Assessing Cognitive Impairment in Older Adults: A Quick Guide

From the National Institute on Aging

As a healthcare professional, you are often the first to address a patient’s complaints—or a family’s concerns—about memory loss or possible dementia. This quick guide provides information about assessing cognitive impairment in older adults.

With this information, you can identify emerging cognitive deficits and possible causes, following up with treatment for what may be a reversible health condition. Or, if Alzheimer’s disease or another dementia is found, you can help patients and their caregivers prepare for the future. Brief, nonproprietary risk assessment and screening tools are available.

Why is it important to assess cognitive impairment in older adults?

alzheimer'sCognitive impairment in older adults has a variety of possible causes, including medication side effects, metabolic and/or endocrine derangements, delirium due to intercurrent illness, depression, and dementia, with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed with treatment. Others, such as Alzheimer’s disease, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for predictable changes.

Many people who are developing or have dementia do not receive a diagnosis. One study showed that physicians were unaware of cognitive impairment in more than 40 percent of their cognitively impaired patients. Another study found that more than half of patients with dementia had not received a clinical cognitive evaluation by a physician. The failure to evaluate memory or cognitive complaints is likely to hinder treatment of underlying disease and comorbid conditions, and may present safety issues for the patient and others. In many cases, the cognitive problem will worsen over time.

Most patients with memory, other cognitive, or behavior complaints want a diagnosis to understand the nature of their problem and what to expect. Some patients (or families) are reluctant to mention such complaints because they fear a diagnosis of dementia and the future it portends. In these cases, you can explain the benefits of finding out what may be causing the patient’s health concerns.

Pharmacological treatment options for Alzheimer’s-related memory loss and other cognitive symptoms are limited, and none can stop or reverse the course of the disease. However, assessing cognitive impairment and identifying its cause, particularly at an early stage, offers several benefits.

Benefits of Early Screening

If screening is negative: Concerns may be alleviated, at least at that point in time.

If screening is positive and further evaluation is warranted: The patient and physician can take the next step of identifying the cause of impairment (for example, medication side effects, metabolic and/or endocrine imbalance, delirium, depression, Alzheimer’s disease). This may result in:

  • Treating the underlying disease or health condition
  • Managing comorbid conditions more effectively
  • Averting or addressing potential safety issues
  • Allowing the patient to create or update advance directives and plan long-term care
  • Ensuring the patient has a caregiver or someone to help with medical, legal, and financial concerns
  • Ensuring the caregiver receives appropriate information and referrals
  • Encouraging participation in clinical research


When is screening indicated?

The U.S. Preventive Services Task Force, in its recent review and recommendation regarding routine screening for cognitive impairment, noted that “although the overall evidence on routine screening is insufficient, clinicians should remain alert to early signs or symptoms of cognitive impairment (for example, problems with memory or language) and evaluate as appropriate.” A Dementia Screening Indicator can help guide clinician decisions about when it may be appropriate to screen for cognitive impairment in the primary care setting.

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 patient, 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 Alzheimer’s Disease Center may also accept referrals.

Genetic testing, neuroimaging, and biomarker testing are not generally recommended for clinical use at this time. These tests are primarily conducted in research settings.

Interviews to assess memory, behavior, mood, and functional status (especially complex actions such as driving and managing money are best conducted with the patient alone, so that family members or companions cannot prompt the patient. Information can also be gleaned from the patient’s behavior on arrival in the doctor’s office and interactions with staff.

Note that patients who are only mildly impaired may be adept at covering up their cognitive deficits and reluctant to address the problem.

Family members or close companions can also be good sources of information. Inviting them to speak privately may allow for a more candid discussion. Per HIPAA regulations, the patient should give permission in advance. An alternative would be to invite the family member or close companion to be in the examining room during the patient’s interview and contribute additional information after the patient has spoken.

Brief, easy-to-administer informant screening tools, such as the short IQCODE (PDF, 62K) or the AD8 (PDF, 565K), are available.

Points to Remember

Patients should be screened for cognitive impairment if:

  • the person, family members, or others express concerns about changes in his or her memory or thinking, or
  • you observe problems/changes in the patient’s memory or thinking, or
  • the patient is age 80 or older.(12)
  • Other risk factors that could indicate the need for dementia screening include: low education, history of type 2 diabetes, stroke, depression, and trouble managing money or medications.
  • Instruments for brief screening are available and can be used in an office visit.
  • Patients, particularly those who express a concern, likely want to know what the underlying problem is.
  • Refer to a specialist if needed.


