Conversations aimed at reducing anxiety about cognitive decline should involve listening to patient and family concerns and discussing supportive or protective interventions. One option is for patients to participate in wellness and behavioral interventions aimed at preserving cognitive function. Strout and colleagues conducted a systematic review evaluating and summarizing behavioral interventions in current literature that targeted community-dwelling older adults in the prevention of cognitive decline.15 The authors identified interventions in the form of physical activity and intellectual stimulation that resulted in a statistically significant increase in measurements of cognition. Specifically, establishing or maintaining a realistic amount of physical activity and balanced nutritional intake, as well as eliminating intoxicants and carcinogens such as excessive alcohol and tobacco use, were found to be valuable. Tai chi was reported to be a powerful intervention that also included an important social component. Walking groups are also a worthy intervention to offer to patients. Intellectual stimulation includes learning new tasks such as learning to read music and play a musical instrument, as well as learning a new language. Many of the outcomes were strengthened or only seen when stimulating programming was performed in group settings, therefore supporting the value of socialization in cognition preservation.15
Brain-training exercises and programs have been explored widely in the literature and compliment the support demonstrated in Strout et al.15 Hill and colleagues conducted a systematic review aimed at summarizing the outcomes of computerized cognitive training for adults with mild cognitive impairment or dementia.16 The investigators found that the effects of such programs were small to moderate; however, changes in cognition and visuospatial skills were demonstrated. Lampit et al also conducted a systematic review on the same topic.17 An analysis of 52 studies concluded that computer training was best delivered at a minimum frequency of 3 short sessions per week in groups, and the training was modestly effective in maintaining cognition. Both of these reviews were limited to short-term outcomes.
Strout and Howard highlight the importance of addressing emotional wellness.18 This includes managing negative emotions by accepting one’s feelings, building resiliency, coping with depressive symptoms, and addressing stress with adaptive coping mechanisms. This domain of emotional wellness, as outlined in the Six Dimensions of Wellness Model, also emphasizes the importance of autonomy and aging in place. This research suggests that acceptance of aging and its potential limitations may have a protective effect on cognition. Collectively, these behavioral interventions focused on holistic wellness have promise for cognitive health and could provide hope for patients with identified cognitive decline. A notable advantage of these nonpharmacologic interventions is the safety and accessibility for older adults.
The World Health Organization (WHO) recently published dementia risk reduction guidelines with recommendations based on current evidence.3 The publication was derived derived from the greater WHO 70th World Health Assembly draft global plan on the public health response to dementia 2017-2025. The authors make recommendations of varying strength but overall support increased physical activity; tobacco cessation; a Mediterranean-like diet; reduced alcohol consumption; social activity; weight management; and management of conditions including hypertension, diabetes mellitus, dyslipidemia, depression, and hearing loss.
How to Screen for Cognitive Decline
Cognitive screening usually includes basic questions about a patient’s change in memory, language, or ability to complete routine tasks. The process of screening is most concisely available via the Alzheimer’s Association Cognitive Assessment Toolkit for providers.4 The screening algorithm includes the “trigger” scores that would suggest further evaluation for dementia or other causes of cognitive impairment. A positive screen would warrant that the clinician be prepared to know local resources for referral or the appropriate steps in working up differential diagnoses related to cognitive impairment.
The Alzheimer’s Association Cognitive Assessment Toolkit was the product of a synthesis review completed by Cordell et al in response to the Affordable Care Act Medicare Annual Well Visit requirement to screen for cognitive impairment in primary care.4 Participants in the workgroup were selected based on their expert knowledge in the field and were geographically dispersed throughout the United States. The group analyzed 5 systematic evidence review studies published after 2000. The goal of their review was to report a consensus on cognitive screening tools best suited for primary care settings. Cordell et al determined that there was not a consensus in the literature regarding validated screening tools.4 Rather, screening for dementia requires a stepwise approach and should not be limited to utilizing a single tool. Therefore, an algorithm was devised for the assessment of cognition to aid the primary care provider in determining if a full dementia evaluation is warranted.
Grober et al concluded that screening for dementia can be improved using 2-step screening methods with a strong support for informant-based screening.19 Informant-based screening outperformed patient-based screening, demonstrating a specificity of 92% vs 83%, respectively. The value of informant-based screening is that it is void of educational bias and therefore has promise for screening in lower education and lower socioeconomic settings, both of which are risk factors for underdiagnosed dementia. Informant-based screening should be a prioritized screening strategy in all settings in which a knowledgeable informant is available.19
Multiple systematic reviews have attempted to identify the best validated screening tools to use with both patients and informants in primary care settings. These reports fail to offer a consensus on the best tools; instead, they stress provider judgment and preference. Cordell et al4 and Paddick et al20 assessed the most widely used tools in separate meta-analyses. Primary care providers should consider the following patient-based tools for cognitive assessment: Mini-Mental Status Examination (MMSE), Mini-Cog, and Memory Impairment Screen (MIS). The MMSE remains the most used and studied tool with support for validation in low-literacy populations. For informant interviews, providers should consider a formal tool such as the General Practitioner Assessment of Cognition (GPCOG), 8-item Informant Interview to Differentiate Aging and Dementia (AD8), or the short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). These instruments have been validated in a primary care setting, require <5 minutes to administer, and are in the public domain. Providers should never underestimate the value of clinical judgment and understand that screening tools are imperfect and just a component in the suspicion of cognitive impairment.
