Transcript PMA 2020 Alzheimer’s Disease Curricula

ACT on Alzheimer’s
Disease Curriculum
Module V: Cognitive Assessment and
the Value of Early Detection
Cognitive Assessment and the
Value of Early Detection
• These slides are based on the Module V:
Cognitive Assessment and the Value of Early
Detection text
• Please refer to the text for all citations,
references and acknowledgments
2
Module V: 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 for
conducting assessments and demonstrate an
understanding of the recommended course of
action when cognitive impairment is identified.
•Articulate the value of early detection of
Alzheimer’s disease.
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 physician’s 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 who screens positive
Cognitive Assessment 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
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
• 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 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
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
• Takes seven minutes to administer
MMSE
• 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
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
SLUMS
• 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
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
MoCA
• 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
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
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
Dementia
Sensitivity
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 age 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 nonpharmacological interventions
– Helps patients avoid situations that might cause harm