Cognitive Impairment in Older Adults: Screening -- Older Adults


General

Grade: I

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

Practice Considerations

Patient Population Under Consideration

This recommendation applies to community-dwelling older adults 65 years or older, without recognized signs or symptoms of cognitive impairment. Early detection and diagnosis of dementia through the assessment of signs and symptoms recognized by the patient, family, or clinician, which may be subtle, are not considered screening and are therefore not the focus of this recommendation.

Assessment of Risk

Increasing age is the strongest known risk factor for cognitive impairment.9 The ε4 allele of the apolipoprotein E (apoE) gene is a reported risk factor for Alzheimer disease in white and Asian populations.10 Other risk factors include cardiovascular risk factors (eg, diabetes, hypertension, or hypercholesterolemia), depression, physical frailty, low education level, and low social support level.10-13 Several dietary and lifestyle factors have been reported as associated with decreased risk of cognitive impairment. These include adequate folic acid intake, low saturated fat intake, higher longer-chain omega-3 fatty acid intake, high fruit and vegetable intake, the Mediterranean diet, moderate alcohol intake (1 to 6 drinks per week vs abstention), higher educational attainment, cognitive engagement, social engagement, and higher physical activity levels.10111415

Screening Tests

Many different brief screening tests for cognitive impairment are available. Screening tests generally include asking patients to perform a series of tasks that assess 1 or more domains of cognitive function. These tests are not intended to diagnose MCI or dementia. A positive screening test result should lead to additional testing that can include blood tests, radiology examinations, and a medical and neuropsychologic evaluation to confirm the diagnosis of dementia and determine its subtype.

The most well-studied screening instrument is the Mini-Mental State Examination (MMSE). Other screening instruments include the clock drawing test (CDT), Memory Impairment Screen (MIS)/MIS by Telephone (MIS-T), Mental Status Questionnaire (MSQ), Mini-Cog verbal fluency, 8-Item Informant Interview (AD8), Functional Activities Questionnaire (FAQ), 7-Minute Screen (7MS), Abbreviated Mental Test (AMT), Montreal Cognitive Assessment (MoCA), St. Louis University Mental Status Examination (SLUMS), Telephone Instrument for Cognitive Status (TICS), and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). For more information on all screening instruments reviewed by the USPSTF, see the full evidence report.1617

Treatment and Interventions

Treatment of cognitive impairment may focus on one or more signs and symptoms, including cognition, quality of life, mood, and behavioral impairments.

Several pharmacologic and nonpharmacologic interventions aim to slow, prevent, or reverse cognitive impairment; stabilize or improve functional performance; improve caregiver burden and depression; or improve patient, caregiver, and clinician decision-making. Pharmacologic treatments approved by the US Food and Drug Administration for Alzheimer disease include acetylcholinesterase inhibitors (AChEIs) and memantine. Nonpharmacologic interventions include cognitive training, cognitive rehabilitation, cognitive stimulation interventions, exercise, peer support, psychoeducation, and care management.

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Dementia affects an estimated 2.4 to 5.5 million persons in the United States, and its prevalence increases with age. Dementia affects an estimated 9.9% of persons aged 75 to 84 years and 29.3% of those 85 years or older.2 Subjective memory issues are common in adults, with studies showing that approximately 50%18 to 75%19 of adults have at least minor concerns about their memory.

Although there is insufficient evidence to recommend for or against screening for cognitive impairment, there may be important reasons to identify cognitive impairment early. Burdens of cognitive impairment include direct effects on the patient (eg, loss of function and relationships, financial misjudgments, and nonadherence with recommended therapies), direct effects on caregivers (eg, burden and depression), and effects on society (eg, costs of care). Early detection of cognitive impairment can allow for identification and treatment of reversible causes, may help clinicians anticipate problems patients may have in understanding and adhering to medical treatment plans, and may also be useful by providing a basis for advance planning on the part of patients and families. Clinicians should remain alert to early signs or symptoms of cognitive impairment (eg, problems with memory or language) and evaluate the individual as appropriate. However, none of the potential benefits of screening have been clearly demonstrated in clinical trials.

Potential Harms

Evidence about the harms of screening is limited. One potential harm is labeling a person with an illness that is typically progressive and for which treatment appears to have limited effectiveness. Some studies have shown higher stress, greater depression, and lower quality of life in persons aware of a diagnosis of cognitive impairment,20 while others have found no such association.2122 Evidence about the effects of false-positive results is limited. AChEIs are associated with harms, some of which are serious, including central nervous system disturbances, bradycardia, and falls. Evidence about the harms of nonpharmacologic interventions is limited, but these harms are assumed to be small.

Current Practice

Most commonly, evaluation for or diagnosis of cognitive impairment occurs as a result of patient- or caregiver-reported concerns or symptoms, or clinician’s suspicion. As many as 29% to 76% of patients with dementia are unrecognized in the primary care setting.23-25 In 2011, Medicare added detection of cognitive impairment to its annual wellness visit. The Centers for Medicare & Medicaid Services recommend assessing a patient’s cognitive function by direct observation; considering information and concerns reported by the patient, family members, friends, caregivers, and others; and, if deemed appropriate, using a brief validated, structured cognitive assessment tool.26

 

Update of Previous USPSTF Recommendations

This recommendation updates the 2014 USPSTF recommendation on screening for cognitive impairment in older adults. In 2014, the USPSTF concluded that the evidence was insufficient to assess the balance of benefits and harms of screening for cognitive impairment.36 For the current recommendation, the USPSTF again concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults.

 

 


Rationale

Importance

According to the American Psychiatric Association’s < i>Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (< i>DSM-5), dementia (also known as major neurocognitive disorder) is defined by a significant decline in 1 or more cognitive domains that interferes with a person’s independence in daily activities. The 6 cognitive domains identified in the < i>DSM-5 are complex attention, executive function, learning and memory, language, perceptual motor function, and social cognition.1 Dementia affects an estimated 2.4 to 5.5 million persons in the United States, and its prevalence increases with age. Dementia affects an estimated 3.2% of persons aged 65 to 74 years, 9.9% of those aged 75 to 84 years, and 29.3% of those 85 years or older.2

Mild cognitive impairment (MCI) differs from dementia in that the impairment is not severe enough to interfere with independent daily functioning. Some persons with MCI may progress to dementia, while some do not. One systematic review found that 32% of persons with MCI develop dementia over 5 years.3 However, studies have also shown that between 10% and 40% of persons with MCI may return to normal cognition over approximately 4 to 5 years.4-6 The prevalence of MCI is difficult to estimate, in part because of differing diagnostic criteria, leading to a wide range of prevalence estimates (3%-42%) in adults 65 years or older.78 In this recommendation statement, “cognitive impairment” refers to both dementia and MCI.

USPSTF Assessment of Magnitude of Net Benefit

The US Preventive Services Task Force (USPSTF) concludes that the evidence is lacking, and the balance of benefits and harms of screening for cognitive impairment cannot be determined (Table).


Others

No information available.


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