nursing assessment tools for dementia

Dementia is a progressive neurological disorder that impairs cognitive function, affecting an individual’s memory , thinking, reasoning, and daily functioning. It is not a single disease but rather an umbrella term that encompasses a range of conditions characterized by the decline of cognitive abilities beyond what is considered normal aging. The condition exerts a great impact not only on individuals but also on their families, caregivers , and society at large.

As the global population ages, understanding dementia becomes increasingly essential for nurses. This nursing note discusses into the various aspects of dementia , highlighting its causes, symptoms, diagnosis, medical management, and nursing interventions .

Table of Contents

What is dementia, statistics and incidences, clinical manifestations, assessment and diagnostic findings, pharmacological management, nursing assessment, nursing diagnosis, nursing care planning and goals, nursing interventions, documentation guidelines.

Dementia is a term used to describe a group of progressive neurological disorders that result in a decline in cognitive function and memory. It affects thinking, behavior, and the ability to perform daily activities. It often results from underlying medical conditions, substance use, or medication effects. It has a slow, insidious onset, and is chronic, progressive, and irreversible.

Cases of dementia are increasing due to the longer life expectancy of the world population.

• There are four clinical dementia syndromes accounting for 90% of all cases after excluding other common reversible causes of cognitive impairment .
• The rise in dementia and Alzheimer’s disease is alarming and is expected to double every 20 years, from 47 million people in 2015 to 75 million people in 2030 and 131 million in 2050.

The following are major etiologic categories for the syndrome of dementia:

• Dementia of the Alzheimer’s type. The exact disease of Alzheimer’s disease is unknown, but several theories have been proposed, such as reduction in brain acetylcholine, the formation of plaques and tangles, serious head trauma , and genetic factors. Pathologic changes in the brain include atrophy, enlarged ventricles, and the presence of numerous neurofibrillary plaques and tangles.
• Vascular Dementia. This type of dementia is caused by significant cerebrovascular disease. The client suffers the equivalent of small strokes caused by arterial hypertension or cerebral emboli or thrombi, which destroy many areas of the brain. The onset of symptoms is more abrupt than in AD and runs a highly variable course, progressing in steps rather than a gradual deterioration.
• Dementia due to HIV disease. The immune dysfunction associated with human immunodeficiency virus ( HIV ) can lead to brain infections by other organisms. HIV also appears to cause dementia directly.
• Dementia due to head trauma . The syndrome of symptoms associated with dementia can be brought on by a traumatic head injury .
• Dementia due to Lewy Body Disease. Clinically, Lewy Body disease is fairly similar to AD,; however, it tends to progress more rapidly, and there is an earlier appearance of visual hallucinations and Parkinsonian features (Rabins et al, 2006). This disorder is distinctive by the presence of Lewy bodies-eosinophilic inclusion bodies- seen in the cerebral cortex and brainstem (Andreasen and Black, 2006).
• Dementia due to Parkinson’s disease. Parkinson’s disease is caused by a loss of nerve cells in the substantia nigra of the basal ganglia. The symptoms of dementia associated with Parkinson’s disease closely resemble those of AD.
• Dementia due to Huntington’s disease. This disease is transmitted as a Mendelian dominant gene, and damage occurs in the areas of the basal ganglia and the cerebral cortex.
• Dementia due to Pick’s disease. Pathology occurs from atrophy in the frontal and temporal lobes of the brain. Symptoms are strikingly similar to those of AD, and Pick’s disease is often misdiagnosed as AD.
• Dementia due to Creutzfeldt-Jakob disease. This form of dementia is caused by a transmissible agent known as a “slow virus” or prion. The clinical presentation is typical of the syndrome of dementia and the course is extremely rapid, with progressive deterioration and death within one year after onset.
• Dementia due to other general medical conditions. A number of other general medical conditions can cause dementia. Some of these include endocrine conditions, pulmonary disease, hepatic or renal failure , cardiopulmonary insufficiency, fluid and electrolyte imbalances , nutritional deficiencies, frontal or temporal lobe lesions, uncontrolled epilepsy , central nervous system or systemic infections, and other neurological conditions.
• Substance-induced Persisting Dementia. This type of dementia is related to the persisting effects of substances such as alcohol, inhalants, sedatives, hypnotics , anxiolytics, other medications, and environmental toxins.

The following symptoms have been identified with the syndrome of dementia:

• Memory impairment. Impaired ability to learn new information or to recall previously learned information.
• Impairment in abstract thinking , judgment, and impulse control.
• Impairment in language ability , such as difficulty naming objects. In some instances, the individual may not speak at all ( aphasia ).
• Personality changes are common.
• Impaired ability to perform motor activities despite intact motor abilities (apraxia).
• Disorientation.  Patients may feel disoriented regarding their current place, time, o names of persons they are close with.
• Wandering.  Because of disorientation , patients with dementia may often wander from one place to another.
• Delusions are common (particularly delusions of persecution).

Laboratory tests can be performed to rule out other conditions that may cause cognitive impairment .

• Complete blood cell count (CBC). Abnormalities in complete blood cell count and cobalamin levels require further workup to rule out hematologic disease.
• Liver enzyme levels. Abnormalities found in screening of liver enzyme levels require further workup to rule out hepatic disease.
• Thyroid-stimulating hormone (TSH) levels. Abnormalities in thyroid-stimulating hormone levels require further workup to rule out thyroid disease.
• Rapid plasma reagent. Abnormalities in rapid plasma reagent (RPR) require further workup to rule out syphilis.
• HIV serology. Abnormalities in HIV serology and/or PCR require further workup to rule out HIV/ AIDS .
• Paraneoplastic antibodies. Abnormalities in paraneoplastic antibodies require further workup to rule out autoimmune encephalitis .
• CSF proteins. Abnormalities in CSF proteins tau, P-tau, and 14-3-3 require further workup to rule out Creutzfeldt-Jakob disease.

Medical Management

To date, only symptomatic therapies are available and thus do not act on the evolution of the disease.

• Experimental therapies. A variety of experimental therapies have been proposed for dementia; these include anti-amyloid therapy, reversal of excess tau phosphorylation, estrogen therapy, vitamin E therapy, and free radical scavenger therapy; however, the results of these studies have yielded disappointing results.
• Dietary measures. There are no special dietary considerations for dementia; however, caprylidene (Axona) is a prescription medical food that is metabolized into ketone bodies, and the brain can use these ketone bodies for energy when its ability to process glucose is impaired. Brain-imaging scans of older adults and persons with dementia reveal a dramatically decreased uptake of glucose .
• Physical activity. Routine physical activity and exercise may have an impact on dementia progression and may perhaps have a protective effect on brain health; the patient’s surroundings should be safe and familiar; maintaining structured routines may be helpful to decrease patient’s stress in regard to meals, medication , and other therapeutic activities aimed at maintaining cognitive functioning.

The mainstay of therapy for patients with dementia is the use of centrally acting cholinesterase inhibitors to attempt to compensate for the depletion of acetylcholine in the cerebral cortex and hippocampus.

• Cholinesterase inhibitors. Cholinesterase inhibitors are used to palliate cholinergic deficiency.
• N-Methyl-D-Aspartate antagonists. The only drug in the N-methyl-D-aspartate (NMDA) antagonist class that is approved by the US Food and Drug Administration is memantine; this agent may be used alone or in combination with AChE inhibitors.
• Nutritional supplement. Medical foods are dietary supplements intended to compensate specific nutritional problems caused by a disease or condition; caprylidene is indicated for clinical dietary management of metabolic processes associated with mild to moderate dementia.

Nursing Management

The nursing management of a client with dementia includes the following:

Assessment of a client with dementia includes the following:

• Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status with a thorough description of behavior, flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgment.
• Serial assessment . Serial assessment of psychiatric status is necessary for determining the fluctuating course and acute changes in mental status, interviews with family members should be included and can be crucial in the treatment of infants and young children with cognitive disorders.

Nursing diagnoses that you can use for developing nursing care plans for patients with dementia include:

• Risk for trauma related to disorientation or confusion .
• Risk for self-directed or other-directed violence related to delusional thinking.
• Chronic confusion related to alteration in structure/function of brain tissue.
• Self-care deficit related to cognitive impairment .
• Risk for falls related to cognitive impairment.

The major nursing care planning goals for dementia are:

• The client will accept explanations of inaccurate interpretations within the environment.
• With assistance from the caregiver , the client will be able to interrupt non-reality-based thinking.

The nursing interventions for a dementia client are:

• Orient client. Frequently orient the client to reality and surroundings. Allow the client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation.
• Encourage caregivers about patient reorientation. Teach prospective caregivers how to orient clients to time, person, place, and circumstances, as required. These caregivers will be responsible for client safety after discharge from the hospital.
• Enforce positive feedback. Give positive feedback when thinking and behavior are appropriate, or when the client verbalizes that certain ideas expressed are not based in reality. Positive feedback increases self- esteem and enhances the desire to repeat appropriate behavior.
• Explain simply. Use simple explanations and face-to-face interaction when communicating with clients. Do not shout messages into the client’s ear. Speaking slowly and in a face-to-face position is most effective when communicating with an elderly individual experiencing hearing loss.
• Discourage suspiciousness of others. Express reasonable doubt if the client relays suspicious beliefs in response to delusional thinking. Discuss with the client the potential personal negative effects of continued suspiciousness of others.
• Avoid the cultivation of false ideas. Do not permit the rumination of false ideas. When this begins, talk to the client about real people and real events.
• Observe the client closely. Close observation of the client’s behavior is indicated if delusional thinking reveals an intention for violence. Client safety is a nursing priority.

The outcome criteria for a patient with dementia include:

• With assistance from the caregiver, the client is able to distinguish between reality-based and non-reality-based thinking.
• Prospective caregivers are able to verbalize ways in which to orient clients to reality, as needed.

Documentation needed for a client with dementia include the following:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Sources and references for this study guide for delirium :

• Black, J. M., & Hawks, J. H. (2005).  Medical- surgical nursing . Elsevier Saunders,.
• Videbeck, S. L. (2010).  Psychiatric- mental health nursing . Lippincott Williams & Wilkins.

2 thoughts on “Dementia”

Reorientation can be extremely stressful and damaging to patients with dementia, not to mention the caregiver. Current advice revolves around the idea of redirection, distraction, and reassurance to the patient.

I agree with Katie . Orientation needs to be done with sensitivity and care to avoid distressing the pwd and damaging their self esteem. It is more effective at the very early stages of dementia when most of their cognitive functioning is still intact but as the disease progresses its kinder not to challenge them. Correcting them when they are struggling to make sense of the world and their ability to retain new information is hampered, only serves to upset them and doesn’t improve the quality of their life

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Assessment scales in dementia

Dementia involves progressive and often remorseless decline in cognition, function, behaviour and care needs. Assessment in dementia relies on collateral as well as patient-derived information. Many assessment scales have been developed over decades for use in dementia research and care. These scales are used to reduce uncertainty in decision making, for example in screening for cognitive impairment, making diagnoses of dementia and monitoring change. Ideal scales used in dementia should demonstrate face validity and concurrent validity against gold standard assessments, should be reliable, practical, and should rely on objective rather than subjective information. Assessment scales in the domains of cognition, function, behaviour, quality of life, depression in dementia, carer burden and overall dementia severity are reviewed in this article. The practical use of these scales in clinical practice and in research is discussed.

Introduction

Dementia is a term for a clinical syndrome characterized by progressive acquired global impairments of cognitive skills and ability to function independently. Many patients show varying levels of behaviour disturbance at some point in the illness. Care burden, for family carers as well as state/other care funders, increases as the condition progresses. The syndrome is caused by many diseases, with Alzheimer’s disease, vascular dementia and dementia with Lewy bodies together accounting for around 90% of cases. Incidence and prevalence of dementia are strongly age dependent. With global aging of populations, dementia prevalence is rising and is projected to continue to do so for much of the present century. The collateral damage in dementia is vast. Carer burden in terms of physical work, psychological distress and financial obligations is great. Many nonspecialist branches of medicine now operate some system for screening for and diagnosing dementia – for example, primary care, neurology or general hospital inpatient services. Rating scales are often advocated for use in influential guidelines [ NICE, 2006 ].

A vast industry in generation, validation and reporting of properties/utility of rating scales in most branches of medicine, including dementia, has emerged. Many scales have been devised just in the field of dementia [ Burns et al . 2002 ]. The purpose of an assessment scale is to increase the precision of a decision by reducing subjectivity and increasing objectivity; for example, using a cognitive screening test score to screen for underlying dementia, to distinguish impairment due to dementia from normal age-related cognitive change or to monitor the effects of treatment of dementia in a clinic or controlled trial. The properties of an ideal assessment scale would be that it is valid, that is, it has face validity (experts like clinicians, patients and carers would agree that the questions are relevant and important), that it has construct validity (it measures the construct it was designed to measure), concurrent validity (when used alongside a gold standard assessment like a very well validated scale or an expert clinical assessment, it performs well), that it shows reliability – typically inter-rater reliability (two or more raters using the scale in the same subjects and conditions come up with the same result) and test–retest reliability (the same rater using the scale on another occasion in the same subject comes up with the same result). Importantly, it should be practical to use – in practice, this often depends on it being short (so it can be used in busy clinical practice or as an outcome measure in a trial such that participants are not overburdened by long interviews) and acceptable – so it does not upset, exhaust or embarrass the patient or assessor. The key task in using assessment scales in dementia (as in any field) is clarifying what they are to be used for, and by whom. Scales are frequently misunderstood and misused, wasting patients’, carers’ and assessors’ time. Another aspect of dementia which distinguishes it from other progressive neurological disorders is the increased reliance on others to assess clinical and practical problems. Dementia may from its earliest stages affect judgement, speech and memory, making patient judgements less reliable. Proxies such as family or professional carers need to be consulted at all stages in the care journey, altering the traditional assessment method to a shared patient/carer encounter (for example, the combination of a patient-facing cognitive assessment with a structured or unstructured informant interview in diagnosing dementia). This is directly relevant to the choice of assessment scales to be used in dementia care and research. In particular, judgements about functional impairment, quality of life and behaviour problems may have to be mainly, or entirely, derived from proxy reports.

An overview of assessment scales in dementia

In clinical practice and in research, cognition is considered the key change we want to observe in people with dementia. Diagnostic criteria for dementia depend on the presence of cognitive impairment [ APA, 2000 ], and other aspects of the clinical picture in dementia (behaviour, impairment in function, increased costs, carer stress) ultimately derive from impaired cognition. Function refers to abilities to carry out activities of daily living, a direct consideration at the point of diagnosis of dementia [ APA, 2000 ] and also in assessing change and planning care interventions. Behaviour changes seen in dementia, often referred to as Behavioural and Psychological Symptoms in Dementia (BPSD) are of special importance in influencing prescribing (often hazardous), institutionalization of patients and carer stress. Proper evaluation of interventions for BPSD can only be carried out using reliable scales. Quality of life (QOL) is a multidimensional concept which reflects the patient’s perception of the effect of their illness on their everyday physical and emotional functioning. Measurement of QOL is increasingly popular. In dementia, subjective evaluations are frequently impossible, and patients and carers have very different ratings of QOL. Scales for measuring QOL include patient and proxy versions, and generic and dementia-specific scales. Depression is common in dementia; rating this fundamentally subjective experience is especially challenging in patients with cognitive impairment. Carer burden is a major issue in dementia; service- and research-level interventions may look to measure effects on carers using generic measures of psychological distress or measures designed specifically to measure carer burden. Overall dementia severity assessments are designed to assign a level of severity to a patient’s condition, and are especially useful in assorting cases in research or service development. This paper considers scales used for each of these areas.

