Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Evaluation of cognitive impairment and dementia

Eric B Larson, MD, MPH
Section Editors
Steven T DeKosky, MD, FAAN, FACP, FANA
Kenneth E Schmader, MD
Deputy Editor
April F Eichler, MD, MPH


Dementia is a disorder that is characterized by a decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, social cognition) [1]. The deficits must represent a decline from previous level of function and be severe enough to interfere with daily function and independence. This characterization of dementia reflects a 2013 revision of earlier definitions, which is discussed in more detail below.

Alzheimer disease (AD) is the most common form of dementia in the elderly, accounting for 60 to 80 percent of cases. As the population ages, the overall burden of dementia is increasing worldwide. In the United States in 2012, an estimated 5.2 million individuals over 65 years of age had AD, a number that is expected to reach 6.7 million by 2025 [2,3]. Clinicians will need to accurately diagnose and manage the early cognitive manifestations of AD and other dementias, particularly as new pharmacological agents are developed.

This topic will discuss the evaluation of cognitive impairment and dementia. An approach to diagnosis and evaluation of early-onset dementia (ie, adults younger than 65 years of age) is presented separately. (See "Early-onset dementia in adults".)

The clinical, diagnostic, and pathologic aspects of specific dementia syndromes and the treatment, risk factors, and prevention of dementia are also discussed separately. (See "Treatment of dementia" and "Risk factors for cognitive decline and dementia" and "Prevention of dementia".)


