Transforming dementia care with better detection tools [PODCAST]

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Neuroscientist Adrian Owen discusses his KevinMD article, “A wake-up call for dementia detection: the urgent need for precision tools across health care.” Adrian highlights the alarming rate of dementia diagnoses worldwide and examines the shortcomings of outdated detection tools like MMSE, SLUMS, and MoCA. He emphasizes the need for innovative, digitally-enabled cognitive assessment tools to ensure early and accurate diagnoses. The conversation explores actionable strategies to integrate advanced neuroscience into primary care, aiming to reduce health care costs and improve patient outcomes.

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This episode is cited in the KevinMD record on aging and dementia.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Today we welcome Adrian Owen. He’s a neuroscientist, and today’s KevinMD article is “A wake-up call for dementia detection: the urgent need for precision tools across health care.” Adrian, welcome to the show.

Adrian Owen: Thanks for having me on.

Kevin Pho: All right. Let’s start by briefly sharing your story and journey.

Adrian Owen: Of course. Well, I actually started working in this area about thirty-five years ago, I’m a bit embarrassed to say. I was a PhD student in the U.K., 1988, working on developing cognitive tools for the detection and the assessment of patients who, in those days, we would just refer to as having dementia. Many of them were Alzheimer’s sufferers.

I went on to take those tools and continue to develop them through the 1990s, the early 2000s. I got into brain imaging, did a lot of studies with positron emission tomography, PET, and fMRI. Then eventually we developed a set of online cognitive tools that are being used quite widely now to assess people in the early stages of dementia, people with MCI who are progressing to dementia, these sorts of things. I do that in the context of my research here at the University of Western Ontario in London, Ontario.

Kevin Pho: All right. We’re going to talk, of course, about your article, “A wake-up call for dementia detection: the urgent need for precision tools across health care.” Now, before talking about your article, I’m a primary care internal medicine physician. So just to give us some context, what are some traditional methods that we use to measure cognition and dementia today?

Adrian Owen: It’s still very widely the case that we use what I would refer to as extremely blunt cognitive tools, things like the Mini-Mental State Examination, which goes back to the 1970s. Slightly more modern, but really a sort of similar tool, is the so-called Montreal Cognitive Assessment. These are simple pen-and-paper tools that ask questions like, “Who are you? Where are you? What day of the week is it?” And we use these to assess whether people’s cognitive capacity is as it should be, given their age.

Now, they’re very blunt. I mean, obviously, if you don’t know what day of the week it is or where you are, then there’s something very seriously wrong with you. And if you can answer all of those questions and more, then there’s probably not something wrong with you. The problem is many, many people fall somewhere in between. The challenge is trying to come up with something that’s a little bit more sensitive to early detection.

It’s not good enough just to be able to know that somebody has dementia. We need to know that somebody is on the road to dementia so that, if we have interventions, we can get in early. If they want to make plans to change their life, they can do that early. And I think that’s the real challenge here.

Kevin Pho: So you’re saying here in the United States, we have the Medicare annual wellness visit exam, where we make patients, for instance, draw a time on an analog clock. We have them say three words and then repeat those three words a certain time later. But those types of assessments, you think, are pretty blunt and not specific enough to measure the spectrum of cognitive defects?

Adrian Owen: That’s absolutely true. There are two problems, in fact. I mean, the first is that they’re very blunt. Obviously, if you can’t draw a clock, then there is something seriously wrong. That’s fair enough. But by then it’s too late. You’re already well down the road of cognitive deterioration.

And the other thing is these tools have been around, these sorts of things have been around, for a long time. And of course, we’ve made massive advances in neuroscience over the last thirty years. We can do better than this. We have sensitive cognitive tools now that can pick up signs of deterioration very early.

But the second issue is: How do we distinguish between different types of brain pathology? How can we tell both between different types of dementia, but also between whether somebody is having a dementing illness versus whether they’ve had a TBI, for example? Well, there are tools that can do this, but things like whether you can draw a clock or whether you know what day of the week it is won’t tell you the difference between those things.

Kevin Pho: All right. So let’s talk about some of these new approaches, which you articulate in your KevinMD article. So tell us how we can move forward.

Adrian Owen: Well, we’ve developed a series of tools, and there are others as well, but we’ve developed a series of tools at creyos.com. I mean, I started doing this back in my PhD days in the late 1980s. The tools are computerized. They now run over the web on a touchscreen. They’ll run on any tablet, and they’re extremely sensitive.

We know that because we’ve conducted many studies in patients with dementia. In fact, tens of thousands of patients have now been tested. But also we’ve conducted brain imaging studies using techniques like fMRI. We’ve done pharmacological studies where we’ve used drugs to show that very small doses of drugs can lead to detectable changes. So we know they’re very sensitive to small changes in cognition. You don’t need to not be able to draw a clock for us to be able to pick up a deficit.

