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An informant-based screening tool for dementia may be useful in population-based studies of minority populations.
Investigate the feasibility of screening for very mild dementia in a community sample of African Americans using an informant-based screening tool (AD8).
Cohort study
147 persons from the African American Health (AAH) project were screened for dementia; 61 of 93 who were invited had follow-up clinical assessments for dementia diagnosis.
The AD8, Mini-Mental State Examination (MMSE), Short Blessed Test (SBT), Brief Instrument for Dementia Detection (BIDD), and a neuropsychological battery were administered at visit 1. The Clinical Dementia Rating (CDR) was administered at visit 2 by clinicians blinded to visit 1 results; the presence of dementia was determined by a CDR greater than 0.
465 individuals from the AAH cohort were sent a letter describing the study and, among this group, 252 individuals were contacted by phone to request participation in this study. 6% (14 / 252) of participants contacted by phone were unable to identify an informant (required for the AD8). 150 individuals agreed by phone to participate of which 2% (n=3) did not have an informant available at the time of participation. The AD8 alone was effective at discriminating between CDR 0 and CDR 0.5 (area under the curve = .847; p <.001; 95% confidence interval 0.73-0.96).
A brief informant-based instrument, the AD8, has high sensitivity and specificity for distinguishing CDR 0 from CDR 0.5 in the community. Informant availability may not be a barrier to using the AD8 in an African American community sample; however, further study in larger samples with a higher response rate, different community settings (e.g., community clinics), and among older age groups (e.g., age 75+) is warranted to confirm this.
PMCID: PMC2763355  PMID: 19484913
African Americans; Dementia; Screening
2.  Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease 
Neurology  2009;73(21):1738-1745.
Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established.
A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained.
Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect).
The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.
= Alzheimer disease;
= area under the curve;
= deep brain stimulation;
= Diagnostic and Statistical Manual of Mental Disorders, 4th edition;
= Geriatric Depression Scale;
= Hopkins Verbal Learning Test;
= instrumental activities of daily living;
= mild cognitive impairment;
= Mini-Mental State Examination;
= Montreal Cognitive Assessment;
= negative predictive value;
= Parkinson disease;
= Parkinson disease dementia;
= positive predictive value;
= quality of life;
= receiver operating characteristic;
= Tower of London-Drexel;
= Unified Parkinson’s Disease Rating Scale.
PMCID: PMC2788810  PMID: 19933974
3.  Physician and Nurse Acceptance of Technicians to Screen for Geriatric Syndromes in the Emergency Department 
The objective of this study was to evaluate emergency medicine physician and nurse acceptance of nonnurse, nonphysician screening for geriatric syndromes.
This was a single-center emergency department (ED) survey of physicians and nurses after an 8-month project. Geriatric technicians were paid medical student research assistants evaluating consenting ED patients older than 65 years for cognitive dysfunction, fall risk, or functional decline. The primary objective of this anonymous survey was to evaluate ED nurse and physician perceptions about the geriatric screener feasibility and barriers to implementation. In addition, as a secondary objective, respondents reported ongoing geriatric screening efforts independent of the research screeners.
The survey was completed by 72% of physicians and 33% of nurses. Most nurses and physicians identified geriatric technicians as beneficial to patients without impeding ED throughput. Fewer than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluated for fall risk significantly more often than physicians, but no other significant differences were noted in ongoing screening efforts.
Dedicated geriatric technicians are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. Most nurses and physicians are not currently screening for any geriatric syndromes.
PMCID: PMC3236152  PMID: 22224145
4.  Feasibility of the STarT back screening tool in chiropractic clinics: a cross-sectional study of patients with low back pain 
The STarT back screening tool (SBT) allocates low back pain (LBP) patients into three risk groups and is intended to assist clinicians in their decisions about choice of treatment. The tool consists of domains from larger questionnaires that previously have been shown to be predictive of non-recovery from LBP. This study was performed to describe the distribution of depression, fear avoidance and catastrophising in relation to the SBT risk groups. A total of 475 primary care patients were included from 19 chiropractic clinics. They completed the SBT, the Major Depression Inventory (MDI), the Fear Avoidance Beliefs Questionnaire (FABQ), and the Coping Strategies Questionnaire. Associations between the continuous scores of the psychological questionnaires and the SBT were tested by means of linear regression, and the diagnostic performance of the SBT in relation to the other questionnaires was described in terms of sensitivity, specificity and likelihood ratios.
In this cohort 59% were in the SBT low risk, 29% in the medium risk and 11% in high risk group. The SBT risk groups were positively associated with all of the psychological questionnaires. The SBT high risk group had positive likelihood ratios for having a risk profile on the psychological scales ranging from 3.8 (95% CI 2.3 - 6.3) for the MDI to 7.6 (95% CI 4.9 - 11.7) for the FABQ. The SBT questionnaire was feasible to use in chiropractic practice and risk groups were related to the presence of well-established psychological prognostic factors. If the tool proves to predict prognosis in future studies, it would be a relevant alternative in clinical practice to other more comprehensive questionnaires.
