COGNITIVE

ASSESSMENT TOOLKIT
A guide to detect cognitive impairment quickly and efficiently
during the Medicare Annual Wellness Visit

TABLE OF CONTENTS

Overview ...............................................................................................................................................................3

Medicare Annual Wellness Visit Algorithm for Assessment of Cognition ..........................................................4

General Practitioner Assessment of Cognition (GPCOG) .....................................................................................5

Memory Impairment Screen (MIS) .......................................................................................................................7

Mini-Cog .............................................................................................................................................................9
TM

Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE) ....................11

Eight-item Informant Interview to Differentiate Aging and Dementia (AD8) ...................................................14

Alzheimers Association Recommendations for Operationalizing the Detection of Cognitive

Impairment During the Medical Annual Wellness Visit in a Primary Care Setting ..........................................17

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OVERVIEW

The Alzheimers Association dedicated to fueling the advancement of early detection and diagnosis of
dementia has developed an easy-to-implement process to assess cognition during the Medicare Annual
Wellness Visit. Developed by a group of clinical dementia experts, the recommended process outlined on
page 4 allows you to efficiently identify patients with probable cognitive impairment while giving you the
flexibility to choose a cognitive assessment tool that works best for you and your patients.
This Cognitive Assessment Toolkit contains:
The Medicare Annual Wellness Visit Algorithm for Assessment of Cognition, incorporating patient
history, clinician observations, and concerns expressed by the patient, family or caregiver
Three validated patient assessment tools: the General Practitioner Assessment of Cognition (GPCOG),
the Memory Impairment Screen (MIS) and the Mini-Cog . All tools:
TM

Can be administered in 5 minutes or less

Are equal to or superior to the Mini-Mental State Exam (MMSE) for detecting dementia
Are easily administered by medical staff members who are not physicians
Are relatively free from educational, language and/or cultural bias
Three validated informant assessment of patient tools: the Short Form of the Informant Questionnaire
on Cognitive Decline in the Elderly (Short IQCODE), the Eight-item Informant Interview to Differentiate
Aging and Dementia (AD8) and the GPCOG
The Alzheimers Association Recommendations for Operationalizing the Detection of Cognitive
Impairment During the Medical Annual Wellness Visit in a Primary Care Setting,as published in the
journal Alzheimers and Dementia.
For more information on the detection, diagnosis and treatment of Alzheimers disease, as well as direct
access to patient and caregiver resources, please visit our Health Care Professionals and Alzheimers center
at alz.org/hcps.

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ALZHEIMERS ASSOCIATION
Medicare Annual Wellness Visit Algorithm for Assessment of Cognition
A. Review HRA, clinician observation, self-reported concerns, responses to queries

YES

Signs/symptoms present

NO
NO

Informant available to confirm

B.* Conduct brief structured assessment

Patient Assessment: Mini-Cog or GPCOG or MIS
Informant assessment of patient: Short IQCODE, AD8 or GPCOG

YES

Follow-up during subsequent AWV

Brief assessment(s) triggers concerns: Patient: Mini-Cog
3 or GPCOG <5 (5-8 score is indeterminate without informant)
or MIS4 or Informant: Short IQCODE 3.38 or AD8 2 or
GPCOG informant score 3 with patient score <8

NO

YES
C. Refer OR Conduct full Dementia Evaluation
* No one tool is recognized as the best brief assessment to determine if a full dementia evaluation is
needed. Some providers repeat patient assessment with an alternate tool (e.g., SLUMS, or MoCA)
to confirm initial findings before referral or initiation of full dementia evaluation.

AD8 = Eight-item Informant Interview to Differentiate Aging and Dementia; AWV = Annual Wellness
Visit; GPCOG = General Practitioner Assessment of Cognition; HRA = Health Risk Assessment; MIS
= Memory Impairment Screen; MMSE = Mini Mental Status Exam; MoCA = Montreal Cognitive
Assessment; SLUMS = St. Louis University Mental Status Exam; Short IQCODE = Short Informant
Questionnaire on Cognitive Decline in the Elderly
Cordell CB, Borson S, Boustani M, Chodosh J, Reuben D, Verghese J, et al. Alzheimers Association
recommendations for operationalizing the detection of cognitive impairment during the Medicare
Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2012. In press.

800.272.3900 | alz.org

Patient name:__________________________

Date: _____________

GPCOG Screening Test

Step 1: Patient Examination
Unless specified, each question should only be asked once
Name and Address for subsequent recall test
1.

I am going to give you a name and address. After I have said it, I want you to repeat
it. Remember this name and address because I am going to ask you to tell it to me
again in a few minutes: John Brown, 42 West Street, Kensington. (Allow a maximum
of 4 attempts).

Time Orientation
2.

Correct

Incorrect

What is the date? (exact only)

Clock Drawing use blank page

3.

Please mark in all the numbers to indicate

the hours of a clock (correct spacing required)

4.

Please mark in hands to show 10 minutes past

eleven oclock (11.10)

Information
5.

Can you tell me something that happened in the news recently?

(Recently = in the last week. If a general answer is given,
eg war, lot of rain, ask for details. Only specific answer scores).

Recall
6.

What was the name and address I asked you to remember

John
Brown
42
West (St)
Kensington

(To get a total score, add the number of items answered correctly
Total correct (score out of 9)

/9

If patient scores 9, no significant cognitive impairment and further testing not necessary.
If patient scores 5-8, more information required. Proceed with Step 2, informant section.
If patient scores 0-4, cognitive impairment is indicated. Conduct standard investigations.
University of New South Wales as represented by the Dementia Collaborative Research Centre Assessment and Better Care;
Brodaty et al, JAGS 2002; 50:530-534

Informant Interview
Date: ____________

Informants name: ___________________________________

Informants relationship to patient, i.e. informant is the patients: _____________

These six questions ask how the patient is compared to when s/he
was well, say 5 10 years ago
Compared to a few years ago:

Yes

Does the patient have more trouble remembering things

that have happened recently than s/he used to?

Does he or she have more trouble recalling conversations

a few days later?

When speaking, does the patient have more difficulty in

finding the right word or tend to use the wrong words
more often?

Is the patient less able to manage money and financial

affairs (e.g. paying bills, budgeting)?

Is the patient less able to manage his or her medication

independently?

Does the patient need more assistance with transport

(either private or public)?

No

Dont
Know

N/A

(If the patient has difficulties due only to physical problems, e.g bad leg, tick no)

(To get a total score, add the number of items answered no, dont know or N/A)
Total score (out of 6)
If patient scores 0-3, cognitive impairment is indicated. Conduct standard investigations.
University of New South Wales as represented by the Dementia Collaborative Research Centre Assessment and Better Care;
Brodaty et al, JAGS 2002; 50:530-534

MEMORY IMPAIRMENT SCREEN (MIS)

Instructions for Administration
1. Show patient a sheet of paper with the 4 items to be recalled in 24-point or greater uppercase
letters (on other side), and ask patient to read the items aloud.
2. Tell patient that each item belongs to a different category. Give a category cue and ask patient to
indicate which of the words belongs in the stated category (eg, Which one is the game?). Allow
up to 5 attempts. Failure to complete this task indicates possible cognitive impairment.
3. When patient identifies all 4 words, remove the sheet of paper. Tell patient that he or she will be
asked to remember the words in a few minutes.
4. Engage patient in distractor activity for 2 to 3 minutes, such as counting to 20 and back, counting
back from 100 by 7, spelling WORLD backwards.
5. FREE RECALL 2 points per word: Ask patient to state as many of the 4 words he or she can
recall. Allow at least 5 seconds per item for free recall. Continue to step 6 if no more words have
been recalled for 10 seconds.
6. CUED RECALL 1 point per word: Read the appropriate category cue for each word not recalled
during free recall (eg, What was the game?).

