ACE III

Question 1

what does the ACE-III examine

Answer 1

cognitive function

Question 2

what does cognition mean

Answer 2

mental abilities (memory, attention, language, perception, problem solving)

Question 3

what are cognitive functions

Answer 3

they enable us to learn and remember, concentrate, communicate, understand, carry out everyday actions and solve problems.

Question 4

what is cognitive impairment

Answer 4

when an individual has trouble with abilities such as remembering, learning new things, concentrating, solving problems or making decisions that affect everyday life.

Question 5

describe the difference between mild and severe impairment

Answer 5

Mild impairment- individuals may begin to notice changes in their mental abilities (e.g difficulty remembering a conversation, concentrating on a book, word finding problems, difficulties cooking, using money), but STILL CAN COMPLETE EVERYDAY ACTIVITITES. Severe impairment can lead to losing the ability to remember things, to recognise people, places or objects, to talk or write, and to carry out basic actions, resulting in the INABILITY TO LIVE INDEPENDENTLY

Question 6

name some causes of cognitive impairment

Answer 6

Alzheimer’s disease
Vascular conditions (e.g stroke, vascular dementia, multi-infarct dementia)
Fronto-temporal lobe dementias
Lewy Body dementia
Parkinson’s disease
Huntington’s disease
Progressive Supranuclear Palsy
Multiple sclerosis
Traumatic brain injury
Normal pressure hydrocephalus
Toxic conditions (e.g. alcohol related conditions, effects of street drugs and social drugs, environmental and industrial neurotoxins)
Infectious processes (e.g. HIV infection and AIDS, Lyme disease, Chronic fatigue syndrome, Herpes simplex encephalitis)
Brain tumours
Oxygen deprivation (e.g. following heart attack, carbon monoxide poisoning)
Metabolic and Endocrine disorders (e.g. hypothyroidism and liver disease)
Nutritional deficiencies (e.g. Vitamin B12 deficiency)
Prescribed Medication
Mood problems (e.g. stress, anxiety, depression)
Psychiatric problems (e.g. psychosis)
Delirium
Infections (e.g. chest infection and urinary tract infection)
Intellectual disabilities
Pain and discomfort

Question 7

what is static cognitive impairment

Answer 7

when the cognitive impairment will remain constant, compared to degenerative

Question 8

can cognition be affected by emotional difficulties

Answer 8

yes- eg. depression, anxiety

Question 9

what are some possible causes of cognitive impairment

Answer 9

Medication
Alcohol/drugs- not reliable assessment
pain
head injury
learning disability
mood

Question 10

what is the commonest cause of dementia and describe it

Answer 10

Alzheimer’s disease
memory problems, a progressive deterioration in the ability to perform ADL, and behaviour changes, mainly apathy and social withdrawal, but also behavioural disturbances. Cognitive difficulties vary between individuals, and worsen as the disease progresses.

Question 11

how does vascular dementia affect cognition

Answer 11

Damage to the network of vessels in the brain can result in loss of oxygen supply to the brain and associated brain damage / cognitive problems
A common problem is narrowing of the vessels due to build up of deposits on the vessel walls. This would have a gradual effect on some aspects of cognition. Typically, memory and speed of processing are affected. The problems tend to get worse, especially if risk factors such as high blood pressure or high levels of cholesterol go untreated.

Common physical problems include urinary incontinence, decreased mobility and balance problems (more common that AD.

Question 12

what are characteristic features of dementia with lewy bodies

Answer 12

fluctuation of awareness from day-to-day and signs of parkinsonism such as tremor, rigidity and slowness of movement, or poverty of expression. Visual hallucinations or delusions occur frequently. Falls are also common. DLB is associated with progressive cognitive decline and parkinsonism.

Question 13

what is frontotemporal dementia and how does it present

Answer 13

primarily cause problems with behaviour and/or language.
typically changes in behaviour such as disinhibition, lack of judgement, loss of social awareness and loss of insight.
In temporal variant FTD - now termed Primary Progressive Aphasia (PPA), people develop language problems including loss of knowledge of words, objects and/or people.

Question 14

what are different type of Primary Progressive Aphasia (PPA) also known as frontotemporal dementia

Answer 14

Semantic Dementia
Progressive Non-fluent Aphasia (PNFA)
Logopenic Progressive Aphasia (LPA)

Question 15

what is mixed dementias

Answer 15

mixtures of two or more active dementias (one or more may be dominating)

Question 16

is the ACE-III sensitive to the early stages of dementia

Answer 16

yes
cognitive screening tool

Question 17

what are the 5 subscales of ACE-III

Answer 17

attention
language
fluency
memory
visuospatial

Question 18

what is the overall score of ACE-III
and the overall score of mini-ACE

Answer 18

100
30 (shorter, only takes 5 minutes, if administration of ACE-III is not practical)

Question 19

is the ace a diagnostic tool

Answer 19

no

Question 20

why use the ace

Answer 20

Standardised and reliable
Sensitive to early stages of Alzheimer’s disease
The memory tests reflect the importance of episodic memory characteristic of early Alzheimer’s Disease
Assesses memory recognition and verbal fluency, assisting differential diagnosis
Provides subscale scores for each cognitive domain it assesses
Cognitive screening tools offer a time-efficient, objective initial assessment of cognitive functioning
The ACE-III has been found to be reliable and valid in the assessment of dementia.

