Transcript ASCP Medi-Cog Presentation 2011

Katherine Anderson, PharmD, CGP, FASCP
Pharmacists International Consulting Specialists, ISU College of Pharmacy Affiliate Faculty
[email protected]
Annie Lam, PharmD, CGP, FASCP
Clinical Associate Professor, University of Washington School of Pharmacy
[email protected]
CE CODE: GGW668
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Disclosure
 Presenters Anderson and Lam have no conflict
of interest to report
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Professional Resources & Business Development
Learning Objectives
 Demonstrate the value of using cognitive and pillbox
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skills assessments for patients and caregivers to better
individualize patient medication education during care
setting transitions.
Administer and score Montreal Cognitive Assessment
(MoCA©).
Administer and score Mini-Cog©.
Administer and score pillbox organizational skills
assessments.
Interpret screening results and distinguish between
educable and non-educable patients and the degree to
which they can appropriately self-manage medications.
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Session Goals
 Learn or refine techniques in conducting cognition
and pillbox skills assessments
 Cognition: Montreal Cognitive Assessment (MoCA)
Mini-Cog
 Pillbox skills/literacy: Medication Transfer Screen (MTS)
 Cognition/pillbox skills/literacy: Medi-Cog
 Med organizational skills: Pillbox Assessment
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Introduction
 Medication non-adherence is associated with injury,
higher healthcare expenditures, loss of quality of life
 Health outcomes improve with pillbox use
 Efficient screens are needed to identify patients who
would benefit from pillbox education
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~77 Million Boomers
 Average medication compliance rate in developed
countries is ~50%1
 Non-adherence is associated with no pillbox usage2
 Medication continuation is associated with using
reminder tools such as a pillbox3
 Pillbox users demonstrate better adherence4
1. http://worldofdtcmarketing.com/medication-compliance-rates-in-developed-countries-of-just50-percent/cost-of-healthcare-in-the-u-s/. Accessed 8/31/2011.
2. Melloni C, et al. Predictors of early discontinuation of evidence-based medicine after acute
coronary syndrome.
Am J Cardiol. 2009 ; 104(2):175-81.
3. Kripalani S, et al. Medication use among inner-city patients after hospital discharge: patientreported barrier
and solutions. Mayo Clin Proc. 2008;83(5):529-35.
4. Zelikovsky N, et al. Perceived barriers to adherence among adolescent renal transplant candidates.
Pediatr
Transplant. 2008;12(3):300-8.
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New Paradigms for Pillbox
Education Are Needed
 Medication mismanagement - toll on QOL
 48% reported non-adherence to regimen after
hospital discharge3
 47% veterans reported unable to load their
pillboxes to an 80% accuracy at the time of hospital
discharge5
 Quick screening methods are needed to identify
patients who would benefit from pillbox
education starting in mid-life
5. Anderson K, et al. Identifying Patients at Risk for Medication Mismanagement: Using Cognitive Screens to
Predict a Patient’s Accuracy in Filling a Pillbox. Consult Pharm 2008;23(6):259-72.
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Identify at Risk Patients
 We need an efficient screening process
 Does the patient have adequate cognition and skills
to manage his/her medications safely?
 Is the patient a candidate for using a pillbox?
 If already using a pillbox, is it being loaded correctly?
 Dual screening
 Cognitive assessment
 Pillbox skills assessment
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Assessment Tools
 Need brief screens to assess patient level of
medication adherence and pillbox educability
 Mini-Cog© - validated cognitive screen
 Medication Transfer Screen (MTS) - public domain
 Medi-Cog (Mini-Cog+MTS) - developed as a brief
assessment for cognition, literacy, pillbox skills
 Identify patients who have cognitive deficit
 Alert for literacy deficits
 Flag patients who would benefit from pillbox education
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Montreal Cognitive Assessment
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MoCA Administration & Scoring
 ~15 minute, 30-point, validated cognitive screen
 Instructions for administration and scoring are
provided in handouts
 Sum all subscores listed on the right-hand side of form
to derive the total score
 Add one point for an individual who has 12 years or
fewer of formal education, for a possible maximum of 30
points
 A final total score of >26 is considered normal
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MoCA Administration & Scoring
Audience Participation
1) MoCA Form
2) MoCA Instructions
3) Pencil
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Mini-Cog Method
 2 minute screen - assesses for clinically significant
cognitive impairment
 Three item recall (TIR) - screener names 3
unrelated objects (banana/sunrise/chair); patient
repeats them back. Patient is told they will be
asked to recall the words in two minutes
 Clock drawing test (CDT) - subject is asked to
draw the face of a clock, then to draw the hands of
the clock depicting 11:10. “Ten minutes after
eleven.”