The other thing that’s very important about these is that they have repeated versions. They can be used longitudinally. I actually monitor many of my older family members every three months. I ask them to log into the website, do our tests, and that way we can very easily pick up if somebody is just starting to fall off, much earlier than you could if you were to use a traditional paper-and-pencil test. So they’re very, very sensitive.

They can also distinguish between different conditions. Again, this is largely out of my hands. I mean, one of the great things that’s happened to me over the last thirty years is that people started to use these tests in other labs. I think there’s about three hundred labs around the world that have used the tests now. And of course, they use them to look at other conditions, things like depression, cognition in depression, or anxiety, or ADHD, which then allows us, as we put all the pieces of the puzzle together, to actually come up with patterns of impairment, profiles, if you like, that distinguish particular conditions. And that means we can tell the difference between, for example, a TBI and a dementing illness.

Kevin Pho: So tell us a little bit more about what these tests entail. What’s it like from the patient standpoint? You mentioned they’re on a tablet or on a computer. How many questions are there? How long does it take? And give us an example of the type of questions that are being asked.

Adrian Owen: So these tests are very gamified. I mean, we found very early on that people have to actually enjoy doing these. So they’re presented, as I say, on a tablet, a touch-sensitive screen, or you can do them on a regular computer using a mouse if that’s your preference. They’re little games. In fact, they do all last between 1.5 minutes and 3 minutes. So they’re very short.

That doesn’t mean they’re ineffective or insensitive. We really worked hard to find ways of using the internal algorithms to compute somebody’s ability by altering the test on the fly. So again, unlike a paper-and-pencil test, where it is what it is, you sit down, you do the whole thing, if somebody’s doing really well on one of our tests, we’ll give them harder and harder problems. If somebody’s doing very poorly, we’ll give them easier and easier problems. And in that way, in a very short period of time, we can iterate towards finding out exactly how good they are.

So, as I said, they’re gamified. The things are enjoyable to do. You get points for scoring well. You lose points if you don’t do so well. There’s a lot of feedback, and they’re fun to do.

An easy one to describe is our so-called odd-one-out task, where the idea is you just look at patterns on the screen. You decide which is the odd one out, and this involves a certain amount of problem-solving and reasoning. We start off very easily. There are nine shapes, typically. There may be eight yellow ones and one blue one. Obviously, the blue one is the odd one out. That’s pretty easy.

But the next trial will then get more complicated. They may be squares and triangles that are yellow and blue, and you’ve got to work out which is the odd one out. Then they may get even more complicated. Maybe there are different numbers of squares and triangles of different colors. So we ramp up the difficulty quite quickly, and in that way we can really quite efficiently work out what people can do and what they can’t do and what their actual cognitive abilities are.

Kevin Pho: So as a physician, of course, I’m interested in the clinical implications of these tests. You mentioned that these tests can get more granular in terms of the different types of cognitive deficits. So give us a scenario, an example, about how these digital tests can tease out different points within that spectrum of cognitive deficit and what kind of information I can glean as a physician from those tests.

Adrian Owen: Great question. So let me give you a very straightforward answer. These tests, as I was designing them back in the ’80s and ’90s, the original versions, they were tested on patients who’d had specific lesions of their brain, typically neurosurgical excisions for the removal of tumors or the relief of intractable epilepsy. So some of the early information we had really related performance of the task to particular brain areas. I then went on to use imaging, as I’ve told you, brain imaging studies, to again look at the networks that underpin performance.

Now, what that gives us is a tremendous amount of interpretive power. So, for example, if you perform the twelve tests, which in total is going to take you about thirty minutes, there are shorter versions of the battery, but let’s say you do the whole thing, I can very easily pinpoint that what you might have is a specific impairment of executive functions, in the sense that the tests that load on the frontal lobes are the ones that you’re really bad at.

Maybe your medial temporal lobe tests, your memory performance, is intact, but you’re having problems with problem-solving, with planning, and with reasoning. And that would allow me not only to conclude that you have a cognitive impairment, but that it is located in the frontal lobes of your brain. Maybe you have a more frontal type of dementia than a patient who has a straightforward memory impairment involving the medial temporal lobes.

Kevin Pho: Do you see these tests being used in a primary care setting, or do you see these tests being used in a formal neuropsychological evaluation?

Adrian Owen: So I think they go somewhere in between. As you know, a full two- or three-hour neuropsychological evaluation still remains the gold standard, but it’s extremely expensive, and it’s extremely time-consuming, and not everybody can wait that long.

What the Creyos battery provides is a sort of a quick way of triaging, if you like, who should go on and have that more formal cognitive assessment. I mean, not everybody needs to have that, and we can very quickly work out whether somebody is experiencing problems that need to be looked at more carefully or whether they don’t. And that can be achieved in a primary care setting.

The other thing that we haven’t discussed here is that these tests can be self-administered. Depending on the patient involved, you may want to have somebody sitting with them, leading them through the test, but it doesn’t have to be that way. These are designed so that somebody is fully instructed. They’re given practice trials. Somebody can test themselves, and that means that it can be deployed in a number of different settings.

