Honing Efficient Cognitive Screening and Pillbox Skill Assessment Techniques Katherine Anderson, PharmD, CGP, FASCP Pharmacists International Consulting Specialists, ISU College of Pharmacy Affiliate Faculty kitty.pharmacists.intl.consulting@gmail.com Annie Lam, PharmD, CGP, FASCP Clinical Associate Professor, University of Washington School of Pharmacy aylam@u.washington.edu

CE CODE: GGW668

Disclosure Presenters Anderson and Lam have no conflict of interest to report

Learning Objectives Professional Resources & Business Development Demonstrate the value of using cognitive and pillbox skills assessments for patients and caregivers to better individualize patient medication education during care setting transitions. Administer and score Montreal Cognitive Assessment (MoCA©). Administer and score Mini-Cog©. Administer and score pillbox organizational skills assessments. Interpret screening results and distinguish between educable and non-educable patients and the degree to which they can appropriately self-manage medications.

Session Goals Learn or refine techniques in conducting cognition and pillbox skills assessments Cognition: Montreal Cognitive Assessment (MoCA) Mini-Cog Pillbox skills/literacy: Medication Transfer Screen (MTS) Cognition/pillbox skills/literacy: Medi-Cog Med organizational skills: Pillbox Assessment

Introduction Medication non-adherence is associated with injury, higher healthcare expenditures, loss of quality of life Health outcomes improve with pillbox use Efficient screens are needed to identify patients who would benefit from pillbox education

~77 Million Boomers Average medication compliance rate in developed countries is ~50%1 Non-adherence is associated with no pillbox usage2 Medication continuation is associated with using reminder tools such as a pillbox3 Pillbox users demonstrate better adherence4 1. http://worldofdtcmarketing.com/medication-compliance-rates-in-developed-countries-of-just-50-percent/cost-of-healthcare-in-the-u-s/. Accessed 8/31/2011. 2. Melloni C, et al. Predictors of early discontinuation of evidence-based medicine after acute coronary syndrome. Am J Cardiol. 2009 ; 104(2):175-81. 3. Kripalani S, et al. Medication use among inner-city patients after hospital discharge: patient-reported barrier and solutions. Mayo Clin Proc. 2008;83(5):529-35. 4. Zelikovsky N, et al. Perceived barriers to adherence among adolescent renal transplant candidates. Pediatr Transplant. 2008;12(3):300-8. 7

New Paradigms for Pillbox Education Are Needed Medication mismanagement - toll on QOL 48% reported non-adherence to regimen after hospital discharge3 47% veterans reported unable to load their pillboxes to an 80% accuracy at the time of hospital discharge5 Quick screening methods are needed to identify patients who would benefit from pillbox education starting in mid-life 5. Anderson K, et al. Identifying Patients at Risk for Medication Mismanagement: Using Cognitive Screens to Predict a Patient’s Accuracy in Filling a Pillbox. Consult Pharm 2008;23(6):259-72. Our first speaker describes the evolutionary process of various neuropsychiatric exams and administration techniques. An enhanced knowledge of cognitive screening may aid us in our quest to efficiently identify seniors at risk for medication mismanagement 8

Identify at Risk Patients We need an efficient screening process Does the patient have adequate cognition and skills to manage his/her medications safely? Is the patient a candidate for using a pillbox? If already using a pillbox, is it being loaded correctly? Dual screening Cognitive assessment Pillbox skills assessment 9

Assessment Tools Need brief screens to assess patient level of medication adherence and pillbox educability Mini-Cog© - validated cognitive screen Medication Transfer Screen (MTS) - public domain Medi-Cog (Mini-Cog+MTS) - developed as a brief assessment for cognition, literacy, pillbox skills Identify patients who have cognitive deficit Alert for literacy deficits Flag patients who would benefit from pillbox education

Montreal Cognitive Assessment

MoCA Administration & Scoring ~15 minute, 30-point, validated cognitive screen Instructions for administration and scoring are provided in handouts Sum all subscores listed on the right-hand side of form to derive the total score Add one point for an individual who has 12 years or fewer of formal education, for a possible maximum of 30 points A final total score of >26 is considered normal

MoCA Administration & Scoring Audience Participation 1) MoCA Form 2) MoCA Instructions 3) Pencil 13

Mini-Cog Method 2 minute screen - assesses for clinically significant cognitive impairment Three item recall (TIR) - screener names 3 unrelated objects (banana/sunrise/chair); patient repeats them back. Patient is told they will be asked to recall the words in two minutes Clock drawing test (CDT) - subject is asked to draw the face of a clock, then to draw the hands of the clock depicting 11:10. “Ten minutes after eleven.” After performing the CDT, the subject is asked to recall the 3 words 6. Borson S, et al. J Am Geriatr Soc 2005;53:871-4. 14

