intern Med. 2015;175(9):1459 PMID: 26053392
  19. Jongstra S, van Gool WA, Moll van Charante EP et al Improving Prediction of Dementia in Primary Care. Ann Fam Med May/June 2018 vol. 16 no. 3 206-210 PMID: 29760023 Free Article http://www.annfammed.org/content/16/3/206
  20. Rolland Y, Tavassoli N, de Souto Barreto P et al Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial. JAMA Netw Open. 2020 Feb 5;3(2):e200049. PMID: 32101308 Free Article
  21. Fowler NR, Perkins AJ, Gao S, Sachs GA, Boustani MA. Risks and Benefits of Screening for Dementia in Primary Care: The Indiana University Cognitive Health Outcomes Investigation of the Comparative Effectiveness of Dementia Screening (IU CHOICE)Trial. J Am Geriatr Soc 2020 Mar; 68:535. PMID: 31792940 https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16247
  22. Rico BMH et al. Advancing cognitive assessment in telemedicine: Validity and reliability of the telephone 10-point cognitive screener. J Am Geriatr Soc 2023 Mar; 71:977. PMID: 36273404 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18091
  23. Motter JN et al. Association of performance on olfactory and cognitive screening tests with conversion to dementia in a biracial cohort of older adults. Neurology 2023 Jul 6; [e-pub] PMID: 37414570
  24. NEJM Knowledge+
  25. Section II, Neurocognitve Disorders. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC: American Psychiatric Association; 2013:602 - Mao HF, Chang LH, Tsai AY et al Diagnostic accuracy of Instrumental Activities of Daily Living for dementia in community-dwelling older adults. Age Ageing. 2018 Jul 1;47(4):551-557 PMID: 29528375
  26. Jia J et al. Biomarker changes during 20 years preceding Alzheimer's Disease. N Engl J Med 2024 Feb 21; 390:712-722 PMID: 38381674 https://www.nejm.org/doi/10.1056/NEJMoa2310168