Word

Cue

Checkers

Game

Saucer

Dish

Telegram

Message

Red Cross

Organization

Free recall (2 pts.)

Scoring
The maximum score for the MIS is 8.
5-8 No cognitive impairment
4 Possible cognitive impairment

Copyright 1999 Albert Einstein College of Medicine. All rights reserved.

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Cued Recall (1 pts)

WORD LIST

CHECKERS
SAUCER
TELEGRAM
RED CROSS

Copyright 1999 Albert Einstein College of Medicine. All rights reserved.

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MINI-COG

TM

Instructions
ADMINISTRATION

SPECIAL INSTRUCTIONS

1. Get patients attention and ask him or her

to remember three unrelated words. Ask
patient to repeat the words to ensure the
learning was correct.

Allow patient three tries, then go to next item.

The following word lists have been validated in a clinical study:13
Version 1
B anana
Sunrise
Chair

Version 3
V illage
Kitchen
Baby

Version 5
C aptain
Garden
Picture

Version 2
Daughter
Heaven
Mountain

Version 4
River
Nation
Finger

Version 6
Leader
Season
Table

2. Ask patient to draw the face of a clock.

After numbers are on the face, ask patient
to draw hands to read 10 minutes after
11:00 (or 20 minutes after 8:00).

Either a blank piece of paper or a preprinted circle (other side) may be used.
A correct response is all numbers placed in approximately the correct positions AND the
hands pointing to the 11 and 2 (or the 4 and 8).
These two specific times are more sensitive than others.
A clock should not be visible to the patient during this task.
Refusal to draw a clock is scored abnormal.
Move to next step if clock not complete within three minutes.

3. Ask the patient to recall the three words

from Step 1.

Ask the patient to recall the three words you stated in Step 1.

Scoring
3 recalled words
1-2 recalled words + normal CDT
1-2 recalled words + abnormal CDT
0 recalled words

Negative for cognitive impairment

Negative for cognitive impairment
Positive for cognitive impairment
Positive for cognitive impairment

References
1. B orson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive vital signs measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021-1027.
2. 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(10):1451-1454.
3. McCarten JR, Anderson P Kuskowski MA et al. Finding dementia in primary care: the results of a clinical demonstration project. J Am Geritr Soc. 2012;60(2):210-217.
Mini-CogTM Copyright S Borson. Reprinted with permission of the author ([email protected]). All rights reserved.

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10

CLOCK DRAWING TEST

Patient Name:

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Date:

11

Short Form of the Informant Questionnaire on Cognitive

Decline in the Elderly (Short IQCODE)

by A. F. Jorm
Centre for Mental Health Research
The Australian National University
Canberra, Australia

There is no copyright on the Short IQCODE. However, the author appreciates being
kept informed of research projects which make use of it.

Note: As used in published studies, the IQCODE was preceded by questions to the
informant on the subject's sociodemographic characteristics and physical health.

12

Now we want you to remember what your friend or relative was like 10 years ago and
to compare it with what he/she is like now. 10 years ago was in 19__. Below are
situations where this person has to use his/her memory or intelligence and we want
you to indicate whether this has improved, stayed the same or got worse in that
situation over the past 10 years. Note the importance of comparing his/her present
performance with 10 years ago. So if 10 years ago this person always forgot where
he/she had left things, and he/she still does, then this would be considered "Hasn't
changed much". Please indicate the changes you have observed by circling the
appropriate answer.
Compared with 10 years ago how is this person at:
1

1. Remembering things about

family and friends e.g.
occupations, birthdays,
addresses

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

2. Remembering things that

have happened recently

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

3. Recalling conversations a
few days later

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

4. Remembering his/her
address and telephone number

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

5. Remembering what day and

month it is

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

6. Remembering where things

are usually kept

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

7. Remembering where to find

things which have been put in
a different place from usual

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

8. Knowing how to work

familiar machines around the
house

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

13

9. Learning to use a new

gadget or machine around the
house

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

10. Learning new things in

general

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

11. Following a story in a book Much

improved
or on TV

A bit
improved

Not much
change

A bit
worse

Much
worse

12. Making decisions on

everyday matters

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

13. Handling money for

shopping

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

14. Handling financial matters

e.g. the pension, dealing with
the bank

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

15. Handling other everyday

arithmetic problems e.g.
knowing how much food to
buy, knowing how long
between visits from family or
friends

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

16. Using his/her intelligence

to understand what's going on
and to reason things through

Much
improved

A bit
improved

Not much
change

A bit
worse

Much
worse

14

AD8 Dementia Screening Interview

Remember, Yes, a change indicates that

there has been a change in the last several
years caused by cognitive (thinking and
memory) problems.

Patient ID#:__________
CS ID#:___________
Date:___________
YES,
A change

NO,
No change

N/A,
Dont know

1. Problems with judgment (e.g.,

problems making decisions, bad
financial decisions, problems with
thinking)
2. Less interest in hobbies/activities

3. Repeats the same things over and

over (questions, stories, or
statements)
4. Trouble learning how to use a tool,
appliance, or gadget (e.g., VCR,
computer, microwave, remote control)
5. Forgets correct month or year
6. Trouble handling complicated financial
affairs (e.g., balancing checkbook,
income taxes, paying bills)
7. Trouble remembering appointments
8. Daily problems with thinking and/or
memory

TOTAL AD8 SCORE

Adapted from Galvin JE et al, The AD8, a brief informant interview to detect dementia, Neurology 2005:65:559-564
Copyright 2005. The AD8 is a copyrighted instrument of the Alzheimers Disease Research Center, Washington University, St. Louis, Missouri.
All Rights Reserved.

15

The AD8 Administration and Scoring Guidelines

A spontaneous self-correction is allowed for all responses without counting as an error.
The questions are given to the respondent on a clipboard for selfadministration or can be read
aloud to the respondent either in person or over the phone. It is preferable to administer the AD8
to an informant, if available. If an informant is not available, the AD8 may be administered to the
patient.
When administered to an informant, specifically ask the respondent to rate change in the
patient.
When administered to the patient, specifically ask the patient to rate changes in his/her ability
for each of the items, without attributing causality.
If read aloud to the respondent, it is important for the clinician to carefully read the phrase as
worded and give emphasis to note changes due to cognitive problems (not physical problems).
There should be a one second delay between individual items.
No timeframe for change is required.
The final score is a sum of the number items marked Yes, A change.
Interpretation of the AD8 (Adapted from Galvin JE et al, The AD8, a brief informant interview to detect dementia,
Neurology 2005:65:559-564)

A screening test in itself is insufficient to diagnose a dementing disorder. The AD8 is, however,
quite sensitive to detecting early cognitive changes associated many common dementing illness
including Alzheimer disease, vascular dementia, Lewy body dementia and frontotemporal
dementia.
Scores in the impaired range (see below) indicate a need for further assessment. Scores in the
normal range suggest that a dementing disorder is unlikely, but a very early disease process
cannot be ruled out. More advanced assessment may be warranted in cases where other
objective evidence of impairment exists.
Based on clinical research findings from 995 individuals included in the development and
validation samples, the following cut points are provided:
0 1: Normal cognition
2 or greater: Cognitive impairment is likely to
Reciever Operator Characteristics (ROC) curve for AD8
be present
1.0

