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ACT on Alzheimer’s

Alzheimer’s Disease Curriculum

Module VI: Screening

GUIDELINES AND RESTRICTIONS ON USE OF DEMENTIA CURRICULUM MODULES

This curriculum was created for faculty across multiple disciplines to use in existing coursework and/or to develop as a stand-alone course in dementia. Because not all module topics will be used within all disciplines, each of the ten modules can be used alone or in combination with other modules. Users may reproduce, combine, and/or customize any module text and accompanying slides to meet their course needs.

Use restriction: The ACT on Alzheimer's®-developed dementia curriculum cannot be sold in its original form or in a modified/adapted 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 fully represented (e.g., the screening module appears in total within the diagnosis module because the diagnosis module will not be used for all audiences).

© 2016

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Acknowledgement

We gratefully acknowledge the funding organizations that made this curriculum development possible: the Alzheimer’s Association MN/ND 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 specifically 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 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, GCSJim Pacala, MD, MSPatricia Schaber, PhD, OTR/LJohn SelstadEricka Tung, MD, MPHJean Wyman, PhD., RN, GNP-BC, FAAN, FGSA

This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services

(DHHS) under Grant Number UB4HP19196 to the Minnesota Area Geriatric Education Center (MAGEC) for $2,192,192 (7/1/2010—6/30/2015). This information or content and conclusions are

those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.

Minnesota Area Geriatric Education Center (MAGEC)Grant #UB4HP19196

Director: Robert L. Kane, MDAssociate Director: Patricia A. Schommer, MA

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Overview of Alzheimer’s Disease Curriculum

This is a module within the Dementia Curriculum developed by ACT on Alzheimer’s. ACT on Alzheimer’s is a statewide, volunteer-driven collaboration seeking large-scale social change and community capacity-building to transform Minnesota’s response to Alzheimer’s disease. An overarching focus is health care practice change to ensure quality dementia care for all.

All of the dementia curriculum 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: Dementia as an Organizing Principle of Care

Module IX: Quality Interventions

Module X: Caregiver Support

Module XI: Alzheimer’s Disease Research

Module XII: Glossary

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ACT on Alzheimer's has developed a number of practice tools and resources to assist providers in their work with patients and clients who have memory concerns and to support their care partners. Among these tools are a protocol practice tool for cognitive impairment, a decision support tool for dementia care, a protocol practice tool for mid- to late-stage dementia, care coordination practice tools, and tips and action steps to share with a person diagnosed with Alzheimer's. These best practice tools incorporate the expertise of multiple community stakeholders, including clinical and community-based service providers:

• Clinical Provider Practice Tool• Electronic Medical Record (EMR) Decision Support Tool• Managing Dementia Across the Continuum• Care Coordination Practice Tool• Community Based Service Provider Practice Tool• After A Diagnosis

While the recommended practices in these tools are not location-specific, many of the resources referenced are specific to Minnesota.  The resource sections can be adapted to reflect resources specific to your geographic area. To access ACT practice tools and resources, as well as video tutorials on screening, assessment, diagnosis, and care coordination, visit: http://actonalz.org/provider-practice-tools

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Module VI: Learning Objectives

Upon completion of this module the student should:

Gain insight into the topic of screening including: tips, screening measures, and

recommendations.

Summarize screening measures used for assessing cognitive functioning.

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Module VICognitive Screening

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, 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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Initial Considerations for ScreeningThere are multiple screening tools available to providers to aid in the identification of dementia and Alzheimer’s disease. There are a number of issues that a provider should consider before implementing a screening program:

Consider relevant research findings related to screening. Strike a balance between the time devoted to screening and the sensitivity/specificity. Establish how the practice will incorporate screening. Establish who will administer the tests, e.g., physicians, nurses, social workers, allied

health professionals. Establish a process path for what happens once a screen is positive.

General Screening TipsThere are a number of steps one can take to more effectively administer a screening 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. General practice recommendations include:

Avoid cognitive screening solely on the basis of age. Screen vulnerable elderly patients at their initial visit and annually thereafter. Ensure that all patients who undergo cognitive screening are tested for depression.

Actions to Avoid During ScreeningWhile 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 Screening 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 (e.g. 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

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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 concerns about sensitivity, more recent studies have used a score <4 to distinguish pass from failure (McCarten, et al., 2011). Generally, scores <4 are considered failing whereas scores ≥ 4 indicate passing. 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.

Mini-Cog Administration and Scoring tutorial videos: http://www.actonalz.org/video-tutorials

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.

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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 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.

SLUMS Administration and Scoring tutorial videos: http://www.actonalz.org/video-tutorials

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

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and disorders of medial temporal function). Other advantages include the fact that the 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 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).

