Research for podcast episode with Dr Linda Sommerlade, Head of Operations with GT Diagnostics
Current Approach in Primary Care for Patients with Memory Problems
When a patient visits a primary care clinic with memory complaints, the process typically follows a structured but limited approach due to time constraints, lack of specialist training, and resource availability. Here’s a step-by-step breakdown of what happens in most primary care settings:
Step 1: Patient History & Symptom Inquiry
History-taking is crucial. The physician asks the patient (and often a caregiver) about:
Onset and progression (When did you first notice memory problems? Are they worsening?)
Impact on daily life (Are you forgetting appointments, misplacing things, struggling with finances?)
Other cognitive issues (Difficulty finding words? Getting lost?)
Behavioral or mood changes (Anxiety, depression, apathy?)
Family history (Any relatives with dementia?)
Medication review (Certain drugs can cause confusion—benzodiazepines, anticholinergics, etc.)
Substance use (Alcohol, recreational drugs?)
✅ Challenge:
Patients often downplay symptoms, making early detection difficult.
Caregivers might misinterpret memory lapses as normal aging, delaying medical help.
Step 2: Cognitive Screening Tests
Cognitive Test are measured by Sensitivity (How accurately able to detect cognitive impairment) & Specificity (How accurately it is able to rule out other things)
If memory impairment is suspected, a brief cognitive test is done to assess cognitive domains (memory, language, attention, executive function).
Most common tests:
MMSE (Mini-Mental State Exam)30-point questionnaire that assesses orientation, registration, attention, recall, and language. (5–10 min)
MoCA (Montreal Cognitive Assessment)30-point test assessing multiple cognitive domains, including executive function, attention, memory, language, visuospatial skills. (10–15 min)
Mini-Cog (3-word recall + clock drawing) (3–5 min)
GPCOG (General Practitioner Assessment of Cognition) (includes informant report)
Comprehensive neuropsychological tests are used in specialist settings for more detailed assessment. (100-point test covering attention, memory, fluency, language, and visuospatial ability which takes 20-30 minutes)
✅ Challenge:
These tests aren’t very sensitive for early-stage dementia or mild cognitive impairment (MCI).
Time constraints: A busy GP might skip or rush the test.
Education and language barriers can affect scores, leading to false negatives.
Step 3: Basic Physical and Neurological Exam
The doctor checks for neurological signs that could indicate stroke, Parkinson’s, or other conditions:
Reflexes, eye movement, balance, gait (walking problems could signal neurodegeneration).
Signs of sensory impairment (vision, hearing loss, which can mimic cognitive decline).
✅ Challenge:
Many primary care doctors lack specialized neurology training, so subtle signs might be missed.
Step 4: Rule Out Other Causes (Blood Tests & Imaging)
Memory problems can stem from treatable conditions, so doctors check for:
Vitamin B12 deficiency
Thyroid dysfunction (TSH test)
Diabetes & metabolic issues
Liver/kidney problems
Infections (e.g., syphilis, HIV in high-risk patients)
If necessary, brain imaging (CT scan or MRI) is ordered to check for:
Stroke or vascular damage
Brain tumors or hydrocephalus
Atrophy suggestive of Alzheimer’s or frontotemporal dementia
✅ Challenge:
Not all clinics have access to imaging, especially in rural areas.
Costs and waiting times can delay diagnosis.
Dementia biomarkers (e.g., amyloid PET scans, cerebrospinal fluid tests) are rarely available in primary care.
Step 5: Referral to Specialist (If Needed)
If screening suggests significant cognitive decline, patients are referred to a neurologist, psychiatrist, or geriatrician for in-depth evaluation.
In some cases, patients may be referred to a memory clinic for neuropsychological testing.
✅ Challenge:
Long referral wait times (can be months in public healthcare systems).
Many regions lack specialist memory clinics, forcing GPs to manage dementia cases without specialist input.
Patients with mild symptoms may not meet referral criteria, delaying early intervention.
Step 6: Management and Follow-Up
If dementia is suspected but not severe, the primary care doctor may:
Monitor symptoms over time (follow-up every 6–12 months).
Discuss lifestyle modifications (exercise, diet, cognitive stimulation).
Start treatment if needed (e.g., cholinesterase inhibitors for Alzheimer’s).
Provide supportive care (caregiver resources, legal planning discussions).
✅ Challenge:
Most primary care doctors aren’t trained in dementia care, so guidance on non-drug interventions (social engagement, music therapy, cognitive stimulation) is often lacking.
Caregivers get minimal support, leading to burnout.
Key Challenges in Primary Care Dementia Detection
Time Constraints – Consults are often only 10–15 minutes, making detailed memory assessment difficult.
Limited Sensitivity of Screening Tools – MMSE/MoCA miss subtle early-stage cognitive decline.
Lack of Specialist Training – Many GPs aren’t confident diagnosing dementia or discussing long-term care.
Overlapping Symptoms – Depression, anxiety, and hearing loss can mimic dementia, leading to misdiagnosis.
Patient Reluctance – Many people avoid memory testing due to stigma or denial.
