Currently Used Measures of Cognitive Impairment An HBRN Scholar Special Presentation & Discussion

Transcription

1 Currently Used Measures of Cognitive Impairment An HBRN Scholar Special Presentation & Discussion Laura M. Vitkus MPH Student, Health Behavior Health Promotion, Class of 2018 University of Arizona, College of Public Health Program Coordinator, Arizona Geriatric Workforce Enhancement Program University of Arizona Center on Aging Valerie J. Edwards, PhD Research Psychologist Centers for Disease Control and Prevention Hossein Ehsani, PhD Postdoctoral Research Associate, Department of Biomedical Engineering University of Arizona Affiliate, University of Arizona Center on Aging

2 Establish and advance a public health research, translation, and dissemination agenda Build the evidence base Build workforce capacity of public health professionals

3 Presenters Laura Vitkus, HBRN Scholar Laura will receive her MPH in May. Her research focus is on healthy aging, fall prevention, oral health for older adults, quality of life for older Deaf adults and includes the impact of age related hearing loss on cognition. Hossein Ehsani, PhD, HBRN Scholar Dr. Ehsani received his BSc, MSc and PhD degree in Biomedical Engineering (Biomechanics) from Tehran s Polytechnic, Tehran, Iran. His research is mainly focused on computer simulation of musculoskeletal system, computational motor control and neuromechanics of human movement. Recently his work has centered on developing novel methods to identify cognitive status of older adults Valerie Edwards, PhD Dr. Edwards received her Ph.D. in Social Psychology from the University of Texas at Austin. In 1989, after completing postdoctoral work at Emory University in developmental psychology and epidemiology, she joined the CDC.

4 ML(1 National Center for Chronic Disease Prevention and Health Promotion Measuring Cognitive Decline and Diagnosing Alzheimer s Disease and Dementia Valerie J. Edwards, Ph.D. Health Scientist Alzheimer s and Healthy Aging Program Division of Population Health Centers for Disease Control and Prevention

5 Slide 4 ML(1 I modified your 1st and last slide, given that you will be putting these through clearance. We are supposed to use the 1st and last slide from the template. McGuire, Lisa (CDC/ONDIEH/NCCDPHP), 4/13/2018

6 There are many types of Dementia

7 Slide 5 ML(2 Is this slide what is dementia or there a many types of dementia? both are okay, but I would rephrase the question. McGuire, Lisa (CDC/ONDIEH/NCCDPHP), 4/13/2018

8 Behavioral Manifestations of Alzheimer s Disease and Dementia

9 Neurological manifestations of Alzheimer s Disease

10 Neurological manifestations of Alzheimer s Disease

11 Neurological manifestations of Alzheimer s Disease

12 ML(3 Physical versus Behavioral Manifestation of Alzheimer s Disease What is the correlation between neuropsychological tests and changes in brain? Measuring Cerebral Atrophy and White Matter Hyperintensity Burden to Predict the Rate of Cognitive Decline in Alzheimer Disease Adam M. Brickman, PhD; Lawrence S. Honig, MD, PhD; Nikolaos Scarmeas, MD; Oksana Tatarina, BA; Linda Sanders, BA; Marilyn S. Albert, PhD; Jason Brandt, PhD; Deborah Blacker, MD, ScD; Yaakov Stern, PhD Cognitive Decline Strongly Correlates with Cortical Atrophy in Alzheimer s Dementia PETER R. MOUTON,*1 LEE J. MARTIN,* MICHAEL E. CALHOUN,* GLORIA DAL FORNO, AND DONALD L. PRICE*

13 Slide 10 ML(3 not sure the purpose of this slide---it might be to drive home the point of what we see in slide 4 is what is going on in the brain in slides 5-7? McGuire, Lisa (CDC/ONDIEH/NCCDPHP), 4/13/2018

14 Dr. Valerie J. Edwards cdc.gov For more information, contact CDC CDC INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

15 Currently Used Measures of Cognitive Impairment Laura M. Vitkus MPH Student, Health Behavior Health Promotion, Class of 2018 University of Arizona, College of Public Health Program Coordinator, Arizona Geriatric Workforce Enhancement Program University of Arizona Center on Aging

16 Learning Objectives Discuss the importance of screening for cognitive impairment Understand which measures of cognitive assessment are currently used. Discuss the strengths and weaknesses of popular screening tools. Identify the different tests by sight.

