James R. Kilgore, DMSc, PhD, PA-C: Cognitive Decline Diagnostics

The emphasis to curb the prevalence and burden of Alzheimer disease—predicted to affect approximately 6 million Americans and counting among the aging population¹—begins at the earliest presentations of cognitive decline. As such, it’s key that primary care clinicians are well-equipped to adequately and expeditiously monitor signs of worsening cognition.

In an interview with HCPLive during the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, James R. Kilgore, DMSc, PhD, PA-C, associate professor of PA Medicine at the University of Lynchburg, discussed the critical point of identifying cognitive decline in patients at risk of progressing to dementia and Alzheimer disease. As he noted, the average person may imagine an elderly patient who lacks faculties to self-care or perform general life activities when they hear “cognitive decline.”

“And that's not really where the important intervention is,” Kilgore said. “A lot of people in their 50s and 60s can have mild cognitive decline. We all know that people will get mild cognitive decline as they age, like, 'I don't know where my keys are, I can't remember where I parked my car.' But the realities are, if you don't identify those people early and get them on appropriate treatment and lifestyle changes, then their disease can progress.”

Kilgore stressed that frontline caregivers implement an entry-level screening during a wellness visit for patients in this age range—baseline tests to assess a person’s capacity to remember habitual information and adequately perform routine tasks. If such a screening indicates cognitive difficulties, there’s a clear opportunity to schedule more screening and potential refer to a neurologist.

“But there are a lot of things that we can do today. And some of it is lifestyle changes,” Kilgore said. “So, those need to be done in the 50s and 60s, not in the late 70s and 80s, because most of our drugs today are really just maintaining you where you are. We want to intervene as early as we can.”

Regarding screening tools, Kilgore advocated for the Ascertain Dementia 8 questionnaire (AD8),² a brief 8-item test that gauges patients on seemingly “superficial” but common indicators of forgetfulness, such as an inability to remember how to program a television remote control, Kilgore said—details that which a patient with early cognitive decline may first present with. He additionally mentioned the Montreal Cognitive Assessment (MoCA) as a beneficial front-line assessment tool.³

“These are really for the primary care provider to do early, preferably in a wellness visit once a year, or when the patients come in,” Kilgore said. “Even if they don't have any medical problems, we'll give them an AD8 to screen.”

Kilgore did note that patients who score particularly low on the AD8 may necessitate more testing or follow-up before being referred for cognitive decline consultation; he often finds anxiety and/or depression may be exacerbating test scores in middle-age patients. Once contributing factors are accounted for, clinicians can value AD8 and MoCA scoring as a baseline for their patient’s cognition.

“And we do not compare these to any standards—it's compared to the patient,” Kilgore said. “So, how you are today versus how you are 5 years down the road. You're compared to where you are, not to any standard in the country or in any expectation of where you should score on those tests.”

References

1. ^{2023 Alzheimer's disease facts and figures. Alzheimers Dement. 2023;19(4):1598-1695. doi:10.1002/alz.13016}
2. ^{Chen HH, Sun FJ, Yeh TL, et al. The diagnostic accuracy of the Ascertain Dementia 8 questionnaire for detecting cognitive impairment in primary care in the community, clinics and hospitals: a systematic review and meta-analysis. Fam Pract. 2018;35(3):239-246. doi:10.1093/fampra/cmx098}
3. ^{Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment [published correction appears in J Am Geriatr Soc. 2019 Sep;67(9):1991]. J Am Geriatr Soc. 2005;53(4):695-699. doi:10.1111/j.1532-5415.2005.53221.x}