Identifying cognitive impairment during the Annual Wellness Visit: Who can you trust?

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Original Research

Identifying cognitive impairment during the Annual Wellness Visit: Who can you trust?

J Fam Pract. 2011 November;60(11):653-659

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References

1. 111th US Congress. Patient protection and affordable care act. HR3590, section. 4103. Medicare coverage of annual wellness visit: providing a personalized prevention plan. Available at: http://thomas.loc.gov/cgi-bin/bdquery/z?d111:H.R.3590:#. Accessed February 19, 2011.

2. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Amendment to HR 3590, section 4103, subpart B §410.15 (v). Fed Regist. November 29, 2010;75:73613-73614.

3. Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2003;138:927-937.

4. Valcour VG, Masaki KH, Curb JD, et al. The detection of dementia in the primary care setting. Arch Intern Med. 2000;160:2964-2968.

5. Ganguli M, Rodriguez E, Mulsant B, et al. Detection and management of cognitive impairment in primary care. J Am Geriatr Soc. 2004;52:1668-1675.

6. Chodosh J, Petitti DB, Elliot M, et al. Physician recognition of cognitive impairment: evaluating the need for improvement. J Am Geriatr Soc. 2004;52:1051-1059.

7. Boise L, Neal MB, Kaye J. Dementia assessment in primary care: results from a study in three managed care systems. J Gerontol A Biol Sci Med Sci. 2004;59:M621-M626.

8. Callahan C, Hendrie H, Tierney W. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med. 1995;122:422-429.

9. Boise L, Camicioli R, Morgan DL, et al. Diagnosing dementia: perspectives of primary care physicians. Gerontologist. 1999;39:457-464.

10. Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42:1871-1894.

11. Boise L, Eckstrom E, Fagnan, L. The Rural Older Adult Memory (ROAM) study: a practice-based intervention to improve dementia screening and diagnosis. J Am Board Fam Med. 2010;23:486-498.

12. Brown J, Pengas G, Dawson K, et al. Self administered cognitive screening test for detection of Alzheimer’s disease cross sectional study. BMJ. 2009;338:b2030.-

13. Solomon P, Hirschoff Kelly B, et al. A 7 minute neurocognitive screening battery highly sensitive to Alzheimer’s disease. Arch Neurol. 1998;55:349-355.

14. Borson S, Scanlon J, Brush M, et al. The Mini-Cog: a cognitive vital signs measure for dementia screening. Int J Geriatr Psychiatry. 2000;15:1021-1027.

15. Sevush S, Leve N. Denial of memory deficit in Alzheimer’s disease. Am J Psychiatry. 1993;150:748-751.

16. Lehmann S, Black B, Shore A, et al. Living alone with dementia: lack of awareness adds to functional and cognitive vulnerabilities. Int Psychogeriatr. 2010;22:778-784.

17. Partnership to Fight Chronic Disease. Letter submitted via Internet to Donald Berwick, MD, Administrator; Centers for Medicare and Medicaid Services. Available at: http://www.google.com/url?sa=t&source=web&cd=3&ved=0CCsQFjAC&url=https%3A%2F%2Fwww.thenationalcouncil.org%2Fgalleries%2Fpolicy-file%2FMedicare%2520Wellness%2520visit%2520-%2520final.pdf&ei=W2x_ToCRMuzTiAL1xIi7Aw&usg=AFQjCNFPWOe8s5xD117o0zfwOpZ69rskAw. Accessed February 19, 2011.

18. Galvin JE, Roe CM, Powlishta KK, et al. The AD8, a brief informant interview to detect dementia. Neurology. 2005;65:559-561.

19. Marsh-Richard D, Hatzis E, Mathias C, et al. Adaptive visual analog scales (AVAS): a modifiable software program for the creation, administration, and scoring of visual analog scales. Behav Res Methods. 2009;41:99-106.

20. Keller S, Bann C, Dodd S, et al. Validity of the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer pain. Clin J Pain. 2004;20:309-318.

21. LaStayo P, Larsen S, Smith S, et al. Feasibility and efficacy of eccentric exercise with older cancer survivors. J Geriatr Phys Ther. 2010;33:135-140.

22. Zisapel N, Tarrasch R, Laudon M. A comparison of visual analog scale and categorical ratings in assessing patients’ estimate of sleep quality. In: Lader MH, Cardinali DP, Pandi-Perumal SR, eds. Sleep and Sleep Disorders. New York, NY: Springer Science+Business Media; 2006:220–224.

23. Kindler C, Harms C, Amsler F, et al. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns. Anesth Analg. 2000;90:706-712.

24. Bruce B, Fries JF. The Stanford Health Assessment Questionnaire: dimensions and practical applications. Health Qual Life Outcomes. 2003;1:20.-

25. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”: a practical method for grading cognitive states of patients for the clinician. J Psychiatr Res. 1975;12:189-198.

26. Clionsky M, Clionsky E. Development and validation of the Memory Orientation Screening Test (MOST™): a better screening test for dementia. Am J Alzheimers Dis Other Demen. 2010;25:650-656.

27. Wechsler D. Wechsler Memory Scale–Revised. New York, NY: Psychological Corporation; 1987.

28. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165-173.

29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

30. Morris JC. The Clinical Dementia Rating Scale (CDR): current version and scoring rules. Neurology. 1993;43:2412-2414.

31. NIH Clinical Trials Registry. Further validation of the Memory Orientation Screening Test (MOST): a 5-minute screening test for dementia in primary care practice. Available at: http://clinicaltrials.gov. Identifier NCT01057602. Last updated February 7, 2010. Accessed March 4, 2011.

