, Author at ReaDementia

The Role of Cognitive Reserve in Dementia

Dr. Yasmin Aghajan Blog April 4, 2021October 15, 2021cognitive reserve, dementia

It is important to understand the crucial role of cognitive reserve in dementia and how it affects diagnosis.

What is Cognitive Reserve?

Many studies are ongoing to determine what risk factors predict development of dementia, as well as to foresee who will more rapidly progress from mild cognitive impairment to dementia.

Cognitive reserve (CR) is a new area of interest in predicting how quickly dementia may worsen.

It is defined as a coping strategy against brain damage. This is the ability to use different brain networks to cope against loss of performance.

One way to think of CR practically is the brain’s capacity to improvise and find other ways of getting the job done to overcome obstacles and challenges.

CR was first thought of in the 1980s, when researchers found brain changes on autopsy consistent with advanced Alzheimer’s disease in people who had no symptoms when they were alive.

This meant these patients continued to function as usual, despite brain damage from Alzheimer’s pathology. This triggered a wide interest in research on whether people with a greater cognitive reserve can cope with brain changes of dementia (or even other disorders such as multiple sclerosis, Parkinson’s disease, or stroke).

“CR protects a person from clinical dementia”

The theory is, the higher a person’s CR, the more protected he or she would be against clinical dementia and loss of functioning.

Studies have tried to link dementia level to variables such as education, literacy, IQ, and engagement in cognitive exercises.

CR is the latest such variable to be added to the list of variables that can influence the development of dementia.

Genetics and exposure to environments (education, cognitively stimulating activities, and occupation) help develop CR.

There are some emerging predictive factors for converting from mild cognitive impairment to dementia.

Higher risk has been found for lack of occupation in the elderly, low formal education level, and difficulty coping with common situations.

Higher CR may be linked to decreased risk for dementia

Although larger studies are needed, a major research study published in JAMA neurology in 2019 of over 1600 patients in the Rush University Memory and Aging Project showed that those who scored in the highest cognitive reserve category had a reduced risk for dementia, even if they had high amounts of Alzheimer’s brain pathology at autopsy.

This strongly suggests that increased CR could reduce dementia risk.

How does one increase Cognitive Reserve?

Researchers propose that being exposed to an enriched environment, meaning high opportunities to participate in physical activity, ongoing learning, and keeping up social interactions may produce structural (and functional) changes in the brain.

Specifically, the hippocampus is important for memory and becomes impaired in Alzheimer’s disease, may be altered with practicing the above tasks.

Some have theorized learning a second language or doing Sudoku-type puzzles may “train” the brain’s CR, however, this has not yet been scientifically proven to delay or prevent Alzheimer’s disease.

How is Cognitive Reserve measured?

CR can be measured clinically by your doctor; in general, a person’s education level, work activities and activities performed in leisure can help gauge an estimate of CR.

There also exists a Cognitive Reserve Index questionnaire (CRIq) which formally assesses years of education, vocational training, type of occupation (ranging from unskilled to highly intellectual occupation), leisurely activities (reading newspapers, domestic chores, driving, sports, games, and using new technologies), and social activities.

Results are scored and then interpreted as low, medium-low, medium, medium-high, or high cognitive reserve.

It is important to note that these cutoffs have not yet been proven to predict a clinical outcome, but could be a useful tool and certainly an important research tool.

Why is Cognitive Reserve important?

CR may be very important in compensating for progressive brain damage in dementia. Although it doesn’t prevent dementia, high CR could mask the development of symptoms until a certain threshold.

For example, a person with a high CR can go undiagnosed until the damage becomes severe, whereas a person with a low CR may decompensate clinically much sooner.

What, besides increasing cognitive reserve, can be done to reduce the risk of dementia?

Studies show eating a healthy, plant-based diet with fruit, vegetables and legumes may be protective. Regular exercise including cardiac fitness, getting enough high-quality sleep, stress management, and nurturing social connections are all good practices to prevent cognitive issues later in life.

Continuing to challenge the brain with learning new material may be helpful as well.

Other heart-healthy activities such as quitting smoking, controlling high blood pressure and cholesterol, and working with your doctor to reduce the risk of heart disease can prevent vascular dementia as well.

Cognitive Tests for Dementia: 8 Tests Explained

Dr. Yasmin Aghajan Blog, Prevention February 16, 2021August 19, 2026cognitive tests, dementia

Cognitive tests for dementia and memory assessment

There are several cognitive tests for dementia that healthcare professionals can use when someone is experiencing changes in memory, thinking, language or other cognitive abilities.

