Dr. Alex Germano // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Alex Germano as she discusses how rehab providers are incredibly positioned to screen cognition in older adults, what the current barriers are to cognitive screening, and which measures would be best to use to identify early signs of cognitive impairment.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

ALEX GERMANO
Welcome to the PT on Ice show brought to you or the daily show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Jerry on Ice. My name is Alex Germano. I'm a member in the older adult division. This weekend I was talking with our students out in Madison, Wisconsin about cognition being a risk factor for falls. And I really wanted to dive into a more complete conversation about our role as rehab providers in screening for cognition. I guess I'll be specifically talking to the physical therapists, but also occupational therapists. And I know speech language pathologists actually do a really great job at cognition and cognitive screening. So I'm kind of talking to more of that PTOT group of humans. Today, we're gonna highlight why we encourage cognitive screening on older patients, and especially older patients without a known diagnosis of cognitive decline, and which cognitive screens will give you the best information. All right, so preface the conversation. This is going to be really talking about those who do not have a known diagnosis that could cause the symptom of dementia. If our patient has a known diagnosis of Alzheimer's disease, I don't really need to be doing a cognitive screen telling me that there is a problem. We know that they have a known diagnosis. It would be more beneficial for me to do something like a global deterioration scale to kind of categorize their level of dementia. and deterioration and then track that over time. So remember, if they have a known diagnosis already, probably no really need to screen.

HOW AND WHEN TO PERFORM A COGNITIVE SCREEN
So we're talking about people who are telling you that they are cognitively normal, that they do not have a diagnosis that affects their cognition. So why would we recommend this for these patients? Can't you just tell that they're cognitively normal and won't people be offended if I just start screening their cognition and they believe that they're normal? This is probably a number, these are probably a number of the questions that you're wondering right now. So let's make sure we reach out to all of those.

