ACT on Alzheimers Disease Curriculum Module V Cognitive

ACT on Alzheimer’s Disease Curriculum Module V: Cognitive Assessment and the Value of Early Detection

Cognitive Assessment and the Value of Early Detection • These slides are based on the Module V: Cognitive Assessment and the Value of Early Detection text • Please refer to the text for all citations, references and acknowledgments 2

Module V: Learning Objectives Upon completion of this module the student should: • Identify tips for detection of cognitive impairment and the use of observation as an assessment tool. • List and describe a variety of cognitive tools for conducting assessments and demonstrate an understanding of the recommended course of action when cognitive impairment is identified. • Articulate the value of early detection of Alzheimer’s disease.

Early Detection

Early Detection • Despite increasing instances of Alzheimer’s disease, fewer than 50% of all cases are diagnosed • Early detection of Alzheimer’s disease is very difficult • Healthcare providers play a critical role in detecting the disease

Early Detection • Cognitive screening in the physician’s office has recently been introduced to facilitate early detection • Research is emerging regarding the direct benefits of pre-symptomatic cognitive assessment • Studies have demonstrated indirect benefits of cognitive assessment due to the beneficial effects of substantive interventions

Early Detection • The following observations may indicate to a healthcare provider the presence of an undiagnosed cognitive disorder – Forgetting medications – Repeated phone calls to provider – Reported unusual sleeping habits – Inappropriate clothing, behaviors or speech – Personal hygiene issues – Excessive weight gain or loss

Practice Tips for Early Detection • Raise your expectation of the older patient • Clinical interview in which the individual answers questions without help • Notice whether social skills remain intact • Notice whether individual repeats him/herself • Obtain family observations • Check on mental status by asking about current events • Remember to rely on formal assessment tools to identify dementia

The Medicare Wellness Visit • Began January 1, 2011 • Prior to this time, Medicare did not pay for an annual check-up/physical • Medicare will now pay for an annual wellness visit • Included in the wellness visit is screening for possible cognitive impairment • Wellness visit may be performed by doctor, nurse practitioner, physician assistant, clinical nurse specialist, or other health professional

Cognitive Assessment

Cognitive Assessment Considerations • There are multiple cognitive assessment tools available to healthcare providers to aid in the diagnosis of dementia and Alzheimer’s disease • The clinical context should impact the decision on which cognitive assessment tool to use • A clinic also needs to decide which healthcare provider should administer the test • A pathway for intervention should be established for any patient who screens positive

Cognitive Assessment Tips • There a number of steps one can take to more effectively administer a cognitive assessment test – Maintain a laid back demeanor – Clearly explain the test – Encourage individuals to do their best – Provide support, especially if the patient is struggling

Cognitive Assessment Tips • The following list are actions a tester should avoid: – Do not allow the patient to give up prematurely – Do not deviate from the standard instructions – Do not offer multiple choice answers – Do not bias score by coaching – Do not be soft on scoring

Cognitive Assessment Measures • Wide range of options – Mini-Cog – Mini-Mental State Exam (MMSE) – St. Louis University Mental Status Exam (SLUMS) – Montreal Cognitive Assessment (Mo. CA) – Kokmen Test of Mental Status

Mini-Cog • Mini-Cog is a five point cognitive screen – 3 word verbal recall – Clock draw • Takes 1. 5 to 3 minutes • Short administration time makes it ideal for rushed primary care settings

Mini-Cog • Pros § Takes only 1. 5 -3 minutes to administer § Clock drawing sensitive to both visuospatial & executive dysfunction § Simple scoring and interpretation • Cons § Not considered as sensitive for MCI or early dementia when compared to longer screens § Brevity means less information to interpret

Mini-Cog • Performance unaffected by education or language • Borson Int J Geriatr Psychiatry 2000 • Sensitivity and Specificity similar to MMSE (76% vs. 79%; 89% vs. 88%) • Borson JAGS 2003 • Does not disrupt workflow and increases rate of diagnosis in primary care • Borson JGIM 2007 • Failure associated with inability to fill pillbox • Anderson et al Am Soc Consult Pharmacists 2008