17 Selected Cognitive Assessments AD8 Montreal Cognitive Assessment (MoCA) Mini Mental State Examination (MMSE) General Practitioner Assessment of Cognition (GPCOG) The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Mini COG Memory Impairment Screen (MIS) St. Louis University Mental Status Examination (SLUMS)

18 Primary Care vs Specialist Screening Assessment in Primary Care Referral for Diagnostic Testing Dementia Diagnosis

19 Why Screen? American Academy of Neurology recommends clinicians assess for cognitive impairment using use a brief, validated cognitive assessment instrument in addition to eliciting patient and informant history regarding cognitive concerns 1. Often, MCI/dementia is not diagnosed by PCP 1 Early detection and intervention

20 Testing Components Measuring Particular Cognitive Impairments Screening for MCI vs. Dementia and assessing progression of MCI Demen a Cognitive Burden/Cognitive Load Reliability & Validity Cultural Issues

21 Screening Measures Memory/Recall Visuospatial awareness Verbal fluency/expressive language 2,3,4 Executive Function Gait Dual Task

22 AD8

23 AD8 Strengths Short 8 questions Detects MCI Can be completed by patient or caregiver Not biased by gender, education, culture or English proficiency Validated High sensitivity and specificity for MCI and AD Reliable Inexpensive 5 Weaknesses Informant based can be subject to bias Knowledgeable informants may not be available

24 The Montreal Cognitive Assessment (MoCA)

25 MoCA Video Demonstration

26 MoCA Strengths Designed to test for MCI Available in multiple languages Tests many separate cognitive domains Detected 90% of MCI compared to MMSE 18% Validated Weaknesses Education bias ( 12 years) Lacks studies in general practice settings Test is new enough that use is limited Test takes longer than other assessments, 10 minutes Relies on hearing for word recall 6

27 Mini Mental State Examination(MMSE)

28 MMSE Strengths Used widely and studied worldwide The standard test against which other assessments are measured Validated Weaknesses Biased by education, age, language and culture Highly educated impaired subject will pass the test Test must be purchased from developer Relies on hearing for word recall Developed for testing for Alzheimer s Disease. Not sensitive for MCI 7

29 General Practitioner Assessment of Cognition (GPCOG)

30 General Practitioner Assessment of Cognition (GPCOG) Strengths Quick 2 5 minutes to complete Used widely in primary care Translatable into other languages High sensitivity Validated in primary care Can be given to the patient or caregiver Tests for all dementia Weaknesses Lacks data on language/culture bias Relies on hearing for name/address recall Does not cover attention/working memory

31 The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)

32 IQCODE

33 The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Strengths Sensitivity and specificity for dementia Available in multiple languages Weaknesses Requires extensive knowledge of the patient, 10+ years Test takes longer than other assessments, minutes Complex scoring Suboptimal test for MCI 8

34 Mini COG

35 Draw a clock with the time showing 10 minutes after 11.

36 Mini Cog Video Demonstration

37

38 Mini COG Strengths Quick, 2 4 minutes Validated for use in primary care Validated in multiple languages Scoring is uncomplicated Tests for a wide variety of cognitive impairment Weaknesses Failure rate can be affected by using different word lists Relies on hearing for word recall Primary domain covered is verbal recall

39 Memory Impairment Screen (MIS)

40 Memory Impairment Screen (MIS) Strengths Quick, 4 minutes No writing or drawing required Minimal training required to administer test Can be conducted by telephone Weaknesses Does not test executive function or visuospatial skills Tests verbal memory only Lower sensitivity and specificity, particularly with MCI Relies on hearing for word recall

41 St. Louis University Mental Status Examination (SLUMS)

42 St. Louis University Mental Status Examination (SLUMS) Strengths Easy to administer Relatively short, 7 minutes Assesses several cognitive domains Does not require collateral informants Excellent predictor of mortality and institutionalization over 7 8 years (in veterans) Weaknesses Takes longer than some of the other tests Validity being determined Unknown ability to differentiate MCI vs depression Possible culture, language and education bias 9

43 Cognition and dual tasking With Hossein Ehsani, PhD, Biomedical Engineering Department, University of Arizona Imagine a quick objective screening tool to measure cognition.

