Incorporate Screenings into Practices

There are more than 5 million americans aged 65 and older living with Alzheimer disease, with the number expected to triple by 2050, according to the Alzheimer’s Association.¹

The World Health Organization estimates that about 50 million individuals have dementia worldwide, and the most common form is Alzheimer disease.² However, a recent report suggests that 50% of primary care physicians may not be prepared to handle the increasing number of people with the disease.¹ Evidence shows that cognitive health screenings can be successfully incorporated into community pharmacy practices and can help identify at-risk patients for physician referrals.^3,4 Because pharmacists are extremely accessible health care professionals, they can play an integral role in performing cognitive health screenings.

The US Preventive Services Task Force recently issued a controversial statement that there is insufficient evidence to determine the benefits and risks of screening for cognitive impairment in adults age 65 years and older.⁵ However, screenings can help identify patients with cognitive issues and those with drug-induced dementia caused by anticholinergic drugs, benzodiazepines, corticosteroids, opioids, or vitamin deficiencies such as vitamin B12. The American Academy of Neurology recommends that all patients aged 65 and older receive an annual cog- nitive health assessment.⁶

There are a variety of cognitive health screening tests that can be integrated into the community pharmacy setting to assess for mild cognitive impairment. However, these cannot assess the cause of cognitive decline, so further testing is important to address the issue and diagnose the condition. The Mini-Cog is a 3-minute screening that consists of a 3-item recall test for memory and a simply scored clock drawing test.⁷ Patients should be instructed to listen carefully and remember 3 unrelated words and repeat them back now and later. Next, the patient should be asked to draw a clock with numbers in a circle that is already drawn and set the hands to 10 past 11. The last step is to ask the patient to recall the 3 words that were given in the beginning of the test. One point is given for each word recalled correctly without cues (maximum score 3) and 2 points for a normal clock (all numbers written once clockwise with 2 hands correctly positioned) or 0 for an abnormal clock drawing. A total score of 3, 4, or 5 indicates a lower likelihood of dementia, but it does not rule out cognitive impairment.⁷

The Montreal Cognitive Assessment (MoCA) is a brief 30-question test that was first validated in 2000, and it is widely available in almost 200 countries in an application or paper format.⁸ The MoCA has a sensitivity of 90% for detecting mild cognitive impairment, and the test assesses attention, concentration, executive functions, language, orientation to place and time, short-term memory, visuospatial abilities, and working memory. Training and certification have been mandatory since September 1, 2019. The test has also been validated for remote testing through various platforms including FaceTime, Skype, and teleconference, which is especially useful during the coronavirus disease 2019 (COVID-19) pandemic. Score ranges describe the degree of cognitive impairment: 18 to 25: mild cognitive impairment; 10 to 17: moderate cognitive impairment; less than 10: severe cognitive impairment.⁸

The Mini-Mental State Exam (MMSE), developed in 1975, takes about 10 minutes to administer and assesses a variety of cognitive domains.⁹ The maximum MMSE score is 30 points. The following scores indicate the degree of cognitive impairment: 20 to 24: mild dementia; 13 to 20: moderate dementia; 12 or less: severe dementia. Individuals with Alzheimer disease typically have an MMSE score that decreases about 2 to 4 points each year.⁹

Cognivue is a computerized screening cleared by the United States Food and Drug Administration that assesses cognitive function, and it is available as 3 different products.¹⁰ Cognitive Clarity is a 10-minute self-administered test that can be done in a medical facility. The device, which weighs less than 8 lb and folds up like a laptop, evaluates 6 cognitive domains: abstraction, delayed recall, executive function/attention, language/naming, memory, and visuospatial.

The clinical scoring is 75 or greater: normal cognitive function; 51 to 74: low cognitive impairment; 50 or less: moderate to severe cognitive impairment. Cognivue Thrive is a 5-minute self-ad- ministered screening that can be implemented in the pharmacy setting, and the device is also easily folded and can be transported to different areas of an ambulatory care setting or community pharmacy. Cognivue Thrive evaluates executive function, memory, and visuospatial, and includes a report, with scores for 3 cognitive domains, and a letter that can be shared with the patient’s health care provider. Cognivue Advanced is a 10-minute self-administered test that evaluates 6 cognitive domains, along with reaction time and speed processing, and it includes a patient and physician report.¹⁰

Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and Pharmacy Times® contributor who resides in South Florida.

REFERENCES

• Primary care physicians on the front lines of diagnosing and providing Alzheimer’s and dementia care: half say medical profession not prepared to meet expected increase in demands. Alzheimer’s Association. March 11, 2020. Accessed September 28, 2020. https://www.alz.org/news/2020/primary-care-physicians-on-the-front-lines-of-diag
• Dementia. World Health Organization. September 21, 2020. Accessed September 28, 2020. https://www.who.int/news-room/fact-sheets/detail/dementia
• Rickles NM, Skelton JB, Davis J, Hopson J. Cognitive memory screening and referral program in community pharmacies in the United States. Int J Clin Pharm. 2014; 36(2):360-367. doi:10.1007/s11096-013-9904-7
• Breslow RM. Patient attitudes regarding pharmacist-administered memory screen- ing in community pharmacies. J Am Pharm Assoc. 2013;53(6):648-651. doi:10.1331/ JAPhA.2013.12227
• Owens DK, Davidson KW, Krist AH, et al. Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendations statement. JAMA. 2020;323(8):757-763. doi:10.1001/jama.2020.0435
• Foster NL, Bondi MW, Das R, et al. Quality improvement in neurology: mild cognitive impairment quality measurement set. Neurology. 2019;93(16):705-713. doi:10.1212/WNL.0000000000008259
• Screening for cognitive impairment in older adults. Mini-Cog. Accessed September 28, 2020. https://mini-cog.com/
• FAQ. MoCA Montreal Cognitive Assessment. Accessed September 28, 2020. https://www.mocatest.org/faq/
• Medical tests. Alzheimer’s Association. Accessed September 28, 2020. https:// www.alz.org/alzheimers-dementia/diagnosis/medical_tests
• Community pharmacy is ideally positioned to provide cognitive screenings to consumers. Cognivue. Accessed September 29, 2020. https://www.cognivue.com/ customers/community-pharmacy/