Conducting Cognitive Assessments

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the referral question? (cognitive screening, dementia evaluation, capacity assessment, medication-induced cognitive concerns, post-delirium cognitive assessment) — default: cognitive screening
2. What is the patient's age and educational level? (critical for score interpretation) — default: obtain at intake
3. What is the patient's primary language and literacy level? — default: English, assess at intake
4. Is there a collateral informant available? (required for reliable history in cognitive evaluations) — default: strongly recommended
5. Are there sensory deficits that may affect testing? (hearing loss, visual impairment) — default: assess and accommodate
6. Has the patient been screened for delirium? (CAM, 4AT — delirium must be excluded before diagnosing dementia) — default: screen first
7. What cognitive screening tools are available and appropriate? (MoCA, MMSE, SLUMS, Mini-Cog) — default: MoCA
8. Has reversible etiology workup been completed? (TSH, B12, folate, CBC, CMP, RPR, HIV, brain imaging) — default: order if not completed

Documents to Request

• Prior cognitive testing results (for comparison and tracking trajectory)
• Brain imaging (MRI preferred over CT for structural evaluation)
• Laboratory results: TSH, B12, folate, CBC, CMP, RPR/VDRL, HIV (if risk factors), heavy metals (if exposure history)
• Current medication list (identify anticholinergics, benzodiazepines, opioids, and other cognitively impairing medications using Anticholinergic Cognitive Burden Scale)
• Neuropsychological testing reports if previously completed
• Collateral informant questionnaire (AD8, IQCODE, or Functional Activities Questionnaire)
• Prior psychiatric records (depression, psychosis, substance use history)
• Driving records and safety incidents

Step 1: Pre-Assessment Preparation and Delirium Screen

Before conducting cognitive testing, rule out delirium using a validated tool:

Confusion Assessment Method (CAM) — requires all of:

1. Acute onset and fluctuating course
2. Inattention
3. PLUS either: disorganized thinking OR altered level of consciousness

4AT Rapid Assessment:

• Alertness (0-4), AMT4 (0-2), Attention (0-2), Acute change/fluctuation (0-4)
• Score ≥4: possible delirium; Score 1-3: possible cognitive impairment; Score 0: delirium/severe cognitive impairment unlikely

If delirium is present, defer formal cognitive testing. Treat the underlying cause and reassess cognition after delirium resolves (typically 2-4 weeks after medical stabilization).

Assess for factors that may invalidate testing:

• Acute intoxication or withdrawal
• Severe pain
• Untreated depression (pseudodementia) — administer PHQ-9 or GDS
• Sensory deficits requiring accommodation
• Fatigue, time of day, medication timing

Step 2: Cognitive Screening Tool Administration

Montreal Cognitive Assessment (MoCA) — Preferred First-Line Screen

• Total score: /30 points. Cutoff: ≥26 normal (add 1 point if ≤12 years education)
• Domains assessed: Visuospatial/executive (5), naming (3), attention (6), language (3), abstraction (2), delayed recall (5), orientation (6)
• Strengths: More sensitive than MMSE for MCI, tests executive function, free and available
• Limitations: Education and cultural bias, ceiling effect in high-functioning individuals
• Document score for each domain, not just total

Mini-Mental State Examination (MMSE)

• Total score: /30 points. Cutoff: ≤23 suggests dementia (education-adjusted cutoffs recommended)
• Domains: Orientation (10), registration (3), attention/calculation (5), recall (3), language (8), visuoconstruction (1)
• Limitations: Poor sensitivity for MCI, does not test executive function, copyrighted
• Severity staging: 20-24 mild, 10-19 moderate, <10 severe

Saint Louis University Mental Status (SLUMS)

• Total score: /30 points
• Cutoffs: High school education: ≤26 MCI, ≤20 dementia. Less than high school: ≤24 MCI, ≤19 dementia
• Advantage: Free, includes executive function items, education-adjusted cutoffs

Mini-Cog (Quick Screen, 3 minutes)

• 3-word recall (0-3) plus clock drawing (0-2)
• Score 0-2: positive screen (refer for full evaluation)
• Useful in primary care and time-limited settings

Step 3: Supplementary Domain-Specific Testing

When screening suggests impairment, expand assessment with domain-specific tests:

• Executive Function: Trail Making Test B, clock drawing (assess for planning errors, spatial disorganization, perseveration), verbal fluency (animals in 60 seconds: <15 abnormal, <12 concerning)
• Memory: Word list learning (CERAD 10-word list), story recall, recognition vs. free recall pattern (amnestic AD shows poor recognition; subcortical/vascular shows benefit from cues)
• Language: Boston Naming Test (short form), category fluency, comprehension testing
• Visuospatial: Clock drawing, intersecting pentagons, cube copy
• Attention: Digit span forward and backward, months of year backward, serial 7s

