Download Cognitive Screening in Primary Care

Cognitive Screening in Primary
Care
Marilyn Malone, MHSc, MD, FRCPC
Geriatric Medicine
March 18, 2015
Objectives


Know how to define and differentiate mild cognitive
impairment from dementia syndromes.
Better understand the use of and interpretation of common
cognitive screening tools
Cognitive Screening in Primary Care



What is dementia? What is mild
cognitive impairment (MCI)?
Who is at risk?
Tool kit





Mini-Cog
Clock drawing
MoCA
MMSE
Case examples
What is Dementia?


Demonstrable impairment of memory (DSM-4)
Other impairment in at least one of:







Language (naming)
Judgment / executive function
Construction / visuospatial function
Abstraction
Personality
Impairment interferes with function and ADL
Insidious, and > 6 months (ICD-10)
What is Dementia?




DSM 5: neurocognitive disorder
Mild
Moderate
Severe
Dementia IS NOT
a test score
Collateral
history is
crucial …
Prevalence of Dementia in Canada
8% of 65+
yr olds
Almost 50%
of 85+ yr
olds
Who is at risk?

Age


Family Hx


Risk doubles every 5 yrs
Risk doubles for each 1st
degree relative
Cardiovascular disease

Risk doubles for each
vascular risk factor
Risk ≥ 15% justifies cognitive assessment.
AGE
%
<65
1
65
2
70
4
75
8
80
16
85
32
Case #1: Mr. A. Phib

You have known Mr. A. Phib, age 65, for about 3
years. He missed his last 2 routine appointments,
and you have concerns since it has been more
difficult to titrate his INR. You wonder if he stopped
taking his warfarin as prescribed. He has never
complained about memory, and has no family.
You wonder if he should have his memory checked.
He comes in for a 15 minute appointment. What
next?
Mr. Phib, age 65, 1 vascular risk factor
AGE
%
<65
1
65
2
70
4
75
8
80
16
85
32
Dementia risk is 2 x 2 = 4%
Due to low calculated risk, a full cognitive assessment isn’t usually
indicated. Therefore, you decide to do a “Mini-Cog” rather than an MMSE.
Mr. Phib, Mini-Cog Scenario 1:
Step 1: Register 3 words
Step 2: Draw a clock
Step 3: Word recall
Step 4: Score
Remembers 1 of 3 words
Normal clock, 1/3 words =
negative screen for dementia
Mr. Phib, Mini-Cog Scenario 2:
Step 1: Register 3 words
Step 2: Draw a clock
Step 3: Word recall
Remembers 2 of 3 words
Step 4: Score
Abnormal clock, 2/3 words =
positive screen for dementia
Collateral
history is
crucial …
Case #2: Ms. Diane Bettick




Ms. Diane Bettick, age 60, is well known to you, and has been your patient
for 20 years. She used to be a hospital administrator and has been
enjoying “the good life” since retiring 4 years ago. She is an avid golfer
and sometimes you see her forcing her clubs into the tiny trunk of her
convertible after finishing a round.
She has Type 2 DM with HbA1C of 6.8%, controlled HTN with BP 124/80,
stable ischemic heart disease, lipids well controlled on atorvastatin.
You have never worried about her cognition, but her husband says she is
having difficulty managing money. Also, he thought she seemed confused
and overwhelmed at the Heathrow airport when they went to visit relatives
over Christmas.
She comes in for a 15 minute appointment without her husband. What
next?
Ms. Bettick, age 60, 4 vascular risk factors
AGE
%
<65
1
65
2
70
4
75
8
80
16
85
32
Dementia risk is 1 x 2 x 2 x 2 x 2 = 16%
Due to high calculated risk, you decide to do a full screening test.
What test do you do?
Ms. Bettick, Mini-Cog:
Step 1: Register 3 words
Step 2: Draw a clock
Step 3: Word recall
Remembers 2 of 3 words
Step 4: Score
Abnormal clock, 2/3 words =
positive screen for dementia
Ms. Bettick
MoCA score 18/30
Now what?
Does she have a
dementia or not?
Ms. Bettick, Clock + MMSE
Temporal Orientation: “Spring, Saturday, April 8, 2010”
Spatial Orientation:
all correct
Registration:
one trial
Attention/Calculation:
DLORW
Recall:
2 out of 3
Naming:
all correct
Repetition:
all correct
3-stage command:
all correct
“CLOSE YOUR EYES”
correct
Written sentence:
“This is stupid”
Pentagon copy:
all correct
MMSE score 27/30
Now what?
Ms. Bettick, next steps






She failed the Mini-Cog, MMSE 27/30, MoCA 18/30
Collateral information from husband suggests there is
functional impairment (finances, travelling)
You correctly conclude that she has an early dementia
What about driving?
What about more investigations?
What about treatment?
Case #3: Miss Ida Frett

