Now What?
Steps to Take When You Notice Cognitive Decline.
Noticing signs of forgetfulness or cognitive challenges in yourself or a loved one can be unsettling, often raising fears about dementia – a condition many consider one of the most daunting aspects of aging.
But negative cognitive changes do not necessarily indicate the start of dementia. In fact, there are several other possible explanations. For example, cognitive function can be negatively affected by:
mental health conditions such as depression or anxiety;
medications;
stroke;
urinary tract infections; and
traumatic brain injury.
That’s why diagnosing dementia is such a complex and often lengthy process, requiring careful evaluation to uncover the true cause. The process involves in-depth assessment, often administered by a memory specialist, that in part focuses on ruling out any other potential causes of cognitive decline.
The first step, before diving into a more in-depth evaluation, is usually a brief cognitive screening test.
This helps quickly assess cognitive function and determine if further examination is necessary.
A wide range of cognitive screening tests have been developed over the years. In this article, we highlight some of the most commonly used by healthcare professionals, along with a few that you can try at home.
TESTS ADMINISTERED BY HEALTH PROFESSIONALS
Three cognitive tests that are widely used by health professionals for cognitive screening are the Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), and Mini-Cog.
MINI-MENTAL STATE EXAM (MMSE)
The MMSE was created in 1975 and includes 11 questions/tasks such as counting backward by sevens, stating the date and location, naming and recalling objects in the room, copying a drawing, and writing a short sentence. It takes about five to ten minutes to complete.
MONTREAL COGNITIVE ASSESSMENT (MOCA)
The MoCA is a newer test, validated in 2005, that includes activities such as memorizing a short list of words, reading a list of letters while tapping the hand when saying each letter, naming animals shown in pictures, copying a simple stick drawing of a bed, counting backward by sevens, and naming as many words as possible in 60 seconds that start with a given letter. (You might have noticed that some of these tasks overlap with what’s included in the MMSE.) MoCA is available as a paper version or an app and takes about ten to 15 minutes to complete.
MINI-COG©
The Mini-Cog is a test, introduced in 2000, that is even quicker than the MMSE and MoCA – it takes just three minutes to complete and includes only two components: (1) a three-item recall test for memory and (2) a clock drawing test. The test is administered in three steps:
01 the test-taker is instructed to listen carefully and repeat three words chosen by the test-giver (for example: banana, sunrise, chair)
02 a clock drawing test is administered
03 the test-taker is asked to repeat the three words from step 1
MINI-COG© SCORING:
Recall Score (1 point for each word correctly recalled in step 3) + Clock Drawing Score (2 points for normal clock or 0 points for abnormal clock) = Total Score (from 0 to 5).
A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment, while a total score of 3, 4, or 5 indicates lower likelihood of dementia. A score of 3 or more does not, however, rule out some degree of cognitive impairment entirely.
ALZHEIMER’S QUESTIONNAIRE (AQ©)
The three tests described earlier are all completed by the person who is experiencing cognitive difficulties. Another way that health professionals sometimes do initial cognitive screening is by asking a care partner questions about the person experiencing cognitive difficulties.
One such “informant-based” test is the Alzheimer’s Questionnaire (AQ©). The 21 questions are answered “yes” or “no,” with each “yes” getting a score of 1 or 2, and each “no” getting a score of 0.
1. Does your loved one have memory loss?
Y = 1 N = 0
2. If so, is their memory worse than a few years ago?
Y = 1 N = 0
3. Do they repeat questions, statements,or stories in the same day?
Y = 2 N = 0
4. Have you had to take over tracking events or appointments, or does the patient forget appointments?
Y = 1 N = 0
5. Do they misplace items more than once a month?
Y = 1 N = 0
6. Do they suspect others of hiding or stealing items when they cannot find them?
Y = 1 N = 0
7. Does your loved one frequently have trouble knowing the day, date, month, year, and time; or do they have to use cues like the newspaper or the calendar to know the day and date more than once a day?
