The Quick Mild Cognitive Impairment (Qmci) screen: developing a new screening test for mild cognitive impairment and dementia

Introduction: Identifying mild cognitive impairment (MCI) is challenging. Few short instruments have sufficient sensitivity and specificity for use in busy clinical practice. This thesis explores the development, psychometric evaluation and validation of a new short (3–5 min) cognitive screening instrument, designed to screen for MCI and early dementia, called the Quick Mild Cognitive Impairment (Q\u1d62e\u1d624\u1d62a) screen. Specific aims included assessing 1) content validity, 2) concurrent validity against other short screens, 3) construct validity against detailed global and neuropsychological tests and 4) refining the Q\u1d62e\u1d624\u1d62a into a ‘home’-carer administered “Quick Memory Check-QMC”. Methods: A secondary analysis of data from three Canadian databases was conducted to validate the Q\u1d62e\u1d624\u1d62a. The Q\u1d62e\u1d624\u1d62a was then externally validated in different settings (memory clinic, movement disorder clinic, general practice, rehabilitation unit) in Ireland. Translation and external validation in other languages was also begun. Results: The Q\u1d62e\u1d624\u1d62a was more accurate than the ABCS 135, 6CIT, GPCOG, SMMSE and had similar sensitivity but greater specificity than the MoCA in differentiating MCI from normal. Cut-off scores using maximal accuracy and Youden’s Index, adjusted for age and education, were produced. The Q\u1d62e\u1d624\u1d62a correlated with global functional measures (Lawton-Brody ADL scale and CDR) and the Standardised ADAS-cog. The Q\u1d62e\u1d624\u1d62a had excellent inter-rater and test-retest reliability. A shortened Q\u1d62e\u1d624\u1d62a, administered by caregivers (QMC), was acceptable and had comparable accuracy to a battery of short cognitive screens. Discussion: This thesis presents the development and psychometric evaluation of the Q\u1d62e\u1d624\u1d62a screen. It also demonstrates the potential of shortening the instrument to allow caregivers score patients at home in an attempt to reduce performance anxiety. This project also suggests that the Q\u1d62e\u1d624\u1d62a could be substituted for more detailed and longer instruments in a wide variety of settings, as a rapid screening test for cognitive impairment, particularly where the suspicion favours the presence of MC

Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression

Short but accurate cognitive screening instruments are required in busy clinical practice. Although widely-used, the diagnostic accuracy of the standardised Mini-Mental State Examination (SMMSE) in different dementia subtypes remains poorly characterised. We compared the SMMSE to the Quick Mild Cognitive Impairment (Qmci) screen in patients (n = 3020) pooled from three memory clinic databases in Canada including those with mild cognitive impairment (MCI) and Alzheimer’s, vascular, mixed, frontotemporal, Lewy Body and Parkinson’s dementia, with and without co-morbid depression. Caregivers (n = 875) without cognitive symptoms were included as normal controls. The median age of patients was 77 (Interquartile = ±9) years. Both instruments accurately differentiated cognitive impairment (MCI or dementia) from controls. The SMMSE most accurately differentiated Alzheimer’s (AUC 0.94) and Lewy Body dementia (AUC 0.94) and least accurately identified MCI (AUC 0.73), vascular (AUC 0.74), and Parkinson’s dementia (AUC 0.81). The Qmci had statistically similar or greater accuracy in distinguishing all dementia subtypes but particularly MCI (AUC 0.85). Co-morbid depression affected accuracy in those with MCI. The SMMSE and Qmci have good-excellent accuracy in established dementia. The SMMSE is less suitable in MCI, vascular and Parkinson’s dementia, where alternatives including the Qmci screen may be used. The influence of co-morbid depression on scores merits further investigation

Euthanasia and physician-assisted suicide: Attitudes of Irish consultant physicians

Introduction: This study examines the attitudes of Irish consultant physicians towards euthanasia and physician-assisted suicide. Methods: Data were collected between May and October 2016. A questionnaire was distributed to all consultant physicians listed in the Irish Medical Directory under general internal medicine specialties. Demographic details were collected. Likert-type questions assessed attitudes towards euthanasia and physician-assisted suicide. Results: The overall response rate was 28.7% (238/830). The majority, 67.2%, opposed legalising euthanasia, with 14% in favour and 18.8% remaining neutral. A majority, 56.3%, also opposed legalising physician-assisted suicide, while 17% were in favour and 26.7% remained neutral. Over one-third, 37.5%, had received a request from a patient to hasten that patient’s death. Receiving such a request did not significantly influence attitudes towards either euthanasia (p=0.53) or physician-assisted suicide (p=0.48). There was a significant association between self-expressed level of religiosity and opposition to both euthanasia (p<0.001) and physician-assisted suicide (p<0.001). Attitudes were not significantly affected by respondents’ age. Discussion: The majority of Irish physicians who responded to the survey were opposed to euthanasia and physician-assisted suicide. This is the first published study of the attitudes of Irish physicians in this regard and constitutes an important contribution to the ongoing national debate on these issues

