Do Clinical Tests for Alzheimer's Miss the Highly Educated?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With the forthcoming changes to regulations by National Health Services in the U.K., many Alzheimer's patients who have formerly been denied treatment with cholinesterase inhibitors may soon have the opportunity to benefit from such treatment. With that in mind, a story in today's Telegraph raises an interesting point.

The point is that the Mini Mental State Exam (MMSE), a short test of memory and judgment used by many physicians to detect cognitive problems, is not sensitive enough to distinguish early stage Alzheimer's disease from subtle symptoms associated with normal, healthy aging. As such, many people, particularly those who are highly educated, might continue to pass that test until deep into the progression of a debilitating disease like Alzheimer's. These people, it is argued, would be presumed healthy and neither evaluated further nor treated for any emerging problem. It's a valid point.

The solution is for clinicians to embrace a newer generation of assessment tools suited for a primary care environment. A comprehensive, expert review of such technologies is currently underway through the non-profit organization Prevent AD 2020. A summary of their findings is expected to be published in the Journal of Alzheimer's & Dementia (the journal of the National Alzheimer's Association) early in 2011.

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How to Best Detect Early Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Sometimes, a lot of press coverage is devoted to an interesting misinterpretation of a fact that, once correctly understood, is not nearly as interesting. This is one of those times.

Over the past week, I have seen intense coverage of a story about how friends and family are better at spotting early signs of Alzheimer's dementia compared to traditional tests that a doctor might use. This sounds great until you unpack the headline and understand the facts.

Even Mild Dementia is a Severe State of Health
The problem, as we point out often in this space, is the definition of "dementia". Even mild dementia, which sounds like a subtle condition, is actually a severely impaired state of mental health. To meet the definition of dementia, even mild dementia, a patient must be so impaired that their loss of function interferes with their occupational or social life. Demented people, even mildly demented people, cannot completely care for themselves.

Detecting Dementia does not Require a Test
With this is mind, many experts make the case (and I agree with them), that a test for dementia is not necessary. Dementia is a readily apparent condition that a friend or family member should easily recognize. The fact that doctors still use tests that cannot accurately distinguish between a demented person and a non-demented person is indicative of ineffective clinical practices.

For the record, there are newer, more accurate tests, such as the MCI Screen, that detect dementia with almost perfect accuracy. More importantly, they also identify much earlier and subtler stages of decline known as mild cognitive impairment. However, this current finding from Washington University and published in Brain, compared the ability of friends and family at spotting spot Alzheimer's dementia with the accuracy of "traditional" tests. This is a clear and damming comment about the poor accuracy and minimal utility of the "traditional" test they used for comparison, the Mini-Mental State Exam (MMSE).

In this study, input was collected with an instrument called the AD8, an eight item questionnaire that is completed, on behalf of the patient, by an informant (friend of family member). It was shown to be better at identifying demented patients than the MMSE. That is great news and the AD8 is a non-invasive tool that would be a pragmatic improvement over the MMSE in a primary care setting.

The Bottom Line
I think the most important message, buried in this recent spate of press, is that the traditional tests are not as good as the AD8 at detecting dementia, but detecting dementia doesn't really require a test. To intervene early against Alzheimer's disease, and to reassure healthy patients that their perceived memory decline is not caused by underlying disease, physicians need instruments that accurately detect mild cognitive impairment.

Advances in detecting dementia are not interesting stories, regardless of how much press they get.

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Driving With Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation
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As most physicians will tell you, one of the barriers preventing patients from pro-actively voicing memory concerns is the patients' fear of losing the right to drive. However, the medical system is poorly equipped to assess driving ability and the steps between discussing a cognitive concern with a doctor and losing one's driving license are not as clear or straight forward as most patients would presume.

One the one hand, we all empathize with the natural desire to remain independent and, in the USA, where public transportation is spotty at best, the right to drive is a key enabler of independence. On the other hand, driving is a judgment intensive activity and impaired drivers need to be taken off the roads for everyone's safety.

The reality is that a patient must be severely impaired before actions initiated in the medical system will result in the loss of driving privileges. The American Academy of Neurology recently updated guidelines to help their members better assess driving skills as part of delivering comprehensive care. The new guidelines can be downloaded at their site.

The principle findings of the panel that issued the guidelines were that patients and caregivers are not very reliable sources of information about the patients' driving skills nor are standard neuro-psychological tests like the Mini-Mental State Exam. One of the best indicators that the patient may no longer drive safely is if they admit to having changed driving habits to avoid challenges such as driving in unfamiliar locations or night time driving.

Tests to Identify Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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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 Tests
I 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 Utility
The 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 Late
The 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.