Evaluation of Suspected Dementia

Nathan Falk; Ariel Cole; T. Jason Meredith

<< Previous article

Next article >>

Mar 15, 2018 Issue

Evaluation of Suspected Dementia

NATHAN FALK, MD, and ARIEL COLE, MD, Florida Hospital Family Medicine Residency, Winter Park, Florida

T. JASON MEREDITH, MD, Offutt Air Force Base Family Medicine Residency, Offutt Air Force Base, Nebraska

Am Fam Physician. 2018 Mar 15;97(6):398-405.

Author disclosure: No relevant financial affiliations.

Article Sections

Abstract
Epidemiology and Risk Factors
Diagnostic Criteria
Initial History and Physical Examination
Brief Initial Screening Tests for Cognitive Impairment
Cognitive Tests for Patients Who Screen Positive on Initial Testing
Diagnostic and Secondary Evaluation
References

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).

Enlarge Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
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, 33–37
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 recommendation	Evidence rating	References
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, 33–37
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

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.

References

show all references

1. Mather M. Population Reference Bureau. Fact sheet: aging in the United States. January 2016. http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet.aspx. Accessed April 29, 2017....

2. Alzheimer's Association. 2016 Alzheimer's disease facts and figures. Alzheimers Dement. 2016;12(4):459–509.

3. U.S. Preventive Services Task Force. Cognitive impairment in older adults: screening. March 2014. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cognitive-impairment-in-older-adults-screening. Accessed January 27, 2017.

4. American Academy of Family Physicians. Clinical preventive service recommendation. Dementia. 2014. http://www.aafp.org/patient-care/clinical-recommendations/all/dementia.html. Accessed April 25, 2017.

5. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007;29(1–2):125–132.

6. Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimers Dement. 2013;9(1):63–75.e2.

7. Xie J, Brayne C, Matthews FE; Medical Research Council Cognitive Function and Ageing Study collaborators. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up. BMJ. 2008;336(7638):258–262.

8. Wu YT, Fratiglioni L, Matthews FE, et al. Dementia in western Europe: epidemiological evidence and implications for policy making. Lancet Neurol. 2016;15(1):116–124.

9. Matthews FE, Arthur A, Barnes LE, et al.; Medical Research Council Cognitive Function and Ageing Collaboration. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet. 2013;382(9902):1405–1412.

10. Satizabal CL, Beiser AS, Chouraki V, Chêne G, Dufouil C, Seshadri S. Incidence of dementia over three decades in the Framingham Heart Study. N Engl J Med. 2016;374(6):523–532.

11. Langa KM, Larson EB, Crimmins EM, et al. A comparison of the prevalence of dementia in the United States in 2000 and 2012. JAMA Intern Med. 2017;177(1):51–58.

12. Benjamin EJ, Blaha MJ, Chiuve SE, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association [published corrections appear in Circulation. 2017;135(10):e646 and Circulation. 2017;136(10):e196]. Circulation. 2017;135(10):e146e603.

13. Hebert LE, Weuve J, Scherr PA, Evans DA. Alzheimer disease in the United States (2010–2050) estimated using the 2010 census. Neurology. 2013;80(19):1778–1783.

14. Whitmer RA, Gunderson EP, Barrett-Connor E, Quesenberry CP Jr, Yaffe K. Obesity in middle age and future risk of dementia: a 27 year longitudinal population based study. BMJ. 2005;330(7504):1360.

15. Whitmer RA, Sidney S, Selby J, Johnston SC, Yaffe K. Midlife cardiovascular risk factors and risk of dementia in late life. Neurology. 2005;64(2):277–281.

16. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anti-cholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015;175(3):401–407.

17. Larson EB, Yaffe K, Langa KM. New insights into the dementia epidemic. N Engl J Med. 2013;369(24):2275–2277.

18. Rusanen M, Kivipelto M, Quesenberry CP Jr, Zhou J, Whitmer RA. Heavy smoking in midlife and long-term risk of Alzheimer disease and vascular dementia. Arch Intern Med. 2011;171(4):333–339.

19. Haenisch B, von Holt K, Wiese B, et al. Risk of dementia in elderly patients with the use of proton pump inhibitors. Eur Arch Psychiatry Clin Neurosci. 2015;265(5):419–428.

20. Goldstein FC, Steenland K, Zhao L, Wharton W, Levey AI, Hajjar I. Proton pump inhibitors and risk of mild cognitive impairment and dementia. J Am Geriatr Soc. 2017;65(9):1969–1974.

21. Kalantarian S, Stern TA, Mansour M, Ruskin JN. Cognitive impairment associated with atrial fibrillation: a meta-analysis. Ann Intern Med. 2013;158(5 pt 1):338–346.

