Dementia screening and diagnosis tools for health-care providers


This page provides an overview of some key resources and tools that health-care providers can use for dementia screening, assessment and diagnosis.

At the doctor's office, with a patient and a family member.

Note: If you are a member of the public looking for information about dementia testing and diagnosis, please refer to our pages How to get tested for dementia: Tips for individuals, families and friends and/or How to get a diagnosis for young-onset dementia. The information below is customized for and targeted to health-care providers. 

Many health-care providers know that Alzheimer's disease and most other dementias are progressive, degenerative diseases. Individuals and/or caregivers may consult a health-care provider when they begin to notice symptoms such as loss of memory, judgment and reasoning, difficulty with day-to-day tasks and changes in vision, movement, communication, personality, mood and behaviour.

Cognitive impairment and dementia are present in about 20 per cent of older adults and are consistently rated among the top three concerns of of this population.1 Early detection of dementia provides an opportunity for the individual to adjust to the diagnosis and to participate actively in planning for the future.

The importance of early diagnosis

Symptoms of irreversible dementia can be similar to those of other conditions such as depression, thyroid or heart disease, infections, drug interactions or alcohol abuse disorder.

Finding out the cause of the symptoms can help people understand the changes they are experiencing, receive care, treatment and support and plan for the future.

Download our PDF brochure: Information for health-care professionals: The importance of early diagnosis (print-friendly version).

Cognitive screening tests

                                Instrument   Time       (min)    Cut-off score/Total score              Reference
 Mini-mental state examination (MMSE)  7-10   ≤23-26/30   Folstein et al., 1975 
 Modified mini-mental state examination (MMSE)  10-15  ≤77-86/100   McDowell et al., 1997 
 Hopkins verbal learning test – total recall   5  ≤14-18/36   Frank and Byrne, 2000
 Memory impairment screen   4  ≤4/8   Buschke et al., 1999 
 Clock drawing test   1-3  Scoring methods varied   Royall et al., 1992
 Cambridge cognitive examination   20  ≤80/107   Lolk et al., 2000 
 Community screening interview for dementia  30  Formula used   Hall et al., 1993 
 Montreal cognitive assessment (MoCA)  10  ≤25/30  Nasreddine et al., 2005 
 Behavioural neurology assessment (Long form)  40-50  ≤182/250   Darvesh et al., 2005
 Behavioural neurology assessment (Short form)  20-30  ≤82/114  Darvesh et al., 2005
 Canadian Indigenous Cognitive Assessment  10  <34/39  Walker et al., 2021

 

Screening tools for dementia diagnosis

Watch the video I’m a doctor - is there a good way to check out a memory complaint? A five-step brain health check for doctors.

The material was created by TCD, through the NEIL Programme at the Institute of Neuroscience with support from GENIO.
© 2014 The Provost, Fellows, Foundations Scholars, and the Other Members of Board, of the College of the Holy and Undivided Trinity Of Queen Elizabeth, near Dublin. Permission to use this material was granted by TCD which reserves all rights in the material.

Disclosing and communicating a diagnosis

Once a diagnosis has been determined, it’s important to communicate the diagnosis clearly. We have a new, user-tested set of guidelines to do just that, along with a brief toolkit and infographic. You can find this at guidelines.alzheimer.ca

Cognitive decline and hearing loss

There is a clinically significant association between hearing loss and cognitive decline. Individuals with hearing loss demonstrate an accelerated rate of cognitive decline and an increased risk for cognitive impairment3. The potential mechanisms behind this relationship between hearing loss and cognitive loss, in particular the increased risk for incident dementia4, remain to be determined. Possible reasons for this association may include increased social isolation, changes to the brain, and/or a common process that is influencing both hearing and cognitive functioning in older individuals.

Below you will find some issues that may be common in your practice, some implications for assessment, and some suggestions for solutions you can implement to ensure that you are providing your patients with the best care possible.

As individuals age, they may experience changes in their auditory processing and/or cognitive abilities 

  • These changes may lead older individuals to require additional time to process and understand the sounds they hear3.
  • Ensure ample time for your assessments in order to maximize your patient’s ability to understand your questions, instructions, and/or important information you are sharing with them. Encourage the person to ask for repetitions.
  • If possible, involve a caregiver.
  • Provide patients with written instructions (e.g., take your Metoprolol with food or just after eating) that they can refer to at home.

People with hearing loss may be hesitant to seek help

  • The average time between an individual noticing a hearing loss and seeking help is 10 years4.
  • Do not assume that, simply because your patient does not own hearing aid(s), they do not have trouble hearing you.
  • There are a few simple questions you can ask to screen for hearing loss, e.g., “Do you find that you have to ask people to speak up?”; “Do you have to increase the volume on the radio or television in order to understand what is being said?”; “During conversations, does it sound like other people are mumbling?”; “Is it difficult for you to follow conversations when in a noisy restaurant?”
  • Consider investing in a personal amplification system, such as a “Pocketalker” to use during your appointments.
  • If you have a question about your patient’s hearing, refer them to an Audiologist. Throughout Canada, there are various options for funding both hearing tests and hearing devices such as hearing aids. Talk to an Audiologist to find out more.

