Dementia & Alzheimer’s Disease
There are a variety of ways doctors can test cognitive function in a person with dementia.
Often, a patient or a family member has picked up on clues that there is a problem with cognition.
However, are there ways to formally and objectively assess this?
The answer is, yes there are a host of cognitive tests for dementia that range from simple bedside tests that take a few minutes to perform to in-depth neuropsychiatric testing that can take a few hours.
While imaging of the brain can provide insights into brain structure and some types of brain imaging can even show metabolic and blood flow function, cognitive tests directly observe performance in certain domains and remain essential in the diagnosis of dementia.
In this article, we will describe what these tests are and how they affect the diagnosis and testing for dementia.
What Do Cognitive Screening Tests Show
Cognitive screening tests are simple, quick, basic tests. They help reveal if theres a problem in some aspect of your cognition.
Cognitive screening tests dont reveal any information about:
- Why there might be cognitive impairment.
- The location in your brain of the cognitive impairment.
- The condition that might be causing the cognitive impairment.
- The severity of the cognitive impairment.
Based on your score, you may need more in-depth testing. If so, your healthcare provider will order a neuropsychological assessment.
How Accurate Is The Acls
The results of the ACLS test can often detect potential problems with independence.
The ACLS has also been compared to typical cognitive tests like the Montreal Cognitive Assessment and the MMSE. Researchers have found it to be accurate by using a process called validation.
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How Is This Test Used
The ACLS is used to help figure out if a person has the thinking and physical abilities to safely do the tasks they need to do every day. This is called functional cognition.
People in different situations can benefit from being tested with the ACLS.
For example:
- An occupational therapist might be asked to give the test to an adult in a nursing home who is recovering from a hip fracture.
- The ACLS can be helpful for people recovering from brain injuries, people in recovery from drug misuse or overdose, and people who have mental health conditions.
- The test may show that person needs someone to make meals for them or give them their medications. Some people may need help handling money or doing chores. Other people need to have care 24 hours a day because it’s not safe for them to live alone.
Cognitive Screening And Assessment
Why is an assessment for cognitive impairment and dementia so important? It is because an early diagnosis means early access to support, information and medication.
There is no single definitive test for diagnosing dementia. Assessment will account for behavioural, functional and psychosocial changes, together with radiological and laboratory tests. The assessment process may take three to six months to achieve.
Assessment:
Assess cognition if you have any indication or suspicion of impairment in your patient. This is the first step in determining whether or not your patient needs further evaluation.
DSM-5 definition and warning signs.
Take note of the history regarding cognition and function from informant:
It is important to take notes about the history of the patient from an “informant”. An informant is someone who knows the patient well and has observed their cognition and function over time, for instance, a family member or close friend.
You could ask the ‘informant’ about the following in relation to your patient:
- Risk factors – vascular disease , alcohol, head injury, mood disorders, behavioural and psychological symptoms, recent illness, medications
- Activities of Daily Living , instrumental ADLs, cognitive complaints, mood, driving, safety
- Information from carer, family regarding changes and functional decline
Informant tools:
The General Practitioner assessment of Cognition
Mini-Mental State Examination
Clock Drawing Test
Kimberly Indigenous Cognitive Assessment
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How Accurate Is The Mmse
Studies have shown that the MMSE is better at ruling out dementia than telling someone whether they have it. Very rarely will the MMSE tell someone who does not have dementia that they do have the disease . It is more common for someone who does have dementia to achieve a score that would indicate they dont have the disease. This happens more than 20 percent of the time, because people who are highly educated or only in the early stages of the disease can still score above 24 even if Alzheimers is present in the brain. Again, the MMSE should not be used alone as a tool for diagnosing dementia.
What Are The Most Common Cognitive Screening Tests
- Montreal Cognitive Assessment : This test involves memorizing a short list of words, naming objects shown in pictures, copying shapes and performing other tasks. This test takes about 15 minutes to complete.
- Mini-Mental State Exam : This test involves counting backward, identifying objects in the room, stating the date and other common, well-known facts. This test takes about 10 minutes.
- Mini-Cog: This test involves memorizing and recalling a three-word list of unrelated words and drawing a circle clock adding all time points, then drawing hands to show a specific time. This test is the shortest and easiest to complete.
There are many other screening tests. Others include the Memory Impairment Screen /MIS by Telephone , Mental Status Questionnaire , 8-item Informant Interview , Functional Activities Questionnaire , 7-Minute Screen , Abbreviated Mental Test , St Louis University Mental Status Examination , Telephone Instrument for Cognitive Status and Informant Questionnaire on Cognitive Decline in the Elderly .
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A Computerized Cognitive Test Battery For Detection Of Dementia And Mild Cognitive Impairment: Instrument Validation Study
1Department of Biosciences, Rice University, Houston, TX, United States
2BrainCheck, Inc, Houston, TX, United States
3Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
4Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
5Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
How The Mini Mental Status Exam Works
The MMSE is commonly used because it only takes 5 10 minutes and doctors or nurses dont need any equipment or special training.
