EpxCogScreen -- A Phone-based Rapid Cognitive Screen (RCS)

Telemedicine is a modern field of clinical medicine that incorporates telecommunication and
information technology to diagnose and manage health care remotely. Interventions range from
telephone reminders to remote physician consultation by video conference. Simple technology
such as telephones and SMS texting are ubiquitous forms of communication that have the
potential to increase the frequency of physician-patient contact. Use of SMS messaging, for
example, may help to improve patient adherence, promote education and engagement, allow
real-time collection of critical biometric and clinical data over time, and bridge the gap
between recognizing adverse events and actual disease management.

One geriatric syndrome that may benefit from early detection is dementia. Dementia is
characterized by impairments in cognitive function, such as memory, comprehension,
visual-spatial orientation, language, and/or judgement. The most common form of dementia is
Alzheimer's disease, but vascular dementia and Lewy-body dementia can also cause cognitive
impairment. It is estimated that 47.5 million people are affected with dementia worldwide and
it is the most common form of disability in the geriatric population over the age of 65,
affecting 1 in 9 people in that population [van der Linde, et al., 2016]. A formal diagnosis
for Alzheimer's relies primarily on clinical evaluation by a clinician (e.g., neurologist,
psychiatrist), usually in conjunction with results from neuropsychological testing and/or
informant reports re patients' memory and thinking.

In 2011, the Affordable Care Act added routine cognitive screening as a component of the
Medicare Annual Wellness Visit, but did not recommend a universal screening tool [Cordell et
al., 2012]. This initiative was supported by many public organizations, including the
Alzheimer's Association. The U.S. Preventative Services Task Force (USPSTF) currently does
not recommend universal cognitive screening for older adults [Lin et al., 2013]. Nonetheless,
there may be benefits to case finding among older adults patients through the use of
screening measures. For example, early intervention has been shown to delay placement into
nursing homes, empower patients to be more involved with their care plan, and allow
physicians to identify and manage comorbidities such as depression, malnutrition, and falls
more effectively [Dubois et al., 2016; Weimer et al., 2009]. Delayed admission into nursing
homes and fewer hospitalizations are associated with decreased healthcare costs for patients,
their families, and the healthcare system [Weimer et al., 2009]. It also has been reported
that a lot of Alzheimer's patients are undiagnosed, in part, because screening has not yet
reached standard-of-practice in geriatric and primary care clinics [Dubois et al., 2016].

Healthcare professionals may not be able to regularly screen for cognitive dysfunction due to
time constraints in clinical practice. Typical neuropsychological tests for cognitive
dysfunction, such as the Mini-Mental State Exam (MMSE), are administered in the physician's
office and can take 7 to 15 minutes to complete. The Rapid Cognitive Screen (RCS) is a 3-item
screening tool that takes less than 5 minutes to complete. This screen has exhibited good
sensitivity and specificity in detecting both mild cognitive impairment and dementia in
patients over the age of 65 [Malmstrom et al., 2015]. EpxCogScreen utilizes the RCS to create
a phone-based screen for cognitive dysfunction that can be done in-home when administered by
a caregiver.

In this study, the RCS will be administered in a healthcare clinic using standard procedures,
and at home using a telemedicine (text-based) format called EpxCogScreen. Patients-caregiver
dyads will be recruited from a geriatric medicine clinic at an academic medical health
center. A healthcare professional will administer the RCS to a patient in the clinic, one
month subsequent to this, a caregiver will administer the RCS to patients in-home via
EpxCogScreen using SMS messaging on a smartphone. Each caregiver will be given the option to
receive RCS administration instructions via text, or to use directions from a handout that
the caregiver received while in clinic. Patient responses will be recorded through text.
Physicians will be notified immediately through EpxCogScreen system if a patients in-home RCS
score is 3 or more points lower than their RCS score from the previous month's healthcare
clinic visit. Individuals will have the ability to opt out of the study electronically via
text and phone at any point during the study.

The association of in-home RCS scores with the clinic RCS scores and with the clinical
diagnosis of cognitive dysfunction in medical records will be investigated in this study.
Data analysis will evaluate the association of RCS components (recall, clock drawing,
insight) and total scores for in-home versus clinic measurements; and the sensitivity and
specificity of the in-home, SMS text-based RCS will be determined by comparison to clinical
diagnosis of cognitive dysfunction from chart review, and by comparison to RCS clinic
results.

Inclusion Criteria:

- Patients must be >65 years old

- Patients must have a caregiver or family member who can administer the intervention at
home

- Caregivers must be between 18-90 years old

- Caregivers must have a working cellular device with SMS texting capabilities

- Both patients and caregivers must speak English

Exclusion Criteria:

- Patients under the age of 65