Clock Draw: Age 60 - Family Hx AD

Numerical Order and Positioning

Poor Planning or Wrong Time

Macular Degeneration (not CI)

Delirium

Post CVA

Mini-Cog Summary 1) Three Item Recall (TIR) – short term memory 2) Clock Draw Test (CDT) – long term memory, ability to sequence and locate, etc. TIR - 1 point for each item recalled (0-3 possible) CDT - 2 points for a correct clock; if all numbers are not present, or not in correct sequence or position, the score is zero (Either 2 or 0 points) 3) Score All 3 words of TIR OR Correct clock and recall at least one word 21

Mini-Cog Scoring Mini-Cog – 2 part screen Score 0-5 points Three Item Recall (TIR) - 1 point for each item recalled (0-3 possible) Clock Draw Task - 2 points for a correct clock; if all numbers are not present, or not in correct sequence or position, the score is zero Score 0-5 points Passing score >3 All 3 words of TIR OR Correct clock and recall at least one word 22

Mini-Cog Administration & Scoring Audience Participation 1) Blank sheet of paper 2) Pencil 23

Brief Pillbox Skills Assessment Gold standard pillbox assessment is to have the patient load their own medications Time constraints limit this in the clinical setting 5 minute screen to assess literacy and ability to interpret prescription instructions Medication Transfer Screen (MTS) Form + pencil Adaptable to any clinical setting

Medication Transfer Screen (MTS) On the table write the number of pills as instructed into the correct compartments: Example: TAKE ONE TABLET EVERY DAY AT BEDTIME (Patient fills in remaining slots). 1. TAKE ONE TABLET EVERY DAY IN THE MORNING 2. TAKE ONE TABLET 3 TIMES DAILY WITH MEALS 3. TAKE TWO TABLETS M-W-F IN THE EVENING 4. TAKE ONE-HALF TABLET ON SATURDAY AT BEDTIME 5. How many pills total are in the pill box for the entire day of Saturday? __ S M T W Th F Morn Noon Eve Bed 1 1* Score: 1 point for each MTS question (0 to 5 points) 25

MTS Instructions Demonstrate how the grid represents a pillbox Read the Example; explain that the marks represent pills in the “bedtime” compartments Ask the patient to fill in the last three marks Point out the four prescription directions Remind to also read and perform instruction #5 Ask the patient to read each instruction and place the “pills” in the pillbox independently Reassure the patient all questions will be answered upon completion of the exercise

Medi-Cog Study 1 results demonstrated that Medi-Cog screen scores correlated 0.72 with patient accuracy in loading medications in a pillbox at time of hospital discharge.5 Study 2 results 0.65 among highly cognitive community dwellers7 Screen utilized in various practice settings At time of discharge from hospital, LTC, SNF ALF admit and routine screen for self administered meds Community pharmacy Senior centers screenings 7. Lam AY, et al.  A pilot study to assess cognition and pillbox fill accuracy by community-dwelling older adults.  Consult Pharm, 2011;26 (4), 236-43.  

Medi-Cog Administration & Scoring Audience Participation 1) MTS Form 2) Pencil 31

Pillbox Assessment Method Demonstrate how to use a 28-compartment pillbox (open lids, locate the four compartment rows for morning, noon, eve, bedtime, and instruct to load medications as described on pill vials) Reassure questions will be answered after completing the task Patients load personal medications independently without any prompting After scoring, assist the patient in correcting any mistakes and provide appropriate education

Pillbox Assessment Score Form Dosing Frequency Categories # Meds # Correctly loaded pills Total # pills # Correct / Total # pills Point Daily/HS BID TID QID Taper or irregular dosing # Pillbox rows correctly loaded Row ratio __ / 4 Total points/ # entries Point Key 100%=1; 75=0.75; 0.8 = “passing” Pillbox Fill Score

Pillbox Fill Scoring Method Tally all meds by dosing frequency category and enter under # Meds Quantify accuracy by counting correct # Pills in each category Calculate the row ratio score (measures understanding of dosing frequency) Tally points and divide by the # Entries to derive the Pillbox Fill Score