The test has 30 questions that are each worth 1 point. These questions test memory, orientation, and math skills.
The MMSE includes questions that measure:
- Sense of date and time
- Sense of location
- Ability to remember a short list of common objects and later, repeat it back
- Attention and ability to do basic math, like counting backward from 100 by increments of 7
- Ability to name a couple of common objects
- Complex cognitive function, like asking someone to draw a clock
The grading scale is:
- 25 or more points = no problem
- 21-24 points = mild cognitive impairment
- 10-20 points = moderate cognitive impairment
- 0-9 points = severe cognitive impairment
If someone gets a score in the 0 to 20 range, it can indicate cognitive issues. But it doesnt mean that they have dementia.
What it does mean is that more physical and cognitive testing should be done to better understand whats causing the cognitive issues.
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How Is Cognitive Impairment Evaluated
Positive screening results warrant further evaluation. A combination of cognitive testing and information from a person who has frequent contact with the person, such as a spouse or other care provider, is the best way to more fully assess cognitive impairment.
A primary care provider may conduct an evaluation or refer to a specialist such as a geriatrician, neurologist, geriatric psychiatrist, or neuropsychologist. If available, a local memory disorders clinic or Alzheimers Disease Research Center may also accept referrals.
Genetic testing, neuroimaging, and biomarker testing are recommended for limited clinical uses at this time., These tests are primarily conducted in research settings and may require consultation with the medical provider, a counselor, and the family and caregivers, as there are complex ethical, legal, and social implications that should be considered.
Interviews to assess memory, behavior, mood and functional status ) are best conducted with the patient alone, so that family members or companions cannot prompt the person. Information can also be gleaned from the persons behavior on arrival in the doctors office and interactions with staff.
Note that people who are only mildly impaired may be adept at covering up their cognitive deficits and reluctant to address the problem. In some cases, patients may not have insight into their cognitive and functional problems due to the nature of their illness.
How To Take / Administer The Mmse
The Mini-Mental State Exam is best administered by a neurologist, or other healthcare professional, in a doctors office-like environment. However, an online version of the MMSE / Folstein Test is relatively simple, only takes about 15 minutes to complete and can be administered by a friend or family member without special training. If you choose to do this, be aware that the results should not be considered definitive.
Should you not wish to administer the MMSE using your phone or computer, there are numerous MMSEs online that can be printed. Again, you do not need special training and these printed options give easy-to-understand instructions. If you want to take or give the test, follow these basic guidelines and then consult a doctor:
Step 1. There are multiple versions online, and they all ask roughly the same questions. The link above contains a good version that is easy to score.
Step 2 Seat your loved one, the person being tested, in a quiet and well-lit room. Ask for attention. Do not set a timer.
Step 4 Give the person as much time as needed. The MMSE generally takes about 10 minutes to complete, but there is no time limit. Do not rush in any way. In fact, be as positive and encouraging as possible.
Step 6 If more than a few questions were answered incorrectly, youll want to take the finished test to a primary care doctor, who will go over it and decide whether a referral to an expert like a neurologist is appropriate.
Scoring the MMSE
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The Hospital Anxiety And Depression Scale
The Hospital Anxiety and Depression Scale is a popular screening test for depression and anxiety which was originally aimed at patients in hospital, though it has been used much more widely in recent years. It takes 35 min and is self-reported. Though easy to use and accurate at detecting depression, it has little practical use for older patients with significant cognitive impairment.
How Accurate Is Slums
SLUMS is thought to be more sensitive than the MMSE, another assessment of cognitive function. That means that it can more reliably determine who is in various levels of cognitive decline.
In a 2012 study, Saint Louis University researchers used both the SLUMS and the MMSE to test 533 men who were at least 60 years old and treated at the Geriatric Research Education Clinical Center, Veterans Administration Hospitals in St. Louis.
While both tools detected dementia, only the SLUMS recognized a group of patients as having mild cognitive problems.
A second study involving 58 nursing home residents compared the SLUMS’ ability to detect early stages of dementia to that of the MMSE, as well as the Short Test of Mental State and the Test Your Memory screenother cognition assessments.
They found that the SLUMS test was significantly better at being able to identify dementia in its early stages as compared to the other tests.
Research also found that although both the SLUMS and the MMSE have a total of 30 points, the average score of the SLUMS is approximately five points lower than that of the MMSE. This supports the idea that the SLUMS is a more difficult test and, thus, likely to be more sensitive to mild cognitive impairment.
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What Does A Slums Score Mean
Once the test taker hands in their SLUMS test to the test administrator, the administrator tallies up their responses and the accuracy of each. Then the test taker is assigned an overall score thats between 0 and 30.
