Montreal Cognitive Assessment (MoCA): Dr. Zeid … Cognitive Assessment... · Spanish Thai. MoCA:...
Transcript of Montreal Cognitive Assessment (MoCA): Dr. Zeid … Cognitive Assessment... · Spanish Thai. MoCA:...
Charles J. Vella, PhD
2010
Montreal Cognitive Assessment (MoCA):
Dr. Zeid Nasreddine
Be Careful in Diagnosis
Mental Status tests are evidence for cognitive dysfunction, not necessarily diagnosis or etiology.
Need to carefully consider testing context: amount of sleep, alcohol, medications, effort level of pt, attitude of pt toward you
MS testing tells you whether you should refer for further assessment (Medical, NeuroPsych, Neurology).
Unless severe deficits are evident, do not use MS testing to make dementia diagnosis for DMV purpose. It is not a tool for estate planning!
MoCA: Montreal Cognitive Assessment
Free of charge
Designed to separate normals from MCI and dementia
10 minutes
30 points; 26+ = normal
Limitations: No studies on ethnicity and education effects
Best substitute for MMSE with higher educated patients
http://www.mocatest.org/
MoCA: Forms in 15 Languages
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MoCA vs. MMSE
MMSE and MOCA
Using a cutoff score of 26:
• MMSE: sensitivity of 18% to detect MCI
• MoCA: sensitivity of 90% to detect MCI
For the mild AD patients, the sensitivity was 78% and
100% respectively.
Specificity excellent for both screening tests (100% and
87% respectively).
Nasreddine, et al., JAGS, 2005
Strategy Recommendation: MMSE & MoCA
Patient presents with cognitive complaints
and functional limits
• Administer Mini-Cog or MMSE 1st
• If MMSE ≥ 26 (normal), administer MoCA
Patient presents with cognitive complaints
and no functional limits:
• Administer MoCA1st
Different Cognitive Domains
Measured by MoCA
Executive functions
Visuoconstructional skills
Language
Memory
Attention and concentration
Calculations
Conceptual thinking, abstraction
Orientation.
MoCA: Montreal Cognitive Assessment
MoCA 1: Executive Processing
Nasreddine ZS, et al., J. Am Geriatr Soc 53:695–699, 2005.
MoCA 2
MoCA 3
The MoCA© may be used without permission for clinical and educational
non-commercial purposes
Alternating Trail Making
"Please draw a line, going from a number to a letter in ascending order.
Begin here [point to (1)] and draw a line from 1 then to A then to 2 and so on.
End here [point to (E)]." (Rule: “Number Letter Number Letter”)
Alternating Trail Making
Scoring: Allocate one point if the subject
successfully draws the following pattern:
• 1 −A- 2- B- 3- C- 4- D- 5- E, without drawing
any lines that cross.
• Any error that is not immediately self-
corrected earns a score of 0.
Cube
“Copy this drawing as accurately as you can, in the space below”.
Visoconstructional Skills (Cube)
Scoring: One point is allocated for a correctly executed drawing.
• • Drawing must be three-dimensional
• • All lines are drawn
• • No line is added
• • Lines are relatively parallel and their length is similar(rectangular prisms are accepted)
A point is not assigned if any of the above-criteria are not met.
Draw Clock
Draw a clock. Put in all the numbers and set the time to
10 after 11.
Visuoconstructional Skills (Clock):
Administration: Indicate the right third of the space and give the following instructions: “Draw a clock. Put in all the numbers and set the time to 10 after 11”.
Scoring: One point is allocated for each of the following three criteria:
• Contour (1 pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle);
• Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour;
• Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the clock center.
A point is not assigned for a given element if any of the above-criteria are not met.
Wrong!
Correct?
Add NAB Judgment Scale if fail Executive items on MoCA
Executive Dysfunction
Poor decision making capacity (legally incompetent to
make financial, medical, treatment decisions)
Do not learn from negative feedback
Inability to live without supervision
Inability to use psychotherapy
Need behavioral management
Adult Protective Services, Public Guardianship, Need for
Conservatorship
Naming
Beginning on the left, point to each figure and say:
“Tell me the name of this animal”.
Naming
Scoring: One point each is given for the following responses:
(1) camel or dromedary,
(2) lion,
(3) rhinoceros or rhino
Ethnicity: rhino unfamiliar
Word finding difficulty is most common
normal aging deficit
Possible presence of language disorder
(dysphasia, aphasia)
Naming Deficit
Memory Registration
Need to make sure words are actually encoded, therefore
2 repetitions. If cannot do perfect 2nd trial, suspect amnestic
disorder.
