Check-engine-light for the Brain: Part 2

Mild Cognitive Impairment: Screening Tools

Jul 24, 2023

Here is the second installment of the exploration: Check Engine Light for the Brain”, (see Part 1 for the background to this exploration).

In this email (Part 2 of our ongoing exploration) we start exploring how to track changes in cognition over time, and explore whether the types of tests used by clinicians to screen for mild cognitive impairment are useful ingredients for the “check engine light for the brain” idea.

This post is public so feel free to share it.

About this Exploration

Before diving into the substance, here are a few caveats:

we are doing this exploration because a group of Longevity Explorers are interested in finding out whether or not there is a way they can cobble together some type of “check-engine-light for the brain” to use for themselves.
We are not doing it to try and sell anything to anyone. Apart from possible subscriptions to this newsletter, we do not make money in any way by doing this work. The companies (if any) mentioned in this exploration do not compensate us either directly or indirectly.
During this exploration, we will be “learning in public”. This means we will be sharing what we learn as we learn it. While we try to be objective and accurate, it is possible we will make mistakes. Feel free to share what you know in the comments, and help us learn, and correct us if we make errors (please provide facts and references rather than assertions).
While our explorer community includes individuals with relevant experience for this exploration, you should not rely on results of our exploration for medical advice of any sort. When it comes to your personal health, “consult your physician” is always good advice.

Who is this Exploration For?

The way we conceive of the “check-engine-light for the brain” is as a tool to be used by older adults who want to plan for the future, and who want to have a tool to help them think about their own cognition and keep an eye on any changes to it.

In the world of healthcare, the sort of people who might want this are sometimes called the “worried well”.

This exploration is not designed for people who have cognitive impairment or dementia, or for their caregivers. However some of the things we learn might be useful for those groups.

Tools to Track Cognition Over Time

As described in Part 1 of this exploration, a key ingredient for the check-engine-light idea is a way to measure “cognition” in some way and track it over time.

Cognition Monitor Requirements

This "cognition monitor" would satisfy some specific criteria (see below).

It does not need to be perfect, or absolute, although those would be good attributes. But it needs to measure and track a proxy for cognition or dementia risk over time. And tell you something about where you stand compared to some metric of "goodness or badness".
The cognition score needs to be given to you, as the older adult (ie you are in charge, not "the system") — with educational tools so you know what it means. It might need to involve a family member as well, or even instead, if there is signficant cognitive impairment.
And ideally this would all happen at home, and not require a trip to see some type of healthcare person.
And it would be up to the older adult to decide who was allowed to see the cognition score, and what they would do about it (perhaps with pre-agreed involvement of a family member at certain score levels?).
And it would track changes over time. Because often it would be changes over time that would trigger a desire to "do something" rather than an absolute number.
And the score would need some peer-reviewed validation.
Especially important: the score would need to cover all the relevant aspects of cognition. It should not be limited to just one aspect (eg memory) if there are other aspects of cognition that matter for measuring dementia and cognition impairment.

Cognition is a Broad and Confusing Subject

As soon as you dig into the scientific literature about the brain and aging and dementia, you realize that there is a lot the scientific community does not yet know about this topic.

Even if we narrow the focus to measuring cognition, the discussion can easily veer off into the metaphysical. People ask questions like: “What is cognition?” or “What is intelligence”?

Luckily, as we thought more about the exploration, we realized we don’t really need to tackle those sorts of questions to make progress. Here is how we narrowed our scope.

We are interested in any measurements that relate to cognitive abilities, but most relevant are measurements that relate to the potential for future cognitive impairment. Furthermore, while there are powerful and fascinating measurement techniques (like fMRI and PET) used for research that are relevant to our topic, we are looking for measurements that can be done at home without large or expensive equipment, and which can be tracked over time by the DIY explorer.

Tools to Explore

If you think about it, measuring things relating to cognition happens at many points in one’s life. For example, consider the IQ tests and various exams (SAT’s in the USA) that are key way points along the path to adulthood for many of us.

However, for this exploration we started by focusing on measurement techniques used by the scientific community to study cognition in older adults. Of especial relevance are the measurement techniques clinicians use in studies that look for risk factors for dementia and cognitive impairment.