Document individual domain scores and pattern of impairment. The pattern aids differential diagnosis:

• Alzheimer's disease: Predominant memory impairment (encoding deficit, poor recognition)
• Vascular dementia: Executive dysfunction, processing speed deficits, relatively preserved recognition memory
• Lewy body dementia: Visuospatial deficits, fluctuating attention, visual hallucinations
• Frontotemporal dementia: Executive dysfunction, personality change, language decline (semantic or non-fluent variants)

Step 4: Collateral History and Functional Assessment

Obtain structured collateral information from a reliable informant:

AD8 Dementia Screening Interview (informant-rated):

• 8 yes/no questions about change in the past several years
• Score ≥2: suggestive of dementia (sensitivity 85%, specificity 86%)

Functional Activities Questionnaire (FAQ):

• 10 activities rated 0-3 (dependent to independent)
• Score ≥9: consistent with functional impairment from cognitive decline

Key functional domains to assess:

• Managing finances (paying bills, balancing checkbook)
• Managing medications independently
• Cooking, housekeeping, home maintenance
• Driving safety (accidents, getting lost in familiar areas, traffic violations)
• Shopping (managing purchases, making change)
• Using technology (phone, remote, microwave)
• Personal hygiene and self-care
• Navigating in familiar and unfamiliar environments

Step 5: Differential Diagnosis and Diagnostic Formulation

Integrate cognitive testing, history, collateral data, labs, and imaging into a diagnostic formulation:

Rule out reversible causes:

• Depression (pseudodementia): Onset coincides with depressive episode, patients complain of memory loss (unlike true dementia), effortful performance, respond "I don't know" rather than confabulating
• Hypothyroidism: Check TSH
• Vitamin B12 deficiency: Check B12 level (methylmalonic acid if borderline)
• Normal pressure hydrocephalus: Triad of gait disturbance, urinary incontinence, cognitive decline; brain imaging shows ventriculomegaly out of proportion to sulcal enlargement
• Medication effects: Review Anticholinergic Cognitive Burden Scale, eliminate benzodiazepines, anticholinergics, sedating antihistamines
• Chronic subdural hematoma: Brain imaging
• Neurosyphilis: RPR/VDRL, confirmatory FTA-ABS

Classify cognitive impairment:

• Subjective Cognitive Decline: Patient reports decline, testing normal
• Mild Cognitive Impairment (MCI): Objective cognitive impairment (1-1.5 SD below age norms) with preserved functional independence
• Major Neurocognitive Disorder (Dementia): Objective cognitive impairment with functional dependence

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was delirium screened for and excluded before cognitive testing?
2. Are cognitive screening scores documented by domain (not just total score)?
3. Was educational level and language documented and used in score interpretation?
4. Was collateral history obtained and documented?
5. Were reversible causes of cognitive decline assessed with appropriate laboratory and imaging workup?

Quality Audit

• Delirium screen (CAM or 4AT) administered and documented before cognitive testing
• Patient education level and primary language documented
• Cognitive screening tool selected with rationale
• Individual domain scores documented (not just total score)
• Education-adjusted cutoffs applied where applicable
• Collateral informant history obtained (or documented as unavailable with reason)
• Functional assessment completed (FAQ, ADL/IADL review)
• Reversible etiology labs ordered or reviewed (TSH, B12, CBC, CMP, RPR)
• Brain imaging obtained or reviewed
• Medication review for cognitively impairing agents completed
• Depression screened with validated tool (PHQ-9 or GDS)
• Pattern of cognitive deficits described and linked to differential diagnosis
• Diagnosis classified per NIA-AA framework (SCD, MCI, or major NCD)
• Safety assessment included (driving, firearms, financial exploitation risk, wandering)
• Follow-up plan with repeat testing interval specified (typically 6-12 months)

Guidelines

1. Never diagnose dementia based on a single cognitive screening score — screening tests identify who needs further evaluation, not who has dementia.
2. Always adjust interpretation for education, cultural background, and primary language — a MoCA score of 24 in a patient with 8 years of education may be normal.
3. Exclude delirium before attributing cognitive deficits to dementia — delirium is common, treatable, and frequently missed in the elderly.
4. Always obtain collateral history — patients with anosognosia (common in Alzheimer's disease) will minimize or deny deficits.
5. Order the reversible etiology workup before rendering a neurodegenerative diagnosis — missing hypothyroidism or B12 deficiency is indefensible.
6. Document driving safety assessment in every cognitive evaluation of an older adult — clinicians have a duty to report unsafe drivers in many jurisdictions.
7. When MCI is diagnosed, schedule follow-up cognitive testing in 6-12 months to track trajectory — approximately 10-15% of MCI patients convert to dementia annually.