Download Module III - ACT on Alzheimer`s

Running head: COGNITIVE ASSESSMENT
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ACT on Alzheimer’s
Alzheimer’s Disease Curriculum
Module V – Cognitive Assessment and the Value of Early Detection
GUIDELINES AND RESTRICTIONS ON USE OF DEMENTIA CURRICULUM MODULES
This curriculum was created for faculty across multiple disciplines to use in existing coursework
and/or to develop as a stand-alone course in dementia. Because not all module topics will be
used within all disciplines, each of the ten modules can be used alone or in combination with
other modules. Users may reproduce, combine, and/or customize any module text and
accompanying slides to meet their course needs.
Use restriction: The ACT on Alzheimer's®-developed dementia curriculum cannot be sold in its
original form or in a modified/adapted form.
NOTE: Recognizing that not all modules will be used with all potential audiences, there is some
duplication across the modules to ensure that key information is fully represented (e.g., the
screening module appears in total within the diagnosis module because the diagnosis module will
not be used for all audiences).
© 2016
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Acknowledgement
We gratefully acknowledge the funding organizations that made this curriculum development
possible: the Alzheimer’s Association MN/ND and the Minnesota Area Geriatric Education
Center (MAGEC), which is housed in the University of MN School of Public Health and is
funded by the Health Resources and Services Administration (HRSA).
We specifically acknowledge the principal drafters of one or more curriculum modules,
including Mike Rosenbloom, MD; Olivia Mastry, MPH, JD; Gregg Colburn, MBA; and the
Alzheimer’s Association.
In addition, we would like to thank the following contributors and peer review team:
Michelle Barclay, MA
Terry Barclay, PhD
Marsha Berry, MA, CAEd
Erin Hussey, DPT, MS, NCS
Sue Field, DNP, RN, CNE
Julie Fields, PhD, LP
Jane Foote EdD, MSN, RN
Helen Kivnik, PhD
Kenndy Lewis, MS
Riley McCarten, MD
Teresa McCarthy, MD, MS
Lynne Morishita, GNP, MSN
Becky Olson-Kellogg, PT, DPT, GCS
Jim Pacala, MD, MS
Patricia Schaber, PhD, OTR/L
John Selstad
Ericka Tung, MD, MPH
Jean Wyman, PhD., RN, GNP-BC, FAAN, FGSA
This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health
Resources and Services Administration (HRSA), Department of Health and Human Services
(DHHS) under Grant Number UB4HP19196 to the Minnesota Area Geriatric Education Center
(MAGEC) for $2,192,192 (7/1/2010—6/30/2015). This information or content and conclusions are
those of the author and should not be construed as the official position or policy of, nor should any
endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.
Minnesota Area Geriatric Education Center (MAGEC)
Grant #UB4HP19196
Director: Robert L. Kane, MD
Associate Director: Patricia A. Schommer, MA
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Overview of Alzheimer’s Disease Curriculum
This is a module within the Dementia Curriculum developed by ACT on Alzheimer’s. ACT on
Alzheimer’s is a statewide, volunteer-driven collaboration seeking large-scale social change and
community capacity-building to transform Minnesota’s response to Alzheimer’s disease. An
overarching focus is health care practice change to ensure quality dementia care for all.
All of the dementia curriculum modules can be found online at www.ACTonALZ.org.
Module I:
Disease Description
Module II:
Demographics
Module III:
Societal Impact
Module IV:
Effective Interactions
Module V:
Cognitive Assessment and the Value of Early Detection
Module VI:
Screening
Module VII: Disease Diagnosis
Module VIII: Dementia as an Organizing Principle of Care
Module IX:
Quality Interventions
Module X:
Caregiver Support
Module XI:
Alzheimer’s Disease Research
Module XII: Glossary
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ACT on Alzheimer's has developed a number of practice tools and resources to assist providers
in their work with patients and clients who have memory concerns and to support their care
partners. Among these tools are a protocol practice tool for cognitive impairment, a decision
support tool for dementia care, a protocol practice tool for mid- to late-stage dementia, care
coordination practice tools, and tips and action steps to share with a person diagnosed with
Alzheimer's. These best practice tools incorporate the expertise of multiple community
stakeholders, including clinical and community-based service providers:
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Clinical Provider Practice Tool
Electronic Medical Record (EMR) Decision Support Tool
Managing Dementia Across the Continuum
Care Coordination Practice Tool
Community Based Service Provider Practice Tool
After A Diagnosis
While the recommended practices in these tools are not location-specific, many of the resources
referenced are specific to Minnesota. The resource sections can be adapted to reflect resources
specific to your geographic area.
