Signs and Symptoms of Dementia and Brief Cognitive Tests Available in VA
A Synthesis of the Evidence
VA's Office of Geriatrics and Extended Care (OGEC), part of Patient Care Services, has primary responsibility for VHA initiatives regarding the treatment of dementia among Veterans. The OGEC convened a Dementia Steering Committee that requested VA's Health Services Research and Development Services' (HSR&D) Evidence Synthesis Program (ESP) to review the evidence on several important topics related to dementia.
Investigators with the ESP Center affiliated with the Portland VA Medical Center conducted a literature review to answer key questions regarding the signs and symptoms of dementia. They also assessed brief cognitive tests for dementia that are available within the VA healthcare system.
Investigators examined data from 37 studies to answer the following key questions:
- What signs and symptoms should prompt VA providers to assess cognitive function as part of an initial diagnostic workup for dementia?
- Which measures of cognitive function provide the optimal sensitivity, specificity, and time to completion among the measures available to VA providers?
- What are the adverse consequences of using these measures?
Findings regarding Question 1 showed that relatively few studies have rigorously evaluated signs and symptoms that may help distinguish people with mild to moderate dementia from individuals without dementia. Subjective memory complaints (SMC) and neuropsychiatric symptoms have been the best studied symptoms. The ability, however, of SMC to discriminate effectively between healthy elderly adults and those with dementia is uncertain. In populations with low rates of dementia, the absence of SMC may have some utility in excluding a diagnosis of dementia. In general, the absence of neuropsychiatric symptoms would not effectively rule out a dementia diagnosis, but the presence of certain symptoms such as apathy, delusions, and/or hallucinations was associated with a dementia diagnosis and may suggest the need for further evaluation.
With regard to Question 2, all six cognitive screening instruments available in VA test for recall ability, and five of the six measures assess executive function. The assessment of cognitive domains, such as orientation, abstraction, math, and language skills varies among the six measures. Variations are detailed in the report.
As for Question 3, investigators found no evidence on adverse effects of the six cognitive tests of interest to VA. However, studies report that high proportions of older adults are unwilling to be routinely tested for memory problems, or to undergo further diagnostic assessment for dementia after having positive results on cognitive screening tests. The high refusal rates of screening and diagnostic workup indicate the need for further research to understand the psychological burden associated with cognitive tests and assessment for dementia.
Efforts to improve dementia case finding in general practice settings may be hampered by the protean manifestations of the disease and the low sensitivity of many of the signs and symptoms encountered in practice. All of the signs and symptoms evaluated in this study were poorly sensitive in detecting mild dementia. This may reflect inter-individual variation in clinical manifestations of dementia, variations in the methods for detecting these signs and symptoms, or may simply be a reflection of the almost sub-clinical nature of early dementia. This study also found that the six cognitive tests available in VA all test for memory impairment, while apraxia and executive function (including a clock drawing test) are assessed in all measures except the BOMC (Blessed Orientation-Memory-Concentration).
To view the full reports, go to http://www.hsrd.research.va.gov/publications/esp/reports.cfm.
This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.
Reference: Kansagara D and Freeman M. A Systematic Review of the Signs and Symptoms of Dementia and Brief Cognitive Tests Available in VA. VA-ESP Project #05-225; 2010.
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