Identification of Cognitive Impairment in HIV patients Belinda Vicioso MD FACP, AGSF Jose Garcia Professor of Medicine UTSW
New emphasis on cognition Why? Common in our patient population Often overlooked Cognitively impaired individuals use more services ER, more admissions, more prescriptions Poorer prognosis
GOOD NEWS Cognitive assessment does not take long More helpful than routine lung and heart examination in asymptomatic patients Impactful to quality of life and patient well being
Common Cognitive Screening Tools in Geriatrics Practice Mini-cog Quick, office based tool Minimal language requirement Does not require specialized testing materials Clock drawing tests executive function MMSE Long history of validation and use Copyrighted Insensitive in HIV patients MoCA Translated in 35 languages and dialects and there are 3 English versions for longitudinal use Easy website access and available for free use Foto test Used in low literacy, non-english speaking populations
Mini-Cog Developed by Soo Borson et al in 2000 Validated in 295 pts; 154 non-english speakers in native languages Clock Drawing Test significantly affected by education, not by primary language Memory test not education specific although choice of cognitively resonant words can influence ability to register and cue Journal of Gerontology 1999; JAGS 2003
The Mini-Cog Assessment Instrument for Dementia The Mini-Cog assessment instrument combines: Uncued 3-item recall test Clock-drawing test (CDT) Mini-Cog can be administered in about 3 minutes, requires no special equipment, and is relatively uninfluenced by level of education or language variations. Administration The test is administered as follows: 1. Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat the words. 2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as 11:10. These instructions can be repeated, but no additional instructions should be given Give the patient as much time as needed to complete the task 3. Ask the patient to repeat the 3 previously presented words. Scoring Give 1 point for each recalled word after the CDT distractor. Score 1 3. A score of O indicates positive screen for dementia. 1 or 2 with an abnormal CDT indicates positive screen for dementia. 1 or 2 with a normal CDT indicates negative screen for dementia. 3 indicates negative screen for dementia. The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. Source: Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive vital signs measure for dementia screening in multi-lingual elderly. Int J Geriatr P s y c h i a t r y 2000; 15(11): 1021 1027
MINI-COG PLUS No pre-formed circle Note if need to repeat instructions Use eleven ten, not ten past eleven If words forgotten, give categorical cue
12 11 1 10 2 9 3 8 4 7 6 5
BONUS ELEMENTS OF MINI-COG Mini-cog plus Importance of cued recall Working memory? Size of face Placement of numbers Placement of hands Presence of arrows Extra items
If Mini Cog score is low If impaired memory and cued recall lead the way, Consider AD If function still good, consider medication If memory impaired but cueing helps Consider treatable causes AC burden, metabolic, depression If executive function leads the way Consider non-ad dementias including HIV Need good history, neuro exam
HIV DEMENTIA Dementia implies functional decline Without functional decline, MCI Dementia in HIV HAND or other chronic infections Vascular brain injury AD
College Graduate
Montreal Cognitive Assessment Developed by Z. Nasreddine, 2005 Originally intended as screening tool for MCI Validated in many languages Patients with less education do poorly so; 2 points added to those with 4-9 years of education 1 point for 10-12 years of education MoCa for the Blind
HS, English
GOOD NEWS! Cognitive assessment does not take long All team members can do it More helpful than routine lung and heart examination in asymptomatic patients Impactful to quality of life and patient well being
QUESTIONS????