To access ACT practice tools and resources, as well as video tutorials on screening, assessment,
diagnosis, and care coordination, visit: http://actonalz.org/provider-practice-tools
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Module V: Learning Objectives
Upon completion of this module the student should:

Identify tips for detection of cognitive impairment and the use of observation as an
assessment tool.

List and describe a variety of cognitive tools for conducting assessments and demonstrate an
understanding of the recommended course of action when cognitive impairment is identified.

Articulate the value of early detection of Alzheimer’s disease.
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Module V
Cognitive Assessment and the Value of Early Detection
Case Study:
Mr. Johnson, a 71 year-old man with a history of diabetes who currently lives alone, is
brought into the clinic by his son, Dave. Mr. Johnson does not believe he has any
significant memory problems, yet Dave describes 2.5 years of progressive memory
deficits characterized by increasing late fees while paying bills and difficulty maintaining
the household. Over the past three months, Dave has received repeated phone calls from
his father in which he complains repeatedly about losing items around the household. At
one point, he wondered whether somebody was stealing his keys and reading glasses.
Originally, Dave suspected that his father was fixated on this topic but, over time, it
became clear that he had forgotten about the original conversations. His cognitive
review of systems is remarkable for forgetting appointments and becoming lost while
driving in familiar neighborhoods. Dave mentions that he is worried about his dad’s
driving as well. He denied any specific symptoms for depression.
The past medical history includes diabetes and hypertension. He was previously on a
more complicated medication regimen aiming for “tighter” blood sugar control. He is
now taking metformin, which is taken two times a day, lisinopril, and a baby aspirin,
which can be taken once a day. He will occasionally take Tylenol PM (with
diphenhydramine) at night for sleep. The primary provider is hoping that simplifying the
medication regimen will make it easier for Mr. Johnson to follow instructions accurately.
Mr. Johnson is a retired janitor with a high school education. No active smoking or
drinking. There is a family history of Alzheimer’s disease in his father who developed
symptoms at age 81.
Neurological exam was non focal. Neuropsychological screening showed a MoCA=21
(losing points for cube copy, 1/5 words after 5 minutes [could not recognize when given a
list], orientation to date, clock draw).
Laboratory studies showed normal complete blood count, electrolytes, LFTs, glucose,
thyroid stimulating hormone, and B12 levels. A referral was made for
neuropsychological testing: Mr. Johnson showed severe deficits in learning and memory,
moderate deficits in visuospatial function, and mild executive impairments. The Geriatric
Depression Scale score was 2 and within normal limits. Brain MRI was positive for
bilateral hippocampal and parietal atrophy, but no evidence for stroke or focal lesions.
Mr. Johnson was diagnosed by his primary provider with probable Alzheimer’s disease.
Dave inquired about any interventions that can possibly slow or treat the disease
process. It is clear that Dave is distressed about his father’s new diagnosis. He has many
questions about his father’s safety and how he can proactively take steps to ensure his
dad’s well-being.
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Early Detection as a Critical Gateway to Beneficial Interventions
Both the prevalence and incidence of Alzheimer’s disease are increasing rapidly, yet fewer than
50% of individuals with the disease actually receive the diagnosis in primary care (Kerwin,
2009), (Borson, 2006), (Valcour, 2000). Difficulty in making a diagnosis is in no way confined
to primary care; in a study of centers for Alzheimer’s disease where patients were followed to
neuropathological examination, the sensitivity ranged from 70%-87.3% and specificity from
44.3-70.8% (Beach TG J Neuropathol Exp Neurol, 2012). Even among those who are identified,
these individuals often receive the diagnosis late in the disease process, which prevents them
from accessing information, guidance, support, and effective interventions that improve quality
of care and life as well as reduce direct and indirect health care costs (Borson, 2006). Healthcare
providers play a critical role in detecting the disease and providing a diagnosis, which then
serves as a gateway to information, guidance, and supportive interventions.
Early detection can be very challenging as the symptoms of Alzheimer’s and related dementias
develop slowly and may go unnoticed even by those who are in close contact with the
cognitively impaired individual. This issue is further complicated by the fact that many
individuals with dementia often lack insight into their cognitive decline, a common characteristic
of dementia that can prevent them from reporting their problems.