Miss Ida Frett is a new patient to you. She is a
retired school librarian, lives alone, and takes the
bus to church on Sundays. She takes various
vitamins and herbal remedies but no other
medications. She is terribly worried that she has
early Alzheimer’s disease and wants to get
“checked out.” Both parents had Alzheimer’s in
their late 80’s, and she just turned 84. What next?
Miss Frett, age 84, no vascular risk
factors, both parents had AD
AGE
%
<65
1
65
2
70
4
75
8
80
16
85
32
Dementia risk is 16 x 2 x 2 = 64%
Due to high calculated risk, you decide to do a full screening
test.
What test do you do?
Miss Frett, Clock + MMSE
Temporal Orientation: “Spring, Saturday, April 10, 2010”
Spatial Orientation:
all correct
Registration:
one trial
Attention/Calculation:
DLROW
Recall:
3 out of 3
Naming:
all correct
Repetition:
all correct
3-stage command:
all correct
Written sentence:
“You are the best doctor in the world”
Pentagon copy:
all correct
MMSE score 30/30
Now what?
Miss Frett
MoCA score
25/30
Now what?
Does she have a
dementia or not?
Miss Frett


You correctly determine that she has MCI
Her specific risk for dementia is:




12% per year
50% at 5 years
At 5 years, she has a 30% chance of being the same, and a 20%
chance of improvement without intervention
You ask your nurse to recheck the MoCA in 6
months.
Case #4: Mrs. Ima Strong

Mrs. Strong is an 86 year old lady with known
dementia and frequent falls. Her 90 year old
husband brought her in for an annual checkup – you
hear Ima yelling at him in the waiting room. Last
year she scored 23/30 on an MMSE, and you
recommended home supports that she promptly
fired. She doesn’t take any medications except
Ativan for sleep. Both Ima and her husband Ernest
look exhausted. Ima looks thin and disheveled, and
Ernie is trying not to cry. What next?
MMSE score 12/30
Now what?
Mrs. Strong, Clock + MMSE
Temporal Orientation: “Fall, September, 1929”
Spatial Orientation:
“Victoria, Canada”
Registration:
one trial
Attention/Calculation:
DLOD
Recall:
0 out of 3
Naming:
1 correct
Repetition:
“No ifs or buss”
3-stage command:
2 correct steps
“CLOSE YOUR EYES”
correct with a prompt
Written sentence:
“I love you”
Pentagon copy:
no overlap
Mrs. Strong




You are very worried about Ernie’s health and Ima’s
outbursts of rage
You identify verbal aggression as a key target
symptom for treatment.
You realize Ativan is a problem, but you also know
that atypical antipsychotics such as risperidone can
double mortality in demented patients
You refer Ima for specialist assessment
Symptom Progression in AD
30
25
Mild AD
 Forgetfulness
20
 Short-term
memory
loss
Moderate AD
MMSE
 Repetitive
15
questions
 Progression
of
cognitive deficits
 Hobbies,
interests lost
10
 Impaired
 Agitation
 Dysexecutive
instrumental
functions
5
Severe AD
 Aphasia
 Altered
sleep
patterns
syndrome
 Impaired
 Anomia
ADL
 Transitions
 Total
in care
0
1
2
3
4
5
Years
6
7
dependence:
dressing, feeding,
bathing
8
9
Adapted from Feldman & Woodward. Neurology. 2005;65:S10-7.
Management of Patients with Dementia
1.
Define specific target symptoms
A.
B.
C.
2.
3.
4.
ADL/IADL: e.g. household chores
BEHAVIOUR: agitation/aggression/apathy
COGNITION: memory, language, executive function
Consider rational pharmacologic treatment
Ensure non-pharmacologic management
Caregiver support, family education
Less Than Expected Decline:
An Appropriate Treatment Goal in AD
Hypothetical Treatment Expectations vs. Expected Decline in AD1
“…functional abilities, behaviour, caregiver burden, quality of life, and resource
utilisation all need to be comprehensively assessed to fully evaluate effects in
patients with AD…postponing or slowing decline in any of these areas may represent
an important clinical benefit.”2
1. Geldmacher DS, et al. J Nutr Health Aging 2006;10:417-29;
2. Winblad B, et al. Int J Geriatr Psychiatry 2001;16:653-66.
Dementia IS NOT
a test score
Key Points

Dementia:






IS loss of function due to cognitive loss
IS NOT a test score
Screen those at risk: 2 x 2 rule
Identify target symptoms: A, B, C
Consider non-pharmacologic and pharmacologic
treatments
First Link
Medical Management of Patients with
Dementia: avoid Pitfalls
Recommended Guidelines for Treatment of a
chronic disease may no longer apply.
1.
Diabetes
Hypertension
Simplify medications as much as possible
2.

3.
4.
Specialized diets
Avoid multiple doses, anticholinergics, benzodiazepines
Consider frailty and its impact on medical/surgical
management and prognosis
What is important to the patient?
CSHA Frailty Scale
1
Very fit
Robust/active/energetic/well motivated/fitexercise regularly - most fit group for age
2
3
Well
Without active disease - less fit than group 1
Well, with treated
co-morbid disease
Disease symptoms well controlled compared
with those in category 4
4
Apparently vulnerable
Not frankly dependent, commonly complain
being “slowed up” or have disease symptoms
5
Mildly Frail
With limited dependence on others for
instrumental activities of daily living
6
Moderately Frail
Help is need with both instrumental and noninstrumental activities of daily living
7
Severely frail
Completely dependent on others for activities of
daily living, or terminally ill