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Cognitive.pdf
Review
Cognitive Screening in Persons With Chronic Diseases in Primary Care: Challenges and Recommendations for Practice
Ponrathi Athilingam, PhD, RN, ACNP, MCH, FAANP 1 ,
Constance Visovsky, PhD, RN, ACNP-BC 1 ,
Amanda F. Elliott, PhD, RN, ARNP 1 , and Philip J. Rogal, MD, FACC
1
Abstract An integrative literature review was performed to identify the challenges in current cognitive screening. The aim of the review was to serve as an evaluative resource to guide clinicians in the selection of the best available cognitive screening measures for early assessment of mild cognitive impairment (MCI) in people with chronic diseases. The review classified the available cognitive screening measures according to purpose, time to administer, and cognitive domains assessed as: 1) simple/ brief cognitive screening measures, 2) disease specific screening measures, 3) domain specific screening measures, 4) self-administered screening measures, and 5) technology-based screening measures. There is no single optimal cognitive measure for all patient populations and settings. Although disease specific cognitive screening measures are optimal, there is a lack of validated screening measures for many chronic diseases. Technology-based screening measure is a promising avenue for increasing the accessibility of cognitive screening. Future work should focus on translating available screening measures to mobile technology format to enhance the utility in busy primary care settings. Early cognitive screening in persons with chronic disease should enhance appropriate referrals for detailed neurocognitive examination and cognitive interventions to preserve and or minimize cognitive decline.
Keywords cognitive impairment, cognitive screening, chronic diseases, measures, technology
Introduction
The United States Census Bureau predicts that the population
of adults older than 65 years of age will double and the pop-
ulation older than 85 years of age will triple by 2060. 1
The
prevalence of Alzheimer’s disease (AD) is also increasing at
an alarming rate. By 2050, the number of people with AD
aged 65 and older may nearly triple, from 5 million to as many
as 16 million. 2
The annual rate of conversion to dementia in
people with mild cognitive impairment (MCI) ranged from
6% to 25% with an average of 10% per year, which is much higher than the dementia incidence rate of 1% to 2% seen in the general population.
3,4 Although MCI is not an inevitable
consequence of aging, age is a major risk factor and the risk
is greater in people with chronic diseases with profound con-
sequences. 5
The longitudinal Einstein Aging Study reported
an overall prevalence of dementia at 4.9%, with amnestic MCI at 11.6% and nonamnestic MCI at 9.9% among community- dwelling older adults.
6 Alarmingly, the prevalence of MCI
among older adults with chronic comorbid conditions is
reported to be much higher; 28% in persons with heart failure, 26% in persons with chronic obstructive pulmonary disease (COPD), 23% in individuals with cancer, and 14% in persons
with diabetes. 7
Given the increased prevalence of MCI among
persons with chronic diseases, in this article, we have focused
on identifying the etiological heterogeneity for MCI in chronic
diseases, challenges in current cognitive neuropsychological
evaluation, general review of available cognitive screening
measures, and emphasis on utilizing technology-based screening
for early assessment.
Mild cognitive impairment is a clinical syndrome that com-
monly arises as a result of neurodegenerative pathology, and in
chronic diseases MCI indicates early cognitive decline beyond
the normal range according to respective age and level of
education. 8
It is believed that by the time AD is diagnosed, suf-
ficient neuronal injury has occurred to the extent that reversal
of the disease is unlikely. 9
Mild cognitive impairment in
1 Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Corresponding Author:
Ponrathi Athilingam, PhD, RN, ACNP, MCH, FAANP, College of Nursing,
University of South Florida, 12901 Bruce B Downs Blvd, MDC22, Tampa,
FL 33612, USA.
Email: [email protected]
American Journal of Alzheimer’s Disease & Other Dementias®
2015, Vol. 30(6) 547-558 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1533317515577127 aja.sagepub.com
chronic diseases may result from hypoperfusion or reduced cer-
ebral blood flow, 10
neuronal cell death, 11
focal brain abnorm-
alities ranging from multiple cortical or subcortical infarcts
to small vessel disease with white matter lesions and lacunar
infarcts, 12,13
cortical atrophy, 14
and gray matter reductions, 15
suggesting an etiological heterogeneity.
