RAPCOG

RAPCOG

The RAPid COmmunity COGnitive screening Programme

Introduction to RAPCOG

As Irish [1] and European [2] populations age the prevalence of dementia is set to rise across the continent. New pharamceutical and non-pharmaceutical advances have raised the possiblilty of modifying disease progression, particularly if initiated at an early stage disease known as mild cognitive impairment (MCI). This then raises questions about how to screen people for memory problems and whether this is practical and clinically justified. Part of the lack of evidence relates to a lack of suitable, short cognitive screens. Older adults and their caregivers should be actively involved in the diagnostic process.

The screening tools

The Quick Mild Cognitive Impairment screen (Qmci), is a short, cognitive instrument for the detection of MCI. MCI represents a heterogeneous group of disorders of memory impairment that often precedes the onset of dementia. Individuals with MCI have variable, subtle, cognitive changes making it difficult to detect. Early diagnosis of MCI is important so that appropriate management can be initiated. Existing cognitive screening instruments used internationally such as the mini-mental state examination (MMSE)[3] and its standardized version, the SMMSE [4,5], while useful in dementia screening are insensitive to MCI. The Qmci has been shown to more sensitive at differentiating normal cognition and dementia from MCI than these other tests [6]. The Qmci is composed of six subtests, orientation, registration, clock drawing, delayed recall, verbal fluency and logical memory, scored out of 100 points.

The Quick Memory Check (QMC) is another newly developed cognitive screening instrument. It is designed to be used by members of the public including family and caregivers where they have concern for older adults they know. The QMC contains a subjective assessment of memory completed by the caregiver and objective tests of orientation, verbal fluency and logical memory, scored out of 100 points.

 RAPCOG project overview

Our target area, Cork County (South Lee) with a total population of c 180,000, has approximately 20,000 adults over 65 years. 8% of these, 1,600, are expected to have evidence of dementia although the true prevalence remains unclear.

This project is developing screening instruments for use in a community wide screening initiative for MCI and dementia. RAPCOG is coordinated by the centre for gerontology and rehabilitation (CGR) in University College Cork as part of the Collaboration on Ageing (COLLAGE), Irelands two star reference site for active and healthy ageing under the EIP on AHA. Parallel work, by the CGR, has already informed the initiative. The Optimal Dementia Care in Acute Care settings, ODCACS (see other link) found a high prevalence of dementia and delirium (40%) in older people admitted to six acute hospitals in Cork [7]. A point prevalence study of delirium in Cork University Hospital also revealed a point prevalence of acute confusion i.e. delirium in approx. 20% of adult inpatients [8]. The CGR is also participating in the FP7 funded project NILVAD, See NILVAD.eu and the pre-frailty study PERSSILAA See, https://perssilaa.com/ (including patients with MCI) expertise obtained from this project is being used in RAPCOGs development.  

Everyone in our target area (South Lee) will be invited to screen friends or family members, without known cognitive deficits, using the QMC. Copies of the QMC, will be posted or emailed via a link, in a staggered fashion, to all households in our target area over a one year period. Subjects screening positive will be asked to attend their primary care physician (GP) for assessment using the Qmci. All older adults screening positive for cognitive impairment by their primary care physician will be reviewed in the Cork memory clinic in St Finbarrs. Copies of the QMC will be made available in all HSE (Irish department of health) offices and GP surgeries. Those patients or family members and caregivers with access to email/computer access will provided with a link to an electronic version. Members of the public will be invited to attend workshops/lectures on how to score the QMC in conjunction with a local health promotion initiative. Individuals over 65 with concerns will be advised to re-screen annually. In the long-term we will analyse the impact of RAPCOG by comparing rates of institutionalisation and hospitalisation seen in the CARTS (community assessment of risk treatment) programme before and after introduction of the programme [9-11]. The CGR has developed expertise in assessing older perons ability to use information technology (IT) [12, 13] and have trialed the use of brain training and other IT approaches as therapeutic modalities in MCI [14].

Timeline

The validation and publication of the Qmci in English is complete [15-18].  The Qmci Iphone App, launched on the Apple App Store in 2012, is available but requires translation for use in other countries. Different language versions of the Qmci will be validated with a view to using this tool in other European centres. The Qmci is validated in Dutch as part of preparation for the PERSSILAA study, where a Dutch version is used as a cognitive screen with Dutch patients [19]. GPs in Cork have received training in the Qmci and inter-rater reliability is complete [20]. The QMC has recently been validated in the Cork memory clinic against the SMMSE and is being prepared for publication. The QMC will be converted into an application and local funding is available to complete this. Screening is expected to be complete by summer 2017. Validation of the programme will be complete by 2018.

Role in EIP on AHA

The Rapid Cognitive Community Screening Program targets the first pillar 'prevention, screening and early diagnosis', as well as the action group A3. It is a renewed committment under the EIP on AHA A3 action group. Through using the QMC we aim to improve patient literacy, empowering older people and their carers to take charge of their own health through self screening. It also targets the second pillar 'care and cure', under the EIP on AHA, providing a training programme for healthcare workers and creating a framework for integrating dementia services across our target area.

References

1. O'Shea E (2007). Implementing policy for dementia care in Ireland: The time for action is now. The Alzheimer's society of Ireland. 

2. Rachel et al.Ageing in the European Union. Lancet 2013;381(9874):1312@22.

3. Folstein M F, Folstein S E, McHugh P R. 'Mini-mental state'. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.

4. Molloy DW, Alemayehu E, Roberts R. Reliability of a standardized Mini-Mental State Examination compared with the traditional Mini-Mental State Examination. Am J Psychiatry 1991;148:102-5. 