PMCID: PMC3105955  PMID: 21526986
5.  Neuropsychological screening tests in African Americans. 
Neuropsychological tests are instruments used to diagnose a variety of cognitive conditions. This article will review a few of the brief scales commonly used in screening for dementia. It will also discuss the properties of and problems with some of the brief scales that are commonly used to screen African Americans for dementia, highlighting the various biases. The Mini-Mental State Examination (MMSE) is the most widely known and utilized cognitive impairment instrument in the United States. Whether or not it is biased to race after adjusting the scores for educational attainment remains controversial. The Blessed Information-Memory-Concentration Test (BIMC), Blessed Orientation-Memory-Concentration Test (BOMC), Short Portable Mental Status Questionnaire (SPMSQ), and Neurobehavioral Cognitive Status Examination (NCSE) are other screening tests used to diagnose dementia. Some of these tests have been found to misclassify many more African Americans as demented compared to the proportion of whites that are misclassified. The Cambridge Cognitive Examination (CAMCOG) is the only brief neuropsychological scale designed to actually diagnose early dementia, but it is not known if it is biased for African Americans.
PMCID: PMC2593968  PMID: 11560287
6.  Subgrouping low back pain: A comparison of the STarT Back Tool with the Örebro Musculoskeletal Pain Screening Questionnaire 
Clinicians require brief, practical tools to help identify low back pain (LBP) subgroups requiring early, targeted secondary prevention. The STarT Back Tool (SBT) was recently validated to subgroup LBP patients into early treatment pathways.
To test the SBT’s concurrent validity against an existing, popular LBP subgrouping tool, the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ), and to compare the clinical characteristics of subgroups identified by each tool.
Two hundred and forty-four consecutive ‘non-specific’ LBP consulters at 8 UK GP practices aged 18–59 years were invited to complete a questionnaire. Measures included the ÖMPSQ and SBT, disability, fear, catastrophising, pain intensity, episode duration and demographics. Instruments were compared using Spearman’s correlations, tests for subgroup agreement and discriminant analysis of subgroup characteristics according to reference standards.
Completed SBT (9-items) and ÖMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and ÖMPSQ scores was ‘excellent (rs = 0.80). Subgroup characteristics were similar across the low, medium and high subgroups, but, the proportions allocated to ‘low’, ‘medium’ and ‘high’ risk groups were different, with fewer patients in the SBT’s high risk group. Both instruments similarly discriminated for reference standards such as disability, catastrophising, fear, comorbid pain and time off work. The ÖMPSQ was better at discriminating pain intensity, while the SBT was better for discriminating bothersomeness of back pain and referred leg pain.
The SBT baseline psychometrics performed similarly to the ÖMPSQ, but the SBT is shorter and easier to score and is an appropriate alternative for identifying high risk LBP patients in primary care.
PMCID: PMC2809923  PMID: 19223271
Low back pain; Classification; Primary care; Early identification; Psychological factors
7.  A Score Based on Screening Tests to Differentiate Mild Cognitive Impairment from Subjective Memory Complaints 
Neurology International  2013;5(3):e16.
It is not easy to differentiate patients with mild cognitive impairment (MCI) from subjective memory complainers (SMC). Assessments with screening cognitive tools are essential, particularly in primary care where most patients are seen. The objective of this study was to evaluate the diagnostic accuracy of screening cognitive tests and to propose a score derived from screening tests. Elderly subjects with memory complaints were evaluated using the Mini Mental State Examination (MMSE) and the Brief Cognitive Battery (BCB). We added two delayed recalls in the MMSE (a delayed recall and a late-delayed recall, LDR), and also a phonemic fluency test of letter P fluency (LPF). A score was created based on these tests. The diagnoses were made on the basis of clinical consensus and neuropsychological testing. Receiver operating characteristic curve analyses were used to determine area under the curve (AUC), the sensitivity and specificity for each test separately and for the final proposed score. MMSE, LDR, LPF and delayed recall of BCB scores reach statistically significant differences between groups (P=0.000, 0.03, 0.001 and 0.01, respectively). Sensitivity, specificity and AUC were MMSE: 64%, 79% and 0.75 (cut off <29); LDR: 56%, 62% and 0.62 (cut off <3); LPF: 71%, 71% and 0.71 (cut off <14); delayed recall of BCB: 56%, 82% and 0.68 (cut off <9). The proposed score reached a sensitivity of 88% and 76% and specificity of 62% and 75% for cut off over 1 and over 2, respectively. AUC were 0.81. In conclusion, a score created from screening tests is capable of discriminating MCI from SMC with moderate to good accurancy.
PMCID: PMC3794451  PMID: 24147213
mild cognitive impairment; subjective memory complaints; screening cognitive test; diagnostic score
8.  Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease 
Annals of internal medicine  2012;156(12):848-W296.
Hospitalization, frequently complicated by delirium, can be a life-changing event for patients with Alzheimer disease (AD).
