MORE THAN 5 million people are living with Alzheimer disease in the US, and that number is expected to rise to nearly 14 million by 2050.1 Alzheimer-related deaths have increased by 89% since 2000, making it the sixth-leading cause of death in the US.1,2 By 2050, Alzheimer disease will cost the US an estimated $1.1 trillion.2

Currently, healthcare professionals are struggling to detect patient memory problems and families touched by Alzheimer disease are struggling to plan for future care, financial matters, advance directives, and support needs. Early identification of cognitive impairment through screening can allow for quicker interventions, potentially facilitating discussions regarding health, financial, and legal decision-making while the patient still retains decision-making capacity.3 This article reviews traditional screening options for patients with Alzheimer disease as well as other forms of dementia and discusses a new computerized screening tool that patients administer themselves.

What is dementia?

Alzheimer disease accounts for 60% to 80% of cases of dementia, a disorder characterized by a decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, or social cognition).1,4 In cases of dementia, these changes lead to a decline in cognitive function that interferes with a person's daily life and the ability to function independently.1 Factors associated with dementia include older age, gene polymorphisms, race and ethnicity, and family history. Age is the most influential risk factor for dementia, which affects 5% of those ages 71 to 79.5 However, dementia is not a natural or inevitable inevitable consequence of aging.6

The Lancet Commission on Dementia Prevention, Intervention, and Care estimates that approximately 35% of dementia cases are attributable to a combination of nine potentially modifiable risk factors:

* low educational attainment

* midlife hypertension

* midlife obesity

* hearing loss

* late-life depression

* diabetes

* physical inactivity

* smoking

* social isolation.5,7

Traditional screening options

Available screening tests for cognitive function include the Mini-Mental State Examination (MMSE), the Mini-Cog test, the Montreal Cognitive Assessment (MoCA), and the Saint Louis University Mental Status exam (SLUMS). The MMSE has been available since 1975 and is the screening tool most widely used today.8

As many as 29% to 76% of people with dementia in primary care are undiagnosed because of inadequate screening.3 Unfortunately, screening is frequently overlooked due to the nurse's lack of knowledge or understanding as well as time constraints during office visits. Only half of all older adults undergo screening and only one in seven patients receives regular assessments.1

The subjective interpretation of cognitive screening tools can lead to false-positive and false-negative dementia classification, which contributes to some agencies reporting insufficient evidence to support screening asymptomatic individuals.9 The US Preventive Services Task Force stated in a report this year that screening instruments adequately detect cognitive impairment, but there is no empirical evidence to suggest that screening for cognitive impairment improves patient or caregiver outcomes or causes harm.3 It may be difficult to identify best practices for screening for cognitive decline, but nonetheless the consistency and feasibility of cognitive screening options need to be addressed.

A new tool

Cognivue was the first computerized testing device to receive marketing approval from the FDA for cognitive assessment in adults age 55 or older. Approved in 2015, Cognivue screening is designed to identify cognitive decline relative to baseline test performance of other age-normal adults and to track patterns or changes in cognitive function over time, allowing providers to refer patients for further testing as needed.10 Cognivue offers two assessment tools for testing cognitive function: a 10-minute assessment (Cognivue Clarity) and a 5-minute assessment (Cognivue Thrive).

To initiate testing, patients enter their name, date of birth, gender, education level, and preferred language. Patients then complete the test independently. Although a non-clinical operator should be available to assist the patient when needed, the computer program administers the 10-minute assessment, which evaluates six cognitive domains: visuospatial, executive function/attention, naming/language, memory, delayed recall, and abstraction. This test presents 10 brain function tests in 10 minutes.

The 5-minute assessment evaluates three cognitive domains: memory, visuospatial, and executive function. The tests measure two speed performance parameters, reaction time and processing speed, and patients are scored based on the timing and accuracy of their responses.10 At completion, a one-page report is generated with a single clinical score for easy interpretation of results.12 Cognivue is not intended to be used alone for diagnostic purposes.11,12

When compared with traditional screening such as the SLUMS exam, the Cognivue scoring system avoided misclassifications of impairment versus no impairment, and demonstrated superior reliability and good psychometric validity.11 Further research is needed to compare Cognivue to other frequently used screening tools, such as the MoCA or the MMSE.

Nursing implications

Nurses need to become comfortable discussing cognitive screening with their patients. Nurses are often at the forefront of setting up screenings, explaining the screening, and then educating patients on the need for follow-up appointments. Nurses are also involved with getting patients set up for the testing and cleaning the machine between uses.

Nurses also inform patients of normal results and set up a provider consultation for those with abnormal results. Nurses should advise the patient to bring a close friend or family member to their consultation appointment to review abnormal results and participate in a discussion about patient and family observations of the cognitive decline.

It would be ideal if nurses received training on detecting mild cognitive impairment (MCI), a stage between normal aging and early dementia, so awareness and early detection could be a priority.13 Those with MCI need to be screened more frequently, possibly every 3 months, to monitor for discrete cognitive changes.13

Early action improves outcomes

Current guidelines suggest that action needs to be taken to improve early detection of cognitive impairments. Screening facilitates early detection, which helps ensure that healthcare providers are doing their part to educate patients about treatment choices and improve patient outcomes.

REFERENCES