Although a number of definitions exist for dementia, the Diagnostic and Statistical Manual (DSM) definition provides a reasonable framework for the concept of dementia in clinical practice. According to DSM-5, released in 2013, the criteria for dementia (now called major neurocognitive disorder) include the following [1]:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Aug 3, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  2. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol 2003; 60:1119.
  3. Alzheimer's Association. 2012 Alzheimer's disease facts and figures. http://www.alz.org/downloads/facts_figures_2012.pdf (Accessed on March 19, 2013).
  4. Knopman DS, DeKosky ST, Cummings JL, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56:1143.
  5. Kawas CH. Clinical practice. Early Alzheimer's disease. N Engl J Med 2003; 349:1056.
  6. Barrett JJ, Haley WE, Harrell LE, Powers RE. Knowledge about Alzheimer disease among primary care physicians, psychologists, nurses, and social workers. Alzheimer Dis Assoc Disord 1997; 11:99.
  7. Kukull WA, Larson EB, Reifler BV, et al. The validity of 3 clinical diagnostic criteria for Alzheimer's disease. Neurology 1990; 40:1364.
  8. Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology 2000; 55:1724.
  9. Wang PN, Wang SJ, Fuh JL, et al. Subjective memory complaint in relation to cognitive performance and depression: a longitudinal study of a rural Chinese population. J Am Geriatr Soc 2000; 48:295.
  10. Petersen RC, Smith G, Kokmen E, et al. Memory function in normal aging. Neurology 1992; 42:396.
  11. Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology 1999; 52:1392.
  12. U.S. Department of Health and Human Services Agency for Health Care Policy and Research. Clinical Practice Guidelines, Number 19. Recognition and initial assessment of Alzheimer's disease and related dementias. November 1996; AHCPR Publication No. 97-0702.
  13. Jorm AF, Fratiglioni L, Winblad B. Differential diagnosis in dementia. Principal components analysis of clinical data from a population survey. Arch Neurol 1993; 50:72.
  14. U.S. Preventive Services Task Force. Screening for dementia: recommendation and rationale. Ann Intern Med 2003; 138:925.
  15. Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003; 138:927.
  16. Caselli RJ. Current issues in the diagnosis and management of dementia. Semin Neurol 2003; 23:231.
  17. Knopman DS, Boeve BF, Petersen RC. Essentials of the proper diagnoses of mild cognitive impairment, dementia, and major subtypes of dementia. Mayo Clin Proc 2003; 78:1290.
  18. Morris JC. Dementia update 2003. Alzheimer Dis Assoc Disord 2003; 17:245.
  19. Clarfield AM. The reversible dementias: do they reverse? Ann Intern Med 1988; 109:476.
  20. Rahkonen T, Eloniemi-Sulkava U, Rissanen S, et al. Dementia with Lewy bodies according to the consensus criteria in a general population aged 75 years or older. J Neurol Neurosurg Psychiatry 2003; 74:720.
  21. Knopman DS, Parisi JE, Boeve BF, et al. Vascular dementia in a population-based autopsy study. Arch Neurol 2003; 60:569.
  22. Campbell NL, Boustani MA, Lane KA, et al. Use of anticholinergics and the risk of cognitive impairment in an African American population. Neurology 2010; 75:152.
  23. Carrière I, Fourrier-Reglat A, Dartigues JF, et al. Drugs with anticholinergic properties, cognitive decline, and dementia in an elderly general population: the 3-city study. Arch Intern Med 2009; 169:1317.
  24. Geldmacher DS, Whitehouse PJ. Evaluation of dementia. N Engl J Med 1996; 335:330.
  25. Karlawish JH, Clark CM. Diagnostic evaluation of elderly patients with mild memory problems. Ann Intern Med 2003; 138:411.
  26. Knopman DS. The initial recognition and diagnosis of dementia. Am J Med 1998; 104:2S.
  27. Tsoi KK, Chan JY, Hirai HW, et al. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med 2015; 175:1450.
  28. Larson E. ACP Journal Club. Review: Brief screening tests for dementia have pooled sensitivity of 76% to 92% and specificity of 81% to 91. Ann Intern Med 2015; 163:JC10.
  29. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189.
  30. Tangalos EG, Smith GE, Ivnik RJ, et al. The Mini-Mental State Examination in general medical practice: clinical utility and acceptance. Mayo Clin Proc 1996; 71:829.
  31. Anthony JC, LeResche L, Niaz U, et al. Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among hospital patients. Psychol Med 1982; 12:397.
  32. Freidl W, Schmidt R, Stronegger WJ, et al. Mini mental state examination: influence of sociodemographic, environmental and behavioral factors and vascular risk factors. J Clin Epidemiol 1996; 49:73.
  33. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993; 269:2386.
  34. Kukull WA, Larson EB, Teri L, et al. The Mini-Mental State Examination score and the clinical diagnosis of dementia. J Clin Epidemiol 1994; 47:1061.
  35. Grigoletto F, Zappalà G, Anderson DW, Lebowitz BD. Norms for the Mini-Mental State Examination in a healthy population. Neurology 1999; 53:315.
  36. Dufouil C, Clayton D, Brayne C, et al. Population norms for the MMSE in the very old: estimates based on longitudinal data. Mini-Mental State Examination. Neurology 2000; 55:1609.
  37. Hensel A, Angermeyer MC, Riedel-Heller SG. Measuring cognitive change in older adults: reliable change indices for the Mini-Mental State Examination. J Neurol Neurosurg Psychiatry 2007; 78:1298.
  38. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005; 53:695.
  39. Davis DH, Creavin ST, Yip JL, et al. Montreal Cognitive Assessment for the diagnosis of Alzheimer's disease and other dementias. Cochrane Database Syst Rev 2015; :CD010775.
  40. Rossetti HC, Lacritz LH, Cullum CM, Weiner MF. Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample. Neurology 2011; 77:1272.
