BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
Cognitive Impairment in the Elderly –
Recognition, Diagnosis and Management
Effective Date: July 15, 2007
Scope
This guideline summarizes current recommendations for recognition, diagnosis and longitudinal
management of cognitive impairment and dementia in the elderly. Where the guideline refers to
“people affected by dementia”, this indicates not only the person with dementia but also the people in
their “network of support”.
Summary recommendation Care Objectives
The primary care objectives are to encourage early recognition and assessment of cognitive
impairment and to support general practitioners in the development of a comprehensive care plan that
includes the identification of community resources for the people affected by dementia. A summary is
provided for this guideline and can be used as a worksheet in the physician’s office.
Part I: Recognition and Diagnosis
recommendation 1 Recognition
a. General population screening in asymptomatic individuals is not recommended at this time.
b. Cognitive impairment should be suspected when there is a history that suggests a decline in
occupational, social or day-to-day functional status. This might be directly observed or reported by
the patient, concerned family members, friends and/or caregivers.
Symptoms of Cognitive Impairment
• Asksthesamequestionrepeatedly
• Cannotrememberrecentevents
• Cannotprepareanypartofamealormayforgetthattheyhaveeaten
• Forgetssimplewords,orforgetswhatcertainobjectsarecalled
• Getslostinownneighbourhoodanddoesnotknowhowtogethome
• Dressesinappropriately(e.g.maywearsummerclothingonawinterday)
• Hastroubleguringoutabill,orcannotunderstandconceptssuchasbirthdays

Course •Stableandprogressive • Fluctuates:worseatnight •Diurnal:usuallyworse
  VaD*:usuallystepwise • Lucidperiods  inmornings,improves
      asdaygoeson

Alertness •Generallynormal • Fluctuateslethargicorhyper-vigilant •Normal

Orientation •Maybenormalbutoften • Alwaysimpaired: •Usuallynormal
  impairedfortime/later  time/place/person
  inthedisease,place
Memory •Impairedrecentand • Globalmemoryfailure •Recentmemorymaybe
  sometimesremotememory    impaired
    •Long-termmemory 
     intact
Thoughts •Slowed;reducedinterests •Disorganized,distorted,fragmented •Usuallyslowed, 
 •Makespoorjudgements •Bizarreideasandtopicssuchas  preoccupiedbysad
 •Wordsdifculttond  paranoidgrandiose  andhopelessthoughts;
 •Perseverates    somaticpreoccupation
    •Moodcongruent 
     delusions
Perception •Normal •Distorted:visualandauditory •Intact
 •Hallucinations(oftenvisual) •Hallucinationscommon •Hallucinationsabsent
      exceptinpsychotic 
      depression
Emotions •Shallow,apathetic,labile • Irritable,aggressive,fearful •Flat,unresponsiveor
 •Irritable    sadandfearful
    •Maybeirritable
Sleep •Oftendisturbed,nocturnal • Nocturnalconfusion •Earlymorningwakening
  wanderingcommon
 •Nocturnalconfusion
Otherfeatures •Poorinsightintodecits •Otherphysicaldiseasemaynotbe •Pasthistoryofmood

disorientation

Presenceofdecitsinexecutivefunctions:Problem-solving,sequencing,multi-tasking,  
conceptualizing,mentalexibility,abstractthinking,etc.

Presence of language deficits: Difficulty finding words, loss of speech fluency, word
substitutions, problems with verbal comprehension, etc.

Presence of agnosia(impairmentofrecognitionoffacesorobjects):Notcommonasa  
presenting feature of dementia

Presenceofapraxia(impairmentofperformingprogrammedmotortasks):Examples:playing 
an instrument, tying shoelaces or a tie, sewing or knitting

Presence of delusions:Examples:paranoiddelusionssuchasirrationalsuspiciousness,  
concerns of infidelity, etc.