Mini-Cog • Borson and colleagues administered MC to 524 patients ≥ 65 in primary care setting – Screening did not disrupt clinic flow – 18% screen failure rate (MC score<4) – Only 17% of providers took appropriate action with screen fails » Borson et al. J. Gen. Intern. Med 2007 • Mc. Carten and colleagues administered MC to 8, 342 patients aged ≥ 70 in VA setting – Screen well-accepted by older veterans – Testing completed between 1 -3 minutes – 25. 8% failure rate among asymptomatic population » Mc. Carten et al J Am Geriatr Soc

MMSE • Mini Mental Status (MMSE) is one of the most widely used cognitive assessment tools • Test has a 30 point scale and tests orientation, memory, visuospatial, construction and language • Takes seven minutes to administer

MMSE • Pros § Widely accepted and validated tool for dementia screening § 30 -point scale well known and score is easily interpretable § Measures orientation, working memory, recall, language, praxis • Cons § Scale developed 40 years ago, before MCI criteria and when early dementia less well understood § Lacks sensitivity to MCI and early dementia § Takes 7 min. to administer § Copyright issues

SLUMS • The St. Louis University Mental Status Exam (SLUMS) was one of the first cognitive assessment tools to address MCI • Test has a 30 point scale • Takes 10 minutes to administer

SLUMS • Pros § More measures of executive functioning § Good balance between easy and difficult items § More sensitive than MMSE in detecting MCI and early dementia § 30 -point scale similar to MMSE § Score range for MCI and dementia § Free online • Cons § Takes 10 min. to administer § Slightly more complex directions than MMSE § Less name recognition than MMSE

Mo. CA • The Montreal Cognitive Assessment (Mo. CA) was developed at the Montreal Neurological Institute • Mo. CA is one of the most sensitive cognitive screens available • Takes 12 -15 minutes to administer • Tests executive function in addition to language, visuospatial function and memory

Mo. CA • Pros § Much more sensitive than MMSE in detecting MCI and early dementia § More content tapping higher level executive functioning § 30 -point scale similar to MMSE § Translations available in 35+ languages § Free online • Cons § Takes 10 -14 min. to administer § More complex administration and directions than MMSE

Kokmen Test of Mental Status • The Kokmen Test was developed at the Mayo Clinic • Has a 38 point scale • Takes longer than the MMSE to administer • More sensitive to MCI by including a longer word list for recall

AD 8 • 8 items questionnaire • Administered to an informant, such as a caregiver, rather than the patient • The cognitive domains include: orientation, executive functions, and interests in activities • If the result is abnormal a more thorough assessment is indicated

Cognitive Assessment Tools Cognitive assessment Test Administration Time Scale (pts) MCI Sensitivity Dementia Specificity Mini. Cog 1 -3 min 5 NA 76% 89% MMSE 7 min 30 18% 78% 88 -100% SLUMS 10 min 30 92% 100% 81% MOCA 12 min 30 90% 100% 87%

Recommendations for Cognitive Screening • It is recommended that geriatric patients 70 and older undergo an annual cognitive screen • Some advise the screening begin at age 65 • In busy primary care settings, the Mini-Cog can be used • Benefits of screening the asymptomatic geriatric population are currently being studied

Model for Cognitive Impairment Identification • Healthcare providers should be prepared to act on a positive screen • An individual failing the Mini-Cog should follow-up with a more sophisticated test • After a second failure, the individual should undergo a formal dementia evaluation • Provider tools exist to guide the process

Benefits of Early Detection • Early detection: – Helps to rule out other causes of cognitive impairment – Helps explain current symptoms – Allows time to implement care management strategies – Can help avoid future medical crises – Allows individuals to participate in clinical trials – Allows earlier pharmacological and nonpharmacological interventions – Helps patients avoid situations that might cause harm