AGS Alzheimer’s Disease: New Diagnostic Technologies and Treatments Podcast

Evaluation of Cognition and Cognitive Disorder

• American Geriatrics Society • Season 1 • Episode 2

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Join Dr. Michael Harper, Professor of Medicine at the University of California, San Francisco; Dr. Esther Oh, Professor of Medicine, Psychiatry and Behavioral Sciences and Pathology at the Johns Hopkins University School of Medicine and Co-Director, Johns Hopkins Memory and Alzheimer's Treatment Center and; Dr. Mfon E. Umoh, Assistant Professor in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine, as they discuss Evaluation of Cognition and Cognitive Disorder.

To view a transcript click here then select the transcript tab. 

Michael Harper:

Well, hello and welcome. My name is Dr. Michael Harper. I'm a professor of medicine at the University of California, San Francisco, and a geriatrician. And I'm really pleased to be moderating today's podcast, which is part of the American Geriatric Society's new educational curriculum on Alzheimer's disease, new diagnostic technologies and treatments. We put this curriculum together. I'm really delighted over the course of this series, we're gonna have a number of experts talk about various aspects of diagnosing and treating Alzheimer's disease. And we've done this really in the context of this really emerging and changing landscape in Alzheimer's disease diagnosis and treatment. And we've designed this really to support our both experienced clinicians and also our geriatrics fellows, who we think it's important are really able to fully care for folks who are living with cognitive impairment, particularly Alzheimer's disease, and so that they can advise and ultimately provide the best care for them. So today I'm really excited to be speaking with Drs. Esther Oh and Mfon Umoh, the authors of a module entitled Evaluation of Cognition and Cognitive Disorder. So let me just tell you a little bit about each of them and introduce them and welcome them. So first I want to introduce Dr. Esther Oh. She's a geriatrician and a professor of medicine, psychiatry, and behavioral sciences and pathology at Johns Hopkins. She's the co-director of the Johns Hopkins Memory and Alzheimer's Treatment Center. And her research and her clinical work is focused on the sort of Alzheimer's disease and its inner relationship with delirium, biomarkers, and hearing loss. I've known Esther for a long time. We've been colleagues for a long time, and I'm really delighted that she's here with us today. So, Esther, welcome.

Esther Oh:

Thank you.

Michael Harper:

And she's joined by her colleague, Mfon Umoh, who's a geriatrician and an assistant professor at Johns Hopkins. She's also got joint appointments in neurology and psychiatry. She's also a scholar in the Sarah Miller-Colson Center for Innovative Medicine Human Aging Project. And she sees patients in the Johns Hopkins Memory and Alzheimer's Treatment Center along with Dr. Oh. And her research is focused on improving cognitive outcomes for older adults by examining biological and social factors that contribute to cognitive decline. So, Dr. Umoh, welcome. Thanks. Glad to be here. So I'm really excited to talk to you both today. As you know, the better than most, the world is really changed as when we think about Alzheimer's disease. You know, not long ago, you know, the care was really supportive. And while that's still important, we have new emerging technologies, which I think makes the diagnosis and the evaluation of cognition and cognitive disorders all the more important for all clinicians, but particularly for our members. I wanted to ask to start out, given that sort of broader context, what are some sort of overarching key points you think either have changed or haven't changed when we think about evaluating folks who are coming with complaints or being referred for complaints of cognitive problems?

Esther Oh:

So I would say that I've been doing this for many, many years. The changes that I have seen is patients are coming to our clinic at an earlier stages. And I think that really dovetails with the fact that now there are treatments for mild cognitive impairment due to underlying Alzheimer's disease pathology available, both FDA approved and CMS is covering the dose treatment. So when there are some memory concerns and people understand that if earlier intervention or diagnosis is more important, so their family members are encouraging to come to seeing patients in earlier and earlier stages. I would say what is not different is that both the patients and their family members or friends basically still want the same thing, which is that not just be about drugs, but that we take a holistic approach. So they're very much interested in also finding about, well, how about dietary interventions? Uh should I be exercising and what type of exercise? You know, how can I be more supportive of my parents? So I would say there's a lot of conversation around dementia that still rings true, that's uh no different from uh, you know, many years ago.

Michael Harper:

And but do you sort of say it the same way, same way, or do you have any different perspective?

Mfon Umoh:

No, I have a similar perspective in my three years since I started fellowship and uh a couple months since I started on faculty. Um, I think that it's really establishing the goal of why the patient is being seen and what their concerns are. I think that patients and their care partners really want people to work up their concerns. I think maybe what has shifted a little is people just thinking that cognitive decline is a normal part of aging. And so people taking it seriously and seeking care for it. So I think that that hasn't really changed. I think that what has changed more is just what's available now to work it up. Um, and sometimes patients and their care partners can be focused on that, but really need to understand what each tool is doing and how it supports something that has been and still remains a clinical diagnosis.