The rest of this Part 2 of our exploration is about our experience as we explored these “screening tools” for Mild Cognitive Impairment (“MCI”).

Screening & Diagnostic Tools: MCI

Clinicians today have some tools that let them measure aspects of cognition and they use these tools to help diagnose mild cognitive impairment (MCI) and dementia, for example. These do not satisfy all the criteria above, but are an obvious starting point for this exploration.

If you are wondering about how a doctor goes about deciding whether or not a person has MCI or dementia, there are a couple of excellent posts by Dr Leslie Kernisan (a Geriatrician) on that topic in the references at the end of this post (Ref 1).

A key part of the workup for deciding whether or not a person has MCI is a simple “assessment test” that is typically performed in the doctor’s office. These “assessments” are very relevant to this exploration, and we explored them in some depth.

There are several “assessments” that are used (Ref 2), with different clinicians preferring one or the other of them (there are pluses and minuses of each). These assessments include:

MiniCOG;
Montreal Cognitive Assessment (MOCA);
Mini Mental State Examination (MMSE);
St Louis University Mental Status Exam (SLUMS);
Self-administered Gerocognitive Examination (SAGE).

These assessments have some common features.

They typically involve a series of questions that test different aspects of cognition.
They are quite short, designed to be completed in a “few” minutes and to fit into a short physician visit.
Here are some examples of what these assessments might include:
1. naming things (label a picture of a camel for example);
2. visuospatial / executive function (connect numbers and letters in some specific way for example)
3. memory (remember some key words); and aspects of
4. attention, language, abstraction, delayed recall, and orientation.
They were designed with the idea that you would be sitting in front of the physician who would direct the questioning and observe the responses.
Some of the assessment tasks would likely be impacted by physical impairments, and not just cognition issues. For example, some require motor skills (drawing a clock face) and most require either hearing or vision or both. In addition, the tests assume comprehension of the language of the doctor (eg english).

Wondering How You Would Score?

For the intellectually curious older adult, it’s hard not to wonder “how would I score on one of these assessments?”

So, a handful of Longevity Explorers decided to try out some of these tests, in part out of interest, and in part to see if they might be relevant as a check-engine-light metric.

If you are interested, it turns out to be easy to do a self assessment, so read on if you want to know how.

Cognitive Screening “Home Evaluation”

Of course, you could go to your doctor and ask for a MCI screening test.

So long as you can find a friendly geriatrician, and so long as you can get an appointment, and so long as you don’t mind the cost, and so long as you are not embarrassed to do that.

If you are worried you might have MCI, we would recommend talking to a suitably qualified doctor.

However, for our exploration and for the check-engine-light concept, the explorers wanted something simpler, cheaper, and more in their control. We wanted a digital version of one of the above tests that could be done at home.

The Home MCI Screening Evaluation We Used

We decided the ideal test we wanted to try was one that met this set of criteria:

digital so it can be done at home using some simple electronics (like a tablet or phone);
developed by doctors and scientists and validated in peer-reviewed journals;
“similar” in “screening perfection” to the office based tests above;
trackable over time (so you can see how you perform over years);
private (so you can see the data but it does not immediately get sent to others unless you want it to be shared);
overseen by medical professionals in some way;
with a simple business model (such as pay per test) so we did not worry too much that the goal was to somehow resell our data;
not part of a marketing initiative by a pharma company.

While there may be other tests that meet these criteria, we found one that we liked and which seemed to work well as we tried it out over a six month period.

BrainTest

The assessment test service that we used is called BrainTest (see Ref 3 for links to it).

Here is what the BrainTest website says about the science behind the test:

“BrainTest is based on the Self-administered Gerocognitive Examination (SAGE), created by Dr. Douglas Scharre, Professor of Clinical Neurology and Psychiatry at Ohio State University’s Wexner Medical Center. The SAGE is a scientifically proven assessment for Mild Cognitive Impairment (MCI) and early dementia, and is being used in numerous clinical settings.”

The website also includes a list of references to various scientific publications relating to the validation etc of the tests.

