11/27/2017. Ryan Jones, PsyD CoxHealth Department of Neuropsychology Stroke Conference: December 8, 2017

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1 Ryan Jones, PsyD CoxHealth Department of Neuropsychology Stroke Conference: December 8, 2017 About Me Springfield Native Outdoor enthusiast Neuropsychologist for CoxHealth Outpatient clinic in the Jared Neuroscience Center Primary referrals come from neurology and primary care See primarily adults (16+) 60-70% of referrals are dementia related Objectives Discuss the appropriate use of psychiatric/cognitive screeners post stroke and be able to implement into clinical practice Identify important factors to consider when choosing psychiatric/cognitive screeners for clinical use 1

2 Overview Review of neuropsychology and cognitive assessment Important factors to consider when choosing a screener Review of available screeners Integration into practice Disclosures: None Neuropsychology Assessment of brain-behavior relationships Emphasis on functional abilities Typical Format: Initial consultation/interview Purposes: information gathering, to ensure that testing is appropriate Testing May range significantly in duration typically between 2 and 8 hours Difficulty of tasks range in severity; tailored to patient s needs Feedback to referring doctor and patient, and family/friends as appropriate Areas that are commonly assessed Orientation Intelligence Memory Language-Expressive and Receptive Visual-spatial skills Higher-level abilities (e.g., multitasking, problem solving) Applied Functional Abilities (e.g. simulated ADLs) Motor abilities (e.g., fine motor coordination) Emotional functioning (e.g., depression, anxiety) 2

3 Example Why screen for cognitive deficits Estimated that 75% of CVA survivors experience cognitive impairment (CI) Clinical observation alone is limited in identifying deficits (Edwards et al, 2006) Anomia-97% missed; Visualspatial-61% missed; Memory-31% missed CI is associated with poorer outcome post CVA Lack of adherence to medications or treatment plan Reduced judgment/decision making in health behaviors Guide treatment planning and rehabilitation needs Internal/External Threats to Validity Fatigue Associated with attention/vigilance, processing speed, hand-eye coordination, executive functioning, memory Testing in the morning is typically best Medications Anticholinergics, benzos, narcotics, neuroleptics, AEDs, sedatives Environment Quiet and distraction free Normative data was collected in this type of environment Psychiatric effects Depression, Anxiety, Apathy/Motivation, Anger 3

4 Other factors to consider Premorbid functioning Education-highest level, grade repetition, hx of special education/ld Occupation Age Pre-existing conditions before the CVA 10% have dementia before first CVA (Pendlebury 2009) Stats Stats Primer Sensitivity: Probability that the screener will identify impairment in those that have impairment (True Positive vs False Positive) Specificity: Probability that the screener will be negative for impairment for those that don t have impairment (True Negative vs False Negative) Positive Predictive Value: Chance that a person with a positive screener truly has impairment (True positive/true positive + False Positive x100) Negative Predictive Value: Chance that a person with negative screener truly in cognitive intact (True negative/true negative+false Negative x 100) 4

5 Stats Reproduced From Mausner et al (1985) Cognitive Screeners Important questions to ask before selecting a screener Normative sample (age, education, ethnicity) Clinical samples Administration time Special populations (hearing/visually impaired; language) Cost Who can administer and ease of administration 5

6 Aphasia Rule out aphasia, especially with left hemisphere stroke Aphasia can impact all other domains on cognitive screeners Clinical observation is limited Edwards et al (2006) found 79% undetected by observation only Aphasia screeners: Frenchay Aphasia Screening Test (FAST): 10 mins/ 3 mins for short form Language Screening Test (LAST): 3 mins Mobile Aphasia Screening Test (MAST*): 3 mins Mississippi Aphasia Screening Test (MAST): 5-10 mins Aphasia Screeners Validation Studies El Hachioui et al, 2017 Popular Cognitive Screeners Sensitivity MOCA SLUMS MMSE 90% MCI 100% dementia 92% MCI 100% Dementia Specificity 87% 81% 100% Public Domain Yes Yes No 18% MCI 78% Dementia Interpretation is based on global score rather than raw scores of each items While sensitive to cognitive impairment, differentiation of cognitive patterns to assist with localization is more challenging with a brief cognitive screener (Nasreddine et al, 2005) 6

