1. Mild Cognitive Impairment (MCI) Screening Tools for Primary Care Providers Jamila Hussain, PGY-3 Faculty Development Cook County-Loyola-Provident Family Medicine Residency Thursday, January 23 rd, 2014

2. Faculty Development Session Agenda  1. Introduction (2.5 minute)  2. Pretest (2.5 minute)  3. 10 Minute Didactic Power Point Presentation titled “Mild Cognitive Impairment (MCI) Screening Tools for Primary Care Providers”  4. 20 minute Small Group Cases  5. 15 minute Large Group Discussion  6. Post-test  7. Lecture Evaluation

3. Objectives  Define Mild Cognitive Impairment  Review the importance of utilizing a screening tool for mild cognitive impairment in the primary care setting.  Describe the ideal screening tool as voiced by primary care physicians.  Discuss the dilemma primary care physicians face in screening.  Discuss four screening tools that primary care physicians may or may not choose to use.  Discuss what can be concluded from the effectiveness of screening tools.

4. http://www.smh.com.au/news/pets/pampered-pets-are-going-senile/2007/08/26/1188066987568.html

5. Case  Mrs. M is a 70 year old woman who has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep track of appointments and recent telephone calls, but the process has been insidious. She lives independently in the community; she drives a car, pays her bills, and is normal in appearance.

6. Case Take a moment to think about whether this patient has Mild Cognitive Impairment.

7. What is Mild Cognitive Impairment?  Decline in cognitive function beyond that associated with typical aging; the decline is often recognized by those experiencing it and occasionally by those around them  76.5% elderly patients are reported to age successfully, experiencing no cognitive decline

8. Types of Mild Cognitive Impairment Amnestic type:  Clinically significant memory impairment that does not meet the criteria for dementia  Subtle decline in memory. Forgetting appointments, medications, names of friends  Cognitive capacities relatively preserved such as executive function, use of language, and visuospatial skills  Functional activities are intact, except for mild inefficiencies Dress, Drive or Eat oneself but more slowly  Precursor of Alzheimer’s Dementia

9. Types of Mild Cognitive Impairment Nonamnestic type:  Subtle decline in functions not related to memory, affecting: attention, use of language, visuospatial skills  Precursor for Non-Alzheimer’s types of dementia: Frontotemporal or Lewy Body

10. Who has Mild Cognitive Impairment? http://blogforalzheimers.com/2012/01/27/men-more-likely-to-suffer-mild-memory-loss-than- woman-alzheimers-articles-information-and-resources/

11. Who cares about Mild Cognitive Impairment?  The number of cognitively impaired individuals will increase dramatically as the elderly population increases  10-15% of patients in the Primary Care setting have mild cognitive impairment

12. Who cares about Mild Cognitive Impairment?  Alzheimer’s Dementia and other forms of Dementia such as Fronto-temporal dementia or Lewy body dementia may present as mild cognitive impairment, as the non-amnestic and amnestic types. peterson, R.C. (2011). Mild cognitive impairment. The New England Journal of Medicine, 364: 2227-2234.

14. How do we diagnosis patients with Mild Cognitive Impairment?  It’s a clinical diagnosis  History raises clinical suspicion  Family members can corroborate  Neuropsych testing can help distinguish mild decline from normal aging….but that takes too long  What can a primary care physician do in the office to screen for Mild Cognitive Impairment?

16. Importance of Utilizing Screening Tools in the primary care setting  The diagnosis of Mild Cognitive Impairment is often missed in busy Primary Care offices  Primary Care Physicians would like to learn how to diagnose and evaluate patients with MCI/Dementia but state they need screening tools JAGS 60:1027-1036, 2012

17. Ideal Screening Tool  The ideal cognitive screening test for the use in the primary care setting would be  brief  easily administered without props  easily memorized and scored  have high sensitivity and specificity JAGS 60:1027-1036, 2012

18. Dilemma  U.S. Preventive Services Task Force (USPSTF) has NOT recommended routine cognitive screening.  Early Detection of cognitive impairment in the primary care settings has potential benefits, including identification of individuals who may need help managing chronic illness. JAGS 60:1027-1036, 2012

19. Screening for Cognitive Impairment: Comparing the Performance of Four Instruments in Primary Care  A Cross-sectional comparison of cognitivie screening tests involving 826 independently living veterans age 65 years and older without prior diagnosis of dementia Holsinger, T., et al. Screening for Cognitive Impairment: Comparing the performance of Four Instruments in Primary Care. JAGS. 60:1027-1036, 2012.