Cognition: screening for dementia

Scales in this section are included as they are used in clinical or research settings to screen for dementia, are brief (under 30 min), involve professionals interacting with patients and have been either recommended in reviews or guidelines [ Brodaty et al . 2006 ; Holsinger et al . 2007 ; Milne et al . 2008 ; Appels and Scherder, 2010 ], or widely reported. Psychometric properties for each scale are summarized in Table 1 . It should be noted that single cutoffs are never clearly best on any screening scale – those quoted have good combinations of sensitivity and specificity.

Short dementia screening tests suitable for primary and secondary care.

Bold text indicates scoring direction of positive screen for dementia.

ACE-R, Addenbrookes Cognitive Assessment – Revised; AMTS, Abbreviated Mental Test Score; DSM, Diagnostic and Statistical Manual of Mental Disorder ; GPCOG, General Practitioner assessment of Cognition; MIS, Memory Impairment Screen; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; TYM, Test Your Memory.

Abbreviated Mental Test Score

The Abbreviated Mental Test Score (AMTS) [ Qureshi and Hodkinson, 1974 ] is a 10-item scale derived from a longer scale introduced previously [ Hodkinson, 1972 ]. Any clinician can use this, and it takes only 3–4 min. It assesses orientation, registration, recall and concentration, and scores of 6 or below (from maximum of 10) have been shown to screen effectively for dementia, though as with many brief screens, low positive predictive values mean a second-stage assessment is always necessary [ Antonelli Incalze et al . 2003 ]. Its brevity and ease of use have made it popular as a screening test in primary and secondary care nonspecialist settings.

Clock drawing

Numerous versions of the clock-drawing test have been devised, with many scoring algorithms [ Brodaty and Moore, 1997 ]. Patients are typically asked to draw a clock face with numbers and hands (indicating a dictated time). It was designed as a quick and acceptable screening test for dementia. It is fast, requires no training and most scoring methods are fairly simple. It shows fairly good sensitivity and specificity as a screening test. It assesses only a very narrow part of cognitive dysfunction seen in dementia, and many other conditions (e.g. stroke) will affect it directly.

The Mini-Cog [ Borson et al . 2000 ] is a very short test (3 min) suitable for primary care screening for dementia. It incorporates the clock-drawing test, adding a three-item delayed word recall task. It showed comparable sensitivity and specificity to the Mini-Mental State Examination (MMSE) in classifying community cases of dementia [ Borson et al . 2003 ].

The 6-CIT [ Brooke and Bullock, 1999 ] was designed for screening in a primary care setting. It takes 3–4 min to administer, and scoring is between 0 and 28, with cutoffs of 7/8 showing good screening sensitivity and specificity. It is easy to administer, though scoring is less intuitive than AMTS.

Test Your Memory

The Test Your Memory [ Brown et al . 2009 ] test is a recently developed 10-item cognitive test designed to be self-administered under medical supervision. The maximum score is 50; at a score of 30 or below, the test has good specificity and sensitivity [comparable to MMSE and Addenbrookes Cognitive Assessment – Revised (ACE-R)] in distinguishing dementia from nondementia cases [ Hancock and Larner, 2011 ]. This form of test may be attractive for time-limited clinicians wanting to screen for dementia, especially in primary care.

General Practitioner assessment of Cognition

The General Practitioner assessment of Cognition (GPCOG) [ Brodaty et al . 2002 ] was designed for use in primary care and includes nine direct patient cognitive items, and six informant questions assessing change over several years. In total, it takes about 6 min. It has strong performance on sensitivity and specificity versus MMSE in detecting dementia in a typical primary care population [ Ismail et al . 2009 ].

Memory Impairment Screen

The Memory Impairment Screen is a very brief four-item scale taking under 5 min to administer, and showing good sensitivity and specificity in classifying dementia [ Buschke et al . 1999 ]. It lacks executive function or visuospatial items. Its use is likely to be confined to primary care, as an alternative to GPCOG, 6-CIT, clock-drawing, Mini-Cog or AMTS.

Mini-Mental State Examination

The MMSE [ Folstein et al . 1975 ] is by some way the best known and most widely used measure of cognition in clinical practice worldwide. This scale can be easily administered by clinicians or researchers with minimal training, takes around 10 min and assesses cognitive function in the areas of orientation, memory, attention and calculation, language and visual construction. Patients score between 0 and 30 points, and cutoffs of 23/24 have typically been used to show significant cognitive impairment. It is widely translated and used. A standardized version [ Molloy et al . 1991 ] improves its reliability, and is probably most important for research settings. The MMSE is unfortunately sometimes misunderstood as a diagnostic test, when it is in fact a screening test with relatively modest sensitivity. It has floor and ceiling effects and limited sensitivity to change. This in theory should limit its wider use in detecting change in clinical work and in research studies, though in these contexts it is still widely used, and even advocated [ NICE, 2006 ].

Montreal Cognitive Assessment

The Montreal Cognitive Assessment [Nasreddine et al . 2005] was originally developed to help screen for mild cognitive impairment (MCI). It takes minimal training and can be used in about 10 min by any clinician. It assesses attention/concentration, executive functions, conceptual thinking, memory, language, calculation and orientation. A score of 25 or lower (from maximum of 30) is considered significant cognitive impairment. It performs at least as well as MMSE, including in screening for dementia. It has been widely translated. As it assesses executive function, it is particularly useful for patients with vascular impairment, including vascular dementia.

Addenbrookes Cognitive Assessment

The ACE [ Mathuranth et al . 2000 ] and its commonly used revision the ACE-R [ Mioshi et al . 2006 ] was originally developed as a screening test for dementia which, unlike the MMSE, would rely less on verbal than on executive abilities. It takes 15–20 min to administer and includes the items which lead to a MMSE score. It has been shown to have very high reliability and excellent diagnostic accuracy, and it is a practical option for clinical services intent on precision in diagnoses.

Longer cognitive assessments

Alzheimer’s disease assessment scale – cognitive section.

The Alzheimer’s Disease Assessment Scale – Cognitive section (ADAS-Cog) [ Rosen et al . 1984 ] is a detailed cognitive assessment for dementia, and takes a trained interviewer about 40 min to administer. It covers all cognitive areas in dementia and has good sensitivity to change.

The length of the assessment makes it generally unsuitable for clinical settings, but it is included as it is the leading assessment of cognitive change in drug trials in dementia, with a four-point difference between treatment groups considered clinically important [ Rockwood et al . 2007 ].

Cambridge Assessment of Memory and Cognition

The Cambridge Assessment of Memory and Cognition [ Roth et al . 1986 ] is the cognitive section of the comprehensive CAMDEX assessment. It covers a range of cognitive functions, including orientation, language, memory, attention, praxis, calculation, abstract thinking and perception. It takes around 25–40 min for a clinician to administer and requires a modest degree of training. It performs well against MMSE with no ceiling effects and conventional cutoffs of 79/80 have demonstrated excellent sensitivity and specificity for dementia [ Huppert et al . 1995 ]. Its combination of breadth and relative brevity make it suitable for clinical use, particularly new assessments of patients in memory clinics. It has the added advantage of including questions to generate an MMSE score.

Bristol Activities of Daily Living Scale

The Bristol Activities of Daily Living Scale (BADLS) [ Bucks et al . 1996 ] was designed specifically for use in patients with dementia and covers 20 daily living activities. It takes a carer (professional or family) 15 min to administer. It is sensitive to change in dementia and short enough to use in clinical practice (carers may fill it in while clinicians are performing direct assessment of patients). It is regularly used as an outcome measure in clinical trials, where it is world leading as a dementia-specific measure. This outcome is among those recommended by a consensus recommendation of outcome scales for nondrug interventional studies in dementia [ Moniz-Cook et al . 2008 ].

Barthel Index

The Barthel index [ Mahoney and Barthel, 1965 ] is probably the best known assessment of functional ability for older people. It takes 5 min of informant’s time and has been widely translated and validated. It focuses on physical disability in 10 domains and should not be used other than to assess physical functional deficits in people with dementia, among whom cognitive deficits tend to confound assessment.

The Functional Independence Measure

The Functional Independence Measure [ Keith et al . 1987 ] measures overall disability. It is observer rated and covers multiple important domains, including self-care, sphincters, mobility, communication, psychosocial function and cognition. Some training is required for its use. A UK version is available and it has been used in repeated observations of inpatients in general hospital [ Zekry et al . 2008 ]. It is therefore an example of a scale which addresses cognitive as well as physical function, and is likely to be especially useful in inpatient or rehabilitation settings.

Instrumental Activities of Daily Living

The Instrumental Activities of Daily Living scale [ Lawton and Brody, 1969 ] takes 5 min for a basically trained interviewer to assess ability in eight complex daily living tasks such as telephone use, shopping, housekeeping and finances. These abilities are more complex than the more basic abilities assessed by the Barthel scale, and therefore more sensitive to the cognitive changes seen in dementia. It is very commonly used in European memory clinics [Ramirez-Diaz et al . 2005].

The Informant Questionnaire on Cognitive Decline in the Elderly

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) [ Jorm and Jacomb, 1989 ] is a questionnaire administered to an informant outlining changes in everyday cognitive function. It aims to establish cognitive decline independent of premorbid ability by concentrating on 16–26 (depending on version) functional tasks, including recall of dates/conversations/whereabouts of objects, handling finances and using gadgets. It takes about 10 min to administer, and is conventionally used at the assessment stage in diagnosing dementia, usually combined with a direct cognitive assessment of the patient. This combination increases accuracy of diagnoses versus cognitive assessment alone [ Jorm, 1994 ]. It is therefore suitable as a screening tool rather than in assessing change in function.

Neuropsychiatric Inventory

The Neuropsychiatric Inventory [ Cummings et al . 1994 ] assesses a wide range of behaviours seen in dementia for both frequency and severity. These include delusions, agitation, depression, irritability and apathy. The scale takes 10 min for a clinician to administer to a carer. It has good psychometric properties and is widely used in drug trials, while being short enough (especially with patients without a wide range of behavioural issues) to consider for use in clinical practice.

Cohen-Mansfield Agitation Inventory

The Cohen-Mansfield Agitation Inventory [ Cohen-Mansfield, 1986 ] takes 15 min for carers to rate, but requires some training. Up to 29 behaviours seen in dementia are rated for frequency – the lack of focus on severity is corrected by the breadth of behaviours covered. The behaviours covered include many of those found most disruptive, including verbal aggression, repetitiveness, screaming, hitting, grabbing and sexual advances. It is most commonly used in research settings.

The BEHAVE-AD [ Reisberg et al . 1987 ] takes 20 min for a clinician to use, and is therefore most commonly used in interventional research studies. It covers most of the important disruptive behaviours, including aggression, overactivity, psychotic symptoms, mood disturbances, anxiety and day/night disturbances. Respondents are asked about the presence of behaviours and how troubling they are. It is reliable, sensitive to change and to stage of disease.

Quality of life

Generic measures of quality of life.

The EuroQol measure [ EuroQol Group, 1990 ] is a short, freely available generic measure of health-related quality of life. It can be simply administered to patients or carers in the form of a very brief self-completed questionnaire. There are two core components to the instrument: a description of the respondent’s own health using a health state classification system with five dimensions, and a rating on a visual analogue thermometer scale. It takes 2 min to complete. Like many quality of life instruments, carer and proxy ratings diverge widely, many patients with dementia cannot fill out the instrument, and the chief use of EuroQoL in dementia is as a health utility measure for measuring the economic impact of interventions in trials.

Short Form-36

The Short Form-36 (SF-36) [ Ware and Sherbourne, 1992 ] and its shorter descendant the SF-12 [ Ware et al . 1996 ] are examples of generic measures of quality of life which use recall over particular periods of time (typically 1 or 4 weeks) and are used to estimate health burden in large populations. These instruments have been shown to have high rates of noncompletion among frail older people and especially among those with moderate to severe dementia. They may have limited use for carers of people with dementia, but probably cannot routinely be used in practice with patients.

Dementia-specific quality of life instruments

Alzheimer’s disease-related quality of life scale.

The Alzheimer’s Disease-related Quality of Life scale (QoL-AD) [ Logsdon et al . 1999 ] is a 13-item scale which has been extensively validated, is disease specific, can be completed by patient or carer and is suitable for use across the range of severity of dementia [ Hoe et al . 2005 ]. It takes 10–15 min to administer. Patient and proxy versions are available. In a controversial area, its disease- specific properties, along with those of the health-related quality of life in dementia instrument (DEMQOL), make it a leading choice if quality of life is to be assessed [ Moniz-Cook et al . 2008 ].

DEMQOL [ Smith et al . 2007 ] is a 31-item, disease-specific instrument for evaluating health-related quality of life in dementia, which shows comparable psychometric properties to the best available instruments and has been validated in a UK population. It has both patient-completed and proxy forms. Like QoL-AD, it is primarily likely to be used in research studies.

Depression in dementia

The geriatric depression scale.

The Geriatric Depression Scale (GDS) [ Yesavage et al . 1983 ] is the most commonly used assessment of depressed mood among older people, and has been shortened to numerous versions, including a popular 15-item version (GDS-15) [ Sheikh and Yesavage, 1986 ]. GDS-15 is usually self rated though can be rated by an assessor. It is sensitive to change and is reliable in older people in institutional care. It takes about 5–10 min to administer. Its major drawback in dementia is that it has been validated for people with mild dementia, but not for those with moderate to severe dementia (among whom completion rates may be low due to difficulty comprehending questions).

Cornell Scale for depression in dementia

The Cornell Scale [ Alexopoulos et al . 1988a ] is a 19-item scale in which questions are asked of the patient and the carer, meaning that the patient does not need to be able to answer questions for it to be used. The maximum score is 38. It has been validated patients with and without dementia [ Alexopoulos et al . 1988b ]. In patients with dementia, it is considered the gold standard for quantifying depressive symptoms.

The Montgomery Asberg Depression Rating Scale

The Montgomery Asberg Depression Rating Scale (MADRS) [ Montgomery and Asberg, 1979 ] takes about 15–20 min for a trained assessor to complete. It is useful among older patients in that mainly psychological rather than confounding physical symptoms are assessed. It is particularly sensitive to change and often used in interventional research but the same issues as with GDS will limit its usefulness outside mild dementia.

The Hamilton Depression Rating Scale

The Hamilton Depression Rating Scale [ Hamilton, 1960 ] is one of the most commonly used depression rating scales. It requires 20–30 min of questions in a semi-structured interview by a trained interviewer, and is therefore unlikely to be used in people with dementia. It is commonly used in antidepressant drug trials, and like MADRS, has a preponderance of psychological rather than physical items.

The Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale [ Zigmond and Snaith, 1983 ] is a popular screening test for depression and anxiety which was originally aimed at patients in hospital, though it has been used much more widely in recent years. It takes 3–5 min and is self-reported. Though easy to use and accurate at detecting depression, it has little practical use for older patients with significant cognitive impairment.

Carer burden

General health questionnaire.

The General Health Questionnaire, 12-item version [ Goldberg and Williams 1988 ] is a short self-rated scale designed to screen for psychological distress in the community. It is probably the most widely used and validated self-rated instrument for detection of psychological morbidity. It takes only a few minutes to administer.

