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Cognitive Assessment

Cognitive Assessment . Dr Karen Addy Clinical Psychologist Memory Clinic Ynys Mon. Types of Dementia. Differential diagnosis. Alzheimer’s and fronto-temporal dementia. Assessment of People with Dementia . Explanation Structure Interpretation Feedback and recommendations

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Cognitive Assessment

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  1. Cognitive Assessment Dr Karen Addy Clinical Psychologist Memory Clinic Ynys Mon

  2. Types of Dementia

  3. Differential diagnosis

  4. Alzheimer’s and fronto-temporal dementia

  5. Assessment of People with Dementia • Explanation • Structure • Interpretation • Feedback and recommendations • Possible diagnostic disclosure • Next steps: Information and advice Links with self-help or voluntary groups Links with other parts of the service Psychosocial intervention Medical intervention

  6. Assessment of People with Dementia • Before and during assessment: • explain reasons for assessment • discuss implications of finding cognitive problems • give information in writing as well as verbally • secure informed consent • establish what (and who) the person wants to be told

  7. Assessment • Dementia vs Pseudodementia • Acute vs Insidious • Global vs Focal impairments • Stable vs Fluctuating problems • Define the impairments • Co-morbid problems • Strengths • Effect on family/carer

  8. Why Early Assessment is Important • Early detection provides an opportunity for pharmacological intervention • Evidence indicates that psychological interventions are more effective in the early stages of dementia (Moniz-Cook & Woods, 1997; Moniz-Cook et al, 1998) • Early diagnosis allows individuals time to adjust to and make plans for their illness whilst they are still cognitively able • Early intervention can help avoid secondary / excessive disabilities that may lead to early residential care

  9. Importance of Screening • Currently 683,597 people with dementia in UK • Dementia becoming more common as population ages • forecast to increase to 940,110 by 2021 and 1,735,087 by 2051 • Large number of cases not detected • 10-32 month gap between initial symptoms and diagnosis (Bond et al, 2005) • Alzheimer's Society (2007) Dementia UK: the full report, produced by King's College London and the London School of Economics, London: Alzheimer's Society.

  10. Screening for Dementia in Primary Care • GP’s may be first point of contact after the patient noticing initial symptoms of cognitive decline in 74 % of cases • 79% of patients consider GPs to be easily accessible • GPs in the best position to identify dementia early however studies have suggested that many mild cases may be missed Refs: • Boustani et al. (2007). The challenge of supporting care for dementia in primary care. Clinical Interventions in Ageing, 2(4), 631-636.

  11. Screening Tools • Common elements are: • Memory tests • Orientation • Language • Executive task • Use of informant view • Screening tools cannot act as a complete diagnostic tool as are too simplistic: passing does not mean that cognition is intact, therefore the additional information provided through clinical interview is essential in considering differential diagnosis or the need for onwards referral.

  12. Screening Tools • 7 MINUTE SCREEN • MIS • GPCOG • MMSE • IQCODE • ACE-R • CAMCOG

  13. Screening Tools • Recent reviews indicated that the GPCOG, MMSE and MIS are the most appropriate screening tools for primary care in that they are quick to use and have high sensitivity and specificity to diagnose cognitive impairment (>80%) Ref: Brodaty et al, 2002; Brodaty et al 2005; Borson et al, 2000; Borson et al 2005; Buschke et al 2006; Lorentz et al 2002; Milne et al 2008.

  14. MIS • 4 words to remember • Category clue for each word • Count from 1 – 20 and backwards for 2 mins • Free recall of 4 words • Cued recall of 4 words Score – (2xfree recall) + Cued Recall. Overall score lower than 4 suggest possible dementia.

