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Department of Health & Human Services, Centers for Medicare & Medicaid ServicesLTSS ResearchCognitive Assessment ToolsDecember 15, 2017

LTSS ResearchCognitive Assessment ToolsContentsIntroduction . 2Cultural Considerations. 2Cognitive Assessment Tools . 2Cognitive Assessment Profiles . 3Mini-Cog . 3Memory Impairment Screen (MIS) . 4General Practitioner Assessment of Cognition (GPCOG) . 4Montreal Cognitive Assessment (MoCA) . 5Saint Louis University Mental Status (SLUMS) . 5Mini-Mental State Examination (MMSE) . 6References . 7This publication was supported by GS-00F-0012S/HHSM-500-2016-00065Gawarded by the Centers of Medicare & Medicaid Services. The opinions,findings, conclusions, and recommendations expressed in this publicationare those of the authors and do not necessarily represent the official positionor policies of the Department of Health and Human Services or the Centers forMedicare & Medicaid Services.1

LTSS ResearchCognitive Assessment ToolsIntroductionAlzheimer’s disease and related dementias (ADRD) are a serious concern in IndianCountry due to the rapid increase of the population over 65 years of age among theAmerican Indian and Alaska Native (AI/AN) population, and health and economicdisparities that put AI/AN’s at higher risk for developing ADRD (Griffin-Pierce et al.,2008). Recent reports suggest that the prevalence of ADRD may be higher in AI/ANthan in other groups (Chen & Panegyres, 2016; Mayeda, Glymour, Quesenberry, &Whitmer, 2016). Additionally, there is a lack of culturally appropriate cognitiveassessment tools to improve detection of cognitive impairments among AI/ANs. Culturaland linguistic diversity among AI/AN communities makes creating a universal cognitiveassessment challenging (Griffin-Pierce et al., 2008).Although efforts have been initiated in other indigenous populations, at present nocognitive assessment tools have been validated for use with AI/AN populations (Jervis& Manson, 2002; LoGiudice, Smith, & Thomas, 2006; Gleason, 2017; Winchester,2017). Until adapted cognitive assessments are developed, clinicians must rely oncultural sensitivity and awareness of the population being served when selectingappropriate methods of monitoring cognitive behavior. This document provides anoverview of cognitive assessment tools and presents six tools that can be adapted foruse in Indian Country.Cultural ConsiderationsUsing a method that is appropriate for the community to screen and test for dementiahelps to reduce an inaccurate assessment due to bias when using cognitiveassessment tools. A health care provider may inaccurately attribute a language barrieras poor cognitive function. Similar misattributions can occur secondary to an individual’slow education level, physical limitations, or cultural differences (Cordell et al., 2013).Considering sociocultural factors or involving family in the process supports theindividual to feel comfortable and perform their best. Caregiver training ensuresconsistent monitoring and awareness of the signs and symptoms of dementia, whichcan be reported to the provider once cognitive ability has diminished or during routinecheck-ins (Gleason, 2017). Further, training in cultural sensitivity and local culturesincreases awareness about an individual’s history and preferred language or practicesthat could otherwise be misinterpreted (Winchester, 2017).Cognitive Assessment ToolsBrief cognitive assessment tools are used to identify cognitive impairments anddetermine whether a full dementia evaluation is needed to assess for a possibledementia syndrome. The assessment results can prompt further testing or be used inconjunction with interview and other observational data to support a clinical diagnosis ofdementia. Providers may use multiple screening tools to effectively assess cognitivefunction or track progress overtime. While there is a consensus that dementiarecognition and diagnosis is valuable, there is currently not a consensusrecommendation for population based screenings for dementia.Importantly, caregivers and family members can contribute to a more accurateassessment of an individual’s cognitive abilities, as they may be aware of subtlechanges. Several cognitive assessment tools include participation from caregivers and2