0.8

Sensitivity

Administered to either the informant (preferable) or the

patient, the AD8 has the following properties:
Sensitivity > 84%
Specificity > 80%
Positive Predictive Value > 85%
Negative Predictive Value > 70%
Area under the Curve: 0.908; 95%CI: 0.8880.925

0.6

0.4

0.2

0.0
0.0

0.2

0.4

0.6

1 - Specificity

0.8

1.0

16

Copyright 2005. The Eight-item Informant Interview to Differentiate Aging and Dementia is a
copyrighted instrument of Washington University, St. Louis, Missouri. All Rights Reserved.
Permission Statement
Washington University grants permission to use and reproduce the Eight-item Informant Interview to
Differentiate Aging and Dementia exactly as it appears in the PDF available here without
modification or editing of any kind solely for end user use in investigating dementia in clinical care or
research in clinical care or research (the Purpose). For the avoidance of doubt, the Purpose does
not include the (i) sale, distribution or transfer of the Eight-item Informant Interview to Differentiate
Aging and Dementia or copies thereof for any consideration or commercial value; (ii) the creation of
any derivative works, including translations; and/or (iii) use of the Eight-item Informant Interview to
Differentiate Aging and Dementia as a marketing tool for the sale of any drug. All copies of the AD8
shall include the following notice: Reprinted with permission. Copyright 2005. The Eight-item
Informant Interview to Differentiate Aging and Dementia is a copyrighted instrument of Washington
University, St. Louis, Missouri. All Rights Reserved. Please contact [email protected] for
use of the Eight-item Informant Interview to Differentiate Aging and Dementia for any other intended
purpose.

17

Alzheimers & Dementia 9 (2013) 141150

Alzheimers Association recommendations for operationalizing

the detection of cognitive impairment during the Medicare Annual
Wellness Visit in a primary care setting
Cyndy B. Cordella,*, Soo Borsonb,c, Malaz Boustanid,e,f, Joshua Chodoshg,h, David Reubenh,
Joe Verghesei, William Thiesa, Leslie B. Friedj,k; for the Medicare Detection
of Cognitive Impairment Workgroup
a
Alzheimers Association, Chicago, IL, USA
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
c
Memory Disorders Clinic and Dementia Health Services, University of Washington School of Medicine, Seattle, WA, USA
d
Indiana University Center for Aging Research, Indianapolis, IN, USA
e
Regenstrief Institute, Inc., Indianapolis, IN, USA
f
Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
g
Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA, USA
h
Division of Geriatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
i
Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
j
American Bar Association, Washington, DC, USA
k
Alzheimers Association Medicare Advocacy Project, Washington, DC, USA
b

Abstract

The Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual
Wellness Visit (AWV), effective January 1, 2011. The AWV requires an assessment to detect cognitive impairment. The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because there is no single, universally accepted screen that
satisfies all needs in the detection of cognitive impairment. To provide primary care physicians
with guidance on cognitive assessment during the AWV, and when referral or further testing is
needed, the Alzheimers Association convened a group of experts to develop recommendations.
The resulting Alzheimers Association Medicare Annual Wellness Visit Algorithm for Assessment
of Cognition includes review of patient Health Risk Assessment (HRA) information, patient observation, unstructured queries during the AWV, and use of structured cognitive assessment tools
for both patients and informants. Widespread implementation of this algorithm could be the first
step in reducing the prevalence of missed or delayed dementia diagnosis, thus allowing for better
healthcare management and more favorable outcomes for affected patients and their families and
caregivers.
2013 The Alzheimers Association. All rights reserved.

Keywords:

Annual Wellness Visit; AWV; Cognitive impairment; Assessment; Screen; Dementia; Alzheimers disease;
Medicare; Algorithm; Patient Protection and Affordable Care Act

1. Introduction
The Patient Protection and Affordable Care Act of 2010
added a new Medicare benefit, the Annual Wellness Visit
*Corresponding author. Tel.: 312-335-5867. Fax: 866-699-1246.
E-mail address: [email protected]

(AWV), effective January 1, 2011. The AWV includes

routine measurements such as height, weight, and blood
pressure; a review of medical and family history; an assessment to detect cognitive impairment; and establishment of
a list of current medical providers, medications, and schedule for future preventive services. In addition, during the first
AWVonly, beneficiaries are to be screened for depression (if

1552-5260/$ - see front matter 2013 The Alzheimers Association. All rights reserved.
http://dx.doi.org/10.1016/j.jalz.2012.09.011

142

C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

not completed under a separate Medicare benefit) and for

functional difficulties using nationally recognized appropriate screening questions or standardized questionnaires. Although the U.S. Preventive Services Task Force (USPSTF)
in 2003 concluded that there was insufficient published evidence of better clinical outcomes as a result of routine
screening for cognitive impairment in older adults, the
Task Force recognized that the use of cognitive assessment
tools can increase the detection of cognitive impairment
[1]. As per the Centers for Medicare and Medicaid Services
(CMS) regulation, the AWV requires detection of cognitive
impairment by . assessment of an individuals cognitive
function by direct observation, with due consideration of information obtained by way of patient report, concerns raised
by family members, friends, caretakers, or others [2]. During the public comment period, several organizations, including the Alzheimers Association, noted that the use of
a standardized tool for assessment of cognitive function
should be part of the AWV.
These comments are supported by a number of studies
showing that cognitive impairment is unrecognized in
27%81% of affected patients in primary care [37]. The
use of a brief, structured cognitive assessment tool
correctly classifies patients with dementia or mild
cognitive impairment (MCI) more often than spontaneous
detection by the patients own primary care physicians
(83% vs 59%, respectively) [8].
In response to concerns submitted during public comment,
CMS elected not to recommend a specific tool for the final
AWV benefit because There is no nationally recognized
screening tool for the detection of cognitive impairments at
the present time. [9]. However, CMS recognizes that without clarification, the full intended benefits of the AWV cognitive assessment may not be realized [10]. CMS is working
with other governmental agencies (e.g., National Institutes
on Aging) on recommendations for use of specific tools.
Understanding that, under the present regulation, each
healthcare provider who conducts an AWV would have to
determine how best to detect cognitive impairment, the
Alzheimers Association convened the Medicare Detection
of Cognitive Impairment Workgroup to develop recommendations for operationalizing the cognitive assessment component in primary care settings. This workgroup was
comprised of geographically dispersed USA experts with
published works in the field of detecting cognitive impairment during primary care visits. The focus on primary care
was deliberate, as most Medicare beneficiaries will receive
their AWV in this setting.

2. Guiding principles for recommendations

2.1. Consensus on general principles
Based on their expertise, the workgroup agreed on the following general principles to guide the development of recommendations for cognitive assessment:

Detection of cognitive impairment is a stepwise, iterative process.

Informal observation alone by a physician is not sufficient (i.e., observation without a specific cognitive
evaluation).

Detection of cognitive impairment can be enhanced by
specifically asking about changes in memory, language, and the ability to complete routine tasks.

Although no single tool is recognized as the gold standard for detection of cognitive impairment, an initial
structured assessment should provide either a baseline
for cognitive surveillance or a trigger for further evaluation.

Clinical staff can offer valuable observations of cognitive and functional changes in patients who are seen
over time.

Counseling before and after cognitive assessment is an
essential component of any cognitive evaluation.

Informants (family member, caregiver, etc.) can provide valuable information about the presence of
a change in cognition.
2.2. Principles specific to the AWV

The AWV requires the completion of a Health Risk Assessment (HRA) by the patient either before or during
the visit. The HRA should be reviewed for any reported
signs and symptoms indicative of possible dementia.