Sleep disturbance in older patients in the emergency department: prevalence, predictors and associated outcomes

Impaired sleep is common in hospital. Despite this, little is known about sleep disturbance among older adults attending Emergency Departments (ED), particularly overnight-boarders, those admitted but housed overnight while awaiting a bed. Consecutive, medically-stable patients aged ≥70, admitted through a university hospital ED were evaluated for overnight sleep quality (Richards Campbell Sleep Questionnaire/RCSQ) and baseline sleep (Pittsburgh Sleep Quality Index/PSQI). Additional variables included frailty, functional and cognitive status, trolley location, time in ED and night-time noise levels. Over four-weeks, 152 patients, mean age 80 (± 6.8) years were included; 61% were male. Most (68%) were ED boarders (n = 104) and 43% were frail. The majority (72%) reported impaired sleep quality at baseline (PSQI ≥ 5) and 13% (20/152) had clinical insomnia. The median time spent in ED for boarders was 23 h (Interquartile ± 13). After adjusting for confounders, median RCSQ scores were significantly poorer for ED boarders compared with non-boarders: 22 (± 45) versus 71 (± 34), respectively, (p = 0.003). There was no significant difference in one-year mortality (p = 0.08) length of stay (LOS) (p = 0.84), 30-day (p = 0.73) or 90-day (p = 0.64) readmission rates between boarders and non-boarders. Sleep disturbance is highly prevalent among older adults admitted through ED. ED boarders experienced significantly poorer sleep, without this impacting upon mortality, LOS or re-admission rates

Validity of the Japanese version of the quick mild cognitive impairment screen

Early detection of dementia provides opportunities for interventions that could delay or prevent its progression. We developed the Japanese version of the Quick Mild Cognitive Impairment (Qmci-J) screen, which is a performance-based, easy-to-use, valid and reliable short cognitive screening instrument, and then we examined its validity. Community-dwelling adults aged 65–84 in Niigata prefecture, Japan, were concurrently administered the Qmci-J and the Japanese version of the standardized Mini-Mental State Examination (sMMSE-J). Mild cognitive impairment (MCI) and dementia were categorized using established and age-adjusted sMMSE-J cut-offs. The sample (n = 526) included 52 (9.9%) participants with suspected dementia, 123 (23.4%) with suspected MCI and 351 with likely normal cognition. The Qmci-J showed moderate positive correlation with the sMMSE-J (r = 0.49, p < 0.001) and moderate discrimination for predicting suspected cognitive impairment (MCI/dementia) based on sMMSE-J cut-offs, area under curve: 0.74, (95%CI: 0.70–0.79), improving to 0.76 (95%CI: 0.72 to 0.81) after adjusting for age. At a cut-off of 60/61/100, the Qmci-J had a 73% sensitivity, 68% specificity, 53% positive predictive value, and 83% negative predictive value for cognitive impairment. Normative data are presented, excluding those with any sMMSE-J < 27. Though further research is required, the Qmci-J screen may be a useful screening tool to identify older adults at risk of cognitive impairment

Identification of community-dwelling older adults at risk of frailty using the PERSSILAA screening pathway:A methodological guide and results of a large-scale deployment in the Netherlands

Abstract Background Among community-dwelling older adults, frailty is highly prevalent and recognized as a major public health concern. To prevent frailty it is important to identify those at risk of becoming frail, but at present, no accepted screening procedure is available. Methods The screening process developed as part of the PERSSILAA project is a two-step screening pathway. First, older adults are asked to complete a self-screening questionnaire to assess their general health status and their level of decline on physical, cognitive and nutritional domains. Second, older adults who, according to step one, are at risk of becoming frail, are invited for a face-to-face assessment focusing on the domains in depth. We deployed the PERSSILAA screening procedure in primary care in the Netherlands. Results In total, baseline data were available for 3777 community-dwelling older adults (mean age 69.9 (SD ± 3.8)) who completed first step screening. Based on predefined cut-off scores, 16.8% of the sample were classified as frail (n = 634), 20.6% as pre-frail (n = 777), and 62.3% as robust (n = 2353). Frail subjects were referred back to their GP without going through the second step. Of the pre-frail older adults, 69.7% had evidence of functional decline on the physical domain, 67% were overweight or obese and 31.0% had evidence of cognitive decline. Conclusion Pre-frailty is common among community-dwelling older adults. The PERSSILAA screening approach is a multi-factor, two-step screening process, potentially useful for primary prevention to identify those at risk of frailty and who will benefit most from preventive strategies

