What is the recommended approach for screening for dementia?

Recommended Approach for Screening for Dementia

Routine screening for dementia in asymptomatic individuals is not recommended, but cognitive assessment should be performed when cognitive impairment is suspected based on direct observation, patient report, or concerns raised by family members, friends, or caregivers. 1, 2

When to Screen for Cognitive Impairment

• Screening should be targeted at individuals with:
  • Observed cognitive or functional decline
  • Patient-reported memory or thinking problems
  • Concerns raised by family members or caregivers
  • Risk factors for cognitive impairment
  • Recent delirium or head injury

Recommended Screening Tools

Brief Initial Screening Tools (2-5 minutes)

• Mini-Cog: Combines three-word recall with clock drawing; ideal for rapid dementia screening in primary care settings 2, 3
• GPCOG (General Practitioner Assessment of Cognition): Includes patient assessment (2-5 minutes) and informant component (1-3 minutes) 1, 2
• MIS (Memory Impairment Screen): Four-item delayed free and cued recall test 2

More Comprehensive Assessment Tools (7-15 minutes)

• Montreal Cognitive Assessment (MoCA): Best for detecting mild cognitive impairment (MCI); requires training/certification 1, 2, 3
• Mini-Mental State Examination (MMSE): Well-studied for dementia detection but less sensitive for MCI; proprietary; not free for clinical use 1, 2
• Modified Mini-Mental State (3MS) examination: More comprehensive than MMSE 1
• SLUMS Examination: Suited for MCI and dementia detection, particularly in VA populations 2

Important Considerations When Selecting Screening Tools

1. Patient characteristics:

   • Education level (add 1 point adjustment for ≤12 years of education with MoCA) 2
   • Language proficiency
   • Cultural background (consider RUDAS for culturally diverse populations) 1

2. Test interpretation:

   • MMSE: Cut point of 24/25 for most primary care populations 2
   • MoCA: ≥26 normal cognition; 23-25 possible MCI; 19-22 mild dementia; <19 moderate to severe dementia 2

3. Limitations of screening tools:

   • False positives more common in older adults with lower education levels 1
   • False negatives more common in younger adults with higher education levels 1
   • Positive predictive value is limited when screening unselected patients 1, 4

Comprehensive Evaluation After Positive Screen

A positive screen is not a diagnosis and requires comprehensive evaluation:

1. Functional assessment using validated tools:

   • Pfeffer Functional Activities Questionnaire (FAQ) 1, 2
   • Disability Assessment for Dementia (DAD) 1, 2

2. Informant assessment using standardized tools:

   • AD8 (Ascertain Dementia 8) questionnaire 1
   • IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) 1
   • Combining cognitive tests with functional screens and informant reports improves case-finding 1

3. Assessment of behavioral and psychological symptoms:

   • Neuropsychiatric Inventory (NPI-Q) 1
   • Mild Behavioural Impairment Checklist (MBI-C) 1
   • Patient Health Questionnaire-9 (PHQ-9) for mood assessment 1

4. Diagnostic evaluation:

   • Brain imaging (MRI preferred) to evaluate for cerebrovascular disease and structural abnormalities 2
   • Laboratory tests to screen for reversible causes of cognitive impairment 2
   • Medication review for cognitive side effects 2

Follow-up and Monitoring

• Serial cognitive assessments every 6-12 months using the same version of cognitive tests 2
• Regular evaluation of activities of daily living using validated tools 2
• Education about cognitive impairment and risk of progression 2
• Discussion of advance care planning while cognitive capacity is preserved 2

Cautions and Limitations

• No empirical evidence that screening for cognitive impairment in asymptomatic individuals improves patient or caregiver outcomes 5
• Misdiagnosis and overdiagnosis can have significant long-term effects including stigmatization and loss of autonomy 6
• Health systems may not have the capacity to respond to increased demand resulting from universal screening 6
• Early recognition allows clinicians to anticipate problems with understanding and treatment adherence, and helps families plan for future care needs 1