cognitive screening in primary care -...

Cognitive Screening in Primary Care

Zahinoor Ismail MD FRCPC

Clinical Associate Professor of Psychiatry and Neurology Hotchkiss Brain Institute, University of Calgary

Assistant Professor

Department of Psychiatry University of Toronto

United Council of Neurologic Subspecialties Behavioural Neurology and Neuropsychiatry

Integration of Psychiatry into Primary Health Care_Kuwait_27 Jan 2014

Cognitive Screening

l  Objectives l  Review the principles and practice of dementia

assessments l  Discuss barriers to assessment of dementia in

primary care l  Explore assessment tools that are useful in

primary care populations

Dementia Diagnosis l  Development of multiple cognitive deficits

l  Memory impairment and l  One or more of:

l  Aphasia l  Apraxia l  Agnosia l  Executive functioning

l  Functional impairment and a decline from previous functioning

l  Gradual onset, continuing course l  Not due to other medical conditions or drugs

Types of Dementia

Alzheimer’s Dementia l  Alzheimer’s Disease

NINCDS-ADRDA l  Dementia established

clinically + cog testing l  Progressive worsening of

cog domains l  No disturbance of

consciousness l  Not due to other brain/

systemic illness l  Supportive features

l  Altered behavioural patterns

l  FH of similar illness

l  Differential Diagnosis l  Vascular Dementia

§  Abrupt or step-wise

l  Mixed l  Lewy Body

§  Fluctuations, hallucinations, Parkinson sx

l  Parkinsons Dementia l  FTLD

§  Early, insidious, gradual §  Personality change or apathy §  Behaviour and/or language

l  Mild Cognitive Impairment

Alzheimer’s Dementia

Vascular Dementia

Epidemiology

l  Age 65-74 1% l  Age 75-84 6.9% l  Age 85 + 26%

Canadian Study of Health and Aging

Cognitive Screening l  Advantages

l  Diagnosis can help explain changes in behaviour, mood, cognition and function

l  Allow caregivers to plan for POAs, end of life care l  Earlier benefit from medication

l  Disadvantages l  False positives l  Overwhelm health care system

Who to screen… l  Opportunistic case finding l  High risk individuals

l  Late-onset depression, anxiety or psychosis l  Subjective cognitive impairment l  Age greater than 75 l  Functional decline

l  In superficial conversation, even impaired patients can appear cognitively intact

l  Screening doesn’t necessarily equate with diagnosis of dementia

Who else to screen…

l  Caregiver / Family member l  This is essential!!!! l  A common cause of diagnostic error is to ignore

the family l  In early AD, patients deny symptoms l  Patients may not be aware of safety issues

What else to screen for…

l  Mood and behaviour l  97% of people with AD will have at least 1

neuropsychiatric symptom in the first 5.3 years of their illness

l  Neuropsychiatric symptoms are associated with faster cognitive decline, higher rates of hospitalization and institutionalization and greater caregiver burnout

Shulman, K. I., N. Herrmann, et al. (2006). "IPA survey of brief cognitive screening instruments." Int Psychogeriatr 18(2): 281-94.

Current screening practices

l  Specialists l  MMSE and its variants 100% l  CDT 72% l  Delayed word recall 56% l  Verbal fluency 35% l  Similarities 27% l  Trail making 25%

Current screening practices l  MMSE 76% l  DWR 56% l  CDT 53% l  AS 13% l  MoCA 5%

Iracleous, P., J. X. Nie, Ismail, Z et al. Int J Geriatr Psychiatry (2009). "Primary care physicians’ attitudes toward cognitive screening: findings from a national postal survey."