Despite recent advances in the identification of MCI-
related biomarkers, neuropsychological assessment remains
a critical component of evaluation to ensure that cognitive
function correlates with biomarker abnormalities to assist in
detecting and tracking progression of MCI to early AD. 16
In
addition, the long-term progression from MCI to dementia or
AD (ie, 3 years) may be predicted by the presence of abnormal
levels of brain amyloid neurodegeneration seen by magnetic
resonance imaging and positron emission tomography scan. 16
Why Screen for Cognitive Impairment in Chronic Diseases?
Persons with chronic diseases such as heart failure, stroke,
COPD, HIV, diabetes, multiple sclerosis, and Parkinson’s dis-
ease have higher incidence of MCI that affects daily self-care
practices. Persons with chronic diseases are required to detect
changes in their physical condition that require them to take
action and implement a treatment strategy as prescribed by
their physician. 17,18
Changes in memory, judgment, and the
inability to complete usual activities can result in poor disease
management, impact medication adherence, and ultimately
have a negative effect on quality of life. 19
Poor performance
on cognitive screening tests suggests the presence of cognitive
deficits and provides a rationale for comprehensive follow-up
of neurocognitive assessment. 20
The rationale for early cognitive screening in persons with
chronic diseases is to make referrals appropriately for detailed
neurocognitive examination and cognitive interventions to
preserve and or minimize memory decline. 17,18
Although over
50 cognitive screening instruments are available, evidence
remains unclear on an ideal cognitive screening tool for use
in persons with chronic diseases. Most research studies have
used 4 to 16 neurocognitive batteries to determine incidence
and risk of cognitive impairment and/or to describe common
cognitive domains affected in various chronic diseases. 21,22
A
plethora of studies among varied populations have documen-
ted that the Mini-Mental Status Examination (MMSE), the
commonly used screening instrument, is not sensitive to iden-
tify subtle cognitive changes seen in MCI related to chronic
diseases. 23
In persons with memory complaints seen in pri-
mary care, cognitive screening with MMSE did not identify
those who require further examination for dementia, thus
defeating the intended purpose of early referral. 24
Despite
clear limitations, the MMSE has proved resilient in the clini-
cal arena for more than 30 years.
The common elements that are most predictive of progres-
sion of MCI are related to poor performance in neuropsycho-
logical testing at baseline and the number of different
cognitive domains that are impaired. 25
Current challenges in
the neuropsychological evaluation of MCI include test
selection, the availability of normative databases, the effect
of different base rates of MCI and AD in different settings,
establishing cutoff points for cognitive impairment, and
developing measures more sensitive to specific chronic dis-
eases, while having sufficient specificity to distinguish
between etiologically different chronic conditions. 25
In addi-
tion, cognitive complaints experienced by older adults are
overtly masked by the presence of chronic diseases. 26
Because, MCI associated with chronic disease is subtle and
is often not identified by clinicians until the person displays
an inability to carry out everyday activities that are often
reported by family members and/or caregivers. 27
Such subtle
cognitive impairment challenges the persons’ ability to learn
and remember self-care management for chronic disease con-
ditions such as heart failure, 28
diabetes, 29
COPD, 30
hyperten-
sion, 31
and multiple sclerosis. 32
Evidence also indicates that
MCI associated with chronic diseases is associated with poor
medication adherence, 33,34
poor quality of life, 35-37
and
increased mortality rate. 38,39
A prospective study of patients
with heart failure (N ¼ 577) reported an association with poor self-care adherence and memory impairment.
