Download 0.92 vs MMSE: 0.81

UNC GERIATRIC ACE UNIT LECTURE SERIES
How to use this Guide:
1. Print out all pages in front/back format.
2. Pages 11-14 are handouts for the learners. Several copies should be printed.
3. Notes on the reverse of this page can be used as an outline for an introduction the scope of
dementia and use of the cognitive assessment tools.
4. If time allows, may include participation in any of the following ways (or others):
a. Have learners race through the Trails B
b. Have learners practice using a new cognitive assessment tool on each other.
UNC GERIATRIC ACE UNIT LECTURE SERIES
Cognitive Impairment and Assessment
A. Dementia / Major Neurocognitive Impairment
a. Prevalence
i. 5% of age 65 and older
ii. 15% of age 70 and older
iii. 35-50% of age 80 and older
b. Cost
i. total monetary cost of dementia in 2010 was between $157 billion and $215 billion
c. Definition (see appendix: DSM V excerpt)
d. Assessment
i. There are countless screening tools in the literature, we will review a subset of highly recognized tools
along with pros and cons of each
ii. Will also review tools for specific questions in cognitive impairment (TMTB and driving)
iii. Optional: trails making task B race between learners
e. Treatment
i. Cognition
1. All available medication modalities offer a modest, at best, improvement in function. There
are two major options
a. Anticholinesterase Inhibitors (Donepizil, Rivastigmine, Galantamine)
i. Side effects are not uncommon (dizziness, bradycardia, urinary incontinence,
hallucinations)
b. NMDA Receptor Antagonist (Memantine )
ii. Behavior
1. Nonpharmacologic Interventions are standard of care
a. Redirection
b. Soothing
c. Assessment for unmet needs (pain, pruritis, delirium, etc)
2. For behavior threatening safety of self or others: Antipsychotics
a. Black Box warning: 2.5 x increase in death with use of antipsychotics in this patient
population
i. Attributed to PNA and CV events
iii. Preventative / Adaptive
1. Early recognition of cognitive decline can spark discussion of advanced directives while a
patient can still participate thoughtfully.
2. Medical interventions may require proxy for consent or application of treatment plan (ie. Help
with medications).
Pros
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Cons
10-12 minutes
High predictive value for dementia and
MCI
Includes testing in a variety of cognitive
domains: executive function /
visuospatial, abstraction, attention,
complex language, orientation
Performs better in the highly educated
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Not as readily recognized as the MMSE
Length of time to complete worse for more
severely impaired
Still affected by illiteracy, visual and
auditory impairment
Does not assess praxises
Area Under the ROC
Curve:
MOCA: 0.92
vs
MMSE: 0.81
Pros
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Cons
10-12 minutes
High predictive value for dementia
Most easily recognized screening tool
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Ceiling effect in the highly education (does
not detect MCI well)
Floor effect in low education
Lacks testing of executive function,
complex verbal skills, delayed recall and
abstraction
Pros
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Cons
2-3 minutes to complete
High predictive value for dementia and
MCI
o Performs similarly to MMSE in
sensitivity and specificity
No printout/extra tools required
Easy to interpret
Can be used in all levels of education and
translated to almost any language
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Still affected by visual / hearing impairment
Pros
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Cons
10 or less minutes
Time to complete > 180 seconds
associated with driving safety issues
Included in the AMA endorsed testing for
the elderly driver
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Not specific for poor driving
Requires follow up assessment by
occupational therapy