It is estimated that worldwide there are more than 55 million people living with Alzheimer’s disease and other causes of dementia, and this number is estimated to rise to 78 million by 2030 and 139 million by 2050. There are simply not enough neurologists, psychiatrists, geriatricians, neuropsychologists, and other specialists to diagnose these individuals with cognitive decline and dementia. Primary care providers will need take the lead.
Although this may sound like the obvious and simple solution, my friends who are primary care providers remind me that they barely have time to do the basics — like blood pressure and diabetes management — and that they have no time to administer fancy cognitive tests. Even a simple test like the Mini-Cog (clock drawing and three words to remember) is too long for them. So how are we going to diagnose the increasing numbers of individuals with Alzheimer’s and other dementias in the next few decades?
A self-administered test can screen for memory loss
In 2010, clinicians at the division of cognitive neurology in The Ohio State University Wexner Medical Center developed a cognitive test to screen for memory loss that individuals can self-administer. This concept of a self-administered cognitive test can solve the problem of the time-crunched primary care provider. Individuals can take this test in the privacy of their own home and bring the results with them to the office. The results can then be used to determine whether additional work up and/or referral to a specialist is indicated.
The test, the Self-Administered Gerocognitive Examination (SAGE), has compared favorably to clinician-administered tests such as the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA), as well as to standard neuropsychological testing. What was not known, however, is how well SAGE would be able to predict who would develop Alzheimer’s disease or another cause of dementia.
Predicting the future
To answer this question, the authors performed a retrospective chart review on 655 individuals seen in their memory disorders clinic, with a follow-up of up to 8.8 years. They compared their SAGE test to the MMSE.
Based on both initial and follow-up clinic visits, they divided their clinic population into four groups. Before I describe the groups, let me explain a few terms:
- Dementia is when cognitive impairment leads to impaired function.
- Mild cognitive impairment (MCI) is when there is cognitive impairment, but function is normal.
- Subjective cognitive decline is when individuals are concerned about their thinking and memory, but both cognition and function are normal.
The four groups they compared were individuals with
- Alzheimer’s disease dementia
- MCI who converted to Alzheimer’s disease dementia
- MCI who converted to another type of dementia
- subjective cognitive decline.
They found a surprisingly high correlation between the SAGE test and the MMSE in being able to predict how each of these groups did over time. Moreover, they found that the SAGE test could predict the conversion of an individual with MCI who would develop dementia six months earlier than the MMSE.
What is needed to bring this test into current practice
Even a self-administered test that individuals can do at home will still require training for primary care providers, to understand how the test should be used and how to interpret the results. There is no question, however, that such training will be worthwhile. Once the training is complete, the knowledge gained should be able to save literally thousands of hours of clinician time, in addition to missed — or improper — diagnoses.
Another question is how individuals will react when they are told that they need to perform a 10-to-15-minute cognitive test at home and bring the results to their doctor. Will they do it? Or will the ones who need the test the most avoid doing it — or cheat on it? My suspicion is that people who are concerned will do the test, as will people who generally follow their doctor’s instructions. Some individuals who would benefit from the information that the test provides may not do it, but many of those individuals wouldn’t do the “regular” pencil-and-paper testing with the doctor or clinic staff either.
A new model of cognitive screening
Previously, there were two types of screening instruments to help determine if someone is developing cognitive impairment that could lead to dementia: clinician-administered cognitive tests and family/caregiver questionnaires. Now there is a third type of screening instrument: a self-administered test. Use of these self-administered tests will be key in detecting the increasing numbers of individuals with Alzheimer’s disease and other causes of dementia who will be with us in the next several decades.
Want to test yourself?
You can download the SAGE test here. As it says on the website, please take the answer sheet to your doctor so they can score it and speak with you about the results.
Bible verses for today’s meditation and inspiration: Matthew E. McLaren’
1 Timothy 2: 3
3 I thank God, whom I serve, as my ancestors did, with a clear conscience, as night and day I constantly remember you in my prayers.
4 Recalling your tears, I long to see you, so that I may be filled with joy. 5 I am reminded of your sincere faith, which first lived in your grandmother Lois and in your mother Eunice and, I am persuaded, now lives in you also.
6 For this reason I remind you to fan into flame the gift of God, which is in you through the laying on of my hands. 7 For the Spirit God gave us does not make us timid, but gives us power, love and self-discipline.
8 So do not be ashamed of the testimony about our Lord or of me his prisoner. Rather, join with me in suffering for the gospel, by the power of God.
9 He has saved us and called us to a holy life-not because of anything we have done but because of his own purpose and grace. This grace was given us in Christ Jesus before the beginning of time,
10 but it has now been revealed through the appearing of our Savior, Christ Jesus, who has destroyed death and has brought life and immortality to light through the gospel.
1Timothy 3: 1
1 Here is a trustworthy saying: Whoever aspires to be an overseer desires a noble task. 2 Now the overseer is to be above reproach, faithful to his wife, temperate, self-controlled, respectable, hospitable, able to teach,
3 not given to drunkenness, not violent but gentle, not quarrelsome, not a lover of money. 4 He must manage his own family well and see that his children obey him, and he must do so in a manner worthy of full[a] respect. 5 (If anyone does not know how to manage his own family, how can he take care of God’s church?)
7 He must also have a good reputation with outsiders so that he will not fall into disgrace and into the devil’s trap.
1 Timothy 4: 1
The Spirit clearly says that in later times some will abandon the faith and follow deceiving spirits and things taught by demons. 2 Such teachings come through hypocritical liars, whose consciences have been seared as with a hot iron.
Have nothing to do with godless myths and old wives’ tales; rather, train yourself to be godly.
If you point these things out to the brothers and sisters,[a] you will be a good minister of Christ Jesus, nourished on the truths of the faith and of the good teaching that you have followed. 7 Have nothing to do with godless myths and old wives’ tales; rather, train yourself to be godly.
12 Don’t let anyone look down on you because you are young, but set an example for the believers in speech, in conduct, in love, in faith, and in purity.
15 Be diligent in these matters; give yourself wholly to them, so that everyone may see your progress.
Tom 5 Do not rebuke an older man harshly but exhort him as if he were your father. Treat younger men as brothers, 2 older women as mothers, and younger women as sisters, with absolute purity.
Recommended contacts for prayer requests and Bible study