MoCA Administration and Scoring tutorial videos: http://www.actonalz.org/video-tutorials

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

ACT on Alzheimer’s Tools:

The Clinical Provider Practice Tool provides physicians a streamlined protocol for managing cognitive impairment and guiding decisions for screening, diagnosis, and disease management.  This tool incorporates current best practices for efficient and appropriate dementia care.

The Community Based Service Provider Practice Tool supports clients with memory concerns

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and their care partners. Community based service providers are critical in providing quality care to clients with dementia and their care partners.

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Module VI: Question for Review

1. Which of the following recommendations should be followed when performing a mental status examination?

a. If your patient struggles with finding the correct word, offer options for her to choose from.

b. If your patient struggles with concentrating on the question you are asking, provide coaching to keep her attention.

c. If your patient becomes frustrated with the test and asks to talk about a different topic, move on to a different assessment.

d. If your patient is having a difficult time with the test, do not allow your patient to give up prematurely.

2. When administering the Mini-Cog, which of the following word combinations yields the highest sensitivity?

a. Apple, table, pennyb. Mr. Johnson, charity, applec. Leader, season, tabled. Apple, season, leadere. Mr. Johnson, table, charity

3. Which of the following tests is available in >30 languages?a. Mini Mental Status Examinationb. Montreal Cognitive Assessmentc. Short Test of Mental Statusd. St. Louis University Mental Status Examinatione. Mini-Cog

4. Which of the following tests is administered to an informant, rather than the patient?a. Mini Mental Status Examinationb. Montreal Cognitive Assessmentc. Short Test of Mental Statusd. AD8 Dementia Screene. St. Louis University Mental Status Examinationf. Mini-Cog

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References

Borson, S., Scanlan, J., Brush, M., Vitaliano, P. & Dokmak, A. (2000). The mini-cog: a

cognitive 'vital signs' measure for dementia cognitive assessment in multi-lingual elderly.

International Journal of Geriatric Psychiatry, 15(11): 1021-1027.

Borson, S., Scanlan, J.M., Chen, P. & Ganguli, M. (2003). The Mini-Cog as a screen for

dementia: validation in a population-based sample. Journal of the American Geriatric

Society, 51(10):1451-1454.

Borson, S., Scanlan, J., Hummel, J., Gibbs, K., Lessig, M. & Zuhr, E. (2007). Implementing

routine cognitive assessment of older adults in primary care: process and impact on

physician behavior. Journal General Internal Medicine, 22(6):811-817.

Chen, R., Xiong, K.P., Huang, J.Y., Lian, Y.X., Jin, F., Li, Z.H., Zhao, M.Y. & Liu, C.F. (2011).

Neurocognitive impairment in Chinese patients with obstructive sleep apnoea hypopnoea

syndrome. Respirology, 16(5):842-848.

Dalrymple-Alford, J.C., MacAskill, M.R., Nakas, C.T., Livingston, L., Graham, C., Crucian,

G.P., Melzer, T.R., Kirwan, J., Keenan, R., Wells, S., Porter, R.J., Watts, R. & Anderson,

T.J. (2010). The MoCA: well-suited screen for cognitive impairment in Parkinson

disease. Neurology. 75(19):1717-1725.

Dong, Y., Venketasubramanian, N., Chan, B.P., Sharma, V.K., Slavin, M.J., Collinson, S.L.,

Sachdev, P., Chan, Y.H. & Chen, C.L. (2012). Brief cognitive assessment tests during

acute admission in patients with mild stroke are predictive of vascular cognitive

impairment 3-6 months after stroke. Journal of Neurology, Neurosurgery and Psychiatry.

83(6):580-585.

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Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975). "Mini-mental state". A practical method

for grading the cognitive state of patients for the clinician. Journal of Psychiatric

Research. 12(3):189-198.

Ismail, Z., Rajji, T.K. & Shulman, K.I. (2010). Brief cognitive assessment instruments: an

update. International Journal of Geriatric Psychiatry. 25(2):111-120.

Kokmen, E., Naessens, J.M. & Offord, K.P. (1987). A short test of mental status: description and

preliminary results. Mayo Clinic Proceedings. 62(4):281-288.

Larner, A.J. (2012). Cognitive assessment utility of the Montreal Cognitive Assessment (MoCA):

in place of--or as well as--the MMSE? International Psychogeriatrics. 24(3):391-396.

McCarten, J.R., Anderson, P., Kuskowski, M.A., McPherson, S.E. & Borson, S. (2011).

Cognitive assessment for cognitive impairment in an elderly veteran population:

acceptability and results using different versions of the Mini-Cog. Journal of the

American Geriatric Society. 59(2):309-313.

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.

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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

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

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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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