Presence of hallucinations:VividhallucinationsaresuggestiveofDLB

Gait abnormalities:AriselaterinAD;earlierinVaD,DLBandnormalpressurehydrocephalus 
(NPH)

Urinaryincontinence:Ifurinaryandgaitproblemsoccurearlyinthecourseofcognitive  
impairment,considerNPH

Impairedinstrumentalactivitiesofdailyliving:Aprerequisiteforthediagnosisofdementia 
Examples:cannolongerperformjobsatisfactorily,unabletomanagenances,trouble
driving, cannot play bridge or keep score in golf, cannot cook from a recipe, unable to use public
transit, etc.


dementia with B12 treatment.
3

Othertestsmaybeaddedasindicatedbyclinicalsuspicion(e.g.SerologicalTestforSyphilis[STS],
HIV,renalfunctiontests,liverfunctiontest).
4. NEUROIMAGING
4,5
 Neuroimaging(CTorMRIofhead)isnotroutinelyindicatedbutmaybeusefulwhen:
 • Thepatientislessthan60yearsold
 • Theonsethasbeenabruptorthecourseofprogressionrapid
 • Thereisahistoryofsignicantrecentheadinjury
 • Thepresentationisatypicalorthediagnosisisuncertain
 • Thereisahistoryofcancer
 • Therearenewlocalizingneurologicalsignsorsymptoms
 • Vasculardementiaissuspected
 • Thepatientisonanticoagulantsorhasableedingdisorder
 • Thereisahistoryofurinaryincontinenceandearlypresentationofgaitdisorder
5. COGNITIVE TESTING
• Diagnosticcriteriarequirethatthereshouldbeobjectiveevidenceofamemorydecitto
support the diagnosis.
 • PerformanobjectivetestofcognitionsuchastheStandardizedMiniMentalStateExamination
 (SMMSE).WhilethenormalrangeforSMMSEscoresis24-30,performanceonthistestmust 
be interpreted along with the other information gathered such as sensory impairment,
 educationattainment,languageandculturalissues.CognitivestatusindicatedbytheSMMSE
 isanimportantbenchmarkforfollowingthecourseofcognitiveimpairment(AppendixC).
 • Supplementarytesttoconsider:ClockDrawingTest(AppendixD).

6. WORKING DIAGNOSIS
Arriving at a specific dementia sub-type diagnosis will aid in treatment planning and counselling.
BroaderuseofDSM-IVTRcategoryof‘dementiaduetomultipleetiologies’isencouraged,with

Temporal
Dementia
1. Slowprogressiveonset
2. Multiplecognitivedecitsmanifestedbyboth:
 • Memoryimpairment
 • Oneormoreadditionalcognitivedecitssuchasaphasia,apraxia,agnosia,disturbancein 
  executivefunctioning
3. Associatedsignicantfunctionaldecline
4. Notexplainedbyotherneurologicorsystemicdisorders
ThedegenerativechangesofADandthevascularchangesofVaDcommonlyco-exist.Presentationmore
commonlyofADpatternwithsignicantvascularriskfactors+/-smallvascularevents
1. Corefeatures:
 • Fluctuatingcognitionwithpronouncedvariationinattentionandalertness(memorydecline
  maynotbeanearlyfeature)
 • Recurrentvisualhallucinationsthatarewellformedanddetailed
 • SpontaneousmotorfeaturesofParkinsonism
2. Featuressupportiveofdiagnosis:
 • Repeatedfalls
 • Syncopeortransientlossofconsciousness
 • Hypersensitivitytoantipsychotics(typicalandatypical)
 • Systematizeddelusions;non-visualhallucinations
3. DLBhasreducedprevalenceofrestingtremorandreducedresponsetoL-dopacomparedtoidiopathicPDD
4. PresenceofREMsleepdisorderinthesettingofadementiasuggestsDLB&relatedconditions
5. DLBshouldoccurbeforeorconcurrentlywithonsetofParkinsonism
1. ThecognitivefeaturesmayappearsimilartoDLB(decitsinattentionandalertness)
2. LookformotorParkinsoniansymptomsthattypicallyarepresentmanyyearsbeforetheonsetofthe
 dementiaforPDD
1. Insidiousonsetandgradualprogression;tendstopresentinmiddle-agedpatients
2. Characterchangespresentearlyandincludeapathy,disinhibition,executivefailurealoneorincombination
3. Relativelypreservedmemory,perception,spatialskillsandpraxis