Here is how we used it:

While the first test is free, for subsequent tests you pay a fee (we paid $25 per explorer for each subsequent test).
They recommend a retest every 6 months and send an email when it is time. The app tracks results over time in a nice display.
You take the assessment at home, using either a tablet or touchscreen computer (you do need one of these: we used an iPad).
It takes maybe 5-15 minutes to take the test.
The results get “read” by a doctor who scores it and that score is sent back to you, with an accompanying (short) video in which a doctor discusses the test, your results, and what they mean. You never see or talk to the doctor (other than in the video, which is a prerecorded video not a two-way interaction). Results come back in a few days.
You don’t need any sort of referral from anyone to use it. You just sign up online. We did not explore whether insurance would pay for it (we suspect not), and in fact we saw it as a plus that it was private and not something insurance would be involved with.

Our Impressions: BrainTest

Overall we liked this product / service. It did exactly what we wanted.

Here are some things to note:

We found the interface easy to use. The process of taking the test and getting the scores back worked well. It was nice to get a reminder after 6 months to retake the test and we liked the way you can see a graph of score over time.
We noticed a few bugs in the app, but they did not get in the way of using it to take the test.
It helps to wear your reading glasses, and use a stylus rather than your finger to take the test. And there seemed to us to be a “small” learning curve effect in taking the test, so the second time the results were a bit better than the first for some of the explorers. (for example it asks you the date, and it’s hard not to mentally prepare for that the second time).
Is it exactly as good as the assessment administered by a doctor? Experienced geriatricians use other questions and observations to help with a diagnosis of MCI or dementia in addition to the “assessment” (see Dr. Kernisan in Ref 1). By its nature, this test does not include those additional questions or observations, and so there might be situations where that would be important.
It does require ability to use a tablet or touchscreen. For people with certain physical impairments that might be hard, or lead to inaccurate results.
We have no financial relationship with BrainTest and do not benefit in any way from mentioning them and using their tool. We do plan to reach out to them and ask for any feedback or corrections about this article.

How these Explorers Will Use the Assessment

The explorers who took part each scored highly on the BrainTest in both the initial assessment and the 6 month followup. In all the cases, the score came with the message that:

“Individuals with these scores are very likely to be normal”

The consensus among the explorers was that this was “expected” but nonetheless reassuring. The general feeling was that if the score had come back with anything else, that would have triggered a “visit to the doctor” for further discussion.

Going forward, different older adults are likely to have different points of view about how to include this type of assessment in their lives.

One point of view: keep doing the test every 6 months as a sort of “safety net” / “early warning” tool,
Alternate view: stop using it for now, but try it again if one notices any worrying issues related to cognition either in themselves or in a spouse.
OR: don’t use this type of test at all. Wait until something bad happens, then go to the doctor.

Are There Other Similar Tools?

We did not find another MCI screening tool that seemed to fit all our criteria, but our search was not exhaustive. Feel free to mention other tools in the comments (ideally with your experience using them).

However we found several similar tools designed to be used by healthcare professionals to administer similar assessments remotely. Examples of these include MOCA, which has an on line version called e-MOCA, and an organization called BrainCheck, Inc. See Ref 4 for links, but as best we can tell these are not for DIY use.

Also, see Ref 5 for some additional tests found by one of our readers (via ChatGPT) and suggested in the comments.

Is This What We Want for the Check-engine-light Concept?

Now that we understand in more detail what these MCI screening assessments measure, and how they can be used, we conclude they are not quite right for the check-engine-light concept. Although they definitely have a role as a sort of “screen”.

The trouble with these MCI screening tests is that they are not sensitive to small changes in the cognition of high functioning individuals. Or, another way to think about this is that the questions are designed to be easy to answer for high functioning individuals, and to show changes as a person approaches the threshold of “Mild Cognitive Impairment”.

We decided that for the check-engine-light concept we want a tool that starts to show changes far before the MCI threshold is reached.

In Part 3 of this exploration, we look at other approaches we have found for the “check-engine-light concept” that might be more suited to the goals we have for the concept.

This Exploration: Next Steps

Stay tuned for the next installment of this ongoing exploration.

Next time we will be writing about our experiences with a different type of “tool” that we think might be a better fit for the check-engine-light for the brain concept.

Please Share Your Opinions and Ideas

Some of you may well have opinions on this topic. We welcome your comments and suggestions in the comments (button below).

We are especially interested if you know of a product or service that does some or all of what we describe above. We would like to learn more about it, especially if you have personal experience with it.

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