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Professional Development Resources offers a variety of online Alzheimer’s and Dementia-related continuing education (CE/CEU) courses to help healthcare professionals stay current on the science and research to support evidence-based practice.

Holiday Hints for Alzheimer’s Caregivers

By the National Institute on Aging

Holiday hints for Alzheimer’s caregiversHolidays can be a wonderful time to visit and reconnect with family, friends, and neighbors for people with Alzheimer’s and caregivers. Balancing special holiday activities with everyday care for a person with Alzheimer’s disease may also seem overwhelming. Here are some tips for making things a little easier:

  • Set your own limits, and be clear about them with others. You don’t have to do everything you used to do.
  • Encourage friends and family to visit even if it’s difficult, but limit the number of visitors at any one time.
  • Explain to guests ahead of time that memory loss is the result of the disease and is not intentional.
  • During the hustle and bustle of the holiday season, be sure to take care of yourself. Guard against fatigue and find time for adequate rest.

For more tips on how to prepare ahead of time and find a good balance during the holidays, download Alzheimer’s Caregiving Tips: Holiday Hints. This free tip sheet is available as a PDF and an eBook.

Latest Alzheimer’s Research Progress Report Released

2010 Alzheimer’s Disease Progress Report: A Deeper Understanding2010 Alzheimer’s Disease Progress Report: A Deeper Understanding, the latest annual Alzheimer’s research report from the National Institutes of Health (NIH), is now available online. Prepared by the National Institute on Aging, which leads the NIH effort conducting and supporting research on age-related cognitive decline and Alzheimer’s disease, the report highlights important developments and directions in NIH-funded research, including:

  • risk for developing Alzheimer’s
  • genes that play a role in the disease
  • neuroimaging and biomarkers that detect and track the disease
  • research into new treatments
  • lifestyle factors that may worsen or protect against the disease
  • help for caregivers

Special features include animation showing the progression of Alzheimer’s in the brain and video interviews highlighting new insights into the disease.

Read online or download @ http://www.nia.nih.gov/alzheimers/publication/2010-alzheimers-disease-progress-report-deeper-understanding.

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New Alzheimer’s Criteria Would Change Diagnosis for Millions

By: Rachael Rettner, MyHealthNewsDaily Staff Writer

New Alzheimer's Criteria Would Change Diagnosis for MillionsAlmost everyone currently diagnosed with a mild form of Alzheimer’s disease would be downgraded to not having the condition, if new proposed criteria for the diagnosis of cognitive problems were applied, a new study shows.

Instead, people diagnosed as having “very mild” and “mild” Alzheimer’s disease would be reclassified as having mild cognitive impairment (MCI), which is currently recognized as an intermittent stage between the normal loss of mental function that comes with age and the development of dementia.

The new criteria broaden the definition of mild cognitive impairment, and this will cause confusion when doctors try to diagnose MCI and Alzheimer’s, said study researcher Dr. John Morris, a professor of neurology at Washington University School of Medicine in St. Louis.

Moreover, the new criteria highlight the fallacy of thinking about MCI and Alzheimer’s as different entities, Morris said.

“[The] idea that there is an MCI stage, distinct from very early Alzheimer’s disease, is artificial,” Morris said. “It really is the same disease process.”

Instead of widening the criteria so more people are diagnosed with MCI, researchers should do the opposite — try to figure how to winnow down the group of patients with MCI to find those who will go on to develop Alzheimer’s disease, Morris said. In fact, if a patient’s memory and thinking troubles are due to early Alzheimer’s, and not due to depression or medication use, “We can just call it very early Alzheimer’s disease. There’s no need to have this distinction,” Morris said.

The report is published online today (Feb. 6) in the Archives of Neurology.

Alzheimer’s Continuum

Previously, mild cognitive impairment was defined as a decline in cognitive function — which could include memory and language problems — that do not interfere with everyday activities.

But the new criteria, proposed by the National Institute on Aging and the Alzheimer’s Association, state that people with MCI have “independence in functional activities.”