“This is a memory test. I am going to read a list of words that
you will have to remember now and later on. Listen carefully.
When I am through, tell me as many words as you can remember.
It doesn’t matter in what order you say them”.
“I am going to read the same list for a second time.
Try to remember and tell me as many words as you can,
including words you said the first time.”
Memory 1
Administration: The examiner reads a list of 5 words at a rate of one per second, giving the following instructions:
“This is a memory test. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember. It doesn’t matter in what order you say them”.
“I am going to read the same list for a second time. Try to remember and tell me as many words as you can, including words you said the first time.”
Memory 2
At the end of the second trial, inform the
subject that (s)he will be asked to recall
these words again by saying,
“I will ask you to recall those words
again at the end of the test.”
Scoring: No points are given for Trials One
and Two.
Attention
“I am going to say some numbers and when I am through,
repeat them to me exactly as I said them”.
Read the five number sequence at a rate of one digit per second.
Now I am going to say some more numbers, but when I am
through you must repeat them to me in the backwards order.”
Read the three number sequence at a rate of one digit per
second.
Attention 1: Digit Span
Forward Digit Span:
“I am going to say some numbers and when I am through, repeat them to me exactly as I said them”. Read the five number sequence at a rate of one digit per second.
Backward Digit Span:
“Now I am going to say some more numbers, but when I am through you must repeat them to me in the backwards order.” Read the three number sequence at a rate of one digit per second.
Scoring: Allocate one point for each sequence correctly repeated, (N.B.: the correct response for the backwards trial is 2-4-7).
Attention 2: Vigilance, Letter A
Vigilance:
“I am going to read a sequence of letters. Every
time I say the letter A, tap your hand once. If I
say a different letter, do not tap your hand”.
Scoring: Give one point if there is zero to one
errors (an error is a tap on a wrong letter or a
failure to tap on letter A)
Attention 3: Serial Sevens
“Now, I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop.” Give this instruction twice if necessary.
Scoring: This item is scored out of 3 points. Give no (0) points for no correct subtractions, 1 point for one correction subtraction, 2 points for two-to-three correct subtractions, and 3 points if the participant successfully makes four or five correct subtractions. Count each correct subtraction of 7 beginning at 100. Each subtraction is evaluated independently; that is, if the participant responds with an incorrect number but continues to correctly subtract 7 from it, give a point for each correct subtraction. For example, a participant may respond “92 – 85 – 78 – 71 – 64” where the “92” is incorrect, but all subsequent numbers are subtracted correctly. This is one error and the item would be given a score of 3.
Attention Problems
If Digit Span, Vigilance and Serial Sevens
impaired, consider possible attention
deficit or working memory issue.
30% of normals fail Serial Sevens
Language
“I am going to read you a sentence. Repeat it after me,
exactly as I say it [pause]:
I only know that John is the one to help today.”
“Now I am going to read you another sentence.
Repeat it after me, exactly as I say it [pause]:
The cat always hid under the couch when dogs
were in the room.”
Sentence Repetition
Administration:
“I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is the one to help today.”
“Now I am going to read you another sentence. Repeat it after me, exactly as I say it [pause]: The cat always hid under the couch when dogs were in the room.”
Scoring: Allocate 1 point for each sentence correctly repeated. Repetition must be exact/perfect. Be alert for errors that are omissions (e.g., omitting "only", "always") and substitutions/additions (e.g., "John is the one who helped today;" substituting "hides" for "hid", altering plurals, etc.).
Verbal Fluency
Administration:
“Tell me as many words as you can think of that begin with a certain letter of the alphabet that I will tell you in a moment. You can say any kind of word you want, except for proper nouns (like Bob or Boston), numbers, or words that begin with the same sound but have a different suffix, for example, love, lover, loving. I will tell you to stop after one minute. Are you ready? [Pause] Now, tell me as many words as you can think of that begin with the letter F. [time for 60 sec]. Stop.”
Scoring: Allocate one point if the subject generates 11 words or more in 60 sec. Record the subject’s response in the bottom or side margins
Language issues
If repetition and/or fluency impaired,
consider language disorder
Impaired repetition may imply underlying
memory deficit as opposed to language
problem.