44 Cognition and Dual tasking What is dual tasking The opportunity to use dual task to test cognition Gold standard: MoCA How did the project develop

45 Upper Extremity Function (UEF) test Motor component: Rapid elbow flexion (a.k.a Upper extremity function UEF) Cognitive component: Counting backwards by one and three Data collection: Wearable motion sensors

46 Upper Extremity Function (UEF) test (continued ) Sensor outputs: Angle and angular velocity of upper arm and forearm

47 Upper Extremity Function (UEF) test (continued ) Data analysis: Dual task cost and variability

48 UEF in a nutshell

49 Dual Tasking Findings An objective, low cost, quick test is needed Could be routinely used in outpatient clinics for older adult cognition screening (like BP) Could be used to measure change over time

50 Key Take Home Messages Cognitive assessment screening is not diagnostic, but highly predictive 1,2,3. A highly sensitive & specific, quick, and low cost tool for MCI and early AD is needed Differences in culture, language, educational level and some disabilities can impact results. Hearing loss should be accounted for in cognitive assessment.

51 Quiz 1. What is the gold standard measure of assessment? 2. What are common limitations/biases of screening tests? 3. What characteristics make the best assessment tool? Answers: 1. MoCA 2. Education, culture, language, age 3. Valid, quick, inexpensive, unbiased

52 References 1. American Academy of Neurology. (2017) Practice Guideline Update: Mild cognitive Impairment Cullen B, O Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. Journal of Neurology, Neurosurgery, and Psychiatry. 2007;78(8): doi: /jnnp Cordell, C. B., Borson, S., Boustani, M., Chodosh, J., Reuben, D., Verghese, J.,... & Fried, L. B. (2013). Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer's & dementia: the journal of the Alzheimer's Association, 9(2), Dementia Action Collaborative Washington State Brief Cognitive Screening Tools for Primary Care Practice. (November): Screening Position Paper.pdf. 5. Galvin, J. E., Roe, C. M., Powlishta, K. K., Coats, M. A., Muich, S. J., Grant, E.,... & Morris, J. C. (2005). The AD8 A brief informant interview to detect dementia. Neurology, 65(4), Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I.,... & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), Tombaugh, T. N., & McIntyre, N. J. (1992). The mini mental state examination: a comprehensive review. Journal of the American Geriatrics Society, 40(9), Jorm, A. F., & Jacomb, P. A. (1989). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): sociodemographic correlates, reliability, validity and some norms. Psychological medicine, 19(4), Stern, S. (2014). Psychometric Properties of the Saint Louis University Mental Status Examination (SLUMS) for the Identification of Mild Cognitive Impairment (MCI) in a Veteran Sample. 10. Lin FR, Yaffe K, Xia J, et al. Hearing Loss and Cognitive Decline Among Older Adults. JAMA internal medicine. 2013;173(4): /jamainternmed doi: /jamainternmed

53 Thank you! Questions? Laura M. Vitkus Hossein Ehsani, PhD This presentation was supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1QHP28721, Arizona Geriatrics Workforce Enhancement Program. 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 HRSA, HHS or the U.S. Government.

54 The CDC Healthy Brain Research Network is a Prevention Research Centers program funded by the CDC Alzheimer s Disease and Healthy Aging Program. Efforts were supported in part by cooperative agreements from CDC's Prevention Research Centers Program: U48 DP , , , , , and The findings from this presentation are those of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. networks/hbrn/ The CDC Healthy Brain Research Network is a Prevention Research Centers program funded by the CDC Healthy Aging Program Healthy Brain Initiative. Efforts are supported in part by cooperative agreements from CDC's Prevention Research Centers Program.