Cognitive Tests for Dementia: Diagnostic Tools For Primary Care

Dementia is an umbrella term for conditions characterized by decline in memory, reasoning, and thinking skills. There are many different types of dementia—but one example of its prevalence is reports that 33.3% of people aged 85 or older have Alzheimer’s disease in the U.S.

As our population ages, there will be greater demand for cognitive testing, including mild cognitive decline and early dementia assessment. Unfortunately, if dementia isn't caught in its early stages it's less likely that a patient's symptoms can be reduced.

The risks of not addressing this demand potentially include:

• More pressure and demand on healthcare providers
• Greater costs to the healthcare system
• Longer wait times for appointments and referrals
• More frequent clinic visits for progressed cognitive concerns
• Higher rates of discharge to longer-term care
• Increased family member and caregiver burden
• Decreased patient quality of life

In this article, we'll discuss who should be tested for dementia, what kinds of tools are available to screen for signs of mild cognitive impairment (MCI), and how primary care providers can ease the burden on healthcare as a whole as more patients age. By being aware of the right tools and how to use them, clinicians can be equipped to screen patients and diagnose dementia more effectively and earlier.

Who Should Be Evaluated for Dementia?

So, what are the symptoms of dementia in the elderly? As a primary care physician, here's what to look out for when assessing patients:

Common symptoms

Signs of dementia may include:

• Disruptive memory loss
• Difficulty planning or problem solving
• Challenges with determining time or place
• Struggles with images and spatial relationships
• Problems with spoken or written vocabulary
• Reluctance to work or join social activities
• Mood swings and personality changes

Typical demographics

The typical demographic that receives cognitive screening for dementia is anyone over 65 years old. According to the Alzheimer’s Association, about 6.7 million Americans in this age group live with Alzheimer’s disease in 2023.

While it's true that people who are over 65 years old are more susceptible to dementia, that doesn't mean younger people can't be affected as well. In fact, early-onset dementia can happen to someone as young as 30 years old. Although this is much rarer than dementia in older adults, being aware that younger patients may be affected can help clinicians detect early signs of the disease.

Preventative care perspectives

Preventative care for dementia focuses on a patient's modifiable risk factors. These include sleep quality, diet, physical activity, smoking, and staying socially and mentally active. Patients who make healthy choices with their modifiable risk factors have a better chance of slowing their cognitive decline. A study found that the cognitive performance of patients aged 40 to 79 who made healthy choices was similar to people 10 to 20 years younger.

Additionally, telehealth and computerized assessments may be key to helping patients track their symptoms and improve their cognitive health. One large clinical trial called Maintain Your Brain has delivered Internet-based lifestyle interventions and assessments to over 6000 older adults, demonstrating that online strategies to prevent cognitive decline are feasible for many patients. The benefits potentially include better quality of life, reduced emergency visits, and decreased caregiver depression.

Indicators That a Referral Is Needed

When is the right time to refer a patient with possible cognitive impairment to a specialist? It's a difficult question with no clear cut answer, but here are a few indicators to look out for to help clinicians make a decision:

• Mild cognitive impairment
• Signs of younger-onset dementia
• Cognitive testing for older adults
• Family or caregiver request

Mild cognitive impairment

How can a clinician effectively evaluate cognition and the severity of a patient's cognitive complaints? If a patient or their loved ones express concern about changes to their memory, attention, or problem solving, consider running the patient through a questionnaire that measures subjective cognitive decline to quantify reported concerns before getting a second opinion from a specialist.

Patients with mild cognitive impairment are at risk for developing dementia. Studies estimate that:

• 10–15% of patients with MCI then develop dementia each year
• One-third of people with MCI develop Alzheimer’s disease within five years
• Some patients with MCI do not experience additional cognitive decline or even revert to their baseline cognition

Early screening is critical. Even before concerns arise, a cognitive test can provide a baseline of a patient’s cognitive function, which can then be used to detect significant changes in performance that might signal decline and the need for a specialist opinion and further testing.

While common assessments used in primary care only detect more severe forms of cognitive decline and dementia, fortunately there are cognitive performance tasks today that offer greater sensitivity. These, used in combination with questionnaires, can offer an objective record of a patient’s experience and make the referral process more efficient.

Signs of younger-onset dementia

Research has shown that about 110 of every 100,000 people ages 30-64 years have younger-onset dementia. While that number may seem small compared to older patients, the impacts may compound. A younger patient is more likely to have a career, dependents, and various other responsibilities that will be affected over a longer period of time.

A younger person might not attribute their symptoms to dementia, meaning they don't get the support they need in time—which is why getting a specialist's assessment as soon as possible is so important.