Abstraction
Abstraction 1
Administration:
“Tell me how an orange and a banana are alike”. If the subject answers in a concrete manner, then say only one additional time: “Tell me another way in which those items are alike”. If the subject does not give the appropriate response (fruit), say, “Yes, and they are also both fruit.” Do not give any additional instructions or clarification.
After the practice trial, say: “Now, tell me how a train and a bicycle are alike”. Following the response, administer the second trial, saying: “Now tell me how a ruler and a watch are alike”. Do not give any additional instructions or prompts.
Abstraction 2
Scoring: Only the last two item pairs are scored.
Give 1 point to each item pair correctly answered.
The following responses are acceptable: • Train-bicycle = means of transportation, means of
traveling, you take trips in both;
• Ruler-watch = measuring instruments, used to measure.
The following responses are not acceptable:• Train-bicycle = they have wheels;
• Ruler-watch = they have numbers.
Poor Abstraction
Consider executive processing deficit.
Verbal abstraction can be normal,
while nonverbal is impaired.
Latter is more important.
Delayed Recall
“I read some words to you earlier, which I asked you
to remember. Tell me as many of those words as
you can remember.”
Delayed Recall 1
Administration:
“I read some words to you earlier, which I
asked you to remember. Tell me as many
of those words as you can remember.”
Scoring: Allocate 1 point for each word
recalled freely without any cues.
Delayed Recall 2: Not Optional
Following the delayed free recall trial, prompt the subject with the semantic category cue provided below for any word not recalled. Make a check mark in the allocated space if the subject remembered the word with the help of a category or multiple-choice cue. Prompt all non-recalled words in this manner. If the subject does not recall the word after the category cue, give him/her a multiple choice trial, using the following example instruction,
“Which of the following words do you think it was, NOSE, FACE, or HAND?”
FACE: category cue: part of the body multiple choice: nose, face, hand
VELVET: category cue: type of fabric multiple choice: denim, cotton, velvet
CHURCH: category cue: type of building multiple choice: church, school, hospital
DAISY: category cue: type of flower multiple choice: rose, daisy, tulip
RED: category cue: a color multiple choice: red, blue, green
Scoring: No points are allocated for words recalled with a cue.
For memory deficits due to retrieval failures, performance can be improved with a cue.
For memory deficits due to encoding failures, performance does not improve with a cue
Normal vs. Memory Deficit Types
Normal: 4-5 spontaneously recalled
Encoding Failure: poor spontaneous recall and recognition (cueing does not help), i.e. Alzheimer's
Retrieval Failure: Poor spontaneous recall: 1-3 on spont. Recall, normal recognition (cueing helps), i.e. subcorticals (Korsakoff, alcohol abuse, PD, HD, HIV, depression)
Orientation
“Tell me the date today”.
If the subject does not give a complete answer,
then prompt accordingly by saying:
“Tell me the [year, month, exact date, and day of the week].”
Then say:
“Now, tell me the name of this place, and which city it is in.”
Orientation
Administration:
“Tell me the date today”. If the subject does not give a complete answer, then prompt accordingly by saying: “Tell me the [year, month, exact date, and day of the week].” Then say: “Now, tell me the name of this place, and which city it is in.”
Scoring: Give one point for each item correctly answered. The subject must tell the exact date and the exact place (name of hospital, clinic, office).
No points are allocated if subject makes an error of one day, for the day and date.
Poor Orientation
Most often correlated with amnestic
disorder.
Can reveal confabulation (poor judgment).
Total Score: New rules
Sum all subscores listed on the right-hand side.
Add 2 additional point for an individual who has
4-9 years of formal education, 1 point for 10-12
years of education for a possible maximum of 30
points.
A final total score of 26 and above is considered
normal.
To decrease possible learning effects
when the MoCA is administered
repetitively, four alternative MoCA forms
are in development.
Two versions in English (validation study
completed) will be shortly posted on the
MoCA website, and two French alternate
versions are undergoing validation.
Cautions
Level of effort
Context: Hospital, Clinic, ER
Presence of Psychiatric Disorder
Amount of Sleep, medications
Did they come in voluntarily or were they
brought in with AMS
Executive ↓ more important than Memory↓
MoCA Patterns
Attention and Language most commonly
normal
If language impaired, aphasic?
If attention impaired, delirium?
Poor executive processing and memory
most serious deficits.
MoCA Patterns 2
Beside MoCA score, are there functional
deficits in ability to care for themselves?