ESTABLISH A BASELINE
So first we are recommending screening or labeling our patients with a known cause of dementia because we need to establish a baseline. It's also very important that we are identifying problems on the earlier end of the spectrum. Let's think about another problem where we encouraged to do, we encourage like an early screen. That would be for frailty. It's very important to identify people as early as possible because it is so much easier to treat and change the trajectory of a patient experiencing pre-frailty than it is to change the trajectory of the person who's already in the depths of frailty. The same thing goes for cognition. It's much easier to change the trajectory of the human with mild cognitive impairment than it is once they are already in the depths of Alzheimer's disease and dementia. Pre-frailty, just like mild cognitive impairment, are really hard to see, right? It can be really hard to see. There can be a community dwelling older adult who is going to the senior center and seems really active, but they could be experiencing clinical levels of pre-frailty. And it's just, it's hard to see based on maybe the activities they're telling you that they do, maybe their physical function. They walked in without a walker, so they're probably, you know, not pre-frail. But this stuff is really hard to see, and it's why it warrants us screening for it. People do a really good job masking, especially those early signs of cognitive impairment. And from my clinical experience, when if you're not working in the home with them, sometimes the home is where you see this person a little bit more raw, and you see a little bit more of their habits, and you can kind of pick up on some issues. But if you're not with them for some of those critical moments, and they're coming to you in a clinic, you're probably thinking, I just work with super high level outpatient older adults. This is silly, they're not cognitively impaired. Well, let's share some statistics. So the current prevalence for older adults experiencing mild cognitive impairment from age just 60 to 64 is already about 7%. That's a pretty significant chunk. And that increases progressively with each age range up to the ages of 80 to 84, where those 80 to 84-year-olds, 25% of that population, mild cognitive impairment has a prevalence of 25% within that age group, 80 to 84, a one out of four. That's a huge chunk of the population. And actually there was a study done that one out of five older adults that use outpatient physical therapy services are estimated to have a cognitive impairment. So to use a phrase from the spine division, You may not think you're seeing patients with cognitive impairment, but they are seeing you. It's critical to establish this cognitive baseline for our patients like we do their physical abilities. We have no problem taking a grip strength. We're not weird about it. We just say, Hey, let's see your grip strength. We say, Hey, let's do that five times sit to stand. And even if we know they're going to blow it out of the water, we still do it, right? We're establishing a baseline. It gives us a complete and holistic view of their health status. If somebody has a cognitive impairment, they're going to be less likely to stick, follow through and progress with physical therapy or occupational therapy. And there's so many conditions within older adults that cause acute changes to cognition or acute on chronic changes to cognition, including a urinary tract infection or normal pressure hydrocephalus. So having the baseline assessment of cognition could be really powerful in making us feel confident to make the call to the physician, to make the call to one of the medical providers to say, hey, something's going on and something's wrong with this person. We are uniquely positioned as therapists and rehab providers because we have so many touch points with patients, way more than the PCP does. So we are providers who are going to be able to catch something very, you know, something sinister very early. And we can prevent these downstream hospitalizations from sepsis or injurious falls. These things occur as a result of having something that seems simple, a urinary tract infection that often presents as a cognitive change first. So, We can save lives by screening cognition and being aware of the cognitive changes that our patients are experiencing. Now, just like we continue to test our one rat maxes and stay informed on the status of our blood markers and other physical health markers, why are we not comfortable doing the same for cognition? Wouldn't it be great information to know that you're experiencing cognitive decline early? Or do you want to know about it when you're already in the worst stages of it? Wouldn't most people want a fighting chance? Well, there's a ton of stigma around cognitive health and cognitive decline. And that is a big barrier to doing some of these screens. But I'm going to share a quote with you from a participant from a town hall from the Alzheimer's Association. They do these big town halls and they get people's subjective experiences. And this person said, an early diagnosis is vital. It's made all the difference in the world in my life. It gives us a purpose and allows us time to get our house in order. On a recent poll, about 54% of Americans would rather know that they had Alzheimer's disease at the earliest stages of mild cognitive impairment. Simultaneously, many Americans are very worried about getting this diagnosis. They're scared because they're worried they're going to learn something serious is going on. They're going to worry that They're going to be over prescribed pills or given the wrong diagnosis. They worry that the symptoms might just go away if they give it time. So we need to work on combating this stigma, right? First, we need to do cognitive screening on all of our patients, right? The ones who don't have a known neurological diagnosis that causes dementia.

NORMALIZING COGNITIVE SCREENING
We have to do these cognitive screenings on everyone. We make it a very normal part of the process. It's as normal as asking the patient, have you had a fall in the last three to six months? We need to explain why we're doing the test. There's going to be nuance to this conversation, and I'm sure we have all worked with a patient or two where we felt a little bit uncomfortable maybe doing the cognitive screen, because we could feel some tension. Maybe the patient did have a mild cognitive impairment, and we felt like they would get maybe a little bit aggressive. I don't want to say combative, but maybe a bit in denial, a bit defensive if we brought in some of this cognitive screening. But I think when we try to lie about what we're doing, we're just going to do like this quick little thing. Ha ha. I don't think that that's giving the patient the, um, the true reasoning behind what we're doing. And I think sometimes that that trickery can elicit some of these defensive behaviors and postures. So what we need to do is be very clear and kind about what we're doing. We are going to be doing a cognitive screen. I do this on everyone because your cognitive health is as important as your physical health.

A SCREENING IS NOT A CONFIRMED DIAGNOSIS
Now, when we get a result that maybe isn't perfect, we need to bring a high level of sensitivity and empathy to this screening process, especially while relaying results. Remember, we're not in the position to diagnose somebody. This is a screening test that maybe can tell us something's going on, but that's all I know, all right? I can't make a formal diagnosis of mild cognitive impairment or dementia with the person sitting in front of me. That's not my job, and that's important that the patient knows that too. So we get the results of the screen. We are very clear about the results that we find. And we say, you know what, this means we just have to connect with our provider. And we're gonna get you connected with them to make sure nothing else is going on or there's nothing else that we can treat here. And we want this whole medical team to come together and rally around the person. We are in the perfect position to provide a ton of hope for this person. to provide a ton of hope. Hey, you're doing exactly what you need to do. You're here with me. We're gonna exercise. We're gonna work on some of this cognition together. We're gonna get you to a medical provider and we're gonna come around you and support you. We can't leave the patient hanging with bad results or good results even, right? We need to educate on what the next steps are. We need to educate on cognitive health and what to do to maximize it. We cannot just leave them there without any of the information and just slap a label on them and move on.

