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O4–04–01: A hierarchical approach to practical assessment of cognitive decline in the elderly
Author(s) -
Simon Ely S.,
Doniger Glen M.,
Cummings Jeffrey L.,
Fillit Howard
Publication year - 2006
Publication title -
alzheimer's and dementia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 6.713
H-Index - 118
eISSN - 1552-5279
pISSN - 1552-5260
DOI - 10.1016/j.jalz.2006.05.318
Subject(s) - cognitive decline , dementia , neuropsychological assessment , cognition , cognitive test , reimbursement , psychology , cohort , referral , neuropsychology , gerontology , clinical psychology , medicine , psychiatry , family medicine , health care , pathology , economics , economic growth , disease
Background: There is a critical need for practical and effective methods for office-based assessment of cognitive decline. We propose a hierarchical approach that has high diagnostic accuracy and considers reimbursement and cost and resource constraints of a busy office. The 3-tiered evaluation algorithm defines appropriate roles for short screening tools, point-of-care comprehensive assessment, and referral to a neuropsychologist. The present focus is on novel point-of-care comprehensive assessment that provides research-quality data and aids in differential diagnosis and longitudinal tracking. Objective: Develop a practical approach for officebased assessment of cognitive decline. Methods: Entry into the algorithm is either via cognitive complaint from the patient or informant or by the physician’s clinical suspicion. Initial neurobehavioral assessment includes the history, examination, chart review, and a brief screening test and results in a determination of whether comprehensive assessment is warranted. For point-of-care cognitive assessment, we used the Mindstreams (NeuroTrax Corp., NY) computerized system. Endpoints were discriminant validity as well as measures of usability and practicality. Results: Previous studies demonstrated better discriminant validity for Mindstreams in early cognitive decline than for paper-based neuropsychological tests and that Mindstreams is robust to the presence of depressive symptoms and low socioeconomic status. The present multi-ethnic cohort was from an ongoing longitudinal study of MCI and mild dementia (N 73; age 73 10.5). Mindstreams results were summarized for each cognitive domain, and a composite MCI Score was computed. ROC curve analysis revealed good discriminability (area under the curve: 0.91, sens 80%, spec 86%). Ease of use and practicality of Mindstreams was measured in a real-life cohort from 9 medical offices (N 680; age 61.6 19.6) of which 37% had no computer experience. Each patient and test administrator separately completed 4 questions regarding ease of use, scored on a 5-point Likert scale. Only 9% of administrators and 8% of patients rated Mindstreams difficult to use, and only 7% rated it hard to understand. Further, office administrators reported success in reimbursement. Conclusions: The advent of valid, objective, and practical computerized assessment affords a solution for point-of-care assessment and makes a hierarchical approach feasible. This should lead to better standardized patient care and system-wide cost savings.