Mitchell Clionsky, Ph.D. and Emily Clionsky, M.D. of CNS-Neuro, announced new data supporting the use of screening tests to identify cognitive loss in older Americans. Their study asked two hundred elderly patients and their families to rate how well they think and remember. They found that the patients answers had no relationship to their tested cognitive ability, that the relatives were minimally better, and that doctors should measure cognition rather than asking about it during the Annual Wellness Visit. These findings, published in the November 2011 Journal of Family Practice (http://www.jfponline.com/pages.asp?id=10018), may help doctors decide which of their patients need treatment for memory loss.
The authors, a neuropsychologist and an internist/psychiatrist, asked patients and their loved ones to rate their abilities to pay attention, remember, start new projects, make judgments and care for themselves. They found that patients were unable to accurately determine if they were normal or not. They also discovered that their loved ones, who accompanied them to a cognitive testing appointment, were scarcely better. By contrast, their 5-minute office test, the Memory Orientation Screening Test (MOST) accurately identified these problems and was significantly better at this than a longer test most often used by doctors, the Folstein Mini-Mental State Exam.
This finding is particularly important since, in January 2011, Medicare has encouraged all seniors to have an Annual Wellness Visit. The AWV is a no-copayment office visit in which doctors are asked to identify cognitive impairment, measure depression, take the patients blood pressure, calculate their body mass index, document all current illnesses and list all current medications to formulate a preventive health plan for the next year. Medicare had not instructed doctors how to identify cognitive problems, instead relying on their office observations and reports of patients and family members. But, the findings of this study suggest that such impressionistic data is misleading. Patients deny or overrate their thinking. They tell doctors that they remember all that they need to remember and they give excuses for their memory failures. If doctors take these reports at face value, they will fail to make a diagnosis of dementia in its early stages and will not start memory-stabilizing medications when they are the most likely to be beneficial. In an era when Alzheimers disease and other dementias affect almost 6 million seniors and is increasing every year, this reliance on inaccurate data leads to a failure to diagnose and treat this important condition.
Dr. Mitchell Clionsky, the lead author and experienced neuropsychologist, reports that most of the patients he sees are referred to him fairly late in their illness. By the time they are identified, they may have given away their savings, caused auto accidents, or become unable to live on their own, he notes. Dr. Emily Clionsky, a physician who specializes in treating dementia, knows that when patients with thinking problems are diagnosed earlier she may be able to improve their memory capacity by treating underlying or contributing medical causes. She also finds that starting memory medications earlier in the illness can alter the course and speed of cognitive decline. Earlier diagnosis may make the difference in how long a person can live in the community and when they may need assisted living or nursing home care. From a general medical perspective, knowing how well a person thinks helps the doctor to know if the patient can be trusted to take medications for other conditions or will become confused and end up with a costly hospital stay. Many of my patients are taking five or more medications for other conditions, says Dr. Clionsky. Their poor memories cause them to have problems regulating diabetes and high blood pressure. We also know that dementia leads to falls and fractures, often putting that patient into a rehabilitation unit or a nursing home when that problem might have been averted.
By using the MOST, a medical assistant can spend five minutes with the patient, have the patient perform a few simple tasks, and produce a simple score that tells the doctor if that patients thinking is normal for someone of that age. The doctor can then reassure a patient who is doing well, order additional tests for one who is beginning to decline, and start treatment for one who has had greater losses. The MOST score then becomes part of the patients record and can be repeated to see how that person is doing over time and in response to treatment. When families and doctors have data, they can make the right choices and get better outcomes, according to Dr. Emily Clionsky. This is no different than measuring blood pressure or cholesterol levels. Having the right test leads to ordering the right treatment and improving patient health and independence. Today, with the cost of medical care rising and everyone looking to save money, preventing medication errors and accidental injuries makes sense and saves health care dollars.
The MOST is currently available in paper form and will soon be released as an iPad application. For more information go to http://cns-neuro.com/ .
Clionsky Neuro Systems, based in Springfield, Massachusetts develops, delivers and supports clinically derived diagnostics and treatment protocols for patients at high risk for cognitive loss.
Contact:
Mitchell Clionsky, Ph.D. mitch(at)cns-neuro(dot)com
Emily Clionsky, M.D.
