Joe Verghese, MBBS, MS. Translating Insights from Community Studies to the Hospital (Mice that roar: Low tech high impact clinical screening tools) Joe Verghese, MBBS, MS. Integrated Divisions of Cognitive & Motor Aging (Neurology) and Geriatrics (Medicine) Albert Einstein College of Medicine, Bronx, NY

Disclosures: Funding received from NIH grants PO1 AGO3949 (NIA), RO1 AGO25119 (NIA), RO1 AGO39330 (NIA), RO1 AGO36921 (NIA/Fogarty), and R21 25572 (NIA/Fogarty)

GOAL Describe easy to use clinical tools and concepts that can be used in clinic and hospital settings to identify cognitive and mobility impairments in older patients.

(Mice that roar: Low tech high impact clinical screening tools) Picture MIS Gait/ Walking While Talking MCR syndrome aAA A, C, E

Kerala-Einstein study (NIA/Fogarty) Journal of the American Geriatrics Society, 2012; 60(11):2116-20 Kerala-Einstein study (NIA/Fogarty)

Qualities of an ideal dementia screening test High sensitivity and specificity Cheap Fast Easy to use Quick training Does not need a doctor Culture fair Not educationally biased Not affected by depression

MMSE Difficult to translate Age and gender effect Strong education effect Mathuranath et al, Int J Geriatr Psychiatry. 2004

Memory Impairment Screen. Buschke et al. Neurology 1999 4-minute, 4-item, delayed free- and cued-recall test of memory impairment. 483 Bronx seniors (50 dementia)

Qualities of an ideal dementia screening test for resource poor settings High sensitivity and specificity ✓ Cheap ✓ Fast ✓ Easy to use ✓ Quick training ✓ Does not need a doctor ✓ Culture fair ✗ Not educationally biased ✗ Not affected by depression ✗ Verghese J et al. J Amer Geriatr Soc 2012

KERALA-EINSTEIN STUDY Baby Memorial Hospital, Kozhikode city, Kerala – Outpatient clinics 304 subjects 65 dementia, 27 MCI Mean age 68 y 55% men Mean education 8 y 167 <10y school

Picture Memory Impairment Screen

Transportation? Body part? Ornament? Animal?

Picture Memory Impairment Screen 2 Minute distraction before recall (any of following) Count back from 20 IADL questionnaire Non-memory tests Verghese J et al. J Amer Geriatr Soc 2012

Picture Memory Impairment Screen SCORING Free recall: 2 points Cued recall (providing clue): 1 point Total: 8 points, range 0 to 8 Abnormal: 5 and below

Picture Memory Impairment Screen SCORING Free recall: 2 points Cued recall (providing clue): 1 point Total: 8 points, range 0 to 8 Abnormal: 5 and below PMIS is based on MIS, but is not the same!

Validity: P-MIS versus MMSE Overall N 304 65 dementia PMIS scores Dementia 1.5 Normal 7.5 Low correlation Age Sex Depression Sensitivity Specificity PPV MMSE ≤ 24 90 80 64 P-MIS ≤ 5 95 Verghese J et al. J Amer Geriatr Soc 2012

Low Education Low education/illiteracy Education ≤ 9 years N 167 Sensitivity Specificity PPV MMSE ≤ 24 90 80 64 P-MIS ≤ 5 88 96 Education ≤ 9 years N 167 30 dementia Sensitivity Specificity PPV MMSE ≤ 24 100 71 63 P-MIS ≤ 5 98 99 93 Verghese J et al. J Amer Geriatr Soc 2012

TRANSPORT? BODY PART? ORNAMENT? ANIMAL?

Meanwhile in the Bronx…

Qualities of an ideal dementia screening test for resource poor settings High sensitivity and specificity ✓ Cheap ✓ Fast ✓ Easy to use ✓ Quick training ✓ Does not need a doctor ✓ Culture fair ✓ Not educationally biased ✓ Not affected by depression ✓ Verghese J et al. J Amer Geriatr Soc 2012

Gait speed predicts: Dementia (JNNP 2009) Falls (J Am Geriatr Soc 2002) Stroke (Stroke 2008) Hospitalization (AAPMR 2006, J Am Geriatr Soc 2006) Disability (J Am Geriatr Soc 2012) Frailty (Age Ageing 2010, J Am Geriatr Soc 2012) Death (J Am Geriatr Soc 2012) SLOW GAIT = 0.7 m/sec or less

…. so dumb he can't walk and chew gum at the same time.

Walking While Talking Test Verghese et al. J Am Geriatr Soc 2002 40 feet: sec aAA A, C, E… Complex

Functional Near Infra-red Spectroscopy (fNIRS)) Youtube

“Old age comes with the first fall, and death with the second.” Gabriel Garcia Marquesa Love in the time of cholera

Verghese, J Am Geriatr Soc 2002

Einstein Aging Study: NIA Journal of the American Geriatrics Society, 2012: 60(10):1901-5. Einstein Aging Study: NIA

(No dementia, no disability, normal walking speeds). EAS: 631 High functioning (No dementia, no disability, normal walking speeds). Mean follow-up 32 months. Short Physical Performance Battery WWT Gait speed Verghese et al. JAGS 2012

Ready for clinic and hospital? Organization Measures Society of Hospital Medicine Get up & go Performance Oriented Mobility Assessment AGS (Falls) Gait Balance AHRQ (Falls) Morse Fall Scale (gait) STRATIFY (no gait) AMA (disability) Gait derangement

Prevalence of frailty in Heart Failure patients 27 NYHA III or IV, LVAD candidates

Einstein Aging Study: NIA Journal of Gerontology: Medical Sciences 2013;68(4):412-8. Einstein Aging Study: NIA

Mild Cognitive Impairment (MCI) syndrome Subjective cognitive complaints Objective cognitive Preserved ADL Absence of dementia

Motor Cognitive Risk (MCR) syndrome Subjective cognitive complaints Objective motoric: slow gait (1 SD below age and sex adjusted means) Preserved ADL Absence of dementia Verghese et al. J Gerontol Med Sci 2012

767 community residing participants. Age 70 and above (mean 79y) Einstein Aging Study 767 community residing participants. Age 70 and above (mean 79y) 60% women Mean follow-up: 42.3 ± 27.2 months J Gerontol Med Sci 2012

Outcomes MCR (n = 52) Controls (n = 715) Hazard Ratio* (95% CI), p-value Any Dementia 8 62 2.7 (1.2 to 5.9), 0.01 Alzheimer’s disease 1 40 0.6 (0.1 to 4.2), 0.57 Vascular Dementia 7 14 11.1 (4.0 to 30.8), <0.001 Adjusted for age, sex, education, medical illnesses and cognition.

MCR (52) Amnestic MCI (69) Non-Amnestic MCI (79) 18 10

Motoric Cognitive Risk syndrome Any older patient (without dementia) who presents with slow gait and cognitive complaints. Verghese et al. J Gerontol Med Sci 2012

Buracchio T, et al. Arch Neurol 2010

Summary: Mice that roar Picture MIS is a simple and reliable screen. MCR syndrome WWT: Mobility stress test approach

Thank you