Staff Education Improves Fidelity of Dementia Screening and Early Intervention

Accuracy of Mini-Cog screening tool enhanced by mandatory training

Estimates indicate that 5 million US adults age 65 and older suffer from Alzheimer’s disease and related dementia. However, screening for these common age-related disorders can be challenging in primary care settings; as a result, early symptoms are frequently missed.

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To address the problem at Cleveland Clinic, the Center for Geriatric Medicine launched a uniform cognitive assessment process at 38 family health care centers (FHCs) around northeast Ohio in 2019. The key to evaluating these patients has been the Mini-Cog, a simple 3-minute dementia screening test.

Experts at the center have are now taking the initiative a step further by instituting a quality improvement project aimed at ensuring that nurses and medical assistants are well-trained to use the Mini-Cog. A recent study focused on the value of annual retraining, presented at the American Geriatrics Society Annual Scientific Meeting in May, shows that in-person and online education improves the fidelity of dementia screening.

“We wanted to compare the results of the clock-draw test as scored by medical assistants and nurses to those scored by physicians,” says Cleveland Clinic geriatrician and study co-author Ronan Factora, MD. “We found that after implementation of the educational module, the gap in test interpretation shrunk, which was excellent news.”

The Mini-Cog, which consists of a three-item recall test plus a clock-drawing component, has been validated in clinical studies based on the Clinical Dementia Rating. After brief training, an allied professional can administer and score the Mini-Cog on a scale of 0 to 5, with 0 to 2 being positive and 3 to 5 being negative.

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Key findings

At Cleveland Clinic, 582 FHC medical assistants and nurses underwent mandatory retraining on Mini-Cog administration. Approximately 6 months after they had finished the module, 190 completed clock-draw tests were evaluated.

Researchers found a 93% agreement rate when comparing the interpretation of the clock-draw tests scored by a physician reviewer. In the 7% of cases in which there was a disagreement, the tests were typically deemed “normal” by the medical assistant or nurse but abnormal by the physician reviewer. These discrepancies were attributed to the potentially inconsistent use of the scoring criteria.

In comparison, data from tests administered prior to clinician retraining showed a 90% agreement between scores tabulated by medical assistants and nurses and those tabulated by physician reviewers.

“We need to follow these providers over time to make sure that they continue to use the Mini-Cog properly,” says Dr. Factora. “And in the event of staff turnover, new nurses and medical assistants must be appropriately trained.”

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Another challenge came to light when the researchers analyzed the responses of primary care providers to the Mini-Cog results. During a 1-month period at the FHCs, 66 patients screened positive, yet only 7.5% were referred to the Center for Geriatric Medicine; no action was taken in 51% of cases. Fifty-eight percent of the patients were subsequently found to have dementia.

“There is only one opportunity to act on a positive Mini-Cog, and if a progressive process is causing the dementia, it’s only going to get worse over time,” explains Dr. Factora. “A patient may eventually develop problems related to memory, such as missing meals or failing to take medication for a chronic condition, including high blood pressure or diabetes. We want to prevent these issues by making the diagnosis early.”

Future implications

The next step for the researchers is to try to identify barriers that prevent physicians from taking action when patients screen positive on the Mini-Cog. “Memory problems are under-recognized simply because clinicians are so pressured to deal with chronic medical problems like high blood pressure, heart failure, and COPD. In lieu of those immediate concerns, signs of dementia are often ignored.”

The advantages of the Mini-Cog, according to Dr. Factora, are that it’s easy, practical, and has little effect on patient flow. Importantly, the tool may benefit both primary care providers and individual patients. “Healthcare providers are judged on quality metrics, such as achieving adherence to diabetic control medication. Those metrics may improve if they can identify and get help for individuals with dementia, many of whom are unable to independently implement a plan of care.”