Resource Shortages – Lack of access to brain imaging, biomarkers, and memory clinics leads to delayed or missed diagnoses.
Digital Cognitive Tests: How Do They Differ?
There has been a rise in digital and AI-powered cognitive assessments, with startups developing new tools that go beyond traditional pen-and-paper tests. These digital platforms aim to enhance accuracy, accessibility, and early detection. Below are the key differentiators:
1. Speed and Efficiency
Digital tests are often shorter (some under 5 minutes) while still providing comparable accuracy to MMSE or MoCA.
Adaptive algorithms adjust difficulty based on performance, reducing redundancy.
2. Greater Sensitivity to Subtle Changes
Digital tools detect early cognitive changes before traditional tests would show impairment.
Example: AI-powered tests analyze patterns in keystrokes, reaction time, and eye-tracking.
3. Remote and At-Home Testing
Unlike MMSE and MoCA, which require a trained professional, digital tests can be self-administered on a computer, tablet, or smartphone.
Example: Cognivue, Altoida, and Linus Health offer FDA-cleared or CE-marked tools for remote monitoring.
4. Gamification and Engagement
Some tests use interactive tasks or games to assess cognitive function, increasing engagement and reducing test anxiety.
Example: Cambridge Brain Sciences offers memory and reasoning games instead of traditional questionnaires.
5. AI and Machine Learning for Deeper Insights
AI analyzes speech patterns, typing speed, and micro-movements to detect cognitive decline.
Example: Neurotrack analyzes eye movement in memory recall tests, while Winterlight Labs uses speech biomarkers to detect dementia.
6. Data Tracking Over Time
Unlike traditional tests, which offer a snapshot, digital tests track cognitive function over months or years to detect trends.
Example: BrainCheck provides long-term monitoring for physicians and individuals.
7. Multimodal Biomarker Integration
Digital platforms integrate wearable data (e.g., sleep, gait, heart rate), genetics, and blood biomarkers for a comprehensive cognitive risk profile.
Example: Altoida uses AR (Augmented Reality) tasks to measure cognitive and motor function for early Alzheimer’s detection.
📌 Brain Functions Assessed in Standard Cognitive Tests
Most cognitive screening tools (e.g., MMSE, MoCA, SLUMS) test five core cognitive domains:
1. Memory (Short-Term & Long-Term) 🏛️
✅ What’s Tested?
Immediate recall (e.g., repeat 3-5 words immediately)
Delayed recall (e.g., remember the same words after 5 minutes)
Recognition memory (e.g., identifying familiar words, faces)
🔹 Test Examples:
MoCA: 5-word recall task
MMSE: 3-word memory test
❌ What’s Missing?
Episodic memory (personal past events, emotional memory)
Procedural memory (e.g., remembering how to ride a bike, type on a keyboard)
2. Attention & Processing Speed ⏳
✅ What’s Tested?
Sustained attention (e.g., serial 7s subtraction test)
Divided attention (e.g., Trail Making Test – switching between numbers & letters)
Selective attention (e.g., ignoring distractions while focusing on a task)
🔹 Test Examples:
MoCA: Alternating Trail Making Test (1 → A → 2 → B …)
Digit Span Test (repeat numbers forward & backward)
❌ What’s Missing?
Reaction time & cognitive processing speed (how fast the brain responds to stimuli)
Multitasking ability under pressure (real-world executive function tests)
3. Executive Function (Problem-Solving & Planning) 🏗️
✅ What’s Tested?
Cognitive flexibility (e.g., ability to shift between different thoughts or tasks)
Abstract thinking (e.g., recognizing patterns, solving logic problems)
Impulse control & inhibition (e.g., suppressing inappropriate responses)
🔹 Test Examples:
MoCA: Clock Drawing Test (measuring executive function & visuospatial ability)
Stroop Test (naming the ink color of a mismatched word)
❌ What’s Missing?
Real-life decision-making tests (e.g., financial decision-making, ethical reasoning)
Creativity & divergent thinking (e.g., generating new ideas, problem-solving in unique situations)
4. Language & Verbal Fluency 🗣️
✅ What’s Tested?
Naming ability (e.g., naming pictures of animals, objects)
Word finding & fluency (e.g., listing words that start with "F" in 60 seconds)
Sentence comprehension & repetition
🔹 Test Examples:
MoCA: Name 3 animals from pictures
Verbal Fluency Test (e.g., say as many words as possible in a category within 1 minute)
❌ What’s Missing?
Social communication (tone, sarcasm, humor, emotional expression in speech)
Writing ability & dysgraphia (decline in written communication, often missed in early dementia)
5. Visuospatial & Motor Skills 🏞️
✅ What’s Tested?
Object perception & spatial awareness (e.g., identifying overlapping objects)
Hand-eye coordination & fine motor skills (e.g., copying a drawing, buttoning a shirt)
🔹 Test Examples:
MoCA: Cube Drawing Test (3D perception)
Clock Drawing Test (planning & spatial awareness)
❌ What’s Missing?
Gait & balance (which can indicate neurodegenerative conditions before cognitive symptoms appear)
Facial recognition (early dysfunction is linked to Alzheimer’s & frontotemporal dementia)