Practical Guidelines for the Recognition and Diagnosis of Dementia

James E. Galvin; Carl H. Sadowsky

doi:10.3122/jabfm.2012.03.100181

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Figure 1.
The Mini-Cog Scoring Algorithm. 0 = Positive for cognitive impairment; 1 or 2 plus an abnormal clock drawing test (CDT) = positive for cognitive impairment; 1 or 2 plus a normal CDT = negative for cognitive impairment; 3 = Negative screen for dementia (no need to score CDT). Reproduced with permission from Borson S et al. Int J Geriatr Psychiatry 2000;15:1021–1027. © 2000 John Wiley & Sons³⁹
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Figure 2.
Neuropsychiatric Inventory Questionnaire¹³

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Table 1. Stepwise Approach to Diagnosing and Assessing Alzheimer Disease in Primary Care

Stage	Purpose	Tools to Use/Information to Obtain
Step 1: Prediagnostic tests	Differential diagnosis and determination of coexisting disorders	Risk factors, including age, female sex, apolipoprotein E4 gene, prior head injury, low education, and family history of AD; stroke, obesity, hypertension, hyperlipidemia, hyperhomocysteinemia, diabetes, hyperinsulinemia, and smoking^10,65,66
		Medical history: Other ailments that mimic dementia include normal age-associated memory changes, depression, delirium, drug reactions, vision and hearing problems¹
		Key questions to ask: Has the patient had any recent illnesses? Has the patient used any new prescription or over-the-counter medications that could cause memory loss, such as benzodiazepines, anticholinergic drugs for urinary incontinence Has the patient used or been exposed to illicit drugs? Has there been any exposure to environmental toxins, eg, fuels or solvents? Has the patient had any head injuries recently? Is there any history of epilepsy?
		Laboratory/medical tests: Complete blood cell count (to ascertain presence of anemia/infection), glucose and thyroid function tests, serum electrolytes, serum B₁₂ levels (to identify vitamin deficiencies), liver function tests, renal function tests, and urinalysis, if appropriate¹ Patients with AD frequently have comorbid medical conditions, eg, cardiovascular disease, infection, pulmonary, renal insufficiency, and arthritis.¹³
		Early warning signs of preclinical dementia: Increased frequency of patient visits to the PCP prior to diagnosis, over a period up to 5 years prior to the diagnosis^34,35 Accelerated weight loss,³⁶ late-life depression, gait disturbances, and physical frailty³⁷
Step 2: Assess performance	Cognitive assessments that help screen for/diagnose AD	Cognitive tests:^* MMSE^12,13 Mini-Cog^39,40,42,67 MoCA⁶⁸
Step 2: Assess performance	Cognitive assessments that help screen for/diagnose AD	Informant-rated tool:^* AD8⁶³
Step 3: Assess daily functioning	Determine level of independence and degree of disability	Daily function assessment tool:^* IADL^48,49
Step 4: Assess behavioral symptoms	Determine presence and degree of behavioral symptoms	Behavioral assessment tool:^* NPI-Q⁵⁷
Step 4: Assess behavioral symptoms	Determine presence and degree of behavioral symptoms	Assess the patient for drug toxicity and medical psychiatric, psychosocial, or environmental problems that may underlie behavioral changes.¹³
Step 5: Identify caregiver and assess needs	Identify the primary caregiver and assess adequacy of family and other support systems	Identify primary carers and establish collaboration: Family caregivers are central to the PCP's assessment and care of the patient.⁵⁹ Establish and maintain collaboration with caregivers.^59,60 Routinely incorporate caregivers' reports of patients' changes in daily routine, mood, behavior, and sleeping patterns.
Step 5: Identify caregiver and assess needs		Assess health of primary caregiver: Regularly monitor the physical and emotional health of the primary caregiver as well as that of the patient.¹³ The PCP should assess the caregiver themselves or refer them to a psychologist, social worker, or other member of the health care delivery team.
Special considerations	Identify culture, language, and literacy of patient and caregiver	Culture: Recognize the caregiving patterns of ethnic minority groups, eg, African American and Hispanic families distribute care among several family members, rather than one primary carer. Ethnic minority groups may place different interpretations on memory and behavioral problems.
		Language: Be aware of the preferred language of the patient and family.⁶⁹
		Literacy: Recognize that paper-and-pencil tests and forms may not work well with diverse patient populations if basic literacy is not present, even when such forms are in the person's native language. Some experts suggest that patients be tested only on what they reasonably may be expected to know,⁷⁰ eg, a person with little schooling may not know how to do the serial sevens on the MMSE, but may be competent at applying simple math, such as subtraction, when handling monetary transactions.