When a clinician suspects a younger patient may have mild dementia, one way to achieve a fast and accurate diagnosis is through routine cognitive check ups. To support the process of getting a specialist opinion for younger-onset dementia, taking routine cognitive performance benchmarks can be a useful tool in understanding and tracking significant change from a person’s baseline.

Routine brain health check ups can include:

• Cognitive screening tests for early signs of dementia
• Appointments to discuss brain health
• At-home assessments via digital questionnaires and monitoring tools
• And more

By making cognitive assessment routine for all patients, there is no stigma, no need to push for testing despite patient or specialist pushback, and there's a younger personalized baseline to compare to as the patient ages. An early diagnosis not only helps to improve a younger patient's quality of life, but also gives them more time to prepare for the future.

Cognitive Testing for Older Adults

The typical age range for conducting a cognitive test for dementia is in adults over 65 years old. However, there are several reasons why physicians might miss detecting early dementia in older adults.

For example, many seniors expect their health care providers to initiate the discussion on cognitive health, but only 26% report that being the case. This suggests there's a degree of uncertainty about who should be the one to start the conversation.

Being able to determine whether an older patient's memory and reasoning are normal for someone their age or if these are symptoms of dementia is key for an accurate diagnosis. Separating the normal signs of aging from dementia requires long-term monitoring and testing.

Family or caregiver request

A patient's family member or caregiver can observe any signs of possible cognitive impairment during the patient's daily life, potentially making them a reliable source for determining if a specialist appointment is required.

Because it might not always be feasible for a family member or caregiver to attend every doctor’s appointment, capturing their statements in questionnaires and session notes can ensure clear and effective communication to any other specialists involved in validating a diagnosis.

Read more: Measure Subjective Cognitive Decline With the Informant Questionnaire on Cognitive Decline in the Elderly, Self Report Version (IQCODE-SR)

What's next? Cognitive care planning

A cognitive care plan can help clinicians monitor an older patient's cognitive abilities and support their quality of life over a long period of time. Through consistent assessments and symptom tracking, clinicians can have the data needed to spot signs of decline, determine if a patient is fit enough to make their own medical decisions, and understand the current extent of their cognitive function.

Read more: Understanding the Gap in Cognitive Care Planning

How Does a Specialist Test for Dementia?

While a primary care provider might be able to generally diagnose a patient with dementia, they might lack the tools to determine the exact cause of their condition. At that point, they need to refer a patient to a specialist for a more detailed assessment.

Among their many roles—whether they are a neurologist, psychiatrist, geriatrician, or other expert—a specialist can provide more detailed insights into the multiple causes of dementia by:

• Ruling out other causes for cognitive deficits
• Conducting more testing on the nature and severity of deficits
• Interviewing the patient and family members
• Using brain imaging or biomarker tests

It may seem like the best course of action is to simply refer a patient with suspected dementia to a specialist as soon as possible, but the truth is specialist appointments can take months to arrange. In a survey, 55% of primary care providers reported that there were too few specialists in their area to meet demand.

The good news is that computerized cognitive screening tests empower primary care providers to get more answers earlier in a patient's health journey, speeding up the process so they can confirm or rule out cognitive impairments as soon as possible, and determine the need for a referral as early as possible. Even after a patient sees a specialist, physicians can continue to be their main healthcare ally by supporting them with a cognitive care plan and additional health resources to ensure they get the best care possible.

What Do Cognitive Tests for Adults With Dementia Measure?

So, how exactly do clinicians assess cognition? Medical tests can generally be divided into two parts: Testing cognitive ability to make a general dementia diagnosis and advanced procedures to determine the root cause of dementia.

The former can be performed by a primary care physician to measure a patient's memory, reasoning, and verbal ability. The latter tests tend to be more time-intensive and expensive. These typically involve procedures administered by specialists, such as brain imaging, CSF testing, and longer neuropsychological exams.

Recommended Cognitive Assessment Tools and Care Experiences

Before physicians start implementing cognitive assessment tests for dementia, they should ensure they’re using the best cognitive screening methods possible. Additionally, primary care providers and specialists often use distinct methods of patient care to fulfill their different goals.

Qualities of recommended cognitive assessment tools

Start by choosing scientifically validated cognitive assessments. Ideally, physicians want to use tests that have a short administration time—between five to twenty five minutes—to make the process more convenient. Similarly, the best tests give patients the freedom to take them without interrupting their daily lives. Consider telehealth or online cognitive tests for dementia instead of pen and paper tests to reduce stress, save time, and make the testing experience easier for patients.