Zarit Burden Interview

The Zarit Burden Interview [ Zarit et al . 1980 ] is a 22-item self-report inventory of direct stress to carers in caring; it was designed for carers of people with dementia and has demonstrated sensitivity to change. Being disease specific gives it primacy in the area.

Overall dementia severity

Clinical dementia rating.

The Clinical Dementia Rating scale [ Morriss, 1993 ] allows more reliable staging of dementia than MMSE, and is based on caregiver accounts of problems in daily functional and cognitive tasks. It takes only a few minutes for clinicians already familiar with individual cases, and classifies people with dementia into questionable, mild, moderate and severe.

Global Deterioration Scale

The Global Deterioration Scale [ Reisberg et al . 1982 ] is essentially for staging dementia and takes only 2 min once relevant clinical information has been collated. It has been well validated and classifies cases into seven stages from no complaints through to very severe. Like CDR, it is mainly used to assort cases by severity in research or in service development, as in an individual case, more subtle changes which are important may not be picked up.

Clinicians Global Impression of Change

The Clinicians Global Impression of Change (CIBIC-Plus) [ Schneider et al . 1997 ] is a comprehensive global measure of detectable change in cognition, function and behaviour, usually requiring separate interviews with patients and carers. It is therefore conceptually attractive for assessing progression, but requires a trained clinician and 10–40 min of interview time so may be unsuited to routine clinical practice.

A key consideration in deciding what dementia assessment scales to choose is to clarify the question being asked. Consensus guidelines have been attempted [ Ramirez Diaz et al . 2005 ; Moniz-Cook et al . 2008 ]. Most of the brief screening instruments like 6-CIT, clock drawing and AMTS are probably psychometrically as good as a common instrument like MMSE in screening for significant cognitive impairment, and are a little shorter. They lack the breadth of assessments in MMSE and are therefore to be used only in settings in which time or frailty make longer assessment impossible. The diagnosis of dementia is always based on a clear history and invariably involves collateral history from an informant along with direct patient assessment. Some comprehensive instruments to aid this diagnosis have been developed. In memory clinics, structured neuropsychological assessment and the use of IQCODE to detail cognitive change as observed by a carer are often used to improve precision of diagnostic decisions. In borderline or mild cases of dementia, assessments probably need to include assessments of at least this complexity, with important guidelines explicitly recommending this [ NICE, 2006 ]. Such assessments will usually involve assessment of premorbid ability and quantification of explicit cognitive deficits, including, but not limited to, memory, and establishing deficits compared with expected norms. Commonly, these specialist assessments involve a specially trained neuropsychologist. Scales like the ACE-R can easily be used in clinical settings by clinicians other than neuropsychologists. In monitoring progress over time, cognition (for example with MMSE, though subject to ceiling/floor effects and relatively insensitive to change), function (e.g. BADLS) or a generic measure of overall severity of dementia(e.g. Clinical Dementia Rating, Global Deterioration Scale, CIBIC) are often used. If cognitive performance is of specific interest, a well validated scale like ADAS-Cog is preferred, despite its length. For clinical trials in which cognition is of primary interest, a de facto gold standard of a four-point change on ADAS-Cog has been established [ Rockwood et al . 2007 ]. In assessing depression in dementia (Cornell scale) and carer stress (Zarit Burden Inventory) there are relatively clear leading assessment scales. Quality of life assessment in dementia is a minefield due to the disparity between patient and proxy ratings, and poor completion rates with more severe dementia. The recent introduction of dementia-specific scales for quality of life, which allow proxy ratings, is at least a significant step forward. Assessing change in behavioural symptoms in dementia is especially important in judging treatment effects (for example – has the patient improved during short-term treatment with antipsychotic medication enough to justify risks of continued prescribing?). Well established scales are available for this purpose. A general principle in dementia assessment is that disease-specific instruments are usually markedly superior in clarifying judgements made. Subject to limitations on clinical and research resources, these instruments should be considered first to maximize clinical practice. A great deal of effort goes into choosing and justifying primary outcome measures in research trials; as clarity about intervention effects is so important, basic familiarity with the strengths and weaknesses of commonly used assessment scales in dementia can help improve the rigour of clinical practice.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest statement: The author declares no conflicts of interest in preparing this article.

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Dementia Care

Effective dementia nursing diagnosis strategies.

Wading through the depths of dementia nursing diagnosis unveils the key to personalized care and enhanced patient well-being.

Key Takeaways

• Thorough cognitive evaluation crucial for dementia diagnosis accuracy.
• Tailored interventions promote safety, independence, and emotional support.
• Regular monitoring and adjustments essential for tracking progress and modifying care plans.
• Collaborative team approach vital for holistic, individualized dementia care.

Understanding Dementia Nursing Diagnosis

Assessment for Dementia Diagnosis

Implementing Nursing Interventions

• Maintaining a Safe Environment : By removing hazards and providing supervision, we strive to prevent accidents and ensure the safety of our patients.
• Assistive Devices and Adaptive Equipment : Encouraging the use of these tools promotes independence and enhances safety for individuals with dementia.
• Emotional Support and Communication Strategies : Tailoring our approaches to meet the unique needs of each patient is crucial for providing the necessary emotional support and effective communication.
• Caregiver Education and Training : Equipping caregivers with knowledge on dementia management and behavioral strategies is essential for successful implementation of nursing interventions.
• Promoting Consistent Daily Routine : Establishing a predictable daily schedule helps reduce confusion and provides a sense of stability for individuals with dementia.

Monitoring Progress and Adjustments

Collaborative Care in Dementia Treatment

• Multidisciplinary Team Approach
• Individualized Care Plans
• Comprehensive Care Model
• Emphasis on Communication and Coordination
• Holistic Approach to Dementia Care

Frequently Asked Questions

What is a nursing diagnosis for dementia?, what is a nanda nursing diagnosis for cognitive impairment?, can a nurse diagnose dementia?, what are the five nursing diagnosis?.

Albert brings a wealth of knowledge and expertise to our writing team. With a background in caregiving and a deep understanding of the challenges faced by caregivers, Albert’s writing resonates with authenticity and empathy. He is committed to delivering high-quality content that empowers and supports caregivers on their journey.

How to Identify Vascular Dementia with ICD Code

10 Reasons Dementia Patients Stare at You

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10 meaningful dementia tattoos symbolizing love and memory.

Intrigued by the profound symbolism and emotional depth, delve into the world of dementia tattoos to uncover their hidden meanings and powerful impact.

Rising Popularity of Dementia Tattoos

Practical Information and Medical Details

Medical Details Table:

Impact on Caregivers and Loved Ones

Starting Conversations and Raising Awareness

Considerations and Future Trends

• Personalized Touch: Future designs may focus on personal stories, incorporating elements that resonate with the individual's unique journey with dementia.
• Symbolic Significance: Choosing symbols that carry personal significance can add layers of meaning to the tattoo, serving as a powerful tribute to the memories shared with the person affected by dementia.
• Awareness and Advocacy: Customizing dementia tattoos with symbols like forget-me-not flowers or puzzle pieces not only adds a personalized touch but also serves as a conversation starter to raise awareness about memory-related disorders in a compassionate and impactful way.

Is There a Symbol for Dementia?

What is a tattoo that represents dementia?, what is the quote for dementia tattoos?, what is the flower for dementia awareness?, how can dementia tattoos symbolize love and memory for alzheimer patients.

Let's continue to stand in solidarity with those affected and advocate for better care and research.

10 Heartfelt Dementia Poems to Stir Emotions

Yearning for solace in the labyrinth of fading memories, 'Dementia Poem' invites you to unravel the profound tapestry of emotions waiting to be discovered.

The Art of Dementia Poems

Expressing Emotions Through Poetry

Impact on Dementia Awareness

• Educating about Care Challenges : Dementia poems provide insights into the daily hurdles faced by both individuals with dementia and their caregivers. They shed light on the need for patience, understanding, and specialized care to support those living with the condition.
• Promoting Compassionate Care : By sharing personal experiences and emotions through poetry, individuals can cultivate a deeper sense of empathy and compassion towards those affected by dementia. This heightened awareness encourages a more caring and supportive environment for individuals and their caregivers.
• Inspiring Supportive Communities : Dementia poems foster a sense of community and solidarity among individuals touched by the condition. They encourage open discussions, mutual support, and initiatives to improve dementia care practices, creating a more compassionate and inclusive society.

Finding Comfort in Poetic Verses

Empathy and Solace in Words

• Validation in Shared Emotions : Poems on dementia offer a profound sense of validation, allowing individuals to feel understood and connected in their struggles and triumphs.
• Empathy for the Journey : These poems reflect the challenges and joys of caring for loved ones with dementia, fostering empathy and understanding among readers towards those navigating this difficult journey.
• Community and Support : By emphasizing empathy, patience, and understanding, these poems create a sense of community and support for individuals affected by dementia, reminding them that they aren't alone in their experiences.

What Is the Poem About Dementia?

What are 3 things not to say to someone with dementia?.

• 'You should remember this'
• 'Do you remember me?'
• 'You're wrong'
• Use simple language
• Avoid rushing them
• Offer support and reassurance in a compassionate manner.

What Is the Average Age of Death for Someone With Dementia?

What stage of dementia is sundowning?, how can dementia poems and tattoos help in expressing emotions and memories.

Can words truly capture the essence of love, patience, and understanding needed to support individuals living with dementia? Let's continue to embrace empathy and compassion in our caregiving journey.

Assisted Living Dementia Care: A Comprehensive Guide for Families

Understanding Dementia Care in Assisted Living

The basics of assisted living and memory care, safety and security measures.

Staff Training and Specialized Care Approaches

How to Pay for Memory Care: Surprising Tips for Families

Exploring insurance and other payment options.

Selecting the Right Community for Your Loved One

Memory Care in Assisted Living: A Promising Third Option

Comparing Services Offered Across Different Facilities

Frequently asked questions about assisted living dementia care.

Senior Care Strategies and Support Systems

Enhancing Quality of Life in Dementia Care

Activities and therapies in dementia care.

Engaging Residents and Promoting Cognitive Health

The Importance of a Supportive Community Environment

Building relationships with caregivers and residents.

Planning for the Future

Next steps as you consider memory care options, keeping an open dialogue with your loved one.

Wrapping It Up: Empowering Families in Assisted Living Dementia Care Choices

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• NICE Guidance
• Conditions and diseases
• Mental health, behavioural and neurodevelopmental conditions

Dementia: assessment, management and support for people living with dementia and their carers

NICE guideline [NG97] Published: 20 June 2018

Tools and resources

• Information for the public

Tools to help you put the guidance into practice.

Implementation support

• My Choice: The information you need to help you to Live Well with Dementia  
• Measuring the use of NICE guidance: NICEimpact dementia  
• Measuring the use of NICE guidance  
• Webinar: Using NICE guidance to improve and evidence quality in adult social care (NICE/SCIE June 2019)  
• Quick guide: Dementia, discussing and planning support after diagnosis - for people with dementia and their family and carers  

Audit and service improvement

• Baseline assessment tool Excel 423 KB 20 June 2018  

Decision aids

• Patient decision aid on antipsychotic medicines for treating agitation, aggression and distress in people living with dementia PDF 437 KB 20 June 2018  
• Patient decision aid user guide on antipsychotic medicines for treating agitation, aggression and distress in people living with dementia PDF 173 KB 20 June 2018  
• Patient decision aid on enteral (tube) feeding for people living with severe dementia PDF 339 KB 20 June 2018  
• Patient decision aid user guide on enteral (tube) feeding for people living with severe dementia PDF 212 KB 20 June 2018  
• Patient decision aids information  

Shared learning

• Shared learning information  

Research recommendations

• Research recommendations information  

Guidance into practice

• About the Into practice guide  
• Practical steps to improving the quality of care and services using NICE guidance  

Cognitive Health Assessment (CHA) Trainings

The cornerstone of our program is a training on an annual screening tool for people 65 or older called the cognitive health assessment (CHA)

What is the cognitive health assessment?

The cognitive health assessment is an approach to screening older adults for dementia in primary care. It can be used like any annual approach to screening, including within the Medicare Annual Wellness Visit. It can also be used as the start of an evaluation for someone with symptoms of dementia. The assessment is completely free and uses instruments validated in primary care that are easy to score and available in multiple languages. And if someone screens positive, the CHA is the start of the next steps in a more thorough assessment and outlines the beginning of a brain health plan.

Take the cognitive health assessment training today!

By taking the training, learners will:

• Learn about dementia and screening tools for dementia.
• Have the confidence to screen for dementia in older adult patients in a primary care setting through examples of real-world implementation of the cognitive health assessment.
• Know how to start a brain health plan with a patient.
• Be able to bill for the assessment, including in patients with Medi-Cal only coverage using CPT code 1494F
• Receive FREE CE and CME/MOC

The cognitive health assessment training is available in two modalities.

1. Online Course: The self-paced e-Learning course includes modules that can be completed over more than one sitting. Eligible trainees can claim 1.5 CE/CME/MOC credit. Click below to sign up for the eLearning course.

2. Live Monthly Virtual Training:   Join us for the cognitive health assessment training on Zoom!  Dementia Care aware offers the CHA training as a FREE 1-hour virtual session multiple times each month to make it easy to find a training that fits your busy schedule. Led by Dementia Care Aware partners at the Alzheimer’s Association and University of California, Irvine and open for anyone who is interested. Eligible trainees can claim 1 free CE/CME/MOC credit with live attendance. 

Sign Up for Upcoming Virtual CHA Trainings

Learners only need to attend one live-virtual CHA training . Eligible learners can only claim one CE credit for the CHA training. No additional CE and CME/MOC is awarded should a learner attend more than one training.

12 to 1 p.m

Cognitive Health Assessment Training with Dr. Mary Norman

CHA in Action

These videos illustrate the cha in action - take a look and sign up for today, the cha administered by a primary care provider, the cha administered by an interprofessional team member, sign up for the cognitive health assessment elearning course today.

Equip your practice with the knowledge and resources to screen patients and make care plans.

Have questions about dementia care? Call our warmline for clinicians today at 1-800-933-1789!

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ALZHEIMER'S LOS ANGELES

Screening & assessment tools, alzheimer's los angeles.

Screening, Assessment, and Other Tools

Download validated cognitive screening tools, caregiver assessment tools, care plans, and caregiver tip sheets that can be used to improve detection of dementia and care management practices.

KAER Toolkit

• KAER Toolkit: 4-Step Process to Detecting Cognitive Impairment and Earlier Diagnosis of Dementia

Dementia Care Specialist Toolkit

Download the whole Toolkit:

or download individual components of the Toolkit:

Caregiver Assessment Tools

• Benjamin Rose Institute Caregiver Strain Instrument (validated tool)
• The Caregiver Self-Assessment Questionnaire (validated tool)
• REACH II Risk Appraisal (validated tool)
• Care Needs Assessment Tool

Validated Cognitive Screening Tools

• AD8 Dementia Screening Interview

Health Risk Assessment

• Health Risk Assessment Cognitive Impairment Trigger Questions

Tools for Identification of Caregivers

• Tool for Identifying Informal or Family Caregiver

Care Plans and Tip Sheets

• Best Practices Care Plans
• IDEA! Strategy for Managing Challenging Behavioral Symptoms
• Caregiver Tip Sheets

Project Replication Materials are available for use with permission from Alzheimer’s Los Angeles by sending a request to  [email protected]

Pages in the for Professionals section

If you are in an emergency, in crisis or need someone to talk to, there is help.

