Tools for Evaluating Alzheimer Disease

Alireza Atri, MD, PhD: I’m going to turn to Mary here. Mary, how do you elicit this information in the clinic, in a busy practice? Are there standardized instruments you like to use to think about daily function, cognition, etcetera?

Mary A. Norman, MD: Absolutely. To your point, in a busy primary care practice, you’ve got a lot of different issues you’re trying to deal with. Oftentimes, cognition is a black box that’s going to take a lot of time, and so it falls to the bottom when that’s not where it belongs. In our practice, we do use multiple standardized instruments that I find incredibly helpful at prioritizing what the goals should be for that visit. I think using something particularly for activities of daily living, and instrumental activities of daily living, there are multiple standardized instruments that are very helpful. And Marc elucidated medication management. You’re going to quickly zero in on, “Hey, I can’t manage hypertension, coronary disease, COPD [chronic obstructive pulmonary disease] unless I’m managing the medications and addressing that cognitive focus first.”

We also use a health risk assessment tool that looks at home safety, driving, other care needs, and other safety concerns you might have in the home. I think that’s a critically important part, and you can quickly zero in on needs that are essential. The Neuropsychiatric Inventory Questionnaire [NPI-Q] for folks whom we know if they have a little bit later or more progressive dementia, which is critical in terms of addressing what’s going to be most important in improving quality of life for both the patient and the caregiver. The Alzheimer’s Association website has a tool kit for the diagnosis of dementia that has links to multiple standardized tools. I think that’s a very important tool for primary care providers.

Alireza Atri, MD, PhD: That’s great. Marc, are there some instruments that are favorites of yours, that always get given; and then I guess some others that are in the tool box that are sometimes given?

Marc E. Agronin, MD: Sure. It’s remarkable, just listening to a survey of all of the different issues we need to address. You need time to cover this, and I think sometimes that’s at a premium in any appointment that someone has. But that time not only to administer different instruments but also just to build a relationship, build rapport with someone. And for me, a mental status examination always starts off with trying to ask someone about some core things about them that they remember, that is going to be enduring, or part of that crystallized intelligence that they have. And that’s a good way for them to form a connection with you and to be more open.

At the same time, instruments are important. Some of the ones that Mary mentioned are good. I would add a few points here. With whichever instrument you use, it’s important that you know it well, and that the individual administering it does it consistently and has had training with it. The perfect example is the Mini-Mental State Examination. You can have 10 different people administering it, and 10 different approaches, and 10 different methods of scoring. And so it makes it difficult to compare it over time, or to really be useful. So no matter who does it in your office, everyone needs to be on the same page.

A cognitive screen like the Mini-Mental or the Montreal Cognitive Assessment are probably the 2 most popular ones, although they are certainly not the only ones that can be used. They allow you to at least get the gestalt of where someone is. You’re not necessarily going to make a diagnosis on those, but having a cognitive screen, having some tracking instrument, is really important in between times when you’re doing more of a full neuropsychological battery, which I know we’re going to talk about. Because at the end of the day, that’s going to be the gold standard.

From the standpoint of psychiatry, I would say that one of the best instruments is the Cornell Scale for Depression in Dementia, because mood changes are ubiquitous across any form of dementia. Just talking to someone at a given time, it can be difficult to fully appreciate what’s going on. The advantage of a scale like the Cornell is that it gives you behavioral changes. You might be asking someone if they feel depressed, what their mood is like, and their subjective report might not always be as accurate as you’d like. But when you have an instrument such as the Cornell, which looks at behaviors like sleep, and appetite, and motor behaviors, these are observable issues that you can see even during the appointment or that the informant can tell you. And then you also bring in informant information, and that’s part of the scoring. It really is ideal from that standpoint. Any instrument that can give you those different elements is going to be a really important part of your tool kit in the clinical setting.

Transcript edited for clarity.