Question 21

when should you use the ACE

Answer 21

if over 50 and present with suspected cognitive impairment

Question 22

when should you not use the ACE

Answer 22

known learning disability
if sedated
delirious/ hallucinations
distressed about completing the test
if no consent
not sufficiently fluent in English

Question 23

what should you do if using a translator

Answer 23

Always meet with the interpreter before patient
Never allow the interpreter to translate items ‘in the moment’
The interpreter should translate test instructions
Instruct the interpreter not to give any additional assistance during testing
Encourage the interpreter to let the clinician know immediately if they feel something has been misunderstood by the patient
Encourage the interpreter to reflect on their personal knowledge of the cultural background the patient is from e.g. education systems in original country
Encourage the interpreter to inform you if a word or phrase does not translate
Encourage the interpreter to inform you if they don’t know the translation – it’s ok!
Encourage the interpreter to disclose any issues that may be important e.g. do they know the patient? Conflicts of interest? Relevant personal difficulties?
Consider using the interpreter when providing feedback to the patient and translating a summary of their test performance and any recommendations.
Although there are many alternative versions of the ACE-III, it is important to remember that interpreters will not have had a professional training in administering cognitive screening tools and research has shown interpreters may inadvertently edit responses, leading to higher scores

Question 24

what can the ace tell you

Answer 24

indication of whether or not a patient is performing as expected, compared to people of the same age
If they perform below the cut off on the ACE-III, this indicates the possibility of a degree of cognitive impairment
The ACE-III cannot identify the cause of a patient’s cognitive impairment

Question 25

what should happen at the pre screening convo

Answer 25

gain informed consent by:
saying why you want to administer it
possible outcomes
what is involved
let them know its their choice

Question 26

what views from the Scottish Dementia Working Group have on person-centred principles

Answer 26

language has an impact (like test, poor performance, fail, bad score)
setting influences performance
make sure they are informed
give feedback so as to not feel apprehensive about their performance
acknowledge the patients viewpoint more

Question 27

what are some good administration tips

Answer 27

no one else in the room
unless specifically requested (but they cannot give hints)
do in a quiet room
make sure there are no interruptions

positive reassurance
therapeutic rapport
ask if they want to discontinue if anxious
they can stop at any time
give them time to answer
follow instructions- standardised test so dont invalidate results

Question 28

what to consider during testing

Answer 28

Check if the patient wears glasses/hearing aid and if these items are to hand
For patients with known literacy difficulties omit the following:
Language Comprehension: writing and reading items
The ACE-III can be photocopied to A3 size for those with visual difficulties
Write down all responses on the record form – correct and incorrect responses
Do not score the ACE-III as you are administering it….. this distracts patients if they see scores
For ease of administration, instructions to be given to the patient are stated on the record form

Question 29

what are common errors when using the ace

Answer 29

Calculating total scores

Attention Domain
Numbers Item
Common Error: Not assigning points for correct subsequent subtractions of 7 following a mistake. The instructions state that ‘If subject makes a mistake, do not stop them. Let the subject carry on and check subsequent answers (e.g. 93, 84, 77, 70, 63 – score 4)’

Memory Domain
Name and Address Recognition Item
Common Error: Not assigning points for the items remembered on the name and address recall item previous to this. The instructions for this item specify to ‘…start by ticking items recalled in the shadowed column on the right hand side’.

Language Domain
Naming
Some patients point to the barrel when asked to point to the picture that has a nautical connection. This should be scored as incorrect. Although it can be argued that a barrel has indeed got a nautical connection, it is not the most likely answer. The test cut-off scores have been devised based on scoring the ACE-III in this way and so we recommend you can score this as incorrectly, yet perhaps ask ‘could it be something else’ to determine whether they would select the anchor. Even if they point to the anchor following this prompt, this should still be scored 0, but it can be noted that they identified the anchor on prompting for qualitative information
Single Word Repition Item
Common Error: Assigning points when a word is pronounced incorrectly at first attempt but correctly upon a second attempt. The instructions state that ‘Only first attempt is scored’

Visuospatial Domain
Clock Item
Common Error: Not assigning points for partly correct positioning of numbers/hands. Using the scoring guide when scoring performance is essential so you can review examples.

Question 30

what happens after testing

Answer 30

provide positive feedback
feedback in future
score without patient

Question 31

describe feedback

Answer 31

Cut-off scores of 88 and 82 out of 100 are recommended for suspicion of dementia.
Cut-off scores of 25 and 21 out of 30 are recommended for the M-ACE.
Explain to the patient that the test has a cut-off score – (how you would expect of someone of their age to perform)
Do not tell the patient what the cut off scores are
If a patient scores below 82, inform the patient that their performance was not as high as you would have expected and therefore you would like to refer them for further assessment by a specialist
If a patient scores between 88 and 82 you should tell them that they have scored within a ‘borderline’ range, which means that they have performed slightly below the cut off and as a result you would like to refer them on for further assessment.
Whether a patient scores in the ‘borderline’ range or below 82, you should tell the patient, and their significant other (e.g if a relative or friend is in attendance) that there are a range of possible reasons for performing below the cut off and that further assessment would be beneficial,
helpful if the patient has a significant other (e.g. relative or friend) present when you are providing feedback
You should be familiar with what the next step will be in your health board area.
If a patient scores 89 or above you can usually reassure them that they have performed above the cut off.

Question 32

what is the exception to feedback if they got above 89

Answer 32

can still be referred if clinical concerns (like the patient has had a high level of educational or occupational achievement)

presenting unusually

concern may be raised by the patient or relative (personality change)