5
 • PatientswithMCImayprogresstodementiaatarateof16%peryear.
7
Once identified,
 patientswithMCIshouldbere-examinedperiodically(e.g.every6months)sothattreatment 
and counselling can be offered and incident dementia can be identified.
8. STAGING
  SomecliniciansstageADusingtheGlobalDeteriorationScale(SeeAppendixF).
recommendation 3 Diagnosis Disclosure
a. The disclosure of a diagnosis of dementia should be done as soon as possible, but can cause
signicantstress.Thetimingandextentofdisclosureshouldbeindividualizedandisbestcarried
outoverafewvisitssupportedbyreferraltoothersupportresources(seePatient/CaregiverGuide).
 •Ingeneral,thereareonlyafewexclusionstodisclosure,includingprobablecatastrophic 
reaction, severe depression or severe dementia
 • Disclosureisfacilitatedthroughaninitialopen-endedapproach,e.g.asking:“What do you think
the change in your memory and thinking is due to?”
b. Insettingupthevisitfordisclosure,considerpatientprivacyandaskwhetherthecaregivercanbein
attendance(theanswerwillbeyesinmostsituations).
c. At the initial disclosure visit highlight:
 • Dementiawithdementiasub-typeasaclinicaldiagnosis
 • Anticipatedprognosis
 • Indicatethatyouwillfollow-upandprovideongoingsupport
 • ProvidethePatient/CaregiverGuide,discussothersupportresourcesasappropriate
 • Provideascheduleofvisitsandbookthenextvisit
d. Atfollow-upvisitsdiscuss(atleastevery6months):
 • Informationneedsandconcerns
 • Advanceplanningwithrespecttonancesandpatientpreferences
 • Safetyplanning
 • Availabilityofeducationandsupportresources
e. Disclosure when mild cognitive impairment is diagnosed needs to be carefully considered.

affected patient about eventual driving cessation. Assist the affected driver to make the necessary
lifestyle changes early and to cease driving by choice rather than by compulsion. Encourage
patienttoregisterwithHandyDart,HandyPASSandTaxiSavers(seeResourcessection).
b. An individual’s competence for driving should be assessed using both cognitive and non-cognitive
criteria(e.g.othermedicalconditionsandspecialsensorydefects),andincludecollateralhistory
about the individual’s driving habits from observers. On cognitive testing, deficits in attention,
visuospatialabilitiesandjudgmentmaybepredictorsofdrivingrisk.Whendoubtexistsabouta
patient’s driving competence, physicians should recommend a performance-based evaluation
suchasare-examroadtestbytheInsuranceCorporationofBritishColumbia(ICBC)oradriver
tnessreviewthroughtheOfceoftheSuperintendentofMotorVehicles.
c. InaccordancewiththeBC Motor Vehicle Act,physiciansarerequiredtodocumentpatientsunder
their care who have a condition incompatible with safe driving and to instruct these patients to
stopdriving.Ifthephysicianlearnsthatthepatientcontinuestodrivedespitethisinstruction,the
physicianisrequiredtonotifytheSuperintendentofMotorVehicles(Motor Vehicle Act section 230,
subsections 1-3).
d. Notwithstandingtheseminimumrequirements,physiciansmayopttonotifytheSuperintendentof
MotorVehiclesofanypatientwithaconditionincompatiblewithsafedriving.
e. When approached by friends or family members of individuals who may be driving unsafely due to
a medical condition, but who do not attend a physician, those members of the public can be told
tonotifytheSuperintendentofMotorVehiclesoftheirconcerns.
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8
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Diagnostic
Code: 290
recommendation 6 Self-Neglect, Neglect and Abuse
a. Physicians need to be aware of the potential risks for self-neglect, neglect and abuse by caregivers

e. Wandering
• Thepatientshouldalwayscarryidenticationwhenoutalone
 • ConsideranIDbraceletthroughtheSafely Home
®
– Alzheimer Wandering Registry
Web site: www.alzheimer.ca/english/safelyhome/about.htm

