Dementia: Cognitive Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within the 12 months preceding a dementia encounter during the measurement period

Attribution: The American Psychiatric Association’s (APA), The Physician Consortium for Performance Improvement's (PCPI), and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the Measure are acknowledged.
 

 

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An estimated 5.8 million adults in the US were living with dementia in 2019. Dementia is often characterized by the gradual onset and continuing cognitive decline in one or more domains including memory, communication and language, ability to focus or pay attention, reasoning and judgment and visual perception (Alzheimer’s Association, 2019). Cognitive deterioration represents a major source of morbidity and mortality and poses a significant burden on affected individuals and their caregivers (van den Kieboom et al., 2020; Lanctôt et al., 2024). Although cognitive deterioration follows a different course depending on the type of dementia, significant rates of decline have been reported. For example, one study found that the annual rate of decline for Alzheimer's disease patients was more than four times that of older adults with no cognitive impairment (Wilson et al., 2010). Nevertheless, measurable cognitive abilities remain throughout the course of dementia (American Psychiatric Association, 2007). Initial and ongoing assessments of cognition are fundamental to the proper management of patients with dementia. These assessments serve as the basis for identifying treatment goals, developing a treatment plan, monitoring the effects of treatment, and modifying treatment as appropriate.

Ongoing assessment includes periodic monitoring of the development and evolution of cognitive and noncognitive psychiatric symptoms and their response to intervention (Category I). Both cognitive and noncognitive neuropsychiatric and behavioral symptoms of dementia tend to evolve over time, so regular monitoring allows detection of new symptoms and adaptation of treatment strategies to current needs... Cognitive symptoms that almost always require assessment include impairments in memory, executive function, language, judgment, and spatial abilities. It is often helpful to track cognitive status with a structured simple examination (American Psychiatric Association, 2007).
The American Psychiatric Association recommends that patients with dementia be assessed for the type, frequency, severity, pattern, and timing of symptoms (Category 1C). Quantitative measures provide a structured replicable way to document the patient's baseline symptoms and determine which symptoms (if any) should be the target of intervention based on factors such as frequency of occurrence, magnitude, potential for associated harm to the patient or others, and associated distress to the patient. The exact frequency at which measures are warranted will depend on clinical circumstances. However, use of quantitative measures as treatment proceeds allows more precise tracking of whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed (Reus et al., 2016).
Conduct and document an assessment and monitor changes in cognitive status using a reliable and valid instrument, e.g., Montreal Cognitive Assessment (MoCA), Ascertain Dementia 8 (AD8) or other tool. Cognitive status should be reassessed periodically to identify sudden changes, as well as to monitor the potential beneficial or harmful effects of environmental changes (including safety, care needs, and abuse and/or neglect), specific medications (both prescription and non-prescription, for appropriate use and contraindications), or other interventions. Proper assessment requires the use of a standardized, objective instrument that is relatively easy to use, reliable (with less variability between different assessors), and valid (results that would be similar to gold-standard evaluations) (California Department of Public Health, 2017).
Recommendation: Perform regular, comprehensive person-centered assessments and timely interim assessments.
Assessments, conducted at least every 6 months, should prioritize issues that help the person with dementia to live fully. These include assessments of the individual and care partner’s relationships and subjective experience and assessment of cognition, behavior, and function, using reliable and valid tools. Assessment is ongoing and dynamic, combining nomothetic (norm based) and idiographic (individualized) approaches (Fazio et al., 2018).
Recommendation: Assess cognitive status, functional abilities, behavioral and psychological symptoms of dementia, medical status, living environment, and safety. Reassess regularly and when there is a significant change in condition (Wiener et al., 2016).

Higher score indicates better quality

Reference Type: Citation

Reference Text: 
Alzheimer’s Association. (2019). 2019 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 15(3), 321–387. https://alz.org/media/Documents/alzheimers-facts-and-figures-2019-r.pdf

Reference Type: Citation

Reference Text: 
American Psychiatric Association Work Group on Alzheimer’s Disease and Other Dementias. (2007). Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias (2nd ed.). American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines/legacy-practice-guidelines-for-alzheimer-s-disease

Reference Type: Citation

Reference Text: 
California Department of Public Health. (2017). California guidelines for Alzheimer’s disease management, 2017. https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/CDPH%20Document%20Library/Alzheimers'%20Disease%20Program/ALZ-CareGuidelines.pdf