• Dementia: Screening & Assessment
• Screening & Assessment
• Resources & References

Text adapted from "The patient with dementia" in  Psychiatry in primary care by  Kenneth Le Clair, Dallas Seitz and Julia Kirkham .  (CAMH, 2019). 

Evaluating Cognitive Impairment and Dementia

Screening includes office-based assessments of cognitive function, as well as laboratory testing and neuroimaging. All patients suspected of having dementia should have a physical examination, including a screening neurological examination and review of medications, as a part of the evaluation.

Quick Cognitive Screening Tests

Mini-mental state examination.

The Mini-Mental State Examination (MMSE) is an 11-item test that takes five to 10 minutes to administer (Folstein et al., 1975).

• Scoring: suggested cut-off of 24 or less out of 30 should raise concerns about possible dementia.
• Performance affected by age and education
• Test items that are most sensitive to detection: orientation to date (especially year), delayed word recall and intersecting pentagons
• Pros: familiar and takes a relatively short time to administer
• Cons: takes longer than other similar tests; tests a limited number of cognitive domains (relatively less emphasis on memory and executive functioning); often not sensitive to early cognitive change

The Mini-Cog is a first-line cognitive screen for primary care, although it has not been evaluated as extensively as the MMSE or the Montreal Cognitive Assessment. The Mini-Cog combines the delayed three-word recall test and the clock-drawing test (Borson et al., 2000).

Delayed three-word recall test

• Tell the patient: “I am going to say three words. I want you to repeat them back to me.” Explain that you will later ask the patient to recall the words.
• Use the clock-drawing test (see below) as a distracter for the three-word recall. The scoring of the clock is similar to the Mini-Cog scoring described on page 229.
• Ask the patient to recall the three words.

Clock-drawing test

This test involves one item, and takes one to two minutes to administer.

• Test: “Please draw a clock and make the time show 10 minutes past 11:00.”
• Scoring: normal (perfect or near perfect) or abnormal by inspection; any abnormal clock should raise suspicion of dementia and prompt further evaluation.
• Pros: not influenced by age or education; easy, very quick and acceptable to most patients; some measure of visuospatial and executive function
• Cons: does not test memory or language abilities
• Recommended for detection and monitoring, including delirium

Scoring the Mini-Cog

• 3 out of 3 on delayed recall indicates normal; 0 out of 3 indicates likely dementia.
• 1 or 2 out of 3 on word recall: normal clock-drawing test = no dementia; abnormal clock-drawing test = dementia

Animal Naming

• This word-generation test asks patients to name as many four-legged animals as they can in one minute.
• Tell patients that the test is not a race and that they will have one minute to complete the test from the point that they say the first word.
• People with dementia are 25 times more likely to name fewer than 10 animals in one minute.

Montreal Cognitive Assessment (MoCA)

The MoCA is an 11-item test that takes 10 to 15 minutes to administer (Nasreddine et al., 2005).

• Scoring: total score possible is 30 (like MMSE); 26–30 = likely normal; 20–25 = possibly mild cognitive impairment or early dementia; < 20 = suspicious for dementia
• Good follow-up test if abnormalities are found on the clock-drawing test or Mini-Cog to further evaluate cognition and for people with cognitive complaints and normal scores on brief screening exams
• Test packages and instructions available online in multiple languages; adjustment for education included in the testing
• Pros: free, easy to access, available in more than 20 languages; sensitive for dementia and mild cognitive impairment; tests executive function in detail and features a more rigorous memory section; trail-making section for evaluating driving safety; very useful in primary care
• Cons: more time-consuming than other tests; may be frustrating for people with more advanced cognitive impairment; may be affected by sensory deficits such as visual or hearing impairment; may be affected by literacy and education level, which can limit the test’s utility in some populations. 

Laboratory Screening Tests

Routine laboratory tests should include:

• complete blood count
• serum electrolytes
• serum calcium
• TSH and glucose.

Further investigations that may be useful in evaluating for possible dementia include measures of renal function and liver enzymes, and an ECG.

Indications for Neuroimaging

Neuroimaging is not routinely recommended for evaluating dementia. Specific situations in which neuroimaging (CT scan of the head) should be considered include:

• age at dementia onset < 60
• focal neurological signs
• rapid progression of dementia
• recent head trauma
• use of anticoagulants
• unusual symptoms or gait disturbance.

Neuroimaging is also recommended to evaluate concomitant cerebrovascular disease because it may affect management.

In Dementia :

• The Primary Care Practitioner Role 
• Assessing dementia and cognitive impairment in the real world
• Beyond cognition: Five areas to assess in dementia
• Differentiating Types of Dementia
• Managing Challenging Behaviours Associated with Dementia
• Medications for Treating Behavioural and Psychological Symptoms

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Am Fam Physician. 2018;97(6):398-405

Related letter : More Evidence Needed Regarding the Utility of Genetic Testing for Alzheimer Dementia

Author disclosure: No relevant financial affiliations.

Dementia is a significant and costly health condition that affects 5 million adults and is the fifth leading cause of death among Americans older than 65 years. The prevalence of dementia will likely increase in the future because the number of Americans older than 65 years is expected to double by 2060. Risk factors for dementia include age; family history of dementia; personal history of cardiovascular disease, cerebrovascular disease, diabetes mellitus, or midlife obesity; use of anticholinergic medications; apolipoprotein E4 genotype; and lower education level. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults. If dementia is suspected, physicians can use brief screening tests such as Mini-Cog or General Practitioner Assessment of Cognition. If the results are abnormal, further evaluation is warranted using more in-depth screening tools such as the Montreal Cognitive Assessment, Saint Louis University Mental Status Examination, or Mini-Mental State Examination. Diagnostic testing and secondary evaluation, including screening for depression, appropriate laboratory studies for other conditions that cause cognitive impairment, and magnetic resonance imaging of the brain, should be performed when cognitive impairment is confirmed. Routine cerebrospinal fluid testing and genetic testing for the apolipoprotein E4 allele are not recommended.

Dementia is the fifth leading cause of death in Americans older than 65 years. The United States population is aging, with 46 million persons older than 65 years—a number that is expected to double by 2060. 1 Consequently, by 2050, the estimated number of Americans living with dementia will increase from 5 million to 14 million, and the estimated cost of dementia care will increase from $236 billion to $1 trillion. 2 Early recognition of cognitive impairment is integral to patient counseling, advance care planning, assessment of secondary or reversible causes of impairment, and consideration of medical therapy. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults. 3 , 4

This article focuses on the evaluation of patients with suspected dementia, including diagnostic criteria, brief screening tests suitable for use during primary care office visits, and diagnostic testing ( Figure 1 ) .

Epidemiology and Risk Factors

The overall prevalence of dementia is approximately 5%, increasing to 37% in persons older than 90 years. 5 The lifetime risk of dementia is approximately 17%, with the incidence doubling each decade after 60 years of age. 6 The median survival time after diagnosis of dementia is 4.5 years, but this varies based on age at diagnosis, ranging from 10.7 years for patients diagnosed in their 60s to 3.8 years for patients diagnosed in their 90s. 7 Alzheimer disease accounts for 60% to 80% of dementia cases. Vascular dementia in isolation accounts for 10% of cases, but it commonly presents as a mixed dementia with Alzheimer disease. Lewy body dementia, Parkinson-related dementia, normal-pressure hydrocephalus, and frontotemporal dementia represent most of the remaining cases. Frontotemporal dementia, while accounting for less than 10% of total dementia cases, represents 60% of dementia cases in patients 45 to 60 years of age. 2

Although the number of patients with dementia has risen with the aging population, longitudinal studies have demonstrated an overall decrease in prevalence since 2000, with a prevalence reduction ranging from 22% to 44% in recent studies. 8 – 11 This decrease mirrored a 25% reduction in deaths attributable to cardiovascular disease, a major risk factor for dementia, from 2004 to 2014. 12 The mechanisms of dementia are unclear, but increased education level and improved treatment of diabetes mellitus and cardiovascular disease are associated with lower dementia risk. 8 , 10 , 11

Older age remains the greatest risk factor for dementia. 13 Other strong risk factors include family history of dementia; personal history of cardiovascular disease, cerebrovascular disease, diabetes, or midlife obesity; use of anticholinergic medications; apolipoprotein E4 genotype; and lower education level. 14 – 17 Other potential risk factors with weaker supporting evidence include smoking; atrial fibrillation (independent of stroke risk); use of substances and medications such as alcohol, proton pump inhibitors, and benzodiazepines; and head trauma. 18 – 22

Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders , 5th ed., updated the diagnostic criteria for dementia and mild cognitive impairment, introducing the terms major and minor neurocognitive disorders. 23 Major neurocognitive disorder requires demonstration of significant cognitive decline in at least one of the following cognitive domains: complex attention, executive function, language, learning and memory, perceptual-motor, or social cognition. This decline must be based on both subjective and objective findings, and interfere with instrumental activities of daily living. Minor neurocognitive disorder requires only modest cognitive decline that does not interfere with instrumental activities of daily living. 23 Table 1 outlines the new diagnostic guidelines for neurocognitive disorders. 23 , 24

Initial History and Physical Examination

Concerns for early dementia may arise from the patient, the physician, or the patient's loved ones. Physicians can recognize signs of worsening cognitive function from aberrant patient behaviors, such as missed appointments or vague answers to questions. A history to evaluate for cognitive impairment should include the input of a reliable informant (e.g., family members, close friends, caregivers) because patients of ten have poor insight into their own functional status. 25 , 26 The history should include education level, timeline of symptom presentation, and speed of progression. 25 , 26 Table 2 outlines diagnostic clues for each cognitive domain. 23 , 24 Early in the disease course, dementia often impairs instrumental activities of daily living, such as paying bills, balancing the checkbook, or remembering to take medications. Disease progression may further impair activities of daily living, including difficulty with eating, bathing, dressing, toileting, walking and transferring, and continence.

Physicians should review the patient's medications for those that may affect cognition using a resource such as the American Geriatric Society's Beers Criteria (available online with registration at https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medicationuse-in-older-adults/CL001 ). 27 Recent hospitalization should increase suspicion for delirium. Physicians should screen for depression in patients who have abnormal cognitive evaluation findings, and should consider evaluating for cardiometabolic risk factors given their association with cognitive impairment. 24 , 26 Rapid onset and progression of symptoms (weeks to months) increase the likelihood of uncommon causes of cognitive impairment and should prompt subspecialty referral. The VITAMINS mnemonic (vascular, infectious, toxic-metabolic, autoimmune, metastasis/neoplasms, iatrogenic, neurodegenerative, systemic/seizure/sarcoid) is helpful when identifying causes of rapidly progressing symptoms. 28

Although physical examination findings are usually normal in patients with dementia, they can assist in identifying potentially reversible causes of cognitive decline, including hypothyroidism, vitamin deficiencies, neurosyphilis, intracranial tumors, normal-pressure hydrocephalus, depression, and hypoperfusion from heart failure. 26 , 29 Table 3 lists key findings suggestive of dementia etiologies. 23 – 27 , 30 – 32

Brief Initial Screening Tests for Cognitive Impairment

Brief screening tests are useful to quickly assess the need for further evaluation. In 2013, the Alzheimer's Association recommended three screening tests that could be completed within the time frame of a Medicare wellness visit: Mini-Cog, Memory Impairment Screen, and General Practitioner Assessment of Cognition. 33 These tools require less than five minutes to complete, can be administered by nonphysician personnel, and are validated in the primary care office setting. Subsequently, a systematic review called into question the sensitivity of the Memory Impairment Screen within well-designed studies. 34 The Ascertain Dementia 8-Item Informant Questionnaire is also a quick, validated, and sensitive screening tool. Guidelines advocate combining the Mini-Cog with this questionnaire. 29 , 35 Ascertain Dementia 8-Item Informant Questionnaire is also a quick, validated, and sensitive screening tool. Guidelines advocate combining the Mini-Cog with this questionnaire. 29 , 35

This article briefly discusses the screening tests. A more detailed discussion was published previously in American Family Physician . 36 Additional information can be found in the American Academy of Family Physicians National Research Network's Cognitive Care Kit at http://www.aafp.org/patient-care/public-health/cognitive-care.html .

The Mini-Cog test (available for free at http://mini-cog.com ) takes approximately three minutes to administer and has minimal to no language or education bias. 33 , 37 The patient is instructed to repeat three unrelated words, perform a clock drawing test, and then recall the three words. 29 The Mini-Cog has a sensitivity of 76% to 100% and a specificity of 54% to 85% for detecting cognitive impairment. 34

GENERAL PRACTITIONER ASSESSMENT OF COGNITION

The General Practitioner Assessment of Cognition (available for free at http://gpcog.com.au ) comprises a patient screen and, if necessary, an informant component. Advantages of this test include validation in the primary care setting, little to no education bias, and availability in multiple languages. 34 It has been studied only in Australian populations, however. The patient screen consists of recall, time orientation, clock drawing, and information components. The patient screen takes less than four minutes to complete, and the informant portion takes less than two minutes. The General Practitioner Assessment of Cognition has a sensitivity of 85% and specificity of 86%. 34

ASCERTAIN DEMENTIA 8-ITEM INFORMANT QUESTIONNAIRE

The Ascertain Dementia 8-Item Informant Questionnaire (available for free at http://alzheimer.wustl.edu/cdr/AD8.htm ) is an informant-based test developed to screen for major and minor neurocognitive disorders. It has also been validated for patient-administered screening, but it is less sensitive than informant-based screening. 38 The informant-based test takes less than two minutes to complete, and has a sensitivity of 85% and a specificity of 86%. 34

Cognitive Tests for Patients Who Screen Positive on Initial Testing

Patients who screen positive for cognitive impairment on brief screening tests should be evaluated further to quantify the degree of impairment. 29 A variety of tools are available for this purpose, but only some are practical for the office setting. The following brief cognitive tests have limited sensitivity and specificity, particularly in patients with high intelligence and education levels. Physicians should consider referral for neuropsychiatric evaluation if a patient has normal findings on brief cognitive tests but cognitive impairment is still strongly suspected.

MINI-MENTAL STATE EXAMINATION

The Mini-Mental State Examination (MMSE; available for purchase at http://www.parinc.com/Products/Pkey/238 ) is the most commonly used cognitive evaluation tool. 39 The test has a sensitivity of 89% and specificity of 81% for detecting dementia. 34 A nomogram establishes cutoff scores depending on the patient's age and education.

MONTREAL COGNITIVE ASSESSMENT AND SAINT LOUIS UNIVERSITY MENTAL STATUS EXAMINATION

The Montreal Cognitive Assessment and Saint Louis University Mental Status Examination (available for free at http://www.mocatest.org/ and http://aging.slu.edu/pdfsurveys/mentalstatus.pdf ) are alternatives to the MMSE. Both are 30-point cognitive tests that take approximately 10 minutes to administer. The Montreal Cognitive Assessment is designed for persons scoring above 24 on the MMSE and has excellent sensitivity for detecting mild neurocognitive disorder; it is also accurate in patients with Parkinson disease. 29

Diagnostic and Secondary Evaluation

Patients who have confirmed cognitive impairment should be screened for depression, should receive laboratory tests for other common disorders that can cause cognitive impairment, and should undergo imaging of the brain. Routine cerebrospinal fluid (CSF) analysis and genetic testing are not recommended, but these tests may be appropriate in some patients.

