DeprescribingJessica Visco, PharmD, CGP

SeniorPharmAssist

August 24, 2016

Deprescribing

Jessica Visco, PharmD,

CGP

SeniorPharmAssist

Webinar #1Webinar #19

Geriatric Cognition Screeningwith the Montreal Cognitive Assessment (MoCA)

Jeffrey N. Browndyke, PhD

Elissa Rumer Nickolopoulos, MSW, LCSW-A

Michael Patterson

Disclosures No commercial support has influenced the planning of the

educational objectives and content of the activity. Any

commercial support will be used for events that are not CE

related.

There is no endorsement of any product by DUHS

associated with the session.

No influential financial relationships have been disclosed by

planners or presenters which would influence the planning of

the activity. If any arise, an announcement will be made at

the beginning of the session.

This program is supported by a Geriatric Workforce

Enhancement Program (GWEP) grant (U1QHP28708) from

the U.S. Bureau of Health Professions Health Resources

and Services Administration (HRSA).

Objectives

Basic introduction to cognitive screening.

Cognitive screening best practices.

Describe the MoCA screening process and

proper score comparisons.

Understand the utility and limitations of the

Montreal Cognitive Assessment (MoCA)

screen.

Cognitive Screening - Basics

Cognitive “screening” is just

that…a limited and basic

broad-brush sampling of

cognitive skills and behavior.

Boiling cognitive abilities and

human behavior down to a

single screening value or

score from limited behavioral

sampling is fraught with

numerous measurement

issues.

Cognitive Screening – Basics II

Most cognitive screens have moderate sensitivity and

specificity for severe cognitive impairment and dementia.

Negative results in a screen with high sensitivity may be

good for ruling-out dementia. Positive results in a

screen with high specificity may be good for ruling-in

dementia.

Cognitive screens are generally poor estimators of the

underlying neuropathology or dementia type.

Cognitive screening is just the beginning of the process,

not the end.

Cognitive Screens Modified Mini-mental State

”Examination” (3MS)

Three Word Recall (3WR)

7-minute Screen (7MS)

AB Cognitive Screen (ABCS)

Addenbrooke’s Cognitive

”Examination” Revised (ACE-R)

Abbreviated Mental Test (AMT)

Brief Alzheimer Screen (BAS)

Brief Cognitive Scale (BCS)**

Cognitive Abilities Screening

Instrument (CASI)

Cognitive Assessment Screening

Test (CAST)

Cognitive Capacity Screening

“Examination” (CCSE)

Clock Drawing Test (CDT)

Deterioration Cognitive Observee

(DECO)**

DemTect

Dementia Questionnaire (DQ)**

General Practitioner Assessment of

Cognition (GPCOG)**

Informant Questionnaire on

Cognitive Decline in the Elderly –

Short Form (IQCODE-SF)**

Mini-Cog

Memory Impairment Screen (MIS)

Folstein Mini-mental Status

“Examination” (MMSE)

Montreal Cognitive Assessment

(MoCA) Screen

Neurobehavioral Cognitive Status

“Examination” (NCSE)

Rotterdam Version of Cambridge

Cognitive “Examination” (R-

CAMCOG)

Rapid Dementia Screening Test

(RDST)

Short and Sweet Screening

Instrument (SASSI)

St. Louis University Mental Status

(SLUMS) “Exam”

Symptoms of Dementia Screener

(SDS)**

Short Memory (SMQ)**

**wholly or partly informant based

Cognitive Screening – Best

Practices

Cognitive screening should be an interactive, not a

passive process. This is not a self-directed “let them do it

in the waiting room” method.

Screening selection

should be based upon

maximal sensitivity to

detect desired level of

cognitive impairment

(e.g., MCI, dementia)

while avoiding “ceiling”

or ”floor” effects.

Cognitive Screening – Best

Practices II

Stick to the script, do not rush through or assist.

