Dementia Assessment in Hospitalized Elderly Patients
Begin with a structured three-domain assessment using validated tools: cognitive screening (MoCA preferred), functional evaluation (FAQ or DAD), and informant-based questionnaires (AD8 or IQCODE), as this combination significantly improves diagnostic accuracy compared to any single measure alone. 1
Initial Cognitive Screening
Select your cognitive assessment tool based on suspected severity:
For suspected mild cognitive impairment or early dementia: Use the Montreal Cognitive Assessment (MoCA), which demonstrates superior sensitivity to mild impairment compared to MMSE and should be your first choice when cognitive concerns exist but function appears relatively preserved 1
For moderate dementia: The Mini-Mental State Examination (MMSE) remains highly sensitive and specific, though it lacks sensitivity for detecting MCI or mild dementia 1
For rapid screening (under 5 minutes): Consider the Mini-Cog, Memory Impairment Screen plus Clock Drawing Test, or the 4-item MoCA (Clock-drawing, Tap-at-letter-A, Orientation, Delayed-recall) 1
For patients with limited education or literacy concerns: Use the Rowland Universal Dementia Assessment Scale (RUDAS), which minimizes socioeconomic and educational bias 1
Essential Informant Assessment
Obtain corroborative history from a reliable informant using standardized tools—this is mandatory, not optional, as patients with dementia frequently lack insight into their deficits. 1, 2
Recommended informant-based instruments:
AD8 (Ascertain Dementia 8-Item Questionnaire): Brief, highly sensitive for detecting cognitive change, can be completed quickly 1, 2
IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly): 10-15 items rating cognitive changes over time on a 5-point scale, excellent for capturing longitudinal decline 1
ECog (Everyday Cognition): Measures informant's report of cognitive changes in daily activities 1
Combining cognitive tests with informant reports improves case-finding accuracy substantially over either method alone 1, 2
Functional Assessment
Evaluate both instrumental and basic activities of daily living using objective measures with patient AND informant input:
Pfeffer Functional Activities Questionnaire (FAQ): Rapid screening of functional autonomy, particularly sensitive to IADL impairments 1, 3
Disability Assessment for Dementia (DAD): Comprehensive evaluation of both IADLs and ADLs 1, 3
Key functional domains to assess: 4
- Financial management (paying bills, managing accounts)
- Medication management (taking medications correctly, on schedule)
- Transportation (driving safety, using public transit)
- Household management (cooking, cleaning, shopping)
- Technology use (phone, computer, appliances)
The distinction between MCI and dementia fundamentally rests on whether functional impairment is present—cognitive deficits alone without functional impact indicate MCI, not dementia 1
Behavioral and Mood Assessment
Screen for neuropsychiatric symptoms using validated instruments:
NPI-Q (Neuropsychiatric Inventory-Questionnaire): Brief version assessing behavioral and psychological symptoms of dementia 1, 3
MBI-C (Mild Behavioural Impairment Checklist): Particularly useful for detecting early behavioral changes 1
PHQ-9 (Patient Health Questionnaire-9) or Cornell Scale for Depression in Dementia: Essential for mood assessment, as depression frequently coexists with or mimics dementia 1, 3
Geriatric Depression Scale (GDS): Alternative for depression screening, though less sensitive as dementia progresses 1
Laboratory and Imaging Evaluation
Order the following laboratory tests to identify reversible causes: 5, 6
- Complete blood count
- Comprehensive metabolic panel (particularly sodium, calcium, glucose)
- Thyroid function tests (TSH, free T4)
- Vitamin B12 and folate levels
Neuroimaging indications (MRI preferred over CT): 1, 2
- Cognitive symptom onset within past 2 years
- Unexpected or rapid decline in cognition or function
- Recent significant head trauma
- New neurological signs (seizures, focal deficits, gait disturbances)
- History of cancer with brain metastasis risk
- Significant vascular risk factors
- Symptoms suggesting normal pressure hydrocephalus
MRI demonstrates superior sensitivity for vascular lesions and specific dementia subtypes; use 3T over 1.5T when available 1
Critical Pitfalls to Avoid
Do not rely solely on patient self-report without informant corroboration—anosognosia (lack of insight) is common in dementia, making self-reports unreliable and leading to missed diagnoses 1, 2
Do not use unstandardized cognitive assessment—structured tools detect cognitive impairment 2-3 fold more effectively than unaided clinical impression 1
Do not assess cognition in isolation—combining cognitive testing with functional screens and informant reports is essential for accurate diagnosis 1
Do not overlook medical contributors—evaluate for sleep disorders (particularly sleep apnea), sensory deficits (hearing loss, vision impairment), pain, and mobility problems that may affect cognitive performance 2, 6
Do not forget caregiver burden assessment—use the Zarit Burden Interview or similar tool, as caregiver burden is a major determinant of hospitalization and nursing home placement 1, 3
Practical Hospital Implementation
Assign cognitive screening to nursing staff or physician assistants—objective assessments can be successfully completed by multiple team members, not just physicians 1
Use a two-visit approach if time-constrained: First visit for rapid screening (Mini-Cog, verbal fluency test, or Sweet 16); if abnormal, order labs and imaging, then conduct comprehensive assessment at second visit with MMSE/MoCA, functional assessment, and behavioral screening 7
Document all three domains systematically: cognitive performance using validated instruments, functional status with structured tools, and neuropsychiatric symptoms with standardized scales—this documentation is essential for longitudinal tracking and treatment planning 2