f.
Socialization
• Patientswithdementialivingaloneinthecommunitymaybecomesociallywithdrawn   
• Considerreferraltoanadultdaycentre(contactHomeandCommunityCare)
g. Legal issues
• Asearlyaspossibleinthecourseofdementia,engagethepatientinadiscussionofadvance 
planning issues
 • Encouragethepatienttohaveanup-to-datewill,anancialrepresentative,ahealthcare  
 proxyandsomeformofadvancemedicaldirective
 • ARepresentationAgreementpermitsthepatienttoappointbothanancialrepresentativeand
  ahealthrepresentative(guideavailableatwww.trustee.bc.ca).APowerofAttorney(withan
  eduringclause)istherecommendedlegaldocumenttoappointanancialrepresentative
h. Other safety issues
 • Considerothersafetyhazards,suchasunsafesmoking,rearmsinthehome,etc.
 • Lifelineor911stickersonthetelephone
9
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Diagnostic
Code: 290
recommendation 8 Co-Morbid Conditions
Address co-morbid conditions to prevent further unnecessary impairment of cognition in demented
individuals. The underlying dementia has implications for management of other conditions, particularly

),galantamine(Reminyl
®
)andrivastigmine(Exelon
®
).Theyare
currentlyapprovedbyHealthCanadaforthesymptomatictreatmentofmildtomoderatedementiaof
theAlzheimer’stype(AD).ThereisinsufcientevidencetorecommendthemforMCI.
5
• EarlierstudieshavedemonstratedsmalltomodestefcacyofAChEIsincognitiveandglobal
outcome measures, while recent studies have included maintenance of activities of daily living and
reductionofcaregiverburdenasoutcomes.Inameta-analysisofstudieswithglobaloutcomes
(subjectiveassessmentbyclinicianand/orcaregiverofchangeoverall),thenumberneededtotreat
(NNT)is12(3-6months)foroneadditionalpatienttoexperiencestabilizationorimprovementon
global response.
8
Intheliterature,thereislittledenitiveevidencefordurationofefcacybeyond
two years.
• WhilesomeevidencesuggestsaroleforAChEIsinthetreatmentofsymptomsassociated
withsevereADandinothertypesdementias(VaDandDLB),
9,10
the clinical meaningfulness of
randomizedcontrolledtrialoutcomemeasuresiscontroversialanddonepezilistheonlyAChEI
currentlyapprovedbyHealthCanadafortheseindications.
• 8%morepatientsexperienceadverseeventsonAChEIscomparedtoplacebo(numberneededto
harm[NNH]=12)
10
10
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Cognitive impairment in the elderly – reCognition, diagnosis and management

• Caregiversmaybeaskedtokeepawrittenrecordofpersonalimpressions,commentonadverse
drug reactions, sleep disturbances etc., to support assessment
• Afterinitiationofthemedication,theinitialvisitschedulewillbedeterminedbythetitration
schedule(i.e.every2-6weeksuntildosereached)
• Areviewforsideeffectsshouldbecarriedoutwithintherst3months,usuallyatthetitration
visit(s)
• Every6months, monitor for changes from baseline in stabilization or deterioration of cognition,
function, behaviour and global assesment of change
• Usepatient-specicinformationtoinformreassessment of continued drug therapy
• Currentliteratureiscontroversialwithrespecttoadverseeffectsfromdiscontinuingtreatment
Effective October 22, 2007, PharmaCare,
through the Alzheimer's Drug Therapy
Initiative,willprovidecoverageof
donepezil, rivastigmine and galantamine
for eligible individuals diagnosed with
mild to moderate Alzheimer's disease,
including patients with Alzheimer's
disease with a vascular component or
Parkinsonianfeatures.Fordetailsonthis
initiative please visit: lth.
gov.bc.ca/pharme/adti
11
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Diagnostic
Code: 290
Table 3. Starting dose and titration schedule of AChEIs
Drug*
Starting Titration Dose Increase Usual Effective
Dose Period Per Titration Max Dose