• bill paying, memory deficits, medication
noncompliance, etc.
• latter less common in MCI, more common in
dementia of Alzheimer’s type.
Norms
Moca superior to MMSE for MCI detection
MoCA and MMSE
Context of Decision Making Capacity 1
Dissociation of Verbal ability and rest of
cognitive functioning
Information from collateral sources: status
of home (mold, leaking roof), refrigerator,
food, bathroom
Level of cleanness of apartment, mold,
garbage
Method for remembering medications
Presence of paranoia or hallucinations
Context of Decision Making Capacity 2
Evidence of burning pots, not paying bills
Presence, or lack thereof, of supervision
by family members
APS involvement
Executive function level
Anosognosia (denial of deficits): including
toward testing deficits
Dementia: Cognitive ↓, not etiology
WNL: MoCA 28/30, Mem 3/5 +1 cue
58 yo, WNL, Memory 5/5
36 yo, 2 y college
36 yo male, hx alcohol abuse
Hosp: AMS, multifactorial
Encephalopathy: morbid obesity (360),
hypothermia, septic shock,
2 week coma, liver & renal failure
Binges on weekends: 12x 24oz
? Anoxia
Score: 25/30
Memory: 3/5 + 1 cue
Conclusion:
WNL
Alcohol Abuse
59 yo, WNL
59 yo female, BA educ
Mild Stroke 6 y previous
Brief delirium with paranoid
Ideation following abd surgery
Prior MOCA = 23/30 days bef
Cognistat: WNL
Conclusion:
Resolved delirium
Alcoholic Korsakoff Syndrome
Classic profile:
• Normal Cognition
• Amnesia*
•Importance of doing
MS Testing
age 94, with 79 yo gf
Age 94
Therapist: ? Memory
Score: 25/30
Executive 3/5
Memory 2/5 + 1
Recommendation:
Full NP testing
60 yo, schizophrenia, delirium
60 yo female, 1 y college
Schizophrenia, 30 y work
Delirium
Paranoid perceptions
Prior Moca 15/30; Mem 0/5 +4 cue
Score: 15/30
Memory 0/5 + 4 cue
Conclusion: Unresolved delirium
65, H.S. education, CCC referral
Score: 23/30
Executive: 5/5
Memory: 0/5, no cue help
Recommendation:
MCI
Full NP testing
77yo, Overdose or not?
Cognistat: Impaired
Repitition
Block Design
Memory ***
Similarities
Judgment
Conclusion:
Dementia
Supervision of
Medication
71 yo AA male, 2 MAs
71 yo AA male, retired teacher, ESRD
Fell out of bed, trapped
Between dialysis machine & bed
x 2 days; ants; wife downstairs
Prior MoCAs: 16/29; 20/30; Mem 3/5
? Can he do peritoneal dialysis alone
Cognistat:
Comprehension: 2 step only
Block Design: 0/3
Memory: 0/4 +3 cueing
Visual memory: poor
Similarities: 2/4
Conclusion:
MCI
No peritoneal dialysis
56 yo male, post CABG
56 yo male, sp CABG, episode of agitation
req restraints; anx disorder; hx alcohol
abuse; hoarder; odd & eccentric; tax work
Prior MoCA: 23/30; Exec 2/5; Mem 4/5
Current Score: 27/30
Executive: 4/5 (clock)
Fluency: 1/3
Memory: 5/5
Conclusion: Cognition OK;
Psychiatric fu
70 yo, computers, cardiovascular
70 yo male, gifted computer career “genius”
CV hx: CAD with stent, MI, afib, SOB,
fluid in lungs, old CVA, renal insuff, DM
SI, “not worth living”, no plan, irritable
Lives alone
Cognistat:
Memory: 0/4, no cueing help
Judgment: 0/3
Partial MoCA:
OK clock, poor trails
Fluency: 5 in 1 min
Conclusion:
Cognitive Disorder
Needs Assisted Living
72 yo, college educ., APS
Score: 14/30
Executive: 1/5
Memory: 0/5
Conclusion:
Dementia
1st: 41 yo, AIDS
Score: 15/30*
Memory Register: 4x
Executive: 2/5
Memory: 0/5, 2 cue
Conclusion:
Dementia
2nd : AIDS, CD4=40
Score: 3/30**
Executive: 1/5
Memory: 0/5
Conclusion:HIV Dementia
64 yo AA woman, ESRD, dialysis combative
Consult ?: combative during
Dialysis, “I am 64, AA, activist;
I have the right…”
Score: 10/29*
Executive: 2/4
Memory: 2/5, 0 with cue
Conclusion:Personality
Disorder & Dementia