CHOOSING THE RIGHT SCREEN
Now, choosing the right screen is also very important. Interestingly, only 32% of PTs when asked about performing a cognitive screen as a part of a falls risk assessment, only 32% of PTs were performing that cognitive screen. Only 53% of PTs in the home health setting felt like they actually had the skill set to do cognitive testing. And in a study looking at occupational therapists, only a third of the occupational therapists were, I mean, sorry, a third of the occupational therapists were using only clinical observation or ADL assessment in isolation to report that there was a problem. So we kind of have an issue within our profession when it comes to what we are screening for and these screens that we're actually using. Um, We know that a number of people are only screening very specific aspects of cognition, including alertness and orientation, or choosing measures that are only sensitive for dementia, but not sensitive enough for mild cognitive impairment. Think like mini mental state exam. So we are really trying to specifically capture people in this conversation who are experiencing mild cognitive impairment. We need to choose measures that are more sensitive for that condition. These measurements include, just to name a few, The Mocha, okay? Mini Cog. Mini Cog is super easy, very free. You can get it from the Alzheimer's Association right now. The Short Bless Test, the Slums, the Brief Alzheimer's Screen. These are all sensitive enough for mild cognitive impairment. Many of them you'll see have like overlapping qualities. There's a clock on them. They're going to ask to remember some different words. You're going to have to like count backwards, name the months of the year. A lot of them will feel very similar. So just find ones that you think you can fit into your clinical practice and start looking through them and get familiar with some of them to use and pull out with your patients.

SUMMARY
Okay, let's wrap this thing up. So one, we are uniquely positioned to be screening providers for cognitive decline, especially those who might appear normal for a while, but then have an acute change to their cognition. We can catch those people and get them medical help much earlier than if they were to wait to see their PCP again, right? It is incredibly important for us to find out who is starting their journey on cognitive decline, who's experiencing that mild cognitive impairment, so that we can triage our approach and make sure to get the medical team involved, the family involved, make sure we start talking a lot about cognitive health with these patients and get the patient motivated to fight back against this decline. We also need to work on reducing the stigma of cognitive testing. Do not make it weird. I have no other piece of advice than that. Don't make it weird. Be very clear about your intentions on what you're doing. Report the results in a very meaningful way. Give hope when something comes out badly, right? We have to be choosing the right tests and measures when it comes up to cognitive screening. We've got to be picking measurements sensitive enough for mild cognitive impairment. Now we have, if this stoked your fire like it does mine, we have an entire week in our online level two course dedicated to cognitive impairment. We are very proud to have taken a very deep dive into the variety of neurodegenerative conditions that causes the symptoms of dementia, as well as provide a very meaningful and hopeful clinical considerations and strategies for treatment in this population. Our next online level two starts May 16th. We also have a variety of live courses coming up in the next few weeks. For my east coasters, my east coasters, listen up. We are up and down the country until basically July for the east coast. We've got courses in Raleigh, North Carolina, Burlington, New Jersey, Aspinwall, Pennsylvania, Richmond, Virginia, and Virginia Beach from now until July. After that, our east coasting slows down significantly. So if that's your territory, please look at those courses now. and consider getting into one of those options. We would be so excited to see you out there. Head to the PTOnIce.com website to find out more about our online live courses. And I'm looking forward to seeing you guys soon. All right, bye now.

OUTRO
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