The AWV will likely occur in a primary care setting.
Tools for initial cognitive assessments should be brief
(,5 min), appropriately validated, easily administered
by non-physician clinical staff, and available free of
charge for use in a clinical setting.

If further evaluation is indicated based on the results of
the AWV, a more detailed evaluation of cognition
should be scheduled for a follow-up visit in primary
care or through referral to a specialist.
3. Review of available brief tools for use during the AWV
3.1. Workgroup review process
Although there is no single cognition assessment tool that
is considered to be the gold standard, there is a plethora of
tools in the literature. A MEDLINE (PubMed) search conducted in October 2011, using the key words screening or
detection of dementia or cognitive impairment, yielded
over 500 publications. To narrow the search to tools more
applicable to the AWV, the workgroup sought to determine
whether the literature offered a consensus regarding brief
cognitive assessment during time-limited primary care visits.
The workgroup focused on systematic evidence review
(SER) studies published since 2000 resulting in four studies
by Lorentz et al, Brodaty et al, Holsinger et al, and Milne et al
[1114]. Although each SER had a similar objectiveto
determine which tools were best for administration during


Relevance of study to the VA

setting

Admin time

Sensitivity

Specificity

Cost

Summary of other
studies and strength/
weaknesses of tools

Newer tools that address weaknesses








Admin time
Study quality
Likelihood ratios
Domains tested
Utility in special
situations











Face validity, sensitivity, and
specificity

Sociodemographic biases

Comparison with MMSE

Acceptability

Ease of use by nonspecialists
Comparison
criteria

Abbreviations: MMSE, Mini-Mental State Examination; NPV, negative predictive value; PC, primary care; UK, United Kingdom; VA, US Department of Veteran Affairs.

Tools identified by the VA as

alternatives to the MMSE

Tools most frequently
used in PC

Tools recommended or
newly used in PC

Admin time suitable for
PC in UK

Geriatric PC screens for
cognitive change

Studied in patients
60 years

Criterion to diagnose
dementia acceptable

Admin 5 min and simple

Validated in community or PC

Misclassification rate
 MMSE

NPV  MMSE

Study validity

Applicability to PC

Psychometric properties

Administration characteristics
Inclusion
criteria

Admin 10 min

Performance characteristics
evaluated in 1 community
or clinical setting

Practicality
Feasibility
Applicability
Psychometric properties

Kansagara and Freeman, 2010 [16]

Ismail et al, 2010 [15]
Milne et al, 2008 [14]
Holsinger et al, 2007 [13]
Brodaty et al, 2006 [12]
Lorentz et al, 2002 [11]

Table 1
Review articles of brief cognitive assessment toolsselect inclusion and comparison criteria

C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

143

primary care visitsdifferent comparison criteria to select

the tools were applied (Table 1). Two other studies were
also considered relevant to the development of the workgroup recommendations: Ismail et al [15] conducted a literature review designed to identify widely used and most
promising newer brief cognitive tools being used in primary
care and geriatrics, and an SER by Kansagara and Freeman
[16] of six brief cognitive assessment tools that could serve
as possible alternatives to the Mini-Mental State Examination (MMSE) for use by the U.S. Department of Veterans
Affairs (VA). Neither study was designed to determine which
brief tool is the best, but both provided evidence related to
primary care use and performance characteristics of brief
assessments of cognition (Table 1).
3.2. Workgroup review results
Of the five publications that focused specifically on
identifying brief cognitive assessments most suitable or
most used in primary care settings [1115], all selected
the Memory Impairment Screen (MIS), and four of these
publications [11,12,14,15] also selected the General
Practitioner Assessment of Cognition (GPCOG) and the
Mini-Cog (Table 2).
The following attributes of the GPCOG, Mini-Cog, and
the MIS contributed to their selection as most suited for routine use in primary care:

Requires 5 minutes or less to administer.

Is validated in a primary care or community setting.

Is easily administered by medical staff members who
are not physicians.

Has good to excellent psychometric properties.

Is relatively free from educational, language, and/or
culture bias.

Can be used by clinicians in a clinical setting without
payment for copyrights.
Charging a fee for clinical use of brief cognitive assessment tool has become an issue because of increased enforcement of the MMSE copyright. First published in 1975 [17],
the MMSE copyright is now held by Psychological Assessment Resources, Inc., which charges a fee for each use (for
exact fees see www.parinc.com). The comparative SER
within the VA [16] evaluated alternatives to the proprietary
MMSE, including the GPCOG and the Mini-Cog, along
with four other brief tools (Table 2). The Mini-Cog and
MIS are copyrighted, but the owners, Soo Borson, MD,
and Albert Einstein College of Medicine, respectively, allow
free use by clinicians as clinical tools with distribution restrictions for other entities (e.g., commercial companies).
The GPCOG has similar use rules.
3.3. Patient structured cognitive assessment tools
recommended for AWV
In alignment with the workgroups guiding principles
and supported by data in the six selected SERs/reviews,

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Table 2
Brief cognitive assessment tools evaluated in multiple review articles
Assessment Tool
7-Minute Screener
AMT
CAMCOG
CDT
GPCOG
Mini-Cog
MIS
MMSE
MoCA
RUDAS
SAS-SI
SBT (BOMC, 6-CIT)
SPMSQ
STMS
T&C

Lorentz et al,
2002 [11]

Brodaty et al,
2006 [12]

Holsinger et al,
2007 [13]

Milne et al,
2008 [14]

Ismail et al,
2010 [15]

X
X
X
X
Most suited
Most suited
Most suited
X

X
X
Suitedy
Suitedz
X
X
Suitedz
Suitedx
Suitedy

X
X

X
Most suited
Most suited
Most suited
X

X
X
X
X
X

X
X
X
X
X

X
X
X

X
Most suited
Most suited
Most suited
X

X
X

X
Most suited
Most suited
Most suited
X
X
X

Kansagara and
Freeman, 2010* [16]

X
X

X
X

Abbreviations: 6-CIT, 6-Item Cognitive Impairment Test; AMT, Abbreviated Mental Test; BOMC, 6-item Blessed Orientation-Memory-Concentration Test;
CAMCOG, Cambridge Cognitive Examination; CDT, Clock Drawing Test; GPCOG, General Practitioner Assessment of Cognition; MIS, Memory Impairment
Screen; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; RUDAS, Rowland Universal Dementia Assessment; SAS-SI, Short
and Sweet Screening Instrument; SBT, Short Blessed Test; SLUMS, St Louis Mental Status; SPMSQ, Short Portable Mental Status Questionnaire; STMS, Short
Test of Mental Status; T&C, Time and Change Test.
X 5 assessment reviewed, but not identified as most suited for general use in primary care.
Suited 5 tool appropriate for the following clinical issue: y available time is not limited; z available time is limited; and x cognitive impairment is at least
moderate. Most suited 5 tool identified as most suited for routine use in primary care.
*Kansagara and Freeman evaluated six tools, including the SLUMS, which was not evaluated in any other review.

the GPCOG, Mini-Cog, and MIS are brief structured

tools that are suitable for assessment of cognitive function during the AWV. Each tool has unique benefits.
The GPCOG has patient and informant components
that can be used alone or together to increase specificity
and sensitivity [18]. The Mini-Cog has been validated in
population-based studies and in community-dwelling
older adults heterogeneous with respect to language, culture, and education [1922]. The MIS is a verbally
administered word-recall task that tests encoding as
well as retrieval [23], and is an option for patients who
have motor impairments that prevent use of paper and
pencil.
3.4. Structured cognitive assessment tools for use with
informants
Cognitive assessment combined with informantreported data improves the accuracy of assessment
[2427]. If an informant is present during the AWV,
use of a structured informant tool is recommended.
Similar to cognitive assessment tools for use with
patients, there is no single gold standard informant
tool; however, relatively few brief informant tools
have been validated in community and/or primary care
settings. Brief tools appropriately validated include the
Short IQCODE [25], the AD8 [28], which can be administered in-person or by telephone, and the aforementioned GPCOG [18], which has both patient and
informant components.

