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

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

3. 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 ….

4. 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.

5. 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)

6. 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 

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

8. 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

9. Montreal Cognitive Assessment (MoCA)
takes min; requires score sheet and pencil
assesses different cognitive domains (attention, executive functions, memory, language, visuospatial skills, orientation)
total score (<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 (

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

11. 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

12. There are useful videos on administration and scoring of MoCA at…