Often, the first signs are noticed by the person themselves or by a family member. They may become more forgetful, have difficulty following conversations, struggle with familiar tasks or show other changes in thinking and behavior.

Cognitive tests provide a more structured way to assess these concerns. Some can be completed in only a few minutes, while more detailed neuropsychological assessments may take several hours.

However, an important point is that no single cognitive test can diagnose dementia on its own. A diagnosis normally involves a broader medical evaluation that may include a health history, physical and neurological examination, medication review, laboratory tests and, in some cases, brain imaging such as MRI, CT or PET scans.

The Alzheimer’s Association recommends using cognitive screening tools to identify people who may need further evaluation rather than treating a screening score as a definitive diagnosis.

In this article, we look at eight cognitive tests and assessment methods that may be used when dementia or cognitive impairment is suspected.

Who Performs Cognitive Tests for Dementia?

An initial cognitive assessment can often be performed by a primary care physician.

Depending on the person’s symptoms and circumstances, they may also be assessed by specialists such as neurologists, geriatricians, psychiatrists or psychologists and neuropsychologists.

The Alzheimer’s Association notes that referral to a specialist may be particularly helpful when the diagnosis is unclear, symptoms are unusual, dementia begins at a younger age, significant behavioral or psychiatric symptoms are present, or a second opinion is wanted.

Cognitive testing may be used as part of the process of determining whether someone has dementia or mild cognitive impairment. Tests may also be repeated at appropriate intervals to help healthcare professionals monitor changes in cognitive function.

8 Cognitive Tests for Dementia

Different cognitive tests examine different aspects of thinking and memory.

They may assess areas such as memory, orientation, attention, language, executive function, visuospatial abilities and problem-solving.

The appropriate test depends on factors such as the person’s symptoms, age, language, education, medical history and the clinical setting.

1. Mini-Mental State Examination (MMSE)

The Mini-Mental State Examination, commonly known as the MMSE, is one of the best-known cognitive screening tests.

It examines areas including orientation, memory, attention, calculation, language and visuospatial ability.

The original MMSE is scored out of 30 points and usually takes only a few minutes to administer. A newer version, the MMSE-2, is also available in standard, brief and expanded forms.

The MMSE and MMSE-2 are professional assessment instruments. Unlike some cognitive screening tools, they are commercially published rather than freely available for unrestricted online use. More information is available from the official MMSE-2 publisher.

A person’s score should not be interpreted in isolation. Factors such as age, education, language, hearing, vision and other medical conditions can influence cognitive test performance.

2. Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment, or MoCA, is another widely used cognitive screening tool.

The full MoCA is scored out of 30 and generally takes around 10 minutes to administer. It assesses several areas of cognition, including short-term memory, visuospatial abilities, executive function, attention, concentration, working memory, language and orientation.

The MoCA was developed particularly to help identify mild cognitive impairment and can detect difficulties that may not be obvious during a routine conversation or medical appointment.

Official information about the assessment is available from MoCA Cognition.

MoCA administration and scoring should follow the official instructions and applicable training requirements. A particular score should not be viewed as proof that someone does or does not have dementia.

3. Saint Louis University Mental Status Examination (SLUMS)

The Saint Louis University Mental Status Examination, usually shortened to SLUMS, is another cognitive screening assessment.

It evaluates areas such as orientation, memory, attention, calculation, executive function and visuospatial ability.

Saint Louis University describes SLUMS as a screening tool for mild cognitive impairment and dementia in adults aged 60 and older.

The university provides the assessment and professional guidance through its official SLU Mental Status Exam resource.

Importantly, Saint Louis University states that SLUMS results do not represent a clinical diagnosis. An abnormal result should be interpreted as part of a broader evaluation by a qualified healthcare professional.

4. Clock Drawing Test

The Clock Drawing Test is a simple cognitive task commonly incorporated into other assessments.

A person may be asked to draw a clock face, place the numbers correctly and position the hands at a specified time.

Although the task looks simple, successful clock drawing requires several cognitive abilities working together. These can include visuospatial skills, planning, executive function, attention, comprehension and motor skills.

Difficulty completing a clock drawing can indicate that further assessment may be appropriate, but the result does not by itself diagnose dementia.

Clock drawing is also incorporated into screening tools including the Mini-Cog and SLUMS.

