Early Diagnosis, Testing, and Treatment of Dementia - Episode 11
Alireza Atri, MD, PhD: Doing that assessment, Mary, and again, in the internal medicine, primary care, geriatric office, Marc started talking a little bit about the brief instruments that he uses that are standardized. But what do you like to do? What’s your approach?
Mary A. Norman, MD: Yes, I think it’s important. We use, for cognition, if there’s any suspicion, starting even in a busy primary care practice, the Mini-Cog. The Mini-Cog is an outstanding instrument looking at recall, and that’s just a 3-item recall and clock drawing. I get a tremendous amount of information just from those 2 questions. And then based on your other clinical suspicions, you can add on other tools from your tool chest, whether it’s more visuospatial…I like using the Trail Making Test, parts A or B. It’s very easy to administer in a busy primary care practice as well. We do screen regularly for both alcohol as well as depression. Even the 2-item depression screen is helpful, with your tool chest ready to ask more questions and to make referrals to your colleagues and friends. Our practice has a social worker who’s a gerontologist, who is able to do more advanced testing right on site. But wherever you are, having that team of providers that assist you to make sure that your patient gets the work-up they deserve.
Alireza Atri, MD, PhD: Mary, you had mentioned the annual wellness visit as being an opportunity to at least discuss that. Very recently, the American Academy of Neurology put out a position statement that individuals who are seen in our types of practices, and neurology, geriatrics, etcetera, who are age 65 and older should also be assessed by one of these instruments every year. I think that’s a step forward. And the choice of it, again, depends on proficiency, and there are lots of them to choose from.
Mary A. Norman, MD: Exactly, and time.
Alireza Atri, MD, PhD: And time.
Mary A. Norman, MD: The Mini-Cog only takes a couple of minutes. I love to do the MMSE [Mini-Mental State Examination] or the MoCA [Montreal Cognitive Assessment] screen if we have a bit more time. I think it gives you more opportunities to see multiple domains of cognition.
Alireza Atri, MD, PhD: And you mentioned time. Does it have to be done all in 1 visit?
Mary A. Norman, MD: Good question. Typically, when you’re talking about a work-up for cognitive behavioral syndrome, we’re looking at several visits. The annual visit is, I find, an easy way to put the issue on the table, and ask and screen. And then I always set up the next visit with, “Hey, the next time you come in we’re going to really focus on cognition. I want you to bring all the medicines from your cabinet. Can we include a caregiver at that point?” And perhaps we’re starting the work-up already, between the visits, with head imaging or our cognitive laboratory panel.
Alireza Atri, MD, PhD: Maybe later on I’ll hit you up for ways that in primary care, or in geriatrics, you can actually get paid for this—bringing it up in multiple visits, both the evaluation part and the care management part. I think that’s where the practical part is, and is really important.
Mary A. Norman, MD: We’ve got some good news on that front.
Alireza Atri, MD, PhD: Oh, wonderful. Good. Turning to neuropsychology, which I think is a really important resource for all of us, and actually is 1 domain where you can spend time with patients, can you give us some specific examples, Lynn, for when a neuropsychological evaluation can be particularly useful to help your colleagues out here?
Lynn Shaughnessy, PsyD, ABPP/CN: Yes, for a variety of reasons. Sometimes you may not be able to get sufficient information from your office exam. Whether that be time or maybe specific variables having to do with the patient, and you need more information, neuropsychology can be a very helpful resource for that. Sometimes you’ll see a patient with, perhaps, very high education who’s scoring perfectly on your brief or cognitive assessments, and you need a little bit more information there and a more in-depth analysis of cognition to really determine that level of cognitive functioning. And perhaps that individual has some subjective cognitive impairment, or maybe it’s actually mild cognitive impairment compared to where we would expect them to lie initially. I think that’s another benefit of neuropsychology. We give measures that actually look at that crystallized intelligence, and we assess premorbid functioning and where we would expect them to fall prior to whatever pathological processes may be going on at present. And so, we’re able to do that comparison and go from there.
And that’s similar to someone you may see in your office who has very low education and, perhaps, does not do well on your screen. But is that due to limited educational opportunities, or is there actually a change happening there? And so, we can also be very helpful with that. And then, in general, we tend to tailor recommendations to the patient as best we can and to what challenges they are having with cognition. Perhaps someone may be having some trouble at home managing medications, or even driving. We can provide some recommendations and give an idea of next steps, and provide resources, and so on.
Alireza Atri, MD, PhD: That actually brings up a really good point that Mary was suggesting, that we have at our disposal. There are different tools—Mini-Cog, MoCA, etcetera—and there may be blunt cutoffs that we may use, but those are not necessarily adjusted for people with extremes of education, attainment, age, or maybe even language. And so, this is something that neuropsychology can really help us with.
Lynn Shaughnessy, PsyD, ABPP/CN: Absolutely. Or someone who had a long-standing, severe mental illness, or comorbid psychiatric issues, or really complex medical issues. We can help provide more information like that.
Alireza Atri, MD, PhD: That’s great.
Transcript edited for clarity.