Deviation from screening standardization and

administration procedures:

1.) increases measurement error

2.) decreases reliability of results

3.) renders comparisons across sites and/or

time problematic

Use normative data for “cut-off” scores that best

approximate the clinic setting and patient type. Do not

just blindly apply suggested cut-offs. Doing so has

serious implications for sensitivity/specificity.

Montreal Cognitive Assessment

(MoCA)

For decades, the clinical “lingua franca” of geriatric

cognitive screening was the Folstein Mini-Mental Status

“Examination” (MMSE).

The MMSE still has reasonable sensitivity (0.78-84) and

specificity (0.87-0.91) for dementia-level severe cognitive

impairment, but fails relative to other screens (e.g., Mini-

Cog, MoCA) and the in detection of milder cognitive

difficulties.*

Primary reasons for general clinical shift away from

MMSE?

*Tsol et al. (2015). JAMA Internal Med

Montreal Cognitive Assessment

(MoCA)

Most screens generally fail in detection of milder

cognitive impairment due to a limited range in sampled

cognitive domains, particularly the exclusion of

executive functioning.

Screen Sampled Domains

MMSE Orientation, Memory, Language, Attention, Visuospatial

3MS Orientation, Memory, Language, Attention, Visuospatial

Mini-Cog Memory, Visuospatial, Executive

AMT Orientation, Memory, Attention

CDT Visuospatial, Executive

MoCA Orientation, Memory, Language, Attention, Visuospatial,

Executive

Montreal Cognitive Assessment

(MoCA)

MoCA has 0.84-0.95

sensitivity and 0.71-

0.88 specificity for

dementia.

This reflects better

sensitivity in dementia

detection over MMSE,

but reduced specificity

relative to the MMSE

(0.87-0.91).

*Tsol et al. (2015). JAMA Internal Med

MoCA Sensitivity/Specificity for

Mild Cognitive Impairment

*Tsol et al. (2015). JAMA Internal Med

Why use the MoCA? Comparable ability to rule out dementia and best sensitivity

of any current screen for MCI.

Freely available on paper / nominal fee for iPad.

Multiple alternate forms, translations and variants.

Growing “independent” literature base and normative data

from various groups and settings.

Part of the NACC – Uniform Data Set (UDS ver. 3)

Cognitive Battery.

Potential research & clinical utility in MoCA cognitive

subdomain scores.

MoCA Administration First steps:

1.) Find setting or time that minimizes distraction and interruption.

2.) Preferable to administer to patient alone.

3.) Determine patient visual limitations, literacy and education level.

4.) Pick a form.

MoCA Administration

Visuospatial/Executive Section

Note: section contributes to Executive & Visuospatial supplemental

subdomain scores

MoCA Administration

Naming Section

Note: section contributes to both Language & Visuospatial supplemental

subdomain scores

MoCA Administration

Memory Section

Note: Does NOT contribute to MoCA total, but does contribute to

Attention/Concentration supplemental subdomain score.

MoCA Administration

Attention Section

Note: Contributes to Executive and Attention/Concentration supplemental

subdomain scores.

MoCA Administration

Language Section

Note: Repetition component contributes to Attention/Concentration and

Language supplemental subdomain scores, while Fluency component

contributes to Executive and Language supplemental subdomain scores.

MoCA Administration

Language Section

Note: Repetition component contributes to Attention/Concentration and

Language supplemental subdomain scores, while Fluency component

contributes to Executive and Language supplemental subdomain scores.

Abstraction Section

Note: Contributes to Executive supplemental subdomain score.

MoCA Administration

Delayed Recall Section

Note: Component contributes to Memory Impairment Scale (MIS)

supplemental subdomain score.

Orientation Section

Note: Component contributes to Orientation supplemental subdomain

score.