5. Mini-Cog

The Mini-Cog is a brief cognitive screening test designed to take approximately three minutes.

It combines two tasks: recalling three unrelated words and completing a clock drawing task.

The Mini-Cog is intended to help identify people who may have cognitive impairment and therefore require a more detailed assessment.

According to the official Mini-Cog resource, the test is a screening tool rather than a diagnostic test for dementia.

If the result suggests possible cognitive impairment, the next step is normally a more comprehensive medical and cognitive evaluation.

6. General Practitioner Assessment of Cognition (GPCOG)

The General Practitioner Assessment of Cognition, or GPCOG, is another brief screening tool commonly associated with primary care.

It includes questions and cognitive tasks for the patient and may also include questions for a family member, friend or other person who knows the patient well.

This can be particularly useful because changes in everyday function may be noticed by family members before they become obvious during a short medical appointment.

The Alzheimer’s Association includes GPCOG among brief cognitive assessment tools that may help determine whether a person needs a more complete dementia evaluation.

Like other screening tools, GPCOG is not intended to establish a dementia diagnosis by itself.

7. Addenbrooke’s Cognitive Examination-III (ACE-III)

The Addenbrooke’s Cognitive Examination-III, or ACE-III, is a more detailed clinician-administered cognitive screening assessment.

It evaluates several cognitive areas, including attention, memory, verbal fluency, language and visuospatial ability.

The ACE-III is used to assess cognitive function and can help support the clinical investigation of dementia.

The University of Sydney, which provides the current ACE-III resources, recommends that clinicians and researchers become familiar with the official administration and scoring procedures before using the assessment.

As with other cognitive tests for dementia, ACE-III results need to be considered alongside the person’s medical history, symptoms and other clinical findings.

8. Formal Neuropsychological Testing

Formal neuropsychological testing is much more detailed than a brief cognitive screening test.

Rather than relying on one short questionnaire, a neuropsychologist may use a battery of assessments to examine areas including memory, attention, language, executive function, processing speed, judgment and visuospatial ability.

More comprehensive testing can be particularly helpful when symptoms are subtle, the diagnosis is uncertain or a person has cognitive concerns despite performing relatively well on a short screening test.

The Alzheimer’s Association notes that comprehensive cognitive testing is often performed by a neuropsychologist and may be used to examine executive function, judgment, attention and language in greater detail.

Specialist batteries may include assessments such as the Consortium to Establish a Registry for Alzheimer’s Disease Neuropsychological Battery, commonly known as CERAD-NP.

Neuropsychological evaluation can take considerably longer than brief screening tests and usually requires referral to a qualified professional.

It is not necessary for every person being evaluated for dementia, but it can provide valuable information in more complex cases.

Can Cognitive Tests for Dementia Diagnose Dementia?

No cognitive screening test should be used by itself to diagnose dementia.

A low score may indicate cognitive impairment, but there are many reasons why someone may perform poorly on a test. These can include depression, medication effects, hearing or vision difficulties, language differences, fatigue, anxiety and other medical conditions.

Likewise, performing well on a brief screening test does not necessarily rule out early or subtle cognitive problems.

The Alzheimer’s Association advises that people whose cognitive screening results raise concerns should receive further evaluation or be referred to an appropriate specialist.

A full dementia evaluation may consider:

the person’s symptoms and medical history
information from family members or caregivers
changes in everyday functioning
physical and neurological examination
medications and other health conditions
laboratory testing
cognitive assessment
brain imaging when appropriate

The combination of these findings helps the healthcare professional determine whether dementia or another condition may be responsible for the symptoms.

Can You Take a Dementia Test Online?

It can be tempting to take an online memory or dementia test when you are worried about yourself or someone close to you.

However, online or self-administered tests should not be treated as a substitute for a professional assessment.

The Alzheimer’s Association cautions against relying on home dementia screening tests because results can be misleading and may produce false positives.

If you or someone you know is experiencing persistent changes in memory or thinking, it is better to discuss the symptoms with a healthcare professional.

How Are Cognitive Test Results Interpreted?

Cognitive test scores need to be interpreted in context.

Healthcare professionals consider more than whether a score falls above or below a single number. Education, language, age, cultural background, sensory impairments and medical conditions can all influence performance.

Different tests also have different scoring systems and purposes.

For this reason, it is generally more useful to think of cognitive testing as one part of the diagnostic process rather than as a pass-or-fail dementia test.

When tests are repeated over time, clinicians may also look for meaningful changes in performance rather than relying only on a single result.