revised January 30, 2008
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Diagnostic
Code: 290
Memantine(Ebixa
®
):HealthCanadahasgrantedmemantineaNotice of Compliance with Conditions
as monotherapy or as adjunctive therapy with cholinesterase inhibitors for the symptomatic treatment
of patients with moderate to severe Alzheimer’s Disease. The product monograph advises against
the use of memantine in patients with renal disease, cardiovascular disease and seizure disorders.
Adverseeffectsofmemantinemayinclude:fatigue,pain,dizziness,constipation,anxietyand
hallucinations.
Table 4. Starting dose and titration schedule of memantine
Drug
Starting Titration Dose Increase Usual Effective
Dose Period Per Titration Max Dose
memantine 5 mg 4 wks 5 mg 10 mg b.i.d.
Potential Drug Interactions
MajordruginteractionsassociatedwithmemantineincludedrugswhichincreasethepHinurine(e.g.
carbonicanhydraseinhibitors).Exercisecautionwhenprescribingmemantinewithotherdrugswhich
undergo renal tubular secretion. Dofetilide is considered a very severe risk, due to the potential for
causing arrhythmias. The effects of dopamine agents will be increased when co-administrated with
memantine.
OtherAgents:UseofGinkgoBiloba,VitaminE,anti-inammatorydrugs(suchasNSAIDs),estrogen
and statins is not recommended. There is insufficient evidence of treatment efficacy and/or concerns
have been raised about possible increased risk of negative health impacts.
recommendation 10 Behavioural and Psychological Symptoms of Dementia (BPSD)
a. Symptoms
 • Psychosis(hallucinationsordelusions)

 • Treatsleepdisorderswhennecessarywithtrazodone25-75mgatthehourofsleep
  (*Benzodiazepinesarenotrecommendedduetotheirhighpotentialforadverseeventssuchas
 confusionandfalls)
 • Treatpsychosis(hallucinationordelusions)withantipsychoticmedicationsonlywhenthe 
patient is particularly disturbed by these symptoms
 • Treataggressionoragitationwith:
- Cholinesterase inhibitors, or
- Trazodone 25-50 mg does up to 200 mg a day, or
  - Antipsychotics:typical(Loxapine)oratypical(risperidone,olanzapineorquetiapine)only 
  afterenvironmentalandpsychosocialinterventionshavebeenconsidered,exceptinurgent
situations
Exercise caution when prescribing antipsychotic medications.
All antipsychotics have side effects and a risk-benefit assessment
needs to be carefully adjudicated in each case.

Antipsychotic medications are only recommended when:
 • Alternatetherapiesareinadequateontheirown
 • Thereisanidentiableriskofharmtothepatientandothers
 • Symptomsaresevereenoughtocausesufferinganddistress
When using antipsychotics, initiate a careful trial of a low dose antipsychotic and slow upward
titration(e.g.risperidone0.125mginveryfrailpatientswithslowupwardtitrationto1.5–2mg
maximumaday).InpatientswithDLBandPDD,considersensitivitytomedication(e.g.increased
riskofextrapyramidialsideeffectswhenusingantipsychotics).Monitortheeffectsclosely
andreviewtodeterminewhetheramaintenancedosemaybeneeded(itmaybepossibleto
discontinuemaintenancedoseovertime).
 • Atypicalantipsychoticsinclude:risperidone,quetiapineandolanzapine.Risperidonehasbeen
 favouredasthemostefcaciousforagitationindementia,butwithmodestoutcomes.Itisthe
only atypical antipsychotic approved for the short-term treatment of aggression or psychosis in
patients with severe dementia.
 • Atypicalantipsychoticshavebeenassociatedwithsevereadverseeventssuchasincreased 

 • Treatmentofrecurrentinfections
 • Provisionforincreasedservicesathome
 • Indicationsfortransfertohospitalortoahigherlevelofcare
recommendation 12 Caregiver Support
Caregivers need to be well supported. Determine your capability to provide ongoing, regular support,
and/orreferouttootheragencies(SeeRecommendation13forworkingwithcommunityandhealth
careservices).
 • Askaboutthecaregiver’sneeds,copingstrategies,supportsystemandburden
 • Educatepatientsandcaregiversaboutthediseaseandhowtocope,includingadvancecare 
  planning(considerculturalcontextforunderstandingandacceptanceofdementia;seePatient
  &CaregiverGuide)
 • Coordination,communicationandplanningduringtransitionbetweencareenvironments
 • Respiteforcaregiversincludingadultdaycentrereferralforpatientetc.
recommendation 13 Community Care, Mental Health and Specialty Services Resources

