Alzheimer's disease and other dementia are progressive, degenerative diseases. Individuals or their family members may consult a family physician when they begin to notice symptoms such as loss of memory, judgment and reasoning, difficulty with day-to-day tasks and changes in communication abilities, mood and behaviour.
Cognitive impairment and dementia are present in about 20 per cent of the elderly population and are consistently rated among the top three concerns of older adults.1 Early detection of dementia provides an opportunity for the individual to adjust to the diagnosis and to participate actively in planning for the future.
Early diagnosis is important. Symptoms of irreversible dementia can be similar to those of other conditions such as depression, thyroid or heart disease, infections, drug interactions or alcohol abuse.
Finding out the cause of the symptoms can help people understand the source of the symptoms, get the proper care, treatment and support and plan for the future.
Global Deterioration Scale
Some healthcare providers use the Global Deterioration Scale, also called the Reisberg Scale, to measure the progression of Alzheimer's disease. This scale divides Alzheimer's disease into seven stages of ability.
Stage 1: No cognitive decline
- Experiences no problems in daily living.
Stage 2: Very mild cognitive decline
- Forgets names and locations of objects.
- May have trouble finding words.
Stage 3: Mild cognitive decline
- Has difficulty travelling to new locations.
- Has difficulty handling problems at work.
Stage 4: Moderate cognitive decline
- Has difficulty with complex tasks (finances, shopping, planning dinner for guests).
Stage 5: Moderately severe cognitive decline
- Needs help to choose clothing.
- Needs prompting to bathe.
Stage 6: Severe cognitive decline
- Loss of awareness of recent events and experiences.
- Requires assistance bathing; may have a fear of bathing.
- Has decreased ability to use the toilet or is incontinent.
Stage 7: Very severe cognitive decline
- Vocabulary becomes limited, eventually declining to single words.
- Loses ability to walk and sit.
- Requires help with eating.
Reisberg, B., Ferris, S. H., de Leon, M. J., and Crook, T. (1982). Modified from Global Deterioration Scale. American Journal of Psychiatry, 139:1136–1139.
- Instruments to detect cognitive impairment in older adults
- The Assessment and Treatment of Delirium 2014 guideline update from the Canadian Coalition for Seniors' Mental Health
- Burns A, Bagshaw P, A new dementia currency in primary care. NHS England, March 2016.
- Cognitive screening of older patients. By Frank Molnar and Chris Frank. Source: Canadian Family Physician.
- Screening tools for virtual assessment of cognition. By Chris Frank, Philip St John and Frank Molnar. Source: Canadian Family Physician.
Watch the video I’m a doctor - is there a good way to check out a memory complaint? A five-step brain health check for doctors.
The material was created by TCD, through the NEIL Programme at the Institute of Neuroscience with support from GENIO.
© 2014 The Provost, Fellows, Foundations Scholars, and the Other Members of Board, of the College of the Holy and Undivided Trinity Of Queen Elizabeth, near Dublin. Permission to use this material was granted by TCD which reserves all rights in the material.
Cognitive screening tests
|Cut-off score/Total score|
|Mini-mental state examination||Folstein et al.,
|Hopkins verbal learning test – total recall||Frank and Byrne,
|Memory impairment screen||Buschke et al.,
|Clock drawing test||Royall et al.,
|1-3||Scoring methods varied|
|Cambridge cognitive examination||Lolk et al.,
|Modified mini-mental state examination||McDowell et al.,
|Community screening interview for dementia||Hall et al.,
|Montreal cognitive assessment||Nasreddine et al.,
|Behavioural neurology assessment
|Darvesh et al.,
|Behavioural neurology assessment
|Darvesh et al.,
Cognitive loss and hearing loss
Did you know…
- There is a clinically significant association between hearing loss and cognitive decline. Individuals with hearing loss demonstrate an accelerated rate of cognitive decline and an increased risk for cognitive impairment3.