To determine risks for institutionalization, cognitive decline, or death associated with hospitalization and delirium in patients with AD.
Prospective cohort enrolled between 1991 and 2006 into the Massachusetts Alzheimer’s Disease Research Center (MADRC) patient registry.
771 persons aged 65 years or older with a clinical diagnosis of AD.
Hospitalization, delirium, death, and institutionalization were identified through administrative databases. Cognitive decline was defined as a decrease of 4 or more points on the Blessed Information-Memory-Concentration test score. Multivariate analysis was used to calculate adjusted relative risks (RRs).
Of 771 participants with AD, 367 (48%) were hospitalized and 194 (25%) developed delirium. Hospitalized patients who did not have delirium had an increased risk for death (adjusted RR, 4.7 [95% CI, 1.9 to 11.6]) and institutionalization (adjusted RR, 6.9 [CI, 4.0 to 11.7]). With delirium, risk for death (adjusted RR, 5.4 [CI, 2.3 to 12.5]) and institutionalization (adjusted RR, 9.3 [CI, 5.5 to 15.7]) increased further. With hospitalization and delirium, the adjusted RR for cognitive decline for patients with AD was 1.6 (CI, 1.2 to 2.3). Among hospitalized patients with AD, 21% of the incidences of cognitive decline, 15% of institutionalization, and 6% of deaths were associated with delirium.
Cognitive outcome was missing in 291 patients. Sensitivity analysis was performed to test the effect of missing data, and a composite outcome was used to decrease the effect of missing data.
Approximately 1 in 8 hospitalized patients with AD who develop delirium will have at least 1 adverse outcome, including death, institutionalization, or cognitive decline, associated with delirium. Delirium prevention may represent an important strategy for reducing adverse outcomes in this population.
Primary Funding Source
National Institute on Aging and the MADRC.
PMCID: PMC3556489  PMID: 22711077
9.  The Memory and Aging Telephone Screen (MATS): Development and preliminary validation 
Telephone interviews are widely used in geriatric settings to identify eligible research participants and to perform brief follow-up assessments of cognition. This article reports on the development and validation of the Memory and Aging Telephone Screen (MATS), a structured interview for older adults with mild cognitive impairment and/or significant memory complaints. We also developed three alternate forms of the MATS objective memory test to reduce practice effects engendered by multiple administrations.
Participants were enrolled in a longitudinal study that included 120 older adults with amnestic mild cognitive impairment (MCI), subjective cognitive complaints (CC) but without deficit on neuropsychological tests, and demographically-matched healthy controls (HC). An additional 15 patients with mild probable Alzheimer's disease (AD) completed the alternative forms study. All participants received the original MATS version, and a subset (n = 90) later received two of three alternate forms.
The MATS was sensitive to group differences and the alternate forms were equivalent. MATS objective memory test scores showed adequate stability over one year and were moderately correlated with scores on a widely used list-learning test (CVLT-II).
The MATS, a repeatable telephone screen that includes objective and subjective memory assessments, is useful for detecting individuals in the preclinical and early stages of dementia. Results encourage use of the MATS as a reliable and valid cognitive screening tool in research and clinical settings. Longitudinal assessments are being performed to investigate the predictive validity of the MATS for cognitive progression in MCI.
PMCID: PMC2712946  PMID: 19595923
telephone screen; mild cognitive impairment; cognitive complaints; neuropsychological assessment; interview; memory
10.  Canadian Academy of Geriatric Psychiatry Survey of Brief Cognitive Screening Instruments 
Canadian Geriatrics Journal  2013;16(2):54-60.
The use of brief cognitive screening instruments is essential in the assessment of dementia. The purpose of this study is to determine the frequency of use and perceived characteristics of cognitive screening instruments among Canadian psychogeriatric clinicians.
Members of the Canadian Academy of Geriatric Psychiatry (CAGP) and attendees to the 2010 Annual Scientific Meeting were asked to complete a computerized survey. This survey assessed the perceived characteristics and frequency of use of 14 instruments.
The survey had a 55% response rate, with a total of 155 respondents. The most commonly used instruments are the Clock Drawing Test (CDT), Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), and Delayed Word Recall. Effectiveness, ease of administration, and speed of administration were the perceived characteristics of instruments most correlated with frequency of use.
Consistent with previous surveys, a small number of cognitive screening instruments are used by the majority of clinicians. Use of the CDT and the MMSE were comparable. To our knowledge, this is the first survey demonstrating that the MMSE is not the most commonly used tool, and other, newer instruments like the MoCA, are gaining prominence.
