This section provides guidance and tools for conducting a cognitive assessment during a time-limited office visit. Detecting possible cognitive impairment is the first step in determining whether or not a patient needs further evaluation.
Who should be evaluated for cognitive impairment?
- Individuals with memory concerns or other cognitive complaints. Non-memory triggers include personality change, depression, deterioration of chronic disease without explanation, and falls or balance issues
- Informant reports of cognitive impairment, with or without patient concurrence
- Medicare beneficiaries, as part of the Annual Wellness Visit
Benefits of early detection for your patients
- A better chance of benefiting from treatment
- More time to plan for the future
- Lessened anxieties about unknown problems
- Increased chances of participating in clinical drug trials, helping advance research
- An opportunity to participate in decisions about care, transportation, living options, financial and legal matters
- Time to develop a relationship with doctors and care partners
- Benefit from care and support services, making it easier for them and their family to manage the disease
Medicare Annual Wellness Visit
The Medicare Annual Wellness visit was initiated in January 2011 as part of the Affordable Care Act. The yearly Medicare benefit includes the creation of a personalized prevention plan and detection of possible cognitive impairment.
The Alzheimer's Association convened a group of practicing expert clinicians to make consensus recommendations for an effective, practical and easy process for detecting cognitive impairment in the primary care setting.
The resulting algorithm (PDF) incorporates patient history, clinician observations, and concerns expressed by the patient, family or caregiver. Because the use of a cognitive assessment instrument can improve detection of dementia in primary care settings1,the group identified several brief tools to evaluate cognition, all which can be administered in five minutes or less by a physician or other trained staff.
Recommended cognitive assessment tools
These cognitive assessment tools are used to identify individuals who may need additional evaluation. No one tool is recognized as the best brief assessment to determine if a full dementia evaluation is needed. However, the expert workgroup identified several instruments suited for use in primary care based on the following: administration time ≤5 minutes, validation in a primary care or community setting, psychometric equivalence or superiority to the Mini-Mental State Exam (MMSE), easy administration by non-physician staff and relatively free of educational, language and/or cultural bias. For a definitive diagnosis of mild cognitive impairment or dementia, individuals who fail any of these tests should be evaluated further or referred to a specialist.
Patient assessment tools:
- The GPCOG is a screening tool for cognitive impairment designed for use in primary care and is available in multiple languages.
- Mini-Cog - The Mini-Cog is a 3-minute test consisting of a recall test for memory and a scored clock-drawing test. It can be used effectively after brief training and results are evaluated by a health provider to determine if a full-diagnostic assessment is needed.
Informant tools (family members and close friends):
- Eight-item Informant Interview to Differentiate Aging and Dementia (AD8) – is an eight-question interview used to distinguish between normal signs of aging and mild dementia. This tool assesses individual change and can be administered in the primary care setting.
- General Practitioner Assessment of Cognition (GPCOG) – is a screening tool for cognitive impairment designed for use in primary care and is available in multiple languages.
- Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) – the IQCODE screening tool is an informant questionnaire designed to assess cognitive decline and dementia.
Videos demonstrating cognitive assessment
The following videos show a brief cognitive assessment and a peer-to-peer discussion of important aspects of assessing cognition and disclosing an Alzheimer's disease diagnosis during a primary care visit. The videos, part of a three-part instructional series developed for primary care providers, use an actual primary care physician and patient with Alzheimer's disease. The videos were produced by the American College of Physicians Foundation and the Alzheimer's Association.
Assessing cognition and recommending follow-up, and peer-to-peer discussion.
Indications for referral
Not all primary care physicians will want to conduct a full dementia evaluation. Possible indications for referral to a neurologist, neuropsychologist or geriatrician include:
- Inconclusive diagnosis
- Atypical presentation
- Behavioral/psychiatric symptoms
- Younger-onset (< 65 years)
- Second opinion
- Patient/family preference
- Family dispute
- Caregiver support
Help and support for your patients
- 24/7 Helpline 800.272.3900: We can help your patients and their caregivers with questions and local support resources.
- Message boards: Our online support community for people living with dementia and caregivers.
- Caregiving: Information and planning tools for families.
- I Have Alzheimers: Information and tips for people living with Alzheimer's or dementia.
Borson S, Scanlan JM,Watanabe J, Tu S-P, Lessig M. "Improving Identification of Cognitive Impairment in Primary Care." Int J Geriatr Psychiatry. 2006;21:349–55.