In recent years, the concept of cognitive screening in the primary care setting prior to the
development of cognitive symptoms has been introduced as a strategy to facilitate early
detection. Cognitive screening has been shown to increase the rate of detection and increase
physician response rates in providing dementia appropriate care (Borson, 2006). Yet, in contrast
to common medical conditions such as diabetes and cancer, screening is not routinely performed
to facilitate early Alzheimer’s disease (AD) detection within the healthcare setting. With the
limited efficacy of currently approved treatments, there has been reluctance among the medical
profession toward adopting a cognitive screen in the elderly population. In addition, a “goldstandard” cognitive screening test has not yet been defined, and the US Preventative Services
Task Force does not currently recommend cognitive screening in the asymptomatic population
due to lack of studies addressing potential benefits (USPSTF, 2003). However, it is important
that a systemic process toward diagnosis be developed within the healthcare system to address
the growing Alzheimer’s population.
Research is still emerging as to any direct health benefits resulting from performing a cognitive
assessment in the asymptomatic geriatric population. A recent systemic review of the literature
failed to identify any investigations addressing the relationship between cognitive screening in
primary care and clinical outcomes (Lin, et al., Annals of Internal Medicine, 2013). However,
studies have shown indirect benefits of cognitive assessment: individuals with diagnosed
dementia who receive dementia-specific care have a better quality of overall medical care than
those not receiving such care (Callahan, et al., 2006), (Vickrey, et al., 2006). Quality
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interventions producing health benefits include certain drugs in early stages of the disease,
effective care coordination, caregiver support, and overall care management (Boustani, et al,
2003), (Callahan, et al., 2006), (Mittelman, et al., 2006), (Wolfs, et al., 2009). In addition, AD
that is undetected may impact a patient’s compliance with medications and management of
chronic disease, and initial studies have shown that patients with dementia have a higher rate of
non-compliance (Fiss, et al., 2012). Finally, potentially preventable hospitalizations are higher
in individuals with dementia (Phelan, EA JAMA, 2012) and that cognitive screening, followed
by quality care and management, may result in healthcare cost savings (Getsios, et al., 2011). An
economic forecasting study modeled the impact of implementing dementia screening, diagnostic
work-up, and treatment for AD in primary care and estimated that direct annual savings for
Medicare & Medicaid Services could be as much as $22 billion in 2025 and $29 billion in 2050
(Boustani MA, Jermoumi R., 2012).
The hypothetical drawbacks to cognitive screening appear rather minimal, mostly related to time
of administration and potential psychological consequences in patients found to demonstrate
positives on screening tests. There are currently no studies directly addressing the adverse
psychological effects of screening or adverse effects from false positive or negative screening
tests (Lin, et al., Annals of Internal Medicine, 2013). The financial cost of cognitive screening is
relatively modest with the majority of spending deriving from the diagnostic testing that is
generated from a positive screening test (Borson et al., 2013) Extensive investigation of the
cost-effectiveness of cognitive screening has yet to be performed.
Practice Tips for Detection
Even when symptoms are present, not all patients will present with memory loss or cognitive
impairment as their chief complaint. There may be subjective changes and observations on the
part of the healthcare provider that indicate an undiagnosed cognitive disorder. These
observations include:
• Forgetting medications
• Deferring to care partner for medical history
• Repeated phone calls to the provider
• Reported unusual sleeping habits
• Inappropriate clothing, behaviors, or speech
• Personal hygiene issues
• Excessive weight gain or loss
• Change in gait
• Mood changes
The primary care provider, geriatrician, nurse practitioner, social worker, occupational or
physical therapist, and other health providers will have multiple encounters with geriatric
patients for medical conditions who may also be experiencing a cognitive disorder. Providers can
best fulfill their detection role by: 1) watching for indicators of dementia; and 2) using validated
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assessment tools. There are several pieces of knowledge that may provide early insights into an
underlying memory disorder. Providers will increase the likelihood of uncovering dementia
through the following actions:
• Raising expectations regarding the person in question rather than assuming issues are
simply normal aging.
• Conducting a clinical interview in which the individual is allowed to answer questions
without help.
• Noticing whether the individual’s social skills remain intact. It is easy to be fooled by a
sense of humor, irritability, reliance on old memories, or a quiet/affable demeanor.