7 Cognitive Screeners in CVA population MoCA and MMSE had the most studies MMSE had 11 studies: Only 3 had acceptable sensitivity(>80%)/specificity(>60%) MoCA had 5 studies: 4 had acceptable sensitivity/specificity 4 studies compared MoCA and MMSE: MoCA had better sensitivity and slightly poorer specificity RBANS, Cognistat, and Barrow Neurological Institute Screen (BNI) had acceptable psychometrics, though limited studies (1 per measure) (Stolwyk et al, 2014) Cognitive Screeners in acute CVA Van Heugten(2015) reviewed 51 studies of 16 cognitive screeners w/in 1 month of CVA: No screener covered all cognitive domains: MoCA was closest Criterion Validity (80 sens./60 spec.) MMSE-2 of 6 studies met this criteria MoCA-5 of 6 studies met this criteria (6 th one had a sensitivity of 78%) Predictive Validity MMSE (13 studies)-mixed results for long-term CI and functional impairment MoCA (3 studies)-good validity for long-term CI and mixed for functional impairment MoCA was recommended as the best candidate for screening post CVA 30 screeners reviewed and 18 did not meet selection criteria 21 articles assessed the remaining 12 measures in 2148 CVA survivors 3 measures assessed most domains, including executive functioning Addenbrooke s Cognitive Examination (ACE-R); Cognistat; & MoCA MoCA and MMSE could screen for impairments at all severity levels MMSE score of 23/24 was best to detect vascular dementia MoCA better at identifying impairment at any severity level MoCA had the best clinical utility out of the measures Brief administration time, administration requirements, cost 7

8 Montreal Cognitive Assessment (MoCA) Multiple languages (>30) and three versions for repeat testing Blind version available IPAD version being developed 30 point scale similar to MMSE and SLUMS Newer research investigating index scores to assist with differentiating dementia diagnoses and conversion rates from MCI to dementia (e.g. MoCA-Memory Index Score) (Julayanont et al, 2014) Pragmatic Approach Single cut score has limitations due to culture, education, age Study showed >50% of community dwelling adults without history of CVA scored below the cutoff of 26 on the MoCA Multiple cut scores on MoCA can differentiate risk Low risk: >=28 2.4% had mod-sev CI Intermediate risk: % had mod-sev CI High risk: <= % had mod-sev CI (Swartz et al, 2016) Multiple Cut scores 8

9 MoCA in clinical use MoCA does not have a measure of processing speed The addition of the Symbol Digit Modality Test (Oral or Written) is recommended Improved discriminatory ability when SDMT. Cutoff score of <= 32 for education >6 years (Dong et al, 2014) Why screen for depression Depression is a common comorbidity of CVA (11-63%) Other two are Obstructive Sleep Apnea and CI These have a greater impact on long-term functional recovery Post stoke depression is associated with Increased functional disability Longer hospitalization Decreased likelihood of being discharged home 3x mortality risk after controlling for CVA severity and demographics Treatable if identified (Swartz et al, 2016) Practice Gaps in screening Schwartz

10 Treatable SSRI are effective. Avoid anticholinergics (e.g. tricyclics) (Robinson et al, 2016) Not just depression 25% of CVA survivors develop an anxiety disorder Mania 1% of CVA cases Usually right hemisphere lesions Psychosis (e.g. hallucinations, delusions, paranoia) Usually associated with right hemisphere lesions Similar approach to Cognitive Screeners Obtain history about premorbid psychiatric history Collateral information from family Clinical observations Symptoms are multifactorial Organic vs Adjustment Emotional lability Depression 10

