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Table 1

Dementia: theoretical and pragmatic underpinnings of algorithm recommendations

Algorithm ComponentsCommentsReferences
Clinical signs of possible dementiaAge 85 and older: The disease is highly prevalent (∼50%) in this age group but often overlooked by primary care providers, even in its later stages. Experts recommend a very low threshold to screen for dementia even if symptoms of decline (any change in performance of familiar tasks, activity, memory, hygiene, accuracy in bill paying, driving, or taking medications, or symptoms of anxiety, judgment, apathy, depression) are subtle.[5,23,24]
Disconnect between reported pain and pain behaviors: Some data point to exaggerated pain behaviors and attention to pain in those with dementia.[8–10,46]

Dementia screening toolsMini-Cog: 2 items, 3 minutes; max score = 5; score of ≤ 3 = positive screen; assesses short-term verbal recall and visuospatial skills (includes clock drawing). Developed for and validated in primary care with minimal education or ethnicity bias. Very short administration time. One limitation is that the Mini-Cog is a less sensitive test for mild-to-moderate impairment.[12,13,47–49]
  1. Mini-Cog website: www.mini-cog.com

  2. MoCA website: www.mocatest.org

  3. SLUMS website: http://aging.slu.edu/index.php?page=saint-louis-university-mental-status-slums-exam

MoCA (Montreal Cognitive Assessment): 12 items, 10 minutes (longer for severe impairment); max score = 30; score of < 26 = positive screen. Visuospatial/executive functioning (includes clock drawing); naming; attention; repetition; verbal fluency; abstraction; short-term verbal recall; orientation. Developed and validated for mild cognitive impairment and tests many domains. Educational and ethnicity bias exists.
SLUMS (Saint Louis University Mental Status Examination): 11 items, 5–7 minutes; max score = 30; score of < 27 with high school education = positive screen. Orientation; calculation; verbal fluency; short-term verbal recall; attention; visuospatial (includes clock drawing). Assesses multiple cognitive domains and no apparent educational bias. Primarily studied in VA populations.
AD8 (Eight-item Interview to Differentiate Aging and Dementia): 8 items, ∼3 minutes; score of > 1 = positive screen. Assesses intra-individual change across a variety of cognitive domains. Developed as an informant interview; also can be administered to patient. Sensitivity > 84%; specificity > 80%. Can be completed in person or over the telephone.

Verbal pain reporting in those with dementiaEvidence indicates that many patients with dementia can reliably report pain, that is, that their pain reporting is consistent over time.[18]

Need to identify suffering before treating painChronic pain does not disappear; thus reporting the presence of pain is expected in all patients with chronic pain, regardless of cognitive function.[14,44,50]
Pain reporting should not automatically be equated with pain-related suffering.

Use of PAINAD in those unable to report painThis scale requires 5 minutes of observation during activity before scoring.[38]