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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 Adrian highlights the alarming rate of dementia diagnoses worldwide and examines the shortcomings of outdated detection tools like MMSE, SLUMS, and MoCA.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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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: Yeah, of course. Well, I actually started working in this area about 35 years ago. I’m a bit embarrassed to say, I was a PhD student in the UK in 1988, working on developing cognitive tools for the detection and assessment of patients who, in those days, we would just refer to them as having dementia. Many of them were Alzheimer’s sufferers.
I went on to take those tools and continue developing them through the 1990s and the early 2000s. I got into brain imaging, did a lot of studies with positron emission tomography, PET, and fMRI. Then eventually, we developed them into 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. And 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 in dementia today?
Adrian Owen: You know, 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. A slightly more modern but really 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.
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 those questions and more, then there’s probably not something wrong with you. The problem is, many people fall somewhere in between, and the challenge is coming up with something 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. Or if they want to make plans to change their life, they can do that early. I think that’s the real challenge here.
Kevin Pho: So you’re saying here in the United States we have the Medicare annual well visit exam, where we have patients, for instance, draw a time on an analog clock; we have them say three words and then repeat them 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. The first is that they’re very blunt. Obviously, if you can’t draw a clock, then there’s something seriously wrong with you. That’s fair enough—but by then, it’s too late. You’re already well down the road of cognitive deterioration.
The other thing is, these sorts of tools have been around for a long time, and of course we’ve made massive advances in neuroscience over the last 30 years. We can do better than this. We have sensitive cognitive tools now that can pick up signs of deterioration very early.
The second issue is how we distinguish between different types of brain pathology. How can we tell both between different types of dementia and whether someone is having a dementing illness versus, for example, whether they’ve had a TBI? There are tools that can do this, but asking whether you can draw a clock or whether you know what day of the week it is won’t help you tell the difference between these conditions.
Kevin Pho: All right, so let’s talk about some of these new approaches, which you articulate in your KevinMD article. Tell us how we can move forward.
Adrian Owen: We’ve developed a series of tools—and there are others out there as well—but we’ve developed a series of tools at crayos.com. 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, on any tablet, and they’re extremely sensitive. We know that because we’ve conducted many studies in patients with dementia—tens of thousands of patients now—but we’ve also conducted brain imaging studies using techniques like fMRI. We’ve done pharmacological studies where we’ve used drugs to show that very small doses can lead to detectable changes. So we know these tests are very sensitive to small changes in cognition. You don’t need to be unable to draw a clock for us to pick up a deficit.
Another important thing is that these tests have repeated versions, so they can be used longitudinally. I actually monitor many of my older family members every three months—ask them to log in to the website, do our tests—so we can pick up if somebody is just starting to decline, much earlier than you could if you were using a traditional pen-and-paper test.
They’re also capable of distinguishing between different conditions. This is largely out of my hands because one of the great things that’s happened over the last 30 years is that people began using these tests in other labs—about 300 labs around the world have now used them. They’ve used them to look at other conditions like depression or anxiety or ADHD, which has allowed us to build up patterns or profiles that can distinguish particular conditions. That means we can figure out whether someone has a dementing illness.
Kevin Pho: So tell us a little more about what these tests entail. What’s it like from the patient’s standpoint? You mentioned they’re on a tablet or computer. How many questions are there, how long does it take, and give us an example of the type of questions asked.
Adrian Owen: These tests are very gamified. We found early on that people have to enjoy doing them. They’re presented on a tablet with a touch-sensitive screen, although you can do them on a regular computer using a mouse if that’s your preference. They’re little games, typically lasting between one and a half minutes to three minutes each—so very short. That doesn’t mean they’re ineffective or insensitive; we’ve really worked hard on internal algorithms so that, if somebody’s doing really well, we’ll give them harder and harder problems. If someone is doing poorly, we’ll give them easier and easier problems. In a very short time, we can iterate toward finding exactly how good they are.
They’re fun to do—an easy one to describe is our “odd one out” task, where you look at patterns on the screen and decide which is the odd one out. This involves some problem solving and reasoning. We start off very easily: there might be nine shapes, eight yellow ones and one blue one, so obviously the blue one is the odd one out. The next trial will be more complicated—maybe squares and triangles in different colors. We ramp up difficulty quite quickly, and by doing that, we can figure out people’s abilities in a short time.
Kevin Pho: As a physician, I’m interested in the clinical implications of these tests. You mentioned that they can get more granular in terms of the different types of cognitive deficits. Give us a scenario—how can these digital tests tease out different points within the spectrum of cognitive deficit, and what information can I, as a physician, glean from that?
