1. ACT on Alzheimer’s Disease Curriculum Module VI: Screening

2. Screening These slides are based on the Module VI: Screening text Please refer to the text for all citations, references and acknowledgments 2

3. Module VI: Learning Objectives Upon completion of this module the student should: Gain insight into the topic of screening including: tips, screening measures, and recommendations. Summarize screening measures used for assessing cognitive functioning.

4. Screening

5. Screening Considerations There are multiple cognitive assessment tools available to healthcare providers to aid in the diagnosis of dementia and Alzheimer’s disease The clinical context should impact the decision on which cognitive assessment tool to use A clinic also needs to decide which healthcare provider should administer the test A pathway for intervention should be established for any patient who screens positive

6. Screening Tips There are a number of steps one can take to more effectively administer a cognitive assessment test – Maintain a laid back demeanor – Clearly explain the test – Encourage individuals to do their best – Provide support, especially if the patient is struggling

7. Screening Tips The following list are actions a tester should avoid: – Do not allow the patient to give up prematurely – Do not deviate from the standard instructions – Do not offer multiple choice answers – Do not bias score by coaching – Do not be soft on scoring

8. Screening Measures Wide range of options – Mini-Cog – Mini-Mental State Exam (MMSE) – St. Louis University Mental Status Exam (SLUMS) – Montreal Cognitive Assessment (MoCA) – Kokmen Test of Mental Status

9. Mini-Cog Mini-Cog is a five point cognitive screen – 3 word verbal recall – Clock draw Takes 1.5 to 3 minutes Short administration time makes it ideal for rushed primary care settings

10. Mini-Cog Pros  Takes only 1.5-3 minutes to administer  Clock drawing sensitive to both visuospatial & executive dysfunction  Simple scoring and interpretation Cons  Not considered as sensitive for MCI or early dementia when compared to longer screens  Brevity means less information to interpret

11. Mini-Cog Performance unaffected by education or language Borson Int J Geriatr Psychiatry 2000 Sensitivity and Specificity similar to MMSE (76% vs. 79%; 89% vs. 88%) Borson JAGS 2003 Does not disrupt workflow and increases rate of diagnosis in primary care Borson JGIM 2007 Failure associated with inability to fill pillbox Anderson et al Am Soc Consult Pharmacists 2008

12. Mini-Cog Borson and colleagues administered MC to 524 patients ≥65 in primary care setting – Screening did not disrupt clinic flow – 18% screen failure rate (MC score<4) – Only 17% of providers took appropriate action with screen fails » Borson et al. J. Gen. Intern. Med 2007 McCarten and colleagues administered MC to 8,342 patients aged ≥70 in VA setting – Screen well-accepted by older veterans – Testing completed between 1-3 minutes – 25.8% failure rate among asymptomatic population » McCarten et al J Am Geriatr Soc

13. MMSE Mini Mental Status (MMSE) is one of the most widely used cognitive assessment tools Test has a 30 point scale and tests orientation, memory, visuospatial, construction and language Takes seven minutes to administer

14. Pros  Widely accepted and validated tool for dementia screening  30-point scale well known and score is easily interpretable  Measures orientation, working memory, recall, language, praxis Cons  Scale developed 40 years ago, before MCI criteria and when early dementia less well understood  Lacks sensitivity to MCI and early dementia  Takes 7 min. to administer  Copyright issues MMSE

15. SLUMS The St. Louis University Mental Status Exam (SLUMS) was one of the first cognitive assessment tools to address MCI Test has a 30 point scale Takes 10 minutes to administer

16. Pros  More measures of executive functioning  Good balance between easy and difficult items  More sensitive than MMSE in detecting MCI and early dementia  30-point scale similar to MMSE  Score range for MCI and dementia  Free online Cons  Takes 10 min. to administer  Slightly more complex directions than MMSE  Less name recognition than MMSE SLUMS

17. MoCA The Montreal Cognitive Assessment (MoCA) was developed at the Montreal Neurological Institute MoCA is one of the most sensitive cognitive screens available Takes 12-15 minutes to administer Tests executive function in addition to language, visuospatial function and memory

18. Pros  Much more sensitive than MMSE in detecting MCI and early dementia  More content tapping higher level executive functioning  30-point scale similar to MMSE  Translations available in 35+ languages  Free online Cons  Takes 10-14 min. to administer  More complex administration and directions than MMSE MoCA

19. Kokmen Test of Mental Status The Kokmen Test was developed at the Mayo Clinic Has a 38 point scale Takes longer than the MMSE to administer More sensitive to MCI by including a longer word list for recall

20. AD8 8 items questionnaire Administered to an informant, such as a caregiver, rather than the patient The cognitive domains include: orientation, executive functions, and interests in activities If the result is abnormal a more thorough assessment is indicated

21. Cognitive Assessment Tools Cognitive assessment Test Administration TimeScale (pts)MCI Sensitivity Dementia Sensitivity Dementia Specificity MiniCog1-3 min5NA76%89% MMSE7 min3018%78%88-100% SLUMS10 min3092%100%81% MOCA12 min3090%100%87%

22. Recommendations for Cognitive Screening It is recommended that geriatric patients 70 and older undergo an annual cognitive screen Some advise the screening begin at age 65 In busy primary care settings, the Mini-Cog can be used Benefits of screening the asymptomatic geriatric population are currently being studied