20. Four Screening Tools  Modified Mini-Mental State Examination  The Memory Impairment Screen  The Mini-Cog  Novel Two-Item Functional Memory Screen

21. Modified Mini-Mental State Examination  3 MS  Average time to administer 17 minutes  Sensitivity 39% (dementia or CI)  Specificity 89 % (dementia or CI)

22. Modified Mini-Mental State Examination CategoryPointsDescription Orientation to time5Broad to narrow; correlated with future decline Orientation to place5Broad to narrow (streets, floor) Registration3Repeat name items Attention and Calculation 5Serial Sevens; Spelling the word “WORLD” backwards Recall3Recall items registered Language2Naming a pencil and watch Repetition1Speaking back a phrase Complex Commands6Draw Hexagon

23. Back to our case……….  Mrs. M’s mental status examination revealed slight difficulty on delayed recall of four words and recall named items.

24. Modified Mini-Mental State Examination CategoryPointsDescription Orientation to time5Broad to narrow; correlated with future decline Orientation to place5Broad to narrow (streets, floor) Registration3Repeat name items Attention and Calculation 5Serial Sevens; Spelling the word “WORLD” backwards Recall3Recall items registered Language2Naming a pencil and watch Repetition1Speaking back a phrase Complex Commands6Draw Hexagon

25. Modified Mini-Mental State Examination  Scoring: total 30  Normal: greater than 27  Cognitive impairment  Mild: 19-24  Moderate: 10-18  Severe: </= 9

26. The Memory Impairment Screen (MIS)  Average time to administer 4 minutes  Sensitivity 17% (dementia or CI)  Specificity 98% (dementia or CI)

27. The Memory Impairment Screen WordCueFree Recall Cued Recall CHECKERSGAME SAUCERDISH TELEGRAMMESSAGE RED CROSSORGANIZATION

28. The Memory Impairment Screen  Show patient a sheet of paper with the four items to be recalled letters and ask patient to read the items aloud.  Tell patient that each item belongs to a different category. Give a category cue and ask patient to indicate which of the words belongs in the stated category (e.g., “Which one is the game?”). Allow up to five attempts. Failure to complete this task indicates possible cognitive impairment.  When patient identifies all four words, remove the sheet of paper. Tell patient that he or she will be asked to remember the words in a few minutes.  Engage patient in distractor activity for two to three minutes, such as counting to 20 and back,counting back from 100 by seven, spelling WORLD backwards.  FREE RECALL — two points per word: Ask patient to state as many of the four w ords he or she canrecall. Allow at least five seconds per item for free recall. Continue to step six if no more words have been recalled for 10 seconds.  CUED RECALL — one point per word: Read the appropriate category cue for each word not recalled during free recall (e.g., “What was the game?”).

29. The Memory Impairment Screen  Score 5-8, no cognitive impairment  Score </= 5, possible cognitive impairment

31. The Mini-Cog  Average time to administer 3 minutes  Sensitivity 39% (dementia or CI)  Specificity 78% (dementia or CI) http://www.alz.org/alzheimers_disease_steps_to_diagnosis.asp

33. Novel Two-Item Functional Memory Screen  Average time to administer 1.5 minutes  Sensitivity 24% (dementia or CI)  Specificity 93% (dementia or CI)

34. Novel Two-Item Functional Memory Screen  Ask participants about memory problems that affect functioning.  “During the past 12 months, have you noticed a decline in your memory such that you have trouble remembering where you put things, remembering to take your medications, or remembering to pay bills?  “During the past 12 months, have you had problems with your memory or thinking that interfere with your ability to do things that you regularly do such as taking care of your home, managing your checkbook, or keeping up with TV programs?”  Use Self-reporting and Informant reporting

35. Novel Two-Item Functional Memory Screen  Scoring  ½= 50%  2/2= 100%

37. Conclusion  These Four Screening Tools have high specificity and low sensitivity  can correctly identify those without disease but cannot correctly identify those with the disease  If you suspect mild cognitive impairment in your patient you can use one of the tools to rule it out  You should be comfortable using one of the tools in practice  Given low sensitivity, further studies are needed to development higher quality screening tools

38. References  Ebell, M., et al. Brief Screening Instruments for Dementia in Primary Care. Am Fam Physician. 2009 Mar 15: 79 (6):497-500  Holsinger, T., et al. Screening for Cognitive Impairment: Comparing the performance of Four Instruments in Primary Care. JAGS. 60:1027-1036, 2012.  Wikipedia  http://www.alz.org/documents_custom/mis.pdf  peterson, R.C. (2011). Mild cognitive impairment. The New England Journal of Medicine, 364: 2227-2234.  MIS. Copyright © 1999 Albert Einstein College of Medicine.  2014 Older Adult Nursing. Cognitive Impairment.

39. Small Group

40. Take Home Points

41. THANK YOU