Pillbox Fill (PBF) Scoring Method Count correct #pills in each QD, BID, TID category Each correct pillbox row (M – N – E – Bed) = 0.25 point Add the # of correctly loaded rows for a “global” score Two correct rows out of four in pillbox = 2/4 = 0.5 pt Tally points of ALL the category totals and divide by the total # entries to derive the PBF Score Example Daily/HS 21/21 = 100% 1.0 point BID 14/14 = 100% 1.0 point TID 28/42 = 50% 0.5 point Row Score = 50% 0.5 point Pillbox Fill Score 3.0 / 4 entries – 0.75

Self-Assessment Questions 1. How many points are awarded to a Clock Draw Test (CDT) in the Mini-Cog© scoring rubric? A. 0 point B. 1 point C. 2 points D. Either A or C

Self-Assessment Questions 1. How many points are awarded to a Clock Draw Test (CDT) in the Mini-Cog© scoring rubric? A. 0 point B. 1 point C. 2 points D. Either A or C

Self-Assessment Questions 2. In the Mini-Cog© scoring rubric, how many points are awarded for the correct recall of three words in the Three Item Recall (TIR)? A. 1 point B. 2 points C. 3 points

Self-Assessment Questions 2. In the Mini-Cog© scoring rubric, how many points are awarded for the correct recall of three words in the Three Item Recall (TIR)? A. 1 point B. 2 points C. 3 points

Self-Assessment Questions 3. The Medi-Cog is comprised of which of the following screens? A. Clock Draw Test (CDT) B. Three Item Recall (TIR) C. Medication Transfer Screen (MTS) D. All of the above

Self-Assessment Questions 3. The Medi-Cog is comprised of which of the following screens? A. Clock Draw Test (CDT) B. Three Item Recall (TIR) C. Medication Transfer Screen (MTS) D. All of the above

Self-Assessment Questions 4. A patient scores 1 of 5 points on the Medication Transfer Screen (MTS). Other than cognitive impairment, select a reason why the patient may have failed the screen. A. The patient was tired when he was screened. B. The patient is unable to read. C. The patient had never done a task like this before and didn’t understand the instructions. D. The patient was not wearing his glasses. E. All of the above

Self-Assessment Questions 4. A patient scores 1 of 5 points on the Medication Transfer Screen (MTS). Other than cognitive impairment, select a reason why the patient may have failed the screen. A. The patient was tired when he was screened. B. The patient is unable to read. C. The patient had never done a task like this before and didn’t understand the instructions. D. The patient was not wearing his glasses. E. All of the above

Self-Assessment Questions 5. Having the patient fill their pillbox with their own medications gives us the real information we need. Why administer the Medi-Cog when it only predicts pillbox loading accuracy? A. Patients may not have their medications with them. B. Time constraints may not allow adequate time to have a patient demonstrate pillbox loading accuracy. C. Medi-Cog is a brief 7-minute paper and pencil screen that can be done regardless of setting. D. Medi-Cog results give us information regarding short & long term memory, literacy skills, and a ball park idea of how well they might load their pillbox with meds. E. All of the Above

Self-Assessment Questions 5. Having the patient fill their pillbox with their own medications gives us the real information we need. Why administer the Medi-Cog when it only predicts pillbox loading accuracy? A. Patients may not have their medications with them. B. Time constraints may not allow adequate time to have a patient demonstrate pillbox loading accuracy. C. Medi-Cog is a brief 7-minute paper and pencil screen that can be done regardless of setting. D. Medi-Cog results give us information regarding short & long term memory, literacy skills, and a ball park idea of how well they might load their pillbox with meds. E. All of the Above

References 1. http://worldofdtcmarketing.com/medication-compliance-rates-in-developed-countries-of-just-50-percent/cost-of-healthcare-in-the-u-s/. Accessed 8/31/2011. 2. Melloni C, et al. Predictors of early discontinuation of evidence-based medicine after acute coronary syndrome. Am J Cardiol. 2009;104(2):175-81. 3. Kripalani S, et al. Medication use among inner-city patients after hospital discharge: patient-reported barrier and solutions. Mayo Clin Proc. 2008;83(5):529-35. 4. Zelikovsky N, et al. Perceived barriers to adherence among adolescent renal transplant candidates. Pediatr Transplant. 2008;12(3):300-8. 5. Anderson K, et al. Identifying Patients at Risk for Medication Mismanagement: Using Cognitive Screens to Predict a Patient’s Accuracy in Filling a Pillbox. Consult Pharm 2008;23(6):259-72. 6. Borson S, et al. J Am Geriatr Soc 2005;53:871-4. 7. Lam AY, et al. A pilot study to assess cognition and pillbox fill accuracy by community-dwelling older adults. Consult Pharm, 2011;26 (4), 236-43.