NeuroVoices: Dustin Hammers, PhD, on Comparative Performance of Cognitive Screening Techniques

Dustin Hammers, PhD

The FDA’s recent decision to convert lecanemab (Leqembi; Eisai), an antiamyloid therapy indicated for early-stage Alzheimer disease (AD), opened the door for greater access and coverage for the agent. To get Medicare coverage, individuals will need to be enrolled in Medicare Part B, have a diagnosis of mild cognitive impairment or early dementia caused by AD, and have a qualified physician participating in a registry with an appropriate clinical term and follow-up. Clinicians participating in the registry need to complete a short data submission.

The conversation now shifts to the process of implementing this therapy into clinical care settings, and ensuring it reaches potentially eligible patients. Cognitive screening tools like the Montreal Cognitive Assessment (MoCA) and the St. Louis University Mental Status (SLUMS), are more traditional methods used in primary care, while the Linus Health Digital Clock and Recall (DCR) is more relatively new to the field. At the 2023 Alzheimer’s Association International Conference (AAIC), held June 16-20, in Amsterdam, the Netherlands, a group of clinicians assessed the performance of these assessments among primary care patients aged 65 and older presenting for any reason.

Led by Dustin Hammers, PhD, the cohort included 114 individuals who performed as impaired or borderline impaired on the DCR. Results showed that borderline impairment on DCR corresponded to MoCA total scores and MoCA Memory Index Score scores slightly below traditional cutoffs (23.65 [SD, 3.3] and 11.65 [SD, 3.2], respectively). Hammers, an associate professor of neurology at the Indiana University School of Medicine, sat down with NeurologyLive^® ahead of the meeting to discuss the study and how it was conducted. As part of a new iteration of NeuroVoices, Hammers detailed the differences in each assessment, advantages digital tools bring, and how they might play a role with the emerging therapeutics.

Can you provide some insight on the research and why it was of interest?

Dustin Hammers, PhD: We are living and working in an exciting time for Alzheimer disease. With some of the findings coming out for lecanemab (Leqembi) and other drugs, we are at a point where there's a lot of hope about disease modifying treatments. In order for those disease modifying treatments to be able to be implemented to folks at home, we need to have a way to cognitively screen individuals, thus allowing our system to and the drugs that we develop, to be provided to the folks that need them. This study is highlighting some of the work that we've done through the Davos collaboration and our work with Linus health. Through Indiana University School of Medicine and Indiana University Health, we have rolled out an implementation of a certain form of cognitive screening, which is specifically using the Linus Health digital cognitive screening platform. With that, provided [this platform to] the individuals who are coming to 6 different Indiana University Health primary care sites for noncognitive issues, but for any reason whatsoever.

If they're over the age of 65, we’re administering a digital cognitive assessment to them. From there, based on the results of the digital cognitive assessment, those individuals may or may not be referred on to a brain health navigator who will connect them with appropriate resources. That could be from a clinical side related to working with a neurologist, and eventually, hopefully, having them access medications, or on the research side, where we are essentially creating a registry of individuals over 65 [years of age]. Again, these patients are coming from primary care, this was not specialty referred, which we know looks a little different than primary care folks and some of their concerns.

We're hoping to be able to access individuals early on if they're having cognitive difficulties related to Alzheimer's disease, we can access them early on in the disease process. While we were rolling out this implementation, we were able to collect some data on individuals who have gone through this Linus Health digital cognitive assessment. They were able to access both the digital assessment, and when they've met with a brain health navigator, we followed up with providing them with a MoCA or SLUMS test. A lot of clinicians will be much more familiar with the MoCA and the SLUMS, which is the traditional format that individuals are frequently assessed for their cognition, both out of 30 points.

This digital cognitive assessment [Linus Health Digital Clock and Recall] is provided over a tablet and looks a lot like the Mini-Cog. There is a three-word list, followed by a copy of a clock and the completion of the clock upon demand. That is that is done on a digital platform, so not only are overall performances scored, but process, speed, and accuracy, all those details, are incorporated into performance score. Following up, patients undergo the delayed recall of those three words, and it only takes a few minutes for individuals go through. In this study, we are specifically looking at the results of our individuals who took both the DCR and primarily the MoCA: we had all 114 people complete the MoCA, but there was also a smaller subset that additionally did the SLUMS. This was only 13 individuals, so about a little under 10%. But [we] still wanted to at the convergent validity of performance of the DCR on these other abilities and measures.

Although slightly different, what advantages to each of these assessments have?

When we're talking about the MoCA, the MoCA has tradition on its side, as does the SLUMS. The MoCA is probably the most familiar of all 3 measures, and its tapping into a variety of cognitive abilities, orientation, naming, language, memory, and executive functioning. There are visual executive visual skills in there as well. The SLUMS is administered similarly. In my experience, the SLUMS is very frequently administered in a VA (veteran affairs) setting. Looking at similar domains related to the MoCA, both of which take 10 or 15 minutes to assess. Again, these are paper and pencil.

These are established tried and true measures that most of the neurologists who are probably be interested in Alzheimer disease are familiar with. The Linus health digital cognitive assessment, or the DCR, is somewhat different. It's tapping into memory capacity and executive capacity with the drawing of the clock in both the copy and on command, and also visual spatial capacity. Because this is done in a digital format, one of the areas that I was most intrigued with was the ability to look at underlying process scores. That's an area that I'm very interested in for my own research, looking at traditional measures, and the process or patterns of performance underneath those total scores. This may give us some insight into overall functioning or overall difficulty or disease state or something along those lines.

I do feel that each of these bring their own uniqueness. There's not much research on the DCR out there. Any kind of convergence that we are seeing could be helpful, particularly if this is something that's easy to administer in a primary care setting that you don't need a specialized technician for. As a neuropsychologist, my technicians have been extremely well trained, but because of there aren't as many of us as possible. Something that is packable, like a digital tool, could have a lot of potential.

Transcript was edited for clarity. Click here for more NeuroVoices.

REFERENCE
1. Hammers DB, Fowler N, Brosch J, et al. Comparative performance of the Digital Clock and Recall (DCR) test, Montreal Cognitive Assessment (MoCA), and Saint Louis University Mental Status (SLUMS) among patients in primary care. Presented at: 2023 Alzheimer’s Association International Conference; June 16-20; Amsterdam, Netherlands. Abstract 79034