LINDSAY CLARK PHD Assistant Professor Clinical Neuropsychologist UWMadison School of Medicine amp Public Health Department of Medicine Geriatrics Division William S Middleton Memorial Veterans Hospital GRECC ID: 1034817
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1. COGNITIVE ASSESSMENT IN DEMENTIALINDSAY CLARK, PHDAssistant Professor / Clinical NeuropsychologistUW-Madison School of Medicine & Public Health, Department of Medicine, Geriatrics DivisionWilliam S Middleton Memorial Veterans Hospital, GRECClrclark@medicine.wisc.edu
2. WHAT ARE YOUR GOALS?Screen for dementia?Diagnose dementia?Stage dementia?Monitor cognitive function?Knowing your specific needs/goals will help you identify the appropriate tools and approaches
3. Cognitive screening instruments
4. Common tools for cognitive screeningToolFull NameNumber of Items, Approximate Administration Time & Max ScoreFunctions AssessedMMSEMini Mental State Examination11 items5-10 minutesMax score = 30Orientation; registration; attention and calculation; recall; language Mini-CogMini-Cog2 items3 minutesMax score = 5Visuospatial; short-term verbal recall. SLUMSSt. Louis University Mental Status Exam11 items5-7 minutesMax score = 30Orientation; calculation; verbal fluency; short-term verbal recall; attention; visuospatial. MOCAMontreal Cognitive Assessment12 items10 minutes(longer if greater impairment)Max score = 30Visuospatial/executive functioning; naming; attention; repetition; verbal fluency; abstraction; short-term verbal recall; orientation.
5. Common tools for cognitive screeningToolProsConsCutoffsMMSE-Short-$$ to purchase forms-Less sensitive to milder symptoms25-30 WNL18-24 Mild11-17 Moderate<10 SevereMini-Cog-Short-Free-Less sensitive to milder symptoms0-2 Concern for dementia3-5 WNLSLUMS-More sensitive to milder symptoms-Free-Less executive functioning than MoCA-No validated telephone version12+ Education Yrs27-30 WNL21-26 Mildly Impaired1-20 Impaired<12 Education Yrs25-30 WNL20-24 Mildly Impaired1-19 ImpairedMOCA-More sensitive to milder symptoms-Has a validated telephone version (MoCA Blind)-$150 one-hour training/certification program online (but exceptions for faculty, students, research)26-30 WNL<26 concern for MCI<18 concern for dementia
6. Cognitive screening instrumentsQuestions to ask yourself:Is it important for my study that someone definitely has a diagnosis of dementia?Is it important for my study that we measure subtle cognitive decline?Is it important for my study that we target specific cognitive domains (e.g., memory, executive functioning)?If yes to any above, just using a cognitive screen may not be the best choice
7. Expanded cognitive screening batteries NameDomainsAdministration TimeRepeatable Battery for the Assessment of Neuropsychological Status (RBANS)Attention, language, visuospatial function, immediate and delayed memory25-30 minutes20 languagesNormative data 12-89 yearsDementia Rating Scale (DRS-2)Attention, Initiation/Perseveration, Construction, Conceptualization, and Memory15-30 minutesNormative data 56-105 yearsADAS-CogOrientation, word recall and recognition, naming, following commands, constructional & ideational praxis, spontaneous language30 minutesScore 0-70 (higher=more impaired)Translated into several different languagesConsortium to Examine a Registry on Alzheimer’s disease (CERAD)fluency, naming, MMSE, memory, constructional praxis20-30 minutes7 languages
8. How is dementia diagnosed?Cognitive or behavioral (neuropsychiatric symptoms) that:Interfere with the ability to function at work or at usual activitiesRepresent a decline from previous level of functioning Are not explained by delirium or major psychiatric disorderCognitive impairment is detected and diagnosed through a combination of (1) history-taking from the person and a knowledgeable informant and (2) an objective cognitive assessment (e.g., mental status exam or neuropsych testing)The cognitive or behavioral impairment involves a minimum of two of the following domains:Impaired ability to acquire and