Dementia: Grab Your MoCA

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Consider Mr. D Mencha…

DM is a 78 year old known well to clinic. He has heart failure and recently was admitted for heart failure exacerbation and was in a SNF for 2 weeks after. He is accompanied by his wife, who mentions the patient is motivated to stay out of the hospital. His wife has noticed she needs to repeat instructions more than once, and often forgets to take his new medication recently prescribed. They play bridge every week and she recalls while a year ago he was sharp, recently he plays inappropriate hands and gets frustrated when he doesn’t understand the rules. He often goes to the store specifically for eggs and returns only with bread; one time recently he got lost on the way home. During the visit, he tries to recall the name of the OSR who checked him in (who he knows well), but just says “the lady” and gives up quickly. At check out from the visit, he presented his insurance card and checkbook again despite being told he didn’t need to show them again.

What is dementia?

Significant (“major”) or mild (“minor”) decline in ≥1 of 6 areas:

  • Complex Attention (“needs to repeat instructions more than once”)
  • Executive Function (plays inappropriate hands during bridge)
  • Language (calls the OSR whose name he knew “the lady”)
  • Learning and Memory (forgetting to take his new medication)
  • Perceptual Motor (getting lost on the way from the grocery store)
  • Social Cognition (apathetic to forgetting name, easily frustrated during bridge)

Diagnostic Criteria

  • Decline in neurocognitive domains assessed BOTH by history AND objective measurement
  • Cannot exclusively occur during periods of delirium
  • Cannot be explained by another disorder

Objective Measures: Mini-Cog

The Mini-Cog is a quick screening tool for dementia

  • Repeat three unrelated words
  • Draw a clock
  • Recall the three unrelated words

Sensitivity 91%, Specificity 86%

*Mini-Cog is a screen that should be followed by formal assessments

Objective Measures: MMSE

The Mini-Mental Status Examination is the best studied screening measure.

  • Very easy to administer, fast (<10 minutes)
  • Does carry more bias based on educational attainment (some have scaled score cutoffs)
  • Not as effective at detecting subtle memory loss

Sensitivity 81%, Specificity 89%

Objective Measure: MoCA

The Montreal Cognitive Assessment (MoCA) is a brief screening test. 

  • Takes a bit longer (10-15 minutes); still has education-level bias
  • Designed specifically to detect mild cases of dementia earlier
  • Best for people scoring >24 on MMSE

Sensitivity 91%, Specificity 81%

Informant-Based Measure: DSRS

The Dementia Severity Rating Scale is is an 11-item, informant-report questionnaire, assessing a variety of functional and cognitive abilities.

  • Large advantage of picking up on deficits that are clinically important to family but not detected on other tests
  • Drawback: may not be reliable, subject to judgment/biases on what is “normal”
  • Best when combined with patient-based measure (e.g. MoCA, MMSE)

Back to Mr. D Mencha…

Mr. D. Mencha scores a 19 on MMSE, and 40 (moderate) on wife’s DSRS.

“Cannot be explained by another disorder”

We must screen/rule out other causes. 

Evaluate for depression: 

Consider alternative diagnoses through lab testing: 

  • CBC, CMP, thyroid tests, Vitamin B12, consider HIV, treponema

Neuroimaging:

  • Noncontrast Brain MR is recommended per AAN guidelines: 
    • “Structural imaging can improve diagnostic certainty and changes clinical diagnosis in 19% to 28% as well as management of 15% of clinical cases” (data from 1997)
    • General goal: rule out surgical pathology/mass, stroke, subdural hematoma, NPH
  • MRI also recommended per Radiology Appropriateness Criteria
    • Future directions: amyloid PET (currently available, utility not established), Tau PET for diagnosis of Alzheimer’s 

You diagnose Mr. D. Mencha with dementia…

His wife asks “What can we do?”

  • “Can he still go to work part time?”
  • “Should I take his car keys away?”
  • “Can he still make his own medical decisions?”

Neuropsychological Testing

What goes into neuropsychological evaluations:

  • History, physical, chart review, standardized test(s)
  • Not just one test, dozens of standardized tests based on what you’re looking for

Pharmacotherapy

Guidelines based on ACP/AAFP’s Clinical Practice Guideline: 

  • General classes: cholinesterase inhibitors (donepizil, rivastigmine), NMDA agonist (memantine)
    • Cholinesterase inhibitors are FDA approved for mild to moderate AD, and memantine for moderate to severe AD
  • All have demonstrated statistically significant improvements on MMSE scores and other criteria when compared to placebo
  • However, few studies have shown clinically significant improvements
    • Patient-measured outcomes (institutionalization, QoL) not different
  • A few comparative trials have not shown any one to more effective than any other

Nonpharmacologic Treatment

Multiple types of nonpharmacologic treatment are available: 

  • Cognitive Stimulation Therapy
    • Program in social setting of twice weekly small groups with cognitive tasks
    • Best studied and most effective (Cochrane review of 15 studies)
  • Reality Orientation
    • Sessions designed to orient patients to current events, time, place
  • Talk therapies: Reminiscence, Validation
  • Art Therapy 

When to Refer

  • Uncertainty about diagnosis
  • High clinical suspicion/strong collateral for cognitive impairment with normal or borderline objective measures (likely indication for neuropsychology evaluation)
  • Any other need for neuropsychology evaluation with concern for dementia
  • Medication management concerns, access to resources

Take-Home Points!

  • Dementia is defined by decline in one or more major cognitive domains, assessed both clinically and objectively, and after other diagnoses are ruled out
  • MMSE or MoCA, +/- DSRS are good measures we can administer in clinic to assist in diagnosis
  • Neuropsychological testing can be helpful for next medical-legal steps or if there is diagnostic uncertainty
  • Medications may help, but more studies are needed
  • Refer to Memory Disorders Center for any concerns

Blog post based on Med-Peds Forum talk by Cam Ulmer, PGY2

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