Cognitive Screening Of Older Adults Research Articles

Montreal Cognitive Assessment’s auditory items (MoCA-22): Normative data and reliable change indices

Our objective was to establish normative data and reliable change indices (RCI) for the Montreal Cognitive Assessment’s auditory items (MoCA-22). 4,935 cognitively unimpaired participants were administered the MoCA during an in-person visit to an Alzheimer’s Disease Research Center (Mage = 67.9, Meducation = 16.2, 65.8% women, 75.9% non-Hispanic-White), with 2,319 unimpaired participants returning for follow-up. Normative values and cutoffs were developed using demographic predictions from ordinary and quantile regression. Test-retest reliability was calculated using Spearman and intraclass correlations. RCI values were calculated using Chelune and colleagues’ (1993) formula. Education, age, and sex were all statistically related to MoCA-22 scores, with education having the strongest relationship. Notably, these relationships were not consistent across MoCA-22 quantiles, with education becoming more important and sex becoming less important for predicting low scores. These models were integrated into a calculator for deriving normative scores for an individual case. Furthermore, there was adequate-to-good test-retest reliability (ϱ = 0.56 95% CI [.54, .59]; ICC = 0.75, 95% CI [.73, .77]) and changes of at least 2-3 points are necessary to identify reliable change at 1-3-year follow-up. These findings add to the literature regarding utility of the MoCA-22 in the cognitive screening of older adults.

A Prospective Observational Cohort Study of Language Preference and Preoperative Cognitive Screening in Older Adults: Do Language Disparities Exist in Cognitive Screening and Does the Association Between Test Results and Postoperative Delirium Differ Based on Language Preference?

A greater percentage of surgical procedures are being performed each year on patients 65 years of age or older. Concurrently, a growing proportion of patients in English-speaking countries such as the United States, United Kingdom, Australia, and Canada have a language other than English (LOE) preference. We aimed to measure whether patients with LOE underwent cognitive screening at the same rates as their English-speaking counterparts when routine screening was instituted. We also aimed to measure the association between preoperative Mini-Cog and postoperative delirium (POD) in both English-speaking and LOE patients. We conducted a single-center, observational cohort study in patients 65 years old or older, scheduled for surgery and evaluated in the preoperative clinic. Cognitive screening of older adults was recommended as an institutional program for all patients 65 and older presenting to the preoperative clinic. We measured program adherence for cognitive screening. We also assessed the association of preoperative impairment on Mini-Cog and POD in both English-speaking and LOE patients, and whether the association differed for the 2 groups. A Mini-Cog score ≤2 was considered impaired. Postoperatively, patients were assessed for POD using the Confusion Assessment Method (CAM) and by systematic chart review. Over a 3-year period (February 2019-January 2022), 2446 patients 65 years old or older were assessed in the preoperative clinic prior. Of those 1956 patients underwent cognitive screening. Eighty-nine percent of English-speaking patients underwent preoperative cognitive screening, compared to 58% of LOE patients. The odds of having a Mini-Cog assessment were 5.6 times higher (95% confidence interval [CI], 4.6-7.0) P < .001 for English-speaking patients compared to LOE patients. In English-speaking patients with a positive Mini-Cog screen, the odds of having postop delirium were 3.5 times higher (95% CI, 2.6-4.8) P < .001 when compared to negative Mini-Cog. In LOE patients, the odds of having postop delirium were 3.9 times higher (95% CI, 2.1-7.3) P < .001 for those with a positive Mini-Cog compared to a negative Mini-Cog. The difference between these 2 odds ratios was not significant (P = .753). We observed a disparity in the rates LOE patients were cognitively screened before surgery, despite the Mini-Cog being associated with POD in both English-speaking and LOE patients. Efforts should be made to identify barriers to cognitive screening in limited English-proficient older adults.

Patient, Family Caregiver, and Provider Perceptions on Self-Assessment Screening for Cognitive Impairment in Primary Care: Findings From a Qualitative Study.

The purpose of this study was to evaluate patient, family, and provider perspectives on routine cognitive screening of older adults in primary care using a novel self-assessment tool for detection of early cognitive impairment (CI). We conducted four virtual focus groups with patients aged 65 and older with no CI (n = 18) and family caregivers of patients with CI (n = 5) and interviews with primary care providers (n = 11). Patient and family caregiver participants felt that early detection of CI was important in primary care and may facilitate planning for the future including finances, living arrangements, and advance care planning. Providers reported that they do not use a standardized tool to routinely screen patients for CI yet endorsed the use of a self-assessment CI screening tool. These results suggest that routine screening of older adults using a brief, self-assessment screening tool for CI in primary care may be acceptable to patients, family caregivers, and providers. The findings from this study will inform the development of a brief self-assessment CI screening tool for use in primary care.

