Using a digital test to find early signs of cognitive decline

While there is no cure for Alzheimer’s disease, doctors say earlier detection of cognitive decline can lead to more effective interventions.

Researchers at UMass Chan Medical School are studying the use of digital tools to identify patients who may be experiencing cognitive decline, even if it’s not readily apparent.

They are examining how patients fare with a digital test developed by Linus Health, a technology company in Boston. Patients take a short test on an iPad. The test only takes a few moments, which the company says can be done more easily in the workflow of a primary care physician’s office.

John Showalter, chief product officer of Linus Health, notes that paper-based tests can take 10-20 minutes. He also notes that the digital test doesn’t have to be performed by a physician. It could be done by a nurse, nurse practitioner or a medical assistant.

With the Digital Clock and Recall test, patients draw clocks on the tablet, and they are asked to repeat three words they were given at the beginning of the test.

The test evaluates how long patients took to draw the clock, the spacing of numbers, and if the clock is circular. The test also analyzes the tenor and pitch of the patient’s voice in repeating the words to detect signs of cognitive impairment.

The digital tests are also being studied at Indiana University Health and Emory University, Showalter tells Chief Healthcare Executive®.

“The biggest early feedback is people are very excited by this being able to be done in the primary care workflow,” he says. “And then it's been able to be done by somebody other than the primary care provider, whether that's the physician, the NP, or the PA. And we are also hearing that we're identifying a number of individuals that the primary care physicians thought were cognitively normal.”

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The digital test “takes a lot of the subjectivity” out of identifying signs of decline, Showalter says.

“It takes a lot of the human error out of it,” he says. “And that really does increase the accuracy of the clinical guidance.”

(The researchers talk with Chief Healthcare Executive in this video. The story continues below.)

Doctors see ‘a big problem’

David McManus, professor and chair of medicine at UMass Chan Medical School, says the research so far has been encouraging. Researchers talked with primary care doctors to gauge their interest and determine if they were concerned that some patients may be affected by cognitive impairment, even in subtle ways that may not be easily detected.

“Overwhelmingly, they said, interestingly, that it was a big problem,” McManus tells Chief Healthcare Executive.

“I was struck by the degree to which there was consensus, actually, at least at UMass, that in our primary care population, quite a few older adults are treated and our docs are suspicious that they have memory issues and other cognitive impairments or domains that are affected. But they don't routinely screen for these and therefore, they're kind of flying blind,” he adds.

McManus says he has been impressed with the number of patients who have finished the testing in the pilot program, and it’s been useful to physicians.

In some cases, physicians are altering medication plans or taking different approaches in treatment, or they're getting other family involved to tell them their loved one is showing signs of cognitive impairment, McManus says.

Patients are generally comfortable with the digital tests, Showalter says. If patients are a little uneasy with using a tablet, doctors will get them to draw a couple of lines to get more comfortable.

Honghuang Lin, a professor and co-director of the program in digital medicine at UMass Chan Medical School, says it’s important to help patients with Alzheimer’s as soon as possible.

“There's no treatment that can reverse Alzheimer's disease, or cognitive impairment, but we have new treatments that can slow or reduce cognitive impairment,” he says. “But these treatments are most effective for early stages of Alzheimer's disease. And that's why we are interested to see if we can identify people with early signs of Alzheimer's disease as early as possible.”

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Knowledge is power

Some could wonder how useful the testing will be because, as McManus says, treatment options for Alzheimer’s are relatively limited. The Food and Drug Administration last week granted approval of Leqembi, an Alzheimer’s treatment that has been found to slow the progression of the disease.

Still, McManus says there are strong arguments for helping more people detect cognitive decline at an earlier stage.

“From an ethical perspective, and from an operational perspective, it's often very empowering for patients, before they develop dementia, to put their own care plans in place,” McManus says. “Like being able to have a conversation with someone about what might come in the next decade enables them to get their finances in order or to get a durable power of attorney.”

Patients can also determine if they want to be hospitalized or intubated as their disease progresses. “It enables those types of conversations,” he says.

Showalter says he hopes Linus’ digital tests can eventually be utilized by more primary care physicians. While primary care doctors are very pressed for time, he says the fact that the testing can be done in a couple of minutes can make it more feasible. He suggests that could facilitate more conversations and help more patients learn if they are having signs of cognitive decline.

Plus, patients increasingly want to know if they have a problem, he adds.

“There's this disconnect between patients wanting to know and physicians believing that patients want to know because, historically, we haven't believed there's a lot to do,” says Showalter. “But that conversation really is changing.”

Many physicians undoubtedly find it difficult to talk to patients about the possibility of cognitive decline, Showalter says, but he views them as necessary so patients can have their best chance at a higher quality of life, or to at least prepare for what’s coming.

“I'm a primary care physician and these are tricky conversations,” Showalter says. “And what I remind my peers is the fact that we're used to having hard conversations.”

McManus says while the early results are encouraging, he says more study is needed.

“Now, what we have to come back to formally assess at the end of the study, the surveys and interviews with patients and doctors, is the extent to which they think it really helped,” he says.