ACT on Alzheimer’sDisease Curriculum

Module VI: Screening

Screening

• These slides are based on the Module VI: Screening text

• Please refer to the text for all citations, references and acknowledgments

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Module VI: 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 who screens positive

Screening 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

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

• 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

• 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• 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

• 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

• 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

• 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 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 age 65• In busy primary care settings, the Mini-Cog

can be used• Benefits of screening the asymptomatic

geriatric population are currently being studied