70 yo, HS ESL teacher, Vietnamese
70 yo Vietnamese, BA educ
HS ESL teacher
Cerebellar CVA
Score: 4/20
Motor weakness
Memory: 0/5 + 1 cue
Conclusion:
Vascular Dementia
39 yo, TBI, Anterograde Amnesia
51 yo, dropped off in ED by disappeard wife
51 yo, Phil male, janitor, 6th
grade
Dxs: MS, LF CVA, atrial fib,
vascular
dementia, pseudobulbar,
spastic hemiplegia
Claims: no med ill, no klg
Score: 4/25
Executive: 1/5
Memory 0/5
Conclusions:
Vascular Dementia
Lacks capacity
His Clock
age 33, pregnant, delirium
Hx: pregnant, methadone (for Crohn’s) addiction + prednisone
Score: 22/30*
Executive: 5/5
Memory: 3/5, 5 with cue
Conclusion:
Resolved Delirium
66 yo, pelvic mass is food, not cancer
66 yo female, prior colon CA 2 y ago
Bowel obstruction
Now Pelvic Mass, believes its food,
refuses Tx for CA
Tangential
Long hx of untreated delusional disorder
(NASA, government conspiracy vs. her)
Score: 16/30
Memory: 0/5 – 4 + cueing
Judgment Scale: 7/20
Recommendation:
Delusional Disorder
Cognitive Disorder
Lacks medical capacity
Family supports surgery
Her Clock
57 yo, maggots
57 yo retired IRS auditor, MA educ
Medical noncompliance with wound
Physician aversion: prior amputation
of toe 7 m before, claimed no prior
negative med experience;
Wife:
Sore became maloderous; found
maggots 2 m before; Childhood
cerebral palsy, months in hospital;
cured; Traumatized by toe amputation
Score: 24/30
Executive: 3/5
Memory: 2/5 + 3 cue
Conclusion:
MCI
Full NP testing recom
79 yo MD, intubed
79 yo MD, Parkinsonism
Intubed; written responses
Delirium, Paranoid Prior
? Capacity
Memory 2/5 +3 cue
Conclusion:
Resolved Delirium
Cognitive Disorder
Has Capacity
Full NP testing recom.
His writing: Cognitive = Pretentious
1st : 67 yo male, anticholingeric delirium
Hx: bugs everywhere,
then collapse with balance↓,
SOB, vomiting
Score: 17/30*
Executive: 4/5
Fluency: 2
Memory: 2/5, 2 with cue
Conclusion:
Delirium due to
Increase in Nortriptyline
AC 2nd : 67 yo male, delirium
Hx: Nortrip ↑↑
Score: 24/30*
Executive: 4/5
Fluency: 8
Memory: 5/5
Conclusion:
WNL, resolved delirium
Anticholinergic Syndrome: Mad as a hatter
hot as a hare = high temperature
red as a beet
dry as a bone = decreased mucous, dry
mouth, constipation
blind as a bat = blurred vision
mad as a hatter = hallucinations, delirium
Medications: atrophine, tricyclics, anti-
parkinsonian, antihistamines, haldol, digoxin
54 yo, DM, cardiac arrest, 20 min.
Hx: security guard,
visual halluc. of bees,
visual field cut
Score: 14/30*
Executive: 2/5
Fluency: 4 words
Memory: 0/5, 0 with cue*
Conclusion:
Dementia due to
Anoxic Encephalopathy
His conclusion: “I’m screwed.”
1st : 72 yo M.D., Normal MMSE 2006
2nd : 72 yo M.D., 2007, cautionary tale
Score: 26/30*
Executive: 2/5**
Memory: 4/5
Conclusion:
MCI (Executive ↓)
Follow-up:
NP testing: failed WCST,
Category test
Spent $700,000 in 6 months
Conclusion: Frontotemporal
Dementia
72 yo, MA in history
Score: 12/29*
Executive: 1/5 – Note
Serial Sevens
Memory: 1/5
Conclusion:
Dementia
68 yo male, 12 y educ, executive dissociation
Hx: failure to thrive,
medication non-compliant,
house (horrific odor, garbage,
roof leak, mold everywhere),
denied any problems
Score 14/29*
Memory Register: 4
Executive: 3/5
Memory: 0/5, 1 cue*
NAB Judgment: 16/20
Conclusion:
Dementia
75 yo, male, B& C, combative
Score: 5/30*
Memory Register: 2
Executive: 0/5
Memory: 0/5
NAB Judgment: 10/20
Conclusion:
Dementia
Alcoholism, ESRD, failure to thrive
Score: 12/30*
Executive: ↓↓↓
Attention: ↓↓
Memory: Amnesia (cuing
did not help)
NAB Judgment: 11/20
Conclusion:
Dementia
1st : 62 yo AA woman, TGA?
