by Cheryl Dawes
The sooner dementia symptoms in older adults are detected, the sooner they can be addressed. However, physicians often fail to recognize the first signs of problems with thinking and memory in their older adult patients.
In a recent study, ADRC researcher Dr. Soo Borson and her colleagues showed how a simple screening tool called the Mini-Cog could be used to improve detection of dementia in primary care settings. The researchers compared the accuracy with which primary care physicians recognized cognitive impairment in their patients and the accuracy of the Mini-Cog in identifying cognitive impairment in those individuals.
“I’m an advocate for routine cognitive screening in primary care for older adults,” says Borson, professor of Psychiatry and Behavioral Sciences. “Screening is a way to increase physicians’ recognition of cognitive impairment, though by itself it doesn’t tell physicians what to do about it.”
Much of Borson’s research is aimed at answering questions that contribute to improving dementia care policy for the world’s aging population. Better detection may lead to better management and outcomes for patients and their families, she notes.
Results of the study, which involved 371 older adults, showed that the Mini-Cog correctly identified cognitive impairment in 83 percent of the group, whereas the physicians correctly identified cognitive impairment in 59 percent.
The Mini-Cog was particularly sensitive at identifying cognitive impairment at its mildest levels. For individuals with very mild dementia or ‘mild cognitive impairment,’ the Mini-Cog recognized impairment in 58 percent, compared with 6 percent recognition by the physicians. In cases of mild dementia, the Mini-Cog was more than twice as sensitive at detection as the physicians—92 percent compared with 41 percent.
The Mini-Cog is a brief screening instrument that consists of a three-item recall of spoken words and a clock-drawing task, explains Borson. She and others developed the screening tool and first published it in 2000. They have since validated the effectiveness of the Mini-Cog to detect cognitive impairment in a range of different older adult populations. The Mini-Cog is scored with a system of points ranging from 0-5. A score in the range of 0-2 indicates a high likelihood of dementia and a score in the range of 3-5 suggests a low likelihood.
Study participants were a sample of older adults enrolled in a multi-ethnic research registry, designed to over-represent ethnic minorities relative to the population of the Pacific Northwest. The participants were recruited through community screening and referrals from social service agencies. None of the participants was referred by their primary care physician, although each had a primary care physician, and gave Dr. Borson’s research team permission to obtain copies of their medical records.
To determine primary care physicians’ recognition of cognitive impairment, Borson and her colleagues conducted an extensive structured review of the medical records provided by each participant’s physician. The researchers systematically examined the records for documentation of suspected or diagnosed symptoms.
Each participant was assessed with the Mini-Cog as well as a more detailed cognitive assessment in his or her primary spoken language. A cognitive history was obtained for each participant by interviewing a family member or close friend. In addition, Dr. Borson’s team completed a detailed medical history and examination for each participant. Diagnoses of dementia and other cognitive problems followed standard research criteria.
The sample population in the study was an expansion of a smaller, but similar sample that Borson studied when developing the Mini-Cog. “We initially developed the Mini-Cog as a tool for screening a population whose symptoms of dementia might be difficult to identify because of differences in language and cultural norms. Existing screens relied heavily on educational backgrounds and language use that do not necessarily apply in a particular population,” says Borson. “Our goal was to develop a screen that was compatible with the current understanding of dementia in Western scientific culture, but that could be applied more broadly.”
The various settings in which the Mini-Cog is being used suggest it does have broad applicability. According to Borson, the American Geriatrics Society has included the Mini-Cog as one of the recommended screening tools in their manual “Geriatrics At Your Fingertips.” It is currently being studied as a screen for delirium risk in hospitals. A Veterans Affairs study found that the Mini-Cog was useful in identifying low health literacy in veterans awaiting surgery. Additionally, a pharmacy-related study used the Mini-Cog to help determine which patients were likely to have difficulties managing medications after hospital discharge.
The results of Borson’s comparison study are published in the International Journal of Geriatric Psychiatry, volume 21, March 2006. Borson’s co-authors on the study are UW researchers James Scanlan, Jill Watanabe, Shin-Ping Tu and Mary Lessig.