Michael Harper:

When someone comes to uh, you know, a say a primary care geriatrician or some other primary care clinician who's seeing someone who they're either concerned may have a cognitive problem or they're coming because the individual is concerned or the or a family member or loved ones. How do you sort of think about that early evaluation? What are some things that are you think are most important?

Esther Oh:

Yeah, from my perspective, uh just doing even basic screening, I think it's important. You'd be amazed that we obviously have a tertiary memory center. We get referrals just based on memory complaints without having any even you know, not even a mini cock, so to speak, a very you know, short version of a screening test. So it's some type of objective measurement. But more importantly, what's missing often is and I think it's partly because, especially in earlier stages, most patients are going to their doctors by themselves, so if uh there's no care partners involved who can actually give uh additional information. I think informant history is incredibly important. So even if MOCA is informal, although that's a pretty sensitive test, if there's an informant who says, you know, this change from baseline, this is not how this person was, then you should pay attention. So I think that informant history is incredibly important. And so I would say those are kind of two things. One is having some type of adjective measurement, but making sure that getting the informant history. And I would say if that person is not there, get the permission from the patient and say, hey, would you mind if I just talk to your son or daughter or you know, a friend and just giving them a call and seeing if there's a change and then making a referral to the memory clinic.

Michael Harper:

What are some key questions that you like to ask folks, you know, begin to get a sense of whether or not you're dealing with someone who is experiencing cognitive decline and perhaps dementia?

Mfon Umoh:

Yeah. So for the patient themselves, I like to ask them what things have changed in their day-to-day activities, what things they're not able to do, or what things they're limited by, because sometimes people kind of have a concern about changes in their memory where they're like thinking when I was 20, but you know, nothing has changed in the last one year. So getting a context of what someone means by kind of having a memory concern. And then from the informant, I really like to sort of take a structured review of systems where you know what things have changed in terms of the individual's thinking, what things have changed in terms of their activities of daily living that they're doing either independently or needing assistance with or completely dependent in. What things have they noticed in terms of changes in behavior or newer psychiatric symptoms that they've noticed in the patient? And then any changes in things like sensory concerns or motor concerns that could, you know, kind of put together a picture of what's going on. Because when we think about cognitive decline, it's so broad or memory decline, you know, so sort of honing in on exactly what that means and how the individual is different now compared to prior.

Michael Harper:

I I know this is sort of basic, but once you've sort of done this initial evaluation, you've done your early on objective testing, at least that you can do sort of, you know, in a quick office-based assessment. What are the things that make you think, oh, I think this person actually may be living with dementia?

Mfon Umoh:

So when we think about dementia, that's when we have cognitive or behavioral symptoms, and it's interfering with an individual's ability to do their day-to-day usual activities, and it represents a decline from prior. Um, and it's not explained by anything sort of acute like delirium or a psychiatric disorder. So that's kind of how we sort of define dementia. And when we think about that, that's more sort of a clinical syndrome, and then we're trying to identify what actual disease might be leading to it. And so there's some additional workup, which Dr. Oh can talk about since she had a recent amazing review on Annals that goes through that. Um, but I think really differentiating how this is a decline from prior and what it's interfering with to delineate it as dementia. And I also like to go over with my patients and families what mild cognitive impairment is versus dementia, because those terms are sort of thrown around a lot, and sometimes uh patients and families don't understand that completely. And sometimes people put mild cognitive impairment in the record, though that's not exactly what's going on because it seems a little bit maybe quote unquote nicer than dementia. And so when we think about mild cognitive impairment versus dementia, mild cognitive impairment is where those changes are present, but they're really not interfering with an individual's ability to function due to their usual activities. And so when that changes, that's sort of the change into dementia. And I think normalizing what those terms are for patients and families is really important because one seems scarier than the other, but they're all sort of part of this continuum that we know of.

Michael Harper:

And and Esther, so we've made this diagnosis of dementia, and particularly in the context of as we're thinking about Alzheimer's disease, how do we now determine if this person has met those criteria if they actually have Alzheimer's disease, at least on a clinical basis?

