Running head: COGNITIVE ASSESSMENT 1

ACT on Alzheimer’s

Alzheimer’s Disease Curriculum

Module V – Cognitive Assessment and the Value of Early Detection

GUIDELINES FOR AND RESTRICTIONS ON USE OF CURRICULUM MODULESThis curriculum was created for faculty across multiple disciplines to use in existing coursework and/or to develop a stand-alone course in dementia. Due to the fact that not all modules will be used for all disciplines, topics have been divided into ten modules that can be used alone or in combination with other modules. Users may reproduce, combine, and/or customize any module text and accompanying teaching slides to meet course needs. Our only restriction on re-use is that the modules not be sold in their current or modified 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 contained in each module (e.g., screening module is completely duplicated in the diagnosis module because the diagnosis module is not appropriate for all audiences).

© 2012

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Acknowledgement

We gratefully acknowledge our funding organizations, which made development of this curriculum possible: The Alzheimer’s Association MN/ND Chapter 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 also specially 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 the peer review team:Michelle Barclay, MATerry Barclay, PhDMarsha Berry, MA, CAEdErin Hussey, DPT, MS, NCSSue Field, DNP, RN, CNEJulie Fields, PhD, LPJane Foote EdD, MSN, RNHelen Kivnik, PhDKenndy Lewis, MSRiley McCarten, MDTeresa McCarthy, MD, MSLynne Morishita, GNP, MSNBecky Olson-Kellogg, PT, DPT, GCSPatricia Schaber, PhD, OTR/LJohn SelstadEricka Tung, MD, MPHJean Wyman, PhD., RN, GNP-BC, FAAN, FGSA

This curriculum is available for use and/or customization by anyone, as long as it is not sold in its current or modified form.

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Overview of Alzheimer’s Disease Curriculum

This module is part of the Alzheimer’s Disease Curriculum developed by ACT on Alzheimer’s. ACT on Alzheimer’s is a statewide, voluntary collaboration that includes over 50 organizations and 150 individuals seeking to prepare for the budgetary, social, and personal impacts of Alzheimer’s disease. All of the 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: Quality Interventions

Module IX: Dementia as an Organizing Principle of Care

Module X: Caregiver Support

Module XI: Alzheimer’s Disease Research

Module XII: Glossary

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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 VCognitive 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, and 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 InterventionsBoth 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 “gold-standard” 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 Annals Intern Med 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 interventions producing health benefits include certain drugs in early stages of the disease, effective care

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coordination, care-giver 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 (Phalen 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. Forecasting the future impact of early detection and management program for Alzheimer disease. In Rene TJ, Wolfgang H, editors. Dementia care research: scientific evidence, cur- rent issues and future perspectives. Dustri; 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 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 Alzheimer’s and Dementia 2013). Extensive investigation of the cost-effectiveness of cognitive screening has yet to be performed.

Practice Tips for DetectionEven 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

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best fulfill their detection role by: 1) watching for indicators of dementia; and 2) using validated 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 VisitsCognitive 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 Alzheimer’s and Dementia 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 AssessmentThere 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

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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 the test as administration may be performed by physicians, nursing staff, social workers, or allied staff professionals. 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 TipsThere 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 MeasuresThere 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 (eg. frontotemporal degeneration or Parkinson’s Disease Dementia) remains to be studied.

Mini-CogThe 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

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concerns about sensitivity, more recent studies have used a score <4 to distinguish pass from 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 Mini-Cog 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 Mini-Cog 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 Mini-Cog into the annual wellness visit for the geriatric population.

The following video demonstrates the role of the Mini-Cog as a screening tool within the primary care setting:http://www.youtube.com/watch?v=5DS_FVXsdHY&feature=share&list=UUkGrLDa-K4qd7MxA-_k-E5g

Mini-Mental State Exam (MMSE)http://www4.parinc.com/Products/Product.aspx?ProductID=MMSEThe 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

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addressing executive function and patients with frontal deficits may score normally. Finally, the MMSE is copyrighted which constrains free usage of the tool.

St. Louis University Mental Status Exam (SLUMS)http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdfThe 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.

Montreal Cognitive Assessment (MoCA) www.mocatest.orgThe 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 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). Please refer to the following video clip for more information on the MoCA:http://www.youtube.com/watch?v=3e3oKmtRfgM

Kokmen Test of Mental StatusThe 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 InterviewThe 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

TABLE 1:Cognitive Assessment Test

Administration Time

Scale (pts.) MCI Sensitivity

Dementia Sensitivity

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%

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Module V: Questions for Review

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** Score Ranges for MoCA, MMSE, and SLUMS:MoCA:Normal 26-30 Mild 21-25Moderate 15-20Severe 0-14

MMSE: 24 or less

SLUMS: SCHOOL EDUCATION LESS THAN HS ED. 27-30 Normal 25-30 21-26 Mild Neurocognitive disorder 20-24 1-20 Dementia 1-19

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1. Mr. Garcia is a 72-year-old man that 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 medications 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 memoryb. Refer him for neuropsychological testingc. Order an MRI of the braind. 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 Examinationb. Montreal Cognitive Assessmentc. Short Test of Mental Statusd. St. Louis University Mental Status Examinatione. 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 appointmentsc. Repeated phone calls to your officed. Unusual sleeping habits such as dream re-enactmente. All of the above

4. The US Preventive Services Task Force makes which of the following recommendations about screening the general population for dementia?

a. All adults aged 65 and older should be screened for dementia in the primary care setting

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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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delays nursing home placement of patients with Alzheimer disease. Neurology,

67(9):1592-1599.

Nasreddine, Z.S., Phillips, N.A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I.,

Cummings, J.L. & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: a

brief cognitive assessment tool for mild cognitive impairment. Journal of the American

Geriatric Society , 53(4):695-699.

Rossetti, H.C., Lacritz, L.H., Cullum, C.M. & Weiner, M.F. (2011). Normative data for the

Montreal Cognitive Assessment (MoCA) in a population-based sample. Neurology.

77(13):1272-1275.

Tariq, S.H., Tumosa, N., Chibnall, J.T., Perry, M.H. & Morley, J.E. (2006). Comparison of the

Saint Louis University mental status examination and the mini-mental state examination

for detecting dementia and mild neurocognitive disorder--a pilot study. American Journal

of Geriatric Psychiatry. 14(11):900-910.

US Preventive Services Task Force. (2003). Screening for dementia: recommendations and

rationale. http://www.ahcpr.gov/clinic/3rduspstf/dementia/dementrr.htm .

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Valcour V, Masaki K, Curb J, Blanchette P. The detection of dementia in the primary care

setting. Arch Intern Med. 2000;160:2964–8.

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Websites and Web Based Resources

Clinical Provider Practice Tool, ACT on Alzheimer’s in partnership with the Alzheimer’s Association: MN/ND Chapterhttp://www.actonalz.org/provider-practice-tools

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

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Short Blessed Test (SBT)http://www.mybraintest.org/dl/ShortBlessedTest_WashingtonUniversityVersion.pdf

Mini-Coghttp://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

Brief Alzheimer’s Screen (BAS)http://www.medafile.com/bas.htm

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