Prediction of the MoCA and the MMSE in Out-patients with the risks of cognitive impairment

Transcription

1 Prediction of the MoCA and the MMSE in Out-patients with the risks of cognitive impairment Teresa Leung Therapist Prince of Wales Hospital 7 th May, 2012

2 Outline of Presentation Introduction Study Objectives, Methodology Study Result Service Triage for cognitive impaired Cognitive rehabilitation Service flow

3 Introduction Cognitive impairment has become a growing concern for the elderly population in Hong Kong.???

4 Introduction Early detection of cognitive impairment for timely intervention has been the updated trend in management of cognitive impairment for achieving better outcome.

5 Introduction CDAD MoCA MMSE Adas cog DRS Therapists are specialized in cognitive assessment and rehabilitation, and a high volume of outpatients are referred for this purpose.

6 Introduction Screening Therefore, there is a need for effective and efficient cognitive assessment to differentiate those clients with risks of cognitive impairment, thus enhancing an early protocol driven intervention to take place.

7 Introduction MMSE MoCA MMSE and MoCA are the two commonly used screening assessment used by Therapist for elderly with cognitive impairment

8 Comparison: MoCA vs MMSE MoCA MMSE Visuoconstructional skills Executive function Attention and working memory Language Short term memory V (3D) V (trail making, verbal fluency, verbal abstraction V V (sentence repetition + nomination) V (5 items) V (2D) X V V (sentence repetition) V (3 items) Orientation V V Registration V (Not for scoring) V

9 Objectives To study the effectiveness of two commonly used assessments for cognitive screening: the MMSE and the MoCA (Hong Kong Version), in their predictive power for cognitive impairment. To study the correlation between the total scores of the MMSE and the MoCA.

10 Methodology A convenience sample of patients referred for cognitive assessment and screening in therapy out-patient department were reviewed for the scores obtained in the MMSE and the MoCA in the same visit. Those patients with only the MMSE score but no MoCA score were excluded for this study. A total of 232 patients were collected, age ranged from 32 to 94, educational level from illiterate to university graduates.

11 Data Age range (n) Below Above 90 1 Total 232

12 Data Diagnosis (n) MCI 8 Dementia 28 Memory or cognitive decline 64 Alcoholism 4 Stroke 18 DM 27 HT 21 Parkinson s Disease 4 Orthopedic problem 8 Cardiac problem 10 Others 58 Total 250 multiple diagnosis for some subjects

13 Data Valid N Mean Score (SD) or % Range MMSE (total score) MoCA (total score) Formal education (yrs) (4.3) (5.4) (3.8) 0-16

14 Result Linear regression analysis was performed with the MMSE total score, age, gender and education as predictors of the MoCA total score. MMSE MoCA=0.951(MMSE) -0.07(Age) MMSE= (MoCA). MoCA Using the same method of regression analysis, the MoCA total score was the only predictor of the MMSE

15 Result The false positive and false negative values were counted for both tests for the whole sample MMSE Positive MoCA Positive Negative Negative There was no participants detected to be positive in the MMSE but negative in the MoCA However, there were 71 cases who were cognitively impaired according to the MoCA but failed to be positive in the MMSE, The false negative of the MMSE in detecting cognitive impairment was 71/232=30.6%.

16 Decision making tree for Cognitive Assessment flow MMSE MoCA MMSE: Below cut off MMSE: Above cut off MoCA Other Dementia Assessment as indicated Eg. Dementia Rating Scale, CDAD, ADAS Cog Other specific Cognitive Assessment as indicated eg. RBMT, TEA, FAB

17 September, 2011

18 Improvement in Efficiency 245x 51% = 125 patients with MMSE score under cut off, if we can skip MoCA for them, Administration time for each MoCA assessment is around 30 mins 125 x 30mins = 3750mins If the contact time for each outpatient cognitive screening is 45 mins 3750/45 = 83 patients contact time 83/245 = 34%

19 Service for Elderly with cognitive impairment Mild cognitive impairment MMSE 28 to 30 (24%) MoCA 19 to 25.2 ADL maintained at independent level Mild cognitive Impairment Moderate cognitive impairment MMSE 18 to 27 (32%) MoCA 11.4 to 21 Associated functional impairment Severe cognitive impairment MMSE <18 (44%) Associated functional impairment Moderate cognitive Impairment Severe cognitive Impairment

20 Service for Elderly with cognitive impairment Patients with mild cognitive impairment but ADL function maintained at independent level Computer cognitive training Home Based cognitive training (by patient) Group Caregiver Training

21 Service for Elderly with cognitive impairment Patients with moderate cognitive impairment and ADL requires mild assistance Computer cognitive training Home Based cognitive training (by patient and caregivers) Group Care giver training on cognitive training and ADL facilitation techniques Referral to NGO for maintenance training Behavioral management

22 Service for Elderly with cognitive impairment Patients with severe cognitive impairment and ADL requires constant moderate assistance Care giver training on home based cognitive training, community resources and communication skills for people with cognitive impairment Home environment adaptation and aids prescription Referral to NGO for support service for caring Behavioral management

23 Continuum of Cognitive Rehabilitation Service flow Mild Cognitive Impairment Moderate Cognitive Impairment Severe Cognitive Impairment Group for Self Management and Social Engagement Computer Cognitive Training Home Based Cognitive Training Caregiver training Referral to NGO for maintenance training Behavioral Management Environmental Adaptation and Aids prescription Referral to NGO for caring support

24 Computer Cognitive Training

25 Computer Cognitive Training

26 Group

27 Environmental Adaptation

28 Environmental Adaptation

29 Labels to remind on rooms location

30 Labels on Switches

31 Labels for clothing

32 Aids for Medication

33 Aids for time and Appointment

34 Aids for personal Information

35 Safe Electrical Appliance

36 Conclusions: Clients with the MMSE below cutoff may be skipped for MoCA assessment as no false positive has been identified in the MMSE and this can improve the service efficiency. The regression equation found can help in the transformation of the total scores of two tests for clinical and research use. MoCA should be performed with those clients with the MMSE above cutoff as the false negative of the MMSE in detecting cognitive impairment was 30.6%. The effective use of MMSE and MoCA in detecting mild to severe cognitive impairment can help us to choose appropriate service regime for community dwelling elderly in an efficient and effective way.

37 Acknowledgement Dr. Kenneth Fong Associate Professor Department of Rehabilitation Sciences, Hong Kong Polytechnic University Mr. Frederick Au Department Manager Department, Prince of Wales Hospital Ms Connie Cheuk Ms Cindy Wong Ms Yan Leung Ms Elvis Ng Department, Prince of Wales Hospital

38 Thank You