a. TimelyreferraltotheAlzheimerSocietyofBC(ASBC).TheASBCassistspeoplewithalltypesof
dementia and their caregiver’s particularly:
 • Peoplewithearlystagedementia
 • Caregiversforpeoplewithdementiaatanystage
Note: Disclosure of the diagnosis or suspected diagnosis of dementia should occur before
referral to ASBC
b. Asktheopinionofadementiaspecialist(geriatrician,neurologist,psychiatrist)whendiagnosisor
management is problematic
c. RefertoHomeandCommunityCareservicesineachoftheHealthAuthoritiesforlong-termcase
management, home support, home safety assessment, respite care, adult day care or transitions
to alternate living situations
d. RefertoCommunityMentalHealthServicesforsignicantandcomplexmentalhealthconditions
affecting the health and care of the patient and caregiver
Rationale
Alzheimer’sdisease(AD)andrelateddementiasareprogressive,irreversibledegenerativebrain

impairment, increased allocation of resources for long term care facilities, caregiver support and home
care, increased physician training and education in AD and related dementias.
List of Abbreviations
AChEI AcetylcholinesteraseInhibitor
AD Alzheimer's disease
ASBC AlzheimerSocietyofBritishColumbia
BPSD BehaviouralandPsychologicalSymptomsofDementia
CAM ConfusionAssessmentMethod
CDM chronicdiseasemanagement
CDT Clock Drawing Test
CHF congestiveheartfailure
CT (CAT)computerizedaxialtomography
DLB DementiawithLewyBodies
DSMIV-TR DiagnosticandStatisticalManualofMentalDisorders,FourthEd.,TextRevision
GDS GeriatricDepressionScale(Yesavageetal.)
GDS GlobalDeteriorationScale(Reisbergetal.)
MCI mildcognitiveimpairment
MDD majordepressivedisorder
MoCA MontrealCognitiveAssessment
MRI magneticresonanceimaging
NNH numberneededtoharm
NNT numberneededtotreat
NPH normalpressurehydrocephalus
NSAID non-steroidalanti-inammatorydrug
OTC over-the-counter
PDD Parkinson’s Disease Dementia
SMMSE StandardizedMiniMentalStateExam
SR slowrelease
SSRI SelectiveSerotoninReuptakeInhibitor
TBI traumaticbraininjury

potential self neglect, neglect and abuse: www.communityliving.bc.ca
Alzheimer Society of BC assists people with all types of dementia and their caregivers
1-800-667-3742orgoto:www.alzheimerbc.org/
Alzheimer's Drug Therapy Initiative
Allquestions,clinicalandadministrative,canbedirectedtoHealthInsuranceBCat1800663-7100or
go to: www.health.gov.bc.ca/pharme/adti
References
1. WrightCB,LeeHS,PaikMC,etal.Totalhomocysteineandcognitioninatri-ethniccohort:the
NorthernManhattanStudy.Neurology2004;63:254-60.
2. GarciaA,ZanibbiK.Homocysteineandcognitivefunctioninelderlypeople.Canadian
 MedicalAssociationJournal2004;171:897-904.
3. MaloufR,AreosaSastreA.VitaminB12forcognition.CochraneDatabaseofSystematic
 Reviews2003;(3):CD004326.
4. PattersonC,GauthierS,BergmanH,etal.Therecognition,assessmentandmanagement
of dementing disorders: Conclusions from the Canadian consensus conference on dementia
CanadianJournalofNeurologicalScience2001;28(Suppl1):S3-S16.
5. ThirdCanadianConsensusConferenceonDiagnosisandTreatmentofDementia,Montreal,
March9-11,2006.Ofcialconferencepublicationforthcoming.
6. NasredddineZ,PhillipsN,BedirianV,etal.TheMontrealCognitiveAssessment,MoCA:A
briefscreeningtoolformildcognitiveimpairment.JournaloftheAmericanGeriatricsSociety
2005;53:695-699.
7. PetersonRC,ThomasRG,GrundmanM,etal.fortheAlzheimer’sDiseaseCooperative
 StudyGroup.VitaminEanddonepezilforthetreatmentofmildcognitiveimpairment.New
 EnglandJournalofMedicine2005:352:2379-2388.
8. LanctôtK,HerrmannN,YauKK,etal.Efcacyandsafetyofcholinesteraseinhibitorsin
Alzheimer’sdisease:ameta-analysis.CanadianMedicalAssociationJournal2003;169(6):557-64.
9. FeldmanH,GauthierS,HeckerJ,etal.andtheDonepezilMSADStudyInvestigatorsGroup.
A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer’s
disease.Neurology2001;57:613-620.
17