• Noticing whether the individual repeats him/herself, provides tangential, circumstantial
responses, or loses track of the conversation.
• Obtaining family observations through questionnaires or interview:
– “Let’s suppose your family member was alone on a domestic flight across the
country and the trip required a layover with a gate change. Would he/she be able
to manage that kind of mental task on his/her own?”
• Checking in on mental status, for example, an intact older adult should be able to:
– Describe two current events in some detail
– Describe what happened on 9/11, New Orleans disaster
– Name the current president
– Describe his/her medical history and names of some medications
• Recognizing that subjective interviews have been shown to fail to detect dementia in
early stages and relying instead upon formal assessment tools.
Cognitive Screening during Medicare Wellness Visits
Cognitive assessment using validated assessment tools is another way that providers can further
effective and early detection of dementia. On January 1, 2011, Medicare began reimbursing for
an annual check-up/physical, referred to as the “annual wellness visit.” Included within the
wellness visit is reimbursement for cognitive assessment for cognitive impairment. This policy
change represents a significant departure from traditional practice where patients would undergo
cognitive screening following symptom onset. Several national organizations including the
Alzheimer’s Association and the National Institute on Aging (NIA) have strived to use the
annual wellness visit to operationalize the detection of dementia within the population (Borson et
al., 2013). Wellness visits may be performed by a doctor, nurse practitioner, physician assistant,
clinical nurse specialist, or other health professional. Thus, providers can be reimbursed for an
annual cognitive assessment regardless of whether they see indicators of dementia.
Initial Considerations for Cognitive Assessment
There are multiple cognitive assessment tools available to providers to aid in the diagnosis of
dementia and Alzheimer’s disease. It is suggested that vulnerable elderly patients undergo a
cognitive assessment at their initial visit and annually thereafter. The decision on the cognitive
assessment tool should be based on the clinical context. For instance, a rapidly administered
screen with relatively high sensitivity for MCI/AD would be optimal for screening asymptomatic
patients within the primary care setting. On the other hand, a longer screening test may improve
sensitivity for detection in environments where providers have 20-30 minutes to assess a patient.
Thus, the provider will need to strike a balance between time devoted to cognitive assessment
and the sensitivity/specificity. In addition, a decision should be made about who will administer
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the test as administration may be performed by physicians, nursing staff, social workers, or allied
staff professionals. See Clinical Provider Practice Tool http://www.actonalz.org/providerpractice-tools.
Finally, there should be a pathway for intervention should any patients screen positive for
cognitive impairment on the screening test. See the intervention checklist in:
ACT on Alzheimer’s Clinical Provider Practice Tool
http://www.actonalz.org/provider-practice-tools
General Cognitive Assessment Tips
There are a number of steps one can take to more effectively administer a cognitive assessment
test. First, a relaxed demeanor is important. It will hopefully put the patient at ease. Second,
clearly explain the test to the patient and let them know what to expect. Certain questions will be
more difficult, while others will be easier. Encourage the patient to simply do his/her best. The
tester should continue to support the patient throughout the test, especially if the patient is
struggling.
While it is important to foster a nurturing environment for the patient, one should not do
anything to reduce the value/reliability of the test results. The following is a list of actions a
tester should avoid:
 Do not allow the patient to give up prematurely.
 Do not deviate from standard instructions.
 Do not offer multiple choice answers.
 Do not bias the score by coaching.
 Do not be generous in scoring; score ranges already incorporate normal errors.
List of Cognitive Assessment Measures
There are a number of cognitive assessment measures available to providers. Each test has its
own benefits and drawbacks and the provider needs to determine which test will best serve the
interests of his/her patients and the practice. In addition, the screening tests have been studied in
the context of Alzheimer’s disease, and their sensitivity/specificity with respect to the various
non-Alzheimer’s dementias (e.g. frontotemporal degeneration or Parkinson’s disease dementia)
remains to be studied.
Mini-Cog
The Mini-Cog (MC) is a 5 point cognitive screen that incorporates three-word verbal recall (3
points) and a clock draw (2 points; 1 point for numbers and 1 point for clock hands; N.B. length
of hands do not impact the score) (Borson, et al., 2000). The subject is first given three words to
register followed by a clock draw. After the drawing of the clock (which can be created either
from scratch or by filling in a pre-drawn circle), the subject is asked to recall the three words.