4. Recommended algorithm for detection of cognitive

impairment during the AWV
4.1. Incorporating assessment of cognition during the
AWV
The Alzheimers Association Medicare Annual Wellness
Visit Algorithm for Assessment of Cognition for consistency
(Figure 1) illustrates a stepwise process. The process is intended to detect patients with a high likelihood of having dementia. The AWV algorithm includes both structured
assessments discussed previously and other less structured
patient- and informant-based evaluations. By assessing and
documenting cognitive status on an annual basis during the
AWV, clinicians can more easily determine gradual cognitive decline over time in an individual patienta key criterion for diagnosing dementia due to Alzheimers disease and
other progressive conditions affecting cognition.
For patients with a previous diagnosis of MCI or dementia, this should be documented and included in their AWV
list of health risk factors. Annual unstructured and structured
cognitive assessments could be used to monitor significant
changes in cognition and potentially lead to a new diagnosis
of dementia for those with MCI or new care recommendations for those with dementia.
4.2. Detection of cognitive impairment during the AWV
initial HRA review, conversations, and observations
The first step in detection of cognitive impairment during
the AWV (Fig. 1, Step A), involves a conversation between

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145

Medicare Annual Wellness Visit (HCPCS codes G0438 or G0439)

Review HRA (especially reports of functional deficits), clinician observations, and selfreported concerns; and query patient and, if available, informant

Yes

No

Signs/symptoms of cognitive
impairment present
No

Informant
available to
confirm
Yes

Conduct brief structured assessment

Patient Assessment: GPCOG or Mini-Cog or MIS
Informant assessment of patient: AD8 or GPCOG or Short IQCODE

Brief assessment(s) triggers concerns:

-8 score is indeterminate without
informant) or MiniInformant: AD8
patient score <8
3.38

Follow-up during
subsequent AWV

No

Yes

Refer for full dementia evaluation or

Conduct full dementia evaluation
- up same day as AWV and bill for E/M service with
If informant is available during AWV can follow
CPT codes 99201-99215. If not, schedule new visit for evaluation and request presence of
family/companion to facilitate assessment.

* No one tool is recognized as the best brief assessment to determine if a full dementia evaluation is

needed. Alternate tools (eg, MMSE, SLUMS, or MoCA) can be used at the discretion of the clinician.
Some providers use multiple brief tools prior to referral or initiation of a full dementia evaluation.

AWV = Annual Wellness Visit; GPCOG = General Practitioner Assessment of Cognition; HRA = Health Risk Assessment;
MIS = Memory Impairment Screen; MMSE = Mini Mental Status Exam; MoCA = Montreal Cognitive Assessment; SLUMS =
St. Louis University Mental Status Exam; Short IQCODE = short Informant Questionnaire on Cognitive Decline in the Elderly

Fig. 1. Alzheimers Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition.

a clinician and the patient and, if present, any family member

or other person who can provide collateral information. This
introduces the purpose and content of the AWV, which includes: a review of the HRA; observations by clinicians
(medical and associated staff); acknowledgment of any selfreported or informant-reported concerns; and conversational
queries about cognition directed toward the patient and others
present. If any concerns are noted, or if an informant is not
present to provide confirmatory information, further evaluation of cognition with a structured tool should be performed.
Patient completion of an HRA is a required element of the
AWVand can be accomplished with the help of a family member or other knowledgeable informants, including a professional caregiver. Published CMS guidance offers healthcare
professionals flexibility as to the specific format, questions,
and delivery methods that can be used for an AWV HRA
[29]. The following questions may be suitable for the AWV
HRA and have been tested and evaluated in the general popu-

lation through the Behavioral Risk Factor Surveillance System

or presented as HRA example questions:
1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or
is getting worse [30]?
2. During the past 7 days, did you need help with others
to perform everyday activities such as eating, getting
dressed, grooming, bathing, walking, or using the toilet [29]?
3. During the past 7 days, did you need help from others
to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food
preparation, transportation, or taking your own medications [29]?
A noted deficit in activities of daily living (ADLs) (e.g.,
eating and dressing) or instrumental activities of daily living
(IADLs) (e.g., shopping and cooking) that cannot be

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C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

attributed to physical limitations should prompt concern, as

there is a strong correlation between decline in function and
decline in cognitive status across the full spectrum of dementia [31]. In addition to clinically observed concerns, any patient- or informant-reported concerns should trigger further
evaluation [13]. Positive responses to conversational
queries, such as Have you noticed any change in your memory or ability to complete routine tasks, such as paying bills
or preparing a meal? should be followed up with a structured assessment of cognition.
Upon realizing the time constraints of a typical primary
care visit, if no cognitive concerns surface during the initial
evaluation and this information is corroborated by an informant, the clinician may elect not to perform a structured cognitive assessment and assume that the patient is not currently
demented. This approach is supported by studies in populations with low rates of dementia that suggest the absence of
memory difficulties reported by informants and patients reduces the likelihood that dementia is present [32,33].
4.3. Structured cognitive assessment tools for use with
patients and informants during the AWV
The second step in detection of cognitive impairment during the AWV (Figure 1, Step B) requires cognitive assessment using a structured tool. Based on synthesis of data
from the six review articles previously discussed, patient
tools suitable for the initial structured assessment are the
GPCOG, Mini-Cog, and MIS.
Recognizing that there is no single optimal tool to detect
cognitive impairment for all patient populations and settings, clinicians may select other brief tools to use in their
clinical practice, such as those listed in Table 3. The 15 brief
tools listed were evaluated in multiple review articles
(passed through at least two review search criteria for tools
possibly suited for primary care) or are used in the VA. Tools
listed in Table 3 are subject to the inclusion/exclusion criteria of each review and do not represent the entire listing of
the .100 brief cognitive assessment tools that may be suitable for primary care practices.
If an informant is present, defined as someone who can
attest to a patients change in memory, language, or function
over time, it is suitable to use the AD8, the informant component of the GPCOG, or the Short IQCODE, during the
AWV.
4.4. Primary care workflow considerations
According to the algorithm, any patient who does not
have an informant present should be assessed with a structured tool. For such patients (and for practices that implement structured assessments during all AWVs), completion
of this structured assessment can be administered by trained
medical staff as the first step for cognitive impairment detection. This could improve office efficiency. To increase acceptance of a structured assessment, the reason provided to

