Dementia is a growing public health concern with timely diagnosis an important part of high-quality care for older adults. Yet current evidence does not support routine screening of older adults for dementia (USPSTF 2020) resulting in commonly missed or delayed diagnosis of dementia (Bradford et al 2010). Missed or delayed diagnosis of dementia can lead to adverse outcomes, including increased morbidity of comorbid conditions, increased healthcare utilization, and caregiver burden. By recognizing the historical and clinical findings suggestive of dementia, clinicians can diagnose dementia earlier, giving clinicians more time for medical optimization and families and patients time to arrange for future needs.

Studies have demonstrated both practitioner and family ambivalence regarding diagnosing dementia at an early stage (Palazzo et al 2021). Many clinicians will wait until the diagnosis becomes obvious. Many patients are unaware of a problem or not ready to accept the diagnosis in the early stages. However, it is clinically and ethically responsible to disclose the diagnosis and offer supportive care as soon as the patient meets diagnostic criteria. Earlier diagnosis can be made easier by relying on objective and identifiable clues from the patient’s medical, family, and social history.

Clues from History of Present Illness & Social/Functional History:

The Alzheimer’s Association’s campaign to raise awareness of cognitive decline identified “10 Warning Signs of Alzheimer’s Disease” to prompt screenings and discussions with health care providers.  While these are intended for the public, application to a clinical setting is also warranted:

1. Memory loss that disrupts daily life (e.g., forgetting medications, meals, appointments, common objects like keys or wallet)
2. Challenges in planning or solving problems (e.g., how to manage car problems, difficulties with ordering medications)
3. Difficulty in completing familiar tasks (e.g., cooking, cleaning, laundry, bill paying)
4. Confusion with time or place (e.g., repeatedly forgetting where one lives (address, city, state), the date (year, month, day of week)
5. Difficulty understanding visual images and spatial relationships
6. New problems understanding words in speaking or writing (e.g., word finding or naming difficulties, problems speaking in coherent or grammatically appropriate sentences, compared with past abilities)
7. Misplacing things and losing the ability to retrace steps
8. Decreased or poor judgement
9. Withdrawal from work or social activities
10. Changes in mood and personality (e.g., irritability, anger, paranoid ideation, false beliefs that are new compared to 1-2 years ago)

Clues Identifiable by Clinicians  

Checking these components of a patient’s history will assist clinicians in forming a judgment regarding a patient’s pre-test probability of dementia and would ideally lead to administration of validated cognitive assessment tools

Past Medical History:

• Traumatic brain injury history
• Cardiovascular risks (e.g., diabetes, HTN, tobacco use, alcohol use, metabolic syndrome)
• Associated conditions: (trisomy 21, Parkinson’s disease, vascular disease)
• Diagnosis or reference to a memory disorder (e.g., dementia, “senility”, memory loss)

Social History:

• Age: prevalence increases with advanced age
• Family history of neurocognitive disorders

Medication List:

• Neurocognitive enhancing medications (e.g., acetylcholinesterase inhibitors, NMDA receptor antagonists
• Medications to treat Parkinson’s disease (e.g., carbidopa/levodopa, dopamine agonists, COMT inhibitors)
• Supplements sometimes used for neurocognitive enhancement (e.g., gingko biloba, fish oil, other cognitively focused supplements or vitamins)

If clues raise possibility of dementia, use a common clinically validated assessment and screening tools such as:

1. The Montreal Cognitive Assessment (MoCA):  https://www.mocatest.org
2. The Mini-Cog quick screen: https://mini-cog.com/
3. The St Louis University Cognitive Assessment (SLUMS): https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php