This could mean that, as long as a person can do everyday activities by themselves, they would be classified as having MCI, even if they had mild problems with activities such as shopping, paying bills and cooking, Morris said. (In fact, having mild problems with such activities is a criterion for dementia, Morris said.)

To assess what the impact of the new criteria would be on patients diagnosed with Alzheimer’s disease, Morris analyzed information from 17,535 people who had been classified as having normal cognition, MCI or Alzheimer’s disease. Participants were classified based on how well they could function performing a variety of activities, including preparing meals and taking mediation.

The results showed 99.8 percent of patients currently diagnosed with very mild Alzheimer’s disease, and 92.7 percent of those diagnosed with mild Alzheimer’s disease, would be reclassified as having MCI based on the revised criteria.

Considering about 2.5 million people have very mild Alzheimer’s disease, the findings suggest that, very roughly, about 2.2 million people could be reclassified as having MCI (although this calculation is speculative), Morris said.

Need for Biomarkers

William Thies, chief medical and scientific officer at the Alzheimer’s Association, said the proposed criteria for MCI are less than a year old, and experts will likely continue to discuss and tweak them in the years to come.

“We are really now working on trying to identify exactly where people will fit in the continuum of Alzheimer’s disease,” Thies said.

Thies agreed the disease is a continuous process, and said you could likely not tell the difference between someone with the most severe case of MCI and someone with the mildest case of Alzheimer’s disease.

But Thies said he does not think the new criteria will create much confusion. They are intended to be used by experts in the field, some of whom have already been thinking of MCI in the manner described by the new criteria. And others who are very conservative when it comes to diagnosing people with Alzheimer’s disease likely won’t change their ways, he said.

Thies also said the field should move toward identifying which patients with MCI are actually in the early stages of Alzheimer’s disease. This could be done once there are well defined biomarkers for the condition, Thies said.

While the field is moving toward this goal, it will likely be a while before biomarkers are routinely used by doctors to diagnose patients, he said.

Pass it on: Identification of biomarkers for Alzheimer’s disease will make it easier to diagnosis the condition in its early stages.

Source: http://www.myhealthnewsdaily.com/2204-alzhimers-disease-criteria-mild-cognitive-impairment.html

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End of Life: Helping with Comfort and Care

At the end of life, each story is different. Death comes suddenly, or a person lingers, gradually failing. For some older people, the body weakens while the mind stays alert. Others remain physically strong, and cognitive losses take a huge toll. But for everyone, death is inevitable, and each loss is personally felt by those close to the one who has died.

End-of-life care is the term used to describe the support and medical care given during the time surrounding death. Such care does not happen just in the moments before breathing finally stops and a heart ceases to beat. An older person is often living, and dying, with one or more chronic illnesses and needs a lot of care for days, weeks, and sometimes even months.

End of LIfe - Online CE Course

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End of Life: Helping With Comfort and Care, a 1-hour continuing education course for healthcare professionals, hopes to make the unfamiliar territory of death slightly more comfortable for everyone involved. This publication is based on research, such as that supported by the National Institute on Aging, part of the National Institutes of Health. This research base is augmented with suggestions from practitioners with expertise in helping individuals and families through this difficult time. Throughout the booklet, the terms comfort care, supportive care, and palliative care are used to describe individualized care that can provide a dying person the best quality of life until the end. Most of the stories in this booklet are fictitious, but they depict situations that reflect common experiences at the end of life.

When a doctor says something like, “I’m afraid the news is not good. There are no other treatments for us to try. I’m sorry,” it may close the door to the possibility of a cure, but it does not end the need for medical support. Nor does it end the involvement of family and friends. There are many places and a variety of ways to provide care for an older person who is dying. Such care often involves a team. If you are reading this, then you might be part of such a team.

Helping With Comfort and Care provides an overview of issues commonly facing people caring for someone nearing the end of life. It can help you to work with health care providers to complement their medical and caregiving efforts. The booklet does not replace the personal and specific advice of the doctor, but it can help you make sense of what is happening and give you a framework for making care decisions.

