1. ACT on Alzheimer’s Disease Curriculum Module V: Cognitive Assessment and the Value of Early Identification

2. Cognitive Assessment and the Value of Early Detection These slides are based on the Module II: Cognitive Assessment and the Value of Early Detection text Please refer to the text for all citations, references and acknowledgments 2

3. Learning Objectives Upon completion of this module the student should: Identify tips for detection of cognitive impairment and the use of observation as an assessment tool. List and describe a variety of cognitive tools and recommendations for conducting assessments. Demonstrate an understanding of the recommended course of action when cognitive impairment is identified.

4. Early Detection

5. Despite increasing instances of Alzheimer’s disease, fewer than 50% of all cases are diagnosed Early detection of Alzheimer’s disease is very difficult Healthcare providers play a critical role in detecting the disease

6. Early Detection Cognitive screening in the physicians office has recently been introduced to facilitate early detection Research is emerging regarding the direct benefits of pre-symptomatic cognitive assessment Studies have demonstrated indirect benefits of cognitive assessment due to the beneficial effects of substantive interventions

7. Early Detection The following observations may indicate to a healthcare provider the presence of an undiagnosed cognitive disorder – Forgetting medications – Repeated phone calls to provider – Reported unusual sleeping habits – Inappropriate clothing, behaviors or speech – Personal hygiene issues – Excessive weight gain or loss

8. Practice Tips for Early Detection Raise your expectation of the older patient Clinical interview in which the individual answers questions without help Notice whether social skills remain intact Notice whether individual repeats him/herself Obtain family observations Check on mental status by asking about current events Remember to rely on formal assessment tools to identify dementia

9. The Medicare Wellness Visit Began January 1, 2011 Prior to this time, Medicare did not pay for an annual check-up/physical Medicare will now pay for an annual wellness visit Included in the wellness visit is screening for possible cognitive impairment Wellness visit may be performed by doctor, nurse practitioner, physician assistant, clinical nurse specialist, or other health professional

10. Cognitive Assessment

11. Cognitive Assessment 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 that screen positive

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

13. Cognitive Assessment 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

14. Cognitive Assessment 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

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

16. 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

17. 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 & 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

18. 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

19. 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 Test takes seven minutes to administer

20. 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

21. 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 SLUMS takes 10 minutes to administer

22. 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

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

24. 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

25. Kokmen Test of Mental Status The Kokmen Test was developed at the Mayo Clinic The test has a 38 point scale The test takes longer than the MMSE to administer Kokmen is more sensitive to MCI by including a longer word list for recall

26. 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.

27. 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%

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

29. Model for Cognitive Impairment Identification Healthcare providers should be prepared to act on a positive screen An individual failing the Mini-Cog should follow-up with a more sophisticated test After a second failure, the individual should undergo a formal dementia evaluation Provider tools exist to guide the process

30. Benefits of Early Detection Early detection: – Helps to rule out other causes of cognitive impairment – Helps explain current symptoms – Allows time to implement care management strategies – Can help avoid future medical crises – Allows individuals to participate in clinical trials – Allows earlier pharmacological and non- pharmacological interventions – Helps patients avoid situations that might cause harm