Closing Thoughts

There are many cognitive tests for dementia, ranging from brief screening tools such as the Mini-Cog to more detailed assessments performed by neuropsychologists.

Tests such as the MMSE, MoCA, SLUMS, clock drawing test, Mini-Cog, GPCOG and ACE-III can provide useful information about memory and other areas of cognitive function.

However, none should be considered a stand-alone dementia diagnosis.

If cognitive changes are affecting everyday life or causing concern, the most appropriate next step is to speak with a doctor. A healthcare professional can decide which cognitive assessment is appropriate and whether further testing or specialist referral is needed.

References and Further Reading

Alzheimer’s Association. Cognitive Screening and Assessment.

Alzheimer’s Association. Medical Tests for Diagnosing Alzheimer’s and Dementia.

Saint Louis University. SLU Mental Status Exam.

MoCA Cognition. Montreal Cognitive Assessment.

Mini-Cog. Cognitive Screening Resource.

University of Sydney. Addenbrooke’s Cognitive Examination-III.

Geldmacher DS, Whitehouse PJ. Evaluation of dementia. N Engl J Med. 1996;335:330.

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.

Do Neurologists Treat Dementia?

Dr. Yasmin Aghajan Blog February 6, 2021October 16, 2021dementia, dementia treatment, neurologist, neurology

The common question that arises amongst the general public is whether or not do neurologists treat dementia.

While there are various specialists who can diagnose dementia, many patients are referred to a neurologist who determines the type of dementia, as well as treatment options.

What is dementia?

Dementia is a neurologic disease affecting cognition, involving the different aspects of cognitive function (memory, language, attention, social life, planning, and motor skills).

Dementia represents a decline that is severe enough to interfere with daily life and independence. When people think of dementia, Alzheimer’s comes to mind, and that’s because Alzheimer’s Disease is the most common type of dementia.

Alzheimer’s is responsible for about 60-80% of all dementias in older adults. With an aging population, the overall prevalence of dementia is increasing worldwide.

Dementia is a progressive disease, meaning it gets worse over time. In the early stages, it may be diagnosed at mild cognitive impairment (MCI), which is an in-between stage between normal cognition and dementia.

MCI may progress to dementia.

What are different kinds of dementia?

The most common dementia in older adults is Alzheimer’s Disease. However, about 20% of patients with dementia have another form of dementia.

The main dementia syndromes include Dementia with Lewy Bodies, Frontotemporal dementia, Parkinson disease dementia and variants, and vascular or stroke-related dementia.

Who can diagnose dementia and why a neurologist?

Dementia is a diagnosis made by a physician.

While it does not have to be a neurologist to diagnose dementia, many patients are referred to a neurologist to determine what type of dementia they have and to help with treatment options and symptom management.

A primary care physician can make a presumptive diagnosis of dementia if a patient fits certain criteria, and the symptoms are not explained by another mental disorder (such as major depressive disorder or another psychiatric condition).

A neurologist can help distinguish between the different types of dementia.

In some cases, advanced neuropsychiatric testing is done to better clarify the type of dementia.

How is dementia diagnosed?

A full dementia evaluation cannot be done in a quick office visit; a family member or a close friend should accompany the patient to their primary physician or neurologist and be able to recount the history over the past several weeks, months, and even years.

The first steps include a complete history and physical examination, neurologic examination, and laboratory or imaging workup.

The history, or story of the patient’s symptoms, is crucial to the diagnosis.

A doctor might ask when the patient first noticed memory loss, how it has progressed, and what sorts of things he or she is not able to do anymore independently (activities of daily living, or ADLs).

Certain details are key, such as loss of vision or strength, prominent personality changes, behavioral problems, hallucinations, sleep problems, and risk-taking behaviors.

There are several tests available to help with the diagnosis of dementia, which will be discussed further below.

A full evaluation includes a physical and neurologic exam, laboratory testing, and most times imaging tests such as a CT scan or an MRI of the brain.

By official definition, dementia is diagnosed when there is cognitive impairment in at least one cognitive domain (memory, language, attention, executive function, motor function, social function) that is progressive and interferes with independence in every-day activities, that is not explained by another medical or psychiatric disorder.

Why refer to a neurologist for dementia?

A neurologist will be helpful in diagnosing dementia, especially in distinguishing between different types of dementia as their treatments differ.

Also, a neurologist will perform a careful history and exam including labs and imaging to make sure there is nothing else being missed that would otherwise explain the symptoms of dementia.