  41. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993; 43:2412.
  42. Schafer KA, Tractenberg RE, Sano M, et al. Reliability of monitoring the clinical dementia rating in multicenter clinical trials. Alzheimer Dis Assoc Disord 2004; 18:219.
  43. Rockwood K, Strang D, MacKnight C, et al. Interrater reliability of the Clinical Dementia Rating in a multicenter trial. J Am Geriatr Soc 2000; 48:558.
  44. Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15:1021.
  45. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 2003; 51:1451.
  46. Galvin JE, Roe CM, Xiong C, Morris JC. Validity and reliability of the AD8 informant interview in dementia. Neurology 2006; 67:1942.
  47. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975; 23:433.
  48. Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry 1998; 64:588.
  49. Powlishta KK, Von Dras DD, Stanford A, et al. The clock drawing test is a poor screen for very mild dementia. Neurology 2002; 59:898.
  50. Holsinger T, Deveau J, Boustani M, Williams JW Jr. Does this patient have dementia? JAMA 2007; 297:2391.
  51. Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56:1133.
  52. Wilder, D, Cross, P, Chen, J, et al. Operating characteristics of brief screens for dementia in a multicultural population. Am J Geriatr Psychiatry 1995; 3:96.
  53. Cahn DA, Salmon DP, Butters N, et al. Detection of dementia of the Alzheimer type in a population-based sample: neuropsychological test performance. J Int Neuropsychol Soc 1995; 1:252.
  54. Swearer JM, O'Donnell BF, Kane KJ, et al. Delayed recall in dementia: sensitivity and specificity in patients with higher than average general intellectual abilities. Neuropsychiatry Neuropsychol Behav Neurol 1998; 11:200.
  55. Monsch AU, Bondi MW, Salmon DP, et al. Clinical validity of the Mattis Dementia Rating Scale in detecting Dementia of the Alzheimer type. A double cross-validation and application to a community-dwelling sample. Arch Neurol 1995; 52:899.
  56. Bracco L, Amaducci L, Pedone D, et al. Italian Multicentre Study on Dementia (SMID): a neuropsychological test battery for assessing Alzheimer's disease. J Psychiatr Res 1990; 24:213.
  57. Loewenstein, DA, Duara, R, Arguelles, T, et al. Use of the Fuld Object-Memory Evaluation in the detection of mild dementia among Spanish and English-speaking groups. Am J Geriatr Psych 1995; 3:300.
  58. Fisk, JD, Rockwood, K, Hondas, B, et al. Cognitive screening in a population-based sample of community-living elderly: effects of age and education on the construct of cognitive status. Int J Geriatr Psychiatry 1995; 10:687.
  59. Chandler MJ, Lacritz LH, Hynan LS, et al. A total score for the CERAD neuropsychological battery. Neurology 2005; 65:102.
  60. Beeri MS, Schmeidler J, Sano M, et al. Age, gender, and education norms on the CERAD neuropsychological battery in the oldest old. Neurology 2006; 67:1006.
  61. Hutchinson AD, Mathias JL. Neuropsychological deficits in frontotemporal dementia and Alzheimer's disease: a meta-analytic review. J Neurol Neurosurg Psychiatry 2007; 78:917.
  62. Holtzer R, Verghese J, Wang C, et al. Within-person across-neuropsychological test variability and incident dementia. JAMA 2008; 300:823.
  63. Nelson, HE. The National Adult Reading Test (NART): test manual. Windsor: NFER-Nelson, 1982.
  64. McGurn B, Starr JM, Topfer JA, et al. Pronunciation of irregular words is preserved in dementia, validating premorbid IQ estimation. Neurology 2004; 62:1184.
  65. Weytingh MD, Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol 1995; 242:466.
  66. Knopman DS, Petersen RC, Cha RH, et al. Incidence and causes of nondegenerative nonvascular dementia: a population-based study. Arch Neurol 2006; 63:218.
  67. Geschwind MD, Shu H, Haman A, et al. Rapidly progressive dementia. Ann Neurol 2008; 64:97.
  68. Kelley BJ, Boeve BF, Josephs KA. Young-onset dementia: demographic and etiologic characteristics of 235 patients. Arch Neurol 2008; 65:1502.
  69. Henderson AS, Easteal S, Jorm AF, et al. Apolipoprotein E allele epsilon 4, dementia, and cognitive decline in a population sample. Lancet 1995; 346:1387.
  70. Statement on use of apolipoprotein E testing for Alzheimer disease. American College of Medical Genetics/American Society of Human Genetics Working Group on ApoE and Alzheimer disease. JAMA 1995; 274:1627.
  71. Small GW, Rabins PV, Barry PP, et al. Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society. JAMA 1997; 278:1363.
  72. Charletta D, Gorelick PB, Dollear TJ, et al. CT and MRI findings among African-Americans with Alzheimer's disease, vascular dementia, and stroke without dementia. Neurology 1995; 45:1456.
  73. Alexander EM, Wagner EH, Buchner DM, et al. Do surgical brain lesions present as isolated dementia? A population-based study. J Am Geriatr Soc 1995; 43:138.
  74. Jacobs DM, Sano M, Dooneief G, et al. Neuropsychological detection and characterization of preclinical Alzheimer's disease. Neurology 1995; 45:957.
  75. U.S. Preventive Services Task Force. Guide to clinical preventive services, 2nd ed, Williams and Wilkins, Baltimore 1996.
  76. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care, Canada Communication Group, Ottawa 1994. p.902.
  77. American Academy of Family Physicians. Age charts for periodic health examination. American Academy of Physicians, Kansas City 1994.
  78. Gifford DR, Holloway RG, Vickrey BG. Systematic review of clinical prediction rules for neuroimaging in the evaluation of dementia. Arch Intern Med 2000; 160:2855.
  79. Becker JT, Davis SW, Hayashi KM, et al. Three-dimensional patterns of hippocampal atrophy in mild cognitive impairment. Arch Neurol 2006; 63:97.
  80. Warren JD, Schott JM, Fox NC, et al. Brain biopsy in dementia. Brain 2005; 128:2016.