cognitive assessment in the elderly

8/3/2019 Cognitive Assessment in the Elderly

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Main Article:H.J. WOODFORD, J. GEORGE. Cognitive assessment in the

elderly: a review of clinical methods. Q J Med 2007; 100:469484

Seminar May 09Piyawat D., M.D. : speaker

Nahathai W., Assis Prof., M.D. : supervisor


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Introductiony Distinguishing normal aging from the early stages of

an abnormal (disease) process

y

Impact on social, functional or occupational activitiesy Impairment not dementia (CIND)

y Prevalence of dementia;

y < 1% of people aged < 65 years

y 311% of those aged 65 years

y Up to 33% of those aged 85 years

y Prevalence of CIND; 17% in people aged


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Introductiony Multiple databases review (to August 2006)

y Cinahl, Embase, Medline and PsychINFO

y MMSE - most commonly used but time consuming


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MMSEy Distinguish organic from non-organic

y Inter-user difference in scoring tests and variation

y

Cut-off points varies;y 23 for those who educated up to high school

y 25 for those who underwent higher education

y It has both a ceiling and floor effect

y

Limited capacity toy Test frontal : executive or visuospatial functions

y Detected non-ADs, such as post-stroke cognitiveimpairment, frontotemporal or subcortical dementias


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Abbreviated Mental Test (AMT)y 10 questions with the components of;

y short and long term memory

y attention and orientationy Score of


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AMT (en.wikipedia.org/wiki/Abbreviated_mental_test_score)


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Six-Item Screener (SIS)y 3 orientation questions and a 3-item recall task

y Lower score signifying more cognitive impairment

y Cut-off of 4Example *

y three-item recall (apple, table, penny)

y In CSI-D is boat, house, and fish

y three-item temporal orientation (day of the week,month, year)

*C. M. CALLAHAN, et al. Six-Item Screener to Identify Cognitive Impairment Among PotentialSubjects for Clinical Research: MEDICAL CARE Volume 40, Number 9, pp 771781.


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Six-Item Cognitive Impairment Test

(6CIT)y Short Orientation-Memory-Concentration Test

y Constructed from six itemsy

One memory, two calculation and three orientationyWeighting when scored (0 - 28)

y Higher numbers representing more significantcognitive impairment

y

Requirement for some mathematicsy Scores of 0-7 are considered normal and 8 or more

significant** Wilber ST, et al. The Six-Item Screener to detect cognitive impairment in older

emergency department patients.Acad Emerg Med. 2008 Jul;15(7):613-6.


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6-CIT(www.patient.co.uk/leaflets/6_item_cognitive_im

pairment_test.htm )


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Clock Drawing Test (CDT)yA screen for visiospatial, constructional praxis and

frontal/executive impairment

y

10 past 11y Many versions and at least 15 different scoring systems

y Three-point scaley one mark for each of: a correctly drawn circle;

y

appropriately spaced numbers;y and hands that show the right time

y Detect early, mild changes in cognition

y Useful screening test (sensitivity/specificity ~ 85%)


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Chula clock-drawing scoring system (CCSS)(Buranee Kanchanatawan, et. al. Validity of Clock Drawing Test (CDT), Scoring by Chula Clock-Drawing Scoring

System (CCSS) in Screening Dementia among Thai Elderly in Community.J MedAssocThai2006; 89 (8): 1150-6.)


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CDT(http://www.dementiaguide.com/aboutdementia/understanding/praxis)


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Mini-CogyAdd a three-word recall test to the CDT

y Having cognitive impairment if they are unable to;

y Recall any of three words (correct complete clock) or,y Recall only 1 or 2 words and draw an abnormal clock (i.e.

any of the circle, numbers and hands are incorrect)

yJust a screening test (Present VS Absent)


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The Mini-Cog Assessment

Instrument for Dementia*Administration1. Instruct the patient to remember 3 unrelated words and then to repeat

them.2. Instruct the patient to draw the face of a clock with the clock circle

already drawn on the page. After the patient puts the numbers on theclock face, ask him or her to draw the hands of the clock to read aspecific time (These instructions can be repeated)

3. Ask the patient to repeat words.

Scoringy Give 1 point for each recalled word after the CDT distractor. Score 13.

y A score of O indicates positive screen for dementia.y A score of 1 or 2 with an abnormal CDT indicates positive screen for

dementia.y A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

*Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive vital signs measure fordementia screening in multi-lingual elderly. Int J Geriatr P s y c h i a t r y 2000;15(11): 10211027.