the patient can be normalized with a statement such as,

This is something I do for all of my older patients as part
of their annual visit. When the initial assessment prompts
further evaluation, explanation of results should be deferred
until a more comprehensive evaluation has been completed.
There are many reasons for not getting every answer correct. More evaluation will help us determine that, is an example statement that may encourage patients to pursue
further testing.
5. Full dementia evaluation
Patients with assessments that indicate cognitive impairment during the AWV should be further evaluated to
determine appropriate diagnosis (e.g., MCI, Alzheimers
disease) or to identify other causes. As reflected in the algorithm (Figure 1, Step C), initiation of a full dementia evaluation is outside the scope of the AWV, but can occur in
a separate visit either on the same day, during a newly scheduled visit, or through referral to a specialist. Specialists who
have expertise in diagnosing dementia include geriatricians,
geriatric psychiatrists, neurologists, and neuropsychologists.
The two-visit approach has been cited as a time-effective
process to evaluate suspected dementia in primary care
[34] and is consistent with the two-step approach widely
used in epidemiologic research on dementia. Regardless of
the timing and setting, clinicians are encouraged to counsel
patients to include an informant in the diagnostic process.
Components of a full dementia evaluation can vary depending on the presentation and include tests to rule in or
out the various causes of cognitive impairment and establish
its severity. Diagnostic evaluations include a complete medical history; assessment of multiple cognitive domains, including episodic memory, executive function, attention,
language, and visuospatial skills; neurologic exam (gait, motor function, reflexes); ADL and IADL functioning; assessment for depression; and review for medications that may
adversely affect cognition. Standard laboratory tests include
thyroid-stimulating hormone (TSH), complete blood count
(CBC), serum B12, folate, complete metabolic panel, and,
if the patient is at risk, testing for sexually transmitted diseases (human immunodeficiency virus, syphilis). Structural
brain imaging, including magnetic resonance imaging
(MRI) or computed tomography (CT), is a supplemental
aid in the differential diagnosis of dementia, especially if
neurologic physical exam findings are noted. An MRI or
CT can be especially informative in the following cases: dementia that is of recent onset and is rapidly progressing;
younger onset dementia (,65 years of age); history of
head trauma; or neurologic symptoms suggesting focal
disease.
6. Discussion
Unfortunately, up to 81% of patients who meet the criteria for dementia have never received a documented diagnosis

C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

147

Table 3
Key advantages and limitations of brief cognitive assessment tools evaluated in multiple reviews and/or for use in the VA
Assessment*

Time (wmin)

Advantages

Limitations

7-Minute Screener [48]

712

AMT [49]

57

CAMCOG [50]

20

Tests many separate domains (7)

CDT [51]

1

GPCOGy [18]
Patient
Informant

Very brief administration time

Minimal education bias

25
13

Mini-Cogy [8, 19]

24

MIS [23,52]

MMSE [17]

710

Developed for and validated in primary care

Informant component useful when initial
complaint is informant-based

Little or no education bias

Multiple languages accessible at www.gpcog.
com.au

Developed for and validated in primary care
and multiple languages/cultures

Little or no education/language/race bias

Short administration time

Verbal memory test (no writing/drawing)

Little or no education bias

Most widely used and studied worldwide

Often used as reference for comparative evaluations of other assessments

Required for some drug insurance reimbursements

MoCAy [53]

1015

Designed to test for mild cognitive impairment

Multiple languages accessible at www.
mocatest.org

Tests many separate domains (7)

RUDAS [54]

10

Designed for multicultural populations

Little or no education/language bias

SAS-SI [55]

10

Detected dementia better than neuropsychologic testing in a community population

SBT (BOMCy and

6-CIT) [56,57]

46

Verbal test (no writing/drawing)

SLUMSy [58]

SPMSQ [59]

34

No education bias

Tests many separate domains (7)

Available at: http://aging.slu.edu/pdfsurveys/
mentalstatus.pdf

Verbal test (no writing/drawing)

STMSy [60]

Validated in primary care

Tests many separate domains (7)

T&C [61]

1

Very brief administration time

Little or no education bias

Little or no education bias

Validated in primary care
Easy to administer
Verbal memory test (no writing/drawing)

Difficult to administer
Complex logarithmic scoring
Education/language/culture bias
Limited use in US (mostly used in Europe)
Does not test executive function or visuospatial
skills

Difficult to administer

Long administration time

Lacks standards for administration and scoring

Patient component scoring has an indeterminate

range that requires an informant score to assess as
pass or fail

Informant component alone has low specificity

Lacks data on any language/culture biases

Use of different word lists may affect failure rates

Some study results based on longer tests with the
Mini-Cog elements reviewed independently

Does not test executive function or visuospatial
skills

Education/age/language/culture bias

Ceiling effect (highly educated impaired subjects
pass)

Proprietaryunless used from memory, test needs
to be purchased at www.parinc.com

Best performance for at least moderate cognitive
impairment

Lacks studies in general practice settings

Education bias (12 years)

Limited use and evidence due to published data
relatively new (2005)

Admin time 10 min

Validated in Australian community

Limited use and evidence due to published data
relatively new (2004)

Does not test memory

Lacks data on any education/language/culture
biases

Education/language/cultural/race bias

Scoring can be cumbersome

Does not test executive function

Limited use and evidence due to published data
relatively new (2006)

Studied in VA geriatric clinic (predominantly white
males)

Scoring can be cumbersome

Does not test short-term memory

Education/language/race bias

Studied in relatively educated subjects, may not be
applicable to general population

Strong language/cultural bias

Abbreviations: 6-CIT, 6-Item Cognitive Impairment Test; AMT, Abbreviated Mental Test; BOMC, 6-item Blessed Orientation-Memory-Concentration Test;
CAMCOG, Cambridge Cognitive Examination; CDT, Clock Drawing Test; GPCOG, General Practitioner Assessment of Cognition; MIS, Memory Impairment
Screen; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; RUDAS, Rowland Universal Dementia Assessment; SAS-SI, Short
and Sweet Screening Instrument; SBT, Short Blessed Test; SLUMS, St Louis University Mental Status; SPMSQ, Short Portable Mental Status Questionnaire;
STMS, Short Test of Mental Status; T&C, Time and Change Test.
*References provide descriptions of assessments.
y
Brief tools used in the VA healthcare system reviewed by Kansagara and Freeman.

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C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

[35]. Delayed or missed diagnosis deprives affected individuals of available treatments, care plans, and services that can
improve their symptoms and help maintain independence.
Studies show that interventions tailored to patients with dementia can improve quality of care, reduce unfavorable
dementia-related behaviors, increase access to community
services for both the patient and their caregivers, and result
in less caregiver stress and depression [3642]. Early
diagnosis of dementia also provides families and patients
an opportunity to plan for the future while the affected
individual is still able to participate in the decision-making
processes.
Early detection and medical record documentation may
improve medical care. The medical record could inform
all clinicians, including those who may be managing comorbidities on a sporadic basis, that treatment and care should be
adjusted to accommodate cognitive impairment. According
to a 2004 Medicare beneficiary survey, among patients
with dementia, 26% had coronary heart disease, 23% had diabetes, and 13% had cancer [43].
It is important to note that the unstructured and structured
cognitive assessments being recommended for the AWV are
only the first steps in diagnosing dementia, and cognitive assessment is best as an iterative process. For example, clinicians concerned with HRA information about decline in
function may proceed directly to a structured assessment
or continue to query the patient for additional information;
a self-reported memory concern coupled with a failed structured cognitive assessment should always result in a full dementia evaluation.
Not all who are referred for further assessment will ultimately receive a dementia diagnosis. In a USA primary
care population aged 65 years (N 5 3340), 13% failed
a brief screen for cognitive impairment and approximately half (n 5 227) agreed to be further evaluated
for dementia [7]. Among the 107 patients ultimately diagnosed with dementia, 81% were newly diagnosed
based on the absence of any medical record of dementia,
thus facilitating appropriate medical and psychosocial interventions [7].
Despite the many advantages of early dementia diagnosis, several barriers to diagnosis still exist. These include
physician concerns of the time burden resulting from testing
and counseling [35] and stigma concerns among physicians,
patients, and caregivers [35,44,45]. Despite these barriers,
successful widespread implementation of a brief cognitive
assessment has been reported. McCarten et al [22] evaluated
the Mini-Cog for routine cognitive assessment of veterans
presenting for primary care. Of the 8342 veterans approached, .96% agreed to be assessed and those that failed
the brief assessment exhibited no serious reactions upon disclosure of test results.
The AWV provides an unprecedented opportunity to
overcome current barriers and initiate discussions about cognitive function among the growing population most at risk