Esther Oh:

Yeah, so obviously, you know, we would done the basic workup to one, rule out uh reversible causes. The other would be, you know, if somebody obviously had a large stroke and that they now have cognitive impairment, um, and that's an acute in presentation, you know, that might be more vascular. So if you've kind of ruled out a lot of other diseases, you know, you have Alzheimer disease, at least that's the way we used to do them. Now I know there's a separate um, you know, module on biomarkers, but here uh we're um at least the memory clinic, and I know that primary care physicians becoming more familiar with it as well will be using uh what we call Alzheimer disease biomarkers. Um I do I do want to be careful in saying that it's Alzheimer disease biomarkers. In fact, you know, um there are many different types. Uh there are sensitivity and specificities are different. But in essence, what we're trying to do is is there um uh basically a protein burden that we can quantify or correlate by taking a blood test? There's other things that we can do in terms of biomarkers, but I would say that's the most common one being uh utilized at this point. And for now, um, if I've done all the workup and it does really look like Alzheimer disease, one thing that I might do is actually the blood test for Alzheimer's disease, uh, see if it correlates with, you know, basically having um a high amyloid burden in the brain.

Michael Harper:

Yeah, I appreciate that. I was curious about the the clinical criteria, these sort of NIA Alzheimer's Association clinical criteria. Are they are they valuable? Are they useful? And and if so, could you share what your thoughts are about them and how to use them?

Mfon Umoh:

So the NIA and the Alzheimer's Association have these core diagnostic criteria, which we explain in the module for when an individual would meet uh criteria for dementia, and they kind of go over dementia as a whole, and then what would meet more specific criteria for a probable Alzheimer's disease dementia in terms of what are those kind of cognitive domains that are impacted, whether the presentation is like an amnestic presentation, meaning that it's mostly sort of the memory domains or other non-amnestic presentations, like a language uh presentation or a presentation visual executive spatial functions in the individual. And so they have that, and I think it is uh beneficial to understand those and to go through it because um, like we shared earlier, dementia is this umbrella term, and there can be many ways that lead to dementia, and so um understanding what presentations are common in terms of an Alzheimer's disease dementia is is is very important. Um, they also have criteria on MCI due to Alzheimer's disease, um, which are really important because there's supportive criteria in terms of, you know, that the decline has been sort of a longitudinal decline, and there are things that you exclude to go down the Alzheimer's path, like Dr. Oh just mentioned. Um, and then there are other things that kind of raise your suspicion, your clinical suspicion that this is going on, like if they have a family history of Alzheimer's disease, or there's other genetic factors that that raise that likelihood. And so with the clinical criteria and some of the biomarker tests that Dr. Oh mentioned, your likelihood of that this condition is due to Alzheimer's disease can change based on um sort of the results from the biomarker data and also the uh clinical criteria. So I think it is helpful to run through that.

Esther Oh:

May I just mention that it's a very fluid transitional stage at this point. So Alzheimer's Association does have a new diagnostic criteria they have put out. I will not be going into um details about that, but I think it's fair to say that in the next one or two years, we'll kind of know, you know, which diagnostic criteria will be adopted. Uh so uh please stay tuned.

Michael Harper:

Just to follow up, the you know, I think in the era before biomarkers, we relied on obviously clinical diagnosis to make the diagnosis of Alzheimer's disease. Are they still how reliable are they? In other words, if you meet the criteria for probable Alzheimer's disease, how well does that correlate with pathology post-mortem, for example?

Esther Oh:

So it depends on obviously who's making the diagnosis. And so in experienced hands, um, I think that has uh the sensitivity and the correlations have been very high. But I think I just want to step back and for the listeners of the podcast to understand, and I think most geriatricians understand this is that when we're really talking about most of the older adults that we're helping and seeing in our clinics, it's really the mixed dementia. So we're talking about Alzheimer's disease, we're talking about amyloid proteins or you know, phosphorylated how biomarkers of Alzheimer's disease. But in fact, when we're really you know talking about it, it's Alzheimer's disease, and there's many other pathologies that's occurring in um you know an individual's brain that um some we can actually quantify, some we can visualize through MRI, but many that we probably don't understand at this point.

Michael Harper:

Yeah, that's a good point to make. Thank you. Um you in in your presentation, your slide presentation, you described the quick dementia rating scale. I wonder if you could share with us how you use it and what role it plays in your evaluation when you're seeing patients.

