Dementia Screening in Primary Care: Tools and Workup Guide

Perform a cognitive assessment in every Medicare Annual Wellness Visit (AWV). CMS requires documentation of the cognitive assessment as part of the AWV, and a brief validated tool satisfies this requirement while delivering meaningful clinical information.

Do not implement universal dementia screening of asymptomatic older adults outside the AWV context. The USPSTF concludes that the balance of benefits and harms cannot be determined — but this does not mean avoiding assessment in any patient who reports or demonstrates concern.

Initiate case-finding — a formal cognitive assessment prompted by concern — whenever the patient, a family member, or a colleague raises a question about memory, language, orientation, or functional change. Case-finding is evidence-supported even where universal screening is not, and informant history is especially valuable when the patient has limited insight.

Consider a lower threshold for cognitive assessment in high-risk groups: age over 75, first-degree family history of dementia, prior stroke or significant vascular disease, Parkinson disease, traumatic brain injury, or Down syndrome. Risk factors do not trigger automatic screening but shift the clinical suspicion upward.

Use the Mini-Cog as the first-line brief tool in primary care. It combines a three-word recall task with a clock-drawing test, takes about three minutes, has good sensitivity for moderate-to-severe dementia, and is free of use restrictions. A score below 3 out of 5 warrants further assessment.

Use the MoCA (Montreal Cognitive Assessment) when mild cognitive impairment is suspected or a Mini-Cog is ambiguous. It takes 10 to 15 minutes, covers attention, executive function, memory, language, visuospatial, and orientation, and is substantially more sensitive than the MMSE for MCI. Use a cutoff of 26 out of 30 for typical adults and complete MoCA training before scoring routinely.

Consider the SLUMS (Saint Louis University Mental Status) examination when executive dysfunction or vascular contribution is prominent, or when institutional policy precludes MMSE use. The SLUMS covers similar domains to the MoCA, probes executive function through animal fluency and clock drawing, and is freely available from Saint Louis University.

Avoid relying on the MMSE alone. It is insensitive to mild cognitive impairment and to executive dysfunction, performs poorly in highly educated or high-functioning patients, and is now subject to copyright and licensing. Use the MoCA or SLUMS instead when a longer tool is needed.

Pair every patient-administered screen with an informant-based questionnaire — the AD8 (8 questions, under 3 minutes) or the IQCODE (16-item short form). Informant tools perform independently of education and language level and catch high-functioning patients who compensate well on in-office testing.

Order a standard laboratory panel for every new dementia workup: complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, vitamin B12, and folate. Consider HIV and syphilis testing where epidemiologically relevant or when clinical features suggest unusual aetiology.

Obtain structural brain imaging — MRI if available, CT otherwise — in every newly diagnosed dementia. Imaging identifies strokes, chronic microvascular disease, subdural haematoma, normal pressure hydrocephalus, and space-occupying lesions that change management.

Review the medication list and reduce anticholinergic burden, benzodiazepines, Z-drugs, opioids, and sedating antihistamines at every visit. The American Geriatrics Society Beers Criteria provide a practical checklist. Expect measurable cognitive improvement within weeks of successful deprescribing.

Screen for depression with the PHQ-9 and for delirium with a 4AT or CAM whenever cognitive decline is being evaluated. Depressive pseudodementia, untreated mood disorder, and superimposed delirium can all masquerade as, or coexist with, dementia. Treat each on its own terms before closing the diagnosis.

Evaluate sensory impairment — particularly hearing and vision — at every cognitive assessment. Uncorrected hearing loss triples the perceived cognitive impact of early dementia and is one of the most modifiable risk factors for accelerated decline.

Refer to neurology, geriatric medicine, or a memory clinic when: mild cognitive impairment is identified, presentation is atypical (young onset under 65, rapid progression, prominent behavioural features), diagnosis is uncertain after initial workup, or the patient is being considered for disease-modifying therapy.

Do not routinely order cerebrospinal fluid biomarkers or amyloid PET imaging from primary care. These are specialist-directed investigations: CSF beta-amyloid 42/40 and phosphorylated tau, and amyloid PET, are most useful when the diagnosis is uncertain, when a disease-modifying therapy is being considered, or in young-onset cases. Referral is the appropriate route.

Discuss plasma biomarker availability (p-tau217, Aβ42/40 ratio) with patients and families when raising referral, but defer ordering from primary care unless a local clinical pathway supports it. Plasma markers are rapidly changing clinical practice and local specialist guidance should direct use.

Ask the patient about their disclosure preferences before testing. Questions like “If we find something, how would you like to hear about it, and who would you want with you?” take 30 seconds and transform the diagnosis conversation. Document the answer in the record.

Schedule a dedicated disclosure visit rather than squeezing the news into the end of a routine appointment. Invite a family member, set aside at least 30 minutes, and explicitly address driving safety, financial capacity, advance care planning, and community support resources.

Address driving safety at every visit once cognitive decline is confirmed. Ask about near-misses and becoming lost; involve occupational therapy or formal on-road testing when capacity is in doubt. Local laws vary regarding clinician reporting obligations — know yours.