Resources

  1. Montreal Cognitive Assessment (MOCA): http://baynav.bopdhb.govt.nz/media/1127/moca.pdf
  2. Practice guideline update summary: Mild cognitive impairment. Ronald C. Petersen, Oscar Lopez, Melissa J. Armstrong, Thomas S.D. Getchius, Mary Ganguli, David Gloss, Gary S. Gronseth, DanielMarson, Tamara Pringsheim, Gregory S. Day, Mark Sager, JamesStevens, Alexander Rae-Grant. Neurology Dec 2017, 10.1212/WNL.0000000000004826; DOI:10.1212/WNL.0000000000004826. http://n.neurology.org/content/90/3/126:


Transcript

Dr. Frank Domino:
KR is a 51-year-old female in your practice, and she presents today and looks worried. She tells you that her oldest daughter just gave birth prematurely and that her mother was recently diagnosed with dementia. She owns her own accounting firm, and it's the middle of tax season. When you ask her what's going on, she states that she keeps forgetting things and she's worried that she too may be developing dementia. Hi, this is Frank Domino, Professor of Family Medicine and Community Health at the University of Massachusetts Medical School. Joining me today is Robert Baldor, Professor and Senior Vice Chair in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Welcome to the show, Bob.

Robert A. Baldor, MD, FAAFP:
Thanks, Frank. Glad to be back here again.

Dr. Frank Domino:

Great to have you. So today, we're gonna talk a little bit about dementia. In particular, the new neurology guidelines on what we should be doing with regard to screening. Can you give me an update on that, please?

Robert A. Baldor, MD, FAAFP:
Sure. I must say that it was interesting to me that this was the first updated guideline on screening for dementia since 2001. So surprising it took that long to have an update. This is a very comprehensive evaluation, covering prevalence, incidents, screening, and treatment. So today, I wanna talk a little bit about some of the prevalence and the screening. But first, let me give you a definition. They're talking about mild cognitive impairment, and so what this is, it's a condition in which individuals demonstrate cognitive impairment, but minimal impairment of what's called instrumental activities of daily living. So somewhat like your patient coming in, talking about. Now, it can be their first cognitive expression of Alzheimer's disease, but it can also be secondary to any number of neurologic processes other than Alzheimer's disease, whether it's a neurodegenerative or a psychiatric disorder.

Now, interestingly enough, mild cognitive impairment is broken into two different classes. The first is amnestic. Amnestic is a syndrome in which mostly it's a memory dysfunction that predominates. A little bit what your friend is worried about, she's forgetting things. The other one is non-amnestic, and this is impairment of other cognitive features, language, executive function, and so on, and those are much more prominent. Just to sync a little bit of what we're talking about here for the incidence, for the syndrome. So the other thing they did in this study, they reviewed what's the incidence of this, in the progression of mild cognitive impairment. And roughly, about 8% of those in their 60s will suffer from mild cognitive impairment, 12% of those in their 70s, and 25%, a quarter of those in their 80s will suffer from mild cognitive impairment.

Now, it is associated with having obtained a lower educational level to begin with. And part of that may be a testing artifact, how well you do on tests, and if you have less education, you're less likely to do well on a test. That may be what's going on there. Now, the question really is, is, okay, does it progress? And fascinating, about 15% of those who have been diagnosed with mild cognitive impairment, over the age of 65, will go on to progress to have dementia. So 15%... Okay, that's not too bad. So what happens to the other 85%? Well, either they'll stay the same or they'll actually improve. And so that was really fascinating, to understand the basic epidemiology of this...

Dr. Frank Domino:
That's pretty fascinating, as well as reassuring. It's a little worrisome that, with the generation that's in their 80s and older, one in four may develop a problem, but that just a small percentage will go on to progress is encouraging. So at the annual wellness visit, we're encouraged and not required to do a cognitive evaluation on our seniors. What do the guidelines suggest we do?

Robert A. Baldor, MD, FAAFP:

Well, it's interesting. They actually picked up on this as being something, that the annual wellness exam suggests that we do an assessment to detect cognitive impairment, and that we actually use some sort of a brief validated instrument. And that's what the guidelines say. We should be assessing for mild cognitive impairment with a validated tool, and that we should be monitoring patients who have been diagnosed with this, over time, repeating the use of that tool. And that we should be looking at modifiable risk factors. And so if you think about this tool, it's really interesting. So they're saying, there's lots of different instruments that are actually out there to be used, and there's no instrument that's actually been proven to be superior to another. And so, for the most part, we've gotta understand these are screening instruments. So if you're screening for mild cognitive impairment and somebody fails the screening instrument, you have to do more formal assessment. And that would be full normal psychological testing.