Mfon Umoh:

So when we think about dementia, there are different stages of dementia that we consider um early, middle, late, which we term mild, moderate, and severe. Um, and uh like Dr. Oh said, you know, there are a variety of uh diseases that can you know lead to a syndrome of dementia and they can progress at different rates. But understanding where the patient is is really important for planning for them and their care partner and making sure that individuals are safe doing sort of the activities of daily living that they are doing, you know. So there's one thing where a patient will say, you know, the things they're doing, but you might notice maybe they're not doing things as well, or you know, it might be a safety issue in terms of managing uh medications on their own where they're still doing it, but maybe not having the ability to. And so the quick dementia rating scale is one of multiple available scales where you can sort of do a quick assessment of what the patient is doing individually, what they're needing assistance with, and that can sort of clue you in on where, in terms of the severity, they're they are at. Um, again, it is a screening sort of scale questionnaire for the quick dementia rating scale. It's um uh 10 questions, and the a knowledgeable informant uh rates it, and then you sort of tally up the questions which divide out by uh behavioral symptoms and cognitive symptoms, and depending on sort of where they score, you have a sense of whether they're more in the mild cognitive impairment range or that mild dementia moderate, severe. Um, and again, this is sort of just an assessment of how they're doing in terms of those daily activities. Um, and it can indicate a variety of dementias, but you get a sense of where they are in terms of the stage.

Michael Harper:

Sort of following up on that, Esther, that you also mentioned the importance of these sort of an objective sort of screening tool in your presentation. You had you gave some a list of some. What are some ones if you again you're a busy clinician seeing lots of folks? What what are sort of your favorites for or that you'd recommend for the busy clinician in terms of a screening tool for cognitive decline?

Esther Oh:

Yeah, so um once again, uh just a quick reminder that I work at the memory clinic. So the test that we utilize the most is MOCA. Now we do find that it's obviously good for picking up executive as a function. But if you're familiar with MMSE, you know, that's something that definitely you can use as well. Many people use that during the annual wellness visit for uh Medicare purposes. So I do see that uh when the primary care physicians uh send some patients to us. So it's whatever you feel comfortable with, I would say that's important. One thing about the self-administer, you know, tests really quickly. So uh Dr. Lima just mentioned the the quick dementia rating system. So the really one of the more difficult things to do is is this more kind of impairment or is this more the dementia stage? And so that's where the PDR can be a very useful tool. And if it's objective, it is designed to be self-administered. So if a patient or the caregiver, especially our uh you know, waiting in your waiting area, you can just quickly give the form to the caregiver and they can you know fill this out with it. From our experience, what we find is that caregivers tend to underscore. So if you have someone who can assist you and actually ask the questions to the caregiver, it always tends to be higher or worse. So when they're rating it, as it was really designed, then they do tend to underscore, meaning they tend to score it more in the milder range. So that's just the you know, little um tips and tricks to just kind of remember.

Michael Harper:

I wanted to also ask, you know, you've now you've described this a little bit, but uh you have a really nice algorithm in your in your slide presentation. What are some what are some steps folks should follow in terms of that? Again, thinking about it before the referral, I'm gonna ask you later about when you think we should refer folks to specialists like yourselves. But again, someone seeing someone in their primary care office, what are some key steps of that algorithm that you think that primary care clinicians can can do prior to a referral?

Esther Oh:

Yeah, so definitely um I would say um history and physical. Um, I always tell my patients, well, because they're always looking for fancy tests. And I say, well, still I would say by the time you know I see you today take history, you know, do a physical exam. I have about 80% of the data that I need. You know, I said if I have 1,000 piece puzzle, I have about 800. And I'm gonna order some additional tests to kind of fill in to have a more clear picture. For primary care providers, I would recommend definitely obviously history and physical, some basic labs that you know that we list in the um module. Most people do um MRI unless there's a contraindication. And nowadays, even in the community radiology centers, you can actually get some volumetric studies done. Um I won't name like brand names, but there are programs that uh radiology centers can actually run to do volumetric assessment. So meaning um is your brain volume or the hippocampal volume, is that how does that, is that like a one percentile, so like smaller on the smaller slide or average slide or a larger slide? And that can be kind of helpful and if it's really um, you know, uh just a really no additional time added to the thing. So those are things that you can do. There's like a lot of controversy. I know it's going to be covered in different modules about whether primary care providers should be ordering blood-based biomarkers or not, or other biomarkers for that matter. And I would say the jury is still out there. Um if you have a panel of large uh patients, you know, large panel of patients who have, you know, cognitive impairment and you're used to using it, I think, you know, I can foresee people you see, um, you know, think that that's okay. Um, but if it's um just one-off or you don't really, this is not, you know, a big part of your practice, then there might be some problems with the interpretation. So I think uh that is a plus minus. And maybe Dr. Uma can add some to it as well.

Mfon Umoh:

Yeah, no, I completely agree. I think that another thing we highlighted in the module is, you know, once you've done sort of that cognitive assessment, um, and Dr. Oh spoke about this earlier, you know, there might be some people who still are within that quote-unquote normal category, but this is a change from their baseline. So considering neuropsychological testing for those individuals might be really helpful and beneficial if that's available in your setting. And then another thing that I think is important in that algorithm for individuals where you've started this workup and it's normal is you know, reassessing. So when we think about dementia and it's being due to neurodegenerative conditions, they're usually progressive, so things change over time. So you might be very early on and not picking up anything, but really following up and and and uh checking in with patients and their care partners about changes is really important in this condition.