The initial assessment of cognitive and functional abilities is important to determine a baseline to which future deficits may be compared. Reassessment of the patient every 6 months is recommended, and more often in cases of sudden changes in behavior or increased rate of decline.¹³
↵* Refer to Table 2 for further details.
AD, Alzheimer disease; AD8, 8-item Ascertain Dementia tool; IADL, instrumental (or intermediate) activities of daily living; MMSE, Mini-Mental State Examination; Mini-Cog, Mini Cognitive Assessment Instrument; MoCA, Montreal Cognitive Assessment; NPI-Q, Neuropsychiatric Inventory Questionnaire; PCP, primary care physician.

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Table 2. Key Screening and Assessment Tools for Alzheimer Disease Used in Primary Care

	Key Features Relevant to Clinical Practice	Number of Items	Time Required	Max Score	Cutoff	Sensitivity/Specificity (%)
Performance testing/screening tools
MMSE	Covers 6 areas: (1) orientation, (2) registration, (3) attention and calculation, (4) recall, (5) language, and (6) ability to copy a figure^12,13 Quick and easy to administer Can track the overall progression of cognitive decline, but not a good test for definitive/early AD diagnosis¹ Results biased according to age, race, education, and socioeconomic status³⁹	30 items	10 minutes	30	23–26	79/88
Mini-Cog	Combines an uncued 3-item recall test with a CDT that serves as a recall distractor	2 items	3 minutes	Maximum, 5		76/89
	Easy to administer and requires no special equipment⁴⁰			0 = Cognitive impairment
	Powerful predictor of impaired activities of daily living⁶⁷			1 to 2 + abnormal CDT = Cognitive impairment
	Good performance in ethnolinguistically diverse populations⁴²			1 to 2 + normal CDT = No cognitive impairment
	Easier to administer to non-English speakers³⁹			3 = Negative for dementia (no need to score CDT)
	Less biased by low educational status and literacy level than MMSE³⁹
MoCA	Cognitive screening tool for detection of MCI in primary care⁶⁸ Addresses frontal/executive functioning Low susceptibility to cultural and educational biases⁴³ High sensitivity and specificity for detecting MCI in those patients who perform within the normal range of the MMSE^68,71	12 items	10 minutes	30	26	Sensitivity of 90% for MCI 100% for mild AD⁶⁸
AD8	Informant-rated change Screening interview: brief, sensitive measure of memory, orientation, judgment, and function Can also be directly administered to the patient as a self-rating tool⁴⁴ Use of the AD8 with a brief patient assessment, e.g. word list, could improve detection of dementia in the primary setting to 97% for dementia and 91% for MCI⁶³ More sensitive to early stages of dementia: strong correlation with biological markers of AD, e.g CSF⁴⁵	8 Yes/No	2 to 3 minutes	Scores of 0 to 1 = normal cognition Scores of ≥2 = probable cognitive impairment		74–80/80–86
Daily functioning assessment
IADL	Evaluates patient's ability to perform more complex activities that are necessary for optimal independent functioning^48,49 Data collected from the patient or informant (e.g. family member, caregiver)	7	10–15 minutes	Three choices of answer per question:		N/A
				I = Patient is completely independent
				A = Assistance required
				D = Dependent on help for each activity
Behavioral assessment
NPI-Q	Rates frequency and severity of behavioral symptoms commonly seen in dementia, and caregiver distress⁵⁷	12 symptoms/questions	5 minutes	Each question is scored as either present or absent		N/A
	Useful tool for family physicians; assesses both severity of symptoms in patient and distress caused to caregiver			Present behaviors are scored for severity and distress:
				Severity: 1 = mild to 3 = severe Distress: 0 = no distress; 5 = extremely distressing

AD, Alzheimer disease; AD8, 8-item Acertain Dementia tool; CDT, clock-drawing test; CSF, cerebrospinal fluid; IADL, instrumental (or intermediate) activities of daily living; MCI, mild cognitive impairment; Mini-Cog, Mini-Cognitive Assessment Instrument; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; NPI-Q, Neuropsychiatric Inventory Questionnaire; N/A, not applicable; PCP, primary care physician.

