Insights About Screening and Assessing for Dementia: Q&A With Teepa Snow

After presenting a recent webinar, Dementia Screening and Assessment: Options and Value, Teepa Snow received many follow-up questions. We’ve featured the questions and her insightful answers here so you can learn more. Her discussion includes some specific assessments, ways to focus on individual strengths, and much more.

Q: Who is an appropriate person to administer the Eight-item Interview to Differentiate Aging and Dementia, or AD8? Can anyone administer it?

A: The AD8 can be given by any trained medical professional.

Q: What are good sources of information on the current state of research?

A: The Alzheimer’s Association has a research page. The National Institute on Aging provides research information as well. McKnight’s Long-Term Care News also provides news and updates.

Q: How do you test someone who might become angry that you are trying to assess them?

A: If someone is very angry that you are assessing them, that can often be a sign that they are experiencing some brain change, and they are anxious about what you might find. However, assessing an individual who is angry or distressed rarely produces accurate results, so it might be best to back off and try again another time.

Q: Should you do these upon admission, or can they be done as baseline for already established residents?

A: Yes. Either or both.

Q: What about a 79-year-old female with recent? ischemic stroke, some memory loss, tearfulness. Screen recommended?

A: I would recommend a depression screen and then a cognitive test such as SLUMS (Saint Louis University Mental Status).

Q: When seniors do the clock, are they looking at the paper?

A: Yes, they draw a clock looking at the paper but preferably not within visual range of a wall clock that they could use as a reference.

Q: What is the importance of family history of dementia?

A: It is always a consideration, but the degree of importance varies widely with the specific type of dementia. For instance, early onset Alzheimer’s is thought to be directly related to genetic factors, while late onset Alzheimer’s development is affected by environmental and lifestyle factors as well as genetics.

Q: Any nutrition recommendations?

A: It is currently believed that a diet rich in fruit, vegetables, whole grains, nuts, fish, and lean proteins help to reduce your risk of developing dementia, while saturated fats, red meat, sugar, and empty carbohydrates increase this risk. Limiting alcohol intake is also important.

Q: So, after this baseline screening or diagnosis from the neurologist, what’s the next recommendation.

A: Once the diagnosis has been made, learning more about the particular type of dementia is recommended, either by reading books, attending classes, or watching videos. Another important step is starting to think about lining up support options, even if they are not needed at that exact time such as support for legal, financial, and health care matters. Joining a support group early on in the process, both for someone living with dementia and those who provide their care, is another option that many find helpful.

Q: Do Parkinson’s and dementia go hand and hand?

A: Yes, many people develop dementia at some point during the disease progression of Parkinson’s. Parkinson’s dementia is thought to be related to Lewy bodies, which are protein deposits found in the nerve cells of people with Parkinson’s disease.

Q: What are your feelings about the Geriatric Depression Scale (GDS)?

A: I personally do not find the GDS to be helpful, as it is quite complex and focuses on what has been lost, rather than what skills abilities still remain. Because of this, I developed my GEMS® States, which is a way of describing brain change that focuses on the abilities that remain.

Q: Is there a Medicare code that covers screening by medical professional?

A: Yes, there is a Medicare code, but reimbursement varies by insurance company.

Q: What is a good assessment to use when someone is already in a dementia unit to monitor further decline?

A: You can use the SLUMS to assess further decline if they are able. However, the animal fluency screen might be a better option as it is much simpler. If they are unable to name animals, you can modify it by showing them pictures of animals and asking them to think of the name. If this is not something they are able to do, then you can show them a picture of an animal and give them two choices and see if they are able to select the correct answer.

Q: How can you tell if there is a change if you don’t have a baseline?

A: If you don’t have a baseline, then you would need to use the standardized numbers for each screen that determine whether or not there is cognitive impairment. For example, for the animal fluency screen, it is generally considered normal for individuals under the age of 65 to be able to name at least 18 animals and for individuals over the age of 65 to be able to name at least 12. Using more than one screening tool is also very helpful in assessment when you do not have a baseline.

Q: Have you ever noticed that grief affects a person’s cognitive functioning?

A: Yes, grief or any sort of stress can have a negative impact on an individual’s cognitive functioning.

Q: With the animal fluency screen, if comparing to a previous normal, how much of a change is considered to be concerning and warrant further assessment?

A: If there is a reduction of three animals or more, this is typically a sign that they are either sick, stressed, tired, or having cognitive changes, and further testing might be a good idea.

