Transcript PMA 2020 Alzheimer*s Disease Curricula

ACT on Alzheimer’s
Disease Curriculum
Module VI: Screening
Screening
• These slides are based on the Module III:
Screening text
• Please refer to the text for all citations,
references and acknowledgments
2
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.
Screening
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 that screen positive
Screening 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
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
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
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
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
• SLUMS 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
• 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
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
• 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
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 65
• In busy primary care settings, the Mini-Cog
can be used
• Benefits of screening the asymptomatic
geriatric population are currently being
studied