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DEMENTIA AND MILD COGNITIVE IMPAIRMENT

1. What is the difference between Mild Cognitive Impairment (MCI) and Dementia?
2. What causes MCI and Dementia?
3. Why is it important to identify MCI?

EVALUATING COGNITIVE ASSESSMENT

1. What is a cognitive assessment?
2. What should one look for when evaluating a cognitive assessment?
3. What does a cognitive assessment identify?
4. How is the accuracy of a cognitive assessment evaluated?

ABOUT THE MCI SCREEN

1. Is the MCI Screen like the MMSE?
2. How accurate is the MCI Screen?
3. What makes the MCI Screen so accurate?
4. Can I administer the MCI Screen on paper?
5. Has the accuracy of the MCI Screen validated?
6. Can anyone administer the MCI Screen?
7. Will a patient's personally identifiable information collected by Medical Care Corporation be used for research?
   
8. Is the MCI Screen designed for a specific age group?
9. To whom will the MCI Screen test results be compared?

1. How much time do I need to incorporate memory assessment services into my practice?
2. How much does it cost to get started?
3. How much does it cost to use Medical Care Corporation's products?
4. Do Medicare and other major payors reimburse for using the MCI Screen to assess for memory loss?
5. Does Medical Care Corporation provide patient education materials?
6. To prescribe cholinesterase inhibitors some insurers require a patient's MMSE score in order to get prior authorization. Will I need to administer the MMSE as well as the MCI Screen?
7. As a physician, do I need to report to the DMV any patients I identify as impaired?

ACCOUNT ADMINISTRATION

1. What happens when I create a trial account?
2. Is it possible to share patient profiles with another doctor in our group?
3. There are multiple doctors in our practice using the product. May we be invoiced as a group?
4. I have forgotten my password. What do I do?
5. I have been locked out of my account. What do I do?

PRODUCTS OTHER THAN THE MCI SCREEN

1. What is the Depression Screen?
2. What is the Prevention Program?
3. What is FAST Staging?

DEMENTIA AND MILD COGNITIVE IMPAIRMENT

a. What is the difference between Mild Cognitive Impairment (MCI) and Dementia?
Neither MCI nor Dementia are diseases. Rather, these two terms refer to differing degrees of reduced cognitive function.

• MCI refers to a subtle yet measurable cognitive deficit. Persons with MCI have impairments limited to one category of cognitive function (e.g. memory, judgment, reasoning, object recognition), but impairment does not interfere with their activities of daily living (such as bathing, dressing, etc.). If the medical condition causing MCI is not treated, the patient will often progress to dementia.

• Dementia refers to impairment in two or more categories of cognitive function that interfere with the person’s ability to function in their daily social, professional, or personal routine.

b. What causes MCI and Dementia?
The main cause of MCI and Dementia is a group of disorders called Alzheimer's disease and Related Disorders (ADRD). Approximately 60% of the cases of MCI or Dementia are due to Alzheimer's disease and another 20% are due to vascular dementia. Smaller numbers of cases are caused by Parkinson's disease, Lewy Body disease and frontal lobe dementia. Approximately 5% of patients with MCI or Dementia will have completely reversible conditions such as depression, vitamin deficiency or thyroid problems. Treatment efficacy for those with ADRD is highly dependant on timely intervention and can be substantially beneficial when treatment is begun early.

c. Why is it important to identify MCI?
Identifying MCI enables early diagnosis of the underlying disorder. Just like other conditions such as diabetes or heart disease, the earlier the diagnosis of a cognitive disorder is made, the more effective treatment will be. Early detection and proper treatment of Alzheimer's disease can delay the progression of the disease by approximately 50% in some cases.

EVALUATING COGNITIVE ASSESSMENT

a. What is a cognitive assessment?
A cognitive assessment is a test that evaluates a person's cognitive function such as memory, language, recognition and judgment and reasoning by asking the patient to answer certain questions or complete specific tasks. These tests can vary, and include simple paper-based tests, computerized tests and in-person or phone interviews administered by professionals.

b. What should one look for when evaluating a cognitive assessment?

• Comparisons to baseline tests - some tests establish a baseline score for patients so that subsequent test results may be compared to previous results in order to identify changes in a patient's cognitive function. Computerized tests facilitate the establishment of baseline scores and enable clinician’s to more easily evaluate longitudinal results.
• Comparisons to normative data - some tests compare an individual's results to normative data for people in their peer groups. Tests can make comparisons on one or two demographic factors (usually age and/or education level) or a wider range of factors such as overall response patterns. In general, the more sophisticated the use of comparison data, the greater the predictive power of the screen.

c. What does a cognitive assessment identify?
Different assessments evaluate different cognitive functions giving insight to the health of the part of the brain associated with that function. These cognitive domains include memory, judgment and reasoning, orientation, verbal fluency, and others. However, cognitive assessments do not provide a final diagnosis. They merely identify suspicious signs that should be further evaluated by a medical professional. The earlier a physician identifies the cause of any problem flagged by a cognitive assessment, the better the likelihood for a good treatment outcome.

d. How is the accuracy of a cognitive assessment evaluated?
The accuracy of a particular cognitive screen must be measured by its ability to correctly identify a cognitive problem (sensitivity) without incorrectly classifying a normal response as impaired (specificity). In general, the higher the sensitivity and specificity of a particular assessment tool are, the more accurate the results of that tool will be.