Studies have shown that the word choice may increase the sensitivity of the screen with the most
sensitive word combination being “leader, season, table” (McCarten, et al., 2011). In addition,
the clock draw is particularly more sensitive when the examiner uses phrasing that is more
abstract by instructing the patient to set the time to “10 past 11” as opposed to 11:10. Originally,
the MC screening test was validated using a cutoff score of <3 representing failure, but due to
concerns about sensitivity, more recent studies have used a score <4 to distinguish pass from
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failure (McCarten, et al., 2011). Advantages of the test include the ability to cover a broad range
of cognitive modalities including executive function, memory, and visuospatial function during a
short administration time ranging from 1.5-3 minutes, making this test ideal for the rushed
primary care setting (McCarten, et al., 2011). Furthermore, the performance on this test is not
affected by education or language (Borson, et al., 2000). Recent studies have compared the MiniCog with the Mini Mental Status Exam (MMSE), which often requires seven or more minutes to
administer, and have demonstrated similar sensitivity and specificity (MC vs MMSE: 76% vs.
79% sensitivity and 89% vs. 88% specificity) (Borson, et al., 2003). On the downside, the MiniCog is not considered to be as sensitive to mild cognitive impairment (MCI) or early dementia as
more elaborate cognitive assessment tools, such as the Montreal Cognitive Assessment (MoCA).
Partly due to the Mini-Cog’s ease of training and administration, several studies have evaluated
the tool as a dementia cognitive assessment test within elderly populations free of cognitive
disorders. Borson and colleagues administered the test to 524 subjects aged ≥65 in the primary
care and geriatric clinic setting (Borson, et al., 2007). The investigators found that there was an
18% failure rate and that the test did not disrupt clinic flow. Interestingly, only 17% of providers
took appropriate action for patients failing the test. McCarten and colleagues administered the
Mini-Cog in 8,342 patients aged ≥70 in the setting of a VA hospital. It was found that the screen
was well-accepted by older veterans and detected a 25.8% failure rate among the asymptomatic
population (McCarten, et al., 2011). Currently, several Minnesota-based hospital systems such
as HealthPartners and the Minneapolis VA are examining the benefits of integrating the MiniCog into the annual wellness visit for the geriatric population.
Mini-Cog Administration and Scoring tutorial videos:
http://www.actonalz.org/video-tutorials
Mini-Mental State Exam (MMSE)
http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE
The Mini Mental State Examination (MMSE) is one of the most commonly used cognitive
assessment tools for dementia developed by Folstein in 1975 (Folstein, et al., 1975). The test is a
30-point scale consisting of questions addressing orientation, memory, visuospatial construction,
and language. Scores ≥24 are considered normal (although recently dementia specialists have
increased the cutoff score to 26). The test can usually be administered within a seven-minute
time period. Traditionally, most dementia centers have been using the MMSE as a screen in
patients with memory loss, and the test is often incorporated as a cognitive marker within clinical
trials.
One of the primary limitations of the MMSE is that the test has a low “ceiling,” and it is not
uncommon for patients with cognitive disorders to score within the normal range. The screen
was developed prior to the concept of mild cognitive impairment. Consequently, the test has an
18% sensitivity for MCI and a 78.7% sensitivity for dementia (Ismail, et al., 2010). In addition,
the screen is heavily weighted toward language function and, therefore, may over-exaggerate
disability in patients with primary language disorders. The MMSE also does a poor job of
addressing executive function and patients with frontal deficits may score normally. Finally, the
MMSE is copyrighted which constrains free usage of the tool.
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St. Louis University Mental Status Exam (SLUMS)
http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
The Saint Louis University Mental Status Exam (SLUMS) was developed at Saint Louis
University and was one of the first cognitive assessment tests to address mild cognitive disorders
in addition to dementia (Tariq, et al., 2006). Performance outcome is divided into normal, mild
neurocognitive disorder (based on Diagnostic and Statistic Manual-IV criteria), and dementia,
and the screen adjusts the normal scores based on education. The test uses a 30-point scale
similar to the MMSE, but it requires more time to administer compared to the MMSE
(approximately 10 minutes). The test is superior to the MMSE in terms of addressing executive
function and includes questions related to orientation, calculation, word generation, working
memory, and visuospatial construction.
The benefits of SLUMS include tasks addressing higher-level executive functions, as well as
increased sensitivity for cognitive disorders compared to the MMSE. The test has a 92%
sensitivity for MCI, 100% sensitivity for dementia, and 81% specificity for dementia. The screen
is available free online which increases its usability.