GERIATRIC DEPRESSION SCALE

Depression is a common and treatable comorbidity in patients with dementia. Several tools are validated to screen for depression in older patients. The five-item Geriatric Depression Scale (available for free at http://www.aafp.org/afp/2012/0115/p139.html#afp20120115p139-t5 ) is brief and sensitive. It is as effective as the 15-item Geriatric Depression Scale and does not require clinician administration. 40 In patients with depression and dementia, treatment for depression should be initiated first. Pseudodementia, or depression causing cognitive impairment, is diagnosed if the impairment resolves with treatment of the depression.

LABORATORY EVALUATION

The standard laboratory evaluation for patients with cognitive impairment includes testing for anemia, hypothyroidism, vitamin B 12 deficiency, diabetes, and liver and kidney disease. 29 Testing for neurosyphilis and human immunodeficiency virus infection should be reserved for patients with risk factors. Other testing should be based on patient history or physical examination findings. For example, inflammatory markers may be appropriate in patients with symptoms of vasculitis.

NEUROIMAGING

Routine structural neuroimaging in patients with suspected dementia is recommended by the American Academy of Neurology and rated as usually appropriate by the American College of Radiology Appropriateness Criteria. 41 , 42 Magnetic resonance imaging without contrast media is the preferred imaging test to exclude other intracranial abnormalities, such as stroke, subdural hematoma, normal-pressure hydrocephalus, or a treatable mass. 41 , 42 Magnetic resonance imaging is more sensitive than computed tomography for distinguishing patterns of regional atrophy and therefore may be helpful in determining dementia subtype. Computed tomography is acceptable if magnetic resonance imaging is contraindicated.

Common age-related changes of white matter, small vessel ischemia, and generalized atrophy often result in ventricular enlargement, a finding also associated with normal-pressure hydrocephalus. This can complicate accurate diagnosis because the cardinal symptoms of normal-pressure hydrocephalus (urinary incontinence, gait disturbance, and cognitive impairment) commonly coexist in patients with dementia. The clinical utility of other imaging modalities such as amyloid positron emission tomography scanning has not been established. 43

CSF TESTING

In patients with rapidly progressive symptoms, CSF analysis should be considered for prion disease or other infectious processes. Testing for CSF 14-3-3 protein is useful when Creutzfeldt-Jakob disease is suspected. 41 The role of CSF biomarker testing for Alzheimer disease in clinical practice is not yet established.

GENETIC TESTING

Genetic testing for the apolipoprotein E4 allele is not recommended as part of the evaluation for cognitive impairment, although adult children of persons with Alzheimer disease may request testing for themselves. 44 Each person inherits a combination of apolipoprotein E alleles from his or her parents. In patients with Alzheimer dementia, the relative risk of having one or more copies of the apolipoprotein E4 allele is approximately 2. 45 , 46 However, multiple other genetic mutations are involved in the development of dementia. Referral for genetic testing should be considered in patients with multiple family members who were diagnosed with Alzheimer disease at a young age in an autosomal dominant pattern.

This article updates previous articles on this topic by Simmons, et al. , 30 Adelman and Daly , 47 and Santacruz and Swagerty . 48

Data Sources: A PubMed search was completed in Clinical Queries using the key terms dementia, Alzheimers, diagnosis, risk factors, cognitive assessment, medications, neuroimaging, and laboratory. Also searched were the Cochrane Database of Systematic Reviews and Essential Evidence Plus. Search dates: October and December 2016; and April, June, and October 2017.

Editor's Note: The Mini-Mental State Examination (MMSE) had been freely available and widely disseminated after first being released in 1975. However, starting in 2000, its authors (Dr. Folstein and others) began enforcing their copyright and in 2001 arranged for Psychological Assessment Resources (PAR) to manage worldwide rights. PAR insists that all users register with their site, complete a four-page permissions request form, and purchase MMSE forms ($74 for 50 forms) and a test manual ($86) [costs as of January 2018]. See https://www.parinc.com/Resources/Permissions-and-licensing . Unfortunately, the creators of the Montreal Cognitive Assessment (MoCA) have followed suit by requiring training and certification to administer the test with restricted use starting in 2021. The training is one hour, and the cost is $125 for the initial two years of certification, which will then require renewal. See https://www.mocatest.org/ . This commercialization of a cognitive screening test seems antithetical to the advancement of science and the practice of medicine. As long as copyright holders of these tools restrict their use, clinicians should know that there are alternatives to the MMSE and MoCA, including the Saint Louis University Mental Status (SLUMS) examination https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php , which has been shown to be more sensitive than the MMSE.—Jay Siwek, MD, Editor Emeritus; Sumi Sexton, MD, Editor in Chief

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.

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Assessment and diagnosis of dementia

Diagnostic criteria, assessment and screening tools, and guidance on disclosing diagnosis.

Diagnostic criteria for cognitive impairment and dementia

Dementia is the umbrella term for a number of neurological conditions, of which the major symptom is the decline in brain function due to physical changes in the brain. It is distinct from mental illness.

Dementia is categorised as a Neurocognitive Disorder (NCD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The NCD category is then further subdivided into Minor NCD and Major NCD. The term “cognitive” refers to thinking and related processes, and the term “neurocognitive” has been applied to these disorders to emphasise that brain disease and disrupted brain function lead to symptoms of NCD.

The NCD category encompasses the group of disorders in which the primary clinical deficit is in cognitive function, which is acquired rather than developmental. Impairment may occur in attention, planning, inhibition, learning, memory, language, visual perception, spatial skills, social skills or other cognitive functions.

Minor neurocognitive disorder

In DSM-5 , a minor neurocognitive disorder is also medically referred to as Prodromal Disease or Mild Cognitive Disorder (MCI) and is defined by the following criteria:

• There is evidence of modest cognitive decline from a previous level of performance in one or more of the domains listed below, based on the concerns of the individual, a knowledgeable informant or the clinician; and a decline in neurocognitive performance, typically involving test performance in the range of one and two standard deviations below appropriate norms (i.e. between the third and sixteenth percentiles) on formal testing or equivalent clinical evaluation.
• The cognitive deficits are insufficient to interfere with independence (for example instrumental activities of daily living such as complex tasks such as paying bills or managing medications, are preserved), but greater effort, compensatory strategies, or accommodation may be required to maintain independence.
• The cognitive deficits do not occur exclusively in the context of a delirium.
• The cognitive deficits are not primarily attributable to another mental disorder (for example major depressive disorder and schizophrenia).

Major neurocognitive disorder

In DSM-5, a major neurocognitive disorder is defined by the following:

• There is evidence of substantial cognitive decline from a previous level of performance in one or more of the domains listed below, based on the concerns of the individual, a knowledgeable informant, or the clinician; and a decline in neurocognitive performance, typically involving test performance in the range of two or more standard deviations below appropriate norms (i.e. below the third percentile) on formal testing or equivalent clinical evaluation.
• The cognitive deficits are sufficient to interfere with independence (i.e. requiring minimal assistance with instrumental activities of daily living).

Cognitive domains

The DSM-5 details six cognitive domains which may be affected in both Minor and Major NCD:

Complex attention

Involves sustained attention, divided attention, selective attention and information processing speed

Warning signs - Patient has increased difficulty in environments with multiple stimuli (TV, radio, conversation). Has difficulty holding new information in mind (recalling phone numbers or addresses just given or reporting what was just said)

Executive function

Involves planning, decision making, working memory, responding to feedback, error correction, overriding habits and mental flexibility

Warning signs:

• Patient is unable to perform both familiar and complex tasks and projects (at work and at home).
• Needs to rely on others to plan instrumental activities of daily living or make decisions.
• Has problems with abstract thinking, displays loss of initiative as well as poor/decreased judgement.

Learning and memory

Involves immediate memory, recent memory (free recall, cued recall and recognition memory) and long term memory

• Patient repeats self in conversation, often with the same conversation.
• Cannot keep track of short list of items when shopping or of plans for the day.
• Requires frequent reminders to orient task at hand, confusion about time and place, and repetitive behaviour.

Involves expressive language (naming, fluency, grammar and syntax) and receptive language

• Patient has significant difficulties with expressive or receptive language.
• Often uses general terms such as 'that thing' and 'you know what I mean'.
• With severe impairment may not recall names of closer friends and family.

Perceptual-motor function

Involves picking up the telephone, handwriting, using a fork/spoon

• Patient has significant difficulties with previously familiar activities (using tools or, driving a motor vehicle) and navigating in familiar environments.

Social cognition

Involves recognition of emotions and behavioural regulation, social appropriateness in terms of dress, grooming and topics of conversation

• Patient may have changes in behaviour (shows insensitivity to social standards, or make decisions without regard to safety).
• Patient usually has little insight into these changes. Becomes socially withdrawn or isolated.

ICD-11 coding for dementia

The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. You can find ICD-11 codes on the World   Health Organisation’s ICD   website .

Assessment for cognitive impairment and dementia

There is no single definitive test for diagnosing dementia. Assessment will account for behavioural, functional and psychosocial changes, together with radiological and laboratory tests. The assessment process may take three to six months.

Assess cognition if you have any indication or suspicion of impairment in your patient. This is the first step in determining whether or not your patient needs further evaluation.

Take notes about the history of the patient from an “informant”: someone who knows the patient well and has observed their cognition and function over time. They might be a partner, family member or close friend.

You could ask the informant about the following in relation to your patient:

• risk factors: vascular disease, alcohol, head injury, mood disorders, behavioural and psychological symptoms, recent illness, medications
• Activities of Daily Living (ADL), instrumental ADLs, cognitive complaints, mood, driving, safety
• behavioural changes and functional decline (time course = onset, progression)

One useful tool for interviewing informants is the AD8   Dementia Screening   Instrument .

The following cognitive assessment tests are the most commonly used; however, it is important to choose the tests most suitable for your patient and for the health setting within which you work.

The General Practitioner assessment of Cognition (GPCOG) is a screening tool for cognitive impairment. It has been designed for general practitioners, primary care physicians, and family doctors.

The MMSE is currently the most widely used cognitive assessment tool. It takes 10-15 minutes to administer. It is scored out of 30, with a score below 24 suggesting dementia.

This test evaluates organisation, planning and conceptualisation by requiring patients to draw an analogue clock set to a given time. The simplest scoring is to rate the numbers as well spaced and whether the hands indicate the right time. It can be scored as either normal (correctly drawn) or abnormal (any other result).

The RUDAS is a cognitive screening instrument that minimises the effects of cultural learning and language diversity on the assessment of baseline cognitive performance.

The Kimberley Indigenous Cognitive Assessment Tool (KICA) is a valid, culturally appropriate dementia screening tool for Aboriginal and Torres Strait Islander people.

Screening for cognitive impairment and dementia

There are several opportunities in the practice to screen your patients for possible cognitive impairment and dementia. These include:

The 45+ Health Check

• An opportunity to pick up younger onset dementia in your patients under 65 years of age
• Build in questions about cognitive function, concerns about memory, mood and behaviour
• Look at possible risk factors for dementia (modifiable and non-modifiable in your patient)
• Can be charged to MBS item #717

The 75+ Health Check

• An opportunity to pick up possible cognitive impairment and dementia in your patient
• Modify the existing 75+ Health Check and include questions about cognitive function, memory, frailty, dexterity, driving and advanced care planning
• Can be charged to MBS item #705

The Chronic Disease Management/ Plan

• An opportunity to screen for possible cognitive impairment - in your patients under 65 years of age as well as over 75 years of age- undertake annually or bi-annually
• #721 (development of plan)
• #732 (review of plan)
• #723 (a Team Care Arrangement)
• #731 (a plan developed for patients in residential aged care)
• #10997 (practice nurse monitoring and support as part of plan).

Mental Health Treatment Plan (MHTP)

• An opportunity to be mindful of a possible diagnosis of dementia/cognitive impairment when preparing and reviewing a MHTP for your patient
• N.B. Dementia is not classified as a mental health disorder under the Better Access to Mental Health Scheme (hence, MBS items cannot be charged)

For more information, visit the Medicare   Benefits Schedule   website .

Screening notes

• If uncertain or inconclusive, repeat tests over time
• Use sensitive language when introducing the tests/assessment process to your patients and their families/carers
• What tests will be conducted?
• Who will be performing the tests and how long will it take?
• Should I prepare for the tests in any way?
• Will any of the tests involve pain or discomfort?
• Will there be any cost involved?
• What follow-up will be necessary and who will follow up?
• How will I be informed of the test results and the diagnosis?

Other diagnostic tests

Mental state and physical examination.

• Differential diagnosis: look for specific conditions that mimic dementia (depressive disorder, delirium and drug/dosing interactions), or that can exacerbate dementia (e.g. cardiac failure, use of anticholinergic drugs).
• Check nutrition, hygiene, visual or hearing impairment.

Blood, urine tests and imaging

• Urinary tract and other infections
• Renal and liver (hepatic) function
• Rule out rare but reversible causes for example abnormal thyroid function, calcium or Vitamin B12 deficiency, electrolyte balance (salt and water), tumour

The following investigations   are usual practice: FBE, EUC, LFTs, Ca, TFT, B12, Folate, MSU, ECG, and if indicated, VDRL, CXR, HIV.

Imaging recommended: CT brain, MRI, and if indicated, PET, SPECT, FRMI.

Assessment for Behaviour and Psychological Symptoms of Dementia (BPSD)

Almost all patients with dementia experience BPSD; these are also referred to as neuropsychiatric, non-cognitive symptoms. The symptoms vary between patients and over time and can include:

• Mood disturbances (anxiety, apathy, depression, euphoria)
• Hyperactivity-type symptoms (aberrant motor behaviour, aggression, agitation, disinhibition, irritability, restlessness)
• Psychotic symptoms (delusions, hallucinations, paranoia)
• Other behavioural symptoms (changes in appetite, hoarding, night-time behaviour disturbances, wandering)

These symptoms become more common as the dementia progresses and present a major cause of stress to carers.

When BPSD occur, assess factors that may cause, aggravate or reduce the behaviour. Assessment should first exclude physical causes, such as delirium (common in patients with dementia), urinary tract infections or a drug interaction. Other factors, such as the environment and behaviours of others, should also be considered.

The assessment should ideally consider:

• Frequency of behaviour over time
• Context and consequences of the behaviour
• Mental health
• Physical health
• Medication side effects
• Previous habits and beliefs
• Psychosocial factors
• Factors in physical environment
• Possible undetected pain or discomfort

For more information about BPSD assessment and clinical support services for your patients, visit the Dementia   Behaviour Management Advisory Services (DBMAS)   website .

Communicating the diagnosis

Providing a diagnosis to a person with dementia is fundamental to the principal of personal autonomy and it should be expected. Your role in disclosing the diagnosis is of paramount importance.

Receiving a diagnosis of dementia has an enormous impact on the person with dementia, their carers and families. Following a diagnosis, patients often report feelings of loss, anger, uncertainty and frustration. Others report feelings of relief to have an explanation for their symptoms.

Although a very small number of people may choose not to know the diagnosis (and this should be discussed during the assessment process), the majority of people want to be informed, so it is important that health professionals are honest and truthful when communicating the diagnosis to the person with dementia.