PMCID: PMC3671013  PMID: 23737930
cognitive screening; dementia screening; Clock Drawing Test (CDT); Montreal Cognitive Assessment (MoCA); neuropsychiatry; geriatric psychiatry; cognitive testing
11.  Walking stabilizes cognitive functioning in Alzheimer's disease (AD) across one year 
AD is a public health epidemic, which seriously impacts cognition, mood and daily activities; however, one type of activity, exercise, has been shown to alter these states. Accordingly, we sought to investigate the relationship between exercise and mood, in early-stage AD patients (N = 104) from California, over a 1-year period. Patients completed the Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), and Blessed-Roth Dementia Rating Scale (BRDRS), while their caregivers completed the Yale Physical Activity Survey (YALE), Profile of Mood States (POMS), the Neuropsychiatric Inventory (NPI) and Functional Abilities Questionnaire (FAQ). Approximately half of the participants were female, from a variety of ethnic groups (Caucasian = 69.8%; Latino/Hispanic Americans = 20.1%). Our results demonstrated that the patients spent little time engaged in physical activity in general, their overall activity levels decreased over time, and this was paired with a change in global cognition (e.g., MMSE total score) and affect/mood (e.g., POMS score). Patients were parsed into Active and Sedentary groups based on their Yale profiles, with Active participants engaged in walking activities, weekly, over 1 year. Here, Sedentary patients had a significant decline in MMSE scores, while the Active patients had an attenuation in global cognitive decline. Importantly, among the Active AD patients, those individuals who engaged in walking for more than 2 h/week had a significant improvement in MMSE scores. Structured clinical trials which seek to increase the amount of time AD patients were engaged in walking activities and evaluate the nature and scope of beneficial effects in the brain are warranted.
PMCID: PMC3766353  PMID: 22959822
Exercise; Physical activity; Alzheimer's; Mild impairment; MMSE; Cognitive decline
12.  Broad Spectrum Assessment of Psychopathology and Adaptive Functioning with the Older Adult Behavior Checklist: A Validation and Diagnostic Discrimination Study 
Self-administered by spouses and other collateral informants, the nationally normed Older Adult Behavior Checklist (OABCL) provides standardized data on diverse aspects of older adult psychopathology and adaptive functioning. We tested the validity of the Older Adult Behavior Checklist (OABCL) scale scores in terms of associations with diagnoses of dementia of the Alzheimer’s type (DAT) and mood disorders (MD) and with 9 measures of psychopathology, cognitive performance, and adaptive functioning.
Informants completed OABCLs for 727 60- to 97-year-olds recruited from a memory disorders clinic, geriatric psychiatry clinic, and community–dwelling seniors. OABCL scale scores were tested for associations with DAT and MD diagnoses, as well as with scores on the Neuropsychiatric Inventory, Mini-Mental State Exam (MMSE), Clock Drawing Test, Alzheimer’s Disease Assessment Scale, Geriatric Depression Scale, Clinical Dementia Rating, Dementia Severity Rating Scale, Trail Making Test Part A, and Instrumental Activities of Daily Living.
OABCL scales had medium to large correlations with the 9 other indices of functioning and significantly augmented MMSE discrimination between patients with DAT vs. MD. OABCL scales also discriminated significantly between patients diagnosed with DAT vs. MD and both these groups vs. nonclinical subjects.
Multiple OABCL scales had medium to large associations with diverse indices of functioning based on other kinds of data. The nationally normed OABCL provides new ways to integrate informant and self-report data to improve assessment of older adults. Specifically, the OABCL can provide discrimination between those who qualify for diagnoses of DAT vs. MD vs. neither diagnosis.
PMCID: PMC2957545  PMID: 20054835
Older Adult Behavior Checklist; Mini-Mental State Exam; Dementia of the Alzheimer’s Type; Mood Disorders; Neuropsychiatric Inventory
13.  The Alzheimer Disease-8 and Montreal Cognitive Assessment as Screening Tools for Neurocognitive Impairment in HIV-Infected Persons 
Journal of neurovirology  2013;19(1):109-116.
The diagnosis of HIV-associated neurocognitive impairment is time-intensive and often omitted in busy outpatient settings. Brief screening tools are needed. The Montreal Cognitive Assessment (MoCA) and the Alzheimer’s disease (AD)-8 have been used in neurodegenerative disorders. We evaluated the sensitivity and specificity of these brief screening tools in HIV-infected persons. The AD-8, MoCA, and formal neuropsychological testing were administered to 200 HIV-infected patients followed at a single institution. Normalized scores on formal neuropsychological testing were used to define neurocognitive impairment. The sensitivity and specificity of the MoCA and AD-8 were assessed to diagnose impairment. Neurocognitive impairment was highly prevalent in this cohort: 127 persons (64%) were diagnosed with neurocognitive impairment based on formal testing. Using the AD-8 and MoCA, 113 (57%) and 101 (51%) persons were identified with neurocognitive impairment, respectively. The sensitivity and specificity of MoCA were 63% and 71%, respectively. The sensitivity and specificity of AD-8 were 61% and 51%, respectively. Our findings highlight that brief screening tools correlate with formal neuropsychological testing. However, the sensitivities of these screening tools are lower than desired. Nevertheless, given their ease in administration, these tools could assist as a first line for identifying individuals who may subsequently require formal neuropsychological testing.