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Understanding Alzheimer’s Disease

Via Scoop.itHealthcare Continuing Education
Understanding Alzheimer's Disease
Free resource from the National Institute on Aging

Many older people forget someone’s name or misplace things from time to time. This kind of forgetfulness is normal. But, forgetting how to get home, getting confused in places a person knows well, or asking questions over and over can be signs of a more serious problem. The person may have Alzheimer’s disease, a disease of the brain that begins slowly and gets worse over time.

This colorful, easy-to-read booklet helps readers learn about Alzheimer’s disease:

  • What it is
  • Signs of the disease
  • When it is important to see a doctor
  • Treatment
  • Research studies
  • How to get help caring for a person with the disease

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Alzheimer’s Continuing Education

Alzheimer's Continuing Education

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Alzheimer’s currently affects one in 10 people over age 65 and nearly half of those individuals over 85. With such an outlook, it’s imperative that healthcare professionals stay current on the research and best practices for treatment and caregiving.

Professional Development Resources offers online continuing education courses to address this growing topic:

Alzheimer’s Disease & Related Disorders (ADRD) – This course provides an in-depth discussion of the management of Alzheimer’s Disease or Related Disorders (ADRD), including disease progression and strategies for care. It considers all aspects of ADRD, including the various stages of the disease, problem behaviors, communication issues, ethical considerations and appropriate activities. In addition, strategies are presented for working with families and caregivers of ADRD patients. 2006 | 47 pages | 27 posttest questions | 3 hours CE

Alzheimer’s Disease: Nutrition Intervention Strategies – Alzheimer’s disease is a disorder of forgetfulness that eventually impacts a person’s ability to participate in activities of daily living. It takes a devastating toll on both patients and those who care for them. Those with Alzheimer’s disease experience immense fear and frustration as they struggle with simple tasks. Family, friends, and caregivers experience pain and stress as they watch Alzheimer’s disease slowly take their loved ones away from them. Many individuals with Alzheimer’s disease and other forms of dementia are cared for in institutional settings. Nutrition plays an important role in meeting the needs of such persons. This course will familiarize readers with the early warning signs of dementia, discuss the pathophysiology of Alzheimer’s disease, identify pharmacological, environmental, and behavioral interventions used at various stages of the disease, and describe nutrition-related complications and intervention strategies. 2002 | 15 pages | 12 posttest questions | 2 hours CE

Alzheimer’s Disease – Overview – Alzheimer’s disease is an increasing concern for the aging American population. It is important for healthcare providers to have a basic familiarity with the disease, in order to provide adequate diagnosis, treatment, and referrals. This course, based on documents from the National Institute on Aging and the Alzheimer’s Association, provides an overview of the prevalence, causes, symptoms, diagnosis, treatment, and progression of Alzheimer’s disease, as well as information about caregiving and caregiver support. As such, this course is relevant to all clinicians who work with elderly individuals, their families, and their caretakers. Course #10-39 | 2010 | 34 pages | 7 posttest questions | 1 hour CE

Alzheimer’s – Unraveling the MysteryAlzheimer’s dementia is a growing concern among the aging Baby Boomers; yet, modern science points the way to reducing the risks through maintaining a healthy lifestyle. This course is based on a publication from the National Institute on Aging, which describes healthy brain functioning during the aging process and then contrasts it to the processes of Alzheimer’s disease. Full of colorful, detailed diagrams, this educational booklet describes the risk factors for Alzheimer’s disease, effective steps for prevention, strategies for diagnosing and treating Alzheimer’s disease, and the search for new treatments. Strategies for caregivers and reducing caregiver stress are also discussed briefly. Course #30-54 | 2008 | 43 pages | 21 posttest questions | 3 hours CE

Caring for a Person with Alzheimer’s Disease – This course is based on the public-access publication, Caring for a Person with Alzheimer’s Disease: Your Easy-to-Use Guide from the National Institute on Aging. The booklet discusses practical issues concerning caring for someone with Alzheimer’s disease, including a description of common challenges and coping strategies. Advice is provided regarding keeping the person safe, providing everyday care, adapting activities to suit their needs, and planning ahead for health, legal, and financial issues. Chapters also discuss self-care for caregivers, sources of assistance for caregivers in need, residential options for care, common medical issues, and end-of-life care. This course is relevant to clinicians who work with elderly individuals, their families, and their caretakers. Course #30-59 | 2010 | 146 pages | 22 posttest questions | 3 hours CE

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