28 Evidence also
indicates increased readmissions rates on people who have
MCI associated with chronic diseases such as heart failure and
thus the associated cost. 28
Current Standard of Cognitive Screening in Persons With Chronic Diseases
The clinical expert consensus guidelines recently recom-
mended early identification of MCI in order to optimize med-
ical management, improve self-care for chronic diseases, offer
better understanding of symptoms associated with chronic dis-
ease conditions, maximize decision-making autonomy, and
planning for the future. 40
A report from the Einstein aging study
showed that 50% to 66% of persons with chronic diseases seen in primary care offices were found to have dementia, yet no such
diagnosis was documented in the medical record. 6
The gold standard for assessment of cognitive abilities
necessitates systematic and detailed evaluation of a broad
range of cognitive processes using multiple neuropsychologi-
cal batteries. 41
Such detailed examination is not always feasi-
ble for use by clinicians in busy outpatient clinic settings due
to cost and time. 20,42
Although multiple cognitive screening
instruments are available, it is unlikely that a ‘‘one size fits
all’’ approach is ideal for cognitive screening due to inconsis-
tencies in the selection and use of screening measures as well
as a lack of robust evidence to support the many screening
measures available for use in clinical practice. 43
Therefore, the aim of this integrative literature review was
to examine evidence on available cognitive screening measures
to serve as an evaluative resource to guide clinicians in the
selection of the best available cognitive screening measures
and provide rationale for the use of novel technology-based
cognitive screening that would be both feasible and valid for
early cognitive screening among persons with chronic diseases.
548 American Journal of Alzheimer’s Disease & Other Dementias® 30(6)
Data Source and Results
The Cochrane Database of Systematic Reviews followed by
PubMed, Medline, EMBASE, CINAHL, and PsychINFO
databases were searched using the subject terms ‘‘cognition
disorders,’’ ‘‘cognitive impairment,’’ ‘‘cognitive dysfunc-
tion,’’ ‘‘memory,’’ ‘‘attention,’’ ‘‘screening,’’ ‘‘screening
tool,’’ and combined them with names of multiple chronic dis-
eases. The searches were then combined with AND, limits to
the search were placed for humans and English language. The
goal was to identify available disease-specific cognitive
screening measures as well as general cognitive screening
measures used among these chronic disease conditions. Addi-
tional articles were identified by hand searches from reference
lists and articles included in systematic reviews and from
authors who have published in this field. In addition, the ini-
tial studies for cognitive screening measures identified were
gathered to identify their psychometrics.
The review classified the cognitive screening measures and
grouped them based on the time to administer the measure,
mode of administration, domains of cognition assessed, and
specific purpose of the measures. From the 240 articles identi-
fied, the measures were categorized as (1) nonspecific simple/
brief cognitive screening measures for a total of 29 mea-
sures, 44-71
(2) disease-specific cognitive screening measures
consisting of 14 disease-specific cognitive screening measures
for 6 chronic disease conditions (ie, Parkinson’s disease, HIV,
stroke, multiple sclerosis, cancer, and schizophrenia), 72-85
(3)
17 domain-specific cognitive screening measures, 86-102
(4) 12
self-reported and telephone-based screening measures, 103-113
and (5) 7 technology-based screening measures utilizing the
Internet or mobile apps. 114-120
These measures are presented
in Tables 1 to 5. Note these are not all exhaustive lists.
Discussion of Results
Utility of Simple or Brief Cognitive Screening Measures
Although brief, the general practitioner assessment of cogni-
tion (GPCOG), 57
Mini-Cog, 60
memory impairment screen, 62
and memory orientation screening test (MOST) 63
are simple
yet structured measures that are valid and suitable for assess-
ment of cognitive function in persons with chronic diseases.
Each measure has the unique benefits that they are easy to
administer by clinicians or nurses, take less than 5 minutes to
administer, and have been validated in the primary care or com-
munity setting. The GPCOG has patient and informant (family
or caregiver) components that can be used alone or together to
increase specificity and sensitivity. 57
The Mini-Cog has been
validated in population-based studies and in community–
dwelling older adults heterogeneous with respect to language,
culture, and education. 60
Kansagara and Freeman reviewed
6 brief cognitive screening measures that could serve as possi-
ble alternatives to the MMSE for use by the US Department of
Veterans Affairs. 121
The review provided evidence that the
Mini-Cog has the shortest administration time (2-4 minutes)
and has been studied in a large population sample as well as
in multiethnic samples compared to other brief cognitive mea-
sures. 121
This was supported in a review that assessed the clin-
ical utility of the GPCOG and Mini-Cog in which both were
found to be equally high in sensitivity and specificity. 122
Simi-
larly, the MOST offers an accurate assessment of cognition and
could be used in the primary care setting. 123
These brief cogni-
tive screening measures may be ideal to screen cases of demen-
tia from clinics or the community as a first step measure but are
considered not appropriate for use in a primary care setting to
screen for MCI in persons with chronic diseases. 122
Although
controversial, the utility of routinely asking about memory
problems with patients and family members followed by a brief
cognitive assessment method in patients with a positive
response offers a platform for early referral and follow-up for
a detailed neuropsychological examination (see Table 1).
