Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review

Sharmila Bishowkarma; Gagan Karki; Ravi Rokaya; Bibek Shrestha

doi:doi:10.11648/j.ajim.20261405.11

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Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review

Sharmila Bishowkarma^*

, Gagan Karki

, Ravi Rokaya

, Bibek Shrestha

Published in American Journal of Internal Medicine (Volume 14, Issue 5)

Received: 15 September 2026 Accepted: 27 September 2026 Published: 29 October 2026

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Abstract

Background Cognitive impairment and dementia are more common in people with type 2 diabetes yet often go undetected. Brief cognitive screening tests could enable earlier identification in routine care, but their diagnostic accuracy and practicality in this population remain uncertain. We systematically reviewed the diagnostic accuracy and feasibility of brief cognitive screening in this population. Methods The review was registered (PROSPERO CRD420261441730) and reported following the PRISMA-DTA guideline. We searched MEDLINE (via PubMed), Embase, CENTRAL and PsycINFO from January 2000 to April 2026, restricted to English-language reports, for studies evaluating a brief cognitive screen against an acceptable reference standard clinical diagnostic criteria or a comprehensive neuropsychological battery or reporting feasibility. Two reviewers independently screened, extracted and appraised studies (QUADAS-2 for accuracy; the Mixed Methods Appraisal Tool for feasibility). Sensitivity and specificity with Wilson 95% confidence intervals were synthesised structurally using paired forest and summary receiver-operating-characteristic plots, and the certainty of evidence was assessed with GRADE. Results Six of 557 records were eligible: four diagnostic-accuracy studies (802 adults) and two feasibility studies. All accuracy studies evaluated the Montreal Cognitive Assessment (MoCA) and one also evaluated the Mini-Mental State Examination (MMSE). At the conventional cut-off (<26) the MoCA was highly sensitive but poorly specific (sensitivity 88-94%, specificity 29-51%); lower, diabetes-specific thresholds improved specificity at the expense of sensitivity (for example 49%/91% at 20/21, and 81%/62% at an optimal 24/25). The single MMSE study showed the reverse profile (66%/96%). Risk of bias was appreciable in every study (incorporation bias, spectrum effects, within-sample thresholds), and a meta-analysis was not appropriate. Two studies supported nurse-delivered screening in primary care (MoCA; and the Mini-Cog, mean 118 seconds, 100% completion). Overall certainty of evidence was low to very low. Conclusions The MoCA is the only brief cognitive screen with replicated accuracy evidence in type 2 diabetes: sensitive but over-referring at the standard cut-off, with a lower threshold better balancing accuracy. Non-specialist screening appears feasible, but the accuracy evidence is limited and at material risk of bias. Diabetes-specific validation against clinical or neuropsychological reference standards is the priority for future research.

Published in	American Journal of Internal Medicine (Volume 14, Issue 5)
DOI	10.11648/j.ajim.20261405.11
Page(s)	80-92
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2026. Published by Science Publishing Group

Keywords

Type 2 Diabetes Mellitus, Cognitive Impairment, Montreal Cognitive Assessment, Diagnostic Test Accuracy, Cognitive Screening

References

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Bishowkarma, S., Karki, G., Rokaya, R., Shrestha, B. (2026). Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review. American Journal of Internal Medicine, 14(5), 80-92. https://doi.org/10.11648/j.ajim.20261405.11

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Bishowkarma, S.; Karki, G.; Rokaya, R.; Shrestha, B. Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review. Am. J. Intern. Med. 2026, 14(5), 80-92. doi: 10.11648/j.ajim.20261405.11

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Bishowkarma S, Karki G, Rokaya R, Shrestha B. Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review. Am J Intern Med. 2026;14(5):80-92. doi: 10.11648/j.ajim.20261405.11