 After performing the CDT, the subject is asked to
recall the 3 words
6. Borson S, et al. J Am Geriatr Soc 2005;53:871-4.
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Clock Draw: Age 60 - Family Hx AD
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Numerical Order and Positioning
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Poor Planning or Wrong Time
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Macular Degeneration (not CI)
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Delirium
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Post CVA
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Mini-Cog Summary
1) Three Item Recall (TIR) – short term
memory
2) Clock Draw Test (CDT) – long term
memory, ability to sequence and locate, etc.
TIR - 1 point for each item recalled (0-3 possible)
CDT - 2 points for a correct clock; if all numbers are not
present, or not in correct sequence or position, the score
is zero (Either 2 or 0 points)
3) Score
All 3 words of TIR OR
Correct clock and recall at least one word
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Mini-Cog Scoring
 Mini-Cog – 2 part screen
 Three Item Recall (TIR) - 1 point for each item
recalled (0-3 possible)
 Clock Draw Task - 2 points for a correct clock; if
all numbers are not present, or not in correct
sequence or position, the score is zero
 Score 0-5 points
 Passing score >3
All 3 words of TIR OR
Correct clock and recall at least one word
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Mini-Cog Administration & Scoring
Audience Participation
1) Blank sheet of paper
2) Pencil
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Brief Pillbox Skills Assessment
 Gold standard pillbox assessment is to have the patient
load their own medications
 Time constraints limit this in the clinical setting
 5 minute screen to assess literacy and ability to
interpret prescription instructions
 Medication Transfer Screen (MTS) Form + pencil
 Adaptable to any clinical setting
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Medication Transfer Screen (MTS)
On the table write the number of pills as
instructed into the correct
compartments:
Example: TAKE ONE TABLET EVERY
DAY AT BEDTIME (Patient fills in
remaining slots).
1. TAKE ONE TABLET EVERY DAY IN
THE MORNING
S
M
T
W
Th
F
S
1
1
1
1
1*
1*
1*
Morn
Noon
2. TAKE ONE TABLET 3 TIMES DAILY
WITH MEALS
Eve
3. TAKE TWO TABLETS M-W-F IN THE
EVENING
4. TAKE ONE-HALF TABLET ON
SATURDAY AT BEDTIME
Bed
5. How many pills total are in the pill
box for the entire day of Saturday? __
Score: 1 point for each MTS question (0 to 5 points)
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MTS Instructions
 Demonstrate how the grid represents a pillbox
 Read the Example; explain that the marks represent
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pills in the “bedtime” compartments
Ask the patient to fill in the last three marks
Point out the four prescription directions
Remind to also read and perform instruction #5
Ask the patient to read each instruction and place the
“pills” in the pillbox independently
Reassure the patient all questions will be answered
upon completion of the exercise
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Medi-Cog
 Study 1 results demonstrated that Medi-Cog screen
scores correlated 0.72 with patient accuracy in loading
medications in a pillbox at time of hospital discharge.5
 Study 2 results 0.65 among highly cognitive community
dwellers7
 Screen utilized in various practice settings
 At time of discharge from hospital, LTC, SNF
 ALF admit and routine screen for self administered meds
 Community pharmacy
 Senior centers screenings
7. Lam AY, et al. A pilot study to assess cognition and pillbox fill accuracy by community-dwelling older
adults. Consult Pharm, 2011;26 (4), 236-43.
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Medi-Cog Administration & Scoring
Audience Participation
1) MTS Form
2) Pencil
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Pillbox Assessment Method
 Demonstrate how to use a 28-compartment pillbox
(open lids, locate the four compartment rows for
morning, noon, eve, bedtime, and instruct to load
medications as described on pill vials)
 Reassure questions will be answered after
completing the task
 Patients load personal medications independently
without any prompting
 After scoring, assist the patient in correcting any
mistakes and provide appropriate education
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Pillbox Assessment Score Form
Dosing Frequency Categories
#
Meds
# Correctly
loaded pills
Total
# pills
# Correct /
Total # pills
Point
Daily/HS
BID
TID
QID
Taper or irregular dosing
# Pillbox rows correctly loaded
Row ratio
__ / 4
Total points/ # entries
Point Key
100%=1; 75=0.75; 0.8 = “passing”
Pillbox Fill
Score
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Pillbox Fill Scoring Method
 Tally all meds by dosing frequency category and
enter under # Meds
 Quantify accuracy by counting correct # Pills in
each category
 Calculate the row ratio score (measures
understanding of dosing frequency)
 Tally points and divide by the # Entries to derive
the Pillbox Fill Score
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Pillbox Fill (PBF) Scoring Method
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Count correct #pills in each QD, BID, TID category
Each correct pillbox row (M – N – E – Bed) = 0.25 point
Add the # of correctly loaded rows for a “global” score
Two correct rows out of four in pillbox = 2/4 = 0.5 pt
Tally points of ALL the category totals and divide by the
total # entries to derive the PBF Score
Example
 Daily/HS 21/21 = 100%
1.0 point
 BID 14/14 = 100%
1.0 point
 TID 28/42 = 50%
0.5 point
 Row Score = 50%
0.5 point
Pillbox Fill Score
3.0 / 4 entries – 0.75
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Self-Assessment Questions
1. How many points are awarded to a Clock Draw Test
(CDT) in the Mini-Cog© scoring rubric?
