Am Fam Physician. 2017;96(10):630-631
Author disclosure: No relevant financial affiliations.
About 14% of older U.S. adults (about 3.4 million persons older than 70 years and 37% of adults 90 years and older) have dementia.1 Many studies predict that with the rapidly aging population, the number of persons with dementia will increase dramatically. Two major challenges for patients, caregivers, and clinicians are to recognize changes in memory, thinking, and other cognitive functions and to distinguish symptoms of normal aging from early dementia.2,3
Early recognition of cognitive decline may help with planning for issues related to health care, finances, and patient safety.4 Although there are tools available for the detection and management of cognitive impairment, a comprehensive set of resources tailored to the needs of primary care is not packaged for streamlined implementation. The creation of a consensus-based toolkit provides an opportunity for primary care physicians to engage patients in discussions about cognitive health early in their care and potentially improve health care delivery related to cognitive function.
The AAFP Cognitive Care Kit (available at https://www.aafp.org/cognitive-care) was designed to give primary care physicians access to recommended materials to identify, screen, care for, and educate patients with cognitive impairment, as well as assist caregivers. As with any office system, having a routine workflow for cognitive evaluation and follow-up improves efficiency, proficiency, accuracy, and familiarity, all helping physicians stay on schedule and ensure quality care. Perhaps the most important thing to remember is that it is impossible to screen, diagnose, manage, and educate in a 10- to 15-minute office visit. This is a process that requires time, rapport, and possibly a consultant, depending on your practice.
Although cognitive screening is not recommended in every individual older than 65 years because of a current lack of evidence for or against screening, the U.S. Preventive Services Task Force advises clinicians to look for early signs or symptoms of cognitive impairment, such as problems with memory or language, and evaluate as appropriate.5 Studies have shown that most patients accept dementia screening and want to know the results so that they can understand what is happening and plan appropriately. Additionally, physicians appreciate a systematic approach to early detection of dementia.6,7 The tools and resources provided in the AAFP Cognitive Care Kit are designed to assist with detecting early symptoms (see the Index Visit section) and establishing a systematic approach to engage patients in regular conversations about cognitive function (see the Prevention section).
If early symptoms of cognitive impairment have been identified and further cognitive evaluation is indicated, one of the 10- to 15-minute diagnostic tests (e.g., Montreal Cognitive Assessment, Saint Louis University Mental Status Examination) can be administered by trained staff between visits or during a follow-up visit. Complete instructions for these instruments can be found under the Cognitive Evaluation section.
The Diagnosis and Disclosure section offers pertinent resources to assist with the clinical and nonclinical aspects of dementia, including ACT on Alzheimer's After the Diagnosis, the Algorithm Guiding the Differential Diagnosis of Dementia, and a driving contract. The driving contract engages patients early on by returning some control, in a situation where they otherwise lack control, by appointing an agent to address their driving status when necessary.
Some important tools in the Caregiver Resources section provide caregivers with next steps in understanding and developing a plan of care, including Tips to Minimize Unwanted Actions in Persons with Dementia, and Communicating Using a Therapeutic Response/Emotional Truth.
Physicians should remember that the main purpose of diagnosing dementia is to start long-term planning with patients and their caregivers as soon as possible. The Long-Term Planning section provides resources such as Five Wishes to help initiate conversations that prepare patients to plan for the aging process.
Physicians and caregivers should review Late State and End-of-Life Care in the Management: Late Stage section because this is often when patients' out-of-hospital do-not-resuscitate orders, orders for life-sustaining treatment, or advance care planning wishes take effect. Timely planning for patient-centered end-of-life decisions can minimize unnecessary, unwanted, and potentially harmful medical interventions.
editor's note: Funding for the AAFP Cognitive Care Kit was provided in part by Eli Lilly and Company; however, AAFP retained decision rights to the final content.