● Visuospatial/executive functioning tasks, consisting of an abbreviated alternating trail-making test (linking 1 to A to 2 to B . . .), copying a cube, and the clock drawing test. ● Naming three animals from pictures. ● Memory task with five words requiring immediate and 5-minute delayed recall. ● Attention tasks, including repeating a list of numbers (5 digits) and repeating a list of numbers in reverse order (3 digits), responding to a specific letter in a list of letters, and serial seven subtractions. ● Language tasks, including repetition of two sentences and fluency assessment of naming words in a category. ● Abstraction assessment requires the identification of similarities between words. ● Orientation assessment includes date, month, year, day, place, and city. The MoCA is readily available (MoCA: Montreal Cognitive Assessment, 2018), and it is becoming more widely used in clinics and research, likely due to relatively recent copyright limitations on the MMSE that have made its use more restricted over the past several years. The suggested cutoff score of ≥ 26 out of a total possible score of 30 delineates normal cognitive function from possible MCI or dementia (Nasreddine et al., 2005). Positive screens for dementia using rapid assessment tools such as the MMSE, Mini-Cog Assessment, or MoCA are suggestive of the need for further testing and do not constitute a diagnosis of dementia or neurocognitive disorder. Once diagnosed with dementia, there are different staging tools that can be used to determine an individual’s cognitive and/or functional level. The Global Deterioration Scale (GDS; Reisberg, Ferris, de Leon, & Crook, 1982) or the Brief Cognitive Rating Scale (BCRS; Reisberg & Ferris, 1988) may be used to classify the stage of dementia based on a prescribed set of clinical characteristics. Both of these tools are based on Reisberg’s seven-stage model described earlier and are clinically friendly for use. The Clinical Dementia Rating (CDR; Morris, 1993) scale is widely used as a staging tool in research but the time required for administration prohibits its use clinically. The CDR is a tool that utilizes information from both the caregiver and patient to determine the level of impairment in memory and orientation, judgment and problem solving, and functioning in self-care, home, and community activities. Scores range from 0 (no impairment) to 3 (severe impairment). Many factors complicate the diagnosis of AD. The disease may go unrecognized because of the common assumption that changes in memory and other cognitive symptoms are part of the normal aging process. The hallmark diagnostic criterion for dementia is that memory, cognitive, or language impairment are significant enough to interfere with daily life functions. In some cases, people may experience MCI, problems with memory, language, or another mental function severe enough to be noticeable to other people and to show up on tests, but not serious enough to interfere with daily life. Studies have demonstrated that 22% to 33% of individuals diagnosed with MCI go on to develop dementia over the ensuing 3 to 5 years (Britt et al., 2011; Kaduszkiewicz et al., 2014).
neuropsychological testing to determine a true diagnosis of dementia. Cultural and language barriers can impact performance on these tests. The MMSE (Folstein, Folstein, & McHugh, 1975) is a widely employed screening tool that has been used extensively in research studies with individuals who have dementia to provide some objective classification of the cognitive status of participants. The tool assesses orientation, registration/ repetition, attention/calculation, recall, and language. Specific questions include: ● Orientation to time (year, season, date, day, month). ● Orientation to place (state, county, town, hospital or building, floor). ● Registration and immediate repetition of three unrelated items. ● Recall memory of three unrelated items after delay and distraction. ● Serial subtraction of 7 from 100, or correct spelling of a five- letter word backwards. ● Naming of visualized objects. ● Following a three-part instruction. The MMSE generally takes about 10 minutes to complete, and respondents receive a point for each correct response for a maximum score of 30. A cutoff score of 24 or 25 is often cited in the literature as consistent with dementia (Creavin, 2016), although a higher cutoff score (27 or greater) has been identified as the optimal sensitivity/specificity balance to delineate no cognitive impairment from MCI for college educated people (O’Bryant et al., 2008). The specific cutoffs to delineate mild from moderate or moderate from severe impairment are often operationally defined in specific studies. The Mini-Cog Assessment involves remembering three items and completing a clock drawing test (CDT; Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000). The CDT entails drawing the face of a clock in a provided circle, including numbers and hands indicating a specified time (“ten past eleven”). While seemingly simple, the CDT is a measure of memory, strategy, vision, and processing of information, and it also serves as a recall distractor to the three uncued items that are shared prior to the CDT. Instructions to draw the clock showing the designated time can be repeated, and individuals are given as much time as needed for the drawing. The CDT is “normal” if all numbers are present in the correct sequence and position and if the hands accurately display the requested time. After completion of the CDT, the person is asked to recall the three items. A recall of all three items (regardless of the CDT outcome), or a recall of one or two items and a normal CDT drawing, indicate a negative screen for dementia. A recall of zero items, or a recall of one or two items with an abnormal CDT, is a positive screen for dementia. The MoCA was developed as a quick way for primary care physicians to screen for MCI (Nasreddine et al., 2005). The most recent version of the tool consists of: ● Writing a sentence. ● Copying a figure. Pharmacology Despite recent encouraging progress with respect to understanding the pathology of AD, there is no cure and no effective treatment for the disease. There are some medications approved for management of AD symptoms; but pharmacological management has proven to be disappointing. The goals of maintaining cognitive functioning, slowing functional decline, and effectively managing disabling symptoms have been elusive. Currently, the U.S. Food and Drug Administration (FDA) has approved five medications for the treatment of AD symptoms. The medications represent two different families of drugs with different mechanisms of action.
MEDICAL MANAGEMENT OF ALZHEIMER’S DISEASE
Three of the approved medications are acetylcholinesterase inhibitors (also called cholinesterase inhibitors ), which stop or slow the action of acetylcholinesterase, an enzyme that breaks down acetylcholine (ACh). ACh is critical for the normal functioning of neurons within the hippocampus and cerebral cortex, is neuroprotective, and has been identified as deficient in individuals with AD. The approved medications are donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl). Medication is prescribed upon diagnosis of the disease and has been demonstrated to be modestly effective in slowing functional and cognitive decline over a course of approximately
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