32. Bradford A, Kunik M, Schulz P, et al. Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors. Alzheimer Dis Assoc Disord. 2009;23:306-314.

33. Pezzotti P, Scalmana S, Mastromattei A, et al. The accuracy of the MMSE in detecting cognitive impairment when administered by general practitioners: a prospective observational study. BMC Fam Pract. 2008;9:29.-

34. Lorentz L. Primary Care Tools for Clinicians: A Compendium of Forms, Questionnaires, and Rating Scales for Everyday Practice. St. Louis, Mo: Elsevier Mosby; 2005.

35. Solomon P, Pendlebury W. Recognition of Alzheimer’s disease: the 7 minute screen. Fam Med. 1998;30:265-271.

36. Peterson R. Mild cognitive impairment. N Engl J Med. 2011;364:2227-2234.

37. Alzheimer’s Association. 2011 Alzheimer’s disease facts and figures. Alzheimers Dement. 2011;7:208-244.

Procedure
An administrative assistant handed each patient and informant the VACS as they checked in at the front desk. We asked them to fill out the questionnaire in the waiting room and advised them not to discuss their ratings with each other. We then conducted a comprehensive neuropsychological evaluation of the patient while another clinician separately interviewed the informant regarding the patient’s current health, cognitive and emotional symptoms, and daily function.

Instruments
The VACS is a 5-item, visual analog scale with parallel forms for patients (VACS-P) and informants (VACS-I). The form instructs the user to “Rate yourself (or the patient with whom you came) in each of these 5 areas by circling a number that best describes how you (they) are doing.” The 5 areas and their descriptions are:

Attention: Keeping focused, avoiding being distracted, completing tasks
Initiation: Starting tasks, following through, staying busy and active
Judgment: Figuring things out and making good decisions
Memory: Remembering new information and how to do things
Self-care: Dressing, bathing, preparing food.

Each area has a visual analog scale of 1 to 10 below it, with each number occupying a box in a continuous sequence. Words appear above some of the numbers to help anchor the ratings in a systematic way: 1=very poor; 4=fair; 7=good; 10=very good.

The MMSE and its properties are well known. The MOST is a 29-point scale comprising 3-word recall, orientation to 6 date-and-time items, unforewarned recall of 12 pictured household items, and an 8-point clock drawing score. The validation study, using a total sample exceeding 1000 patients, demonstrated the MOST correlated highly and significantly (Pearson’s correlation coefficient [r]=0.81; P<.001) with dementia severity and 3 standardized memory tests. At a cutoff score of 18 points, it produced a 0.90 area under the curve (AUC) (95% confidence interval [CI], 0.87-0.94), with a sensitivity of 0.85 and specificity of 0.76, correctly classifying 83% of patients. Test-retest reliability was r≥0.90; P<.001 for both shorter (average 2-month) and longer (average 9-month) intervals.

With each patient, we conducted a diagnostic interview and administered a battery of standardized neuropsychological tests to assess intelligence, attention, executive function, language, and memory. The measures of primary interest for this investigation were the MOST, MMSE, delayed story memory (Wechsler Memory Scale-Revised [WMS-R] Logical Memory-II, or LM-II),²⁷ delayed visual memory (WMS-R Visual Recall-II, or VR-II), delayed recall of a 12-item repeated presentation list of common grocery store items (Shopping List Test-Recall, or SLT-R), and the 15-item Geriatric Depression Scale (GDS-15).²⁸ Additionally, each psychologist made a clinical diagnosis, according to Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] (DSM-IV)²⁹ criteria and rated the patient’s dementia severity (DS) on a 0-to-3 Clinical Dementia Rating-type scale.³⁰ We based diagnoses and severity ratings on age- and education-adjusted neuropsychological test scores, medical and psychiatric history, patient interview, and separate interview with a family informant.

Statistical methods
We calculated VACS totals for each patient and informant. Total VACS scores ranged from 5 to 50. MOST scores, comprising 3-word recall, 6-item orientation, 12-item list memory, and an 8-point clock drawing score, ranged from 0 to 29. We used the MMSE in the traditional method, counting the first error in spelling WORLD backwards, yielding a result of 0 to 30. The GDS score, 0 to 15, reflected the number of items indicating depression. We computed neuropsychological tests using standard scoring techniques. We rated dementia severity as: 0=normal cognition; 0.5=mild cognitive impairment; 1.0=mild dementia; 2.0=moderate dementia; and 3.0=severe dementia. We also assigned half-point ratings from 1 to 3.

We compared MOST, MMSE, VACS-P, and VACS-I scores with dementia severity and the 3 neuropsychological tests of delayed memory and the GDS-15. We computed Pearson’s correlation coefficients and their levels of significance vs 0. Tests of significant differences between correlations used Fisher’s z-transformation and tested the normalized difference vs 0.

Results

Diagnoses and dementia severity levels are listed in TABLE 1. TABLE 2 presents the mean scores for predictor and outcome variables. Correlations and significance ratings between the VACS-P, VACS-I, MOST, and MMSE with the criterion variables of Dementia Severity Rating, LM-II, VR-II, SLT-R, and GDS-15 are shown in TABLE 3.

Patients, on average, rated themselves as having “good” cognition overall. There was no difference in patient self-ratings between the top quartile of dementia severity (mean=34.6; SD= 8.6) and those in the lowest quartile (mean=36.4; SD=9.0). Informants rated the patients, on average, as having only “fair” cognition. Objective neuropsychological tests, however, found the patients, on average, to be mild to moderately demented and to have mild to moderate impairment on objective memory tests. Most patients were not depressed, with an average GDS score well below the clinical cutoff of 7 or more items. However, 30 of the 194 (15.5%) who completed the VACS-P fell into the clinical range for depression.