PMCID: PMC3655767  PMID: 23345074
HIV; Neurocognitive Disorder; MoCA; AD-8; Neuropsychological Testing; Cognition
14.  Brief Memory and Executive Test: evaluation of a new screening test for cognitive impairment due to small vessel disease 
Age and Ageing  2012;41(2):212-218.
Background: cerebral small vessel disease (SVD) is the most common cause of vascular cognitive impairment (VCI). Despite this, there is a paucity of rapid simple screening tools to identify cognitive impairment in SVD and differentiate it from other common dementia types.
Objective: to validate a new screening test for cognitive impairment in SVD, the Brief Memory and Executive Test (BMET) battery, and examine its ability to detect SVD and differentiate it from Alzheimer's disease (AD).
Subjects: 45 patients with SVD, 27 patients with AD and 80 normal controls.
Methods: the BMET includes brief tests of executive functioning and processing speed, with comparative tests of memory and orientation. Group discrimination was calculated using discriminant function analysis.
Results: the BMET took an average of 10 min to administer. It showed high sensitivity (91%) and specificity (85%) in differentiating SVD patients with cognitive impairment from AD patients. As a comparison the mini-mental state examination had lower sensitivity (63%) and specificity (62%).
Conclusions: the BMET is a simple and quick to administer clinical tool for the detection of VCI in SVD and its differentiation from AD impairment. Further multicentre studies are required to evaluate and compare it with other existing screening tests.
PMCID: PMC3280679  PMID: 22267862
vascular cognitive impairment; small vessel disease; stroke; lacunar; rapid screening; elderly
15.  Delirium accelerates cognitive decline in Alzheimer disease 
Neurology  2009;72(18):1570-1575.
To examine the impact of delirium on the trajectory of cognitive function in a cohort of patients with Alzheimer disease (AD).
A secondary analysis of data collected from a large prospective cohort, the Massachusetts Alzheimer’s Disease Research Center’s patient registry, examined cognitive performance over time in patients who developed (n = 72) or did not develop (n = 336) delirium during the course of their illnesses. Cognitive performance was measured by change in score on the Information-Memory-Concentration (IMC) subtest of the Blessed Dementia Rating Scale. Delirium was identified using a previously validated chart review method. Using linear mixed regression models, rates of cognitive change were calculated, controlling for age, sex, education, comorbid medical diagnoses, family history of dementia, dementia severity score, and duration of symptoms before diagnosis.
A significant acceleration in the slope of cognitive decline occurs following an episode of delirium. Among patients who developed delirium, the average decline at baseline for performance on the IMC was 2.5 points per year, but after an episode of delirium there was further decline to an average of 4.9 points per year (p = 0.001). Across groups, the rate of change in IMC score occurred about three times faster in those who had delirium compared to those who did not.
Delirium can accelerate the trajectory of cognitive decline in patients with Alzheimer disease (AD). The information from this study provides the foundation for future randomized intervention studies to determine whether prevention of delirium might ameliorate or delay cognitive decline in patients with AD.
= Alzheimer disease;
= Clinical Dementia Rating;
= Information-Memory-Concentration subtest of the Blessed Dementia Rating Scale;
= Massachusetts Alzheimer’s Disease Research Center;
= Massachusetts General Hospital.
PMCID: PMC2677515  PMID: 19414723
16.  Efficacy of language assessment in Alzheimer’s disease: comparing in-person examination and telemedicine 
Clinical Interventions in Aging  2006;1(4):467-471.
With the large number of aging individuals requiring screening of cognitive functions for dementing illnesses, there is a necessity for innovative evaluation approaches. One domain that should allow for online, at a distance, examination is speech and language dysfunction, if the auditory and visual transmission is of sufficient quality to allow adequate patient participation and reliable, valid interpretation of signs and symptoms (Duffy et al 1997).
Examine the effectiveness of language assessment in mild Alzheimer’s patients using telemedicine (TM) compared with traditional in-person (IP) assessment.
Ten patients with mild Alzheimer’s disease, enrolled at a Geriatric Memory Clinic received a battery of standard language tests under two conditions: face-to-face and via satellite TM.
Comparison of TM and IP testing conditions were assessed within each for scores on each test in the two conditions. On each of the five language tasks, the Wilcoxon signed ranks test indicated no significant difference on performance between the TM and IP conditions for each participant. Overall acceptance of the TM evaluation in an elderly population was rated at a high level except for one individual.
Telemedicine can improve access to speech and language evaluation services which is relevant to both dementia and other neurological diseases of the elderly. In particular, this specific assessment tool can be used to provide evaluations in under-served rural areas.
PMCID: PMC2699639  PMID: 18046923
17.  Diagnosing Delirium in Hospitalized Elderly Patients with Dementia: Adapting the Confusion Assessment Method to ICD-10 Diagnostic Criteria 
The Confusion Assessment Method (CAM) performs well in DSM-IV delirium screening, but the ICD-10 classification utilizes more delirium symptoms.
To compare performance characteristics of the CAM algorithm for screening and delirium diagnosis with ICD-10 and DSM-IV delirium criteria in high-risk patients.
