laura m. vitkus - depts.washington.edu
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Currently Used Measures of Cognitive ImpairmentAn HBRN Scholar Special Presentation & Discussion
Laura M. VitkusMPH Student, Health Behavior Health Promotion, Class of 2018
University of Arizona, College of Public HealthProgram Coordinator, Arizona Geriatric Workforce Enhancement Program
University of Arizona Center on Aging
Valerie J. Edwards, PhDResearch PsychologistCenters for Disease Control and Prevention
Hossein Ehsani, PhDPostdoctoral Research Associate,
Department of Biomedical EngineeringUniversity of Arizona
Affiliate, University of Arizona Center on Aging
• Establish and advance a public health research, translation, and dissemination agenda
• Build the evidence‐base
• Build workforce capacity of public health professionals
PresentersLaura Vitkus, HBRN ScholarLaura 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.
Valerie Edwards, PhDDr. 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.
Hossein Ehsani, PhD, HBRN ScholarDr. 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
National Center for Chronic Disease Prevention and Health Promotion
Measuring Cognitive Decline and Diagnosing Alzheimer’s Disease and DementiaValerie J. Edwards, Ph.D.
Health ScientistAlzheimer’s and Healthy Aging ProgramDivision of Population HealthCenters for Disease Control and Prevention
ML(1
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
There are many
types of Dementia
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
Behavioral Manifestations of Alzheimer’s Disease and Dementia
Neurological manifestations of Alzheimer’s Disease
Neurological manifestations of Alzheimer’s Disease
Neurological manifestations of Alzheimer’s Disease
Physical versus Behavioral Manifestationof Alzheimer’s Disease
What is the correlation between neuropsychological tests and changes in brain?
Measuring Cerebral Atrophy and White MatterHyperintensity Burden to Predict the Rateof Cognitive Decline in Alzheimer DiseaseAdam 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 withCortical Atrophy in Alzheimer’s DementiaPETER R. MOUTON,*1 LEE J. MARTIN,*‡ MICHAEL E. CALHOUN,* GLORIA DAL FORNO,† ANDDONALD L. PRICE*†‡
ML(3
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
For more information, contact CDC1‐800‐CDC‐INFO (232‐4636)TTY: 1‐888‐232‐6348 www.cdc.gov
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.
Dr. Valerie J. EdwardsVAE2@ cdc.gov
Currently Used Measures of Cognitive Impairment
Laura M. VitkusMPH Student, Health Behavior Health Promotion, Class of 2018
University of Arizona, College of Public HealthProgram Coordinator, Arizona Geriatric Workforce Enhancement Program
University of Arizona Center on Aging
• 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.
Learning Objectives
• 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)
Selected Cognitive Assessments
Primary Care vs Specialist
Screening Assessment in Primary
Care
Referral for Diagnostic Testing
Dementia Diagnosis
• 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 concerns1.
• Often, MCI/dementia is not diagnosed by PCP1
• Early detection and intervention
Why Screen?
• Measuring Particular Cognitive Impairments
• Screening for MCI vs. Dementia and assessing
progression of MCI → Demen a
• Cognitive Burden/Cognitive Load
• Reliability & Validity
• Cultural Issues
Testing Components
• Memory/Recall
• Visuospatial awareness
• Verbal fluency/expressive language2,3,4
• Executive Function
• Gait
• Dual‐Task
Screening Measures
AD8
AD8Strengths
• 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• Inexpensive5
Weaknesses
• Informant‐based can be subject to bias
• Knowledgeable informants may not be available
The Montreal Cognitive Assessment (MoCA)
MoCA Video Demonstration
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 recall6
Mini‐Mental State Examination(MMSE)
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 MCI7
General Practitioner Assessment of Cognition
(GPCOG)
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
The Informant Questionnaire on Cognitive
Decline in the Elderly (IQCODE)
IQCODE
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, 10‐15 minutes
• Complex scoring• Suboptimal test for MCI8
Mini‐COG
“Draw a clock with the time showing 10 minutes after 11.”
Mini‐Cog Video Demonstration
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
Memory Impairment Screen (MIS)
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
St. Louis University Mental Status Examination
(SLUMS)
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 bias9
Cognition and dual‐taskingWith Hossein Ehsani, PhD,
Biomedical Engineering Department, University of Arizona
• Imagine a quick objective screening tool to measure cognition.
• What is dual‐tasking• The opportunity to use dual‐task to test cognition• Gold standard: MoCA• How did the project develop
Cognition and Dual‐tasking
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
Upper‐Extremity Function (UEF) test (continued…)
• Sensor outputs: Angle and angular velocity of upper arm and forearm
Upper‐Extremity Function (UEF) test (continued…)
• Data analysis: Dual task “cost” and variability
UEF in a nutshell
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
Key Take‐Home Messages
• Cognitive assessment screening is not diagnostic, but highly predictive1,2,3.
• 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.
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.MoCA2.Education, culture, language, age3.Valid, quick, inexpensive, unbiased
References1. American Academy of Neurology. (2017) Practice Guideline Update: Mild cognitive Impairment.
https://www.aan.com/Guidelines/Home/GetGuidelineContent/8822. 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):790‐799. doi:10.1136/jnnp.2006.095414.3. 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), 141‐150.
4. Dementia Action Collaborative Washington State. 2017. “Brief Cognitive Screening Tools for Primary Care Practice.” (November): 1–10. https://www.dshs.wa.gov/sites/default/files/ALTSA/stakeholders/documents/AD/DAC 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), 559‐564.
6. 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), 695‐699.
7. Tombaugh, T. N., & McIntyre, N. J. (1992). The mini‐mental state examination: a comprehensive review. Journal of the American Geriatrics Society, 40(9), 922‐935.
8. Jorm, A. F., & Jacomb, P. A. (1989). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio‐demographic correlates, reliability, validity and some norms. Psychological medicine, 19(4), 1015‐1022.
9. 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):10.1001/jamainternmed.2013.1868. doi:10.1001/jamainternmed.2013.1868.
Thank you!
Questions?
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.
Laura M. [email protected]
Hossein Ehsani, [email protected]
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.
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 005006, 005002,
005010, 005053, 005000, and 005013.
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.
http://depts.washington.edu/hprc/research/thematic‐networks/hbrn/