It can be very easily used as a sort of an early detection tool to determine, “Yes, this person needs to have a full neuropsychological evaluation. Let’s send them off for that, and let’s prioritize that.” Or actually, this is an example of somebody who’s what we call worried well. Actually, for somebody of their age, they’re doing just fine. They don’t need to worry anymore. They don’t need to go off and have an expensive and time-consuming assessment.

Kevin Pho: So currently, how are these tests being used, either in Canada or elsewhere in the world? Are they available for retail use? Can you just download an app, or is it something that needs to be prescribed by a clinician? So currently, how are these tests being used?

Adrian Owen: So they’re deployed really extensively in the U.S., less so in Canada at the moment. But in the U.S., I think we have them in about a thousand clinics. They are commercially available, but they’re very cost effective because, of course, there’s no physical thing that is required. We don’t have to sell a computer or a button or a gadget. It’s all online. It’s all software, so it’s an extremely cost-effective way of doing this.

And it’s done totally remotely. The trials can be set up from our head offices in Toronto. A clinic might buy a certain number of patient tests, if you like. And as I say, they’re set up with an account. They log in. They test the patients themselves. They’re immediately provided with a full readout of the results. It’s all automated, a brief interpretation.

Obviously, at the end of the day, the diagnosis remains with the physician. We’re not going to diagnose the patient for you, but we will give you a lot of information that will assist with the diagnosis. It’s not that you’re left with a whole bunch of numbers that you’ve got to make sense of, because on the back end, more than fourteen million tests have been taken to date.

We have a normative database of seventy-five thousand individuals that have donated a lot of time and energy to telling us about their lifestyle, their medical histories, their background, these sorts of things. And that’s what we use as that normative database, and we can use that to drive the algorithms that actually analyze the data and provide feedback for the practitioner to use in the rest of their assessment and potential diagnosis.

Kevin Pho: Now, can you tell us a story or a case study of a patient using these tests and altering their clinical course, just so we can see some of these concepts that you’re mentioning in practical action?

Adrian Owen: I can tell you hundreds of stories. One would be, again referring to the worried well, we see many, many examples of patients that, in a sense, clog up the system because they’ll go to their doctor and they’ll say, “My memory is not as good as it used to be.” I’m fifty-eight. My memory is not as good as it used to be either. Because I had these tests available to me, I know that my memory is pretty much as good as most other fifty-eight-year-olds in the Western world.

So there are many examples where we’ve used these tests to reassure people, to say, “Well, no, this is not something you need to be worried about. Sure, you’re not as sharp as you used to be, but neither is anybody else of your age.”

On the other side, the flip side is, again, we’ve seen many patients where we can detect very early on that they do have a problem that needs to be looked at. These are people that, typically, very similar scenario, they’ll come in, typically with a spouse or a friend, and say, “Well, we don’t think things are quite right, but we’re not sure.”

And this is important for us to know because, for example, a patient we saw recently had a family history of dementia, and she was very worried that she needed to make plans to reorganize her family finances in order to accommodate this if this was a problem. And in this case, it was a problem. There was clearly evidence that what presented as mild cognitive impairment, MCI, was mild cognitive impairment, excuse me, MCI, which was going to progress to a full dementing illness.

We were able to inform her and her practitioner that this was very likely to be the case, based on the vast number of cases that we’ve looked at in the past. And what she did immediately was to plan. And I think in many cases that is what people need to do, is to change their life plan to take account of the fact that things are going to change fairly rapidly, and they need to take account of that.

Kevin Pho: We’re talking to Adrian Owen. He is a neuroscientist, and today’s KevinMD article is “A wake-up call for dementia detection: the urgent need for precision tools across health care.” Adrian, let’s end with some take-home messages that you want to share with the KevinMD audience.

Adrian Owen: Well, I think number one is that we have an epidemic on our hands. And I do really wish that I had predicted this thirty years ago when I started on this road. I had no idea that what seemed to be a fairly uncommon problem back then would explode into the dementia epidemic we have today. And it is only going to get worse. Everybody agrees that over the next thirty or forty years, we are going to see a huge increase in the number of people who are living with dementia.

And I think the key is going to be early detection. This is my take-home. It’s early detection because there are more than thirty clinical trials going on in the U.S. alone at the moment for potential Alzheimer’s drugs. It’s early days, but the thing we do know about any of these drugs is that getting in early is going to be what’s essential.

The efficacy is unknown, how good any of them are going to be, but we do know that the earlier you get in, the better they’re going to be. And that requires that we pick up signs of dementia early. It also requires that we, as I’ve said previously, work out who’s not dementing early, because we don’t want to be giving drugs to the wrong people. So I think this is early detection, early and accurate detection, really what we need, and this is where we should be putting our efforts in right now.

Kevin Pho: Adrian, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Adrian Owen: My pleasure. Thanks.

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