In addition, a neurologist trained in cognitive neurology will have special expertise on managing the symptoms of dementia including the newest medications, clinical trials, and symptom management.

Often times, a neurologist will be able to give a prognosis and help guide family members through this chronic, progressive illness.

What does a neurologist examine for a dementia patient?

After taking a careful history of the symptoms, a neurologist will begin with a general physical examination.

Part of this includes the neurologic exam.

A neurologic exam contains six major components; mental status exam, cranial nerve exam, motor exam, sensory exam, reflexes, and cerebellar exam.

Abnormalities on the neurologic exam may give the neurologist clues as to what the diagnosis is.

The mental status exam will assess for orientation, attention, memory, visuospatial function, and language. Some common tools are the MOCA (Montreal Cognitive Assessment) and MMSE (Mini-Mental State Examination).

These are a short series of tasks a neurologist may ask you to fill out, and based on how you score, can help in categorizing the types of deficits and hint as to the type of dementia.

What treatments might a neurologist prescribe for dementia?

There are a few medications that are approved for the treatment of Alzheimer Disease. These include cholinesterase inhibitors (such as donepezil, rivastigmine, and galantamine).

These medications work by modulating neurotransmitters in the brain and have some modest symptomatic benefit in patients with dementia.

Another category of medication includes Memantine, which is an NMDA-receptor antagonist. This works by blocking a different neurotransmitter (NMDA) which may protect the brain.

This also has been shown to have very modest benefits.

Neurologists may prescribe medications to help certain symptoms of dementia, such as behavioral disturbances, hallucinations, sleep problems, depression, agitation, and aggression.

These may include antidepressants, antipsychotics and various other medications.

Nutrition, physical therapy and cognitive rehab are also things a neurologist may consider in the multidisciplinary approach to dementia care.

What conditions can be mistaken for dementia?

There are certain conditions that can mimic dementia. It is essential to make sure these conditions are not responsible for the symptoms, as they are often reversible and treatable.

A good neurologist will rule out “reversible” causes and mimics of dementia.

There are certain “red flags” that should not be missed; these include young age, rapidly progressive dementia (ie someone getting much worse within days, weeks or a few months), or an abnormal or asymmetric neurologic exam such as weakness on one side of the body.

These will need an expedited and different type of evaluation than the standard dementia workup.

Many people confuse the signs of normal aging with dementia.

Normal aging does include a slight degree of cognitive decline including mild changes in memory and information processing. Some people visit their doctor for these symptoms, worried that they may have dementia.

Normal aging is quickly recognizable from dementia

However, normal aging is easily distinguishable from dementia.

It is generally not very progressive and does not affect daily function.

Examples include forgetting where one left the keys or some items on the shopping list at the grocery store.

There are other medical conditions that can mimic dementia. One is delirium.

Delirium is a condition of confusion and an altered sense of awareness of one’s surroundings.

Delirium is often associated with an underlying medical condition, such as an infection, metabolic issue, or prolonged hospitalization.

The time course of delirium (much shorter) and the fluctuations in attention are characteristic and distinguishable from dementia.

Vitamin deficiency, specifically of Vitamin B12 can contribute to dementia, so this should be checked and supplemented if low.

Thyroid tests, and sometimes HIV or syphilis testing is done to make sure symptoms are not due to these other treatable medical conditions.

Depression is an important mimic of dementia. In fact, depression causing dementia has been named “pseudodementia” or “dementia of depression.”

This is because people with uncontrolled depression may exhibit signs similar to dementia (physical and cognitive slowing, giving poor effort, being unable to function in activities of daily life).

It is crucial to recognize pseudodementia because it can be treated and reversed with appropriate psychiatric and psychological care.

Resources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.

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.

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.

Reisberg B, Doody R, Stöffler A, et al. Memantine in moderate-to-severe Alzheimer’s disease. N Engl J Med 2003; 348:1333.

Petersen RC, Smith G, Kokmen E, et al. Memory function in normal aging. Neurology 1992; 42:396.

Geldmacher DS, Whitehouse PJ. Evaluation of dementia. N Engl J Med 1996; 335:330.

Brauner DJ, Muir JC, Sachs GA. Treating nondementia illnesses in patients with dementia. JAMA 2000; 283:3230.

Howard R, McShane R, Lindesay J, et al. Donepezil and memantine for moderate-to-severe Alzheimer’s disease. N Engl J Med 2012; 366:893.