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@article{10.11648/j.ajim.20261405.11,
  author = {Sharmila Bishowkarma and Gagan Karki and Ravi Rokaya and Bibek Shrestha},
  title = {Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review},
  journal = {American Journal of Internal Medicine},
  volume = {14},
  number = {5},
  pages = {80-92},
  doi = {10.11648/j.ajim.20261405.11},
  url = {https://doi.org/10.11648/j.ajim.20261405.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajim.20261405.11},
  abstract = {Background Cognitive impairment and dementia are more common in people with type 2 diabetes yet often go undetected. Brief cognitive screening tests could enable earlier identification in routine care, but their diagnostic accuracy and practicality in this population remain uncertain. We systematically reviewed the diagnostic accuracy and feasibility of brief cognitive screening in this population. Methods The review was registered (PROSPERO CRD420261441730) and reported following the PRISMA-DTA guideline. We searched MEDLINE (via PubMed), Embase, CENTRAL and PsycINFO from January 2000 to April 2026, restricted to English-language reports, for studies evaluating a brief cognitive screen against an acceptable reference standard clinical diagnostic criteria or a comprehensive neuropsychological battery or reporting feasibility. Two reviewers independently screened, extracted and appraised studies (QUADAS-2 for accuracy; the Mixed Methods Appraisal Tool for feasibility). Sensitivity and specificity with Wilson 95% confidence intervals were synthesised structurally using paired forest and summary receiver-operating-characteristic plots, and the certainty of evidence was assessed with GRADE. Results Six of 557 records were eligible: four diagnostic-accuracy studies (802 adults) and two feasibility studies. All accuracy studies evaluated the Montreal Cognitive Assessment (MoCA) and one also evaluated the Mini-Mental State Examination (MMSE). At the conventional cut-off (Conclusions The MoCA is the only brief cognitive screen with replicated accuracy evidence in type 2 diabetes: sensitive but over-referring at the standard cut-off, with a lower threshold better balancing accuracy. Non-specialist screening appears feasible, but the accuracy evidence is limited and at material risk of bias. Diabetes-specific validation against clinical or neuropsychological reference standards is the priority for future research.},
 year = {2026}
}

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TY  - JOUR
T1  - Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review
AU  - Sharmila Bishowkarma
AU  - Gagan Karki
AU  - Ravi Rokaya
AU  - Bibek Shrestha
Y1  - 2026/10/29
PY  - 2026
N1  - https://doi.org/10.11648/j.ajim.20261405.11
DO  - 10.11648/j.ajim.20261405.11
T2  - American Journal of Internal Medicine
JF  - American Journal of Internal Medicine
JO  - American Journal of Internal Medicine
SP  - 80
EP  - 92
PB  - Science Publishing Group
SN  - 2330-4324
UR  - https://doi.org/10.11648/j.ajim.20261405.11
AB  - Background Cognitive impairment and dementia are more common in people with type 2 diabetes yet often go undetected. Brief cognitive screening tests could enable earlier identification in routine care, but their diagnostic accuracy and practicality in this population remain uncertain. We systematically reviewed the diagnostic accuracy and feasibility of brief cognitive screening in this population. Methods The review was registered (PROSPERO CRD420261441730) and reported following the PRISMA-DTA guideline. We searched MEDLINE (via PubMed), Embase, CENTRAL and PsycINFO from January 2000 to April 2026, restricted to English-language reports, for studies evaluating a brief cognitive screen against an acceptable reference standard clinical diagnostic criteria or a comprehensive neuropsychological battery or reporting feasibility. Two reviewers independently screened, extracted and appraised studies (QUADAS-2 for accuracy; the Mixed Methods Appraisal Tool for feasibility). Sensitivity and specificity with Wilson 95% confidence intervals were synthesised structurally using paired forest and summary receiver-operating-characteristic plots, and the certainty of evidence was assessed with GRADE. Results Six of 557 records were eligible: four diagnostic-accuracy studies (802 adults) and two feasibility studies. All accuracy studies evaluated the Montreal Cognitive Assessment (MoCA) and one also evaluated the Mini-Mental State Examination (MMSE). At the conventional cut-off (Conclusions The MoCA is the only brief cognitive screen with replicated accuracy evidence in type 2 diabetes: sensitive but over-referring at the standard cut-off, with a lower threshold better balancing accuracy. Non-specialist screening appears feasible, but the accuracy evidence is limited and at material risk of bias. Diabetes-specific validation against clinical or neuropsychological reference standards is the priority for future research.
VL  - 14
IS  - 5
ER  -

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Sharmila Bishowkarma

Department of Endocrinology, The First Affiliated Hospital of Xuzhou Medical University, Xuzhou, China

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http://orcid.org/0009-0000-6083-980X
Gagan Karki

Department of Orthopedic Surgery, The First Affiliated Hospital of Xuzhou Medical University, Xuzhou, China

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http://orcid.org/0009-0000-8391-8121
Ravi Rokaya

Department of Cardiology, Chitwan Medical College Teaching Hospital, Bharatpur, Nepal

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http://orcid.org/0009-0001-6032-7043
Bibek Shrestha

Department of Ultrasound Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China

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http://orcid.org/0009-0002-3723-9122

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Bishowkarma, S., Karki, G., Rokaya, R., Shrestha, B. (2026). Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review. American Journal of Internal Medicine, 14(5), 80-92. https://doi.org/10.11648/j.ajim.20261405.11

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ACS Style

Bishowkarma, S.; Karki, G.; Rokaya, R.; Shrestha, B. Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review. Am. J. Intern. Med. 2026, 14(5), 80-92. doi: 10.11648/j.ajim.20261405.11

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AMA Style

Bishowkarma S, Karki G, Rokaya R, Shrestha B. Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review. Am J Intern Med. 2026;14(5):80-92. doi: 10.11648/j.ajim.20261405.11

