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The contents of this blog contain topics relevant to end of life care written by our own hospice clinical pharmacists. Continue to check this site regularly for the newest post or subscribe to the RSS feed below.

Dr. Joseph Thomas is a 2013 graduate from Duquesne University Mylan School of Pharmacy. He successfully completed a concentration in the inaugural Pharmaceutical Entrepreneurship program at Duquesne University. Dr. Thomas spent time working as a community pharmacy manager until joining the Delta Care Rx team as a clinical pharmacist in 2015.

Joseph Thomas, PharmD

Cognitive Screening Assessments for Dementia Patients

When it comes to assessing a dementia patient’s cognitive status, there are many different tests that can help determine the patient’s level of impairment. The purpose of these assessments and scales is to help reduce subjectivity in clinical situations. An ideal assessment should have face validity, construct validity, concurrent validity, and inter-rater reliability. Face validity means that clinicians, family members, and patients can agree that the questions are relevant and meaningful. Construct validity means that the assessment accurately tests what it was designed to measure. Concurrent validity means that the assessment can be validated by another gold standard assessment. Inter-rater reliability is when two or more raters can use the same assessment scale and get the same answers.

When it comes to dementia patients, assessments are available to test specifically for function, behavior, and quality of life, but cognition is the coveted characteristic that is attempted to be measured. The most popular cognitive screening test administered is the Mini-Mental State Examination (MMSE). This test is designed to test cognition in areas such as memory, attention, and orientation. It is limited to a low sensitivity to change and it has floor and ceiling effects. Due to copyright enforcement issues surrounding the MMSE, it has started to fall out of favor due to fear of litigation and the Montreal Cognitive Assessment (MOCA) is gaining in popularity due to their promotion of open permission to clinicians to use their assessment without paying for licensing fees or worrying about copyright litigation. The MOCA is a 30 point based assessment and it is more sensitive than the MMSE. It is also useful to assess patients with vascular dementia. It assesses executive function, memory, language, abstraction, orientation, and delayed recall.

The National Hospice and Palliative Care Organization (NHPCO) recommends the Functional Assessment Staging Test (FAST). The FAST scale is designed to evaluate patients when the MMSE cannot reflect changes in a clinically meaningful way and it identifies progressive steps of functional decline. FAST stage 7a is the minimum staging level for hospice enrollment. An assessment used to determine overall dementia severity is the Clinical Dementia Rating (CDR). It is a comprehensive interview based test that assesses memory, orientation, judgement, function, and caregiver burden. Despite being a very useful assessment, one major downside of this assessment is the amount of time it takes to administer.

With many different types of assessments available to clinicians, it is important to select and use a test properly. Many standardized assessments with demonstrated reliability for screening of dementia are available. Clinicians should understand the specifics of an assessment before administering a test. Most tests have training guides to help ensure the correct usage of the assessment. Clinicians should implement the training guides and familiarize themselves with proper administration technique to ensure the validity and reliability of the assessment.


References: 
1. Fast Fact #150. (n.d.). 
2. MoCA Montreal - Cognitive Assessment. (n.d.).
3. Sheehan, B. (2012). Assessment scales in dementia. Therapeutic Advances in Neurological Disorders, 5(6), 349–358.http://doi.org/10.1177/1756285612455733
4. Tsoi KF, Chan JC, Hirai HW, Wong SS, Kwok TY. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(9):1450-1458. doi:10.1001/jamainternmed.2015.2152.

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