Reply to: Comment on: Neuropsychiatric Presentations of Common Dementia Syndromes: A Concise Review for Primary Care Team Members

In Strijkert et al. [1]'s response to our article “Neuropsychiatric presentations of common dementia syndromes: A concise review for primary care team members” [2] describing the neuropsychiatric symptoms (NPS) of common dementia syndromes, they point out that impairment in social cognition may explain many of the symptoms associated with mild behavioral impairment (MBI). Therefore, they advocate for assessing for changes in social cognition during dementia screenings in primary care. We agree that social cognition is an important facet of NPS in emerging dementia syndromes and therefore should be evaluated. However, as the authors point out, social cognition cannot be fully assessed during a routine primary care visit.

In our article, we suggest the use of questionnaires such as the Mild Behavioral Impairment Checklist (MBI-C) and the Neuropsychiatric Symptom Inventory (NSI) to assess for behavioral impairment. In Strijkert et al. [1]'s reply, they point out that these measures rely on subjective sources of information and omit certain aspects of social cognition. Other questionnaires have similar shortcomings [3, 4]. We acknowledge the limitations of these questionnaires and time burden of administering such questionnaires in a primary care setting. In their reply, the authors suggest that well-validated objective neuropsychological measures be used to assess different aspects of social cognition, and we agree. However, as we have noted previously, referral to specialty care, including neuropsychology, though ideal, is not always possible [2, 5]. We are not aware of a standardized way to assess for changes in social cognition in a generalist setting. In the service of providing guidance to individuals in a primary care setting, as was the focus of our original article, we suggest that when there is concern for changes in cognitive, behavioral, or psychiatric functioning in adults age 50+, primary care team members ask broad, open-ended questions that may be sensitive to changes in social cognition. A simple inquiry into the patient's social relationships (e.g., “Have you noticed any changes in your relationships?”) may help to elucidate emerging impairments in social cognition by revealing recent relational tension or discord, as impaired social cognition is expected to negatively affect interpersonal dynamics [6]. A query regarding changes in sexual behavior/sexual health may also be telling, as changes in sexual behavior are often associated with changes in social cognition [7, 8]. If the response to these screening questions conveys a possible decline in social cognition, this becomes another data point that the primary care team member can use to determine whether further evaluation by specialty care is warranted.

In short, we agree that changes in social cognition should be added to the list of NPS that can accompany or predate dementia. However, detailed or standardized assessment is typically not possible within the primary care setting [5]. Primary care team members may be able to expose changes in social cognition through broad screening questions related to social functioning within close relationships.

Zoe Bell wrote the first and all subsequent drafts of this reply. Maureen K. O'Connor and Lauren R. Moo reviewed and provided feedback on all drafts. All authors take full responsibility for the content of the manuscript and satisfy the requirements for authorship.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs, the U.S. government, or the authors' respective institutions.

The authors declare no conflicts of interest.

This publication is linked to a related comment by Strijkert et al. To view this article, visit https://doi.org/10.1111/jgs.19412.