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.
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 (link to our diabetes guide), alcohol, head injury, mood disorders, behavioural and psychological symptoms, recent illness, medications
- Activities of Daily Living (ADL), instrumental ADLs, cognitive complaints, mood, driving, safety
- Information from carer, family regarding changes and functional decline (time course = onset, progression)
The following cognitive assessment tests are the most commonly used; however, it is important to choose the tests most suitable for your patient and for the health setting within which you work.
The General Practitioner assessment of Cognition (GPCOG)
A reliable, valid and efficient instrument for general practitioners to screen for dementia in Australian primary care settings.
The GPCOG involves two parts: a cognitive test for the patient and, if the result is uncertain, a short interview with an informant. The cognitive test takes less than four minutes to administer and includes the clock drawing test.
Research indicates that it as effective as the MMSE in primary care settings. The GPCOG is free.
Mini-Mental State Examination (MMSE)
This test is currently the most widely used cognitive assessment tool. It takes 10-15 minutes to administer. It is scored out of 30, with a score below 24 suggesting dementia.
It is used to assess global cognitive status. It is recommended for use in Acute, Primary, Community and Residential Care.
If used, the clock drawing test should be used as a supplementary test of frontal abilities. This is scored separately to MMSE.
Clock Drawing Test
This test involves asking patients to draw a clock on a blank piece of paper with the time set at 10 minutes past 11, or a variety of other suggested timeframes. A variety of scoring systems exist, but the simplest way is to rate the numbers as well planned or spaced and whether the hands indicate the right time. It can be scored as either normal (correctly drawn) or abnormal (any other result).
It evaluates organisation and planning. It is a useful screen for frontal functions of planning and conceptualisation.
The Rowland Universal Dementia Assessment Scale (RUDAS)
The Rowland Universal Dementia Awareness Scale is a short cognitive screening tool, recommended for use with those from culturally and linguistically diverse backgrounds.
Kimberly Indigenous Cognitive Assessment (KICA)
The only validated dementia assessment tool for older indigenous Australians.
For more information, please visit the Dementia Outcomes Measurement Suite, a Commonwealth Government initiative to assist health professionals in assessing dementia in all settings.
This website has assessment tools, manuals and scoring guides for download.
Opportunities for Cognitive Screening in General Practice
There are several opportunities in the practice to screen your patients for possible cognitive impairment and dementia. These include:
The 45+ Health Check
- An opportunity to pick up younger onset dementia in your patients under 65 years of age
- Build in questions about cognitive function, concerns about memory, mood and behaviour
- Look at possible risk factors for dementia (modifiable and non-modifiable in your patient)
- Can be charged to MBS item #717
The 75+ Health Check
- An opportunity to pick up possible cognitive impairment and dementia in your patient
- Modify the existing 75+ Health Check and include questions about cognitive function, memory, frailty, dexterity, driving and advanced care planning
- Can be charged to MBS item #705
The Chronic Disease Management/ Plan
- An opportunity to screen for possible cognitive impairment - in your patients under 65 years of age as well as over 75 years of age- undertake annually or bi-annually
- Can be charged to MBS item #721 (development of plan), #732 (review of plan), #723 (a Team Care Arrangement) , #731 (a plan developed for patients in residential aged care) and #10997 (practice nurse monitoring and support as part of plan)
Mental Health Treatment Plan (MHTP)
- An opportunity to be mindful of a possible diagnosis of dementia/cognitive impairment when preparing and reviewing a MHTP for your patient
- N.B. Dementia is not classified as a mental health disorder under the Better Access to Mental Health Scheme (hence, MBS items cannot be charged)
For more information:
Please visit the Medicare website
For training and advice on how to 'build dementia practice in your practice', please go to this section on online training.
- If uncertain or inconclusive, repeat tests over time
- Use sensitive language when introducing the tests/assessment process to your patients and their families/carers
- Be prepared for questions from your patient or their families and carers; for example:
- What tests will be conducted?
- Who will be performing the tests and how long will it take?
- Should I prepare for the tests in any way?
- Will any of the tests involve pain or discomfort?
- Will there be any cost involved?
- What follow-up will be necessary and who will follow up?
- How will I be informed of the test results and the diagnosis?
Other diagnostic tests:
Mental state and physical examination
- Differential diagnosis - Look for specific conditions that mimic dementia (Depression - for example), Delirium (for example CAM) and Drugs/dosing interactions) or that can exacerbate dementia: for example cardiac failure, use of anticholinergic drugs
- Check nutrition, hygiene, visual or hearing impairment
Blood, urine tests and imaging
- Urinary tract and other infections
- Renal and liver (hepatic) function
- Rule out rare but reversible causes for example abnormal thyroid function, calcium or Vitamin B12 deficiency, electrolyte balance (salt and water), tumour
The following investigations are usual practice: FBE, EUC, LFTs, Ca, TFT, B12, Folate, MSU, ECG, and if indicated - VDRL, CXR, HIV
Imaging recommended include: CT brain, MRI, and if indicated - PET, SPECT, FRMI
For more information:
- Tests used in diagnosing dementia (Dementia Australia help sheet Q&A 10)
- 14 essentials of good dementia practice in general practice
- Diagnostic criteria for dementia (Dementia Australia help sheet Q&A 11)
Assessment of Behaviour and Psychological Symptoms of Dementia (BPSD)
Almost all patients with dementia experience BPSD; these are also referred to as neuropsychiatric, non-cognitive symptoms. The symptoms vary between patients and over time and can include:
- Mood disturbances (anxiety, apathy, depression, euphoria)
- Hyperactivity-type symptoms (aberrant motor behaviour, aggression, agitation, disinhibition, irritability, restlessness)
- Psychotic symptoms (delusions, hallucinations, paranoia)
- Other behavioural symptoms (changes in appetite, hoarding, night-time behaviour disturbances, wandering)
These symptoms become more common as the dementia progresses and present a major cause of stress to carers.
When BPSD occur, assess factors that may cause, aggravate or reduce the behaviour. Assessment should first exclude physical causes, such as delirium (common in patients with dementia), urinary tract infections or a drug interaction. Other factors, such as the environment and behaviours of others, should also be considered.
The assessment should ideally consider:
- Frequency of behaviour over time
- Context and consequences of the behaviour
- Mental health
- Physical health
- Medication side effects
- Previous habits and beliefs
- Psychosocial factors
- Factors in physical environment
- Possible undetected pain or discomfort
For more information about BPSD assessment and clinical support services for your patients, please go to the dbmas website or phone their national 24-hour helpline on 1800 699 799.
DBMAS provides 24-hour advice, assessment, education, intervention and specialised support to carers and care workers who provide support for people with dementia with moderate to severe behaviours of concern.
Other DBMAS resources:
- DBMAS Behaviour Management: A Guide to Good Practice. Managing Behavioural and Psychological Symptoms of Dementia
- TRACS Community of Inter-professional practice for people with Dementia - this site has been designed for professionals working with people with dementia who are looking to develop their knowledge base with regards managing the behavioural and psychological symptoms of dementia (BPSD).