MoCA: Turn Your Mind to It

The prospect of adding yet another screening test to the list of assessment tools used in the dialysis unit may seem daunting; yet, it affords an exciting opportunity to enhance care and workflow within a dialysis suite. Recent data showing that hemodialysis treatments contribute directly to vascular changes in the brain have helped explain the high burden of cognitive impairment seen in individuals undergoing maintenance dialysis.¹ Dialysis treatments themselves cause cerebral stunning, and they likely contribute to the accelerated rate of decline in cognition seen in kidney disease compared with the general population. The clinical effect of cognitive impairment is wide ranging, with reduced quality of life, independence, and social functioning and a likely effect on patient participation in essential components of disease self-management (e.g., diet and medication). With this in mind, screening offers the opportunity to detect and accommodate, where possible, in response to cognitive deficits.

In this issue of JASN, Drew et al.² provide data supporting the use of the Montreal Cognitive Assessment (MoCA) as a valid cognitive screening tool in the dialysis unit. They used detailed data from a battery of psychometric tests collected from 150 individuals maintained on dialysis to compare results of simple screening tests with an in-depth neuropsychiatric battery. From those screening tools included, the MoCA had the best performance, lowest misclassification, and highest accuracy. Their results suggest it may be a valuable tool for routine use to monitor cognition in the dialysis suite. Although the data collected by Drew et al.² were cross-sectional in nature, the MoCA has also been validated in other populations to follow individuals longitudinally over time. Multiple versions of the MoCA are also available to reduce learning effects, even when used after short intervals.³ The MoCA, however, remains a screening test, and much more is still to be learned about how to use it in the dialysis unit. For example, Drew et al.² include no information on the clinical effect of the cognitive changes that they found, and they did not include patient or family reports on social functioning or quality of life. Both cognitive impairment and dementia are partly defined by their effect on the individual’s ability to function in his or her own environment.⁴ For example, someone with a career background in administration might remain independent despite cognitive decline by using his or her organizational skills to label cupboards or make lists and could, therefore, be deemed as having mild cognitive impairment. However, an individual who, despite milder impairment on testing, is unable to complete functional tasks (e.g., making a cup of coffee) could be diagnosed with dementia. The importance of consultation with the patient and caregivers and further follow-up by a qualified individual is, therefore, paramount in determining appropriate diagnosis and intervention. Other considerations are also important for future research and clinical implementation of the MoCA. For example, it remains unclear when and how often in the patient’s trajectory screening with the MoCA is best applied. Upcoming changes to MoCA training requirements are also important. From September 2020, access to the MoCA will be restricted to users with official certification.³ Although this certification is only composed of a 1-hour online training module (at a cost of US $125), it is likely to be a deterrent for some clinicians. Finally, language proficiency is an important consideration with the MoCA. Although it has been translated into >100 languages, the tool still requires an administrator who is proficient in the client’s language to ensure accurate results. When no such person is available, an alternative screening test designed to minimize the effects of cultural learning and language diversity, such as the Rowland Universal Dementia Assessment Scale,⁵ is advised.

What is in the future? Early recognition of cognitive impairment offers much by way of supporting patients. However, we believe that routine use of the MoCA is recommended only if we implement other changes in how dialysis care is delivered. Dialysis units may wish to modify care such that patients with cognitive impairment receive care in nested “cognitive corners,” where patients are cared for in a consistent and unchanging environment with minimal wait times, stable patterns of activity, and care provided by a limited group of personnel who become familiar to the individuals. Medical teams could develop systems that incorporate cognitive data into their assessments, better prognosticate, and after open and honest discussions with our patients, consider adapting or modifying care along a palliative dialysis path that prioritizes patient experiences over medical targets.^6,7 Finally and perhaps most importantly, key to progress is the engagement of occupational therapists to support patients as they learn how to overcome cognitive deficits and prolong functional independence beyond initial expectations. From the patient perspective, early recognition of cognitive changes may offer an opportunity to plan in advance for upcoming changes, to retain their identity and dignity, and if appropriate, to plan for in-home support or placement.

Funding

Ms. Farragher is supported by a postdoctorial fellowship from the Canadian Institute of Health Research.