Now, you may recall, there was a lot of publicity here, earlier this year, when President Trump had passed his executive physical and said he had passed a cognitive exam. What does that really mean? And it was interesting 'cause there was an article about this in the New York Times. And what he had done was the MoCA. So the MoCA is the Montreal Cognitive Assessment tool. It's a 10-minute screening exam to highlight possible problems that are out there. And so this was designed about 20 years ago, and really meant to replace the mini-mental status exam, which most of us learned and are quite familiar with. MoCA right now is used in all 31 of the NIH Alzheimer's Disease Center. So it's probably a tool we should be thinking about using.

Dr. Frank Domino:
I'm not familiar with the MoCA at all, Bob. What's it entail?

Robert A. Baldor, MD, FAAFP:

Well, Frank, I have a copy right in front of me. We could do the MoCA right now, if you'd like. So, Frank...

Dr. Frank Domino:
Absolutely.

Robert A. Baldor, MD, FAAFP:
Can you name these objects for me? What is that?

Dr. Frank Domino:
That would be a lion.

Robert A. Baldor, MD, FAAFP:
And what's that?

Dr. Frank Domino:
A rhinoceros.

Robert A. Baldor, MD, FAAFP:

And how about that?

Dr. Frank Domino:
That's a camel.

Robert A. Baldor, MD, FAAFP:
So you can see this is... Some of the different screens on here are a little simpler, but some of this pulls off of the mini-mental status. For example, can you copy this cube? Can you draw a line connecting these dots? Can you draw a clock which is 10 past and write on it 10 past 11. And then there's the memory test, of course. Things like serial sevens are on here. Can you repeat some languages? So I only know that John is the one to help today. Can you say that? Repeat that for me.

Dr. Frank Domino:
I only know that John is the one to help today.

Robert A. Baldor, MD, FAAFP:
And the cat always always hid under the couch when dogs were in the room.

Dr. Frank Domino:
The cat always hid under the couch when dogs were in the room.

Robert A. Baldor, MD, FAAFP:
Wonderful. So you're really doing very well. So some of these are just some short-term memory things. But that's the MoCA. It's relatively straight-forward but a little bit of the MoCA. It's a screening test. And for somebody who has a higher level of professional attainment, educational attainment, it's gonna be a little harder to fail this test than somebody who has not been at that point.

Dr. Frank Domino:
Well, Bob, that's great. I'm thrilled to learn about the MoCA and learn that the guidelines, at least, give us some direction in how we should be screening patients. I also really appreciate your admonition that these are screening tools, and if it comes back positive, we should probably do a more confirmatory, much greater examination. Any final thoughts?

Robert A. Baldor, MD, FAAFP:
Well, I just wanna say that, yes, you've done that formal evaluation and now you've confirmed that somebody actually has a mild cognitive impairment. The next steps here are to look for any potentially, risk factors, things that you can do to address this. Number one is medications. Are they on medications that are potentially impairing their cognition? Can we stop those? How necessary are they for their functioning? Number two is look for reversible medical conditions. And number one on that, depression. And depression's probably a little bit more prevalent than we realize. And number two, sleep disorders. People who aren't sleeping well, will then go on to have issues. I wanna come back to that case that you presented.

Dr. Frank Domino:
Yes, KR.

Robert A. Baldor, MD, FAAFP:
That woman sounded really stressed. And so she's stressed, I bet she's not sleeping well, I bet she's depressed. And you think about those as factors, that's probably more likely what's going on in her world than the fact that she's developing dementia. Although you won't know for sure until you actually do some formal validated screening on her.

Dr. Frank Domino:
Well, Bob, thanks so much for coming today, and thanks for bringing this to our attention. In our next podcast, we'll be discussing how to go about treating mild cognitive impairment now once you've made the diagnosis. Practice pointer, consider screening patients who are at risk for mild cognitive impairment with the Montreal Cognitive Assessment, the so-called MoCA test. The link for a MoCA is available on our landing page.