LTSS ResearchCognitive Assessment Toolsfamily members. For example, the General Practitioner Assessment of Cognition(described in the next section) includes a short interview with a caregiver or familymember.In the next section, highlight commonly used tools based on a 2013 Alzheimer’sAssociation report and interviews conducted with subject matter experts who work inIndian Country (Cordell et al., 2013). These profiles list the tools advantages,disadvantages, and availability in Table 1 through Table 6. The profiles do not representan exhaustive list of available monitoring tools, nor are these tools preferred overothers.Cognitive Assessment ProfilesTable 1. Mini-CogMini-CogThe Mini-Cog cognitive screening test measures short-term recall and clock drawing.Short-term recall is the ability to hold a small amount of information in the mind for ashort period of time. For short-term recall, the patient is asked to listen and repeatthree words and to then recall the words later. For the clock drawing test, the patientis asked to draw a clock. Visual and spatial problems are common early signs ofdementia, and those with dementia will frequently misspace numbers on the clock.Administer time: about 2–4 minutesAdvantages identified by the Alzheimer’s Association: Developed for and validated in primary care and multiple languages/cultureslittle or no education, language, or race biasShort administration timeDisadvantages identified by the Alzheimer’s Association: Use of different word lists for short-term recall test may affect failure rates,depending on familiarity with wordsSome study results based on longer tests with Mini-Cog elements are reviewedindependentlyAvailable at:

LTSS ResearchCognitive Assessment ToolsTable 2. Memory Impairment ScreenMemory Impairment Screen (MIS)MIS measures a four-item recall. The patient is asked to place four words into fourcategories and to then say the words 2 to 3 minutes later.Administer time: about 4 minutesAdvantages identified by the Alzheimer’s Association: Verbal memory test (no writing or drawing)Little or no education biasDisadvantage identified by the Alzheimer’s Association: Does not test working memory, mental flexibility, self-control, or ability toidentify visual and spatial relationshipsAvailable at: custom/mis.pdfTable 3. General Practitioner Assessment of CognitionGeneral Practitioner Assessment of Cognition (GPCOG)The GPCOG cognitive screening tool includes recall and clock drawing. GPCOG alsoincludes a caregiver or family member interview (informant interview) that reviews thepatient’s working memory, mental flexibility, and self-control. Working memory isshort-term memory used to accomplish a task, like remembering a grocery list. Mentalflexibility is being able to switch from thinking about one thing to another.Screening administer time: about 2–5 minutesInformant interview administer time: about 1–3 minutesAdvantages identified by the Alzheimer’s Association: Developed for and validated in primary careInformant component is useful when initial complaint is informant-basedLittle or no education biasDisadvantages identified by the Alzheimer’s Association: Patient component scoring is limited to pass/failInformant component alone has limited accuracyLacks data on any language/culture biasesAvailable at:

LTSS ResearchCognitive Assessment ToolsTable 4. Montreal Cognitive AssessmentMontreal Cognitive Assessment (MoCA)The MoCA cognitive test detects mild cognitive impairment by measuring clockdrawing, working memory, mental flexibility, abstract thinking, and self-control.Administer time: about 10–15 minutes1Advantages identified by the Alzheimer’s Association: Designed to test for mild cognitive impairmentTests visuospatial thinking, naming, memory, attention, language, abstractThinking (categorizing objects), and short-term recallDisadvantages identified by the Alzheimer’s Association: Lacks studies in general practice settingsEducation bias of 12 years or moreLimited use and evidenceAvailable at: stsinstructions/MoCA-Test-English 7 1.pdfTable 5. Saint Louis University Mental StatusSaint Louis University Mental Status (SLUMS)The SLUMS tool is a cognitive test produced by the U.S. Department of VeteransAffairs. It consists of 11 items and measures orientation, short-term memory, andattention and includes a clock drawing test and figure recognition.Administer time: about 7 minutes2Advantages identified by the Alzheimer’s Association No education biasesTests orientation, attention, numeric calculation, recall, verbal fluency,executive function (clock drawing), figure recognition (naming), and recall ofcontextual verbal information (story)Disadvantages identified by the Alzheimer’s Association Limited use and evidenceStudied in U.S. Department of Veterans Affairs geriatric clinic, which workswith largely White male patient populationAvailable urveys/slumsexam 05.pdf1Nasreddine, et al., 20052Tariq et al., 20065