BritishColumbiaMedicalAssociationandadoptedbytheMedicalServicesCommission.
Contact Information
Guidelines and Protocols Advisory Committee
POBox9642STNPROVGOVT
VictoriaBCV8W9P1
Phone: 250952-1347 E-mail:
Fax:  250952-1417 Website: www.BCGuidelines.ca
Appendices
AppendixA TheConfusionAssessmentMethod(CAM)DiagnosticAlgorithm
AppendixB GeriatricDepressionScale(GDS)
AppendixC StandardizedMini-MentalStateExam(SMMSE)
AppendixD ClockDrawingTest
AppendixE MontrealCognitiveAssessment(MoCA)
AppendixF GlobalDeteriorationScale
AppendixG CognitiveImpairmentintheElderlyFlowSheet(Optional)
The principles of the Guidelines and Protocols Advisory Committee are to:
• encourageappropriateresponsestocommonmedicalsituations
• recommendactionsthataresufcientandefcient,neitherexcessivenordecient
• permitexceptionswhenjustiedbyclinicalcircumstances.
18
18
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Diagnostic
Code: 290
Associated Documents

The following documents accompany this guideline:

revised January 30, 2008
GERIATRIC DEPRESSION SCALE (GDS)*
Directions to Patient: Please choose the best answer for how you have felt over the past week
DirectionstotheExaminer: Readthequestionstothepatientandrecordtheirresponses.
        Ifappropriate,allowtheclienttocompletetheformonhis/herown.

1. Areyoubasicallysatisedwithyourlife? ❏ Yes ❏ No
2 Haveyoudroppedmanyofyouractivitiesandinterests? ❏ Yes ❏ No
3 Doyoufeelthatyourlifeisempty? ❏ Yes ❏ No
4 Doyouoftengetbored? ❏ Yes ❏ No
5 Areyouingoodspiritsmostofthetime? ❏ Yes ❏ No
6 Areyouafraidthatsomethingbadisgoingtohappentoyou? ❏ Yes ❏ No
7 Doyoufeelhappymostofthetime? ❏ Yes ❏ No
8 Doyouoftenfeelhelpless? ❏ Yes ❏ No
9 Doyouprefertostayathome,ratherthangoingoutanddoingnewthings? ❏ Yes ❏ No
10 Doyoufeelyouhavemoreproblemswithmemorythanmost? ❏ Yes ❏ No
11 Doyouthinkitiswonderfultobealivenow? ❏ Yes ❏ No
12 Doyoufeelprettyworthlessthewayyouarenow? ❏ Yes ❏ No
13 Doyoufeelfullofenergy? ❏ Yes ❏ No
14 Doyoufeelthatyoursituationishopeless? ❏ Yes ❏ No
15 Doyouthinkthatmostpeoplearebetteroffthanyouare? ❏ Yes ❏ NoAscoregreaterthan5issuggestiveofdepression,however,fullscoringinformationfortheGDSis
availableat: />Yesavage:TheuseofRatingDepressionSeriesintheElderly,inPoon(ed.):Clinical Memory
Assessment of Older Adults,AmericanPsychologicalAssociation,1986.
SheikhJI,YesavageJA:GeriatricDepressionScale(GDS):Recentevidenceanddevelopmentof
a shorter version. Clinical Gerontology: A Guide to Assessment and Intervention 165-173,NY:The
HaworthPress,1986.
ThefollowingWebsiteallowsyoutodownloadtheGDSinEnglishorotherlanguages.