Recommendations for disclosing a diagnosis

• Discussion of the diagnosis and its consequences may occur over time or over multiple practice visits, but disclosure should occur as early as practicable.
• Be clear and respectful when communicating a diagnosis to the person with dementia and families and carers.
• The conversation should occur within the context of the wishes of the person with dementia (in a patient-centred approach), their relationship with the medical practitioner providing the diagnosis and the primary purpose for their consultation.
• The diagnosis of dementia should come after discussions about memory and thinking difficulties. Medical practitioners should discuss the possibility of dementia as a diagnosis during the process of assessment (which may take three to six months).
• Provide information about dementia in a clear manner. Highlight that progression of dementia is often slow, symptomatic treatments are available and that research is striving to find cures and better treatments.
• Be aware of your patient’s history of depression and/or self-harm. This news may prove to be particularly challenging especially following the first few months of the diagnosis. Counselling should be offered in these cases as an additional form of support.
• Be aware of the particular issues in communicating a diagnosis to patients from culturally and linguistically diverse (CALD) backgrounds. The term dementia may be interpreted as offensive and disrespectful in some cultures.

Dementia information, advice and support for your patients and clients.

Free and confidential, the National Dementia Helpline, 1800 100 500 , provides expert information, advice and support, 24 hours a day, seven days a week, 365 days a year. No issue too big, no question too small.

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Cognitive Assessment Tools

Patient assessment tools

• Informant tools
• GPCOG website
• GPCOG Tool - English  (PDF)  
• Mini-Cog website
• Mini-Cog  (PDF) 

Informant tools (family members and close friends)

• GPCOG Tool - English  (PDF) 
• IQCODE website  (Australian National University) 
• Short IQCODE  - English (PDF) 

Learn more:  Cognitive Assessment  

Access resources for your patients and their caregivers

Assessment and care planning services now eligible for reimbursement. 

Improve your practice by participating in CME activities

The care needs assessment: support for people with dementia

This page looks at how a person with dementia can get a care assessment, who does an assessment, how they are carried out, who makes the decision, and tips for making the most of the care needs assessment. It also explains the eligibility criteria.

• Assessment for care and support in England
• You are here: The care needs assessment: support for people with dementia
• The carer's assessment: support for carers
• Financial assessments
• Organising and reviewing care and support
• Assessment for care and support - useful organisations

Assessment for care and support

Support for people with dementia: a care needs assessment.

Anyone with dementia is entitled to an assessment of their needs by the local authority. This is called a care needs assessment. It should identify what the person’s needs are, and what support would meet these needs. It also helps the local authority to decide whether or not they will pay towards meeting these needs .

The local authority cannot refuse to carry out an assessment, even if they think the person will have to pay for their own support and care. The information in the assessment will be helpful, even if the local authority does not pay towards the care and support. You can use the information to discuss care and support needs with other organisations and companies such as home care agencies.

Paying for dementia care in England

Dementia care isn't free, and you may need to pay for some of the care you or someone you know needs. We help you understand the different ways to pay for care, and the amount you might be expected to pay.

How do I get a care needs assessment?

There are a number of ways someone can get an assessment. The person with dementia can ask for one themselves. You can also ask your local authority’s social services department for one on their behalf.

This department may be called different things in different areas – for example, ‘adult services’. You can find their contact details:

• on a Council tax bill
• at the GP surgery
• at the local library.

Other people can also arrange the assessment on behalf of the person, such as:

• the person’s GP, consultant, or another health or social care professional such as an occupational therapist
• carer or relative
• hospital social worker (if the person is in hospital).

If you ask for an assessment on behalf of someone, you must get their consent first. Some people with dementia may lack the ability (mental capacity) to give this consent. You can still ask for an assessment, as long as it is in the person’s best interests.

For more information on this see  Mental Capacity Act 2005 .

Who does the assessment?

The local authority adult social services department will carry out most assessments. This will normally be done by a social worker or a care coordinator (they may be referred to as an assessor). They may ask for other professionals to be involved, for example, the person’s doctor or a nurse.

What happens at the assessment?

A care needs assessment will include answering questions, which should be given in advance. They will help the local authority to find out:

• where the person lives and what care they currently receive
• if the person has any health conditions, and what they can and cannot do for themselves
• the person’s views about their support, and how they would like to be supported. For example they might want to go to a day centre or have someone help them with shopping
• the carer’s views. 

These questions and answers are then discussed together with those present at the assessment. However not all assessments are done face-to-face. They may be done through a self-assessment questionnaire.

What is the self-assessment questionnaire?

Sometimes an assessment is done through a questionnaire which the person completes themselves. The person you care for might need help to fill out a self-assessment questionnaire. You or a social worker can help them at home, to make sure that all their needs are considered.

You can ask the local authority for support if the person with dementia needs it. Some local charities may also help with this.

What are telephone assessments?

Assessments can be carried out over the phone. However, this is only appropriate if the person is already known to the local authority and the assessment is a result of a change in their needs, or if their needs are not complex. People with dementia often have more complex needs, such as needs that can change on a daily basis.

Therefore, telephone assessments should not be used as the only way of assessing their care needs. If the person with dementia is offered a self-assessment questionnaire or telephone assessment, they can ask to have the assessment in person. They should explain why they need a face-to-face assessment.

If a face-to-face assessment is still not offered, they can make a complaint about the lack of support they are receiving in having their needs assessed.

Where does the assessment take place?

A face-to-face assessment usually takes place in the person’s home. This can help the assessor to know what care and support they need. If the assessment is arranged elsewhere, it should be somewhere convenient for the person and you, their carer.

Tips for the care needs assessment

If the person with dementia is having a care needs assessment, there are some things that can help them to prepare for it. If the person has got the assessment questions it’s a good idea for them to look through them and think about their answers. If the person hasn’t been given the questions, contact the local authority and ask for a copy.

It can help for the person to make notes so that they can tell the assessor what support they need. It might seem like a lot for the person to think about, but even noting down some of the details listed below will help them to get more from the assessment. A carer can help the person prepare for an assessment and might also find these tips useful. 

Preparing for the assessment

• A diary with details of what daily tasks the person needs help with can be helpful.
• What support does the person currently get from family and carers? This is important because even if the person continues to get care and support from others, the conversation should cover what would happen if they could no longer give this support.
• Is there any equipment or assistive technology that would help? For example, an automated pill dispenser, or ‘smart’ home systems that can be set up to turn off lights.
• What care and support might the person need in the future as their condition gets worse? This can include equipment and assistive technology.
• Collect any letters from the GP or other professionals. This is called ‘supporting evidence’. For example, if the person has problems with getting about or walking, the GP might suggest ramps, grab rails, or help with shopping.
• Make a list of any medication the person is taking and what conditions they are for.
• Make sure any carers or relatives that the person would like to be at the assessment are available.
• Think about what care and support would help and share this in the assessment. It doesn’t necessarily mean the person will get it, but the assessment should consider it. As well as practical care, think about equipment and other items such as assistive technology devices.

During the assessment

• Be honest. Some people feel they need to hide the problems they are having from professionals. However, the point of the assessment is to see how the person’s needs can be met.
• be more active
• stay living at home as long as possible
• engage more with the community by attending social groups and events
• have some help with shopping, going for walks or swimming.

What happens after an assessment?

Once a care needs assessment has been completed, the local authority will decide if it will pay for care and support for the person. They will consider whether the person has an ‘eligible care need’, and also their financial situation .

A person must have an eligible care need for the local authority to consider paying for their care and support. These care needs are organised into ‘criteria’ (conditions) which apply across England.

If the person you care for is told that they do not have eligible care needs and you believe they do, you will need to make a complaint . You should explain why you think their needs do meet the criteria. 

Will the local authority fund care and support?

There are three criteria (conditions) that someone must meet for the local authority to consider funding their care and support.

The person will have eligible needs if:

1. They have care and support needs because they have a physical or mental condition (this includes dementia).

2. The person’s needs mean they are unable to do at least two of the following:

• Manage and maintain nutrition – for example, buying and preparing food and eating and drinking.
• Maintain personal hygiene – for example, washing themselves and their clothes.
• Manage toilet needs – for example, getting to and using the toilet or changing incontinence pads.
• Be appropriately clothed – for example, dressing themselves in clothes suitable for the weather and their needs.
• Be able to make use of their home safely – for example, moving around the home safely (including going up and down stairs), using the kitchen, getting to and using the bathroom and being able to enter and leave the house safely.
• Maintain a habitable home environment – for example, keeping the home clean and safe and being able to manage and pay the bills.
• Develop and maintain family or other personal relationships – for example, staying in touch with others so they don’t become lonely or isolated.
• Access and engage in work, training, education or volunteering – for example, attending a course or volunteering. 
• Make use of necessary facilities or services in the local community including public transport – for example, getting to doctors or other healthcare appointments, using public transport and local services or shops.
• Carry out any caring responsibilities – for example, caring for any children or grandchildren they have.

The person is considered unable to do these things:

• if they cannot do them without help
• if they can do them without help, but it causes them pain, distress, anxiety or puts them (or someone else) in danger
• if it takes them much longer to do them than you would expect.

3. Because of not being able to do these things there is, or is likely to be, a significant impact on the person’s wellbeing.

Dementia Support Line

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• Page last reviewed: 16 February 2021

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Tips about choosing an attorney when you have dementia

Advice about deciding who to appoint through a power of attorney, so they can make decisions on your behalf in future.

How much does dementia care cost?

Looking after your wellbeing while finding the right care for a person with dementia

Glenys Smith, near Bristol, shares the challenges of caring for her husband Ralph who recently moved to a care home. She also shares wellbeing advice for other carers.

I have dementia and I was targeted by scammers

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Money disagreements when a person has dementia

Readers share advice about family disagreements over a person’s finances when they have dementia.

Can people with dementia vote?

Coming to terms with Dad’s dementia and raising awareness through art

Neil Eckersley, in Lancaster, created an art series called ‘I know you’re in there’ in response to his late father’s dementia.

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Alzheimer’s Caregiving: Finding Long-Term Care

You may feel guilty or upset about this decision, but as the disease worsens , it could be the best or even the only way to provide the optimal level of care that your loved one needs. Remember that many caregivers reach this point. Moving the person to a care facility may give you greater peace of mind.

Even after you decide the person needs to relocate, choosing the right place can be challenging. The process involves learning about long-term care facilities , arranging visits, and asking the right questions.

Different types of long-term care facilities

Long-term care facilities are not one-size-fits-all. Facility-based long-term care services include assisted living facilities, group homes, and nursing homes. Some facilities offer only housing and housekeeping, but many also provide personal care and medical services. Many facilities offer special programs for people with Alzheimer’s or other types of dementia.

Learn about the different types of places to determine where the person with Alzheimer’s will feel most comfortable.

• Assisted living facilities. Assisted living facilities have rooms or apartments. They’re for people who may need some help with daily tasks but do not need around-the-clock care. Some assisted living facilities have special Alzheimer’s units with staff who check on and care for people with dementia. You must pay for the cost of the room or apartment, and you may need to pay extra for any special care. Some assisted living facilities are part of a larger organization that also offers other levels of care. For example, continuing care retirement communities offer independent living and skilled nursing care.
• Group homes. A group home is a home for people who can no longer care for themselves. Several people receiving care live in the home. At least one caregiver is on site at all times. The staff takes care of the people living there by making meals, helping with grooming and medication, and providing for other needs. These homes may not be inspected or regulated but may still provide high-quality care.
• Nursing homes. Nursing homes are for people who can't care for themselves anymore and may need ongoing medical care. Some nursing homes have special Alzheimer’s care units. These units are often in separate sections of the building where staff members have special training to care for people with dementia. Some units are designed with the goal of making the person feel more like they are at home. They provide special activities, meals, and medical care. Nursing homes are inspected and regulated by state governments.

Getting help at home

In some cases, getting help with caregiving in your home or the home of the person with Alzheimer’s may meet your needs. Getting help at home may also help ease some stress during the transition period when you are looking for a long-term care facility. There are a variety of services available to help with everyday care, health care, and meals in a person’s home. While these services can be helpful, they may not be enough for some care situations. Eventually, you may need to transition your loved one to long-term care outside of the home.

Learn more about getting help with Alzheimer’s caregiving at home .

Visiting facilities

Once you decide what kind of long-term care facility works for your loved one’s needs, choose a few places to visit. Talk with friends, relatives, social workers, or your religious community to find out what places they suggest. Check with health care providers about which nursing homes they feel provide good care. Call the facilities to learn more and to schedule visits.

Visit at different times of day and meet with the facility’s leaders to get a full understanding of how the facility works and treats the people who stay there.

Ask yourself:

• How does the staff care for the residents?
• Is the staff friendly?
• Does the place feel comfortable?
• How do the people who live there look? Are they clean and well cared for?
• Are mealtimes comfortable for people living there?
• Is the facility well-maintained? Does it look and smell clean?
• Do staff members speak to residents with patience and respect?

Ask the staff:

• What activities are planned for residents?
• How many staff members are at the facility? And how many of them are trained to provide medical
• care if needed?
• How many residents in the facility have Alzheimer’s?
• Does the facility have a special unit for people with Alzheimer’s? If so, what kinds of services does it provide? Are the costs for this unit different than those for the rest of the facility?
• Is there a doctor who checks on residents on a regular basis? How often?
• What is a typical day like for the person with Alzheimer’s?
• Is there a safe place for the person to go outside?
• What is included in the fee? What services or options would cost extra?
• How would my loved one get to medical appointments?

Talk with other caregivers who have a loved one at the facility. Find out what they think about the place. Ask about the total costs of care. Each facility is different, so you want to find out if long-term care insurance, Medicaid, or Medicare will pay for any of the costs.

If you're asked to sign a contract, ensure you understand what you are agreeing to.

Resources for choosing a long-term care facility

There are many sources of information about long-term care facilities. These resources can help you get started:

• Search the Eldercare Locator or call 800-677-1116 for help finding care in your area.
• Visit LongTermCare.gov for information about housing options for older adults and finding local services.
• Call your local Area Agency on Aging , local and state offices on aging or social services, or your tribal organization.
• Use Medicare’s Care Compare tool to find and compare nursing homes and other health care facilities in your state or territory.
• Check the quality of nursing homes and other health care facilities with the Joint Commission’s Quality Check .

Making moving day easier

Moving a person with Alzheimer’s to an assisted living facility, group home, or nursing home is a big change for both the person and their caregiver. You may feel many emotions , from a sense of loss and sadness to guilt or even relief. It is okay to have all these feelings. A social worker or someone from a private service may be able to help you plan for and adjust to this big change. It's important to have support during this difficult step.

Here are some things that may help:

• Know that the moving day can be very stressful.
• Talk to a social worker about your feelings about moving the person into a new place. Find out how to help the person with Alzheimer’s adjust.
• Get to know the staff before the person moves into a facility. Talk with them about ways to make the transition go smoothly.
• Be an advocate for the needs and preferences of the person with Alzheimer’s.
• Be supportive and listen to any concerns, but don't argue with the person with Alzheimer’s about why they need to be there.

Once the person has moved to their new home, check in regularly to see how they are doing. As the caregiver, you probably know the person best. Look for signs that they may need more attention, are taking too much or not enough medication, or may not be getting the care they need. Build a relationship with staff so that you work together as care partners.

You may also be interested in

• Learning more about long-term care
• Reading about ways to pay for long-term care
• Getting tips for how to take care of yourself as an Alzheimer’s caregiver

For more information

NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center 800-438-4380 [email protected] www.nia.nih.gov/alzheimers The NIA ADEAR Center offers information and free print publications about Alzheimer’s and related dementias for families, caregivers, and health professionals. ADEAR Center staff answer telephone, email, and written requests and make referrals to local and national resources.

Alzheimers.gov www.alzheimers.gov Explore the Alzheimers.gov website for information and resources on Alzheimer’s and related dementias from across the federal government.