The role of cognitive assessment tools in primary care

Primary care physicians are often the first person a patient goes to when they want to discuss their cognitive health. When it comes to patients suffering from dementia-like symptoms, the goal is to rule out other causes of MCI (such as depression, medication effects, or temporary delirium) and find out if the patient has dementia.

Once that's been determined through routine cognitive assessments and/or a cognitive care plan, physicians can confidently refer them to a specialist to find out what is causing their dementia.

Creating a seamless specialist referral workflow

Through in-depth procedures and examinations, a specialist should be able to test for clues regarding the cause behind a patient's dementia. This might be Alzheimer's disease or some other condition such as cerebrovascular dementia, or Parkinson's dementia. Once the exact cause is determined, the specialist can administer the appropriate treatment to slow down or minimize symptoms.

Dementia Test Examples

There are many examples of cognitive function tests, but only a few of them are scientifically validated. Here is a brief list to get started:

Typical tools

• Mini Mental State Examination (MMSE): Used to assess advanced deficits in cognitive function, and typically administered by pen and paper.
• Mini-Cog: Combines a memory test and a clock drawing test for cognitive impairment in dementia patients.
• Clock drawing test: A test to check for decline in a patient's cognition by instructing them to draw a clock.
• Montreal Cognitive Assessment (MoCA): Tests for spatial awareness, naming, short-term memory, language, executive function, and attention.
• Saint Louis University Mental Status (SLUMS): Measures attention, delayed and immediate recall, calculation, executive function, visuospatial response, and more.
• Instrumental Activities of Daily Living (IADL) Questionnaire: Measures a patient’s daily living skills to check for cognitive impairment over time.

Computerized tests

While the differences between pen and paper cognitive tests and their computerized counterparts may seem superficial, the benefits of digital testing can potentially lead to an earlier—and more detailed—diagnosis. In-person tests require patients to book appointments and, when considering travel and waiting room times, it often results in a significant interruption to their daily lives—leading to fewer or missed appointments.

On the other hand, routine computerized tests are flexible enough to be easily administered in primary care settings, or can be taken from the comfort of a patient's home. This significantly reduces the time each appointment takes, and removes any travel concerns and other potential stressors for the patient. Additionally, digital tests can be randomized so they can't be memorized. When a patient is given routine repeatable tests over a period of time, you gain the objective data needed to monitor for both current impairments and an objective decline over time, assisting with making an early and accurate diagnosis.

How do computerized cognitive assessments compare to typical tools?

Many of the assessments commonly used and associated with a dementia diagnosis only assess severe impairment and don't test specific cognitive domains. According to a recent study one of the key advantages of modern computerized tests such as Creyos Health is scoring and interpretation:

“Computerized tests can use statistical measures to interpret one individual’s score within the context of thousands of normative data points and provide an objective interpretation of that individual’s performance ‘on-the-fly’. This shift moves away from the traditional intuition-based approach that more typically required a highly trained individual to interpret a constellation of test scores.”

Other Ways to Test for Dementia

Primary care providers and specialists also may use other testing methods in the diagnostic process, such as:

• Medical history: A review of the person's medical history, including family members, psychiatric history, and history of cognitive and behavioral changes.
• Biological lab tests and biomarkers: Diagnostic tests, such as blood tests and CSF tests, may be used to determine the cause of a patient's dementia symptoms. Changes in tau, beta-amyloid, or other biomarkers may be reliably associated with neurodegenerative diseases, like Alzheimer’s disease. Laboratory tests can also reveal other abnormalities that might be linked to cognitive impairment.
• Neuropsychological testing: An in-depth assessment performed by neuropsychologists, generally requiring appointment-based referrals and can take anywhere from 4 to 8 hours.
• Mental health screening: A session with a therapist or psychologist can reveal if a patient's mental abilities are better explained by or also impacted by a mental health disorder so they can get the appropriate treatment.
• Brain imaging: Noninvasive techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) can help determine the cause of a patient's dementia symptoms.

Final Thoughts

Primary care physicians like you are the frontline against the rise of cognitive decline as our population ages. While specialists are trained to get to the root of dementia symptoms, it can take months for patients to book an appointment. And time is limited, especially when it comes to delivering effective treatment for dementia.

Dementia isn’t all or nothing, and often begins with MCI. For a faster process, primary care providers can use computerized cognitive assessment tools that may make the difference between an early or late diagnosis—leading to better patient quality of life down the road. With the help of easy-to-administer computerized cognitive tests that detect and track signs of early dementia, you'll be able to provide your patients with better care and ease the overall burden on healthcare down the line