11 Depression Screeners A lot of screeners have been validated for post stroke depression Most popular include: PHQ2 & PHQ9 Hospital Anxiety and Depression Scale (HADS) Hamilton Rating Scale for Depression (HAMD) Geriatric Depression Scale (GDS) Beck Depression Inventory-2 (BDI-II) Montgomery-Asberg Depression Scale (MADRS) Completed via clinical interview Depression Screeners Most have been validated and shown to be effective Kang et al (2013) examined BDI, HADS-D, MADRS, and HAMD All had good sensitivity and specificity 2 weeks: ROC of year: ROC of Somatic symptoms were associated with misclassification at acute stages BDI and HAMD had more somatic symptoms Depression Screeners 11

12 PHQ-2, PHQ-9, or Both De Man-van Ginkel et al, 2012 Best practices for clinical screeners Select cognitive and psychiatric screeners that have the best combination of psychometrics for a stroke population and pragmatics of the setting Integrate biopsychosocial factors when examining the accuracy of the score Have treatment plans designed for various risk of CI and psychiatric symptoms according to screeners Back to Neuropsychology Remember when. Questions 12

13 References Burton, L., & Tyson, S. F. (2015). Screening for cognitive impairment after stroke: A systematic review of psychometric properties and clinical utility. Journal Of Rehabilitation Medicine, 47(3), doi: / de Man-van Ginkel, J. M., Hafsteinsdóttir, T., Lindeman, E., Burger, H., Grobbee, D., & Schuurmans, M. (2012). An efficient way to detect poststroke depression by subsequent administration of a 9-item and a 2-item Patient Health Questionnaire. Stroke, 43(3), doi: /strokeaha Dong, Y., Slavin, M. J., Chan, B. P., Venketasubramanian, N., Sharma, V. K., Collinson, S. L., &... Chen, C. L. (2014). Improving screening for vascular cognitive impairment at three to six months after mild ischemic stroke and transient ischemic attack. International Psychogeriatrics, 26(5), doi: /s Edwards, D. F., Hahn, M. G., Baum, C. M., Perlmutter, M. S., Sheedy, S., & Dromerick, A. W. (2006). Screening patients with stroke for rehabilitation needs: Validation of the post-stroke rehabilitation guidelines. Neurorehabilitationand Neural Repair, 20, El Hachioui, H., Visch-Brink, E. G., de Lau, L. M. L., van de Sandt-Koenderman, M. W. M. E., Nouwens, F., Koudstaal, P. J., & Dippel, D. W. J. (2017). Screening tests for aphasia in patients with stroke: a systematic review. Journal of Neurology, 264(2), Hinckley, J. J. (2014). A case for the implementation of cognitive-communication screenings in acute stroke. American Journal Of Speech-Language Pathology, 23(1), doi: / (2013/ ) Kang, H., Stewart, R., Kim, J., Jang, J., Kim, S., Bae, K., &... Yoon, J. (2013). Comparative validity of depression assessment scales for screening poststroke depression. Journal Of Affective Disorders, 147(1-3), doi: /j.jad Lees, R., Stott, D. J., Quinn, T. J., & Broomfield, N. M. (2014). Feasibility and diagnostic accuracy of early mood screening to diagnose persisting clinical depression/anxiety disorder after stroke. Cerebrovascular Diseases (Basel, Switzerland), 37(5), doi: / Mausner JS, Kramer S: Mausner and Bahn Epidemiology: An Introductory Text. Philadelphia, WB Saunders, 1985, p Pendlebury ST, Rothwell PM.. Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and metaanalysis. Lancet Neurol. 2009;8: doi: /S (09) Robinson, R. G., & Jorge, R. E. (2016). Post-Stroke Depression: A Review. American Journal Of Psychiatry, 173(3), doi: /appi.ajp Swartz, R. H., Cayley, M. L., Lanctôt, K. L., Murray, B. J., Smith, E. E., Sahlas, D. J., &... Thorpe, K. E. (2016). Validating a Pragmatic Approach to Cognitive Screening in Stroke Prevention Clinics Using the Montreal Cognitive Assessment. Stroke, 47(3), doi: /strokeaha Stolwyk, R. J., O'Neill, M. H., McKay, A. D., & Wong, D. K. (2014). Are cognitive screening tools sensitive and specific enough for use after stroke? A systematic literature review. Stroke, 45(10), doi: /strokeaha