22. Institute of Medicine. Gulf War and Health. Volume 7. Long-Term Consequences of Traumatic Brain Injury. Washington, DC: National Academies Press; 2009. https://www.nap.edu/catalog/12436/gulf-war-and-health-volume-7-long-term-consequences-of. Accessed January 27, 2017.

23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2014.

24. Hugo J, Ganguli M. Dementia and cognitive impairment: epidemiology, diagnosis, and treatment. Clin Geriatr Med. 2014;30(3):421–442.

25. Grossman M, Irwin DJ. The mental status examination in patients with suspected dementia. Continuum (Minneap Minn). 2016;22(2 Dementia):385–403.

26. Hildreth KL, Church S. Evaluation and management of the elderly patient presenting with cognitive complaints. Med Clin North Am. 2015;99(2):311–335.

27. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–2246.

28. Geschwind MD. Rapidly progressive dementia. Continuum (Minneap Minn). 2016;22(2 Dementia):510–537.

29. Galvin JE, Sadowsky CH; NINCDS-ADRDA. Practical guidelines for the recognition and diagnosis of dementia. J Am Board Fam Med. 2012;25(3):367–382.

30. Simmons BB, Hartmann B, Dejoseph D. Evaluation of suspected dementia. Am Fam Physician. 2011;84(8):895–902.

31. Gallego L, Barreiro P, López-Ibor JJ. Diagnosis and clinical features of major neuropsychiatric disorders in HIV infection. AIDS Rev. 2011;13(3):171–179.

32. Tylee A, Gandhi P. The importance of somatic symptoms in depression in primary care. Prim Care Companion J Clin Psychiatry. 2005;7(4):167–176.

33. Cordell CB, Borson S, Boustani M, et al.; Medicare Detection of Cognitive Impairment Workgroup. Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141–150.

34. Lin JS, O'Connor E, Rossom RC, et al. Screening for cognitive impairment in older adults: an evidence update for the U.S. Preventive Services Task Force. Evidence syntheses, No. 107. Rockville, Md.: Agency for Healthcare Research and Quality; 2013. https://www.ncbi.nlm.nih.gov/books/NBK174643/. Accessed October 18, 2017.

35. Tolea MI, Galvin JE. Current guidelines for dementia screening: shortcomings and recommended changes. Neurodegener Dis Manag. 2013;3(6):565–573.

36. Norris D, Clark MS, Shipley S. The mental status examination. Am Fam Physician. 2016;94(8):635–641.

37. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–1454.

38. Dong Y, Pang WS, Lim LB, et al. The informant AD8 is superior to participant AD8 in detecting cognitive impairment in a memory clinic setting. J Alzheimers Dis. 2013;35(1):159–168.

39. Velayudhan L, Ryu SH, Raczek M, et al. Review of brief cognitive tests for patients with suspected dementia. Int Psychogeriatr. 2014;26(8):1247–1262.

40. Hoyl MT, Alessi CA, Harker JO, et al. Development and testing of a five-item version of the Geriatric Depression Scale. J Am Geriatr Soc. 1999;47(7):873–878.

41. Knopman DS, DeKosky ST, Cummings JL, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):1143–1153.

42. Wippold FJ II, Brown DC, Broderick DF, et al. ACR Appropriateness Criteria dementia and movement disorders. J Am Coll Radiol. 2015;12(1):19–28.

43. Johnson KA, Minoshima S, Bohnen NI, et al. Appropriate use criteria for amyloid PET: a report of the Amyloid Imaging Task Force, the Society of Nuclear Medicine and Molecular Imaging, and the Alzheimer's Association. Alzheimers Dement. 2013;9(1):e1–e16.

44. Alzheimer's Association. Position statement of genetic testing. February 2014. http://www.alz.org/national/documents/topicsheet_genetictesting.pdf. Accessed April 15, 2017.

45. Tang MX, Stern Y, Marder K, et al. The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics. JAMA. 1998;279(10):751–755.

46. Kivipelto M, Helkala EL, Laakso MP, et al. Apolipoprotein E epsilon4 allele, elevated midlife total cholesterol level, and high midlife systolic blood pressure are independent risk factors for late-life Alzheimer disease. Ann Intern Med. 2002;137(3):149–155.

47. Adelman AM, Daly MP. Initial evaluation of the patient with suspected dementia. Am Fam Physician. 2005;71(9):1745–1750.

48. Santacruz KS, Swagerty D. Early diagnosis of dementia. Am Fam Physician. 2001;63(4):703–713.

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.