Drawbacks to the SLUMS include the complexity of the screen and increased time of
administration. Furthermore, the test has less name recognition compared to the MMSE.
SLUMS Administration and Scoring tutorial videos:
http://www.actonalz.org/video-tutorials
Montreal Cognitive Assessment (MoCA)
www.mocatest.org
The Montreal Cognitive Assessment (MoCA) is a 30-point scale that was developed at the
Montreal Neurological Institute (Nasreddine, et al., 2005) and is one of the most sensitive and
specific cognitive screens available. The screen builds upon prior tests by providing tasks
related to executive function in addition to language, visuospatial function, and memory. Studies
suggest that individuals with ≤12 years of education have lower average scores on the test, so an
additional point is given to this population during final scoring.
The sensitivity of the test for MCI is 90% and 100% sensitivity for dementia (Nasreddine, et al.,
2005). The specificity is 87% for dementia (Nasreddine, et al., 2005). Studies have shown that
the MoCA is more sensitive, but less specific than the MMSE (Larner, 2012). Thus, the MoCA is
a sufficient screen to capture patients in the earlier stages of MCI. In contrast to the MMSE, the
MoCA includes tasks that are sensitive in detecting impairments in executive function and can
distinguish word retrieval (found in frontal dysfunction) from recognition deficits (found in AD
and disorders of medial temporal function). Other advantages include the fact that the test is free
online and available in over 35 languages.
The major drawback with the MoCA is that the test requires 12-15 minutes to administer and
requires more intensive training for healthcare providers and therefore may be considered
impractical in certain clinical environments. This particular screen would be ideal in a neurology
specialty care environment. In addition, a population-based sample of ethnically diverse subjects
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showed that 66% of individuals fell below the suggested cutoff of 26, thus indicating the need to
take into account demographic factors when interpreting test scores (Rossetti, et al., 2011).
As a result of the screen’s ability to incorporate executive function, the MoCA has been studied
to detect cognitive impairment and dementia in non-AD conditions impacting cognition
including vascular cognitive impairment and vascular dementia (Dong, et al., 2012), Parkinson’s
disease (Dalrymple-Alford, et al., 2012), and obstructive sleep apnea (Chen, et al., 2011).
MoCA Administration and Scoring tutorial videos:
http://www.actonalz.org/video-tutorials
Kokmen Test of Mental Status
The Kokmen is a mental status cognitive assessment test that was developed at the Mayo Clinic
(Kokmen, et al., 1987). The screen consists of 38 points and has questions relating to orientation,
attention, learning, calculation, abstraction, semantic memory, construction, and recall. Scores
≥36 are considered normal, 30-35 consistent with MCI, and ≤29 indicative of dementia. Based
on the initial study published in 1987, the test has a sensitivity of 92% and specificity of 91%
when 29 is used as a cutoff for dementia (Kokmen, et al., 1987).
The test requires more time than the MMSE to administer, but has greater sensitivity for
detecting cognitive impairment with a greater sensitivity for MCI, largely due to including a
longer word list for recall, copying of a three-dimensional cube, and testing of working memory.
The test is distinct from the other screens in that it uses a 38-point scale.
http://www.ncbi.nlm.nih.gov/pubmed/3561043
AD8 Dementia Screening Interview
The AD8 is an eight-item questionnaire that can aid in the diagnosis of dementia. It is unique in
that it is administered to an informant, such as a caregiver, rather than the patient. The cognitive
domains include: orientation, executive functions, and interests in activities. It is to be noted that
this is only a screening test; if the result is abnormal, a more thorough assessment is indicated.
http://alzheimer.wustl.edu/About_Us/PDFs/AD8form2005.pdf
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Module V: Questions for Review
1. Mr. Garcia is a 72-year-old man who is new to your primary care practice. He is a
retired restaurant owner and resides in the community in his own home. Today he is
in the office for diabetes follow-up. As you gather further history from him, you note
that he doesn’t seem like himself today. He appears slightly disheveled, and when
asked about his blood sugars, he readily gets confused. When you examine his
medication bottles, you note that he has brought an extra bottle of a blood pressure
medication that was discontinued several months ago. You voice your concerns
about the change in his behavior and memory. He jokes with you that “can’t an old
guy like me forget a thing or two?” What should you do next?
a. Schedule a follow-up visit in 3 months for re-assessment of his memory.
b. Refer him for neuropsychological testing.
c. Order an MRI of the brain.
d. Ask his permission to contact his family members for collateral history.