MoCA: Importance of Norms

Z-Score Range M SD N Lo 95%CI Hi 95%CI

Controls†: -2.44 25.3-29.6 27.37 2.2 90 26.92 27.82

MCI: -0.04 19.0-25.2 22.12 3.11 94 21.49 22.75

AD: 1.21 11.4-21.0 16.16 4.81 93 15.18 17.14

Community‡: -0.44 NR 23.68 3.84 2148 23.52 23.84

MoCA total score = 22

†Norms from Nasreddine et al. (2005) as found on the MoCA website. The

"controls" were healthy, elderly Canadian (French-Canadian) volunteers

participating in a research study. Patient types are from a private memory

clinic.

‡Norms from Rosetti et al. (2011). "Community" is a group of 2148 individuals

from a general hospital population participating in a case report form study who

did not report cognitive concerns.

MoCA: Wrap Up

Use MoCA forms version 7.1. Limited-to-no empirical

support for “new” version 8.1

Practice before administering either paper or iPad.

Stick to the script.

Determine what you wish to rule out. Severe

impairment/dementia or mild cognitive impairment?

Consider what normative comparison data works best

of your patients and settings. Do not blindly apply cut-

off rules.

Have referral plans ready based upon MoCA results.

MoCA at Duke Outpatient Clinic

Where we started:

• Rarely used in clinic

• Used as validation for referrals (i.e. stat referral to GET

clinic) and/or confirmation of a current crisis

Where we are now:

• Used as a tool to measure functioning, cognitive decline

or improvement, and to prevent crisis

• Used to inform urgency for referrals

• Clinic staff more aware of signs/symptoms of cognitive

impairment

Patient arrives to clinic and checks in

Front desk provides Orange Sheet with Screening Question for patient/family to

complete(CMA to help

complete if needed)

Does patient screen positive?

Mini-cog scoring and clinical evaluation

completed by:1. LCSW or BHC2. If above not

available, then by provider

Does provider/patient/family have

any cognitive impairment

concerns not covered on

screening form?

Re-screen in 1 year

Provider determination of negative screen. Document in chart and re-screen in 1 year

Refer to BHC or LCSW for MOCA full cognitive screen if clinically indicated

MOCA score consistent with

cognitive impairment?

Document in chart and move to “Patient

with Cognitive Impairment”

workflow

NegativeNo

Yes

Positive

Negative

Positive

No

Yes

DOC Geriatric Cognitive Impairment Screening Workflow

Mini-Cog completed

by CMA

Clinic Integration

MoCA: TakeawaysSpeed

• Test is intended to take 10 minutes

• Actual administration time is multifactorial and depends

on:

1. Patient’s level of determination to complete tasks

2. Level of cognitive functioning

Administration Challenges

• Must stick to script

• Family members present

Benefits

• Immediate feedback

• Digs beneath the surface (i.e. not just verbal)

• Informs provider care

Durham Center for Senior Life

Adult Day Health

• Provides a structured day for older adults who may

have difficulty managing on their own because of

frailty or the effects of disease

• Seeks to prolong independence by providing support

and care where each individual’s capabilities are

recognized and enhanced

Benefits for participants and

family caregiversHelp maintain cognitive, social, emotional and physical well-being

• Cognitive: trivia games, sensory stimulation, reminisce; to name a few activities.• Social: craft activities, bingo, sharing meal time;• Emotional: poetry reading, singing, spiritual discussions, relaxation in the garden• Physical: exercise, walks, active games

Promote personal independence and health:• Registered Nurse on staff;• Medication administration• Monthly vital signs• Nutritional lunch and snacks each day

Provide respite and support for families and caregivers• Schedule of extended hours allows caregivers to work full time• Social Worker on staff to support the challenging demands of care giving• Provides caregivers with peace of mind• Monthly Caregiver Dinners – Free – with respite provided for loved ones

Provide opportunities for older adults to stay connected through volunteers and community groups who come in and conduct presentations for the ADH Service

Continuing Education Credits

1 hour of CE credit is being offered for this webinar.

For the live webinar, to obtain the credit you must:

Add your name to the chat box (to verify attendance)

Complete the survey. The survey will open automatically at the end of the webinar and the link will be sent in a follow-up email.

If you did not register for this webinar and would like CE credit, contact gero@duke.edu