Screening

Cognitive impairment and dementia are under-diagnosed in older individuals. This can lead to safety and health consequences, and also delays adequate evaluation and potential treatment. In addition to supporting a diagnosis of cognitive impairment, screening and evaluation of cognition may identify reversible conditions contributing to cognitive changes, or may help to reassure someone with cognitive concerns whose cognition in fact is normal.

The terms dementia, MCI, Major Neurocognitive Impairment and Mild Neurocognitive Impairment are used here with some interchangeability. The current DSM-V terminology is not uniformly used.

Dementia is an acquired decline in memory and/or other areas of cognition or behavior of sufficient magnitude to cause impairment of social or occupational functioning.  DSM V has developed the term Major Neurocognitive Decline (MNCD), used with a variety of billing codes to describe dementia and related conditions.  Major Neurocognitive Disorder (Dementia) as defined by the DSM-V includes:

• Cognitive deficits in one or more areas of cognition, such as memory, language, visuospatial abilities (apraxia, aphasia, agnosia), or executive function),
• Cognitive defects must impair social or occupational functioning,
• Gradual onset and progressive cognitive decline,
• Not due to other CNS cause of dementia, substance abuse, or systemic conditions that can cause dementia,
• Not due to delirium,
• Not accounted for by another Axis 1 disorder.

Mild Cognitive Impairment (MCI), or Mild Neurocognitive Disorder, is marked by focal or multifocal cognitive impairment with minimal impairment of instrumental activities of daily living (IADL) that does not cross the threshold for a dementia diagnosis.  MCI can be the first cognitive expression of Alzheimer disease (AD), or may be secondary to other disease processes (i.e., other neurologic, neurodegenerative, systemic, or psychiatric disorders) that can cause cognitive deficits. Caveat: brief screening tests such as the MiniCog are less sensitive for detection of MCI than for dementia.

Starting the Conversation

When to Begin Discussion of Cognition in an Older Adult:

• Annual Wellness Visit,
• Warning Signs expressed by patient and/or family member,
• Patient who forgets appointments or is noncompliant with medications,
• Upon observation by a healthcare professional during a scheduled office visit.

Screening may be incorporated into the annual health assessment for older individuals, and a screening may require 10 minutes or more.  The Clinical Roundtable recommends the use of the MiniCog as a quick screening tool, and the AD8 to assess caregiver observations of the patient’s behaviors.  Should these assessments identify cognitive impairment, a more thorough evaluation appointment would be appropriate.