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Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]

Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]

Evidence Syntheses - Agency for Healthcare Research and Quality (US)

Version: November 2013

Discussion

We did not identify any direct trial evidence demonstrating that screening for cognitive impairment improves health outcomes or important patient, family, or clinician decisionmaking outcomes. As such, our review primarily addressed two broad questions: 1) How well does screening detect dementia or MCI in primary care? and 2) How effective are interventions to improve patient or caregiver outcomes in people with screen-detected cognitive impairment (i.e., those with mild to moderate dementia or MCI)? Our review identified a very large body of well-conducted diagnostic accuracy studies that evaluated brief screening instruments in unselected older adults outside of specialty care (i.e., memory or neurology clinics). Despite this large number of studies, however, only a handful of instruments have been studied in more than one trial applicable to primary care (Table 16). Nonetheless, it is clear that several brief instruments can have sensitivity and specificity greater than 80 percent to detect dementia, regardless of etiology (e.g., AD vs. VaD). The MMSE (k=25) is the best-studied instrument; however, it has the longest administration time (up to 10 minutes) and is not available for public use (without cost). Other instruments with more limited evidence include the CDT (k=7), Mini-Cog (k=4), MIS (k=5), AMT (k=4), SPMSQ (k=4), FCSRT (k=2), 7MS (k=2), TICS (k=2; also not available for public use), and IQCODE (k=5). However, the AMT, SPMSQ, FCSRT, 7MS, and TICS have very limited evidence (only one study each) in English. Each of these instruments can have reasonable test performance; however, estimates of sensitivity and specificity vary, and the optimal diagnostic threshold/cut-point for many of these instruments is unclear. While other instruments appear promising, such as the 6-Item Screener, VAT, GPCOG, ADLs/IADLs, Benton's Orientation Test, Delayed Recall Test, and Short Concord Informant Dementia scale, they have only been studied once in primary care–relevant populations. No studies directly address the adverse psychological effects of screening or adverse effects from false-positive or false-negative testing. One fair-quality study found that approximately half the older adults who screened positive for cognitive impairment refused to complete a formal diagnostic workup.

Results

No trials examined the direct effect of screening for cognitive impairment on important patient outcomes, including decisionmaking outcomes. We identified 55 studies that address the diagnostic accuracy of brief screening instruments. The majority of these studies were not included in the prior USPSTF review. In order to be included in our review, the study had to assess the performance of an instrument that could be administered in less than 10 minutes or self-administered in less than 20 minutes. To facilitate discussion of results, we categorized these instruments as very brief (administered in ≤5 minutes), brief (within 6 to 10 minutes), or self-administered. We included 29 very brief instruments, 19 brief instruments, and 5 self-administered instruments (Table 1). All of these instruments can be administered and scored with minimal training.

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