Q: Is there any variance by gender of disease progression?

A: There have been several research studies that suggest that women have a faster decline than men, but that likely varies based on the type of dementia and age of onset.

Q: With productivity standards in long-term care, if you are restricted on time, what quick assessment would you recommend as the best indicator?

A: The animal fluency screen is extremely quick, and it is very useful in comparing an individual to themselves over time.

Q: At one time did you say dementia is a symptom versus a “disease”?

A: I believe you may have heard me say that the overall term of dementia is usually considered a syndrome rather than a disease. A disease typically has specific causes and symptoms. A syndrome is a group of symptoms that are more variable and suggest a particular disease process.

Q: Should a person see a neurologist if they suspect someone might have dementia?

A: An individual can certainly start with a screening from their primary care provider, then they and their provider can determine if they would like to pursue further evaluation with a neurologist.

Q: What are your thoughts on the Brief Interview for Mental Status (BIMS)? It is on the Minimum Data Set (MDS) assessment and seems to miss significant problems.

A: I agree that the BIMS is not an ideal screening tool and does tend to miss issues.

Q: When comparing retesting to the baseline assessment, does time of day need to be consistent?

A: This is not absolutely essential but would be ideal.

Q: Which is the most appropriate screen to use on a nursing home resident?

A: The animal fluency test and SLUMS are the two I would typically choose.

Q: Might you be able to list any and other medications that should be avoided that have been associated with dementia?

A: It is generally accepted that being on centrally acting opiates for a long period of time can affect cognitive function in a negative way. Also, they have started to modify the use of Tamoxifen in younger breast cancer patients as they believe it has some cognitive effects. There are similar concerns about the use of estrogen supplements for some women. As far as medications that should be avoided in people who are already living with dementia, Haldol should not be used for those living with Lewy Body dementia. Also, with Lewy Body dementia, antidepressants, anti-anxiety medications, and sleep aids can have strange and paradoxical effects, so should be used with great caution.

Q: Did I miss your discussion on the Self-Administered Gerocognitive Exam (SAGE) and Montreal Cognitive Assessment (MoCA)? Please explain.

A: The SAGE is fairly similar to the SLUMS, and I consider it an effective screening tool. It can be self-administered, which is of interest to some people, or can be administered by someone else. There are four or five different versions, which is helpful because it means that it is harder to become “used to” the test and have an increased score. The MoCA is best for those who have a very high level of baseline intelligence, as it can be frustrating for others who may have a lower baseline cognitive ability.

Q: How related is getting lost while driving? Or walking around town?

A: If someone is getting lost driving in a new area or walking around an unfamiliar town, this can be seen with a normal aging process. However, if someone is getting lost driving or walking around their own town or community where they have lived for several years, then that is a sign that there is likely some cognitive decline.

Q: When (timeframe) should we reassess an individual to compare the results from the assessment tools?

A: Typically, individuals are assessed annually or as needed due to observed status changes. Another tool that can be used when changes are seen is a Cognitive Performance Test (CPT) administered by an occupational therapist, which assesses function in activities of daily living.

Q: Say a 50-year-old did a neuropsychiatric evaluation indicating not early onset Alzheimer’s but “stress,” how long would be recommended to test again?

A: Unless there are further changes or concerns, they could try to reduce their stress levels as much as possible and then retest in a year.

Q: How often can you do the animal fluency?

A: Rechecking every six months to one year is recommended, unless you are noticing significant changes and wish to test sooner.

Q: How do you identify subtle personality changes when working in a large skilled nursing facility (SNF) and you have many patients to see?

A: This can definitely be challenging, but it might be helpful for you to jot down a few notes in a notebook or on your phone when you do happen to notice changes in an individual. If you have an extremely large patient volume, making notes distinguishing characteristics or personality traits of each individual may help, as well.

Q: Any test for helping identify dementia in someone who has severe aphasia?

A: You may use nonverbal aspects of the screening tests such as the clock drawing activity. You may also modify the animal screen by providing them several pictures of animals and the names of the animals and asking them to match them. It will likely be necessary to also rely on observational reports of behavior and ability to complete routine tasks to gain an accurate picture of the individual.

Q: How can we get someone tested when their own doctor dismisses their concerns as “getting older”?

A: If the physician is unwilling to do any sort of screening upon request, even just to have a baseline, then it may be time to look for a different physician.

Q: Is there an easy baseline assessment form to use to admit people into an assisted living memory care unit?