Disease-Specific Cognitive Screening Measures
Results from this review identified validated disease-specific
cognitive screening measures for only 6 chronic disease condi-
tions, namely, Parkinson’s disease (5 measures), 80-84
multiple
sclerosis (4 measures), 76-79
with 2 measures for use in HIV, 74,75
and 1 measure each for use in stroke, 85
cancer, 73
and schizophre-
nia, 72
all of which were developed in recent years. The evolution
of new disease-specific cognitive screening measures in recent
years clearly indicates the need for a detailed synthesis of
available evidence for use by clinicians and researchers.
Strengthening the evidence by utilizing existing screening
measures works to strengthen the validity and reliability of the
currently available screening measures rather than the design
of new measures. When the MMSE was compared with the
disease-specific screening measures, the MMSE could not
achieve the required 80% sensitivity at any cutoff score in persons with Parkinson’s disease.
84 This example illustrates
that when possible clinicians should use validated disease-
specific screening measures for accurate measurement of
cognitive domains affected by specific chronic diseases. This
warrants further examination of cognitive domain-specific
cognitive screening measures compared with disease-specific
cognitive measures to further increase their utility and validity
for early assessments. Table 2 provides a list of the most com-
monly used disease-specific cognitive screening measures.
This is, to our knowledge, a comprehensive list of the available
cognitive screening measures specific for chronic diseases.
Utility of Cognitive Domain-Specific Screening Measures
Although there is no single cognitive screening measure
that is considered to be the gold standard, domain-specific
cognitive screening measures that assess 5 or more cognitive
domains are considered the second best. Most domain-
specific cognitive measures take more than 10 minutes to
administer. The commonly used tests for screening MCI are
the MMSE, 96
Montreal Cognitive Assessment (MoCA), 98
Mattis Dementia Rating Scale, 95
Addenbrooke’s Cognitive
Examination Revised (ACE-R), 87
and the Neurobehavioral
Athilingam et al 549
cognitive status examination. 99
These measures are often used
to validate simple/brief screening measures as well as disease-
specific cognitive measures. The MoCA has shown better sen-
sitivity than the MMSE, takes a short duration of 10 to 12
minutes for administration, and has a wide application in rou-
tine clinical practice. 98
The MMSE lacks sensitivity in identi-
fying subtle cognitive symptoms of MCI associated with
chronic diseases such as in Parkinson’s disease, 124
heart
failure, 125
and stroke. 126
Similarly, compared to ACE-R, the
MMSE demonstrated inferior accuracy. 127
In addition, the
MMSE is not available in the public domain anymore and
charging a fee for clinical use has become an issue because
of the MMSE copyright. Domain-specific cognitive screening
measures offer clinicians’ processes to better describe
patients’ cognitive symptom profile for further assessment
and to make appropriate referrals; therefore, when disease-
specific screening measures are not available, providers
should consider using domain-specific cognitive screening
measures such as the MoCA or ACE-R.
Self-Administered Cognitive Screening
The self-administered screening measures are designed to
rapidly screen large numbers of individuals in the community
Table 1. Simple or Brief Cognitive Screening Measures.