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Table 3. AD8 Dementia Screening Interview

	Yes, a Change^*	No, No Change	N/A, Don't Know
1. Problems with judgment (eg, problems making decisions, bad financial decisions, problems with thinking)	□	□	□
2. Less interest in hobbies/activities	□	□	□
3. Repeats the same things over and over (questions, stories, or statements)	□	□	□
4. Trouble learning how to use a tool, appliance, or gadget (eg, VCR, computer, microwave, remote control)	□	□	□
5. Forgets correct month or year	□	□	□
6. Trouble handling complicated financial affairs (eg, balancing checkbook, income taxes, paying bills)	□	□	□
7. Trouble remembering appointments	□	□	□
8. Daily problems with thinking, memory, or both	□	□	□
TOTAL AD8 SCORE	□	□	□

↵* “Yes, a change” indicates that there has been a change in the last several years caused by cognitive (thinking and memory) problems.
Scores of 0 to 1 indicate normal cognition; scores of ≥2 indicate that cognitive impairment is likely to be present.
AD8, 8-item Ascertain Dementia screening.
Adapted with permission from Galvin J et al. Neurology 2006;67:1942–8. © 2006 AAN Enterprises, Inc.⁶³

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Table 4. Instrumental Activities of Daily Living Scale

Name of patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date. . . . . . . . . . . . . . . .
This form may help you assess the functional capabilities of your older patients. The data can be collected by a nurse from the patient or from an informant such as a family member or other caregiver (I = independent; A = assistance required; D = dependent)
Obtained from		Activity	Guidelines for assessment
Patient	Informant	Activity	Guidelines for assessment
I A D	I A D	Using telephone	I = Able to look up numbers, dial telephone, and receive and make calls without help
			A = Able to answer telephone or dial operator in an emergency, but needs special telephone or help in getting numbers and/or dialing
			D = Unable to use telephone
I A D	I A D	Traveling	I = Able to drive own car or travel alone on buses or in taxis
			A = Able to travel, but needs someone to travel with
			D = Unable to travel
I A D	I A D	Shopping	I = Able to take care of all food and all clothes shopping with transportation provided
			A = Able to shop, but needs someone to shop with
			D = Unable to shop
I A D	I A D	Preparing meals	I = Able to plan and cook full meals
			A = Able to prepare light foods, but unable to cook full meals alone
			D = Unable to prepare any meals
I A D	I A D	Housework	I = Able to do heavy housework (i.e. scrub floors)
			A = Able to do light housework, but needs help with heavy tasks
			D = Unable to do any housework
I A D	I A D	Taking medicine	I = Able to prepare and take medications in the right dose at the right time
			A = Able to take medications, but needs reminding or someone to prepare them
			D = Unable to take medications
I A D	I A D	Managing money	I = Able to manage buying needs (i.e. write checks, pay bills)
			A = Able to manage daily buying needs, but needs help managing checkbook and/or paying bills
			D = Unable to handle money

Adapted with permission from: Lawton MP, Brody EM. Gerontologist 1969;9:179–86. 1969 © The Gerontological Society of America.

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Table 5. Functional Assessment Questionnaire

In the Past 4 Weeks, Did the Subject Have Any Difficulty or Need Help With:	Not Applicable	Normal	Has Difficulty, But Does by Self	Requires Assistance	Dependent
1. Writing checks, paying bills or balancing a checkbook	□	□	□	□	□
2. Assembling tax records, business affairs, or other papers	□	□	□	□	□
3. Shopping alone for clothes, household necessities, or groceries	□	□	□	□	□
4. Playing a game of skill such as bridge or chess, working on a hobby	□	□	□	□	□
5. Heating water, making a cup of coffee, turning off the stove	□	□	□	□	□
6. Preparing a balanced meal	□	□	□	□	□
7. Keeping track of current events	□	□	□	□	□
8. Paying attention to and understanding a TV program, book, or magazine	□	□	□	□	□
9. Remembering appointments, family occasions, holidays, medications	□	□	□	□	□
10. Traveling out of the neighborhood, driving, or arranging to take public transportation	□	□	□	□	□

Adapted from Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323–9. 1982 © The Gerontological Society of America.