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Med 4- Dementia Cognitive assessment, evaluation, tests and interpretation. Dr. Frank Molnar Associate Professor of Medicine University of Ottawa Division.

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Presentation on theme: "Med 4- Dementia Cognitive assessment, evaluation, tests and interpretation. Dr. Frank Molnar Associate Professor of Medicine University of Ottawa Division."— Presentation transcript:

1 Med 4- Dementia Cognitive assessment, evaluation, tests and interpretation. Dr. Frank Molnar Associate Professor of Medicine University of Ottawa Division of Geriatric Medicine. Medical Director, The Ottawa Hospital Geriatric Day Hospital

2 Objectives 1. Describe the principles related to screening for cognitive impairment in high risk elderly and simple tests or tools that can be used. 2. Compare and contrast common assessment tools in dementia in terms of their utility, advantages and limitations. 3. Describe an approach to the evaluation of an elderly person with dementia in terms of differential diagnosis of potential cause(s).

3 Objective 1 Describe the principles related to screening for cognitive impairment in high risk elderly and simple tests or tools that can be used.

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8 The Preliminary Event In order to truly understand the results of the studies to be reviewed we need to understand: In order to truly understand the results of the studies to be reviewed we need to understand: The definitions of sensitivity and specificity The definitions of sensitivity and specificity How sensitivity and specificity are affected by: How sensitivity and specificity are affected by: Cut-off values employed Cut-off values employed Overlap of cognitive scores Overlap of cognitive scores Choice of test Choice of test

9 Definitions Sensitivity % of diseased persons identified as diseased (score below cut-off) Specificity % of normal persons identified as normal (score above cut-off)

10 1. Sensitivity and specificity are affected by the cut-off score employed

11 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x xx x xxx x x xx xx xx xxx x x x xx xxx xx x xx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 25% Sensitivity = 100%

12 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 50% Sensitivity = 87.5%

13 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 75% Sensitivity = 75%

14 Scores for persons with normal cognition Scores for persons with dementia xxx xx x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 100% Sensitivity = 62.5%

15 Scores for persons with normal cognition Scores for persons with dementia xxx xx x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 100% Sensitivity = 35%

16 Take Home Message #1 Sensitivity and Specificity for any given test are dependent on cut-off score studied For scales where high scores are good and low scores are bad (MMSE, MOCA) When cut-off is lowered Sensitivity decreases Specificity increases When cut-off is raise Sensitivity increase Specificity decreases

17 Sensitivity vs. Specificity

18 2. Sensitivity and specificity are affected by the population in which the test is being used - Overlap of cognitive scores (spectrum of disease)

19 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 75% Sensitivity = 62%

20 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 75% Sensitivity = 75%

21 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 75% Sensitivity = 87.5%

22 Scores for persons with normal cognition Scores for persons with dementia xxx x x x x x x x xx x x x x x x x x xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 75% Sensitivity = 100%

23 Scores for persons with normal cognition Scores for persons with dementia xxxx x x x x x x xxx x xx x xxx xx x x x xxxx x x xxx x xxxxxx xx xxx xxx x x Sensitivity 1) Sensitivity = % with disease who are identified as diseased by test (i.e. % of diseased that fall below cut-off score) Specificity 2) Specificity = % of normals who are identified as normal by test (i.e. % of normals that score above cut-off) MOCA or MMSE Specificity = 100% Sensitivity = 100%

24 Less overlap – higher combined sensitivity and specificity Greater overlap – lower combined sensitivity and specificity

25 Correct population distribution Incorrect distribution resulting in exaggerated sensitivity and specificity

26 Take Home Message #2 The sensitivity and specificity depend on the amount of test score overlap between normal and diseased Sensitivity and specificity depend on sample / population Since the populations we take care of clinically are different from those in studies The Sensitivity and Specificity of a test in clinical practice will likely not match that in studies (we cannot know if it does)

27 Objective 2 Compare and contrast common assessment tools in dementia in terms of their utility, advantages and limitations. Sensitivity and Specificity are dependent on the test employed

28 Choosing the right tool for the job For more information on the MOCA go to

29 MOCA validation process Developed based on clinical intuition of main author (ZN) Iterative modification based on 5 years of clinical use Tested on 46 MCI / AD with MMSE > 24 vs. 46 normal 5 items replaced & weighting adjusted Clinical distribution We are now in the stage of validation Ongoing process Main dementia / MCI articles to be reviewed.