Name of the Measure Administration Time Domains Assessed
44Abbreviated Mental Test (AMT) 10-12 minutes Orientation and memory 45Boston Naming Test (BNT) Less than 5 minutes for short form,
10 minutes for full version Memory, recall, and name pictures
46Brief Visuospatial Memory Test—Revised (BVMT-R)
10-15 minutes, delay recall after 25 minutes. Total 40 minutes
Visuospatial Memory Test and delay recall
47California Verbal Learning Test, second edition (CVLT-II)
15-30 minutes Verbal memory, and recognition, delayed recall and recognition
48Clock-Drawing Test (CDT) 3-10 minutes Visuospatial 49
CogStat 10-15 minutes Attention, memory, executive function, psychomotor
50 Cognitive functioning self-assessment scale (CFSS)
20 minutes Self-reported cognitive functioning
51 Community Screening Interview for Dementia (CSID)
15 minutes Memory, abstract thinking, and judgment
52 Controlled Oral Word Association Test 5 minutes Verbal fluency and word finding
53Delayed Word Recall Test (DWR) 7-10 minutes Memory, recall, repeated elaborate encoding of 10 words a filled delay
54Digit Span task of Wechsler Memory Scale-III 8-10 minutes Memory and attention 55
Enhanced Cued Recall (ECR) 15-20 minutes after Recall memory only 10 word-list recall 56Frontal Assessment Battery (FAB) 5-7 minutes Executive function 57
General Practitioner Assessment of Cognition
5 minutes or less 5 minutes for informant interview
Orientation, clock drawing, and word recall
58 Hopkins Verbal Learning Test (HVLT) 5 minutes Verbal learning and memory. Three trials of free-
recall only 59Informant Questionnaire on Cognitive
Decline in the Elderly (IQCODE) 20 minutes Memory (acquisition and retrieval), verbal
intelligence, and performance 60Mini-Cog 5 minutes Memory and visuospatial 61Modified Mini-Mental State Examination
(3MS) 5 minutes Orientation, attention, calculation, and recall
62Memory Impairment Screen (MIS) 5-8 minutes Memory and delayed recall 63Memory Orientation Screening Test (MOST) 5 minutes Three-word recall, time orientation, list memory,
and clock drawing 64Philadelphia Brief Assessment of the
Cognition (PBAC) 20-25 minutes Working memory, executive function, lexical
retrieval/language, and visuospatial 65Ray Auditory Verbal Learning Test (RAVLT) 10 minutes for memory delay recall
tested after 30 minutes Verbal learning, memory, delay recall
66Short Portable Mental Status Questionnaire 5 minutes or less Orientation and calculation 67Six-Item Cognitive Impairment Test (6-CIT) 6-7 minutes Three-item recall and 3-item temporal orientation 68Spatial Span Forward and Backward task 10 minutes Executive function and visuospatial memory 69
Stroop Color Word Test or the Stroop Effect Test
5-7 minutes Executive function
70 Trail making Test Part B (TMT B) 5 minutes or less Executive function and working memory
71Wisconsin Card Sorting Tests (WCST) Short version 10-15 minutes. Full version up to 30 minutes
Executive function visuospatial memory
550 American Journal of Alzheimer’s Disease & Other Dementias® 30(6)
or practice at the same time, they require no setup of a
computer, minimal operator time to administer, test a reason-
able range of cognitive functions, and are sensitive to mild
AD. 128
The test your memory self-administered measure
indicated a sensitivity of 93% and specificity of 86% in the diagnosis of AD but has not been tested on patients with
MCI and in chronic disease condition. 106
Similarly, the Self-
Administered Gerocognitive Examination (SAGE), a pen and
paper examination, encourages patients to complete the self-
administered test and take the completed test to your primary
care physician for interpretation and management. 105
However,
SAGE requires that individuals must be literate and have ade-
quate vision and writing skills to answer the questions, thus it
demands active patient participation and provider training to
score the measure, which may be challenging. 105
In addition, the
Patient Reported Outcomes in Cognitive Impairment (PRO-
COG) has a self-administered detailed screen, which includes
55 items for a total score of 220. 103
The PROCOG as well
as the Patient-Reported Outcome Measurement information
System Cognitive Concerns and Ability Scale takes more than
30 minutes to complete and can be very exhaustive for
patients. 103,104
Often cognitively impaired persons shy away
from being tested and may not fill out the self-administered
test if they take more than 10 minutes.
More recently, cognitive screening measures have been
tested for validity when administered via telephone. 107-113
Currently, several cognitive training intervention trials have
utilized telephone screening to determine eligibility. How-
ever, these measures are not widely tested for their utility in
the primary care setting.