In evaluating the accuracy of various assessment tools, it is important to consider the minimum severity of impairment that the tool can detect. Depending on the underlying medical condition, individuals often have mild cognitive impairment for seven or more years. While many tests claim a high accuracy rate for detecting moderate dementia, very few are sensitive enough to identify early stages of subtler impairment classified as mild cognitive impairment or mild dementia.

ABOUT THE MCI SCREEN

a. Is the MCI Screen like the MMSE?
While both the MMSE and the MCI Screen are used for assessing an individual's cognitive function, there are several key differences between the two. First is the difference in accuracy. The MCI Screen is approximately 99% accurate in identifying early stage dementia, while the MMSE is approximately 70%* accurate. For identifying a subtler stage of decline, mild cognitive impairment, the MCI Screen is 97.3% accurate while the MMSE is approximately 50-60%* accurate.

The MMSE is a paper test that evaluates several functions including: orientation, registration, attention and calculation, recall and language. Such an approach is useful when a medical problem is quite advanced and a physician is monitoring further cognitive decline.

The MCI Screen is a computer-based test focused primarily on short-term memory, but also tests working memory and judgment. Using an advanced scoring algorithm, the MCI Screen can accurately identify very early stage memory loss.

b. How accurate is the MCI Screen?
The MCI Screen is 97.3% accurate in distinguishing disease-related memory loss from normal aging. It is 99% accurate in identifying early stage dementia (specificity of 96% and a sensitivity of 91%).

c. What makes the MCI Screen so accurate?
The MCI Screen is based on the 10-Word Recall Test included in the CERAD (Consortium to Establish a Registry for Alzheimer's Disease) battery, the assessment used by dementia specialists. The 10-Word Recall Test requires the subject to memorize and recall a list of 10 words.

Medical Care Corporation gathered the response patterns on the CERAD wordlist for several hundred subjects as well as complete physiological, neurological, and psychological exam data on each subject. Using advanced mathematics, we analyzed the responses of subjects in the database to isolate differences in the response patterns of normal subjects compared to those with memory disorders. By classifying over one trillion response patterns, we developed methods to accurately identify the earliest stages of memory loss.

d. Can I administer the MCI Screen on paper?
Administering the MCI Screen on paper is possible but not recommended. Since the test is scored electronically, the data must be input into a computer before results can be tabulated. As such, online administration eliminates this necessary data-entry step. Further advantages of online administration include automatic randomization of the wordlist for a given subject and real-time report generation.

e. Has the accuracy of the MCI Screen validated?
Yes. The MCI Screen was originally validated in a study of 471 community dwelling adults whose scores on the Clinical Dementia Rating Scale ranged from 0 (normal: N=119), 0.5 (mild cognitive impairment: N=95), to 1 (mild dementia: N=257). The MCI Screen showed overall accuracy of 98% with sensitivity of 96% for mild cognitive impairment or mild dementia, and 91% specificity for normal aging. The accuracy of the MCI Screen was published in the Proceedings of the National Academy of Sciences (Shankle WR. et al. PNAS. 2005; 102(13): 4919-4924).

The MCI Screen was further validated in a study of 182 patients whose FAST stage ranged from 1 (normal) to 4 (mild to moderate dementia) in primary care settings, and was also compared to Mini Mental State Exam (MMSE) and Clock Drawing Test (CDT). The MCI Screen showed over all accuracy of 97%, while MMSE and CDT showed 76% and 69%, respectively. (Trenkle DL. et al. JAD. 2007; 11(3):323-335.)

f. Can anyone administer the MCI Screen?
Yes. After becoming familiar with the test protocol, anyone can reliably administer the MCI Screen with a high degree of accuracy. No specific training or credentials are required.

g. Will a patient's personally identifiable information collected by Medical Care Corporation be used for research?
No. All patient data is completely protected by HIPAA regulations and cannot be used in any manner that requires patient identity. However, Medical Care Corporation does use de-personalized, aggregated data for research and development purposes.

h. Is the MCI Screen designed for a specific age group?
The data set from which the underlying algorithm was developed included individuals ranging in age from 30 to 89. As such, the technology is most accurate when used on patients across that age range.

i. To whom will the MCI Screen test results be compared?
For each patient, their performance is compared to a group of demographically similar test subjects (same age, gender, race, and level of education).

