• Onset of cognitive changes
• Timeline of progression of changes
• Cognitive domain deficits. Changes in:
  • Learning/Memory: Is the patient repeating questions? Having difficulty keeping track of appointments?
  • Language: Is the patient having difficulty word finding or putting written/verbal sentences together?
  • Complex Attention: Is the patient easily distracted or unable to sustain focus on a task, like reading?
  • Executive function: Is the patient having difficulty with planning or finances?
  • Social cognition: Is the patient acting inappropriately in social situations, or having trouble with social cues?
  • Perceptual-motor: Is the patient having trouble using daily objects (utensils, remote) or difficulty walking?
    
  • Determine degree of impairment defined as what it prevents them from doing.
    • For example, using aids (like appointment book) or not being able to perform activity (like managing own medications)

• ADLs (activities of daily living):
  • feeding
  • continence
  • transferring
  • toileting
  • dressing
  • bathing
    
• IADLs (instrumental activities of daily living):
  • shopping
  • preparing food
  • using the telephone
  • housekeeping
  • doing laundry
  • using transportation
  • handling medications
  • handling finances
    
• It is important to assess whether a person ever participated in an IADL, such as managing the finances, in order to know whether there is a change or not. Some people, for various reasons, may never have performed a particular IADL by themselves.

• falls
• gait changes
• tremors
• sleep changes
• daytime somnolence
• headaches
• weakness
• numbness
• appetite
• weight changes
• vision changes
• hearing changes
• incontinence
• personality changes​

Focus on these particular ares:

• Cardiovascular risk factors and disease
  • stroke
  • hypertension
  • myocardial infarction
  • congestive heart failure
• sleep apnea
• seizures
• head trauma
• psychiatric disorders
• malignancy

• substance use
• sexual history
• educational attainment
• work history
• hobbies​

Focus on medications with anticholinergic properties, sedatives​, opioids.

• driving concerns
• presence of guns in the home
• medication management concerns
• use of power tools

Other tests include: MoCA and MMSE. However, these tools currently require providers to undergo specific training, so it is important to check the latest information to see if any training is required before you can use any copyrighted tools.

• These tools have been compared in numerous studies and publications, with variable findings on which tool is more sensitive and/or specific.
  • In a 2014 study, the authors found similar sensitivity and specificity for detecting mild cognitive impairment and dementia between the SLUMS, MoCA, and STMS (Short Test of Mental Status).
  • In a 2016 study, the authors concluded that the MoCA was better able to detect mild cognitive impairment than the MMSE.
  • Click here for a review of the test performance of numerous cognitive screening instruments.
  • USPSTF evidence report: “There has been very little reproducibility in testing instruments, at consistent cutoffs and for specific conditions, in primary care populations. Well-conducted diagnostic accuracy studies for the most promising instruments or those currently endorsed in national guidance need to be reproduced in relevant populations.”
    
• Due to cultural differences, racial biases, and lack of studying tools in people of various races and ethnicities, many of these cognitive screening tools may cause false positives in non-white individuals, so it is extremely important to remember that these tools are only one section of the entire evaluation​.
• If a patient has severe visual impairment, use the Blind MoCA​.
• If hearing impairment is present, please ensure patient is wearing hearing aids if they have them, or that you obtain a portable hearing amplifier.
• If you are performing a cognitive screening tool over the phone or video, use the TICS-M (Modified Telephone Interview for Cognitive Status).
  • There are numerous tools that have been developed for use over the telephone or video, but the TICS-M is one of the most widely used tools.
  • However, the TICS-M may overestimate cognitive impairment in African Americans.
• A note on using these tools in the inpatient setting: Validation for many of these tools is lacking in the inpatient setting, and acute illness and delirium can impact the scores​.