5. Molloy DW, Standish T I M. A guide to the Standardized Mini-Mental State Examination. Int Psychogeriatrics 1997;9(S1):87-94. 

6. O'Caoimh R, Gao Y, McGlade C, Healy L, Gallagher P, Timmons S, Molloy D W. Comparison of the Quick Mild Cognitive Impairment (Qmci) screen and the SMMSE in Screening for Mild Cognitive Impairment. Age Ageing (2012) doi: 10.1093/ageing/afs059.

7. Timmons S, Manning E, Barrett A, Brady NM, Browne V, O’Shea E, Molloy DW, O'Regan NA, Trawley S, Cahill S, O'Sullivan K. Dementia in older people admitted to hospital:! a regional multi-hospital observational study of prevalence, associations and case recognition. Age and ageing. 2015 Sep 28:afv131.

8. Ryan D, O'Regan N, O'Caoimh R, Clare J, O'Connor M, Leonard M, O'Sullivan K, Meagher D, Timmons S. Delirium in an entire Acute Tertiary Care Hospital adult population: prevalence and risk factors. BMJ Open 2013, Jan 7;3(1). doi:pii: e001772. 10.1136/bmjopen-2012-001772. Print 2013.

9. O’Caoimh R, Sweeney C, Hynes H, McGlade C, Cornally N, Daly E et al. COLLaboration on AGEing-COLLAGE: Ireland’s three star reference site for the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). European Geriatric Medicine 2015 Volume 6, Issue 5; 505-511 DOI: 10.1159/000433432.

10. O’Caoimh R, Gao Y, Svendrovski A, Healy E, O’Connell E, O’Keeffe G, Leahy-Warren P, Cronin U, O’Herlihy E, Cornally N, Molloy DW. The Risk Instrument for Screening in the Community (RISC): A New Instrument for Predicting Risk of Adverse Outcomes in Community Dwelling Older Adults. BMC Geriatrics, 2015 Jul 30;15:92. doi: 10.1186/s12877-015-0095-z.

11. O’ Caoimh R, Weathers E, O’Donnell R, O’ Sullivan R, FitzGerald C, Cornally N, et al. The Community Assessment of Risk Screening and Treatment Strategies (CARTS) – An Integrated Care Pathway to Manage Frailty and Functional Decline in Community Dwelling Older Adults. In: Helfert M et al. (Eds) ICT4AgeingWell, CCIS 578, Springer International Publishing, Switzerland, pp. 1–16, DOI:10.1007/978-3-319-27695-3_1

12. Scanlon L, O’Shea E, O’Caoimh R, Timmons S. Technology use, frequency and self-rated skills: A survey of community dwelling older adults. Journal of American Geriatrics Society, 2015 Jul;63(7):1483-4. doi: 10.1111/jgs.13507 

13. Scanlon L, O’Shea E, O’Caoimh R, Timmons S. Assessment of Cognition using Cognitive Training: Comparison of a Commercial "Brain Training" application with the Montreal Cognitive Assessment. Gerontology 2015, DOI: 10.1159/000433432.

14.O’Caoimh R, Sato S, Wall J, Igras E, Foley MJ, Timmons S, Molloy DW. Potential for a "Memory Gym" Intervention to Delay Conversion of Mild Cognitive Impairment to Dementia. Journal of the American Medical Directors Association 2015, Feb 21. pii: S1525-8610(15)00082-1. doi: 10.1016/j.jamda.2015.01.081. 

15. O’Caoimh R,  Gao  Y,  Gallagher  P, Eustace  J, McGlade C, Molloy DW. Which Part of the Quick Mild Cognitive Impairment Screen (Qmci) Discriminates Between Normal Cognition, Mild Cognitive Impairment and Dementia? Age and Ageing 2013; 42: 324-330.

16. O’Caoimh R, Svendrovski A, Johnston B, Gao Y, McGlade C, Timmons S, Eustace J, Guyatt G, Molloy DW. The Quick Mild Cognitive Impairment screen correlated with the Standardized Alzheimer’s Disease Assessment Scale-cognitive section in clinical trials. Journal of Clinical Epidemiology 2014, 67, 87-92.

17. O’Caoimh R, Timmons S, Molloy DW. Screening for Mild Cognitive Impairment: Comparison of "MCI Specific" Screening Instruments. Journal of Alzheimer’s disease 2016, Feb 6;51(2):619-29. DOI: 10.3233/JAD-150881

18. Clarnette R, O’Caoimh R, Antony D, Svendrovski A, Molloy DW. Comparison of the Quick Mild Cognitive Impairment (Qmci) Screen to the Montreal Cognitive Assessment (MoCA) in an Australian Geriatric Clinic. International J Geriatric Psychiatry, 2016 DOI: 10.1002/gps.4505

19. Bunt S, O’Caoimh R, Krijnen WP, Molloy DW, Goodijk GP, van der Schans CP, Hobbelen JSM. Validation of the Dutch version of the Quick Mild Cognitive Impairment Screen (Qmci-D). BMC Geriatrics, 2015, 15:115 DOI 10.1186/s12877-015-0113-1.

20. O’Caoimh R, Cadoo S, Russell A, Tobin S, Crosbie A, McGlade C, Timmons S, Molloy DW. Comparison of Three Short Cognitive Screening Instruments for Mild Cognitive Impairment and Dementia in General Practice. Irish Ageing Studies Review 2015 6 (1) p295.

CHARGE-UCC

Centre for Gerontology and Rehabilitation , School of Medicine, UCC The Bungalow, Block 13, St. Finbarr's Hospital, Douglas Rd., Cork, Ireland

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