Diagnosis of Dementia and When to Refer
Cordell et al define the need for a full dementia evaluation when brief assessments are positive for cognitive impairment.4 Clinicians need to know their limitations when assessing a patient with cognitive decline. It is reasonable to expect practitioners in primary care settings to complete some initial diagnostic testing to explore the range of differentials. Cordell et al recommend the following: a comprehensive neurologic examination; assessment of activities of daily living and independent activities of daily living functioning; evaluation for depression; medication review with side effect profile; and laboratory testing including thyroid-stimulating hormone, complete blood count, serum B12, folate, complete metabolic panel, and if at risk, testing for sexually transmitted infections including HIV and syphilis.4
The diagnostic guidelines for dementia in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition use the diagnosis label of “major neurocognitive disorder” and offer criteria to consider for a formal diagnosis.21 Neuroimaging is a consideration for a specific diagnosis should the results have meaning for further treatment or supportive care. For providers who are uncomfortable with diagnosing dementia, referrals should be considered after a discussion with patients and family members in a shared decision-making model. Providers most often equipped for dementia diagnosis and initial management include geriatricians, geriatric psychiatrists, neurologists, and neuropsychologists. Referral to these providers may make most sense when there is hope of participation in a clinical trial, ongoing research participant opportunities, or when specialized supportive therapeutics would aid in improving quality of life.21,22
Future of Dementia
Kostas-Polston et al wrote about the importance of shaping health through policy.23 They concluded that clinicians must acknowledge that political engagement is a professional obligation and that active participation in shaping policy is preferred over passive response. This can be accomplished through communicating with elected officials, including visits with staff, serving on advisory boards, belonging to professional organizations, promoting initiatives among peers and social media, speaking publicly, and writing about issues via Op-Ed pieces.23
The creation of the Annual Wellness Visit that includes cognitive screening is a major step in public policy. Building Our Largest Dementia (BOLD) Infrastructure for Alzheimer’s Act (S. 2076/H.R. 4256) became law in December 2018. This legislation, and now law, is focused on establishing Alzheimer disease Centers of Excellence, awarding cooperative agreements with public health departments, and increasing data collection and analysis.24 A component of this bill focused on prioritizing early detection and diagnosis, something that clinicians practicing in primary care are already well positioned to do.
Overall, dementia and Alzheimer disease awareness and advocacy are gaining momentum in the United States. Senator Susan Collins of Maine, Chair of the Special Senate Committee on Aging and founder of the Alzheimer’s Task Force in the Senate, secured an additional $425 million for Alzheimer disease research in 2018, the largest increase in history for such research. According to a statement released in the summer of 2019, “Unless we find ways to change the trajectory and stop this disease, the number of Americans with Alzheimer’s is expected to climb to nearly 14 million by 2050… Alzheimer’s is not only devastating for families but also ranks as our nation’s most costly disease.”25 The Committee on Aging is working toward the goal of preventing or effectively treating Alzheimer disease by 2025.26 This government support paired with the efforts of organizations such as the Alzheimer’s Association and the Alzheimer’s Impact Movement encourages that disease-modifiable treatments and quality-of-life interventions are on the brink of discovery. Therefore, primary care providers need to be primed in screening and early detection as therapies evolve.
Dementia is a collection of symptoms mostly presenting as cognitive decline. Advanced age and positive family history are the most significant risk factors for cognitive impairment. Screening for dementia in primary care settings is underutilized and lacks universal recommendations as well as consensus on the best tools to use. The most widely researched and utilized screening tools are the MMSE, Mini-Cog, and MIS for patients and the GPCOG, AD8, or the IQCODE for informants. Primary care clinicians should consider the available evidence-based resources and incorporate formal cognitive screening into annual preventive care visits with all adults aged 65 years and older. Early detection of dementia and related disease has been shown to improve outcomes. Primary care providers need to be prepared to overcome the barriers of fear, denial, lack of awareness, and lack of knowledge and to discuss the importance of screening, surveillance, and treatment options with patients and their families. Interventions to offer patients with cognitive decline include pharmacologic agents, emotional wellness, physical activity, diet, and brain-training programs. The future of dementia treatment is hopeful with increased organizational and government support of research and advocacy, and clinicians need to take an active role in policy initiatives. Although there are large gaps in research, there is increased focus on this topic that will hopefully result in universal evidence-based screening guidelines and treatment options.
Sean R. Sibley, MSN, APRN, FNP-C, is a lecturer at the School of Nursing, University of Maine and a nurse practitioner at Northern Light Cutler Health Center in Orono. Kelley Strout, PhD, RN, is an assistant professor at the School of Nursing, University of Maine in Orono. Patricia Poirier, PhD, RN, AOCN, is a professor at the School of Nursing, University of Maine in Orono.
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