30 3 MOCA Validation Studies in area of Dementia 1. Nasreddine et al. The Montreal Cognitive Assessment, MOCA: A brief Screening Tool For Mild Cognitive Impairment. Journal of the American Geriatrics Society 2005; 53: Smith et al. The Montreal Cognitive Assessment: validity and Utility in a Memory Clinic Setting. The Canadian Journal of psychiatry 2007; 52; Luis et al. Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southern US. International Journal of Geriatric Psychiatry 2008

31 Nasreddine et al - Results MOCA (cut-off 25/26) 90% SENS to detect MCI 100% SENS to detect AD MMSE (cut-off 25/26) 18% SENS to detect MCI 78% SENS to detect AD MOCA seems to win on SENS (particularly for MCI)

32 Nasreddine et al - Results SPEC = % Normals ≥ 26 (correctly identified as normal MOCA (cut-off 25/26) 87% SPEC to normals Mislabelled 13% as impaired MMSE (cut-off 25/26) 100% SPEC to normals MMSE seems to win on SPECS

33 Nasreddine – Results (my interpretation) The results only describe part of the story If you lowered the MOCA cut-off, its specificity would improve and sensitivity will drop If you raise the MMSE cut-off, its sensitivity would improve and specificity will drop SENS / SPEC are very dependent on cut-offs and on populations studied

34 Tests may have differential sensitivity in different ranges of cognitive decline MOCA MMSE Normal MCI Mild dementia Moderate dementia Severe dementia

35 Nasreddine et al – recommendations If patients have cognitive complaints and functional impairment then likely dementia MMSE first MOCA if MMSE ≥ 26 (MCI, Mild dementia) If patients have cognitive complaints but no functional impairment then likely normal or MCI MOCA first

36 Screening COST: how to read studies & select tests: Cut-off: Sensitivity and Specificity for any given test are dependent on cut-off score Objective: - screen for MCI & dementia in community (high cut-off) - screen for dementia (not MCI) in community (lower cut-off) - NOT for diagnosis - on inpatient setting can only screen for cognitive impairment (delirium, depression, MCI, dementia) Sample: Sensitivity and Specificity depend on sample / population. Since the populations we take care of clinically are different from those in studies the Sensitivity and Specificity of a test in clinical practice will likely not match that in studies Test Characteristics: Sensitivity and Specificity are dependent on the test employed. MOCA has high sensitivity but low specificity (relative to MMSE)

37 Objective 3 Describe an approach to the evaluation of an elderly person with dementia in terms of differential diagnosis of potential cause(s).

38 3 Step Approach Use DSM criteria to: 1. Rule Out Depression 2. Rule Out Delirium 3. Assess for Dementia vs. Mild Cognitive Impairment (MCI)

39 Step 1 – Rule Out Depression MPersistent low mood or anhedonia > 2 weeks SSleep Impairment IInterests decreased GGuilty ruminations / regrets EEnergy decreased CConcentration decreased AAppetite decreased PPsychosomatic complaints / Psychomotor retardation or agitation SSuicidal ideation (Passive vs. Active)

40 Step 2 – Rule Out Delirium DeliriumDementia OnsetAbruptGradual CourseShortLong FluctuationPresentAbsent HallucinationsPresent Absent AttentionImpairedNormal LOCAlteredNormal Psychomotor AlteredNormal It is common for Delirium to be superimposed on Dementia!

41 This table oversimplifies so let us look at exceptions to the rules as well as the most reliable signs of Delirium

42 Onset & Duration (exceptions) Delirium May have prolonged low grade delirium with chronic ETOH, BDZ, Narcotic, Anticholinergic (e.g. TCA, Ditropan) use Dementia Can have rapid onset with strokes or Creutzfeldt-Jakob Disease (see Health Canada CJD website describing rapid progression with changes in balance / mobolity)

43 Fluctuation Delirium New onset unpredictable fluctuation (hour by hour not day by day) Depression Predictable diurnal variation (worse in morning) Dementia Predictable diurnal variation (worse in afternoon or evening)

44 Hallucinations Delirium Especially if family describe new onset hallucinations Dementia / Psychiatric Disorders Long-standing hallucinations E.g. Lewy Body disease, Psychotic Depression, Bipolar disease

45 Attention, Concentration, LOC Delirium Attention, Concentration and altered Level of Consciousness - LOC (i.e. drowsy, somnolent, slow mentation) Depression Can alter Attention, Concentration but not LOC Dementia Normal Attention, Concentration, LOC

46 Patterns of Psychomotor Change in delirium Hyperactive ("wild man!"); 25% Hypoactive (“out of it!”, “snowed”, “pleasantly confused”); 50% Mixed delirium (features of both), with reversal of normal day-night cycle (“sundowning”); 25%