Heres more information on what the SLUMS scores mean:
0 To 20
A score on the SLUMS test between 0 and 20 is considered the lowest score a test taker can receive. With this score, the test taker more than likely has dementia.
21 To 26
A score of 21 to 26 is higher but still not good. The test taker might have a mild neurocognitive disorder.
27 To 30
The highest scores are between 27 and 30. If the test taker has achieved at least a high school education and test results are this high, then they more than likely have normal cognitive functioning .
No matter how a test taker scores on the SLUMS test, further testing to confirm suspicions of dementia and cognitive decline is never a bad idea.
What Is Cognitive Testing For Dementia
Cognition is a combination of different brain processes that include thinking, memory, judgment, language, and what helps you to learn new things. If you have problems with cognition, it is referred to as cognitive impairment. You could be diagnosed with mild to severe cognitive impairment. Cognitive testing for Dementia will help check for cognitive problems.
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Clinical Dementia Rating Scale
The CDR is a global rating scale for staging patients diagnosed with dementia . The CDR evaluates cognitive, behavioral, and functional aspects of Alzheimer disease and other dementias. Rather than a mental status examination or inventory, the rater simply makes a judgment on six categories based on all the information available. The scoring system for the CDR is somewhat complicated and heavily dependent on the memory scores, but the CDR has good interrater reliability in staging dementia. This instrument is a widely used scale in both Alzheimer disease centers and dementia research.
T.K. Khan PhD, in, 2016
Diagnosing Dementia: The Montreal Cognitive Assessment
To detect Alzheimer’s disease and other forms of dementia early on and monitor progression, there are several cognitive evaluations that can assist professionals in a diagnosis.
The Montreal Cognitive Assessment is an accurate test that can give examiners insight into a person’s cognitive ability.
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How Can Physicians And Staff Find Time For Screening
Trained staff using readily available screening tools need only 10 minutes or less to initially assess a patient for cognitive impairment. While screening results alone are insufficient to diagnose dementia, they are an important first step. The AD8, QDRS , and Mini-Cog are among many possible tools.
Assessment for cognitive impairment can be performed at any visit but is now a required component of the Medicare Annual Wellness Visit., Coverage for yearly wellness visits, and importantly, for follow-up visits for cognitive assessment and care plan services, is available to patients who have had Medicare Part B coverage for at least 12 months. Visit the Centers for Medicare & Medicaid Services webpage for more information on cognitive assessment and care plan services , including what it covers and how to bill for it. CMS also created a related educational video for health care providers.
Mental Ability Tests To Diagnose Dementia
People with symptoms of dementia are given tests to check their mental abilities, such as memory or thinking.
These tests are known as cognitive assessments, and may be done initially by a GP.
There are several different tests. A common one used by GPs is the General Practitioner Assessment of Cognition .
Although these tests cannot diagnose dementia, they may show there are memory difficulties that need further investigation.
Most tests involve a series of pen-and-paper tests and questions, each of which carries a score.
These tests assess a number of different mental abilities, including:
- short- and long-term memory
- language and communication skills
- awareness of time and place
It’s important to remember that test scores may be influenced by a person’s level of education.
For example, someone who cannot read or write very well may have a lower score, but they may not have dementia.
Similarly, someone with a higher level of education may achieve a higher score, but still have dementia.
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Alzheimers Disease Assessment Scale Cognitive
The Alzheimers Disease Assessment Scale Cognitive assesses the level of cognitive dysfunction in people with Alzheimers disease.
It is more thorough than MMSE and primarily measures language and memory. It has 11 parts and takes around 30 minutes to complete. A doctor or psychologist performs this test in their office.
How The Moca Works
The MoCA checks different types of cognitive or thinking abilities. These include:
- Orientation: The test administrator asks you to state the date, month, year, day, place, and city.
- Short-term memory/delayed recall:Five words are read. The test-taker is asked to repeat them. After completing other tasks, the person is asked to repeat each of the five words again. If they can’t recall them, they’re given a cue of the category that the word belongs to.
- Executive function/visuospatial ability: These two abilities are checked through the Trails B Test. It asks you to draw a line to sequence alternating digits and letters . The test also asks you to draw a cube shape.
- Language: This task asks you to repeat two sentences correctly. It then asks you to list all the words in the sentences that start with the letter “F.”
- Abstraction: You are asked to explain how two items are alike, such as a train and a bicycle. This checks your abstract reasoning, which is often impaired in dementia. The proverb interpretation test is another way to measure these skills.
- Animal naming: Three pictures of animals are shown. The person is asked to name each one. This is mainly used to test verbal fluency.
- Attention: The test-taker is asked to repeat a series of numbers forward and then a different series backward. This task tests the ability to pay attention.
- Clock-drawing test: You’re asked to draw a clock that reads 10 minutes past 11:00.
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