A. 0 point
B. 1 point
C. 2 points
D. Either A or C
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Self-Assessment Questions
1. How many points are awarded to a Clock Draw Test
(CDT) in the Mini-Cog© scoring rubric?
A. 0 point
B. 1 point
C. 2 points
D. Either A or C
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Self-Assessment Questions
2. In the Mini-Cog© scoring rubric, how many points are
awarded for the correct recall of three words in the
Three Item Recall (TIR)?
A. 1 point
B. 2 points
C. 3 points
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Self-Assessment Questions
2. In the Mini-Cog© scoring rubric, how many points are
awarded for the correct recall of three words in the
Three Item Recall (TIR)?
A. 1 point
B. 2 points
C. 3 points
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Self-Assessment Questions
3. The Medi-Cog is comprised of which of the following
screens?
A. Clock Draw Test (CDT)
B. Three Item Recall (TIR)
C. Medication Transfer Screen (MTS)
D. All of the above
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Self-Assessment Questions
3. The Medi-Cog is comprised of which of the following
screens?
A. Clock Draw Test (CDT)
B. Three Item Recall (TIR)
C. Medication Transfer Screen (MTS)
D. All of the above
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Self-Assessment Questions
4. A patient scores 1 of 5 points on the Medication
Transfer Screen (MTS). Other than cognitive
impairment, select a reason why the patient may have
failed the screen.
A. The patient was tired when he was screened.
B. The patient is unable to read.
C. The patient had never done a task like this before
and didn’t understand the instructions.
D. The patient was not wearing his glasses.
E. All of the above
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Self-Assessment Questions
4. A patient scores 1 of 5 points on the Medication
Transfer Screen (MTS). Other than cognitive
impairment, select a reason why the patient may have
failed the screen.
A. The patient was tired when he was screened.
B. The patient is unable to read.
C. The patient had never done a task like this before
and didn’t understand the instructions.
D. The patient was not wearing his glasses.
E. All of the above
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Self-Assessment Questions
5. Having the patient fill their pillbox with their own medications
gives us the real information we need. Why administer the MediCog when it only predicts pillbox loading accuracy?
A. Patients may not have their medications with them.
B. Time constraints may not allow adequate time to have a patient
demonstrate pillbox loading accuracy.
C. Medi-Cog is a brief 7-minute paper and pencil screen that can
be done regardless of setting.
D. Medi-Cog results give us information regarding short & long
term memory, literacy skills, and a ball park idea of how well they
might load their pillbox with meds.
E. All of the Above
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Self-Assessment Questions
5. Having the patient fill their pillbox with their own medications
gives us the real information we need. Why administer the MediCog when it only predicts pillbox loading accuracy?
A. Patients may not have their medications with them.
B. Time constraints may not allow adequate time to have a patient
demonstrate pillbox loading accuracy.
C. Medi-Cog is a brief 7-minute paper and pencil screen that can
be done regardless of setting.
D. Medi-Cog results give us information regarding short & long
term memory, literacy skills, and a ball park idea of how well they
might load their pillbox with meds.
E. All of the Above
45
References
1. http://worldofdtcmarketing.com/medication-compliance-rates-in-developedcountries-of-just-50-percent/cost-of-healthcare-in-the-u-s/. Accessed 8/31/2011.
2. Melloni C, et al. Predictors of early discontinuation of evidence-based medicine
after acute coronary syndrome. Am J Cardiol. 2009;104(2):175-81.
3. Kripalani S, et al. Medication use among inner-city patients after hospital
discharge: patient-reported barrier and solutions. Mayo Clin Proc.
2008;83(5):529-35.
4. Zelikovsky N, et al. Perceived barriers to adherence among adolescent renal
transplant candidates. Pediatr Transplant. 2008;12(3):300-8.
5. Anderson K, et al. Identifying Patients at Risk for Medication Mismanagement:
Using Cognitive Screens to Predict a Patient’s Accuracy in Filling a Pillbox.
Consult Pharm 2008;23(6):259-72.
6. Borson S, et al. J Am Geriatr Soc 2005;53:871-4.
7. Lam AY, et al. A pilot study to assess cognition and pillbox fill accuracy by
community-dwelling older adults. Consult Pharm, 2011;26 (4), 236-43.
46