remember new informationImpaired reasoning and handling of complex tasks, poor judgementImpaired visuospatial abilityImpaired language functionsChanges in personality or behaviorAlzheimer’s dementia is diagnosed when the patient meets criteria for dementia and has the following characteristics:Insidious onset (gradual onset over months to years)Clear-cut history of worsening cognition by report or observationsInitial and most prominent deficits are evident on history and exam in one of the following categories:Amnestic: Most common presentation (impairment in learning and recall)Non-amnestic: Language, visuospatial, or executive dysfunctionDementia (NIA-AA 2011 diagnostic criteria)Dementia due to probable AD(NIA-AA 2011 criteria)McKhann et al., 2011
9. Three common causes of dementia in older adults9Visuospatial deficitsAttention difficultyExecutive dysfunctionMilder memory lossRapid forgettingWord retrieval/semantic fluencyExecutive dysfunctionSlowed processing speed/inattentionExecutive dysfunctionMilder memory lossIf left-sided MCA stroke, likely aphasiaAlzheimer’s dementiaDementia with Lewy BodiesVascular DementiaFor review, see McKeith et al., 2017For review, see Gorelick et al., 2011For review, see McKhann et al., 2011
10. How is dementia diagnosed?History-taking from person and knowledgeable informantCognitive changes (symptoms, onset, course, frequency) Functional abilities (ADLs, IADLs) Mood/anxiety, substance use, sleep, chronic painMotor symptomsPsychosocial historyObjective cognitive assessmentLearning/memoryExecutive functioningAttention/processing speedLanguageVisuospatial functionMedical evaluationLabsNeuroimagingPhysical examination
11. Commonly used neuropsychological measuresDomainMeasuresScreens or brief cognitive batteriesMMSE, MoCA, SLUMS, Mini-CogRepeatable Battery for the Assessment of Neuropsychological Status (RBANS)Learning/MemoryWMS-IV (includes story memory)Word-list learning/memory (CVLT, HVLT, RAVLT)Visual memory (BVMT)Executive FunctioningTrailmaking TestStroopWisconsin Card Sorting TestDelis-Kaplan Executive Function SystemAttention/Processing SpeedDigit SpanDigit Symbol/CodingLanguageCategory/semantic fluency (e.g., animals)Lexical/phonemic fluency (e.g., FAS, CFL)Object naming (e.g., Boston Naming, MINT)Visuospatial FunctionJudgment of line orientationClock Drawing TestHooper Visual Organization TestRey-O (or other complex figure copy tasks)Intellectual Function or Academic AchievementWechsler Abbreviated Scale of Intelligence (WASI-II)WRAT-5 Reading
12. What is “Impaired”?-1.5 SD7%Increase in certainty of impairment:-Greater the impairment-More tests that are impaired68% of population fall within 1 SD95% of population fall within 2 SDAverage25th-75thHigh Average75-90thLow Average10-25thImpairedBorderline/Mildly ImpairedSuperior to Very Superior>90th3-9th ≤2nd 2%16%Important to consider expected baseline for each individual
13. Cognitive ProfileImpaired (<2nd %ile)Borderline (<10th %ile)PercentilesSeverely impaired immediate and delayed memory including impaired recall & recognition performanceBorderline impaired semantic fluency performanceAverage range performances on measures of visuospatial function and processing speed
14. Cognitive symptom inventoriesFunctional assessmentsMood screensIQCODEEveryday Cognition (E-Cog, E-Cog12)Cognitive Function InstrumentMemory Functioning QuestionnaireADLs: -Katz -BarthelIADLs: -Lawton -FAQPerformance-based assessmentsDepression: Geriatric Depression Scale (GDS, GDS-15), PHQ-9Anxiety: GAS, GAS-10, GAD-7, STAIBehavioral/psychological symptoms of dementia: NPIScreens for cognitive symptoms, functional abilities, mood
15. How is dementia diagnosed?Clinical diagnostic approachAlgorithmic approachConsensus conference review of medical, cognitive, psychosocial data and determination of diagnosisCutoff scores on cognitive tests
16. How is dementia diagnosed?AD definition shifting to a biologically-based definition. How important is it that someone biologically has AD versus a clinical diagnosis in your study?