ADDING MEMORY ASSESSMENT SERVICE TO YOUR PRACTICE

a. How much time do I need to incorporate memory assessment services into my practice?
The time required is minimal. Establishing your online account requires about ten minutes. From there, each individual who will be testing patients should administer two practice tests; this training will take about 20-30 minutes. After those steps have been taken, you will be ready to begin assessing patients. Each patient assessment will likely take between 8 and 13 minutes depending on the cognitive health of the patient.

Click here to see how other physicians have implemented Medical Care Corporation's technology in their practices.

b. How much does it cost to get started?
If you have a computer with an Internet connection in your practice, then you have everything needed to get started. There are no set-up costs or other software or hardware purchases required.

c. How much does it cost to use Medical Care Corporation's products?
Medical Care Corporation charges on a per use basis as follows: MCI Screen, $25; Depression Screen, $10; Prevention Report; $20, Memory Screen; $15. Included in Medical Care Corporation's system is free use of the FAST Staging tool for all patients. You will receive an invoice at the beginning of each month reflecting your activity during the previous month. Invoices are due upon receipt.

d. Do Medicare and other major payors reimburse for using the MCI Screen to assess for memory loss?
Yes. Please review the reimbursement section for further details.

e. Does Medical Care Corporation provide patient education materials?
Yes. To our customers, we provide a free brochure on memory loss both in English and Spanish, which can be placed in waiting rooms and exam rooms. To receive a free brochure, please contact customerservice@mccare.com.

f. To prescribe cholinesterase inhibitors some insurers require a patient's MMSE score in order to get prior authorization. Will I need to administer the MMSE as well as the MCI Screen?
You may use the FAST staging tool, available in our system to stage the patient and determine the corresponding MMSE score. (The FAST staging criteria takes less than 2-minutes to apply.) For many insurance companies, 24 is the highest MMSE score acceptable to authorize a cholinesterase inhibitor prescription, however, this number can vary between different insurers.

g. As a physician, do I need to report to the DMV any patients I identify as impaired?
Most states "permit" physicians or "encourage" physicians to report unsafe drivers to the DMV but few have legal requirements to do so. Of those that have requirements, they are generally restricted to a diagnosis of disorders that are associated with seizures or loss of consciousness. To review the specific guidelines for your state, please follow the URL below to the legal summaries from all 50 states. This is published by the National Highways and Traffic Safety Administration.

http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Chapter8.html

ACCOUNT ADMINISTRATION

a. What happens when I create a trial account?
Once an account has been established, you will gain access to our technology and you will have 15 days to evaluate the system free of charge. When you login after 15 days, you will see a pop-up window asking you to accept our Payment Terms. For continued access to the system, you will need to accept the Payment Terms, which will grant you unlimited access going forward. You will be invoiced at the beginning of each month for all your activity during the prior month. You will only be invoiced for those assessments done after you accepted the payment terms.

b. Is it possible to share patient profiles with another doctor in our group?
Yes. We can link two or more accounts so that all patient records created within a medical group are available to each member of the group. If you would like to have your accounts linked, please contact us at (888) 565-5535 or customerservice@mccare.com. We will need the User ID (email address) for each account.

c. There are multiple doctors in our practice using the product. May we be invoiced as a group?
Yes. Invoices are generated for each user. If you would like multiple users to be included on one invoice please let us know by contacting (888) 565-5535 or customerservice@mccare.com.

d. I have forgotten my password. What do I do?
You may click "Forgot Password" on the login page or, alternatively, visit the following url: http://www.mccare.com/infoducer/forgotpwd.jsp and type in the email address you used to create your account. A new password will be emailed to you immediately. You may change your password by logging into our system at www.mccare.com and clicking on the "change password" link.

e. I have been locked out of my account. What do I do?
If you are not certain of your password and make several attempts to login with an incorrect password, our system will lock you out for security purposes. Please contact us at (888) 565-5535 or customerservice@mccare.com to have your account unlocked.

PRODUCTS OTHER THAN THE MCI SCREEN

a. What is the Depression Screen?
The Depression Screen is a short electronic questionnaire used to assess an individual's depression status. It is based on the DSM-IV criteria for major depressive disorder and is useful in ruling-out depression as a cause of memory loss. In most circumstances, assessing a patient with the Depression Screen qualifies for reimbursement from Medicare and other major payers.

b. What is the Prevention Program?
The Prevention Report is an electronic questionnaire, which assesses dementia risk factors by checking an individual's medical history, life style, and family medical history. After completing the questionnaire, a personalized report is generated containing risk factor identification and analyses, preventative strategy recommendations, and other educational information about the prevention of ADRD. The Prevention Report is based on a comprehensive review of published literature and evidence-based medicine research.

c. What is FAST Staging?
The FAST is an electronic version of the most accepted clinical framework for measuring the course of Alzheimer's Disease. It can be used for differential diagnosis and for measuring treatment effect in Alzheimer's patients under your care. (more about FAST [pdf: 83k]).