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The General Practitioner

Assessment of Cognition (GPCOG)y Similarities with the Mini-Cog (recall task CDT)

y Brief components testing

y Memory of recent events and orientationy Questionnaire in intermediate scores patients


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Comparingb

rief assessment scales


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Comparing brief assessment scalesy More capacities than MMSE;

y CDT - frontal/executive cognitive abnormalities

y 6CIT - milder cases of dementia in selected casesy Mini-Cog - ability to classify ethnically diverse groups

y GPCOG outperform the MMSE in a GP-based sample

y SIS better than Mini-Cog in ER setting

y 2 reviews were recommended;y Mini-Cog, GPCOG, Memory Impairment Screen (MIS)


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Recommendationy SIS, 6CIT and Mini-Cog may be considered as quicker

yet sufficiently reliable alternatives to the MMSE

y

Choice of which is preferred may reflect the testingenvironment

y SIS ER setting

y 6CIT maths

y Mini-Cog pen & paper (+non-Eng speaker)


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Distinguishing causes of impairmenty The brief screening tests - little ability to distinguish

y History of onset, progression and associated features

y PE is also necessary to detect associated signsy Investigations to exclude reversible causes

y Gold standard for the diagnosis of types of cognitiveimpairment currently absence

y NINCDS-ADRDA criteria require autopsy proof fordefinite ADs

y DSM-IV criteria - limited differentiating ability betweensubtypes


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Depressiony Gold standard - psychiatric interview

y Brief screening

y Geriatric Depression Score (GDS)y A score > 5 points is suggestive of depression.*

y A score > 10 points is almost always indicative of depression.*

y Hospital Anxiety and Depression Scale (HADS)

yValidity may be impaired in patients with significantcognitive impairment


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Geriatric DepressionS

cale:S

hort Form*(*http://www.stanford.edu/~yesavage/GDS.html)1. Are you basically satisfied with your life? YES / NO2. Have you dropped many of your activities and interests? YES / NO3. Do you feel that your life is empty? YES / NO4. Do you often get bored? YES / NO

5. Are you in good spirits most of the time? YES / NO6. Are you afraid that something bad is going to happen to you? YES / NO7. Do you feel happy most of the time? YES / NO8. Do you often feel helpless? YES /NO9. Do you prefer to stay at home, rather than going out and doing new things? YES

/ NO

10. Do you feel you have more problems with memory than most? YES / NO11. Do you think it is wonderful to be alive now? YES / NO12. Do you feel pretty worthless the way you are now?YES / NO13. Do you feel full of energy? YES / NO14. Do you feel that your situation is hopeless? YES /NO15. Do you think that most people are better off than you are? YES / NO

y Score 1 point for each bolded answer.


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Deliriumy CAM - screening test to detect delirium

y Compared it to the DSM-IV criteria, the sensitivity and

specificity were 81% and 84%, respectivelyy present or absent result

y Delirium Rating Scale (DRS)


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Delirium Index (DI)(McCusker J. The delirium index, a measure of the severity of delirium: new findings on reliability,

validity, and responsiveness. J Am Geriatr Soc. 2004 Oct;52(10):1744-9.)


