Evaluation of Suspected Dementia

 

Dementia is a significant and costly health condition that affects 5 million adults and is the fifth leading cause of death among Americans older than 65 years. The prevalence of dementia will likely increase in the future because the number of Americans older than 65 years is expected to double by 2060. Risk factors for dementia include age; family history of dementia; personal history of cardiovascular disease, cerebrovascular disease, diabetes mellitus, or midlife obesity; use of anticholinergic medications; apolipoprotein E4 genotype; and lower education level. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults. If dementia is suspected, physicians can use brief screening tests such as Mini-Cog or General Practitioner Assessment of Cognition. If the results are abnormal, further evaluation is warranted using more in-depth screening tools such as the Montreal Cognitive Assessment, Saint Louis University Mental Status Examination, or Mini-Mental State Examination. Diagnostic testing and secondary evaluation, including screening for depression, appropriate laboratory studies for other conditions that cause cognitive impairment, and magnetic resonance imaging of the brain, should be performed when cognitive impairment is confirmed. Routine cerebrospinal fluid testing and genetic testing for the apolipoprotein E4 allele are not recommended.

Dementia is the fifth leading cause of death in Americans older than 65 years. The United States population is aging, with 46 million persons older than 65 years—a number that is expected to double by 2060.1 Consequently, by 2050, the estimated number of Americans living with dementia will increase from 5 million to 14 million, and the estimated cost of dementia care will increase from $236 billion to $1 trillion.2 Early recognition of cognitive impairment is integral to patient counseling, advance care planning, assessment of secondary or reversible causes of impairment, and consideration of medical therapy. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults.3,4

This article focuses on the evaluation of patients with suspected dementia, including diagnostic criteria, brief screening tests suitable for use during primary care office visits, and diagnostic testing (Figure 1).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with suspected dementia, the Mini-Cog, the General Practitioner Assessment of Cognition, or the Ascertain Dementia 8-Item Informant Questionnaire should be used to determine the need for further evaluation.

C

29, 3337

Patients who screen positive for cognitive impairment on brief screening tests should be evaluated further to quantify the degree of impairment.

C

29

The standard laboratory evaluation for patients with cognitive impairment includes testing for anemia, hypothyroidism, vitamin B12 deficiency, diabetes mellitus, and liver and kidney disease.

C

29

Magnetic resonance imaging without contrast media is the preferred imaging test to exclude other intracranial abnormalities, such as stroke, subdural hematoma, normal-pressure hydrocephalus, or a treatable mass.

C

41, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with suspected dementia, the Mini-Cog, the General Practitioner Assessment of Cognition, or the Ascertain Dementia 8-Item Informant Questionnaire should be used to determine the need for further evaluation.

C

29, 3337

Patients who screen positive for cognitive impairment on brief screening tests should be evaluated further to quantify the degree of impairment.

C

29

The standard laboratory evaluation for patients with cognitive impairment includes testing for anemia, hypothyroidism, vitamin B12 deficiency, diabetes mellitus, and liver and kidney disease.

C

29

Magnetic resonance imaging without contrast media is the preferred imaging test to exclude other intracranial abnormalities, such as stroke, subdural hematoma, normal-pressure hydrocephalus, or a treatable mass.

C

41, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating

The Authors

show all author info

NATHAN FALK, MD, is a Sports Medicine and Family Medicine faculty member at the Florida Hospital Family Medicine Residency, Winter Park....

ARIEL COLE, MD, is director of the Geriatric Fellowship at Florida Hospital Family Medicine Residency.

T. JASON MEREDITH, MD, is a Sports Medicine and Family Medicine faculty member at the Offutt Air Force Base (Neb.) Family Medicine Residency.

Address correspondence to Nathan Falk, MD, Florida Hospital Family Medicine Residency, 133 Benmore Dr., Ste. 200, Winter Park, FL 32792 (e-mail: nathan.falk.md@flhosp.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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