2. Mr. Garcia returns to your office with his daughter, with the primary concern of
memory loss, noted by his family. His daughter tells you that he has gotten lost on
his way home from the local mall and that he missed an appointment with his dentist
last month. These are very uncharacteristic behaviors for him. Upon learning more
about his social history, you find that he immigrated to the US at age 50, from
Mexico, and feels much more comfortable discussing medical concerns in his native
language. Which of the following tests can you utilize for a mental status
examination in Spanish?
a. Mini Mental Status Examination
b. Montreal Cognitive Assessment
c. Short Test of Mental Status
d. St. Louis University Mental Status Examination
e. Mini-Cog
3. Which of the following observations should prompt a primary care provider to
consider new cognitive impairment?
a. Worsening blood pressure control in a patient with previously controlled
hypertension
b. Multiple missed appointments
c. Repeated phone calls to your office
d. Unusual sleeping habits such as dream re-enactment
e. All of the above
4. The US Preventive Services Task Force makes which of the following
recommendations about screening the general population for dementia?
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a. All adults aged 65 and older should be screened for dementia in the primary
care setting.
b. All adults aged 75 and older should be screened for dementia in the primary
care setting.
c. There is insufficient evidence to assess the balance of risks and benefits of
cognitive screening in the general population.
d. All adults should undergo neuropsychological testing as part of their Welcome
to Medicare Visit.
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References
Beach TG, Monsell SE, Phillips LE, Kukull W. (2012). Accuracy of the clinical diagnosis of
Alzheimer disease at National Institute on Aging Alzheimer’s Disease Centers, 20052010. J Neuropathol Exp Neurol. 2012 Apr; 71(4):266-73.
Borson, Soo et al. (2013). Improving dementia care: The role of screening and detection of
cognitive impairment. Alzheimer's & Dementia: The Journal of the Alzheimer's
Association, Volume 9, Issue 2, 151 – 159.
Borson, S., Scanlan, J., Brush, M., Vitaliano, P. & Dokmak, A. (2000). The mini-cog: a
cognitive 'vital signs' measure for dementia cognitive assessment in multi-lingual elderly.
International Journal of Geriatric Psychiatry, 15(11):1021-1027.
Borson, S., Scanlan, J.M., Chen, P. & Ganguli, M. (2003). The Mini-Cog as a screen for
dementia: validation in a population-based sample. Journal of the American Geriatric
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Websites and Web Based Resources
ACT on Alzheimer’s Provider Practice Tool
http://www.actonalz.org/provider-practice-tools
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Guidelines for the Detection and Diagnosis of Alzheimer’s and other Dementias “Detection,
Diagnosis and Management of Dementia,” American Academy of Neurology
http://www.aan.com/professionals/practice/pdfs/dementia_guideline.pdf
Mini-mental state examination
http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE
Montreal Cognitive Assessment www.mocatest.org
Saint Louis University Mental Status
http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
US Preventive Services Task Force. Screening for dementia: recommendations and rationale.
June 2003. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdeme.htm
World Alzheimer’s Report 2011, Alzheimer’s International.
http://www.alz.co.uk/research/world-report-2011
CMS list of Recommended Cognitive Screening Instruments
(For Medicare Annual Wellness Visit)
In response to NAPA, CMS requested NIA to suggest tools for the detection of cognitive
impairment. The tools identified for brief assessment were based on NIA selected inclusion
criteria.
Ascertain Dementia (AD8 informant tool)
http://www.alzheimer.wustl.edu/about_us/pdfs/ad8form2005.pdf
Short Blessed Test (SBT)
http://www.mybraintest.org/dl/ShortBlessedTest_WashingtonUniversityVersion.pdf
Mini-Cog
http://geriatrics.uthscsa.edu/tools/MINICog.pdf
Six-Item Screener (SIS)
http://www.scanhealthplan.com/documents/cme/clinical-guidelines/6 item recall.pdf
Short Test of Mental Status (STMS)
http://www.geocities.ws/nimarochester/KOKMENSTMS.doc
Short Portable Mental Status Questionnaire (SPMSQ)
http://www.npcrc.org/usr_doc/adhoc/psychosocial/SPMSQ.pdf
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Brief Alzheimer’s Screen (BAS)
http://www.medafile.com/bas.htm
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