Overcoming Age-Based Stereotypes to Optimize Cognitive Performance in Older Adults: A Systematic Review of Methodology and Existing Evidence.

Age-based stereotype threat (ABST) poses serious risks for the cognitive screening of older adults. This review aimed to identify and critically appraise the methodology and existing evidence of studies investigating the use of threat-removal (TR) strategies to overcome the effects of ABST on the cognitive performance of older adults. The types of strategies, their effectiveness in optimizing cognitive performance, and factors influencing their effectiveness were examined. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PsycINFO, PubMed, Embase, Web of Science, and Scopus were searched from January 1, 1995 to November 6, 2019. Two authors independently assessed article eligibility and appraised methodological quality of eligible articles using an adaptation of the Strengthening the Reporting of Observational studies in Epidemiology guidelines. Narrative synthesis was used to summarize results. Thirty articles, reporting on 36 studies, were eligible and included. Overall, evidence for the effectiveness of TR was mixed and varied according to the explicitness of strategies and comparison conditions used. Studies examining blatant TR strategies, and those using a combination of blatant and subtle TR strategies, provided limited support for their effectiveness in overcoming ABST. However, studies evaluating subtle TR strategies provided preliminary support for their effectiveness in overcoming ABST. Existing studies provide limited evidence regarding the effectiveness of TR strategies in overcoming ABST due to methodological limitations. Recommendations are made for the design of future studies to differentiate the benefits of TR strategies from the detrimental effects of ABST, thus potentially informing their use in clinical practice.

An iPad-based Measure of Processing Speed in Older Adults Hospitalized for Heart Failure.

In older adults hospitalized with heart failure (HF), cognitive impairment is associated with increased hospital readmission and mortality risk. There is no consensus on an objective, scalable method of cognitive screening in this population. The aim of this project was to determine the feasibility, test-retest reliability, and convergent validity of the Processing Speed Test (PST), a test of information processing, attention, and working memory administered on an iPad in older adults hospitalized with HF. Patients hospitalized with HF (n = 30) and age-, sex-, and education-matched controls (n = 30) participated in the study. To determine test-retest reliability, the PST was administered on an iPad on 2 occasions, separated by 12 to 48 hours. The Symbol Digit Modalities Test was administered at the first testing time point to determine convergent validity. Test-retest reliability of the PST was 0.80 and 0.92 in individuals with HF and controls, respectively. Convergent validity was 0.72 and 0.90 for individuals with HF and controls, respectively. Time to complete the PST was similar for both individuals with HF and controls (<5 minutes). The iPad-based deployment of the PST was a feasible, reliable, and valid cognitive screen for older adults hospitalized with HF. Using a tablet-based self-administered cognitive screen in older adults with HF provides a method of cognitive assessment that is amenable to widespread clinical utilization.

Caregivers' Experience of Decision-Making regarding Diagnostic Assessment following Cognitive Screening of Older Adults.

Targeted screening for dementia among older adults in primary healthcare has potential benefits such as better clinical outcomes and the opportunity to access services. Cognitive screening can be followed up by further diagnostic assessment to determine a diagnosis of dementia. Unfortunately, the rates of accepting further diagnostic assessment following cognitive screening are low. The objective of this study was to explore the caregivers' decision-making process regarding uptake of diagnostic assessment following positive screening results. A qualitative design was employed, and interpretative phenomenological analysis was used to analyze the data. Three major themes in caregiver decision-making were identified: gathering information, protecting the patient, and balancing obligation and convenience in caregiving. These findings suggest that the decision-making process involved effort to process information through observations of the patient and that caregivers emphasized quality of life.