Eldercare Locator 800-677-1116 [email protected] https://eldercare.acl.gov

LongTermCare.gov 202-619-0724 [email protected] https://acl.gov/ltc

Family Caregiver Alliance 800-445-8106 [email protected] www.caregiver.org

This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.

Content reviewed: August 12, 2024

nia.nih.gov

An official website of the National Institutes of Health

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• Published: 22 August 2024

A portable and efficient dementia screening tool using eye tracking machine learning and virtual reality

• Ying Xu 1   na1 ,
• Chi Zhang   ORCID: orcid.org/0009-0000-3895-7949 2   na1 ,
• Baobao Pan 2 ,
• Qing Yuan   ORCID: orcid.org/0009-0007-5519-0381 1 &
• Xu Zhang   ORCID: orcid.org/0000-0002-4803-8628 3  

npj Digital Medicine volume  7 , Article number:  219 ( 2024 ) Cite this article

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• Alzheimer's disease
• Cognitive neuroscience

Dementia represents a significant global health challenge, with early screening during the preclinical stage being crucial for effective management. Traditional diagnostic biomarkers for Alzheimer’s Disease, the most common form of dementia, are limited by cost and invasiveness. Mild cognitive impairment (MCI), a precursor to dementia, is currently identified through neuropsychological tests like the Montreal Cognitive Assessment (MoCA), which are not suitable for large-scale screening. Eye-tracking technology, capturing and quantifying eye movements related to cognitive behavior, has emerged as a promising tool for cognitive assessment. Subtle changes in eye movements could serve as early indicators of MCI. However, the interpretation of eye-tracking data is challenging. This study introduced a dementia screening tool, VR Eye-tracking Cognitive Assessment (VECA), using eye-tracking technology, machine learning, and virtual reality (VR) to offer a non-invasive, efficient alternative capable of large-scale deployment. VECA was conducted with 201 participants from Shenzhen Baoan Chronic Hospital, utilizing eye-tracking data captured via VR headsets to predict MoCA scores and classify cognitive impairment across different educational backgrounds. The support vector regression model employed demonstrated a high correlation (0.9) with MoCA scores, significantly outperforming baseline models. Furthermore, it established optimal cut-off scores for identifying cognitive impairment with notable sensitivity (88.5%) and specificity (83%). This study underscores VECA’s potential as a portable, efficient tool for early dementia screening, highlighting the benefits of integrating eye-tracking technology, machine learning, and VR in cognitive health assessments.

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Introduction.

Dementia refers to a spectrum of neurodegenerative syndromes characterized by progressive disturbances in various cognitive functions severe enough to interfere with the patient’s activities of daily living. The rapid increase in the number of patients with dementia has become a global health challenge, with Alzheimer’s disease (AD) being the most common, accounting for 60–70% 1 . Mild cognitive impairment (MCI) refers to the progressive decline of memory or other cognitive functions but does not affect the ability of daily life as dementia 2 . The increasing prevalence of cognitive impairment has caused enormous economic loss 3 , 4 . Accumulating evidence shows that early diagnosis and timely intervention can delay cognitive decline 5 , 6 , 7 . so early screening in the preclinical stage of dementia is necessary.

Currently, cerebrospinal fluid β -amyloid (amyloid β , A β ) and tau, amyloid positron emission tomography (PET) and AD pathogenic gene carrying are diagnostic markers for AD 8 . Though accurate, these approaches could hardly perform as an early screening tool for high costs and surgical invasiveness. Dementia is essentially cognitive dysfunction, so assessment of cognition is an important part of the diagnosis. Neuropsychological paper-based instruments, such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) are commonly used, which cover orientation, memory, attention, calculation, language ability, visuospatial ability, etc. Though valid and reliable, traditional neuropsychological tests must be administered by trained physicians, and are neither simple nor efficient enough to serve as large-scale dementia screening tools. Moreover, neuropsychological assessment results are affected by both the physician’s subjective judgments and the testing environment. Table 1 presents a comparison of various widely used diagnostic or screening methods. At present, there is no efficient solution for large-scale dementia screening.

Eye-tracking, virtual reality (VR), and artificial intelligence (AI) technologies have shown great potential in the diagnosis of cognitive disorders or AD, aiding in the improvement of early screening, diagnosis, and treatment. Eye tracking is a real-time sensor technology that measures gaze points and eye movements, providing information on cognitive function and attention; VR technology allows for cognitive testing in controlled scenarios, accurately assessing cognitive abilities; AI technology can precisely process vast amounts of clinical data, identify subtle changes, and assist in the formulation of diagnostic and treatment plans. Cognitive-related uses of eye-tracking technology have been exploded in recent years, enabling online cognitive activity to be recorded, physicians to connect learning outcomes to the cognitive processes of subjects 9 , and detection of emotional and cognitive states 10 . Numerous studies have shown that analyzing eye movements with algorithms from eye trackers enables quantitative cognitive assessment. Visual Paired Comparison (VPC), which uses non-invasive eye tracking to identify how subjects view novel versus repeated visual stimuli. MCI patients have lower novelty preference scores on VPC compared to healthy controls 11 , 12 . Passive assessment of visuospatial memory using eye tracking, where participants are shown a set of pictures and then presented with modified versions of these pictures. Compared to MCI and dementia patients, healthy controls spend significantly more time looking at the changed parts of the pictures 13 . Visual search tasks test the ability to find a previously seen target stimulus among distractors. Eye movement parameters can identify visual search impairments in MCI patients and early identify individuals at high risk for AD 14 . Visual tracking tasks test stimuli as moving objects, where subtle changes in visual attention can be used for quick MCI detection 15 . Anti-saccade tasks test, where the amnestic MCI group shows more errors, more misses, and fewer corrections compared to control groups 16 . Short-term memory binding tests are used to assess the ability to integrate surface features (e.g., shape and color) as unique representations in memory 17 . Impaired short-term memory binding abilities are common in sporadic Alzheimer’s disease 18 , familial Alzheimer’s disease, and asymptomatic carriers of familial Alzheimer’s disease 19 . Patients with MCI exhibit impaired gaze ability and exploratory eye movement behavior, accompanied by poor short-term memory binding capabilities, which can be used to assess the risk of MCI transitioning to dementia 20 . Serial cognitive task tests aim to assess specific cognitive domains, including deductive reasoning, working memory, attention, and memory recall. The percentage of time spent gazing at the correct answer (target image) is used as a measure of cognitive scoring, correlating well with neuropsychological test scores and showing good diagnostic performance in detecting MCI and dementia patients 21 . No-instruction eye-tracking tests can detect dementia-related cognitive impairments as related eye movement biomarkers for patients who are easily confused, have language difficulties, or are in the later stages of the disease 22 . However, several issues need to be addressed: the lengthy duration required for some eye-tracking cognitive assessments is not efficient such as 30 min VPC 23 ; most existing cognitive assessment paradigms assess a limited range of cognitive domains; the high cost and limited portability of traditional monitor and eye-tracker setups make large-scale application challenging.

VR technology can create controllable virtual scenes for assessing cognitive function, distinguishing between patients with mild cognitive impairment and those at low or high risk for AD 24 , 25 . The combination of eye-tracking technology and VR, with the portability of VR head-mounted display equipment and VR immersive environment, is expected to be applied to large-scale cognitive impairment screening in multiple scenarios. However, two challenging issues have to be handled. First, these technologies should be integrated in a smart way so that efficiency is guaranteed. Moreover, subtle changes in eye movements can potentially serve as biomarkers for early MCI identification, interpreting the vast amount of eye-tracking data poses challenges.

Eye-tracking technology captures and quantifies eye movements related to cognitive behavior, forming an essential data stream for identifying subtle behavioral changes. Machine learning methods in AI are crucial for recognizing these changes. In VPC tasks, machine learning methods have improved the accuracy of AD detection 11 . In visual search tasks involving finding a previously seen target stimulus among distractors, machine learning methods can distinguish between control groups, MCI patients, and dementia subjects, effectively identifying MCI subjects with dementia-like eye movement characteristics 14 . Machine learning has been applied to tasks designed for single cognitive functions. Recent research has proposed a multimodal machine learning analysis framework, which is applied to the analysis of multimodal mental health digital biomarkers 26 . This study enhances our potential to explore the application of machine learning in the analysis of eye movement characteristics across multiple cognitive domains.

In this study, we integrated eye-tracking technology, machine learning, and VR to design and develop an efficient, portable, and quantitative early screening tool for dementia. By conducting a 5-min multi-domain cognitive task within a controlled VR environment, we collected relevant eye movement data and pre-trained classification models using supervised machine learning algorithms. This project aims to facilitate the early detection of cognitive impairment, slow the progression of dementia, and significantly reduce the psychological, caregiving, and economic burdens that dementia imposes on individuals and society.

VR-AI model selection

The model performance was evaluated on the test set using the following metrics: Median Absolute Error (Median AE), Mean Absolute Error (MAE), Root Mean Square Error (RMSE), and Correlation with MoCA score. The model with the best performance was selected to predict paper-based MoCA score (hereinafter referred to as VR-AI model). Each model underwent 5-fold cross-validation and compared in the following metrics (Table 2 ). MAE and RMSE are common metrics which are widely used to describe regression performance. However, there was unpredictable noise in the target value due to human factors and lead to extreme bad cases in both train and test set. Instead, median AE could indicate model performance in a more stable way disregard of outliers. Moreover, absolute error shows more intuitive difference between predictions and labels. Therefore, MAE was weighed more as the metrics to compare models. Higher correlation coefficient between predictions and targets indicates better performance of screening. SVR overperformed other models and baseline under most of our metrics, especially under average median absolute error of 2.04 and correlation coefficient as high as 0.9 and was selected as VR-AI model (Fig. 1 ).

The coordinates of scatter points consist of model predicted scores ( X -axis) and MoCA scores ( Y -axis). Linear regression lines were also given to manifest linear relevance of models and MoCA score ( a VR model vs. MoCA, r  = 0.58, p  < 0.0001; b VR-AI model vs. MoCA, r  = 0.90, p  < 0.0001).

Model interpretability

Contributions of each cognitive task and demographic variable to the prediction were evaluated via SHapley Additive exPlanations (SHAP) analysis, sorted by mean absolute Kernel SHAP values which were computed by special weighted linear regression. Figure 2 illustrates normalized importance of all features for VR-AI model. Years of education was the strongest predictor (mean |SHAP| = 14.6% (s.d. = ±7.7%)), followed by calculation task 4 (mean |SHAP| = 11.5 (s.d. = ±8.5%)). Memory, execution and recall tasks also ranked high among other features.

The x -axis displays the contribution of each feature on the prediction. The y -axis lists the variables in order of decreasing importance. The color gradient from blue to red indicates the variables’ relevance to the score, ascending from low to high. Each point represents an individual participant’s SHAP value for that variable.

Screening evaluation

In this study executed in Shenzhen, demographic characteristics of participants were analyzed (Table 3 ), with a particular focus on educational levels. Given the varying numbers of participants across different educational backgrounds, such as a smaller number of illiterate individuals, participants were systematically categorized into three more evenly distributed groups based on their education levels to facilitate a more effective screening evaluation. The grouping was as follows: Group 1 comprised individuals with 0–6 years of education, including those who are illiterate and those who attended primary school, totaling 61 participants; Group 2 included participants with 6–9 years of education, encompassing junior high school, with a total of 63 participants; and Group 3 consisted of individuals with an education level greater than 9 years, including those who completed high school and those holding a bachelor’s degree or higher, totaling 78 participants.

Referencing the work of Lu et al., it was underscored that the MoCA norms were meticulously crafted to take into account key influential factors. This led to the establishment of distinct optimal cutoff points tailored to the education levels of the individuals: 13/14 for those without any formal education, 19/20 for individuals with 1 to 6 years of education, and 24/25 for individuals educated beyond 7 years. These carefully determined cutoff points demonstrated a sensitivity rate of 83.8% for the detection of all forms of cognitive impairments 27 .

Leveraging these distinct optimal cutoff points, which were directly correlated with the educational levels of individuals, the study’s participants were efficiently categorized and labeled in alignment with Chinese educational standards as follows:

Group 1: 0–6 years of education: normal cognition (MoCA score 14–30), n  = 50; cognitive impairment (MoCA score 0–13), n  = 11.

Group 2: 6–9 years of education: normal cognition (MoCA score 20–30), n  = 44; cognitive impairment (MoCA score 0–19), n  = 19.

Group 3: education level greater than 9 years: normal cognition (MoCA score 25–30), n  = 47; cognitive impairment (MoCA score 0–24), n = 31.

Classification performance of VR-AI model was evaluated due to ROC curves. Optimal thresholds of VR-AI score were given by F-β method which, in screening scenario, weighed more on sensitivity. The whole flowchart of the proposed model is shown in Fig. 3 .

The pipeline includes data acquisition, data processing, feature extraction (including memory (Mem), visual attention (Att), abstraction ability (Abs), and calculation (Calc), Demographics (Demos), machine learning (ML), and Classification.

The screening performance was also evaluated in classification aspect. All subjects were grouped based on education levels and classified by their VR-AI scores and optimal thresholds to compute sensitivity and specificity. The AUCs of three groups were 0.88(95% CI: 0.78–0.97), 0.93(95% CI: 0.89–1.00), and 0.94(95% CI: 0.89–0.99) respectively (Fig. 4 ). The optimal screening cut-off scores for each group are given by F-β score: less than 6 years of education, 13/14; 6 to 9 years of education, 21/22; more than 9 years of education, 23/24. The VR-AI model showed excellent sensitivities of 89, 88, and 89% in screening for cognitive impairment and specificities of 82, 87, and 84%. The sensitivity of the overall screening of cognitive impairment and cognitively normal subjects can reach 88.5% with specificity of 83%.

AUC values are 0.88 for less than 6 years of education ( a ), 0.93 for 6–9 years ( b ), and 0.94 for over 9 years ( c ), demonstrating the model’s effectiveness across varying educational backgrounds. The green solid line represents the VR Screen Classifier, and the gray dashed line indicates Random Guess as a baseline.

To retrospect the sample size of our research, the estimate of the sample size was given according to the general requirements of diagnostic research: (1) screening test sensitivity (Sen) ≥ 0.5, sensitivity tolerance error 0.10; (2) The specificity (Spe) of screening test was ≥0.5, the tolerance error of specificity was 0.10. (3) Significance test level two-sided α  = 0.05. The results are presented in Table 4 . The sample size of the three groups (Group 1 N  = 61, group 2 N  = 63, group 3 = 78) in this study can meet the requirements of statistics.

The classification of participants into three groups based on their education levels aligns with the principles outlined by Lu et al. for adapting the MoCA for the Chinese population. The differentiation by education level is a critical aspect of this adaptation because educational attainment can significantly influence cognitive test performance. By creating distinct groups based on education levels, the VECA can more accurately reflect the cognitive abilities of individuals within those specific contexts, thereby enhancing the test’s sensitivity and specificity for different segments of the population.

Eye movements were highly informative indicators of cognitive function. In our study, together with basic information—gender, age and education, encoded eye movements can excellently classify normal and cognitive impairment subjects within education-based groups via machine learning. As a result, we developed an efficient screening tool to identify subjects that would be labeled cognitive impairment by traditional paper-based instruments. The crucial part is regression of MoCA score. SVM regression outperformed and achieved absolute error of 2.04 and strong correlation with target variable. An important application of our screening tool is providing diagnosis suggestions. The AUCs of three education-based groups were 0.92(95% CI: 0.85–0.99), 0.95(95% CI: 0.89–1.00), and 0.94(95% CI: 0.89–0.99) respectively. Proposed optimal cut-off scores for each group achieve sensitivities of 81.8, 94.7, and 83.8% in screening for cognitive impairment and specificities of 98, 91.1, and 73.6%.

