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This week, I taught the @UCSF IM residents about tools for cognitive assessment in hospitalized patients. For my very first #tweetorial – I’m sharing my pearls with #medtwitter! #FOAM #geriatrics #MedEd 1/
@UCSF Throughout my training, I was taught to use the MoCA (Montreal Cognitive Assessment). But after a few months seeing patients at @VABostonHC, I noticed that most of my patients were getting a score of 21-23. Everyone especially seemed to think this was a hippo. 2/
@UCSF @VABostonHC I wanted to know why! So I looked into the development and validation of the MoCA a bit. Turns out, a cognitive test developed in a mostly white, highly educated, bilingual population (aka the people of Montreal) hasn’t really panned out for use among other groups. 3/
@UCSF @VABostonHC I found one study by @KSinkMD et al, in which out of 414 African Americans WITHOUT dementia, 93.5% scored under 26 – the standard cutoff used to diagnose cognitive impairment.

I stopped used the MoCA after that.

(Image adapted from ncbi.nlm.nih.gov/pubmed/26618003) 4/
@UCSF @VABostonHC @KSinkMD I started using a test developed at the St. Louis VA by @drjohnmorley – the (unfortunately named) SLUMS. It has much better data for patients with varying levels of education. This is now my go-to cognitive test for patients from the US.

slu.edu/medicine/inter…

5/
@UCSF @VABostonHC @KSinkMD @drjohnmorley I like the SLUMS because it’s free, easy to use, tests executive function, and has scoring ranges for mild disease, and varying by education level.

Pro tip: always print out the second page of the PDF with the shapes. Giving the whole thing to the patient is distracting. 6/
@UCSF @VABostonHC @KSinkMD @drjohnmorley What I don’t like about the SLUMS: the story. Every woman I work with who has used it agrees. @drjohnmorley – how about an update? 7/
@UCSF @VABostonHC @KSinkMD @drjohnmorley The SLUMS isn’t my go-to test for non-native English speakers. For those patients, I use the RUDAS (Rowland Universal Dementia Assessment Scale) out of @DementiaAus. Developed in a multi-lingual, multi-ethnic population, and validated in patients with less formal education. 8/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus I like the RUDAS because it’s practical, but I haven’t yet figured out how to administer the “judgment” question despite reading the administration guide. Is the patient allowed to name looking for a crosswalk or a light? If any #dementia experts have tips, send ‘em my way! 9/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus All of these tests are great, but they have limitations in the hospital. #delirium in hospitalized older adults is super common, and under-diagnosed. It’s the brain’s manifestation of acute illness, with many contributing factors. 10/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus In order to diagnose dementia, you have to exclude delirium, to ensure that the patient is in their usual cognitive state. My favorite tool for doing so is the 3D-CAM, by @sharon_inouye and @MarcantonioEd.
ncbi.nlm.nih.gov/pubmed/25329203 11/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus @sharon_inouye @MarcantonioEd You can use the 3D-CAM both to make the initial diagnosis of delirium and to track the patient’s progress day-by-day. It is very fast, but you can make it even faster by skipping questions if the patient answers incorrectly. For example, if they miss 1, you can skip to 4. 12/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus @sharon_inouye @MarcantonioEd But what if your patient is delirious, and you still want to know whether they have dementia? What if they’re in the MRI? Or in a coma? That’s when my absolute favorite tool, the #IQCODE (Informant Questionnaire of Cognitive Decline in the Elderly), comes in handy! 13/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus @sharon_inouye @MarcantonioEd The IQCODE is essentially a structured way of taking a collateral history. It helps you understand both the patient’s cognition and their functional status, all in one handy tool! It’s endorsed by @alzassociation and available for free. rsph.anu.edu.au/research/tools… 14/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus @sharon_inouye @MarcantonioEd @alzassociation I usually ask the informant the questions. My colleague @Geri_IPE suggests handing the sheet to them. I do find that many folks need a lot of redirection when using this test – people get side-tracked with the story of when Mom put the keys in the fridge. 15/
@UCSF @VABostonHC @KSinkMD @drjohnmorley @DementiaAus @sharon_inouye @MarcantonioEd @alzassociation @Geri_IPE So there you have it – some tools to assess your patients’ brains! I’d love to hear your questions and any feedback on improving my tweet-teaching technique. Thanks for your eyeballs! 16/end
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