for Alzheimers disease. Detection of cognitive impairment

during the AWV is further supported by previously published quality indicators that state all vulnerable elders (defined as persons 65 years who are at risk for death or
functional decline) should be evaluated annually for cognitive and functional status [46].
There are limitations to these recommendations. They
are based on assessment of recommendations from review
articles and on expert opinion, not on a new, comprehensive
review of original research to define the optimal approach
to detection of cognitive impairment or review of emerging
technologies that could assist in testing (e.g., use of online
or electronic tablet applications). Further complicating
SERs of brief cognitive assessment tools is that sensitivity
and specificity will vary depending on the dementia prevalence of the study population, the tool(s) used, and the cut
score selected for each tool. Brodaty et al [12] recognized
that published research concerning cognitive impairment
screening tools is uneven in quantity and quality. The literature also is lacking in comparative validity of brief cognitive assessment tools in low-education or illiterate
populations.
The Alzheimers Association Medicare Annual Wellness
Visit Algorithm for Assessment of Cognition is based
on current validated tools and commonly used rule-out
assessments. The use of biomarkers (e.g., CSF tau and
beta amyloid proteins, amyloid tracer positron emission
tomography scans) was not considered as these measures
are not currently approved or widely available for clinical
use.
In 2011, greater than two million Medicare beneficiaries
received their AWV preventive service [47]. There are no
data available as to what methods were used to detect cognitive impairment or how many beneficiaries were assessed
as having cognitive impairment. For future AWVs, the
Alzheimers Association Medicare Annual Wellness Visit
Algorithm for Assessment of Cognition provides guidance
to primary care practices on a process to operationalize
this required AWV element. With widespread implementation of the algorithm, the AWV could be the first step in reducing the prevalence of missed or delayed dementia
diagnoses, thus allowing for better healthcare management
and more favorable outcomes for affected patients and their
families and caregivers.
7. Author Disclosures
Soo Borson is the developer of the Mini-Cog and is the
owner of its copyrights.
Over the past 5 years, Malaz Boustani has received research support for investigator- initiated projects from Forest
Pharmaceutical and Novartis; honoraria from Norvartis and
Pfizer, Inc.; and research support for investigator-initiated
projects from the NIH and AHRQ. Dr Boustani was a member of the US Preventive Services Task Force that published

C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

the systematic evidence review, Dementia Screening, for the

AHRQ in 2003.

RESEARCH IN CONTEXT

1. Systematic review: Our research included comparing

five systematic evidence reviews (SER) of brief dementia screening tools published since 2000 and
a 2010 literature review of newer brief assessments
of cognition. Our research focused on determining
if there was a consensus among the published SERs
as to which tool is most suited for primary care and
if there were any common results across the publications.
2. Interpretation: Our research concluded there is a consensus in the literature concerning suitable tools for
screening for dementia in primary care. We also reaffirmed that many validated tools are available, and
that screening for dementia should not be solely
based on a tool, but should be a stepwise process to
include other assessments.
3. Future directions: Further validation of existing and
emerging screening tools (e.g., iPad applications,
gait monitoring) may result in newer tools being recognized more suitable and practical for primary care
settings.

References
[1] Boustani M, Peterson B, Harris R, Lux L, Krasnov C, Sutton S, et al.
Screening for dementia. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.ncbi.nlm.nih.gov/books/
NBK42773/; 2003. Accessed September 3, 2011.
[2] Anonymous. Patient Protection and Affordable Care Act of 2010, 42
CFR. x410.15(a). 2010. Available at: http://ecfr.gpoaccess.gov/cgi/t/
text/text-idx?c5ecfr&sid56b50669da0f96db4eea346533db23747&
rgn5div8&view5text&node542:2.0.1.2.10.2.35.4&idno542.
[3] Chodosh J, Petitti DB, Elliott M, Hays RD, Crooks VC,
Reuben DB, et al. Physician recognition of cognitive impairment:
evaluating the need for improvement. J Am Geriatr Soc 2004;
52:10519.
[4] Camicioli R, Willert P, Lear J, Grossmann S, Kaye J, Butterfield P.
Dementia in rural primary care practices in Lake County, Oregon.
J Geriatr Psychiatry Neurol 2000;13:8792.
[5] Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med 1995;122:4229.
[6] Valcour VG, Masaki KH, Curb JD, Blanchette PL. The detection of
dementia in the primary care setting. Arch Intern Med 2000;
160:29648.
[7] Boustani M, Callahan CM, Unverzagt FW, Austrom MG,
Perkins AJ, Fultz BA, et al. Implementing a screening and diagnosis
program for dementia in primary care. J Gen Intern Med 2005;
20:5727.

149

[8] Borson S, Scanlan JM, Watanabe J, Tu S-P, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry 2006;21:34955.
[9] Anonymous. Medicare coverage of Annual Wellness Visit providing
a personalized prevention plan. Fed Regist 2010;75:73401.
[10] US Department of Health and Human Services. Advisory Council on
Alzheimers research, care, and services: opportunities and gaps. 2011.
Available at: http://aspe.hhs.gov/daltcp/napa/092711/Mtg1-Slides3.
pdf. Accessed October 14, 2011.
[11] Lorentz WJ, Scanlan JM, Borson S. Brief screening tests for dementia.
Can J Psychiatry 2002;47:72333.
[12] Brodaty H, Low L-F, Gibson L, Burns K. What is the best dementia
screening instrument for general practitioners to use? Am J Geriatr
Psychiatry 2006;14:391400.
[13] Holsinger T, Deveau J, Boustani M, Williams JW Jr. Does this patient
have dementia? JAMA 2007;297:2391404.
[14] Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for
dementia in primary care: a review of the use, efficacy and quality of
measures. Int Psychogeriatr 2008;20:91126.
[15] Ismail Z, Rajji TK, Shulman KI. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry 2010;25:11120.
[16] Kansagara D, Freeman M. A systematic evidence review of the signs and
symptoms of dementia and brief cognitive tests. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/21155200. Accessed June 7, 2011.
[17] 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;12:18998.
[18] Brodaty H, Pond D, Kemp NM, Luscombe G, Harding L, Berman K,
et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc 2002;50:5304.
[19] Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The Mini-Cog:
a cognitive vital signs measure for dementia screening in multilingual elderly. Int J Geriatr Psychiatry 2000;15:10217.
[20] Borson S, Scanlan JM, Watanabe J, Tu S-P, Lessig M. Simplifying detection of cognitive impairment: comparison of the Mini-Cog and
Mini-Mental State Examination in a multiethnic sample. J Am Geriatr
Soc 2005;53:8714.
[21] 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;51:14514.
[22] McCarten JR, Anderson P, Kuskowski MA, McPherson SE, Borson S.
Screening for cognitive impairment in an elderly veteran population:
acceptability and results using different versions of the Mini-Cog.
J Am Geriatr Soc 2011;59:30913.
[23] Buschke H, Kuslansky G, Katz M, Stewart WF, Sliwinski MJ,
Eckholdt HM, et al. Screening for dementia with the memory impairment screen. Neurology 1999;52:2318.
[24] Mackinnon A, Mulligan R. Combining cognitive testing and informant
report to increase accuracy in screening for dementia. Am J Psychiatry
1998;155:152935.
[25] Jorm AF. A short form of the Informant Questionnaire on Cognitive
Decline in the Elderly (IQCODE): development and cross-validation.
Psychol Med 1994;24:14553.
[26] Ayalon L. The IQCODE versus a single-item informant measure to
discriminate between cognitively intact individuals and individuals
with dementia or cognitive impairment. J Geriatr Psychiatry Neurol
2011;24:16873.
[27] Galvin JE, Roe CM, Morris JC. Evaluation of cognitive impairment in
older adults: combining brief informant and performance measures.
Arch Neurol 2007;64:71824.
[28] Galvin JE, Roe CM, Xiong C, Morris JC. Validity and reliability
of the AD8 informant interview in dementia. Neurology 2006;
67:19428.
[29] Goetzel R, Staley P, Ogden L, Strange P, Fox J, Spangler J, et al. A
framework for patient-centered health risk assessmentsproviding
health promotion and disease prevention services to Medicare beneficiaries. Atlanta, GA: US Department of Health and Human Services,