17. How do I measure the stage of dementia?Alzheimer’s disease occurs along a spectrum
18. How do I measure the stage of dementia?For more information: https://knightadrc.wustl.edu/professionals-clinicians/cdr-dementia-staging-instrument/Semi-structured interview of patient and informant30 minutes to completeSix domains: Memory, orientation, judgment & problem solving, community affairs, home & hobbies, personal careGlobal CDR score = Stage 0=Normal 0.5=MCI 1=Mild dementia 2=Moderate dementia 3=Severe dementia10-item self-report questionnaire completed by informant3-5 minutes to completeTen domains: memory, orientation, decision-making and problem-solving, activities outside the home, home and hobbies, toileting and personal hygiene, behavior and personality changes, language and communication abilities, mood, attention and concentration. Can use to generate a valid global CDR and sum of boxes scoreClinical Dementia Rating (CDR) Dementia Staging InstrumentQuick Dementia Rating System (QDRS)Galvin, 2015. The Quick Dementia Rating System (QDRS): A rapid dementia staging tool. DADM. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484882/
19. How do I measure the stage of dementia?Use information from functional questionnaires or clinical history to generate a FAST scoreMore commonly used in clinic than researchhttps://www.mccare.com/pdf/fast.pdf
20. Assessing cognitive change over timeWhat you expect:What you get:
21. Approaches for monitoring cognitive changeStatistical methods:Assessing change for individual patients: Reliable change indices, Regression-based change scores (Duff 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3499091/) Assessing change across group of patients: Longitudinal analysis statistical models (e.g., linear mixed-effects regression models)Use of alternate formsHelpful in reducing some practice effects, but not allUse of cognitive compositesMay be helpful in improving signal-to-noise ratio Common composite in AD research = Preclinical Cognitive Composite (PACC; Donohue et al., 2014 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439182/)
22. Considerations for monitoring cognitive changeHow long do you need to follow people to expect to see a change?May depend on the population and the measures you chooseHow many timepoints do you need?More timepoints = increased reliabilityWhat cognitive domain do you expect to see change in?How cognitively impaired or unimpaired is your populationIf more impaired, may consider a global screen or staging toolIf unimpaired, need a more sensitive measure
23. What about remote assessment?Most evidence available for teleneuropsychology based on satellite models (e.g., televideo from hospital to clinic)Feasible and acceptable for patients and research participantsApplicable in both rural and urban settingsGood reliability and validity of assessments in older adultsDo not need separate teleNP normative data, but important to document use of teleNP and any modifications from standardized proceduresOngoing studies evaluating reliability and validity of direct-to-home televideo assessment for dementiaTelephone cognitive assessment typically more useful for screening vs diagnosisTelephone Interview for Cognitive Status (TICS, TICSm)MoCA BlindFor more detailed information on telephone-based cognitive assessment, see: Carlew et al., ACN 2020 – Cognitive Assessment via Telephone: A Scoping Review of InstrumentsWhy? May increase access for people to participate in research studies, reduce staff/participant burden
24. What about remote assessment?Ohman, Hassenstab, Berron, Scholl, Papp, 2021. Current advances in digital cognitive assessment for preclinical Alzheimer’s disease. DADM.Ongoing studies assessing validity of unsupervised remote cognitive assessment
25. Other considerationsBudgetMany tests cost moneyTrainingTests require initial training and then periodic monitoring throughout to ensure accurate administration/scoring proceduresHarmonizationDoes your study involve potential harmonization with other studies in the future?Cultural factorsCultural factors including language, race/ethnicity, gender identity, socioeconomic status, etc can impact how people approach and perform on cognitive testsMany cognitive tests (and accompanying normative data) were designed with White, non-Hispanic adults – if this is not your population, consult with neuropsychologists and other professionals who work with your community to identify appropriate measures and approaches
26. Take home message