Michael Harper:

You also described the importance that you should talk to the patient and their partners about their goals. Talk a little bit about why you think why you see that as so important.

Mfon Umoh:

I can start. Um, I think that whenever anything we do in medicine, especially geriatric medicine, we think about what matters most to the patients and their care partners, and really setting a goal for the evaluation of what they're hoping to come is really important, especially now that um patients and families are bombarded with commercials and um you know overwhelming amounts of information saying that we have a cure for Alzheimer's disease, which we don't have a cure for Alzheimer's disease, there are new treatments for Alzheimer's disease. I think there's a lot of confusion, and so understanding what patients' goals are with with working up their concerns, and then also so that we don't assume, you know, what people want. Um, you know, there are a lot of challenges with caring for an individual that has Alzheimer's disease dementia, and so um understanding what the goals that the patient and their care partner has set is really helpful so that you can meet those goals and communicating also with them about what you're identifying and what you're picking up. You know, I think we see a lot of patients at the memory clinic, and not everyone has had a cognitive screen, but some have with their primary care provider, and a lot of times they mention, you know, no one ever told me what the results of that were. So just communicating back um, you know, whatever we are identifying and what we're concerned about, because oftentimes patients and their care partners are concerned as well. And so just keeping the communication open.

Esther Oh:

May I just follow up with that just really quickly? That's one of the reasons why I don't just hack on, let's say, a blood-based biomarker as part of, you know, just a laboratory test that I order automatically, like, you know, with let's order, you know, CBC, you know, TSH, and then you know, blood-based biomarker. I always pause because one, it being a memory clinic, very few patients actually come willingly if they're uh actually being brought by their family members. So one, identifying what does the patient want if they can really express themselves, and two, they have to live with the results of that test. You know, it's easy for me to order the test. And so I really describe the test really, you know, um, really in detail. And I can tell you that when I do that, many people would say, you know, I would actually like to think about this. I want to go home and talk about it. And when they're ready to receive that result is when I'm gonna order it. And some people actually never want to know.

Michael Harper:

My last question, um, as memory care specialists, you are clearly a limited and resource. So uh again, thinking as a primary care clinician, what are the kind of folks that we should be thinking about that we should refer to folks like you?

Mfon Umoh:

Yeah, I think that once the evaluation has been sort of started and completed and there's anything atypical or whether there's uncertainty, just like any other type of you know, medicine, it's all collaboration with consultants and figuring out sort of what's next. Um, we talked a lot about the um new therapeutics for people earlier in the disease course, and so people with um early um early features, if there's the goal discussed that they are interested in um additional therapeutics, I think that would be a good time to um refer. Um we also didn't talk much about some other forms of dementia that can be rapidly progressive or atypical. So if that is identified on that initial workup, I think that that's sort of beyond the scope of what someone would anticipate someone in primary care would be managing. So just getting additional help there. But I think what we want to also really stress is that since these new medications for Alzheimer's disease are available, if there is someone who would be a potential candidate and that's within their goals for uh these new therapies, getting them to uh a referral or a place that is able to deliver those is really important, and I think part of what primary care providers need to uh think about now, um much different than before when you know I think the the general sort of consensus was if we don't have anything we can do, then why work it up or refer? Um and I think that as that's changing, our practices for referral should change as well.

Esther Oh:

Um just one more thing I would say is that um although um a lot of us have focused on new therapies and you actually counsel the patients and the family members, many of them don't want the medication. Um, and actually many don't qualify when you go through the inclusion-exclusion criteria. And so we also serve people who are more in the moderate to advanced stages of dementia who come in with neuropsychiatric symptoms. And that's where I think we can be very um useful and helpful uh with the primary care providers who need additional help in uh managing symptomatology of dementia.

Michael Harper:

Well, Drs. Oh and Dr. Umoh, I want to thank you both for joining me uh today to share your wisdom and experience. Um it's interesting to me that we continue to have to always go back to the basics when it comes to our care, and nothing has really changed in that regard. Uh we still have to be able to take a good history and a good physical and be able to talk to informants and get that good history before we embark on the rest of that evaluation. So, sharing, thank you for confirming that for us, but also sharing some of the additional changes that we need to think about in this new thank you, and I appreciate it. Enjoy the rest of your day.

Esther Oh:

Yeah, thank you for having us. Thanks. Bye bye.