The assessment and diagnosis of dementia

There is no single test to diagnose dementia, and healthcare professionals are commonly required to conduct a variety of assessments. As a first step, people with symptoms of dementia are asked to complete a cognitive (mental abilities) test to assess the person’s memory and communication skills. These tests do not ‘diagnose’ dementia but screen people who may benefit from further assessments. The cognitive assessments are often pen-and-paper tests, with a range of questions leading to a final score. These tests include questions about memory, attention, orientation, language, and communication. The tests are often carried out by a GP or healthcare professionals in specialist services such as memory clinics.

Most cognitive tests have been validated and tested in English and have a strong bias for western culture, language, and education. Following an in-depth analysis of currently available cognitive tests, we present four tools below which show promise in being effective in identifying people living with dementia from South Asian backgrounds. These four tools received positive feedback from healthcare professionals during ADAPT workshops designed to evaluate the tools. Please note that while these tools are not without their shortcomings, they are currently the strongest in terms of reliability, validity, and cultural sensitivity. After each summary, we provide a quotation from the workshops to illustrate how the tools are valued by healthcare professionals. 

Dementia diagnosis

Please note that these tools should only be used by trained health care professionals. Also, as mentioned previously, the diagnosis of dementia requires several different types of assessments, and a single cognitive tool should not be relied upon. 

The Addenbrooks Cognitive Examination 3 (ACE III)

The ACE III is considered more diagnostically sensitive and reliable than the Mini Mental State Examination (MMSE) and also more culturally sensitive. The test can be used to identify dementia and mild cognitive impairment. It consists of five cognitive domains: attention, memory, fluency, language, and visuo-spatial abilities. The ACE III is available in Hindi, Guajarati, and Urdu. It is important to be aware that while the ACE III has been used in a number of different languages, the final scores derived from it are heavily influenced by the subject’s level of education and may not be suitable for people with little or no education. 

“The ACE is the standard, it’s what we use in our clinic predominantly, but it's not an appropriate tool for somebody whose first language isn't English. And you know they're not educated in the UK, it doesn't, it's not a one size fits all, it’s back to what works for that person I think.”

Dementia diagnosis

Montreal Cognitive Assessment (MoCA)

The MoCA is a much shorter cognitive test compared with both the ACE III and the MMSE. It is therefore less onerous for people to complete. The MoCA has been shown to be effective in the early detection of dementia and mild cognitive impairment. The test focuses on executive functioning, naming, memory, attention, language, abstraction, and delayed recall. It is currently available in Hindi. 

“Well, the nurses tend to use the ACE III. I know in the pandemic I've been told that they were trained to do the MoCA and it was just easier and quicker to do.”

Rowland Universal Dementia Assessment Scale (RUDAS)

The RUDAS is a new, condense cognitive screening instrument which aims to minimise any effects of cultural learning and language. It focuses on memory, body orientation, praxis, drawing, judgement, memory recall, and language. While the RUDAS is available only in English, it has been found, due to a lack of reliance on cultural knowledge, to be easily administered via an interpreter. 

“We use either the ACE III or we use the MOCA or the RUDAS. So quite often when we're using interpreters we use the RUDAS because it seems to be the one that's the best for people that don't have English as a first language.”

Dementia diagnosis

The Alzheimer’s Questionnaire

The tests above are usually conducted by healthcare professionals once a person has been referred to a dementia service. However, considerable work has been done by community organisations to raise awareness of dementia. Staff often need to be able to identify symptoms before they can signpost people to relevant services. The Alzheimer’s Questionnaire was designed to be used as a screening tool by community workers, encouraging timely diagnosis. In identifying cognitive difficulties, the tool has been found to be as effective as the MOCA and can be easily implemented at a community  level. The questionnaire consists of 21 questions, each with a yes/no response, and it assesses the following domains: memory attention, orientation, functional ability, visuo-spatial, and language skills. The questionnaire is currently available only in English and Bengali but has been widely tested in India.

The English version can be found here: 

It is common for health care professionals to work with translators and interpreters during the assessment process if the person’s first language is not English. The video below highlights some challenges and how to work well with translators during the assessment process.