47 Confusion Assessment Method (CAM) 1. History of acute onset of change in patient’s normal mental status & fluctuating course? AND 2.Lack of attention? AND EITHER 3. Disorganized thinking? 4.Altered Level of Consciousness? Inouye SK: Ann Intern Med 1990;113(12):941-8 Arch Intern Med. 1995; 155:301 Sensitivity: % Specificity: 90-95% Kappa: 0.81

48 Step 3 - Dementia vs. Mild Cognitive Impairment Once again employ the DSM criteria – look for a deficit in each of the following categories (5 As + function + progression) base on history, physical examination, cognitive testing: 1. Amnesia 2. Aphasia, Apraxia, Agnosia, And Executive dysfunction 3. Progressive 4. Impacts on social and / or occupational functioning If do not have 1 deficit in each of 4 categories then have Mild Cognitive Impairment (MCI). Be practical – If MMSE very low (e.g. 20) then Dementia more likely than MCI % of persons with MCI progress on to dementia over 5 – 10 years for a total of 60-70% so follow-up is recommended. Amnestic MCI (memory problems) more likely to progress to dementia.

49 Amnesia – Short-term memory loss Look for changes from baseline Repeating questions or stories Losing items (keys, purse …) Forgetting details of important events Trouble recalling names Mixing up relatives and friends Increased use of compensatory strategies (lists, calendars, memory cues)

50 Aphasia (expressive) Ask if patient has word finding problems (‘words on the tip of their tongue’) Word searching Mixing up languages Losing last language learned first Patterns Sudden loss then stable or improving suggests stroke, bleed Progressive word –finding problems (more frequent and more severe / noticeable) suggests Alzheimer’s Severe and more pronounced than memory problems suggests stroke, bleed, Semantic Dementia, Primary Progressive Aphasia Later develop reading and writing difficulty

51 Apraxia Difficulty executing a motor task despite intact motor and sensory function May notice during dressing post examination On exam can ask patient to show how to: Comb hair Brush teeth Cut paper with a scissor Sometimes difficult to differentiate from executive dysfunction (use of stove, TV, remote…)

52 Agnosia Difficulty identifying objects despite an intact sensory function Difficulty recognizing family members or close friends Differentiate this from difficulty recalling names. In agnosias they cannot recall the person’s role in their life.

53 And Executive Dysfunction Instrumental Activities of daily Living (IADLs) – change from baseline due to cognition SShopping HHousekeeping / Hobbies AAccounting / finances FFood preparation TTelephone / Tool use Transportation (Driving)

54 And Executive Dysfunction ADLs (lose after IADLs) DDressing EEating AAmbulation TTransfers HHygiene

55 And Executive Dysfunction Driving (see Geriatrics and Aging article) Think of this as a ‘super-IADL’ The only IADL that can result in death if patient is too slow (driving is unforgiving – there may not be a second chance to do the task right) If patient has problems with lower level IADLs due to cognition then have to consider fitness-to-drive CMA guidelines: If patient has problems with 2 or more lower level IADLs due to cognition then likely have a moderate dementia and should stop driving

56 Working through the DDX of dementia Common presenting features

57 Alzheimer disease Progressive short-term memory loss Encoding problem so cues do not help MAY present with progressively more frequent / noticeable word-finding changes. When present this is highly suggestive of AD Limited insight – not fully aware of presence of memory loss and impact on function

58 Vascular dementia 3 levels of evidence Neuroimaging performed in the course of the dementia demonstrating cerebrovascular disease (more than mild microangiopathic ischemia) significant enough and in locations to account for deficits (i.e. not pure motor areas) Established arterial disease (stroke, carotid stenosis, CAD, RAS, PVD) – consider the arterial tree as a single organ. If these are present will treat vascular risk factors Vascular risk factors.

59 Vascular dementia Presentation not suggestive of AD Good insight Early apraxia / agnosia with ischemia in relevant regions Retrieval rather than encoding problem – memory loss responds to cues Step-wise decline? Beware of False Negatives – many cannot recall stepwise decline Beware of False Positives – recurrent deliriums with incomplete recovery can give AD a saw toothed pattern that looks like a step-wise decline. Search for neurological changes suggestive of stroke that occurred during period of decline Do not use the term ‘vascular dementia’ with patients – they do not know what this means. Call it ‘Stroke dementia’.

60 Mixed dementia (Alzheimer’s + vascular) Moving ratio concept. When you first see patient they may be 99% vascular and 1% AD (so look like pure vascular) A few years later the ratio will shift and they will be 50% AD. This does not mean you were wrong when you first saw them. The AD component required more time to ‘declare itself’ so follow your vascular dementia patients carefully.