Y = 2 N = 0
8. Do they become disoriented in unfamiliar places?
Y = 1 N = 0
9. Do they become more confused when not at home or when travelling?
Y = 1 N = 0
10. Excluding physical limitations, do they have trouble handling money, such as tips or calculating change?
Y = 1 N = 0
11. Excluding physical limitations, do they have trouble paying bills or doing finances?
Y = 2 N = 0
12. Do they have trouble remembering to take medicines or keeping track of medications taken?
Y = 1 N = 0
13. Do they have difficulty driving; or are you concerned about their driving?
Y = 1 N = 0
14. Are they having trouble using appliances, such as the stove, phone, remote control, or microwave?
Y = 1 N = 0
15. Excluding physical limitations, are they having difficulty completing home repair or housekeeping tasks?
Y = 1 N = 0
16. Excluding physical limitations, have they given up or cut down on hobbies such as golf, dancing, exercise, or crafts?
Y = 1 N = 0
17. Are they getting lost in familiar surroundings, such as their own neighbourhood?
Y = 2 N = 0
18. Do they have a decreased sense of direction?
Y = 1 N = 0
19. Do they have trouble finding words
other than names?
Y = 1 N = 0
20. Do they confuse names of family members
or friends?
Y = 2 N = 0
21. Do they have trouble recognizing familiar people?
Y = 2 N = 0
AQ© SCORING:
Add up all the points to get a total score out of 27.
A score of 4 or less is considered a normal level of cognitive function.
A score of 5-14 (inclusive) suggests mild cognitive impairment.
A score of 15 or more suggests the potential presence of dementia.
AT-HOME TESTS
Many cognitive screening tests are marketed for at-home use, but research reveals significant variation in their quality and accuracy.
Here, we highlight a few at-home cognitive screening tests backed by solid research. This list is not exhaustive, and other high-quality options may be available.
Before using any test, ensure it is supported by research that demonstrates its effectiveness.
SAGE (SELF-ADMINISTERED GEROCOGNITIVE EXAM)
In 2010, Dr. Douglas Scharre and colleagues at The Ohio State University developed a pen-and-paper test – the Self-Administered Gerocognitive Exam (SAGE) – that can be completed at home and then taken in to a primary care physician for scoring and interpretation.
SAGE is a 12-question test that assesses multiple types of cognitive function: orientation, language, calculations, abstraction, and visuospatial and executive function. (One of the questions involves clock drawing, described earlier.) It generally takes 15 minutes or less to complete the entire test. Research has found SAGE compares favourably with tests administered by health professionals such as the MMSE and MoCA.
The print version of SAGE is available free of charge at: sagetest.osu.edu. A digital version (eSAGE or BrainTest®) is now available at braintest.com.
XPRESSO BY MOCA
XpressO by MoCA is a self-administered, digital version of the MoCA test. It’s taken in the comfort and privacy of home, either at portal.mocacognition.com or using an app installed on any device, and can be completed in a few minutes using simple drag-and-drop tasks.
XpressO by MoCA differs from SAGE in that it automatically calculates a score based on speed and accuracy and provides a simple report that shares whether your performance fell within or below the expected range for cognitive performance.
If your performance is within the normal range, you don’t need to take any action. If your performance is below the expected range, then you should book an appointment with your doctor. (With SAGE, you don’t get any results at home and have to visit your doctor to get the results.)
According to the XpressO by MoCA website, “serial test results can be tracked,” meaning that you can self-monitor your cognition over time and watch for any concerning changes.
KEEP IN MIND
Two important things to keep in mind about cognitive screening:
All of the tests described – both the ones administered by health professionals and the ones you can do at home – are for initial screening only. They are not for diagnosing anything; rather, they just provide a rough idea of cognitive function so that your health professional gets a sense of whether you need additional in-depth testing or not.
It can be stressful to take a cognitive screening test and get the results, especially if your score on the test is poor. Remember that there are several potential causes of cognitive decline besides dementia, many of which are treatable and reversible.
If further testing leads to a dementia diagnosis, it’s important to understand that early detection can be highly beneficial. The sooner you know, the sooner you can start medications to slow symptom progression and enhance quality of life. Early diagnosis also gives you more time to plan for the future and actively participate in important decisions about your care, finances, and other aspects of your life.
Source: Mind Over Matter V20