Evidence-based Synthesis Program 

A Systematic Evidence Review 

of the Signs and Symptoms

of Dementia and Brief Cognitive

Tests Available in VA

Department of Veterans Affairs

Health Services Research & Development Service

April 2010

Investigators:

Principal Investigator:

Devan Kansagara, MD

Research Associate:

Michele Freeman, MPH

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

VA Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, MD, Director
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A Systematic Evidence Review of the Signs and Symptoms 

of Dementia and Brief Cognitive Tests Available in VA Evidence-based Synthesis Program

PREFACE

HSR&D’s Evidence-based Synthesis Program (ESP) was established to provide timely and 

accurate syntheses of targeted healthcare topics of particular importance to VA managers 

and policymakers, as they work to improve the health and healthcare of Veterans. The ESP 

disseminates these reports throughout VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• the implementation of effective services to improve patient outcomes and 

to support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, an ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and VISN Clinical Management 

Officers. The Steering Committee provides program oversight and guides strategic planning, 

coordinates dissemination activities, and develops collaborations with VA leadership to identify 

new ESP topics of importance to Veterans and the VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Kansagara D and Freeman M. A Systematic Evidence Review of the 

Signs and Symptoms of Dementia and Brief Cognitive Tests Available in VA. VA-ESP Project 

#05-225; 2010.

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Portland VA Medical Center, Portland, OR 

funded by the Department of Veterans Affairs, Veterans Health Administration, 

Office of Research and Development, Health Services Research and Development. 

The findings and conclusions in this document are those of the author(s) who are 

responsible for its contents; the findings and conclusions do not necessarily represent 

the views of the Department of Veterans Affairs or the United States government. 

Therefore, no statement in this article should be construed as an official position of 

the Department of Veterans Affairs. No investigators have any affiliations or financial 

involvement (e.g., employment, consultancies, honoraria, stock ownership or options, 

expert testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report.
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A Systematic Evidence Review of the Signs and Symptoms 

of Dementia and Brief Cognitive Tests Available in VA Evidence-based Synthesis Program

EXECUTIVE SUMMARY

BACKGROUND

The Veterans Health Administration (VHA) Office of Geriatrics and Extended Care (OGEC) in 

Patient Care Services has primary responsibility for coordination and direction of VHA dementia 

initiatives. OGEC convened an interdisciplinary Dementia Steering Committee (DSC) in 

December 2006, with the goal of making recommendations on comprehensive, coordinated care 

for Veterans with dementia. 

The DSC requested VA HSR&D’s Evidence-based Synthesis Program (ESP) to review evidence 

on selected topics to assist with DSC planning efforts. 

Broad-based dementia screening programs have not been widely advocated given lack of 

evidence that earlier detection will improve health outcomes. Improving the accuracy of 

case-finding techniques depends both on an understanding of signs and symptoms that help 

distinguish patients with dementia from those without, and the reliability of brief assessment 

tests that can be incorporated into primary care practice when appropriate. The purpose of 

this report is to systematically review the evidence on identifying the signs and symptoms of 

dementia in undiagnosed patients, and evaluating several brief mental status measures currently 

being used in VHA. The key questions and scope of this review are the following: 

Key Question #1. What signs and symptoms should prompt VA providers to assess cognitive 

function as part of an initial diagnostic workup for dementia? 

Key Question #2. Which measures of cognitive function provide the optimal sensitivity, 

specificity, and time to completion among the measures available to VA providers? 

Key Question #3. What are adverse consequences of using these measures?

Population: Adults without prior diagnosis of dementia.

Measures to be compared: Blessed Orientation-Memory-Concentration (BOMC) Test, MiniCog, Montreal Cognitive Assessment (MoCA), General Practitioner Assessment of Cognition 

(GPCOG), St. Louis University Mental Status (SLUMS) Exam, and Short Test of Mental Status 

(STMS). 

Outcomes: Likelihood for patients to be appropriately diagnosed and treated for dementia; and 

adverse consequences of assessment, such as depression and anxiety.

Settings: Primary general medicine, mental health, geriatric clinics, specialty clinics, and 

extended-care settings.

The DSC served as the technical expert panel for guiding topic development and reviewing 

drafts of the report.

METHODS

We conducted searches in MEDLINE (PubMed), PsychINFO, CINAHL, HAPI, and AGELINE 

databases for literature published from database inception through July 2009. We obtained 

additional articles from systematic reviews, reference lists of pertinent studies, narrative 

reviews, editorials, and from experts in the field. Two reviewers trained in the critical analysis 
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A Systematic Evidence Review of the Signs and Symptoms 

of Dementia and Brief Cognitive Tests Available in VA Evidence-based Synthesis Program

of literature assessed for relevance the abstracts of citations identified from literatures searches. 

Full-text articles of potentially relevant abstracts were retrieved for further review. We assessed 

the quality of studies of diagnostic test accuracy using the Quality Assessment of Diagnostic 

Accuracy Studies (QUADAS) criteria. We compiled a qualitative synthesis of the evidence.

