Starting with an examination of published systematic evidence review studies, the Workgroup then explored whether or not there was consensus in the literature concerning validated tools and commonly used rule-out assessments most suited for primary care practitioners. In addition to the range of tools identified, the recommendations offer suggested questions to include in the required Health Risk Assessments that patients must provide for the visit. The recommendations include tools that are available in multiple languages and are unaffected by levels of education or different cultural backgrounds.While the Workgroup emphasizes in its recommendations "no one tool is recognized as the best brief assessment to determine if a full dementia evaluation is needed," several tools were found most suited for assessing cognitive impairment at no cost to the health care provider during the visit. These include the Mini-Cog™, the Memory Impairment Screen (MIS), and the General Practitioner Assessment of Cognition (GPCOG). Positive attributes of these tests are that they were relatively free of education, race or cultural bias and take five minutes or less to administer – a very favorable aspect given the often limited time primary care physicians have per patient. Recognized tools suited for those close to the patient such as spouses, family members or friends were the AD8, the Short Informant Questionnaire on Cognitive Decline in the Elderly (short IQCODE), and the Informant GPCOG. Use of a tool allows clinicians to obtain an objective score that indicates either a passed or failed cognitive assessment and can improve detection of impairment that should be further evaluated. One study found that structured tools detected more than 80 percent of patients who during follow-up were diagnosed with mild cognitive impairment or dementia compared to the detection of only 59 percent whose detection relied on physician observation alone. "As a leader in the Alzheimer's community, the Alzheimer's Association believes that part of its role is to fuel the advancement of early detection and diagnosis. The Workgroup recommendations empower and equip physicians with a pathway that allows them to make informed choices about which structured assessment tools work best for them and the patients they serve," said Thies. "Whether the tools the Workgroup identified are used or other detection instruments, informal observation is not enough."