Prospective cohort study
Academic geriatric hospital
102 patients, aged 80–100 years, hospitalized for acute medical illness.
Complete CAM instrument (9 items), scored using the 4-item CAM diagnostic algorithm. Gold standard classification of delirium was rated independently by expert consensus, based on DSM-IV and ICD-10 criteria for delirium.
In 79 hospitalized patients, the CAM performed well for delirium screening (delirium prevalence of 24% by DSM-IV and 14% by ICD-10). Of all CAM features, acute onset and fluctuating course are most important for diagnosis (area under the curve, AUC, 0.92 in DSM-IV and 0.83 in ICD-10). Compared with the DSM-IV reference standard, the CAM diagnostic algorithm had a sensitivity of 0.74, specificity of 1.0, and AUC of 0.88; compared with ICD-10, which had a sensitivity of 0.82, specificity of 0.91, and AUC of 0.85. Adding psychomotor change to the CAM algorithm improves specificity to 97% but sensitivity is reduced to 55% for ICD-10 (AUC 0.96). Alternatively, applying psychomotor change sequentially to only the group identified with no delirium by the CAM algorithm improves sensitivity to 91% with specificity of 85% (AUC 0.95).
While the CAM diagnostic algorithm performs well against a DSM-IV reference standard, adding psychomotor change to the CAM algorithm improves specificity and diagnostic value against ICD-10 criteria over all in aged individuals with dementia, and improves sensitivity and screening performance when applied sequentially in CAM-negative individuals.
PMCID: PMC3422775  PMID: 22881707
delirium; confusional state; old age; dementia; ICD-10; psycho-diagnostic instrument
18.  Relationship of dementia screening tests with biomarkers of Alzheimer’s disease 
Brain  2010;133(11):3290-3300.
Screening tests for Alzheimer’s disease lack sensitivity and specificity. We developed the AD8, a brief dementia screening interview validated against clinical and cognitive evaluations, as an improvement over current screening methods. Because insufficient follow-up has occurred to validate the AD8 against the neuropathologic findings of Alzheimer’s disease, we investigated whether AD8 scores correspond to impairment in episodic memory testing and changes in biomarkers of Alzheimer’s disease (cerebrospinal fluid and amyloid imaging with Pittsburgh compound B) characteristic of symptomatic Alzheimer’s disease. We also compared informant-based assessments with brief performance-based dementia screening measurements such as the Mini Mental State Exam. The sample (n = 257) had a mean age of 75.4 years with 15.1 years of education; 88.7% were Caucasian and 45.5% were male. The sample was divided into two groups based on their AD8 scores: those with a negative dementia screening test (AD8 score 0 or 1, n = 137) and those with a positive dementia screening test (AD8 score ≥2, n = 120). Individuals with positive AD8 scores had abnormal Pittsburgh compound B binding (P < 0.001) and cerebrospinal fluid biomarkers (P < 0.001) compared with individuals with negative AD8 scores. Individuals with positive AD8 tests and positive biomarkers scored in the impaired range on the Wechsler Logical Memory Story A (mean score 7.0 ± 4.5 for Pittsburgh compound B; mean score 7.6 ± 5.3 for cerebrospinal fluid amyloid beta protein 1–42). The AD8 area under the curve for Pittsburgh compound B was 0.737 (95% confidence interval: 0.64–0.83) and for cerebrospinal fluid amyloid beta protein 1–42 was 0.685 (95% confidence interval: 0.60–0.77) suggesting good discrimination. The AD8 had superior sensitivity in detecting early stages of dementia compared with the Mini Mental State Examination. The AD8 had a likelihood ratio of a positive test of 5.8 (95% confidence interval: 5.4–6.3) and likelihood ratio of a negative test of 0.04 (95% confidence interval: 0.03–0.06), increasing the pre-test probability of an individual having symptomatic Alzheimer’s disease. Individuals with AD8 scores of ≥2 had a biomarker phenotype consistent with Alzheimer’s disease and lower performance on episodic memory tests, supporting a diagnosis of Alzheimer’s disease. Informant-based assessments may be superior to performance-based screening measures such as the Mini Mental State Examination in corresponding to underlying Alzheimer’s disease pathology, particularly at the earliest stages of decline. The use of a brief test such as the AD8 may improve strategies for detecting dementia in community settings where biomarkers may not be readily available, and may enrich clinical trial recruitment by increasing the likelihood that participants have underlying biomarker abnormalities.
PMCID: PMC2965421  PMID: 20823087
AD8; Alzheimer’s disease; screening; biomarkers; preclinical; cognition
19.  Cognitive bedside assessment in atypical parkinsonian syndromes 
Objectives: To examine the ability of a brief and simple cognitive screening test to detect cognitive deficits in atypical parkinsonian syndromes.