Cognitive testing 

  • Cognitive testing such as the MMSE and the MoCA often rely on an individual’s ability to hear and respond to questions and instructions given5.Not taking hearing loss into account may result in an inaccurate assessment of cognitive ability.
  • Patients may not hear test questions and/or may not understand test instructions. This may result in an artificially low score on the cognitive test, which could in turn lead to over-estimation of the individual’s level of cognitive impairment.
  • Test patients in a quiet room, and ensure that the volume of your voice is appropriate. Consider using a personal amplification device.
  • Refer your patient to an ENT if they complain of ear pain or a plugged/fullness sensation; they may have ear wax build-up. Removal of wax can improve performance on measures of both hearing and cognition6,7.

Changes in behaviour

  • Changes in behavior (e.g. repetition, becoming upset easily, hallucinations) that are commonly attributed to the individual’s cognitive loss, may be related to disruptions in auditory processing and/or exacerbated by hearing loss.
  • When individuals with cognitive loss present to a clinic, many of their symptoms overlap with changes in behaviour related to hearing loss. For example, decreased speech understanding, increased requests for repetition, short-term memory problems, and difficulty following conversations may all be related to either hearing and/or cognitive loss.
  • Physicians may not automatically consider hearing loss as a factor in these symptoms.
  • Ensure that clients who own hearing aids are wearing them, that the wax guard in the aids is clear, and that the batteries are working.

Resources on cognitive decline and hearing loss

Joining up: Why people with hearing loss or deafness would benefit from an integrated response to long-term conditions, a report from Action on Hearing Loss and the Deafness Cognition and Language (DCAL) Research Centre, 2013.

The importance of considering hearing needs in individuals with cognitive impairment, ASC CDRAKE webinar, presented by Kate Dupuis, Clinical Neuropsychologist, and Debbie Ostroff, Registered Audiologist (May 14, 2014). You can also read the transcript.

Exploring the connections between hearing loss and cognitive health, a brainXchange webinar presented by Dr. Kate Dupuis, hosted by brainXchange in partnership with the Alzheimer Society of Canada and the Canadian Consortium on Neurodegeneration in Aging (CCNA).

Measuring the progression of Alzheimer's disease

Global Deterioration Scale

Some health-care providers use the Global Deterioration Scale, also called the Reisberg Scale, to measure the progression of Alzheimer's disease. This scale divides Alzheimer's disease into seven stages of ability.

Stage 1: No cognitive decline

  • Experiences no problems in daily living.

Stage 2: Very mild cognitive decline

  • Forgets names and locations of objects.
  • May have trouble finding words.

Stage 3: Mild cognitive decline

  • Has difficulty travelling to new locations.
  • Has difficulty handling problems at work.

Stage 4: Moderate cognitive decline

  • Has difficulty with complex tasks (finances, shopping, planning dinner).

Stage 5: Moderately severe cognitive decline

  • Needs help to choose clothing.
  • Needs prompting to bathe.

Stage 6: Severe cognitive decline

  • Loss of awareness of recent events and experiences.
  • Requires assistance bathing; may have a fear of bathing.
  • Has decreased ability to use the toilet or is incontinent.

Stage 7: Very severe cognitive decline

  • Vocabulary becomes limited, eventually declining to single words.
  • Loses ability to walk and sit.
  • Requires help with eating.

Adapted from: Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). Global Deterioration Scale. American Journal of Psychiatry, 139: 1136–1139.

Recommendations of the 5th Canadian Consensus Conference on Diagnosis and Treatment of Dementia

The 5th CCCDTD convened in October 2019 in Quebec City to address topics chosen by the steering committee to reflect advances in the dementia field and build on previous guidelines for the diagnosis and treatment of dementia.

Topics included:

  1. the National Institute on Aging research framework for Alzheimer's disease diagnosis;
  2. updating diagnostic criteria for vascular cognitive impairment, and its management;
  3. dementia case finding and detection;
  4. neuroimaging and fluid biomarkers in diagnosis;
  5. use of non-cognitive markers for better dementia detection;
  6. risk reduction/prevention;
  7. psychosocial and non-pharmacological interventions; and
  8. deprescription of medications.

Read the recommendations of the 5th CCCDTD.

Alzheimer Society resources

Some of the following resources are written for health-care providers and others are intended for individuals, caregivers, or both.

Health-care providers:

Individuals and caregivers:

References

References
  1. Feldman H, et al., Diagnosis and treatment of dementia. Canadian Medical Association Journal, 178 (March 2008), 825- 36.
  2. M. Masellis and S. E. Black. Assessing patients complaining of memory impairment. Geriatrics & Aging (April 08, volume 11, number 3)
  3. Gurgel RK et al. Relationship of hearing loss and dementia: A prospective, population-based study, Otology & Neurotology, 2014.
  4. Lin FR et al. Hearing loss and incident dementia”, Archives of Neurology, 2011, 68(2), 214-220.
  5. Schneider BA et al. Effects of senescent changes in audition and cognition on spoken language comprehension, The Aging Auditory System, Springer Handbook of Auditory Research, 2010, Vol. 34, 167-210.
  6. Davis A et al. Acceptability, benefit and costs of early screening for hearing disability: A study of potential screening tests and models, Health Technology Assessment Journal, 2007, 11(42):1-294.
  7. Pichora-Fuller MK et al. Helping older people with cognitive decline communicate: Hearing aids as part of a broader rehabilitation approach, Seminars in Hearing, 2013, 34(04): 308-330.
  8. Lewis‐Cullinan C, Janken JK, “Effect of cerumen removal on the hearing ability of geriatric patients”, Journal of advanced nursing, 1990, 15 (5), 594-600.
  9. Moore A et al. “Cerumen, hearing, and cognition in the elderly”, Journal of the American Medical Directors Association, 2002, 3 (3), 136-139.