Copy | Download

@article{10.11648/j.ajim.20261405.11,
  author = {Sharmila Bishowkarma and Gagan Karki and Ravi Rokaya and Bibek Shrestha},
  title = {Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review},
  journal = {American Journal of Internal Medicine},
  volume = {14},
  number = {5},
  pages = {80-92},
  doi = {10.11648/j.ajim.20261405.11},
  url = {https://doi.org/10.11648/j.ajim.20261405.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajim.20261405.11},
  abstract = {Background Cognitive impairment and dementia are more common in people with type 2 diabetes yet often go undetected. Brief cognitive screening tests could enable earlier identification in routine care, but their diagnostic accuracy and practicality in this population remain uncertain. We systematically reviewed the diagnostic accuracy and feasibility of brief cognitive screening in this population. Methods The review was registered (PROSPERO CRD420261441730) and reported following the PRISMA-DTA guideline. We searched MEDLINE (via PubMed), Embase, CENTRAL and PsycINFO from January 2000 to April 2026, restricted to English-language reports, for studies evaluating a brief cognitive screen against an acceptable reference standard clinical diagnostic criteria or a comprehensive neuropsychological battery or reporting feasibility. Two reviewers independently screened, extracted and appraised studies (QUADAS-2 for accuracy; the Mixed Methods Appraisal Tool for feasibility). Sensitivity and specificity with Wilson 95% confidence intervals were synthesised structurally using paired forest and summary receiver-operating-characteristic plots, and the certainty of evidence was assessed with GRADE. Results Six of 557 records were eligible: four diagnostic-accuracy studies (802 adults) and two feasibility studies. All accuracy studies evaluated the Montreal Cognitive Assessment (MoCA) and one also evaluated the Mini-Mental State Examination (MMSE). At the conventional cut-off (Conclusions The MoCA is the only brief cognitive screen with replicated accuracy evidence in type 2 diabetes: sensitive but over-referring at the standard cut-off, with a lower threshold better balancing accuracy. Non-specialist screening appears feasible, but the accuracy evidence is limited and at material risk of bias. Diabetes-specific validation against clinical or neuropsychological reference standards is the priority for future research.},
 year = {2026}
}

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TY  - JOUR
T1  - Diagnostic Accuracy and Feasibility of Brief Cognitive Screening in Adults with Type 2 Diabetes: A Systematic Review
AU  - Sharmila Bishowkarma
AU  - Gagan Karki
AU  - Ravi Rokaya
AU  - Bibek Shrestha
Y1  - 2026/10/29
PY  - 2026
N1  - https://doi.org/10.11648/j.ajim.20261405.11
DO  - 10.11648/j.ajim.20261405.11
T2  - American Journal of Internal Medicine
JF  - American Journal of Internal Medicine
JO  - American Journal of Internal Medicine
SP  - 80
EP  - 92
PB  - Science Publishing Group
SN  - 2330-4324
UR  - https://doi.org/10.11648/j.ajim.20261405.11
AB  - Background Cognitive impairment and dementia are more common in people with type 2 diabetes yet often go undetected. Brief cognitive screening tests could enable earlier identification in routine care, but their diagnostic accuracy and practicality in this population remain uncertain. We systematically reviewed the diagnostic accuracy and feasibility of brief cognitive screening in this population. Methods The review was registered (PROSPERO CRD420261441730) and reported following the PRISMA-DTA guideline. We searched MEDLINE (via PubMed), Embase, CENTRAL and PsycINFO from January 2000 to April 2026, restricted to English-language reports, for studies evaluating a brief cognitive screen against an acceptable reference standard clinical diagnostic criteria or a comprehensive neuropsychological battery or reporting feasibility. Two reviewers independently screened, extracted and appraised studies (QUADAS-2 for accuracy; the Mixed Methods Appraisal Tool for feasibility). Sensitivity and specificity with Wilson 95% confidence intervals were synthesised structurally using paired forest and summary receiver-operating-characteristic plots, and the certainty of evidence was assessed with GRADE. Results Six of 557 records were eligible: four diagnostic-accuracy studies (802 adults) and two feasibility studies. All accuracy studies evaluated the Montreal Cognitive Assessment (MoCA) and one also evaluated the Mini-Mental State Examination (MMSE). At the conventional cut-off (Conclusions The MoCA is the only brief cognitive screen with replicated accuracy evidence in type 2 diabetes: sensitive but over-referring at the standard cut-off, with a lower threshold better balancing accuracy. Non-specialist screening appears feasible, but the accuracy evidence is limited and at material risk of bias. Diabetes-specific validation against clinical or neuropsychological reference standards is the priority for future research.
VL  - 14
IS  - 5
ER  -

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