This study aims to employ a quantitative approach for large-scale early screening of dementia, specifically to aid physicians in detecting cognitive impairments across a broader spectrum. The use of VR devices, particularly when combined with eye-tracking technology, presents several advantages over traditional monitor and eye-tracker setups. Portability and applicability: This portability makes VR devices more suitable for large-scale early dementia screenings, allowing for early detection of cognitive impairments in a wider range of settings. Cost-effectiveness: As VR devices with eye-tracking capabilities become more common as consumer electronics, they present a cost-effective option. This affordability makes VR devices a viable choice for large-scale screening efforts. Interference Resistance: VR devices offer better resistance to interference compared to traditional setups involving monitors and eye trackers. Participants undergo assessments in a consistent virtual environment, minimizing the impact of external environmental variables and resulting in more objective and accurate test outcomes. Operational Convenience: In practical screening applications, VR devices do not require a specific assessment location, such as an evaluation room. Moreover, VECA is less time-consumable (5-min test) and fully self-administered. This convenience significantly lowers the barriers to conducting cognitive impairment screenings, making early diagnosis and intervention more feasible.

In summary, this work introduces an approach to early detection of cognitive impairments by leveraging the portability, cost-effectiveness, resistance to interference, and operational convenience of VR devices. This not only assists physicians in detecting cognitive impairments on a larger scale, but also advances cognitive health screening technology, paving the way for future large-scale early dementia screenings.

While certain advancements have been made with the use of the VECA tool and satisfactory screening performance has been demonstrated, there are potential biases and limitations in our study.

Firstly, our participants were sourced from communities within Shenzhen, limiting the diversity of our sample. Information on other variables such as comorbidities, functional dependence, and medication usage could not be collected. This lack of comprehensive data may introduce bias in participant selection and confines the validity of our results to a specific cohort. Future studies should aim to collect more comprehensive data to fully account for the influencing factors that affect evaluation outcomes.

Moreover, the study did not thoroughly assess participants’ acceptance of the VR intervention measures. While the VECA tool has shown potential for early screening of cognitive impairments, the subjective feelings and acceptance levels of participants towards such interventions remain unclear. Future research should include detailed assessments of participants’ acceptance, incorporating both objective measurements and subjective feedback, to ensure that the intervention measures are broadly acceptable and applicable.

Another limitation is the absence of cross-training and testing across different clinical research centers, which restricts our evaluation of the model’s generalizability and reliability. Future research should consider testing the VECA tool across a broader geographic location and population by establishing collaborations with multiple partners, thereby enhancing the model’s generalizability and performance in diverse settings.

Additionally, the interactions between subjects and the VR headset are based on visual and literal capabilities. The absence of either capability could lead the system to misinterpret subjects’ eye movements and produce deviated predictions. At the machine learning level, the validity and authenticity of the target variable (MoCA) are influenced by psychiatrists. Excessive noise in MoCA can distort our model’s distribution and compromise its accuracy. To improve model performance, other informative features could be extracted from raw eye movements. Their validation and integration into the system should be explored in future studies.

Finally, we acknowledge these limitations as omissions in our preliminary research and look forward to addressing these issues through more comprehensive evaluations and broader testing to improve our research methodology.

In conclusion, this research suggests that VECA can be an efficient and portable tool for dementia screening. VECA has the potential to improve early diagnosis and treatment of dementia by helping physicians identify mild cognitive impairment in the early stages. This study highlights the application of eye-tracking technology, machine learning, and VR in cognitive evaluation. Further research with more data is needed to compare the effectiveness of VECA with traditional tests and dementia diagnosis outcomes.

This study has been approved by Shenzhen Baoan Chronic Hospital Ethics Committee and all subjects have signed written informed consent for participation. A total of 201 subjects were evaluated, including 88 from Fuan CRC (Community Rehabilitation Center) and 113 from Wanxiang CRC. Written informed consent was obtained from all participants involved in this study. Overview of participant demographics: (1) aged 65.5 ± 5.1 years; (2) 81 males (40.3%), female = 120 (59.7%); (3) years of education 9.4 ± 3.8 (Table 3 ). The study excluded participants who had psychiatric, ophthalmological, or hearing impairment disorders, as well as those who were unable to sit comfortably due to severe physical illness. Only participants with normal vision or corrected-to-normal vision without color blindness were included. A small number of participants were further excluded from the analysis if they encountered difficulties calibrating to the eye tracker or did not attempt to view the images. Exclusion criteria were applied in cases where the eye tracking equipment faced challenges in achieving proper pupil and corneal reflection due to physiological constraints or visual problems (e.g., droopy eyelid, cataracts, detached retinas, glaucoma, pupils too small), or if participants were unable to complete the eye tracking calibration procedure.

For data acquisition, demographic characteristics including age, gender, and education levels of the participants were collected and each of them underwent paper-based instruments of MoCA Chinese version. Figure 5 depicts the cognitive assessment system based on VR head-mounted display and eye-tracking technology used in the study, collectively referred to as VECA, which takes 5 min only. Eye tracking calibration would be fulfilled before participants started the assessment to make sure gaze points captured by the eye tracker are valid. Cognitive tasks include memory (encoding, storage, and recall), visual attention (smooth pursuit), abstraction ability (ability to form abstract concepts), visuospatial working memory, visuospatial and executive function, calculation, language (understanding and execution of commands), and short-term memory binding. Detailed descriptions of each task are given in supplementary information (Supplementary Figs. 1 – 10 ). In each task, participants were usually given 3 s to understand the task and 5 or 8 s to fulfill related cognitive task. Multiple images including a correct answer (Area of interest, AOI) and distractors (non-Area of interest, non-AOI) were displayed in the VR scene, and subjects were instructed to identify and fixate on the correct answer. All eye movements were captured by the Tobii eye tracker embedded in Pico neo 3 pro eye, 95% of users can track better than 2° when their eyes are looking straight ahead ( https://developer.tobii.com/xr/learn/eye-behavior/hardware-accuracy/ ).

In each task, participants were instructed to understand the task and fulfill related cognitive task. Multiple images including a correct answer (area of interest, AOI) and distractors (non-area of interest, non-AOI) were displayed in the VR scene, and subjects were instructed to identify and fixate on the correct answer.

For data processing, biological eye movements such as fixation and saccade were derived out of raw gaze points with velocity-threshold fixation identification (I-VT) algorithm (Supplementary Fig. 11 ), which automatically classifies excessive noise such as microsaccades as abnormal movements 28 . Gaze points that extremely deviate from their neighbors may be caused by winks or unexpected shivers and were also eliminated. The percentage of time the subject fixates on the AOI over total fixation time of a certain task is calculated and deemed as features. Previous research claimed that age is the biggest risk factor and made gender also a significant risk factor due to longer lifespan of female 29 . Therefore, demographic information such as age and gender of the subjects were supplemented to the feature set. Feature importances of Gender, age, education, cognitive task-related factors were calculated via Gradient Boosting Regression as in Fig. 6 . Education level demonstrated nearly a quarter of importance (23.7%) and task-related factors have the highest importance at 67.8%.

The graph illustrates the relative importance of different features in the VRCA. The importance of each feature is expressed as a percentage. Gender accounts for 5.7%, age contributes 2.8%, education holds a weight of 23.7%, and task-related factors have the highest importance at 67.8%.

Data preprocessing techniques such as one-hot and ordinal encoder were applied to categorical features. Standard scaling was also conducted for scale-sensitive models to eliminate the influence of various scales. All features and corresponding preprocess methods are summarized in Table 5 . MoCA scores were categorized as the target variable so that our system could play as an efficient screening tool. In this way, the target variable better quantified the subjects’ cognitive capability. The whole dataset was 70%–30% randomly split into train set and test set.

For modeling, Oyama et al. averaged each cognitive task score as the eye movement cognitive assessment score 21 , (hereinafter referred to as VR model) which would be the baseline model. Support vector regression (SVR), Multi-layer perceptron (MLP), Lasso regression (Lasso), and Gradient Boost Regression Tree (GBRT) were adopted. Hyperparameters were optimized on train set via grid Search and 5-fold cross validations. Detailed model configurations are listed below:

Multi-layer perceptron (MLP): hidden layer sizes are configured as (16, 32, 16, 6), Rectified Linear Unit was used as activation function. Parameters were solved by Adam stochastic gradient-based optimizer. L2 penalty coefficient was set to 0.05. Max iterations of training was 1000.

Support vector regression (SVR): a linear kernel based support vector regressor with 0.5 L2 penalty is established. Insensitivity interval was set to 0.1 and shrinking option was activated to enhance model generalization performance.

Lasso regression: linear regression with 0.1 L1 penalized. Its maximum training iteration was set to 50.

Gradient Boosting Regression Tree (GBRT): 50 CART base decision trees with depth of 3 were ensembled and trained with learning rate of 0.1.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

Non-identifiable patient data are available upon request to the corresponding author.

Code availability

The program of eye tracking data processing, feature extraction, modeling and evaluation based on the framework of VECA is openly available at https://github.com/zhangchi0923/VECA .

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Acknowledgements

The authors gratefully acknowledge the financial support from the Shenzhen Fundamental Research Program, under Grant No. JCYJ20220531091006014, which made this research possible. Heartfelt gratitude is also extended to Mr. Lee Yick Kuen for his invaluable support and encouragement throughout the course of this research.

Author information

These authors contributed equally: Ying Xu, Chi Zhang

Authors and Affiliations

Shenzhen Bao’an Centre for Chronic Disease Control, Shenzhen, PR China

Ying Xu & Qing Yuan

Shenzhen Yiwei Technology, Shenzhen, PR China

Chi Zhang & Baobao Pan

National Engineering Laboratory for Big Data System Computing Technology, Shenzhen University, Shenzhen, PR China

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Contributions

X.Z. organized the entire project, designed the contents of experiments and VR eye-tracking cognitive tests. Q.Y. is responsible for screening scenes, clinical suggestions, and other resources. Y.X. and C.Z. are responsible for data acquisition, data processing, and modeling. B.P. provided algorithm suggestions. All authors reviewed and approved the final version of the manuscript.

Corresponding authors

Correspondence to Qing Yuan or Xu Zhang .

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Xu, Y., Zhang, C., Pan, B. et al. A portable and efficient dementia screening tool using eye tracking machine learning and virtual reality. npj Digit. Med. 7 , 219 (2024). https://doi.org/10.1038/s41746-024-01206-5

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Published : 22 August 2024

DOI : https://doi.org/10.1038/s41746-024-01206-5

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Image source: University of Dundee

News • Towards personalised risk assessment

Training an ai to early detect dementia with big data, data scientists and clinical researchers will use brain scans from the entire scottish population to build a software tool that they hope will be able to predict a person’s risk of dementia..

The team of 20, from the Universities of Edinburgh and Dundee, has approval to use a unique, large data set made up of CT and MRI brain scans from patients in Scotland from 2008 to 2018, representing 1.6 million images. Approval comes from the Public Benefit and Privacy Panel for Health and Social Care, a part of NHS Scotland. 

The team will then use artificial intelligence and machine learning to analyse the image data alongside linked health records such as demographics and treatment history, without patients being identifiable, to find patterns that could indicate a person’s risk of developing dementia. The ultimate aim is to build a digital healthcare tool that radiologists can use when scanning for other conditions to determine a person’s dementia risk, and to diagnose early stages of related diseases, such as Alzheimer’s .

Image source: University of Dundee, image credit: Edinburgh Innovations

Isolating a patient group with a high risk of dementia will enable the development of more precise treatments for various types of dementia, mostly Alzheimer’s and vascular dementia. The data will be held safely in the Scottish National Safe Haven, commissioned by Public Health Scotland, which provides a secure platform for the research use of NHS electronic data. 

Former journalist Willy Gilder, 71, from Edinburgh, was diagnosed with Alzheimer’s three years ago. He said, “We know that 45% of dementia cases are preventable, and The Lancet has published a list of risk factors including smoking, obesity and air pollution . If you know you’re at risk, you can make changes that are going to improve your brain health. Because I was diagnosed early, I know that keeping very mentally active, for example, is going to help me. Possible new treatments in development for Alzheimer’s are likely to work in the early stages of the disease, which is why early diagnosis is important. With long waiting lists for diagnosis, as well as relatively low funding for dementia research in general compared to cancer, a project like this to predict a person’s risk is extremely important.” 

The project, called Scottish AI in Neuroimaging to predict Dementia and Neurodegenerative Disease (SCAN-DAN), is one of three ‘pathfinders’ from global research collaboration NEURii, which launched a year ago. Comprising global pharmaceutical company Eisai, Gates Ventures, the University of Edinburgh, national health data science organisation Health Data Research UK and medical research charity LifeArc, NEURii aims to translate world-class data, neurology and digital sciences into projects that can enhance quality of life for people living with dementia.

This new data set will be of great use to neurological researchers. And, should we establish a successful proof of concept, we will have a suite of software tools that are smoothly and unobtrusively integrated with routine radiology operations, that assist clinical decision-making and flag the risk of dementia as early as possible Emanuele Trucco

The NEURii collaboration provides funding and expertise to the pathfinder projects to remove barriers to getting digital health tools to market. The research teams are also supported by Edinburgh Innovations, the University of Edinburgh’s commercialisation service. 

Professor Will Whiteley, of the University of Edinburgh’s Centre for Clinical Brain Sciences, is co-leading the SCAN-DAN project. He said, “Better use of simple brain scans to predict dementia will lead to better understanding of dementia and potentially earlier diagnosis of its causes, which in turn will make development of new treatments easier. Currently treatments for dementia are expensive, scarce and of uncertain value. If we can collect data from a large group of people at high risk, who then give their consent to take part in trials, we can really start to develop new treatments. Working with NEURii really gives us the potential for patient impact – to build something that actually makes it into practice. Often modelling doesn’t go anywhere, but motivation from the NEURii team to develop a useful product really concentrates the mind.” 

Professor Emanuele Trucco, an expert in AI and medical imaging at the University of Dundee and SCAN-DAN co-lead, said, “Scotland and the UK are at the forefront of clinical data research, building on the unique National Health Service patient number – called the CHI number in Scotland, as well as the structure, security and good governance of the Scottish National Safe Haven, amongst other data organisations such as the UK Biobank. This new data set will be of great use to neurological researchers. And, should we establish a successful proof of concept, we will have a suite of software tools that are smoothly and unobtrusively integrated with routine radiology operations, that assist clinical decision-making and flag the risk of dementia as early as possible.” 

The project is backed by the NEURii partner organisations. Dr Ricardo Sáinz Fuertes, Global Director of Digital Health Solutions at Eisai and Programme Director for NEURii, said, “The spirit of NEURii is to fulfil the promise of data science for healthcare. Within a year, we plan to support SCAN-DAN through to proof of concept by removing obstacles to commercialisation and providing whatever’s needed, be it funding, collaborations or legal or regulatory input. We are joining forces globally, in a way that hasn’t been done before, to provide innovative digital projects with the chance of becoming solutions to complex neurodegenerative disorders like dementia.” 

Source: University of Dundee

• Alzheimer's (182)
• big data (100)
• brain (511)
• early diagnosis (174)
• machine learning (154)

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