ACT on Alzheimer’s Disease Curriculum

Module V: Cognitive Assessment and the Value of Early Identification

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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

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.

Early Detection

Early Detection

• 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

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

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

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

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

Cognitive Assessment

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

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

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

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

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

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

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

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

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

• 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

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

• 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

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

• 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

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

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.

Cognitive Assessment Tools

Cognitive assessment Test

Administration Time Scale (pts) MCI Sensitivity DementiaSensitivity

Dementia Specificity

MiniCog 1-3 min 5 NA 76% 89%

MMSE 7 min 30 18% 78% 88-100%

SLUMS 10 min 30 92% 100% 81%

MOCA 12 min 30 90% 100% 87%

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

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

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