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Detecting possible cognitive impairment is the first step in determining whether or not a patient needs further cognitive tests and 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​â¶Ä‹â¶Ä‹

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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 of which can be administered in five minutes or less by a physician or other trained staff.

• Full text of the Alzheimer's Association article Cordell CB, Borson S, Boustani M, Chodosh J, Reuben D, Verghese J, et al. “Alzheimer's Association Recommendations for Operationalizing the Detection of Cognitive Impairment During the Medicare Annual Wellness Visit in a Primary Care Setting” (PDF)
• Alzheimer's Association Medicare Annual Wellness Visit Algorithm for the Assessment of Cognition (PDF)
• Medicare Annual Wellness Visit Fact Sheet (PDF)

​Recommended cognitive assessment tools

These cognitive screening 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. 

Note: These cognitive assessment tools are a suggestion of resources. The user may employ the tool of their choosing, as no one tool is recognized as the best brief assessment to determine if a full dementia evaluation is needed. 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. Additional resources may be found on the Alzheimer's Association website or in the Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting (PDF).

Patient assessment tools

• The is a screening tool for cognitive impairment designed for use in primary care and is available in multiple languages. Note: If the patient scores less than 8 on Part 1 of the test, additional information is needed and Part 2 of the test should be completed.
• The is a three-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)

• The 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.
• The is a screening tool for cognitive impairment designed for use in primary care and is available in multiple languages. Note: If the patient scores less than 8 on Part 1 of the test, additional information is needed and Part 2 of the test should be completed.
• screening tool is an informant questionnaire designed to assess cognitive decline and dementia. 

Computerized cognitive tests and devices

A growing area of research is the development of medical devices and technologies to help physicians evaluate cognition and function. Among these are medical devices or digital technologies including computerized testing software; these have several advantages, including giving tests exactly the same way each time.

Digital computerized assessments are designed to measure an individual's performance on a variety of cognitive or functional tasks and may be appropriate for administration in randomized clinical trials or clinical settings, when lengthier standard assessments are not practical.

The U.S. Food and Drug Administration (FDA) has cleared several digital cognitive testing tools for marketing:

• Automated Neuropsychological Assessment Metrics (ANAM)
• Cambridge Neuropsychological Test Automated Battery (CANTAB Mobile®)
• CognICA
• Cognigram
• Cognivue

The FDA has also cleared a medical device called Cognision. This device is a headset with electrodes that are affixed to the scalp to measure electrical activity in the brain responsible for cognitive function.

Depression screen and mood assessment

In addition to assessing mental status, the doctor will evaluate a person's sense of well-being to detect depression or other mood disorders that can cause memory problems, loss of interest in life, and other symptoms that can overlap with 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 physicians, use an actual primary care physician and patient living with Alzheimer's disease. The videos were produced by the American College of Physicians Foundation and the Alzheimer's Association.

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.
• : Patients living with Alzheimer's or another dementia and caregivers can find support and get advice at a local Alzheimer's Association support group. 
• ®: Our online community allows users to post questions about dementia-related issues, offer support, and create public and private groups around specific topics.
• Alzheimer's Association ALZNavigator™: This interactive online tool creates custom action plans for users based on their current situation and helps guide people living with memory loss and their caregivers to information, resources and next steps.

¹Borson 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.