  15. GPCOG • Name and address for subsequent recall "I am going to give you a name and address. After I have said it, I want you to repeat it. Remember this name and address because I am going to ask you to tell it to me again in a few minutes: John Brown, 42 West Street, Kensington " (Allow a maximum of 4 attempts but do not score yet) • Time Orientation What is the date? (accept exact only) • Clock Drawing (visuospatial functioning)use a paper with a printed circle. Please mark in all the numbers to indicate the hours of a clock (correct spacing required) .For a correct response (above), the numbers 12, 3, 6, and 9 should be in the correct quadrants of the circle and the other numbers should be approximately correctly placed. Please mark in hands to show 10 minutes past eleven o'clock (11:10). For a correct response (above), the hands should be pointing to the 11 and the 2, but do not penalise if the respondent fails to distinguish the long and short hands • Information Can you tell me something that happened in the news recently? (recently = in the last week) Respondents are not required to provide extensive details, as long as they demonstrate awareness of a recent news story. If a general answer is given, such as "war", "a lot of rain", ask for details. If unable to give details, the answer should be scored as incorrect

  16. GPCOG • Recall What was the name and address I asked you to remember? Score for each of the 5 components - John, Brown, 42, West Street, Kensington. • GPCOG Patient Score = /9 • GPCOG Informant InterviewAsk the informant: Compared to a few years ago? • Does the patient have more trouble remembering things that have happened recently? • Does he or she have more trouble recalling conversations a few days later? • When speaking, does the patient have more difficulty in finding the right word or tend to use the wrong words more often? • Is the patient less able to manage money and financial affairs (e.g., paying bills, budgeting)? • Is the patient less able to manage his or her medication independently? • Does the patient need more assistance with transport (either private or public)? • Score 1 point for each "no" answer.   • Informant Score = /6 • Combined (overall) score = /15 Overall

  17. GPCOG Scoring • Results >8 or < 5 on the GPCOG patient section were assumed to be cognitively intact or impaired, respectively. • For patients requiring a informant questionnaire, scores of 3 or less out of 6 in this section indicates cognitive impairment. • http://www.patient.co.uk/doctor/General-Practitioner-Assessment-of-Cognition-(GPCOG)-Score.htm • Provides a link to the tool with scoring provided.

  18. MMSE • OrientationWhat is the (year) (season) (date) (day) (month)? 5 • Where are we: (country) (city) (part of city) (number of flat/house) • (name of street)? 5 RegistrationName three objects: (Apple, Table, Penny) 3TRIALSAttention and calculationSerial 7s / Alternatively spell 'world' backwards 5 RecallAsk for the three objects repeated above. 3 LanguageName a pencil and watch 2Repeat the following: 'No ifs, ands or buts' 1Follow a three-stage command: Take a paper in your right hand, fold it in half and put it on the floor' 3Read and obey the following: Close your eyes 1Write a sentence 1Copy a design 1 Total score             /30           

  19. ACE-R • Brief screening assessment covering - attention and orientation, memory, fluency, language and visuo-spatial skills. • Scores of MMSE are possible as this is incorporated into the ACE-R • Three different versions (A, B & C) allows repetition without significant practice effects

  20. ACE-R • Cut off scores – Hodges suggests cut off of 82/100. However this was a university based assessment using clients known to have dementia. • Clinic based studies indicate cut off of 62/100 as appropriate as above this figure many people met MCI criteria and needed reassessment prior to dementia diagnosis. • However if unusual presentation – discuss and possibly refer on regardless of ACE-R scores.

  21. Limitations of Screening Measures Limited specificity to clinical syndromes If repeated frequently participants can become familiar with items – leads to practice effects and so real change in cognition or function is not identified (Brayne, 1998). Consistent evidence demonstrates that MMSE scores are influenced by age and education level (Crum et al. 1993, Spreen and Strauss, 1998) Evidence indicates that occupational status, educational level, physical strain (illness etc) and general life stress are predictive of MMSE scores (Freidle et al. 1996) Brayne, C. (1998)The Mini-Mental State Examination; will we still be using it in 2001?, International Journal of Geriatric Psychiatry, 13: 189 -198., Crum, R.M., Anthony, J.C., Bassett, S.S and Folstein, M. (1993) Population-based norms for the mini-mental state examination by age and educational level, JAMA, 18: 2386-2391. Spreen, O and Strauss, E.A (1998). Compendium of Neuropsychological Tests: Administration, Norms and Commentary (2nd Edition). Oxford University Press. UK Friedl, W., Schmidt, W.J., Stronegger, A., Irmler, B., Reinhart, B and Koch, M. (1996). Mini-Mental state examination: influence of sociodemographic, Environmental, Behavioural and Vascular Risk Factors. Journal of Clinical Epidemiology. 49, 73 – 78.