A: The requirements for this vary by state. Many require a medical diagnosis of dementia to be admitted into memory care.

Q: Do you have any recommendations on how to encourage SNFs or Medicare to use something other than the BIMs or Mini-Mental State Exam (MMSE) that is embedded in the MDS?

A: If you are required to use one of these embedded screens, then use them, but you may also wish to administer one or more of the other screens I am recommending. Then, in the comments section, you should list your misgivings about the accuracy of the BIMs or MMSE, and list the other assessments you did and what the results were. If more and more individuals do this, then hopefully, eventually, these systems will begin to change.

Q: Should these assessments being given in a particular sequence? Can any of these be given on their own and still be helpful?

A: The assessments do not necessarily have to be in a certain sequence. You can use any on their own as a tool of assessment, but using more than one will provide a more complete picture.

Q: I am a COVID long hauler and have several times felt as though it’s early onset. Many people in the group I’m in feel this way. Should I be worried?

A: I’m so sorry to hear that you are experiencing this. It is hoped that cognitive function will be regained over time, but there is unfortunately so much that is yet unknown about COVID-19.

Q: I have a client who is noticing some mild memory issues and not remembering people’s names and having trouble doing routine tasks like cleaning the kitchen. Her Dad had Alzheimer’s, and she is 67. There was a mini-cog done, but the evaluator said, “See you in two months.”

A: It sounds as if she definitely has Mild Cognitive Impairment and possibly more, depending on how often she is struggling with routine tasks and how severe this struggle is. For instance, is she not cleaning the kitchen to her normal spotless standard? Or is she genuinely unable to remember how to locate a sponge or use it? If she is really struggling, it may be worth her having another type of assessment or seeing a different evaluator.

Q: What about the (nine-question) Patient Health Questionnaire (PHQ9) with even three words, year, month, day of the week, being asked to recall the three words? I see people get very disturbed with a decrease in mood. What is a better assessment?

A: The PHQ2, which only consists of two questions, has actually shown to be nearly as sensitive at determining depression, and may not trigger as much distress than the longer screenings.

Q: How would you screen a patient with an intellectual disability?

A: There are screening tests specifically developed for individuals with intellectual disabilities such as the Dementia Scale for Down Syndrome (DSDS) and the Dementia Screening Questionnaire for Individuals with Intellectual Disabilities (DSQIID) that you may wish to look into.

Q: When doing the animal fluency, we have to count repeated things and other items the person says are not animals. We can count birds, fish, and reptiles all as animals correct? I just want to make sure we are giving them all the credit they deserve.

A: You do not count repeated animals, or items that are not animals. Yes, birds, fish, and reptiles all would count as animals.

Q: Can I include a baseline assessment when I do the initial intake and assessment?

A: Yes, this is recommended.

Q: Does race or education impact any of the assessments?

Yes, all assessments can be impacted by many various factors. The best way to combat this is to assess early (ideally, before any cognitive issues are noticed) so that a baseline is established, and you can compare the individual’s results to themselves.

Q: Did you discuss mild cognitive impairment (MCI) during first part of discussion?

A: Mild cognitive impairment is the first stage after normal cognitive function, before the more serious decline of dementia. MCI causes relatively mild problems with memory, language, thinking, judgment, or motor skills. It may affect all of these areas or sometimes only one or two. It is typically variable, meaning that the cognitive impairment becomes worse when an individual is sick, tired, or stressed. It is typically not life-altering, but those close to the individual will be able to notice.

Q: Can you say more about risk reduction?

A: To the best of our knowledge, risk reduction components include regular exercise (including aerobic exercise), not smoking, maintaining a healthy weight, eating nutritious foods, limiting alcohol intake, reducing stress, getting adequate sleep, forming social connections, and challenging your brain to try new and different activities.

Q: Is there a major indicator that might signal it is appropriate to introduce medication intervention for behaviors?

A: The first step is to try all other possible methods of intervention and helping to improve their environment and situation. Possibly try more time with care staff or new activities. Try to evaluate for the possibility of undiagnosed pain, and if you think pain may be a possibility, start with the lowest dose of a pain medication that has the least number of potential side effects
for that individual. Also, have their current medication list checked to make certain that something they are taking might not be contributing to the behaviors you are seeing. If you have tried all of these interventions and there are still significant challenges, start with the lowest dose of medication possible.

You can explore more of Snow’s advice on dementia care by listening to her monthly webcast, Ask Teepa Anything!