Cognitive screening of older adults using serious games: An empirical study

ObjectiveThe goal of the research is to develop three serious games using design for the older adult population, in order to evaluate the cognitive performance of older adults. Simultaneously, the games provide information about the cognitive performance of players with neurocognitive pathology that can be used by health care professionals in clinical monitoring. Subjects and methodsTwo groups of adults aged 50 years or more participated in the study. Group 1 was composed of 52 subjects with high cognitive performance attending a cultural academy and a senior university. Group 2 consisted in 51 patients with cognitive impairment recruited in the Old Age Psychiatric Unit of a university hospital. Each participant played the game and was assessed with a widely-used and well validated neuropsychological instrument (Montreal Cognitive Assessment – MoCA). Concurrent validity was tested for each cognitive domain with Spearman correlation coefficient. ResultsGroups 1 (Senior University) and 2 (Hospital) differed in relation to average age (64.8 vs. 76.5), proportion of female gender (80% vs. 74.1%), educational level and occupation. Subjects in Group 1 scored higher in all assessed cognitive domains and in total MoCA score (24.3 vs. 13.5). The overall game performance was better in Group 1 with the Maximum Level and Group 2 the Maximum Level correlated with all cognitive domains except for abstraction. ConclusionsThe research provides a useful case study in the development of Serious Games for cognitive screening, which can be used independently by players, repeatedly, as cognitive exercise. Thus, these Serious Games are relevant tools that can be used as a stimulus supplement (exercises) and continuous evaluation (normative tables) of the evolution of the players (older adult population), offering useful information (collecting and choosing the data to be analyzed) for follow-up by professionals involved in patient care.

Screening Positive for Cognitive Impairment: Impact on Healthcare Utilization and Provider Action in Primary and Specialty Care Practices.

Alzheimer's disease, the most common cause of dementia, goes unrecognized in half of patients presenting to healthcare providers and is associated with increased acute care utilization. Routine cognitive screening of older adults in healthcare settings could improve rates of dementia diagnosis and patterns of healthcare utilization. To evaluate the impact of screening positive for cognitive impairment on provider action in primary and specialty care practices and patient healthcare utilization. Individuals asymptomatic for cognitive impairment completed cognitive screening with the Mini-Cog (MC). Outcomes included MC screen-positive rates, provider follow-up actions, and healthcare utilization for all participants over a period of 36months (18months prior to and following MC screening). Data were extracted from the electronic medical record (EMR). Healthcare provider interventions and healthcare utilization for screen-positive and -negative groups, before and after screening, were compared. Primary and specialty care patients (n = 787) aged ≥ 65 without history of cognitive impairment seen in HealthPartners, an integrated healthcare system in Minnesota and Western Wisconsin. In primary care and neurology practices combined, over the entire 36-month study window, individuals screening positive showed 32% higher rates of ED visits (p < 0.05) pre and post-screening compared to those screening negative. Screen positive also showed 39% higher rates of hospitalizations pre-screening (p < 0.05) and 58% higher rates post-screening (p < 0.01). While screen-detected cognitive impairment was associated with some relevant provider follow-up action in 32% of individuals, subsequent healthcare utilization did not change between the 18-month pre- and post-screening periods. Despite being associated with higher rates of healthcare utilization, screening positive on the MC led to a change in provider action in a minority of cases and did not reduce post-screening healthcare utilization. Screening for cognitive impairment alone is not sufficient to alter patterns of provider practice or patient healthcare utilization.

Cognitive screening of older adults: the utility of pentagon drawing

Drawing tests have a long history in neuropsychological assessment. A popular geometric figure has been the two intersecting pentagons from the Bender Gestalt test. Reproducing the pentagons is the main visuospatial task on the original Mini-Mental State Examination (MMSE), remaining in use in revised versions of that widely used screening test. Scoring criteria on the MMSE are binary: perfect reproduction of the figure is required, while the Modified MMSE of Teng and Chui (1987) uses a more refined ten-point scoring for the elements of the figure. Here, I report on the use of pentagon drawing from 8,702 older community-dwelling Canadians (59.3% female), with a mean age of 75.5 years (SD = 6.99) and 10.1 years of education (SD = 3.89). Mean scores for the whole sample are reported, as well as for subsamples who underwent a full clinical assessment and were diagnosed as cognitively intact, with dementia, or cognitively impaired, but without dementia. Logistic regression was used to evaluate the utility of pentagon drawing as a diagnostic tool to diagnose cognitive impairment. Binary scoring was less effective in discriminating groups than the ten-point system and showed weaker properties by other criteria. The discussion focuses on the role of simple, non-verbal tasks in the cognitive screening of older adults.

Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases. To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications. Four primary care clinics in a university-affiliated primary care network. A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data. Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age. Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients.