MDS 2025 | An algorithm to guide clinicians on cognitive evaluation in Parkinson’s disease

In terms of who should receive a cognitive evaluation, we’ve come up with a kind of algorithm on the PD Cognicare project, which can help guide clinicians to determine who should receive an assessment and who maybe doesn’t necessarily need one. And before I go into the algorithm, I’ll just preface this by saying that, you know, every individual situation is different and people should use, of course, their clinical judgment when determining who should receive an assessment and shouldn’t. But this just kind of provides a nice evidence-based framework to work off. So the first recommendation is that all people with Parkinson’s disease should be offered some form of brief cognitive screen, like the MOCA, as early as possible after their initial Parkinson’s diagnosis. And this is so that we can have a nice solid baseline to work from. As the disease progresses, we can kind of compare their cognitive test results to that baseline assessment. The next recommendation is that every six to 12 months, people with Parkinson’s and their care partners should be asked, yeah, asked about their cognition. So that’s something as simple as asking, you know, have you noticed any changes in your memory or thinking lately? And the purpose of this is to screen for subjective cognitive decline. And also to just promote the conversation. So this gives people an opportunity if they want to bring up any concerns or questions they have, or they might have about dementia and cognitive impairment. And yeah, promote having those conversations in the clinic on a semi-regular basis. So from there, as soon as someone reports subjective cognitive decline, this is when we recommend that they receive another brief cognitive assessment like the MOCA. And the purpose of this is again to have a more formal screen of whether the person is experiencing objective cognitive decline or impairment. From here, this is where the algorithm kind of splits. So if the person has, you know, a relatively normal score on the MOCA, say above 26, we recommend that they are followed up in a year’s time to see if they still have subjective cognitive impairment and receive another MOCA at that time to track their progression. If the person presents with abnormal cognition, so that’s a MOCA score between say 20 and 26, we recommend that they are referred to a neuropsychologist for a comprehensive neuropsychological assessment to be able to diagnose their particular cognitive disorder if they have one. Finally, with people that score quite poorly on the MOCA, so say below 19, which indicates quite severe cognitive impairment, we recommend that clinical judgment is used to determine whether they should be referred to for neuropsychological assessment. And this is something that came up in our Delphi process that was quite important, was to consider what is the benefit of a cognitive assessment at that time and to weigh it up with, I guess, the risks or the negative outcomes. So for example, people with dementia, you know, they may be fatigued very easily. They may be stressed by their cognitive impairments. They may not have the time or the money to receive a cognitive, a comprehensive cognitive assessment, which can sometimes take hours. So we recommend that clinical judgment is used in these situations. We do acknowledge that sometimes it is important to have neuropsychological assessments to guide care, like cognitive rehabilitation services or certain care services can benefit from knowing what specific domains are affected. And sometimes a formal diagnosis is necessary for more administrative or logistical reasons.

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