Current Screening Practices

l  CDT 93% l  MMSE 91% l  MoCA 80% l  DWR 75% l  TM 44%

Ismail et al 2013 Canadian Geriatrics Journal

Scales administered to patient…

Ideal screening test

1.  Brief in duration 2.  Acceptable to patients 3.  Insensitive to confounding factors such as

culture, language and education 4.  Simple to administer and score 5.  Sensitivity and inter-rater reliability 6.  Cover a broad range of cognitive functions

“No ifs ands or buts…”

MMSE

Foreign Language MMSE Afrikaans Arabic Argentinean Spanish Austrian German Belgian Dutch Belgian French Bosnian Brazilian Portuguese Bulgarian Chilean Spanish Chinese Croatian Czech Danish Dutch Estonian Farsi Filipino Finnish French German Greek Gujarati Hebrew Hindi Hungarian Indian English

Israeli English Italian Japanese Kannada Korean Latvian Lithuanian Macedonian Malay Malayalam Marathi Norwegian Polish Portuguese Romanian Russian Russian for Estonia Serbian Slovakian Slovenian South African English Spanish Swedish Tamil Telugu Turkish UK English Ukrainian Urdu

Escobar 1986, J. Nervous & Mental Dis

Problems with the MMSE l  Poor assessment of frontal / exec function l  Designed in an English speaking population l  MMSE scores are influenced by age,

education, ethnicity, and language of interview

l  Some words can’t be translated and some concepts are not relevant to other cultures

l  Excluding items that were culturally biased, resolved inter-ethnic diff in “severe” dementia

Scazufca, M., O. P. Almeida, et al. (2008). "Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status." Eur Arch Psychiatry Clin Neurosci.

MMSE bias

l  Sao Paolo Ageing & Health Study l  High false positive rate of dementia diagnosis in

older illiterate adults l  Recommend cutoff score of 14/15 for diagnosis in

those with no formal education l  Cutoff of 17/18 for those with >1 year l  MMSE grossly overestimates dementia (vs DSM

criteria) in this population

MMSE development

l  Napkin (serviette)

Clock Drawing Test

l  “This is a clock face. Please fill in the numbers and then set the time to 10 past 11”

CDT

l  Sensitivity to Deterioration in Dementia

CDT

l  Many scoring systems, most of which have good psychometric properties

l  1 minute to perform l  Provides a visual (and thus tangible) example

for family and caregivers l  Much less susceptible to bias due to

education, language and culture

Borson, S., J. Scanlan, et al. (2000). "The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly." Int J Geriatr Psychiatry 15(11): 1021-7.

Mini-Cog

Borson, S., J. M. Scanlan, et al. (2005). "Simplifying detection of cognitive impairment: comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample." J Am Geriatr Soc 53(5): 871-4.

Mini Cog l  Community sample of culturally, linguistically

and educationally heterogeneous older adults l  Mini-Cog had a sensitivity of 99% and correctly

classified 96% of the subjects in the initial study of 249 subjects. Administration time was 3 minutes.

l  Mini-Cog was found to be equal or better than the MMSE in detecting dementia in multiethnic elderly individuals, easier to administer to non-English speakers, and is less biased by low education and literacy

RUDAS – a culturally sensitive tool

Rowland Universal Dementia Assessment Scale (RUDAS) l  Developed specifically for a multicultural

population l  Item development

l  Identify important cognitive domains l  Propose potential items to measure cognition in

each of the domains l  Optimize the psychometric validity, and cultural

and linguistic equivalents of the proposed items l  Develop a full list of items to test in a culturally

heterogeneous population

Montreal Cognitive Assessment (MoCA)

l  For detecting MCI l  Has multiple

cognitive domains l  Frontal and

executive functions well represented

Depression

Scales given to caregiver

IQCODE

l  Asks caregiver to compare current cognition to cognition 10 years ago

l  Multiple domains

SAGE

l  Broad based functional assessment

l  Asks about cognition, ADLs, IADLs and major medical comorbidities

Lawton IADL Scale

l  IADLs l  Patients may deny

many of these issues and caregiver can provide a better history

Neuropsychiatric Interview

l  NPI-Q l  Yes or No l  Rate severity of Yes

symptoms as mild, moderate or severe

l  Long version NPI is frequency x severity scale

Frontal Behavioral Inventory

Caregiver Burden Scale

l  Identify at-risk caregivers

l  Can refer to caregiver support groups

l  Attending to caregiver an prevent ER visits

Summary

l  Opportunistic case finding l  Includes both patient and caregiver l  Be aware of premorbid cognitive abilities and

pay attention to changes over time l  Be aware of language, education and cultural

bias in screening l  Don’t forget neuropsychiatric symptoms l  Cognitive screening is just one part of a

thorough dementia work up