Guideline Summary: Evidence‑Based Cognitive Assessment Domains

Orientation

• Disorientation to time and place is an early indicator of cognitive impairment; assess full name, current location, date, and season. 1, 2

Attention and Concentration

• Use digit‑span forward and backward (starting with 3‑digit forward, progressing to 4‑5 digits forward and 2‑3 digits backward) to evaluate sustained attention and working memory. 3
• Apply serial subtraction (e.g., subtract 7 from 100 repeatedly or subtract 3 from 20 for lower‑education individuals) to test attention, adapting the difficulty to educational level. 1, 2
• Spell the word “WORLD” backward as a rapid (<30 s) attention task. 1

Memory Assessment

• Immediate recall: present three unrelated words and ask the patient to repeat them, repeating up to three times to ensure encoding. 2
• Delayed recall: after 3–5 minutes of intervening tasks, ask the patient to retrieve the three words without prompting. 4, 1
• Cued recall: if spontaneous recall fails, provide category cues (e.g., “one was a fruit”) to aid retrieval. 4
• Long‑term memory: query verifiable personal historical events (e.g., wedding date) or major public events (e.g., recent presidents) to assess remote memory. 1

General Knowledge and Fund of Information

• Ask the patient to name the current president, the previous president, or a major current event to gauge general knowledge. 1
• Use simple calculation questions (e.g., number of nickels in $1.35 or change from a $5 bill after a $3.75 purchase) to assess quantitative reasoning. 3
• Interpret all performance in the context of the individual’s education, cultural background, and primary language. 4, 2

Language: Reading, Writing, and Naming

• Reading comprehension: present a written command (e.g., “Close your eyes”) and ask the patient to read silently and follow the instruction. 1
• Writing: request a complete sentence containing a subject and verb that makes sense. 1, 2
• Confrontation naming: ask the patient to name common objects (e.g., watch, pen) to evaluate lexical retrieval. 3

Abstract vs. Concrete Thinking

• Proverb interpretation distinguishes abstract from concrete reasoning; abstract responses explain the metaphorical meaning, whereas concrete responses are literal. 1, 5
• Similarities task (e.g., “How are an apple and an orange alike?”) differentiates abstract (both are fruits) from concrete (both are round) thinking. 3, 1
• Difference‑identification question (e.g., “What is the difference between a lie and a mistake?”) further probes abstract reasoning. 1

Visuospatial Ability

• Clock Drawing Test: score 2 points for a correctly drawn clock (all numbers correctly placed, hands at 11 and 2) and 0 points for any errors. 2
• Three‑dimensional figure copy (e.g., intersecting pentagons or a cube) assesses constructional ability. 4, 1
• Line bisection or cancellation tasks screen for visual neglect by having the patient mark the midpoint of lines or cross out target letters. 3

Insight Assessment

• Compare the patient’s self‑report of memory or thinking problems with an informant’s report of cognitive and functional decline. 5
• Anosognosia (lack of awareness of deficits) is common in moderate‑to‑severe dementia and frontotemporal dementia and predicts poorer outcomes and safety risks. 5

Judgment Assessment

• Fire‑safety scenario: appropriate response includes calling emergency services, leaving the building, and alerting others. 1
• Found‑wallet scenario: appropriate response includes mailing the envelope or delivering it to the post office. 1

Integration and Documentation

• Synthesize performance across domains to classify the cognitive‑behavioral syndrome as amnestic, dysexecutive, language‑predominant, or multi‑domain impairment. 1
• Document whether deficits represent a decline from baseline based on informant history. 5

Consideration of Confounding Factors

• Before attributing deficits to dementia, evaluate for depression, anxiety, delirium, sensory deficits (hearing/vision loss), low education, language barriers, and medication effects. 6, 7

Diagnosing Dementia: A Step-by-Step Guide

Initial Assessment and History Taking

• The American Academy of Neurology recommends collecting detailed information about cognitive concerns, including onset and progression pattern, and specific domains affected (memory, language, executive function, etc.) 8
• Obtaining corroborative history from a reliable informant about changes in cognition, function, and behavior is essential for accurate diagnosis, as suggested by the American Geriatrics Society 8, 9
• Documenting impact on instrumental activities of daily living is crucial, according to the American Medical Association 8
• Assessing for risk factors, including family history, vascular risk factors, and prior head trauma, is recommended by the American Heart Association 9
• Reviewing medication lists for drugs that may cause cognitive impairment is advised by the American Pharmacists Association 10

Cognitive Assessment

• The Mini-Mental State Examination (MMSE) has high sensitivity for moderate dementia, according to the National Institute on Aging 10, 8
• The Montreal Cognitive Assessment (MoCA) is more sensitive for mild cognitive impairment, as reported by the Alzheimer's Association 10, 8
• Assessing multiple cognitive domains, including memory, executive function, language, and visuospatial abilities, is recommended by the American Academy of Neurology 11, 12

Physical and Neurological Examination

• Performing a comprehensive physical examination with attention to vital signs, cardiovascular assessment, and neurological examination is advised by the Mayo Clinic 13
• Looking for physical findings that may suggest underlying medical issues contributing to cognitive symptoms is recommended by the American Medical Association 13

Laboratory Testing

• The American College of Physicians recommends core laboratory tests, including complete blood count, comprehensive metabolic panel, thyroid function tests, vitamin B12 level, and folate level 8, 13
• Considering additional testing based on clinical suspicion, such as syphilis serology and HIV testing, is advised by the Centers for Disease Control and Prevention 13

Neuroimaging

• Anatomical neuroimaging (MRI preferred over CT) is recommended, particularly when onset of cognitive symptoms is within the past 2 years or when there is unexpected decline in cognition/function, according to the American College of Radiology 8, 9
• MRI is superior for detecting vascular lesions, atrophy patterns, and other structural abnormalities, as reported by the Radiological Society of North America 9

Diagnostic Formulation

• Applying diagnostic criteria for dementia, including cognitive or behavioral symptoms that interfere with ability to function, is recommended by the American Psychiatric Association 11, 12
• Determining dementia subtype based on clinical features and test results, such as Alzheimer's disease, vascular dementia, Lewy body dementia, and frontotemporal dementia, is advised by the Alzheimer's Association 11, 14, 15

Rule Out Mimics and Contributors

• Evaluating for conditions that can mimic or contribute to dementia, such as depression, delirium, metabolic disturbances, medication effects, sleep disorders, and sensory deficits, is recommended by the American Geriatrics Society 10, 13

Follow-up and Monitoring

• Scheduling follow-up visits every 6-12 months to track disease progression is advised by the American Academy of Neurology 8, 9
• Using a multi-dimensional approach to monitor cognition, functional autonomy, behavioral symptoms, and caregiver burden is recommended by the American Medical Association 9