- The potential mechanisms behind this relationship between hearing loss and cognitive loss, in particular the increased risk for incident dementia4, remain to be determined. Possible rationales for this association may include increased social isolation, changes to the brain, and/or a common process that is influencing both hearing and cognitive functioning in older individuals.
Below you will find some issues that may be common in your practice, some implications for assessment, and some suggestions for solutions you can implement to ensure that you are providing your patients with the best care possible.
Implications for Cognitive
|As individuals age, they may experience changes in their auditory processing and/or cognitive abilities.||
People with hearing loss may be hesitant to seek help.
|Cognitive testing (e.g. the MMSE, the MoCA) often relies heavily on an individual’s ability to hear and respond to questions and instructions given5.||
|Behavioural symptoms (e.g. repetition, agitation) that are commonly attributed to the individual’s cognitive loss, may be related to and/or exacerbated by hearing loss.||
5th Canadian Consensus Conference on Diagnosis and Treatment of Dementia
The 5th CCCDTD convened in October 2019 in Quebec City to address topics chosen by the steering committee to reflect advances in the dementia field and build on previous guidelines.
- the National Institute on Aging research framework for Alzheimer's disease diagnosis;
- updating diagnostic criteria for vascular cognitive impairment, and its management;
- dementia case finding and detection;
- neuroimaging and fluid biomarkers in diagnosis;
- use of non-cognitive markers for better dementia detection;
- risk reduction/prevention;
- psychosocial and non-pharmacological interventions; and
- deprescription of medications.
Alzheimer Society brochures for further reading
Some of the following brochures are written for clinicians and others are intended for individuals and their families, or both.
- The importance of early diagnosis | Print-friendly version
- Principles for a dignified diagnosis
- Questions for family physicians and health professionals to ask when cognitive impairment is suspected
Individuals and family members:
- Feldman H, et al., Diagnosis and treatment of dementia. Canadian Medical Association Journal, 178 (March 2008), 825- 36.
- "Assessing patients complaining of memory impairment",Geriatrics & Aging (April 08, volume 11, number 3), Dr. M. Masellis and Dr. S. E. Black.
- Gurgel RK et al. “Relationship of hearing loss and dementia: A prospective, population-based study”, Otology & Neurotology, 2014.
- Lin FR et al. “Hearing loss and incident dementia”, Archives of Neurology, 2011, 68(2), 214-220.
- Schneider BA et al. “Effects of senescent changes in audition and cognition on spoken language comprehension”, The Aging Auditory System, Springer Handbook of Auditory Research, 2010, Vol. 34, 167-210. Schneider BA et al. “Effects of senescent changes in audition and cognition on spoken language comprehension”, 2010, Vol. 34, 167-210.
- Davis A et al. “Acceptability, benefit and costs of early screening for hearing disability: A study of potential screening tests and models”, Health Technology Assessment Journal, 2007, 11(42):1-294.
- Pichora-Fuller MK et al. “Helping older people with cognitive decline communicate: Hearing aids as part of a broader rehabilitation approach”, Seminars in Hearing, 2013, 34(04): 308-330.
- Lewis‐Cullinan C, Janken JK, “Effect of cerumen removal on the hearing ability of geriatric patients”, Journal of advanced nursing, 1990, 15 (5), 594-600.
- Moore A et al. “Cerumen, hearing, and cognition in the elderly”, Journal of the American Medical Directors Association, 2002, 3 (3), 136-139.
More useful links and resources
Joining up: Why people with hearing loss or deafness would benefit from an integrated response to long-term conditions, a report from Action on Hearing Loss and the Deafness Cognition and Language (DCAL) Research Centre, 2013.
The importance of considering hearing needs in individuals with cognitive impairment, ASC CDRAKE webinar, presented by Kate Dupuis, Clinical Neuropsychologist, and Debbie Ostroff, Registered Audiologist (May 14, 2014). You can also read the transcript.
Exploring the connections between hearing loss and cognitive health, a brainXchange webinar presented by Dr. Kate Dupuis, hosted by brainXchange in partnership with the Alzheimer Society of Canada and the Canadian Consortium on Neurodegeneration in Aging (CCNA).