1. 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

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

3. 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.

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

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

6. 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

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

8. 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)

9. 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

10. 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

11. Picture Memory Impairment Screen

12. Transportation?
Body part?
Ornament?
Animal?

13. 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

14. 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

15. 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!

16. 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

17. 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

18. TRANSPORT? BODY PART?
ORNAMENT? ANIMAL?

19. Meanwhile in the Bronx…

20. 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

21. 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

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

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

24. Functional Near Infra-red Spectroscopy (fNIRS))
Youtube

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

26. Verghese, J Am Geriatr Soc 2002

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

28. (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

29. 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

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

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

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

33. 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

34. 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

35. 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.

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

37. 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

38. Buracchio T, et al.
Arch Neurol 2010

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

40. Thank you