Behavioral Risk Factor Surveillance System (BRFSS) Cognitive Decline Module

Cognitive decline, which includes changes in memory, is often the first sign of dementia or Alzheimer's disease. For this reason, CDC measures reported cognitive decline as a critical indicator of dementia, including Alzheimer's disease. These issues have received increased attention as public health threats to our nation.

Public health programs can use this data to understand the burden of cognitive decline in their population and address dementia, including Alzheimer's disease. The data can help inform public education efforts, intervention development, and efforts to address health care and long-term care needs, as well as caregiving supports.

This module identifies U.S. individuals, age 45 and older, with worsening memory loss — known as subjective cognitive decline, or SCD. This can tell us:

• The percentage of adults who experience SCD.
• The percentage of adults who experience SCD and live alone.
• The percentage of adults who have difficulty with daily activities due to SCD.
• The health conditions and behaviors of adults experiencing SCD.
• The relationship between SCD and other behavioral health factors from the BRFSS core or co-administered optional modules.

The module also provides the following state-level data about adults, age 45 and older, who experience SCD:

• How often SCD has caused them to give up household chores or activities outside the home.
• Whether they need assistance with activities due to SCD and whether they can get the help they need.
• Whether they or others have discussed their confusion or worsening memory loss with a health care professional.

The questions measure the BRFSS respondents' perceptions about any memory loss that is happening more often or is getting worse. It asks:

• During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?

This question captures what is known as subjective cognitive decline (SCD). If a respondent answers "yes" to this question, other questions are asked to help understand the impact of SCD on functioning:

• During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do?
• As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities?
• When you need help with these day-to-day activities, how often are you able to get the help that you need?
• During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home?
• Have you or anyone else discussed your confusion or memory loss with a health care professional?

In 2007, CDC's Healthy Aging Program—in collaboration with a national panel of experts—developed a 10-question Behavioral Risk Factor Surveillance System (BRFSS) module to measure subjective cognitive decline (SCD) and its associated effects. BRFSS is a state-based surveillance system that surveys U.S. adults on a wide range of health behaviors.

• The module was developed in response to the Healthy Brain Initiative's recommendation to develop population-based surveillance of cognitive decline in the United States, in the National Public Health Road Map to Maintaining Cognitive Health.
• It reflects the importance of cognitive impairment as a public health issue.

A multi-step process was used to develop the questions for the module.

1. A scientific literature review was conducted to identify existing surveys and questions that measure cognitive decline and impairment.
2. Next, a panel of subject matter experts reviewed questions used on other surveys, adapted existing questions, and developed a set of possible questions for the module.
3. The module was finalized after four rounds of cognitive and field testing in California's BRFSS survey during fall 2008.

In 2009, five states (California, Florida, Iowa, Louisiana, and Michigan) pilot-tested the module in their BRFSS surveys.

In 2011, 47 states and territories added the module (at the time named the Cognitive Impairment module) as an official optional module.

In 2012-2013, 47 states and territories added the module as state-added questions.

In 2015, CDC revised the module's name and questions based on feedback from data users and a panel of experts.

• The new Cognitive Decline module underwent two rounds of cognitive testing before it was finalized and approved to be included as an optional module starting in the 2015 BRFSS.

Beginning in 2015, the BRFSS Cognitive Decline optional module included the following revisions:

• The module was shortened from 10 to 6 questions in response to concerns about the length of the module.
• The module is asked of BRFSS respondents 45 years or older.
  • Data found that this age group was more likely to answer "yes" to the index question than those 44 or younger.
• The name of the module was changed to the Cognitive Decline module to better reflect the measure.
• The introductory text was edited to provide greater clarity based on feedback from the cognitive testing.

In 2015 and 2016, 49 states, D.C., and Puerto Rico administered the current Cognitive Decline module at least once. The states that used the module in 2015 and 2016 are referenced in a report on the prevalence of SCD.

Since 2016, states have continued to administer this module to BRFSS respondents. States administering the Cognitive Decline module vary by year. Information regarding states that administered the current Cognitive Decline module by year are available on the BRFSS website. Corresponding infographics are available.

This statistical brief provides guidance for analyzing data from the current BRFSS Cognitive Decline Optional Module.

It is important to understand that any measure of SCD obtained from the BRFSS is meant for public health purposes to help describe the burden associated with SCD in states.

• Questions are self-reported and not designed to diagnose.
• The data is not intended to be reported as a prevalence measure of a medical condition, like dementia or Alzheimer's disease, and may be an under-reporting of SCD in the U.S.

The BRFSS surveys community-dwelling adults and does not include residents of long-term care homes, group homes, or other facilities.

Additionally, if the selected respondent cannot respond to the survey because of physical or cognitive limitations, that respondent and their entire household are removed from the sample.

• This means the data collected by this module may under-report the extent of cognitive decline in the United States.

Since 2015, CDC, in collaboration with the Alzheimer's Association, has developed a series of state-specific infographics. These infographics depict the data for each year that a state collects BRFSS data using the Cognitive Decline module. Infographics presenting combined national data overall and by various demographic groups are also available.

These data can also be queried using the Alzheimer's Disease and Healthy Aging Data Portal, and a series of data briefs for action are available on select topics.

The CDC publishes various research papers using data from the BRFSS Cognitive Decline module data. View a list of these and other papers.

Researchers not familiar with BRFSS data analyses should familiarize themselves with the methods unique to BRFSS, including weighting methods and complex sampling design.

More information can be found at CDC's BRFSS site. This statistical brief provides an overview and guidance for analyzing data from the current BRFSS Cognitive Decline Optional Module.