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 NOTa test score

Collateral history iscrucial

Prevalence of Dementia in Canada

8% of 65+ yr olds

Almost 50% of 85+ yr olds

Who is at risk?

Age Risk doubles every 5 yrs

Family Hx Risk doubles for each 1st

degree relative

Cardiovascular disease Risk doubles for each

vascular risk factor

Risk 15% justifies cognitive assessment.

AGE %

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 %

Remembers 1 of 3 words

Normal clock, 1/3 words = negative screen for dementia

Mr. Phib, Mini-Cog Scenario 1:

Step 1: Register 3 words

Step 2: Draw a clock

Step 3: Word recall

Step 4: Score

Remembers 2 of 3 words

Abnormal clock, 2/3 words = positive screen for dementia

Mr. Phib, Mini-Cog Scenario 2:

Step 1: Register 3 words

Step 2: Draw a clock

Step 3: Word recall

Step 4: Score

Collateral history iscrucial

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 %

Remembers 2 of 3 words

Abnormal clock, 2/3 words = positive screen for dementia

Ms. Bettick, Mini-Cog:

Step 1: Register 3 words

Step 2: Draw a clock

Step 3: Word recall

Step 4: Score

Ms. Bettick

MoCA score 18/30

Now what?

Does she have a dementia or not?

Ms. Bettick, Clock + MMSETemporal Orientation: Spring, Saturday, April 8, 2010Spatial Orientation: all correctRegistration: one trialAttention/Calculation: D L O R WRecall: 2 out of 3Naming: all correctRepetition: all correct3-stage command: all correctCLOSE YOUR EYES correctWritten sentence: This is stupidPentagon 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 Alzheimers disease and wants to get checked out. Both parents had Alzheimers in their late 80s, and she just turned 84. What next?

Miss Frett, age 84, no vascular risk factors, both parents had AD

AGE %

Miss Frett, Clock + MMSE

MMSE score 30/30

Now what?

Temporal Orientation: Spring, Saturday, April 10, 2010Spatial Orientation: all correctRegistration: one trialAttention/Calculation: D L R O WRecall: 3 out of 3Naming: all correctRepetition: all correct3-stage command: all correctWritten sentence: You are the best doctor in the worldPentagon copy: all correct

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 doesnt 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?

Mrs. Strong, Clock + MMSETemporal Orientation: Fall, September, 1929Spatial Orientation: Victoria, CanadaRegistration: one trialAttention/Calculation: D L O DRecall: 0 out of 3Naming: 1 correctRepetition: No ifs or buss3-stage command: 2 correct stepsCLOSE YOUR EYES correct with a promptWritten sentence: I love youPentagon copy: no overlap

MMSE score 12/30

Now what?

Mrs. Strong

You are very worried about Ernies health and Imas 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

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9

MM

SE

Years

Adapted from Feldman & Woodward. Neurology. 2005;65:S10-7.

ForgetfulnessShort-term memory

lossRepetitive

questionsHobbies,

interests lost Impaired

instrumental functions

Anomia

Progression of cognitive deficits

AphasiaDysexecutive

syndrome Impaired ADLTransitions in care

AgitationAltered sleep

patterns Total dependence:

dressing, feeding, bathing

Mild AD

Moderate AD

Severe AD

Management of Patients with Dementia

1. Define specific target symptomsA. ADL/IADL: e.g. household choresB. BEHAVIOUR: agitation/aggression/apathyC. COGNITION: memory, language, executive function

2. Consider rational pharmacologic treatment3. Ensure non-pharmacologic management4. Caregiver support, family education

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.

Less Than Expected Decline: An Appropriate Treatment Goal in AD

functional abilities, behaviour, caregiver burden, quality of life, and resource utilisation all need to be comprehensively assessed to fully evaluate effects in patients with ADpostponing or slowing decline in any of these areas may represent an important clinical benefit.2

Hypothetical Treatment Expectations vs. Expected Decline in AD1

Dementia IS NOTa 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

1. Recommended Guidelines for Treatment of a chronic disease may no longer apply.

Diabetes Specialized dietsHypertension

2. Simplify medications as much as possible Avoid multiple doses, anticholinergics, benzodiazepines

3. Consider frailty and its impact on medical/surgical management and prognosis

4. What is important to the patient?

CSHA Frailty Scale

1 Very fit Robust/active/energetic/well motivated/fit-exercise regularly - most fit group for age

2 Well Without active disease - less fit than group 1

3 Well, with treated co-morbid diseaseDisease symptoms well controlled comparedwith 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 non-instrumental activities of daily living

7 Severely frail Completely dependent on others for activities of daily living, or terminally ill