Cognitive Impairment Evaluation and Treatment

Diagnostic Assessment

The American Academy of Neurology recommends conducting an objective cognitive evaluation immediately in patients with low cognitive confidence, as it may reflect real cognitive decline or be a manifestation of a psychiatric disorder 1, 2
The Montreal Cognitive Assessment (MoCA) is recommended as the first line to detect mild cognitive impairment 2, 3, 4
The Clock Drawing Test can be used as a complement to the MoCA 4
Obtaining a collateral history from a reliable informant using the AD8 or IQCODE is essential to assess changes in cognition, function, and behavior 3, 4, 5

The American Psychiatric Association suggests that low cognitive confidence often accompanies depression and anxiety 1, 6
The Patient Health Questionnaire-9 (PHQ-9) is recommended for screening depression 2, 3
The Generalized Anxiety Disorder 7-item scale (GAD-7) is recommended for screening generalized anxiety disorder 5

The American Academy of Neurology recommends assessing instrumental activities of daily living using the Pfeffer Functional Activities Questionnaire (Pfeffer FAQ) or the Disability Assessment for Dementia (DAD) 2, 3, 4
Focus on financial management, medication management, transportation, household tasks, cooking, and shopping 4

The American Academy of Neurology suggests investigating reversible causes, especially in patients with cognitive complaints and low cognitive confidence 1, 6
Thyroid function tests (TSH, free T4) are recommended 7, 4
Vitamin B12, folate, and homocysteine levels should be checked 7
A complete blood count and metabolic panel are recommended 7
Evaluation of untreated sleep apnea is essential 1, 6
Review of medications (anticholinergics, sedatives-hypnotics) is necessary 7

The American Academy of Neurology recommends structural neuroimaging (MRI or CT) if there are cognitive symptoms onset within the last 2 years, unexpected decline in cognition/function, or significant vascular risk factors 4, 7, 1, 6

If objective cognitive evaluation is normal, the probable diagnosis is Subjective Cognitive Decline (SCD) with dysfunctional metacognitive beliefs 5
Metacognitive Therapy (MCT) is a specific intervention for dysfunctional metacognitive beliefs measured by the MCQ-30 8
Cognitive training and modification techniques can be beneficial 8
Treatment of comorbid depression/anxiety is necessary if identified 5, 6
Annual follow-up with reevaluation is recommended if there is a positive collateral history 5
If objective cognitive impairment is detected, follow the dementia/CCL protocol 1, 2
Referral to a specialist (neurologist, geriatrician, geriatric psychiatrist) is recommended 7
Formal neuropsychological evaluation is necessary 4
Consider advanced biomarkers if Alzheimer's disease is suspected 7
Follow-up every 6-12 months is recommended 4, 7