Reference Type: Citation

Reference Text: 
Fazio, S., Pace, D., Maslow, K., Zimmerman, S., & Kallmyer, B. (2018). Alzheimer’s Association dementia care practice recommendations. The Gerontologist, 58(S1), S1–S9. https://doi.org/10.1093/geront/gnx182

Reference Type: Citation

Reference Text: 
Lanctôt, K. L., Hahn-Pedersen, J. H., Eichinger, C. S., Freeman, C., Clark, A., Tarazona, L. R. S., & Cummings, J. (2024). Burden of illness in people with Alzheimer’s disease: A systematic review of epidemiology, comorbidities and mortality. The Journal of Prevention of Alzheimer’s Disease, 11(1), 97–107. https://doi.org/10.14283/jpad.2023.61

Reference Type: Citation

Reference Text: 
Reus, V. I., Fochtmann, L. J., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., Jibson, M. D., Lopez, O. L., Mahoney, J., Pasic, J., Tan, Z. S., Wills, C. D., Rhoads, R., & Yager, J. (2016). The American psychiatric association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. The American Journal of Psychiatry, 173(5), 543–546. https://doi.org/10.1176/appi.ajp.2015.173501

Reference Type: Citation

Reference Text: 
van den Kieboom, R., Snaphaan, L., Mark, R., & Bongers, I. (2020). The trajectory of caregiver burden and risk factors in dementia progression: A systematic review. Journal of Alzheimer’s Disease, 77(3), 1107–1115. https://doi.org/10.3233/JAD-200647

Reference Type: Citation

Reference Text: 
Wiener, J. M., Gould, E., Shuman, S. B., Kaur, R., & Ignaczak, M. (2016). Examining models of dementia care (ASPE Final Report No. 0212704.017.000.001). RTI International. https://aspe.hhs.gov/sites/default/files/private/pdf/257216/ExamDCMod.pdf

Reference Type: Citation

Reference Text: 
Wilson, R. S., Aggarwal, N. T., Barnes, L. L., Mendes de Leon, C. F., Herbert, L. E., & Evans, D. A. (2010). Cognitive decline in incident Alzheimer disease in a community population. Neurology, 74(12), 951–955. https://doi.org/10.1212/WNL.0b013e3181d64786

Cognition can be assessed by the clinician during the patient's clinical history.
Cognition can also be assessed by direct examination of the patient using one of a number of instruments, including several originally developed and validated for screening purposes. This can also include, where appropriate, administration to a knowledgeable informant. Examples include, but are not limited to:

 

  
Blessed Orientation-Memory-Concentration Test (BOMC)
 
 

  
Montreal Cognitive Assessment (MoCA)
 
 

  
St. Louis University Mental Status Examination (SLUMS)
 
 

  
Mini-Mental State Examination (MMSE) [Note: The MMSE has not been well validated for non-Alzheimer's dementias]
 
 

  
Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
 
 

  
Ascertain Dementia 8 (AD8) Questionnaire
 
 

  
Minimum Data Set (MDS) Brief Interview of Mental Status (BIMS) [Note: Validated for use with nursing home patients only]
 
 

  
Formal neuropsychological evaluation
 
 

  
Mini-Cog
 

The measure requires a diagnosis of dementia be present before the routine assessment of cognition is performed once during the measurement period or the 12 months prior.
Use of a standardized tool or instrument to assess cognition other than those listed will meet numerator performance if mapped to the concept "Intervention, Performed": "Cognitive Assessment" included in the numerator logic below.
The requirement of two or more visits is to establish that the eligible clinician has an existing relationship with the patient.
In recognition of the growing use of integrated and team-based care, the diagnosis of dementia and the assessment of cognitive function need not be performed by the same provider or clinician.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DMS-5 has replaced the term dementia with major neurocognitive disorder and mild neurocognitive disorder. For the purposes of this measure, the terms are equivalent.
This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patients, regardless of age, with a diagnosis of dementia who have two or more visits during the measurement period

Equals Initial Population

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Patients for whom an assessment of cognition is performed and the results reviewed at least once within the 12 months preceding a dementia encounter during the measurement period

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Documentation of patient reason(s) for not assessing cognition

For every patient evaluated by this measure also identify payer, race, ethnicity, and sex

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