Cognitive screening tests: Montreal Cognitive Assessment (MoCA) Case 6 (Cognitive Health) - Clinical Skills Learning Cognitive screening tests: Montreal Cognitive Assessment (MoCA)

Confusion vs. Delirium Dementia What’s the difference???

Confusion Commonly used term, but ill defined Means different things to different people Disorientated forgetful rambling speech agitated seeing things / hearing things etc …… So much better to be more specific and say what the symptom(s) is ….

Delirium Acute problem - develops over hours/days and tends to fluctuate Disturbance in attention/cognition Usually underlying general medical condition / medications / change of environment Very common in hospitalised older people (15- 60%) and associated with poor outcomes A syndrome, not a diagnosis In practice this disturbance of consciousness may present as drowsiness, or being hyper-alert, overly vigilant. It can take clinical experience to learn ot detect these signs, in particular if they are subtle. The exact cause is not always identified.

Dementia Chronic progressive problem - develops over months/years (may be preceded by mild cognitive impairment/MCI) Generalised impairment of cognition and personality that is so severe that it impacts on day to day living No alteration in level of consciousness Common causes are degenerative (e.g. Alzheimer’s disease, dementia with Lewy bodies etc.) or vascular (e.g. strokes)

Common presenting symptoms of cognitive impairment … memory loss, especially recent events, such as forgetting messages, remembering routes or names, and asking questions repetitively increasing difficulties with tasks and activities that require organisation and planning becoming lost in unfamiliar environments difficulty finding the right words difficulty with numbers or handling money changes in personality and mood 

Assessment of patient presenting with possible cognitive impairment History (patient & informant) Physical examination Cognitive assessment Investigations

Brief cognitive assessments - lots of choice, but MoCA recommended Clock Mini-Cog AMT MMSE MoCA ACE Episodic + ++ +++ Semantic Remote - Spatial Executive Orientation Attention Language Equipment Time(mins) 2 4 6 8 10 15

Montreal Cognitive Assessment (MoCA) takes 10-12 min; requires score sheet and pencil assesses different cognitive domains (attention, executive functions, memory, language, visuospatial skills, orientation) total score 0 - 30 (<26 suggests cognitive impairment, but pattern of strengths/weaknesses and context often more informative than ‘cut-off’) correction (+1 point) for <12 years education not usually used administration instructions on website (www.mocatest.org)

Clock drawing “I want you to draw a clock. Put in all the numbers and set the time at ten past eleven”

Factors that may influence cognitive test scores Not just cognition, but… Poor vision Poor hearing Education Physical impairments Pain First language Anxiety/low mood … so think why the patient performed (and scored) as they did

There are useful videos on administration and scoring of MoCA at… www.youtube.com/watch?v=ryf8SG0NQLQ www.youtube.com/watch?v=y0KFQ7Lgf-w