andPage4,ablankpieceofpaper.
6. Ifthepersonanswers:Whatdidyousay?,donotexplain
orengageinconversation.Merelyrepeatthesame
directionsamaximumofthreetimes.
7. Ifthepersoninterrupts(e.g.Whatisthisfor?),reply:I will
explain in a few minutes, when we are finished. Now if
we could proceed please… we are almost finished.
1. Time: 10 seconds for each reply:
a) What year is this?(acceptexactansweronly).
b) What season is this?(accepteither:lastweekoftheoldseasonorrstweekofanewseason).
c) What month is this?(accepteither:therstdayofanewmonthorthelastdayofthepreviousmonth).
d) What is today’s date?(acceptpreviousornextdate).
e) What day of the week is this?(acceptexactansweronly).
2. Time: 10 seconds for each reply:
a) What country are we in?(acceptexactansweronly).
b) What province are we in?(acceptexactansweronly).
c) What city/town are we in?(acceptexactansweronly).
d) (Inhome)What is the street address of this house?(acceptstreetnameandhousenumberorequivalent
 inruralareas).
 (Infacility)What is the name of this building?(acceptexactnameofinstitutiononly).
e) (Inhome)What room are we in?(acceptexactansweronly).
 (Infacility)What floor of the building are we on?(acceptexactansweronly).
3. Time: 20 seconds
Say: I am going to name three objects. When I am finished, I want you to repeat them. Remember what they
are because I am going to ask you to name them again in a few minutes.
(Saythefollowingwordsslowlyat
approximatelyone-secondintervals):Ball / Car / Man.

 Forrepeateduse:Bell,jar,fan;Bill,tar,can;Bull,bar,pan.
Please repeat the three items for me.(scoreonepointforeachcorrectreplyontherstattempt.)

8. Time: 10 seconds
Say: I would like you to repeat a phrase after me: No ifs, ands or buts.
 Scoreonepointforacorrectrepetition.Mustbeexact,e.g.noifsorbuts,score0).
9. Time: 10 seconds
Say: Read the words on this page and then do what it says.Then,handthepersonthesheetwithCLOSEYOUR
EYESonit.Ifthesubjectjustreadsanddoesnotcloseeyes,youmayrepeat:Read the words on this page and
then do what it says
(amaximumofthreetimes).Scoreonepointonlyifthesubjectcloseseyes.Thesubject
doesnothavetoreadaloud.
10. Time: 30 seconds
Handthepersonapencilandpaper(Page3).Say: Write any complete sentence on that piece of paper.
 Scoreonepoint.Thesentencemustmakesense.Ignorespellingerrors.
11. Time: 1 minute maximum
Placedesign,eraserandpencilinfrontoftheperson.Say: Copy this design please.Allowmultipletries.Wait
untilthepersonisnishedandhandsitback.Scoreonepointforacorrectlycopieddiagram.Thepersonmust
havedrawnafour-sidedgurebetweentwove-sidedgures.
12. Time: 30 seconds
Ask thepersonifheisrightorlefthanded.Takeapieceofpaper,holditupinfrontofthepersonand
say: Take this paper in your right/left hand(whicheverisnon-dominant),fold the paper in half once with both
hands and put the paper down on the floor.
Scoreonepointforeachinstructionexecutedcorrectly.

Takespaperincorrecthand
Foldsitinhalf
Putsitontheoor
Total Test Score:
Adjusted Score
/5
/3
/1

=Score3
=Score3
ScoringWORLDbackwards(instructionsforitem#4)
Write the person’s response below the correct response.
Draw lines matching the same letters in the correct response and the response given.
TheselinesMUSTNOTcrosseachother.Drawonlyonelineperletter.
Theperson’sscoreisthemaximumnumberoflinesthatcanbedrawnwithoutcrossingany.
Examples:
=Score0
Foldalongthislineandshowinstructionstoperson
Foldline
Item11
Item9
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
Sentence Writing
Item10
Cognitive impairment in the elderly – reCognition, diagnosis and management
revised January 30, 2008
AppendixC
Standardized Mini Mental State Examination (SMMSE) Cont’d
Table 1. Stages of Cognitive Impairment as Defined by SMMSE Scores
SCORE DESCRIPTION STAGE DURATION (Years)
30-26 Couldbenormal Couldbenormal Varies
25-20 Mild  Early 0to23
19-10 Moderate Middle 4-7
9-0 Severe
 Late 7-14
Table 2. Areas of Functional Impairment
SMMSE SCORE ACTIVITIES OF DAILY LIVING COMMUNICATION MEMORY