Screening for markers of frailty and perceived risk of adverse outcomes using the Risk Instrument for Screening in the Community (RISC)

BACKGROUND: Functional decline and frailty are common in community dwelling older adults, increasing the risk of adverse outcomes. Given this, we investigated the prevalence of frailty-associated risk factors and their distribution according to the severity of perceived risk in a cohort of community dwelling older adults, using the Risk Instrument for Screening in the Community (RISC). METHODS: A cohort of 803 community dwelling older adults were scored for frailty by their public health nurse (PHN) using the Clinical Frailty Scale (CFS) and for risk of three adverse outcomes: i) institutionalisation, ii) hospitalisation and iii) death, within the next year, from one (lowest) to five (highest) using the RISC. Prior to scoring, PHNs stated whether they regarded patients as frail. RESULTS: The median age of patients was 80 years (interquartile range 10), of whom 64% were female and 47.4% were living alone. The median Abbreviated Mental Test Score (AMTS) was 10 (0) and Barthel Index was 18/20 (6). PHNs regarded 42% of patients as frail, while the CFS categorized 54% (scoring ≥5) as frail. Dividing patients into low-risk (score one or two), medium-risk (score three) and high-risk (score four or five) using the RISC showed that 4.3% were considered high risk of institutionalization, 14.5% for hospitalization, and 2.7% for death, within one year of the assessment. There were significant differences in median CFS (4/9 versus 6/9 versus 6/9, p < 0.001), Barthel Index (18/20 versus 11/20 versus 14/20, p < 0.001) and mean AMTS scores (9.51 versus 7.57 versus 7.00, p < 0.001) between those considered low, medium and high risk of institutionalisation respectively. Differences were also statistically significant for hospitalisation and death. Age, gender and living alone were inconsistently associated with perceived risk. Frailty most closely correlated with functional impairment, r = −0.80, p < 0.001. CONCLUSION: The majority of patients in this community sample were perceived to be low risk for adverse outcomes. Frailty, cognitive impairment and functional status were markers of perceived risk. Age, gender and social isolation were not and may not be useful indicators when triaging community dwellers. The RISC now requires validation against adverse outcomes

Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.

Background: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland

The inter-rater reliability of the Risk Instrument for Screening in the Community

Predicting risk of adverse healthcare outcomes is important to enable targeted delivery of interventions. The Risk Instrument for Screening in the Community (RISC), designed for use by public health nurses (PHNs), measures the one-year risk of hospitalisation, institutionalisation and death in community-dwelling older adults according to a five-point global risk score: from low (score 1,2), medium (3) and high (4,5). We examined the inter-rater reliability (IRR) of the RISC between student PHNs (n=32) and expert raters using six cases (two low, medium and high-risk), scored before and after RISC training. Correlations increased for each adverse outcome, statistically significantly for institutionalisation (r=0.72 to 0.80,p=0.04) and hospitalisation, (r=0.51 to 0.71,p<0.01) but not death. Training improved accuracy for low-risk but not all high-risk cases. Overall, the RISC showed good IRR, which increased after RISC training. That reliability reduced for some high-risk cases suggests that the training programme requires adjustment to further improve IRR

Selecting a bedside cognitive vital sign to monitor cognition in hospital: feasibility, reliability, and responsiveness of logical memory

Although there is a high prevalence of delirium and cognitive impairment among hospitalised older adults, short, reliable cognitive measures are rarely used to monitor cognition and potentially alert healthcare professionals to early changes that might signal delirium. We evaluated the reliability, responsiveness, and feasibility of logical memory (LM), immediate verbal recall of a short story, compared to brief tests of attention as a bedside “cognitive vital sign” (CVS). Trained nursing staff performed twice-daily cognitive assessments on 84 clinically stable inpatients in two geriatric units over 3–5 consecutive days using LM and short tests of attention and orientation including months of the year backwards. Scores were compared to those of an expert rater. Inter-rater reliability was excellent with correlation coefficients for LM increasing from r = 0.87 on day 1 to r = 0.97 by day 4 (p < 0.0001). A diurnal fluctuation of two points from a total of 30 was deemed acceptable in clinically stable patients. LM scores were statistically similar (p = 0.98) with repeated testing (suggesting no learning effect). All nurses reported that LM was feasible to score routinely. LM is a reliable measure of cognition showing diurnal variation but minimal learning effects. Further study is required to define the properties of an ideal CVS test, though LM may satisfy these