Utilizing Technology for Screening, the Future of Cognitive Screening
In the last 3 decades, many validated cognitive assessment
measures have been adapted into an alternative and attractive
strategy to in-person cognitive assessments by utilizing Web
version screening measures that can be self-administered such
as the CogStat. 115
The validated NeuroScreen 119
was compared
with the Samsung Galaxy Note1 smartphone assessing the
same cognitive domains that showed good correlation (r ¼ .61, P < .01) with high levels of acceptability by patients and
potential provider–users. 129
In addition, a Stroop smartphone
application called EncephalApp-Stroop was developed for
screening cognitive dysfunction in patients with cirrhosis. 118
Cognitive processing speed in the elderly patients utilizing the
smartphone application Color-Shape Test was significantly
Table 2. Disease-Specific Cognitive Screening Measures.
Name of the Tool Disease Administration Time Cognitive Domain
72Brief Assessment of Cognition in Schizophrenia (BACS)
Schizophrenia 10-15 minutes Memory, verbal fluency semantic and alphabetical, attention, speed of processing, executive function, and motor speed
73Functional Assessment of Cancer Therapy Cognitive Function (FACT–Cog) scale
Cancer 10 minutes Thinking, concentration, and attention
74 HIV Dementia Scale (HDS) HIV 10-12 minutes Attention, motor speed, construction, and working
memory 75
International HIV Dementia Scale (IHDS)
HIV 10-12 minutes Attention, motor speed, construction, and working memory
76 Brief International Cognitive Assessment for MS (BICAMS)
Multiple sclerosis 10 minutes Memory and verbal learning
77 Brief Repeatable Neuropsychological Battery (BRNB)
Multiple sclerosis 10-12 minutes Selective reminding, spatial recall, verbal learning, and memory
78 Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS)
Multiple sclerosis 12-15 minutes Symbol digit span modalities test, visuospatial memory, and verbal learning
79Multiple sclerosis Neuropsychological Screening Questionnaire (MSNQ)
Multiple sclerosis 8-10 minutes Attention, memory, speed of processing, cognitive ability, personality, and behavior
80Mini-Mental Parkinson (MMP) Parkinson’s disease 5-7 minutes Memory, recall, temporal, and spatial orientation 81
Parkinson’s Disease-Cognitive Rating Scale (PD-CRS)
Parkinson’s disease 5-7 minutes Naming, and working memory
82 Parkinson’s Disease with Dementia Short Screen (PDD-SS)
Parkinson’s disease 10-20 minutes Memory and recall
83Parkinson’s Neuro-psychometric Dementia Assessment (PANDA)
Parkinson’s disease 10-12 minutes Memory, verbal fluency, attention, naming, drawing, and copy
84Scales for Outcomes of Parkinson’s disease—Cognition (SCOPA-COG)
Parkinson’s disease 15-20 minutes Attention, memory, executive functions, visuospatial abilities
85Screening Instrument for Neuro- psychological Impairments in Stroke (SINS)
Stroke 15 minutes Languages, visuospatial, attention, speed in unaffected arm, neglect, apraxia, and memory
Athilingam et al 551
Table 3. Domain-Specific Cognitive Screening Measures.
