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Q&A: Dr Matthew Croucher on dementia test

New Zealand has switched from one dementia screening test to another, from the Montreal Cognitive Assessment (MoCA©) to the Mini-Addenbrooke’s Cognitive Examination (Mini-ACE). The new cognitive screening test evaluates four main areas – orientation, memory, language and visuospatial function. It is now the recommended screening tool for use by primary care and non-specialist dementia services in New Zealand. Here, Dr Matthew Croucher, chair of the New Zealand Dementia Cooperative, tells Eldernet what is different and why the change has been made.

What prompted the switch from the MOCA test to Mini-ACE? 
In June 2019, the MoCA© Clinic and Institute announced that all users of the MoCA© test will be required to complete a training and certification programme every two years at their own cost from 1 September 2020. The potential cost of this announcement to the NZ health sector, in both time and money, is significant. The Ministry of Health and DHB Health of Older People Steering Group sponsored a Cognitive Impairment Assessment Review, managed by the NZ Dementia Foundation, to identify a screening tool appropriate for primary and community care settings, reflecting the predominance of these settings for dementia screening. The Mini-ACE was endorsed as the recommended screening tool.

For someone undergoing the new test, how would that experience differ to the old one? 
The new test is shorter and somewhat less complicated than the old test.

The test itself seems quite simple – what is the science behind it?
The test is designed to find out how well a person’s brain is working over a range of thinking tasks that crop up in everyday life, such as being able to learn and remember things, being oriented to time and place, being able to communicate, and being able to plan and sequence tasks. It is designed to signal when further investigation is necessary, not to diagnose anything by itself. It can also be used to generate a number that measures roughly how well a person can manage certain brain power tasks at one point in time so that this can be compared with past or future ability to track response to treatment or progression of a brain condition. The science behind it went in to working out which tests would be brief enough that they can be done quickly and reliably by different health workers all around the globe, yet still give information that is helpful for the person being tested.

How has the change been accepted by practitioners?
The new test is being picked up rapidly all around New Zealand because the old test is no longer available without paying a significant amount and because trusted representatives of nursing, medicine, psychology and occupational therapy all contributed to choosing the best new test out of the options that were available.

Has the new test changed rates of diagnosis at all?
The new test is not expected to have much impact on rates of diagnosis of dementia illnesses in New Zealand. It is simply a necessary part of a careful diagnostic work-up and it was no longer feasible to use the previously widely used test. The reason that there is minimal impact is that there are much bigger barriers to getting a timely and accurate diagnosis of dementia in New Zealand – and around the world. The main barrier is the stigma that society itself, including health professionals, has when it comes to dementia. People greatly fear dementia illnesses and because there is often no cure available at the moment, there is a widespread but completely false belief that nothing can be done. Imagine if we felt the same about arthritis, heart failure, diabetes, Parkinson’s disease and emphysema! We can’t cure them most of the time either but we don’t seem to have the same response to those conditions. People therefore sometimes avoid telling their GP about memory and brain power problems, and health professionals sometimes avoid doing a careful assessment or making the diagnosis. There are also barriers to do with the confidence that health professionals have to make this diagnosis, because no one wants to get it wrong; and the lack of access to health professional time to carry out the necessary assessment.

What are the big challenges that NZ faces with dementia?
The single biggest problem New Zealand faces is that there is no national coordinated plan to address the fact that current services are already not meeting many of the needs faced by people living with dementia and their whānau, and where there are good services, they are not equally available to everyone. Put this in the context of the number of people affected by dementia rising rapidly and in an entirely predictable way because of our ageing population, and take into account that dementia drives a lot of costs and challenges for people, their families, the health system, and even the economy, and you can see why a national plan is both essential and urgent. That’s why the health sector has developed a national dementia action plan and is working on a similar plan for Māori. What is required is for government to instruct its DHBs to take the problem seriously and adopt these plans.

Is it a high enough priority with health decisionmakers? 
No. There are so many competing demands that health decisionmakers have been continuing in a state closely resembling paralysis.

Dementia is a big focus for the health sector – what advances are coming that will help clinicians and those they are treating? 

Dementia is very important for the health sector; however it is not yet a “big focus”. More like a “big scary smudge”. The main advance at the moment is that a sensible action plan based on good science, best practice, common sense and international experience has been developed. There are changes coming in terms of the science of treating dementia, but they are not yet close despite the frequent media items about the latest piece of the puzzle that keep being hailed as “breakthroughs”. What has already changed is that we now know the kinds of things that can lower our risk of developing dementia in the first place.

There are no surprises! Eat healthily, exercise regularly, don’t smoke or use other drugs, use alcohol sparingly, stay socially active, learn new things, monitor your heart health with your GP from your 30s onward, keep your hearing and vision working as well as possible, minimise the stress that you are under and maximise your ability to cope with it, and get other health problems including mental health problems treated one way or another rather than ignoring them. Guess what? This will also improve your quality of life and lower your risk of cancers, stroke, heart attacks, and diabetes. Not bad, eh?

About Matthew Croucher

Matthew Croucher
Dr Matthew Croucher is a psychiatrist of old age and senior clinical lecturer with mixed clinical and academic roles in the University of Otago, Christchurch, and the Canterbury District Health Board. He is the founder and director of the Canterbury DHB’s Psychiatry of Old Age Academic Unit, which provides teaching, training, research and service management advice in the older person’s mental health sector.

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