LTSS ResearchCognitive Assessment ToolsTable 6. Mini-Mental State ExaminationMini-Mental State Examination (MMSE)The MMSE cognitive test, introduced in 1975, assesses orientation, word recall,attention, and visuospatial thinking.Administer time: about 10 minutes3Advantages identified by the Alzheimer’s Association Most widely used and studied worldwideOften used as reference for comparative evaluations of other assessmentsRequired for some drug insurance reimbursementsDisadvantages identified by the Alzheimer’s Association Education, age, language, and culture biasCeiling effect (highly educated impaired subjects pass)Must be purchasedMost effective when individual has at least moderate cognitive impairmentAvailable at: et al., 20146

LTSS ResearchCognitive Assessment ToolsReferencesChen, H. Y., & Panegyres, P. K. (2016). The Role of Ethnicity in Alzheimer's Disease:Findings from the C-PATH Online Data Repository. Journal of Alzheimer's Disease,51(2), 515–523. doi:10.3233/JAD-151089Cordell, C., Borson, S., Boustani, M., Chodosh, J., Reuben, D., Verghese, J., . . . Fried, L.(2013). Alzheimer’s Association recommendations for operationalizing the detectionof cognitive impairment during the Medicare Annual Wellness Visit in primary caresetting. Alzheimer's & Dementia, 9, 141-150. doi:10.1016/j.jalz.2012.09.011Ewbank, C. (No Date). Cultural Bias in Memory Screening of American Indian Individuals inArizona. doi:10150/528184Gleason, C. (2017, August). Interview. (I. Kauffman & Associates, Interviewer)Griffin-Pierce, T., Silverberg, N., Connor, D., Jim, M., Peters, J., Kaszniak, A., & Sabbagh,M. N. (2008). Challenges to the recognition and assessment of Alzheimer's diseasein American Indians of the Southwestern United States. Alzheimer's & Dementia:The Journal of the Alzheimer's Association, 4(4), 291-299.doi:10.1016%2Fj.jalz.2007.10.012Jervis, L. L., & & Manson, S. M. (2002). American Indians/Alaska Natives and dementia.Alzheimer's Disease and Associates Disorders, 16(Supplement 2), ice, D., Smith, K., & Thomas, J. (2006). Kimberley Indigenous Cognitive Assessmenttool (KICA): development of a cognitive assessment tool for older indigenousAustralians. Interntational Psychogeriatric, 18, 269–280.doi:10.1017/S1041610205002681Mayeda, E., Glymour, M., Quesenberry, C., & Whitmer, R. (2016). Inequalities in dementiaincidence between six racial and ethnic groups over 14 years. Alzheimer's Dementia,12(3), 216-224. doi:10.1016/j.jalz.2015.12.007Nasreddine, Z., Phillips, N., Bedirian, V., Charbonneau, S., Whitehead, V., Collin, I., . . .Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screeningtool for mild cognitive impairment. Journal of the American Geriatrics Society, 53,695-699. doi:10.1111/j.1532-5415.2005.53221.xPradier, C., Sakarovitch, C., Le Duff, F., Layese, R., Metelkina, A., Anthony, S., . . . Robert,P. (2014). The Mini Mental State Examination at the time of Alzheimer's disease andrelated disorders diagnosis, according to age, education, gender and place ofresidence: A cross-sectional study among the French National Alzheimer Database.PLoS ONE, 9(8). Retrieved from PLoS riq, S., Tumosa, N., Chibnall, J., Perry, M., & JE, M. (2006). Comparison of the SaintLouis University Mental Status Examination and the Mini-Mental State Examinationfor detecting dementia and mild neurocognitive disorder: a pilot study. AmericanJournal of Geriatric Psychiatry, 14, hester, B. (2017, August). Interview. (I. Kauffman & Associates, Interviewer)7

The MoCA cognitive test detects mild cognitive impairment by measuring clock drawing, working memory, mental flexibility, abstract thinking, and self-control. Administer time: about 10–15 minutes. 1. Advantages. identified by the Alzheimer’s Association: • Designed to test for mild cognitive impairment