Contributed by: Dennis Fortier, President, Medical Care Corporation________________________________________________
This post starts with a disclosing reminder that I work for Medical Care Corporation, a company focused on developing assessment technologies aimed at helping physicians evaluate patients with memory concerns. As such, I pay close attention to developments in the cognitive testing space.
Two New TestsI have noticed several news items recently on two interesting new instruments: the Five-Word Test (5WT) and the Computer Self Test (CST). A study on the 5WT was
presented in Thessaloniki, Greece at the 25th Annual Conference on Alzheimer's Disease (ADI). Research on the
accuracy of the CST was published in the
Journal of Alzheimer's Disease.These stories are news worthy because Alzheimer's disease is routinely diagnosed at a very late stage of progression when treatment is fairly ineffective. As such, earlier intervention is currently our best opportunity to improve treatment efficacy. Developing brief and accurate assessment technologies for use in primary care settings could facilitate a great advance in standards of care for aging patients with memory concerns.
Daunting Challenge: Ensuring Clinical UtilityThe biggest hurdle is, to make medical, economic and logistical sense, a tool for clinical use must satisfy some daunting criteria that seem to work against one another.
For example, the tool must be highly accurate if used in assisting medical decisions but must also be very brief since primary care physicians are limited in the time they can spend with each patient. The best way to improve accuracy is to add items to a test battery but doing so increases the time requirement for administration which is problematic.
Additionally, the tool must be simple enough to facilitate easy adoption but sophisticated enough to qualify for reimbursement by major insurance payers. This is another challenging trade-off. As we all know, most physician's practices are small businesses and cannot absorb the costs of additional procedures, particularly those that require specialized knowledge and staff training, if they are not paid to conduct these new procedures. All told, developing a clinically effective tool is a tricky and elusive proposition.
Detecting "Dementia" is Too LateThe 5WT and the CST seem to outperform common instruments like the Mini Mental State Exam (MMSA) and the Montreal Cognitive Assessment. Both of these common tests have a purpose but neither has been shown useful in detecting pre-dementia stages of memory loss. Therefore, outperforming them does not necessarily imply clinical utility in detecting subtle memory loss. In fact, the research on the 5WT and the CST was designed to verify accuracy in identifying "dementia".
As we have written here often, dementia is a descriptive term for a fairly severe degree of impairment (a demented person has lost such a degree of mental function that they can no longer care for themselves). Considering this, a tool for identifying dementia does not enable earlier intervention against Alzheimer's disease as, in fact, it is in the dementia stage that primary care physicians are currently intervening. As most physicians will tell you, once a patient is demented, no test is required to determine that something is wrong.
Detecting Mild Cognitive Impairment To improve standards of care, we need tools that separate healthy aging from more subtle stages of memory loss so that physicians can diagnose an earlier stage problem and treat it before it progresses and causes irreparable damage. According to the peer-reviewed medical literature, the most accurate assessment technology suitable for clinical use is the
MCI Screen. It is brief, simple, and accurate in detecting the earliest stages of subtle cognitive decline. And perhaps most importantly, it is reimbursed by Medicare and all major payers.
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