Name of the Measure Administration Time Domains Assessed
86AB Cognitive Screen (ABCS) 10-12 minutes Verbal fluency, orientation, recall, and clock drawing 87Addenbrooke’s Cognitive
Examination Revised (ACE-R) 30 minutes Orientation, attention, memory, verbal fluency, language, and visuospatial ability
88Brief Cognitive Assessment Tool (BCAT)
20 minutes Orientation, verbal recall, visual recognition, visual recall, attention, abstraction, executive function, language, and visuospatial processing
89Cambridge Cognitive Examination (CAMCOG)
20-30 minutes Orientation, expressive and comprehensive language, memory (remote, recent, and learning), attention, praxis, calculation, abstraction, and perception
90Cognitive Abilities Screening Instrument (CASI)
20 minutes Attention, concentration, orientation, short-term and long-term memory, language abilities, visual construction, list-generating fluency, abstraction, and judgment
91Cognitive Assessment Screening Test
15 minutes Visual construction, semantic knowledge, verbal fluency, memory, and language
92Cognitive Capacity Screening Examination (CCSE)
10-15 minutes Verbal memory, orientation, attention, simple and complex mental mathematics, mental speed, and abstraction
93DemTect 3 levels 25 minutes
Word list for memory, delayed recall of word list, number transcoding, semantic word fluency task, and digit span reverse
94IQCODE 10-15 minutes Memory (acquisition and retrieval), verbal intelligence and performance 95
Mattis Dementia Rating Scale 15-20 minutes Attention, memory, conceptualization, construction, and initiation perseveration 96Mini-Mental Status Examination
(MMSE) 10-12 minutes Orientation, memory, attention, language, recall, visuospatial, and command
97Minnesota Cognitive Acuity Screen (MCAS)
15-20 minutes Orientation, attention, delayed word recall, comprehension, repetition, naming, computation, judgment, and verbal fluency
98Montreal Cognitive Assessment (MoCA)
10 minutes Orientation, memory, attention, language, recall, visuospatial, command, and abstraction
99Neurobehavioral cognitive status examination (NCSE)
15-40 minutes Orientation, attention, language, construction, memory, calculations, and reasoning
100Quick Cognitive Screening Test (QCST)
8-15 minutes Vocabulary, abstract reasoning, similarities, orientation, attention, concentration, constructional praxis, memory immediate recall, and delayed recall spatial neglect
101Rowland Universal Dementia Assessment Scale
6-10 minutes Memory, praxis, language, judgment, drawing, and body orientation
102Seven-minute Neurocognitive screening battery
7-8 minutes Enhanced Cued Recall, temporal orientation, verbal fluency, and clock drawing
Table 4. Self-Administered and Telephone-Administered Cognitive Screening.
Name of the Measure Administration Time Domains Assessed
103Patient Reported Outcomes in Cognitive Impairment (PROCOG)
30 minutes Executive function, Navigation, social functioning, leisure time, self-esteem, mood, and functional status
104Patient-Reported Outcome Measurement information System (PROMIS) Cognitive Concerns and Ability Scale
30-40 minutes Perception of one’s cognitive ability with regard to concentration and memory The self-reported version of the scale
105Self-Administered Gerocognitive Examination (SAGE) 12-15 minutes Language, executive, memory, reasoning, visuospatial, and orientation
106Test your memory (TYM) 12-15 minutes Orientation, copying, memory (antegrade and retrograde), calculations, visuospatial, and naming
107Blessed Telephone Information Memory Concentration Test
6-10 minutes Memory and concentration
Telephone screening measures 108Brief Test of Adult Cognition by Telephone (BTACT) 20 minutes Episodic memory, working memory, reasoning, verbal
fluency, processing speed, and executive function 109Modified TICS (TICS-M) 12-15 minutes 13-Item, wordlist, orientation, memory, and language 110
Structured Telephone Interview for Dementia Assessment (STIDA)
15-40 minutes Memory, orientation, judgment and problem solving. Includes subject and informant interview
111 Telephone Cognitive Assessment Battery (TCAB) 15 minutes Attention; verbal learning, memory; executive function;
global cognitive functioning; and self-perceived memory 112
Telephone Interview for Cognitive Status 15 minutes Orientation, concentration, short-term memory, mathematical skills, and language
113 Telephone-Montreal Cognitive Assessment (T-MoCA) 12-15 minutes Attention, memory, abstraction, and orientation
552 American Journal of Alzheimer’s Disease & Other Dementias® 30(6)
correlated with global cognition (MMSE: r ¼ .515, P < .0001).