RESULTS

We reviewed 2,394 titles and abstracts from the electronic search, an additional 88 from 

reference mining, and 57 from an update search of a selected systematic review. We retrieved 

310 full-text articles for further review. Of these, we included 18 studies and 1 systematic review 

in synthesizing evidence for Key Question #1. For Key Question #2, we evaluated the results 

of 15 diagnostic accuracy studies of the 6 VA cognitive measures. To address Key Question #3, 

we included 3 cross-sectional studies on the acceptability of dementia screening and diagnostic 

workup. 

KEY QUESTION #1. What signs and symptoms should prompt VA providers to assess 

cognitive function as part of an initial diagnostic workup for dementia? 

Relatively few studies have rigorously evaluated signs and symptoms that may help distinguish 

people with mild to moderate dementia from non-demented individuals. Subjective memory 

complaints (SMC) and neuropsychiatric symptoms have been the best studied symptoms. 

Epidemiologic studies suggest that SMC – in most cases, elicited with single- or multi-item 

questionnaires rather than spontaneous – are common in community-living elderly adults. The 

ability, however, of SMC to discriminate effectively between healthy elderly adults and those 

with dementia is uncertain. We examined cross-sectional studies comparing rates of SMC 

between persons with dementia and healthy elderly controls. Patient-reported SMC did not 

reliably distinguish demented from non-demented individuals. In populations with low rates 

of dementia, the absence of SMC may have some utility in excluding a diagnosis of dementia. 

Informant-reported memory complaints may better distinguish demented from non-demented 

individuals. 

A limited body of evidence examined neuropsychiatric symptoms in demented and nondemented individuals. In general, the absence of neuropsychiatric symptoms would not 

effectively rule out a dementia diagnosis, but the presence of certain symptoms such as apathy, 

delusions, and/or hallucinations was associated with a dementia diagnosis and may suggest 

the need for further evaluation. Depression and anxiety were common in demented and nondemented individuals, suggesting the presence of either symptom would not be useful in reliably 

ruling in or ruling out a diagnosis of dementia. 

A very limited body of evidence evaluated sleep disturbance, gait disturbance, and physical exam 

findings in demented and non-demented individuals. In general, sleep disturbance is a commonly 

reported symptom in both demented and non-demented individuals, and does not discriminate 

well the two groups. Gait disturbances are probably useful in distinguishing different subtypes of 

dementia, but there is little evidence that gait disturbances can clearly distinguish demented from 

non-demented individuals. Several physical exam findings may be more common in persons with 

Alzheimer’s dementia (AD) than healthy controls. The only finding that was highly specific for 

AD, however, was impaired sense of touch for perceiving the form of an object (stereognosis), or 

the form of a letter or number written on the skin (graphesthesia).
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A Systematic Evidence Review of the Signs and Symptoms 

of Dementia and Brief Cognitive Tests Available in VA Evidence-based Synthesis Program

KEY QUESTION #2. Which measures of cognitive function provide the optimal sensitivity, 

specificity, and time to completion among the measures available to VA providers? 

All 6 measures available in VA test for recall ability, and 5 of the 6 measures assess executive 

function by means of a clock drawing test. The assessment of other cognitive domains, such as 

orientation, abstraction, math, and language skills, varies among the 6 measures. 

The Mini-Cog has the shortest administration time of all 6 tests and has been validated in a large 

sample of the general population. Sensitivity ranged from 76% to 99%, and specificity ranged 

from 83% to 93% in analyses that excluded patients with mild cognitive impairment (MCI). 

The SLUMS test was studied in a VA population and found to have high sensitivity (98-100%) 

and specificity (98-100%) with adjustment for education. The SLUMS takes longer to 

administer than other tests. It was developed more recently than the other tests and has not been 

widely studied.

The STMS has been studied in a primary care setting. The STMS had sensitivity ranging from 

86% to 95%, and specificity was highest (93.5%) when cut-off score was adjusted for age. The 

STMS was evaluated in 2 samples and has not been widely studied. 

The GPCOG has been evaluated in a primary care setting, and includes separate sections for 

patient and informant. The sensitivity of the components ranged from 82% to 98%, but the 

informant section by itself had low specificity (49-66%). The specificity of the combined score 

and 2-stage method ranged from 77% to 86%. 

The BOMC was evaluated in a bi-racial population sample, and found to misclassify more blacks 

than whites as impaired. Specificity ranged from 38% to 94%, and sensitivity ranged from 69% 

to 100%, although the inclusion of patients with previously diagnosed dementia might have 

inflated the sensitivity in 2 studies. 

The MoCA has the longest administration time among the 6 tests, and had low specificity in 2 of 

3 studies (35-50%). The MoCA has been evaluated in a memory clinic population but has not 

been studied in a general practice setting. 

KEY QUESTION #3. What are adverse consequences of using these measures?

We found no evidence on adverse effects of the 6 cognitive tests of interest to VA. Three crosssectional studies assessed the acceptability of dementia screening or diagnostic workup among 

older adults. The studies reported that high proportions of older adults were unwilling to be 

routinely tested for memory problems, or to undergo further diagnostic assessment for dementia 

after having positive results on cognitive screening tests. One survey determined that 80% of 

respondents wanted to know if they had dementia, but only 57% would agree to routine testing 

by a physician. Perceived harms included worry about losing insurance, and fear of losing 

drivers license. The high refusal rates of screening and diagnostic workup indicate the need 

for further research to understand the psychological burden associated with cognitive tests and 

assessment for dementia.