Methods: Addenbrooke's cognitive examination (ACE), the mini-mental state examination (MMSE), and the dementia rating scale (DRS) were applied to 26 patients with multiple system atrophy (MSA), 39 with progressive supranuclear palsy (PSP), and 25 with corticobasal degeneration (CBD). The results were then compared with those obtained in 30 healthy age matched volunteers and 30 patients with Alzheimer's disease.
Results: In all four diseases the rate of detection of cognitive impairment on ACE was higher than on MMSE and comparable with DRS. The severity of cognitive impairment was most pronounced in the CBD group, which showed a similar degree of impairment to the Alzheimer group. In contrast, MSA patients were the least cognitively impaired. The PSP group took an intermediate position.
Conclusions: Cognitive impairment in atypical parkinsonian syndromes can be detected using a brief and clinically applicable bedside test such as ACE.
PMCID: PMC1739531  PMID: 15716539
20.  Scenery Picture Memory Test: A new type of quick and effective screening test to detect early stage Alzheimer’s disease patients 
It is highly desirable to develop a neuropsychological screening test which is sensitive to the early stage of Alzheimer’s disease (AD), and is easy to administer at the primary care physician’s (PCP’s) office.
Participants were 128 AD patients and 54 healthy volunteers. Brief cognitive screening tests were administered to the participants including the Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Verbal Fluency Test (VFT), a Verbal Category Cued Memory test (CCMT) and the Scenery Picture Memory Test (SPMT). In the SPMT, a scenery picture of a living room containing 23 familiar objects was used. The administration of the SPMT comprised the first shallow memory session (Pict 1) and the second deep memory session (Pict 2). The area under the receiver–operator curve (AUC) was used to compare the efficacy of SPMT with other cognitive tests.
Pict 1, which requires less than 2 min to complete, had the same AUC as Pict 2, and showed significantly larger AUC than MMSE, CDT and VFT for all (MMSE 19–23) and very mild (MMSE ≥ 24) AD patients. When we conducted the similar analysis separately for those younger than 75 years and those aged 75 years or older, we obtained the same results as above among the older age group. Pict 1 showed larger AUC than CCMT in overall sample and also in the older age group, although the difference was not statistically significant.
The SPMT could be useful for detection of mild and very mild AD in settings even where time is limited.
PMCID: PMC2892033  PMID: 20446933
dementia; picture superiority; primary care physician; screening test; visual memory
21.  Cholinesterase inhibitor treatment alters the natural history of Alzheimer's disease 
Objective: To describe the effect of cholinesterase inhibitors (CEIs) on the natural course of Alzheimer's disease (AD).
Methods: The short and long term effects of CEIs were evaluated in 135 patients with probable Alzheimer's disease relative to 135 patients who were never exposed to CEIs matched by age, education, duration of the symptoms, and cognitive status. We measured 1 year change in cognitive and functional performance, and the likelihood of arriving at each of four end points: (1) mini mental state examination (MMSE) of 9 or lower, (2) Blessed dementia rating scale for activities of daily living of 12 or higher, (3) nursing home admission, and (4) death, over an average 3 years of observation (36.7 (SD 21.5) months).
Results: Patients on CEIs were better cognitively and functionally after 1 year compared with those patients who never used CEIs. A proportional hazard analysis with CEI use as a time dependent covariate showed that the use of CEIs decreased the risk of nursing home admission. There was no association, however, between use of CEIs and time to cognitive and functional end points, or to death.
Conclusions: This observational study showed that there was an initial cognitive and functional benefit from the use of CEIs in Alzheimer's disease, which waned as the disease progressed. However, the results suggest that there is a long term beneficial effect of the use of CEIs, as indicated by the delay in adsmission to nursing homes.
PMCID: PMC1737770  PMID: 11861686
22.  Cognitive Dysfunction Is Associated With Poor Diabetes Control in Older Adults 
Diabetes care  2006;29(8):1794-1799.
To evaluate the association between cognitive dysfunction and other barriers and glycemic control in older adults with diabetes.
Patients over the age of 70 years presenting to a geriatric diabetes clinic were evaluated for barriers to successful diabetes management. Patients were screened for cognitive dysfunction with the Mini Mental State Examination (MMSE) and a clock-drawing test (CDT) scored by 1) a method validated by Mendez et al. and 2) a modified CDT (clock in a box [CIB]). Depression was evaluated with the Geriatric Depression Scale. Interview questionnaires surveyed activities of daily living (ADLs) and instrumental ADLs (IADLs), as well as other functional disabilities.
Sixty patients (age 79 ± 5 years, diabetes duration 14 ± 13 years) were evaluated. Thirty-four percent of patients had low CIB (≤5), and 38% of patients had low CDT (≤13). Both CIB as well as CDT were inversely correlated with HbA1c, suggesting that cognitive dysfunction is associated with poor glycemic control (r = −0.37, P < 0.004 and r = −0.38, P < 0.004, respectively). Thirty-three percent of patients had depressive symptoms with greater difficulty completing the tasks of the IADL survey (5.7 ± 1.7 vs. 4.6 ± 2.0; P < 0.03). These older adults with diabetes had a high incidence of functional disabilities, including hearing impairment (48%), vision impairment (53%), history of recent falls (33%), fear of falls (44%), and difficulty performing IADLs (39%).
