Administers and interprets cognitive screening tools (MoCA, MMSE, SLUMS) with dementia evaluation. Use when screening for cognitive impairment, administering MoCA/MMSE, or evaluating dementia.
Administers and interprets cognitive screening tools (MoCA, MMSE, SLUMS) with dementia evaluation. Use when screening for cognitive impairment, administering MoCA/MMSE, or evaluating dementia.
Administers and interprets cognitive screening tools (MoCA, MMSE, SLUMS) with structured dementia evaluation and differential diagnosis in compliance with NIA-AA diagnostic frameworks.
Why This Skill Exists
Cognitive impairment affects approximately 16% of adults over age 65 and is a leading cause of functional disability, institutionalization, and caregiver burden. Early detection through systematic cognitive screening enables timely intervention, advance care planning, medication review (discontinuing anticholinergics, managing polypharmacy), safety planning (driving, firearms, finances), and caregiver support. The 2024 NIA-AA (National Institute on Aging–Alzheimer's Association) Research Framework and the APA Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change establish that cognitive assessment must be systematic, use validated instruments, and account for educational, cultural, and linguistic factors that affect test performance.
Misdiagnosis of dementia carries severe consequences: treatable conditions (depression, hypothyroidism, B12 deficiency, normal pressure hydrocephalus, medication effects) are missed when cognitive decline is attributed to neurodegenerative disease without adequate workup. Conversely, failure to diagnose early-stage dementia deprives patients and families of the opportunity for advance planning, clinical trial enrollment, and initiation of symptomatic treatment.
Checkpoint A: Pre-Draft Intake (Mandatory)
What is the referral question? (cognitive screening, dementia evaluation, capacity assessment, medication-induced cognitive concerns, post-delirium cognitive assessment) — default: cognitive screening
What is the patient's age and educational level? (critical for score interpretation) — default: obtain at intake
What is the patient's primary language and literacy level? — default: English, assess at intake
Is there a collateral informant available? (required for reliable history in cognitive evaluations) — default: strongly recommended
Are there sensory deficits that may affect testing? (hearing loss, visual impairment) — default: assess and accommodate
Has the patient been screened for delirium? (CAM, 4AT — delirium must be excluded before diagnosing dementia) — default: screen first
What cognitive screening tools are available and appropriate? (MoCA, MMSE, SLUMS, Mini-Cog) — default: MoCA
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:
Acute onset and fluctuating course
Inattention
PLUS either: disorganized thinking OR altered level of consciousness
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)
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
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 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
Never diagnose dementia based on a single cognitive screening score — screening tests identify who needs further evaluation, not who has dementia.
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.
Exclude delirium before attributing cognitive deficits to dementia — delirium is common, treatable, and frequently missed in the elderly.
Always obtain collateral history — patients with anosognosia (common in Alzheimer's disease) will minimize or deny deficits.
Order the reversible etiology workup before rendering a neurodegenerative diagnosis — missing hypothyroidism or B12 deficiency is indefensible.
Document driving safety assessment in every cognitive evaluation of an older adult — clinicians have a duty to report unsafe drivers in many jurisdictions.
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.