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Dementiay Hachinski Ischaemic score VaD

y < 4 suggests primary dementia (eg, Alzheimer's disease)

y

47 = indeterminatey > 7 suggests vascular dementia

y Dementia of Alzheimer Type (DAT) inventory AD


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Modified Hachinski Ischemic Score(http://www.merck.com/mmpe/sec16/ch213/ch213c.html)


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Informant questionnairesy Ask for an impression of change

y Give an impression of general decline rather than specificdomains of cognitive impairment

y Influenced by factors regardingy The informants state of mind

y Relationship with the patient

y Informant Questionnaire on Cognitive Decline in the

Elderly (IQCODE)y 26 questions based on change in cognitive function over a 10-

year period

y sensitivities/specificities - 100% /86% comparing with MMSE


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Frontal lobe testingy Frontal/Subcortical Assessment Battery (FSAB)

y Luria sequencing task

y

go/no go testy Cortical dementia (AD) also scored poorly in the FSAB

and the additional use of the MMSE

y Frontal Lobe Score (FLS)

y sensitivity of 7892% / specificity of 100%


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Frontal lobe testingy Frontal Assessment Battery (FAB)

y Briefer screening tool of frontal/executive function

y Effective at distinguishing patients with frontal lobeimpairment from normal controls

y Ability to distinguish frontal impairment from othercognitive deficits (e.g. AD) is unknown

y Lower scores -more severe impairment (score 0 18)

y Executive Interview (EXIT25)y AD also score poorly on the EXIT25

y Combination with the MMSE - greater discriminatoryvalue


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Extended versions of the MMSEyAddenbrookes Cognitive Examination (ACE)

y 100-point scale with more detailed components for

memory and frontal/executive functioningy Distinguish between AD and FTD

y Includes the questions from MMSE and CDT

y Score of


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Extended versions of the MMSEy Cognitive Abilities Screening Instrument (CASI)

y Cambridge Mental Disorders of the Elderly

Examination (CAMDEX)y Cambridge Cognitive Examination (CAMCOG)

y Additional cognitive aspects (mainly praxis, abstractthinking and perception)

y Sensitivity of 92% and specificity of 96% to detectorganic

y Combination of the CDT with the MMSE offeredequivalent sensitivity and specificity


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Extended versions of the MMSEy Middlesex Elderly Assessment Memory Score

(MEAMS)

y

Used by occupational therapists than doctorsy Designed to assess frontal and right parietal lobe

function (verbal fluency, motor perseveration andfragmented letter perception)

y Cut off 47 (lower scores - more cognitive impairment)

y Benefit in the MEAMS for detecting non-dementia,isolated cognitive impairments.


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Qualitative assessmentsyAttention

y Recite reverse sequences

y

Serial 7sy Digit span testing

y Characteristically impaired in patients with delirium

y Memory

y Long- and short-term elementsy Short-term memory - limbic system (temporal lobes)

y Long-term memory - cortical processes


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Qualitative assessmentsy Memory

y Episodic memory is related to personal experiences

y

Semantic memory to impersonal factsy Procedural memory to performing actions

y Working memory is the capacity to briefly

y Three words (MMSE)

y Name and address to recall (ACE)y Subcortical dementias - likely to recall information

when given clues than those with cortical deficits

y Visuospatial memories - non-dominant parietal lobe


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Qualitative assessmentsy Language

y Dominant hemisphere

y Subcortical dementia - Loss of prosody, Reduced verbalfluency, Dysarthria

y Repeat complex phrases

y Repeat complex commands

y Naming

yVisuospatial skillsy Either hemisphere, but tend to be more severe when the

non-dominant hemisphere

y Copy diagrams


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Qualitative assessmentsy Frontal/executive function

y Mainly derived from the frontal lobe (also involving

subcortical connections with the basal ganglia)y Planning, abstract thought, and judgement

y Trail-making tests

y List as many words in a 1-min (at least 15 words)

y go/no go tests


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Rating severity of disorder, and

monitoring disease progressionyAD is typically associated with an annual decline on

the MMSE of 34 points

y

18 23 = mildy 17 and below = severe

y Instrumental activities of daily living (IADLs)


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Summaryy Brief tests with a reasonable sensitivity and specificity

include the 6CIT, Mini-Cog and SIS

y

Longer tests may have a small additional benefit insensitivity and specificity to detect cognitiveimpairment, but their main roles may be to helpdefine patterns of cognitive loss and to rate severity

y

Use suitable tests for purposes and environment

cognitive assessment in the elderly

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