Older adults with diabetes have a high risk of undiagnosed cognitive dysfunction, depression, and functional disabilities. Cognitive dysfunction in this population is associated with poor diabetes control.
PMCID: PMC1615865  PMID: 16873782
Indian Journal of Psychiatry  2002;44(1):41-46.
The present study was carried out on the hospitalised geriatric general medical patients. The assessment of the patients was carried out within 24 hours of admission and on every fourth day thereafter using Mini Mental Status Examination (MMSE), Confusion Assessment Method (CAM), Delirium Symptom Interview (DSI) and ICD-10-Diagnostic Criteria of Research for delirium. An overall rate of delirium of 27% was found in the 100 patients who constituted the sample. 19% was the rate of ‘prevalent’ delirium and 8% was the rate of ‘incident’ delirium. It is observed that the CAM is a useful screening method with high sensitivity for diagnosis of delirium at the bedside.
PMCID: PMC2953653  PMID: 21206880
Delirium; elderly; geriatric; epidemiology
24.  Cognitive Declines Precede and Predict Functional Declines in Aging and Alzheimer’s Disease 
PLoS ONE  2013;8(9):e73645.
To investigate the temporal ordering of cognitive and functional declines separately in older adults with or without Alzheimer’s disease (AD).
Design and Setting
A community-based longitudinal study of aging and dementia in Northern Manhattan (Washington Heights/Hamilton Heights Inwood Columbia Aging Project) and a multicenter, clinic-based longitudinal study of prevalent AD at Columbia University Medical Center, Johns Hopkins School of Medicine, Massachusetts General Hospital, and the Hôpital de la Salpêtrière in Paris, France (the Predictors Study).
3,443 initially non-demented older adults (612 with eventual incident dementia) and 517 patients with AD.
Main Outcome Measures
Cognitive measures included the modified Mini-Mental State Exam and composite scores of memory and language derived from a standardized neuropsychological battery. Function was measured with the Blessed Dementia Rating Scale, completed by the participant (in the sample of non-demented older adults) or an informant (in the sample of prevalent AD patients). Data were analyzed with autoregressive cross-lagged panel analysis.
Cognitive scores more consistently predicted subsequent functional abilities than vice versa in non-demented older adults, participants with eventual incident dementia, and patients with prevalent AD.
Cognitive declines appear to precede and cause functional declines prior to and following dementia diagnosis. Standardized neuropsychological tests are valid predictors of later functional changes in both non-demented and demented older adults.
PMCID: PMC3759461  PMID: 24023894
25.  Prevalence and pattern of cognitive impairment in rural and urban populations from Northern Portugal 
BMC Neurology  2010;10:42.
Despite worldwide recognition of the burden of dementia, no epidemiological data is yet available in Portugal. The objective of this study is to estimate the prevalence and describe the pattern of cognitive impairment with dementia or no dementia (CIND) in rural and urban populations from Northern Portugal.
Two random samples of residents aged 55 to 79 years in rural and urban communities were drawn from the health centres registries to be screened for cognitive impairment. The screening criteria for dementia were an abnormal Mini-Mental State Examination (MMSE) score or a Blessed Dementia Scale score. After excluding those who tested positive for dementia, cut-off points for CIND were set at 1 standard deviation below the mean of the MMSE according to educational level. All those who screened positive either for dementia or CIND were examined by a neurologist for establishing a definitive diagnosis.
The prevalence of cognitive impairment was higher in rural than in urban populations, 16.8% (95% CI: 14.3-19.8%) vs. 12.0% (95%CI: 9.3-15.4%), with a rural/urban prevalence ratio (PR) of 2.16 (95% CI: 1.04-4.50) in the eldest and 2.19 (95% CI: 1.01-4.76) in persons with vascular risk factors. The prevalence of dementia was 2.7% (95% CI: 1.9-3.8%) with a rural/urban PR = 2.1 and the prevalence of CIND was 12.3% (95% CI: 10.4-14.4%) and PR = 1.3. The prevalence of dementia increases exponentially with age and in those with cerebrovascular disease or other comorbid conditions while the prevalence of CIND, besides these factors, is also higher in persons with low levels of education or vascular risk factors. Alzheimer's and vascular disease were equally likely aetiologies of dementia (38.7%), the later more common in men PR(F:M = 0.3) as opposed to the former PR(F:M = 2.0). Vascular CIND, associated either with cerebrovascular disease or vascular risk factors was more frequent (39.7%) then depression (18.4%) or any other aetiology.
The prevalence of cognitive impairment is higher in rural compared with urban populations. This is shown in the synergy between age and rurality, with the rural/urban prevalence ratio increasing with age. In this relatively young population from Northern Portugal, cerebrovascular disease as well as vascular risk factors account for 48% of overall cognitive impairment.
PMCID: PMC2905352  PMID: 20540726

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