Sudden AMS at work,
Hotel room supervisor,
5 hours total amnesia,
MRI -, EEG -
Score: 6/30*
Executive: 1/5
Language: ↓
Memory: 0/5 spont.
0/5 Recog*
Orientation: 2/6
Conclusion:
TGA, Dementia?
2nd : 4 days later
2 days later:
MOCA 12/30
(executive & memory)
4 days later:
Cognistat:
Memory: ↓↓
Math: ↓↓
Conclusion:
Cognitive Disorder
(Amnesia)
72 yo woman, no pants
Hx: Earlier RP stroke,
Apt had rotten food, feces
Human services → clerk
2 y ago
Cognistat:
Block Design: ↓↓
Memory: ↓↓
Judgment: ↓↓
Conclusion:
Dementia
87 yo, AA male
Score: 8/30**
Executive: 2/5
Language: ↓↓
Memory: 0/5 spont.
0/5 Recog**
Orientation: 3/6
Conclusion:
Dementia of Alzheimer’s
Type
85 male, failure to thrive, DM
APS, caregiver took over
Apt., “states good memory,
can care for self”
Score: 11/30**
Executive: O/5
Attention: ↓↓
Memory: 0/5 spont.
0/5 Recog.**
NAB Judgment: 6/20
Conclusion:
Dementia of Alzheimer’s Type
85, AMS, episodic delirium, colon CA
MMSE: 17/30*
Score: 10/30
Executive: 0/5
Fluency: ↓↓
Memory: 0/5*
Conclusion:
Dementia of Alzheimer’s
Type
50 yo Male, 20 y Schizophrenia, Suicidal
Executive: 3/5
Similarities: 0/2
Memory: 2/5 +2
Conclusion:
5150d
73 yo, Anxiety
73 yo female, ED, anxiety
Can’t take care of self at home
Lexipro
Sober 4 months
Score: 26/30
Memory 2/5 +1
Recommendation:
Released to son
Full NP recom
70 yo, Master’s degree
Score: 24/30
Memory 0/5
Conclusion
MCI
79, male
Score: 20/30
Executive: 2/5
Attention: ↑↑
Memory: 1/5
Conclusion:
MCI→ Dementia
75 y o, 2 y educ, sound tech
Score: 21/30
Executive: 5/5
Memory 0/5 +2 cue
Conclusion:
MCI
NP testing
77 yo, refuses to leave hospital
77 yo female, hosp SOB, refused
to leave hospital
APS, failure to care for self
5150d grave disability
Prior MoCA = 26/30, Mem 1/5
Recom selling house & assisted
living
3 y college, office work
Names her meds
States can’t care for self
Assessment:
Cognistat WNL (Mem 1/5 +3)
Not psychotic
Fears selling house
Good insight, bad judgment
Needs counseling
83 yo, memory
Cognistat
Memory: 0/4 +2 cue
Comprehension: 1 step only
Similarities: 1 / 4
60 yo schizophrenic in ED
60 yo female, schizophrenic, homeless
“Zen on a Jew…Judaism doesn’t belong
In SF…Muslims trying to kill me”
Score: 16/23
Memory: 1/5 +2 cue
Conclusion:
Shizophrenia
5150d
References
• Holsinger et al. Does this patient have dementia? JAMA, June 6, 2007-Vol 297, No 21;2391-2404.
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• Zadikoff C. et al. A comparison of MMSE to MoCA in identifying cognitive deficits in Parkinson's disease. Movement Disorders Vol 22, suppl. 16, June 2007.
• Martinić Popović I. et al. Mild cognitive impairment in symptomatic and asymptomatic cerebrovascular disease. Journal of the Neurological Sciences Volume 257, Issues 1-2, 15 June 2007, Pages 185-193.
• Hachinski et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke. 2006 Sep;37(9):2220-41. Epub 2006 Aug 17.
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