61 Lewy Body dementia McKeith et al. neurology 1996; 47: Dementia occurring at the same time as mild parkinsonian features Long-standing Hallucinations (visual, auditory) Long-standing Fluctuation (cognition, attention, alertness) Supportive features Vivid nightmares due to changes in REM sleep (lack of muscle paralysis – kick, punch and run in sleep) Neuroleptic sensitivity Cognitive profile (memory responds to cuing, early executive dysfunction, early visuospatial dysfunction – driving skills)

62 Parkinson’s Dementia Common in patients who have passed through the 5 – 10 year ‘honeymoon period’ (motor symptoms only) of Parkinson's disease Similar cognitive profile to Lewy body Disease memory responds to cuing, early executive dysfunction, early visuospatial dysfunction (driving skills) Emre et al. Clinical diagnostic criteria for dementia associated with Parkinson’s disease. Movement Disorders 2007; 22(12):

63 Frontotemporal Lobar Degeneration (FTLD) Behavioural type Classic Frontal Lobe dementia with early loss of executive function (relevant to driving) Earlier onset Presenting symptoms can be positive (impulsiveness, anger control problems) or negative (withdrawal – looks depressed). More commonly referred to Psychiatry. Test well (MMSE 30/30) but function more poorly than screens (that do not test executive function well) would suggest  Neuropsychology helpful in diagnosis

64 Frontotemporal Lobar Degeneration Language types Semantic dementia PPA: Primary (non-fluent) Progressive Aphasia Severe early expressive aphasia with no obvious cause on neuroimaging Test poorly (MMSE 5/30 - because testing is language based) but function much better than test results would predict Neuropsychology and Speech-language Pathology helpful in diagnosis

65 Normal Pressure Hydrocephalous (NPH) AD is a cortical dementia NPH can look more like subcortical dementias (e.g. subcortical vascular, LBD, Parkinson’s dementia …) 3Bs – Brain (cognition), Balance (falls), Bladder (incontinence) Diagnosis with CSF Flow study or LP drain (Do not accept simple LP with fluid withdrawal as prone to False Negative results)

66 Treatments Alzheimer CIs +/- Memantine (in place of CI or if continue to progress on CI Vascular Usual vascular risk factor modification + ASA / Ticlid / Plavix / Coumadin +/- ACEi Lewy Body Exelon, Aricept, Galantamine Parkinson’s Exelon, Aricept Frontotemporal Avoid CIs SSRI, Trazadone in behavioural variant NPH Shunt Follow for emergence of AD

67 Why do all of this!! If you ignore these issues as being “beneath you” or “outside your scope of practice” (outside your specialty area) then you do so at your (and your patients’) peril because identification of dementia, delirium, depression: If you ignore these issues as being “beneath you” or “outside your scope of practice” (outside your specialty area) then you do so at your (and your patients’) peril because identification of dementia, delirium, depression: Allows you to create medical care plans that will actually be followed (relevant to all specialties) Allows you to create medical care plans that will actually be followed (relevant to all specialties) Helps with discharge from hospital (relevant to all specialties) Helps with discharge from hospital (relevant to all specialties) Prevents ER visits and hospitalization (or return to hospital after discharge) Prevents ER visits and hospitalization (or return to hospital after discharge) Other benefits of diagnosing dementia, delirium, depression Other benefits of diagnosing dementia, delirium, depression Allows you to start treatment early and maintain function and safety of your patients. Allows you to start treatment early and maintain function and safety of your patients. Allows you to counsel families and help them with future planning. Allows you to counsel families and help them with future planning. If you cannot assess dementia, delirium, depression (at least to the point of identifying the presence of one of these) then you cannot be a complete and optimally effective physician no matter what specialty you are in. If you cannot assess dementia, delirium, depression (at least to the point of identifying the presence of one of these) then you cannot be a complete and optimally effective physician no matter what specialty you are in.

68 GOOD LUCK To learn more about dementia, delirium, depression and other medical issues consider joining the Canadian Geriatrics Society (CGS). Medical Students can join the Canadian Geriatrics Society (CGS) for free and get full electronic access to CGS educational materials To learn more about dementia, delirium, depression and other medical issues consider joining the Canadian Geriatrics Society (CGS). Medical Students can join the Canadian Geriatrics Society (CGS) for free and get full electronic access to CGS educational materials To join the CGS click on https://www.canadiangeriatric s.com/ssl/membrappl.asp To join the CGS click on https://www.canadiangeriatric s.com/ssl/membrappl.asp https://www.canadiangeriatric s.com/ssl/membrappl.asp https://www.canadiangeriatric s.com/ssl/membrappl.asp


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