  22. Limitations (cont.) • Due to its simplicity and ceiling effects there is lots of room for false negative results and false positives if used independently (White et al, 2002) • Not comparable to functional assessment – high scores on screening measures have no reflection on how an individual may perform on either routine or novel functional tasks (Harborne et al, 2002) • No measures of executive function and so frontal lobe conditions may be missed – ACE-R (Mioshi et al, 2006) developed to include frontal tests and has been shown to have a greater discriminatory power between disorders. White, N., Scott, A., Woods, R.T., et al. (2002) The Limited Utility of The Mini Mental State Examination in Screening People of the age of 75 years for Dementia in Primary Care. British Journal of General Practice, 52. 1002 - 1003 Harborne, A., Walker, Z., & Clare, L. (2003). The role of cognitive measures in predicting decline in functional skills in dementia: a comparison of the MMSE and CAMCOG. PSIGE Newsletter, 82, /38-42.

  23. Normative Data on the MMSE Crum, R.M., Anthony, J.C., Bassett, S.S and Folstein, M. (1993) Population-based norms for the mini-mental state examination by age and educational level, JAMA, 18: 2386-2391.

  24. Screening Completed – So What Next? Is onwards referral needed & if so where to refer to? • Memory Clinic • Community Older Adults Service • Adult Mental Health CMHT • Neurology • Brain Injury Service • Stroke Team

  25. The Role of the Memory Clinic • The role of the memory clinic is to provide an early assessment of cognitive dysfunction and identify its cause. • To distinguish between types of dementia • To provide education to other health professionals on the early signs of dementia • To assist in the recruitment of participants for academic research • To prescribe medication and review its effectiveness • To offer early intervention to avoid secondary / excessive disability

  26. The Role of Neuropsychology in Dementia Care • Provides an understanding of strengths and weaknesses • Provides a baseline to monitor change • Provides a basis for understanding behaviour • Provides an awareness of how to pitch information in order to enable capacity and consent – mental capacity act • Raises others awareness to clients needs and abilities

  27. Neuropsychological assessment: areas to consider Prior (estimate) GENERAL COGNITIVE FUNCTIONING Current MEMORY long-term PERCEPTION EXECUTIVE FUNCTION LANGUAGE Episodic Object Working memory Receptive Spatial Attention Expressive Semantic Executive Autobiographical Prospective

  28. Defining impairment • Scores falling more than 2 standard deviations below the age-specific mean score in the standardisation sample. • Scores falling at or below the 5th percentile for the standardisation sample of the same age-group. • Scores falling at or below a designated cut off score said to discriminate impaired from normal performance • Scores that are markedly discrepant from what would be expected for the individual in view of previous ability and scores on other tests or sub-tests

  29. Neuropsychological Assessment Tool Examples • Pre-morbid (Prior) ability – • WTAR • ToPF • NART • Current ability – • Ravens Progressive Matrices • WAIS IV • WASI

  30. Memory • WMS IV • RBMT • CAMDEN • Doors and People

  31. Perception • VOSP • Rey Complex Figure • Clock Drawing

  32. Executive Function • Delis – Kaplin Executive Function System • Test of Everyday Attention • Behavioural Assessment of Dysexecutive Syndrome (BADS)

  33. Language • Graded Naming Test • Token Test • SCOLP

  34. Interpreting results Functional assessment; other measures Response to assessment History Factors affecting test performance Informant perspective TEST RESULTS Psychological and social aspects Medical tests, scans etc Findings and recommendations

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