150

[30]

[31]

[32]

[33]

[34]
[35]

[36]

[37]

[38]

[39]

[40]

[41]

[42]

[43]
[44]

C.B. Cordell et al. / Alzheimers & Dementia 9 (2013) 141150

Centers for Disease Control and Prevention. Available at: http://www.
cdc.gov/policy/opth/hra/; 2011.
Anonymous. Behavioral Risk Factor Surveillance System Survey
Questionnaire. Bethesda, MD: Centers for Disease Control and
Prevention. Available at: http://www.cdc.gov/brfss/questionnaires/
pdf-ques/2011brfss.pdf; 2011. Accessed January 10, 2012.
Njegovan V, Hing MM, Mitchell SL, Molnar FJ. The hierarchy of
functional loss associated with cognitive decline in older persons.
J Gerontol A Biol Sci Med Sci 2001;56:M63843.
Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individuals complaints of memory impairment in early dementia. Neurology 2000;55:17246.
Tobiansky R, Blizard R, Livingston G, Mann A. The Gospel Oak Study
stage IV: the clinical relevance of subjective memory impairment in
older people. Psychol Med 1995;25:77986.
Simmons BB, Hartmann B, Dejoseph D. Evaluation of suspected dementia. Am Fam Physician 2011;84:895902.
Bradford A, Kunik ME, Schulz P, Williams SP, Singh H. Missed and
delayed diagnosis of dementia in primary care: prevalence and contributing factors. Alzheimer Dis Assoc Disord 2009;23:30614.
Bass DM, Clark PA, Looman WJ, McCarthy CA, Eckert S. The Cleveland Alzheimers managed care demonstration: outcomes after 12
months of implementation. Gerontologist 2003;43:7385.
Callahan CM, Boustani MA, Unverzagt FW, Austrom MG,
Damush TM, Perkins AJ, et al. Effectiveness of collaborative care
for older adults with Alzheimer disease in primary care: a randomized
controlled trial. JAMA 2006;295:214857.
Fortinsky RH, Unson CG, Garcia RI. Helping family caregivers by
linking primary care physicians with community-based dementia
care services: the Alzheimers Service Coordination Program. Dementia 2002;1:22740.
Reuben DB, Roth CP, Frank JC, Hirsch SH, Katz D, McCreath H, et al.
Assessing care of vulnerable eldersAlzheimers disease: a pilot
study of a practice redesign intervention to improve the quality of dementia care. J Am Geriatr Soc 2010;58:3249.
Vickrey BG, Mittman BS, Connor KI, Pearson ML, Della Penna RD,
Ganiats TG, et al. The effect of a disease management intervention on
quality and outcomes of dementia care: a randomized, controlled trial.
Ann Intern Med 2006;145:71326.
Olazar
an J, Reisberg B, Clare L, Cruz I, Pe~na-Casanova J, Del Ser T,
et al. Nonpharmacological therapies in Alzheimers disease: a systematic review of efficacy. Dement Geriatr Cogn Disord 2010;30:16178.
Auclair U, Epstein C, Mittelman M. Couples counseling in Alzheimers disease: additional clinical cindings from a novel intervention
study. Clin Gerontol 2009;32:13046.
Thies W, Bleiler L. 2011 Alzheimers disease facts and figures. Alzheimers Dement 2011;7:20844.
Justiss MD, Boustani M, Fox C, Katona C, Perkins AJ, Healey PJ, et al.
Patients attitudes of dementia screening across the Atlantic. Int J Geriatr Psychiatry 2009;24:6327.

[45] Boustani MA, Justiss MD, Frame A, Austrom MG, Perkins AJ,
Cai X, et al. Caregiver and noncaregiver attitudes toward dementia
screening. J Am Geriatr Soc 2011;59:6816.
[46] Feil DG, MacLean C, Sultzer D. Quality indicators for the care of dementia in vulnerable elders. J Am Geriatr Soc 2007;55(Suppl
2):S293301.
[47] Anonymous. Preventive New Media. Centers for Medicare &
Medicaid Services. Available at: http://www.cms.gov/NewMedia/
02_preventive.asp; 2011. Accessed January 10, 2012.
[48] Solomon PR, Pendlebury WW. Recognition of Alzheimers disease:
the 7 Minute Screen. Fam Med 1998;30:26571.
[49] Hodkinson HM. Evaluation of a mental test score for assessment of
mental impairment in the elderly. Age Ageing 1972;1:2338.
[50] Roth M. CAMDEX: the Cambridge examination for mental disorders
of the elderly. Cambridge: Cambridge University Press; 1988.
[51] Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int
J Geriatr Psychiatry 2000;15:54861.
[52] Kuslansky G, Buschke H, Katz M, Sliwinski M, Lipton RB. Screening
for Alzheimers disease: the memory impairment screen versus the
conventional three-word memory test. J Am Geriatr Soc 2002;
50:108691.
[53] Nasreddine ZS, Phillips NA, B
edirian V, Charbonneau S,
Whitehead V, Collin I, et al. The Montreal Cognitive Assessment,
MoCA: a brief screening tool for mild cognitive impairment. J Am
Geriatr Soc 2005;53:6959.
[54] Storey JE, Rowland JTJ, Basic D, Conforti DA, Dickson HG. The
Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. Int Psychogeriatr 2004;16:1331.
[55] Belle SH, Mendelsohn AB, Seaberg EC, Ratcliff G. A brief cognitive
screening battery for dementia in the community. Neuroepidemiology
2000;19:4350.
[56] Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry 1983;140:7349.
[57] Brooke P, Bullock R. Validation of a 6 item cognitive impairment test
with a view to primary care usage. Int J Geriatr Psychiatry 1999;
14:93640.
[58] Tariq SH, Tumosa N, Chibnall JT, Perry MH 3rd, Morley JE. Comparison of the Saint Louis University mental status examination and the
mini-mental state examination for detecting dementia and mild neurocognitive disordera pilot study. Am J Geriatr Psychiatry 2006;
14:90010.
[59] Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc
1975;23:43341.
[60] Kokmen E, Naessens JM, Offord KP. A short test of mental status: description and preliminary results. Mayo Clin Proc 1987;62:2818.
[61] Inouye SK, Robison JT, Froehlich TE, Richardson ED. The time and
change test: a simple screening test for dementia. J Gerontol A Biol
Sci Med Sci 1998;53:M2816.