1. Additional Assessments

2. Clinicians are encouraged to communicate with the interprofessional team about other resources and next steps in terms of additional assessments that could be provided. The Canadian Best Practice Guidelines 2012 makes reference to additional assessments in Table 7.2B: Summary of Select Screening Tools for Assessment of Vascular Cognitive Impairment in Stroke Patients: http://strokebestpractices.ca/wp-content/uploads/2013/03/Table7.2B- EN.pdf http://strokebestpractices.ca/wp-content/uploads/2013/03/Table7.2B- EN.pdf Other resources the clinician may refer to are: o Stroke Engine www.strokengine.ca/assess/assessmenttool-domains-en.htmlwww.strokengine.ca/assess/assessmenttool-domains-en.html o Evidenced Based Review www.ebrsr.com http://www.ebrsr.com/uploads/Module-12_cognition.pdfwww.ebrsr.com http://www.ebrsr.com/uploads/Module-12_cognition.pdf

3. MMSE Background MMSE was developed to identify dementia, delirium and cognitive changes over time A score of < 26 is an indication of cognitive deficit It lacks sensitivity in detecting mild cognitive impairment and early stages of dementia Additional limitations of the MMSE in the stroke population: Ineffective in differentiating between focal and diffuse lesions Only available in English Performance is dependent on age and education factors Insensitivity to right-sided lesions Mackenzie, G., Gould, L., Ireland, S., LeBlanc, K. and Sahlas, D. (2011) “Detecting cognitive impairment in clients with mild stroke or transient ischemic attack attending a stroke prevention clinic”, Canadian Journal of Neuroscience Nursing, 33(1)

4. 2011 study by MacKenzie et al. examined 20 patients diagnosed with likely TIA in a stroke prevention clinic All were screened for cognitive function MMSE was administered upon admission to the study and the MoCA was administered 2 weeks later - scores were then compared Findings demonstrated that the MoCA was more sensitive than the MMSE in determining the presence of mild cognitive impairments Mackenzie, G., Gould, L., Ireland, S., LeBlanc, K. and Sahlas, D. (2011) “Detecting cognitive impairment in clients with mild stroke or transient ischemic attack attending a stroke prevention clinic”, Canadian Journal of Neuroscience Nursing, 33(1) Comparison of MMSE and MoCA Scores InstrumentParticipants scoring in Normal Range (> 26) Mean Score Standard Deviation MMSE90%27.92.15 MoCA45%23.654.082P=<0.05

5. MoCA and the MMSE MoCA is a more sensitive screening tool than MMSE in detecting the presence of cognitive impairment in acute stroke population. Possible Reasons for Increased Sensitivity: Memory testing involves more words, fewer learning trials and longer delayed recall? More numerous and demanding tasks to assess for visuospatial processing, executive functions, and language abilities. By adjusting the cut off scores it is sensitive to mild post Stroke cognitive impairment (MMSE & MOCA are similar) Godefory et al, Stroke, 2011, (42)