129
Online screening is becoming more popular among
community-dwelling adults. Recently, community-dwelling
older adults (�60 years) with subjective memory complaints (n ¼ 30) and no subjective memory complaints (n ¼ 30) participated in an online screening program containing the
Cognitive Symptom Checklist and the informant Question-
naire on Cognitive Decline in the Elderly shorten version. 130
All 100% of participants completed the online assessment without assistance, including 1 woman who had no previous
experience in using computers indicating the feasibility of
technology-based screening. 130
Recently, the paper version
of the MOST was compared with a computerized (iPad app)
version among 98 older adults and demonstrated an intertest
correlation of .92 (P < .001) with no significant difference
between versions and presentation order. 117
Discussion for Clinical Practice
Recognizing that there is no single optimal screening measure,
clinicians may often be left in limbo to select the appropriate
screening measure and the best mode for administration. Our
review indicates the utility of disease-specific cognitive
screening measures as first choice where available and/or an
alternative domain-specific sensitive measure such as the
MoCA or structured brief screening measures including
GPCOG or Mini-Cog. The GPCOG is recommended as the
next best, since it had both a patient and an informant ques-
tionnaire. 107
Combining an informant questionnaire with
other simple or domain-specific measures improved accuracy
and diagnostic utility. 106
The GPCOG is a 1-page scale that
can be administered in 5 minutes for a total score of 9. A score
of 0 to 4 indicates the need for detailed assessment and a score
5 to 15 warrants the need to get the informant interview that
includes 6 questions for a score of 6, and a score of 0 to 3 war-
rants detailed cognitive assessment. 106
The MoCA, a domain-
specific validated measure showed excellent sensitivity and
specificity among multiple chronic diseases. 124
In addition,
incorporating a simple screening measure such as the MOST
within an annual wellness visit may provide an objective mea-
sure of cognition that will enable providers to develop a better
personalized cognitive screening and a more accurate assess-
ment for monitoring memory change over time. 63-117,123
The Centers for Medicare and Medicaid Services elected not
to recommend a specific screening measure but encourages
providers to use the algorithm for assessment of cognition and
use structured cognitive assessment tools for both patients
and informants utilizing GPCOG or an alternative measure
such as the MoCA. 131
Unfortunately, evidence suggests that
up to 81% of patients who met the criteria for MCI have never received a screening and had no documented diagnosis for
MCI. 40
The first step in diagnosing MCI or dementia in per-
sons with chronic diseases is to develop a best practice to
screen all patients during annual wellness visits to primary
care clinics. The individual practices need to develop a proto-
col for annual cognitive screening.
Patients waiting to be seen by the provider may complete
cognitive screening using computer-based tests or hand-held
devices such as a smartphone or tablet. Early detection and
documentation of early cognitive impairment is vital in
improving medical care and patient outcomes. Diagnosis and
documentation of early cognitive impairment could inform all
clinicians involved in patient care to determine treatment
options that may require aspects of self-care and adjustments
to accommodate cognitive decline. 40
Conclusion and Clinical Recommendation
In summary, clinicians should routinely screen for MCI in
their patients, especially in patients with chronic diseases.
When possible, the choice of test used for screening should
be disease specific. However, there is a lack of validated cog-
nitive screening measures for many chronic diseases. There is
a need for simple measures that take less than 10 minutes such
as the GPCOG, Mini-Cog, and MOST that require little train-
ing for health care personnel to administer. The Pew Internet
survey reported that 90% of American adults own a mobile
Table 5. Technology-Based Cognitive Screening Measures.
Name of the Measure Administration Time Domains Assessed
114CogStat Web version 10-15 minutes Attention, memory, executive function, and psychomotor
115Dementia Risk Assessment 30-40 minutes Memory (Internet based) 116MindStreams 20-30 minutes Memory, executive function, visual spatial skills, and
verbal fluency 117Memory Orientation Screening Test (MOST) iPad Version 5 minutes Memory and attention 118
NeuroScreen Not known Attention, motor speed, construction, and working memory
119 Patient-Reported Outcome Measurement information System (PROMIS) Cognitive Concerns and Ability Scale
30-40 minutes or over
Perception of one’s cognitive ability with regard to concentration and memory The computerized version of the scale
120Stroop Smartphone app Not known Cognitive flexibility and psychomotor speed. Used mainly in minimal hepatic encephalopathy
Athilingam et al 553
phone, 58% of those are smartphones, and 52% use social net- working.
132 Mobile technology is transforming clinical prac-
tice for health care providers and offers powerful tools that are
ultraportable and easy to use. Hence, smartphone-based cog-
nitive screening tests may offer solutions in increasing the
number of patients screened and treated for MCI in the early
phases of cognitive decline. Future work should focus on
translating available validated screening measures to a mobile
technology format to enhance the utility of these screening
tools in the busy primary care setting. More research is needed
at the primary care setting to utilize technology-based smart-
phone apps to screen for early cognitive changes and offer
clinical recommendation to halt the progression of MCI to
AD among persons with chronic disease.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
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