Adrian Owen: Great question. Let me give you a straightforward answer. We originally tested these instruments on patients who’d had specific lesions in their brains, typically from neurosurgical excisions for tumor removal or the relief of intractable epilepsy. Some of our early information really related performance on the tasks to particular brain areas. I then went on to use brain imaging—fMRI—to look at the networks that underpin performance. That gives us a tremendous amount of interpretive power.
So, for example, if you perform the 12 tests—which in total take about 30 minutes (though there are shorter versions)—I can pinpoint whether you might have a specific impairment of executive functions. Maybe your memory performance, reliant on medial temporal lobe function, is intact, but you’re having trouble with problem solving, planning, reasoning—things that load on the frontal lobes. That allows me to conclude not only that you have a cognitive impairment, but that it’s located in the frontal lobes of your brain, maybe indicating a more frontal type of dementia rather than a more 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 them being used in a formal neuropsychological evaluation?
Adrian Owen: I think they go somewhere in between. A full, two- or three-hour neuropsychological evaluation still remains the gold standard, but it’s extremely expensive and time-consuming, and not everybody can wait that long. What the crayos battery provides is a quick way of triaging, figuring out who should go on to have that more comprehensive cognitive assessment. Not everyone needs that, and we can very quickly determine whether somebody’s experiencing problems that require closer examination or not. That can be done in a primary care setting.
Another thing we haven’t discussed is that these tests can be self-administered. Depending on the patient, you might want someone there to guide them, but it doesn’t have to be that way. They’re designed so that people receive clear instructions, get practice trials, and can essentially test themselves. It can be deployed in various settings. It can be an early detection tool, letting you know, “Yes, this person needs a thorough neuropsychological evaluation—let’s send them for that,” or “This person is part of the ‘worried well’; for someone their age, they’re doing fine.”
Kevin Pho: Currently, how are these tests being used in Canada or elsewhere? Are they available for retail use? Can someone just download an app, or does it need to be prescribed by a clinician?
Adrian Owen: They’re deployed really extensively in the U.S., less so in Canada at the moment. 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 there’s no physical gadget—it’s all software, all online. It’s done totally remotely. A clinic might buy a certain number of patient tests, get an account, log in, test their patients, and they’re immediately provided a full readout of the results. It’s all automated, with a brief interpretation. Ultimately, the diagnosis remains with the physician; we’re not diagnosing the patient, but we give you a lot of information to assist in making that diagnosis.
It’s not just a bunch of numbers you have to interpret because, on the back end, we have data from more than 14 million tests that have been taken. We also have a normative database of 75,000 individuals who’ve donated time and information about their lifestyle, medical histories, and so on. We use that as our normative database to drive the algorithms that analyze the data and provide feedback to the practitioner.
Kevin Pho: Can you tell us a story or case study of a patient using these tests and altering their clinical course, so we can see your concepts in action?
Adrian Owen: I can tell you hundreds of stories, but one is the classic “worried well.” We see many people who come to their doctor saying, “My memory’s not as good as it used to be. I’m 58. My memory isn’t as good as it used to be either—but because I have these tests, I know my memory is roughly as good as other 58-year-olds in the Western world.” So there are many cases where we’ve used these tests to reassure people. Yes, you’re not as sharp as you were, but neither is anyone else your age.
On the flip side, we’ve seen many patients where we can detect early on that they do have a problem. It’s a similar scenario: someone comes in with a spouse or friend saying, “We don’t think things are quite right, but we’re not sure.” It’s important to know this especially if, for example, they have a family history of dementia. One patient recently was really worried and wanted to make plans regarding her family finances if she had a problem. In that case, there was clearly evidence that what looked like minimal cognitive impairment (MCI) was mild cognitive impairment likely progressing to a full dementing illness. We informed her and her practitioner that this was likely, and she immediately made plans. That’s what people need to do sometimes, change their life plan to accommodate the fact that things might change fairly rapidly.
Kevin Pho: We’re talking to 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, let’s end with some take-home messages that you want to share with the KevinMD audience.
Adrian Owen: Number one: we have an epidemic on our hands. I wish I’d predicted this 30 years ago when I started, but I had no idea that what seemed like a fairly uncommon problem would explode into the dementia epidemic we see today. It will only get worse. Everybody agrees that over the next 30 or 40 years, we’ll see a huge increase in the number of people living with dementia.
The key is going to be early detection. That’s my take-home. Early detection is crucial. There are more than 30 clinical trials going on in the U.S. alone right now for potential Alzheimer’s drugs. It’s early days, but the one thing we do know is that the earlier you intervene, the better the outcome. That’s going to require us to pick up dementia earlier, and it also requires us to figure out who isn’t dementing early, because we don’t want to give drugs to the wrong people. Early, accurate detection is really what we need to focus on 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 for having me on.
