A comparative evaluation of the short orientation memory concentration test of cognitive impairment

A review of screening tests for cognitive impairment

The merit of screening for dementia and cognitive impairment has been the subject of recent debate. One of the main limitations in this regard is the lack of robust evidence to support the many screening tests available. Although plentiful in number, few such instruments have been well validated in the populations for which they are intended to be used. In addition, it is likely that "one size does not fit all" in cognitive screening, leading to the development of many specialised tests for particular types of impairment. In this review, we sought to ascertain the number of screening tools currently available, and to examine the evidence for their validity in detecting different diagnoses in a variety of populations. A further consideration was whether each screen elicited indices of a range of cognitive, affective and functional domains or abilities, as such information is a valuable adjunct to simple cut-off scores. Thirty-nine screens were identified and discussed with reference to three purposes: brief assessment in the doctor's office; large scale community screening programmes; and identifying profiles of impairment across different cognitive, psychiatric and functional domains/abilities, to guide differential diagnosis and further assessment. A small number of screens rated highly for both validity and content. This review is intended to serve as an evaluative resource, to guide clinicians and researchers in choosing among the wide range of screens which are currently available.

Delirium: guidelines for general hospitals

OBJECTIVE

Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients.

METHODS

Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results.

RESULTS

Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain.

CONCLUSIONS

While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.

Early postoperative cognitive recovery after remifentanil–propofol or sufentanil–propofol anaesthesia for supratentorial craniotomy: a randomized trial

BACKGROUND AND OBJECTIVE

This study was designed to evaluate early postoperative cognitive recovery after total intravenous anaesthesia with remifentanil-propofol or sufentanil-propofol in patients undergoing craniotomy for supratentorial expanding lesions.

METHODS

Sixty patients were consecutively enrolled, and randomly assigned to one of two study groups: remifentanil-propofol or sufentanil-propofol anaesthesia. To evaluate cognitive function the Short Orientation Memory Concentration Test (SOMCT) and Rancho Los Amigos Scale (RLAS) were administered to all patients in a double-blind procedure before surgery at 15, 45 min and 3 h after extubation.

RESULTS

Mean extubation time was similar in the two groups (13 +/- 5 min vs. 19 +/- 6 min). A significantly larger number of patients in the remifentanil-propofol group than in the sufentanil-propofol group required antihypertensive medication postoperatively to maintain mean arterial pressure within 20% of baseline (18/30 vs. 4/29; P = 0.0004). Intergroup analysis showed no differences in baseline SOMCT scores (28 +/- 1 vs. 28 +/- 1) whereas mean SOMCT scores at 15, 45 min and 3 h after extubation were significantly higher in the remifentanil-propofol group (30 patients) than in the sufentanil-propofol group (29 patients) (22 +/- 3 vs. 16 +/- 3; P < 0.0001 and 27 +/- 1 vs. 22 +/- 3; P < 0.0001; 28 +/- 1 vs. 26 +/- 2; P = 0.0126).

CONCLUSIONS

In conclusion, propofol-remifentanil and propofol-sufentanil are both suitable for fast-track neuroanaesthesia and provide similar intraoperative haemodynamics, awakening and extubation times. Despite a higher risk of treatable postoperative hypertension propofol-remifentanil allows earlier cognitive recovery.

Measures of adherence based on self-report exhibited poor agreement with those based on pharmacy records

OBJECTIVE

To assess the level of agreement between a self-reported measure of adherence with prescribed drug and a measure of adherence based on pharmacy data.

METHODS

During an in-home interview, people aged 65+ were asked to report all prescription drugs they had taken in the preceding month. For each drug, a four-item questionnaire was used to determine self-reported adherence. In the pharmacy records, each drug that had been filled at least four times was analyzed, and the percentage of days with the drug available was calculated. Two types of adherence were studied: (1) adherence by individual, and (2) adherence by drug. The level of agreement was assessed using kappa (kappa) statistics and proportions of agreement.

RESULTS

We compared the adherence measures among 189 individuals (880 drugs). Among all, 90 individuals (48%) self-reported adherence, whereas 95 individuals (50%) were adherent according to the records. The level of agreement between these two measures was slight (kappa=0.16 [95% CI: 0.02-0.30]). Individuals self-reported to be adherent for 81% of the drugs, while pharmacy records showed adherence for 83% of them (kappa=0.13 [95% CI: 0.05-0.20]).

CONCLUSION

Self-reported measures of adherence exhibited poor agreement with those based on pharmacy records.

Comparing the Validity of Different Sources of Information on Emergency Department Visits

BACKGROUND

Emergency department (ED) use in Quebec may be measured from varied sources, eg, patient's self-reports, hospital medical charts, and provincial health insurance claims databases. Determining the relative validity of each source is complicated because none is a gold standard.

OBJECTIVE

We sought to compare the validity of different measures of ED use without arbitrarily assuming one is perfect.

SUBJECTS

Data were obtained from a nursing liaison intervention study for frail seniors visiting EDs at 4 university-affiliated hospitals in Montreal.

MEASURES

The number of ED visits during 2 consecutive follow-up periods of 1 and 4 months after baseline was obtained from patient interviews, from medical charts of participating hospitals, and from the provincial health insurance claims database.

METHODS

Latent class analysis was used to estimate the validity of each source. The impact of the following covariates on validity was evaluated: hospital visited, patient's demographic/clinical characteristics, risk of functional decline, nursing liaison intervention, duration of recall, previous ED use, and previous hospitalization.

RESULTS

The patient's self-report was found to be the least accurate (sensitivity: 70%, specificity: 88%). Claims databases had the greatest validity, especially after defining claims made on consecutive days as part of the same ED visit (sensitivity: 98%, specificity: 98%). The validity of the medical chart was intermediate. Lower sensitivity (or under-reporting) on the self-report appeared to be associated with higher age, low comorbidity and shorter length of recall.

CONCLUSION

The claims database is the most valid method of measuring ED use among seniors in Quebec compared with hospital medical charts and patient-reported use.

Brief Screening Tests for the Diagnosis of Dementia: Comparison With the Mini-Mental State Exam

Dementia is a common and under-diagnosed problem among the elderly. An accurate screening test would greatly aid the ability of physicians to evaluate dementia and memory problems in clinical practice. We sought to determine whether simple and brief psychometric tests perform similarly to the Mini-Mental State Examination (MMSE) in screening for dementia. Using a retrospective analysis, a series of standard, brief, psychometric tests were compared with each other and to the MMSE as screening tests for very mild dementia, using DSM-III-R criterion as the gold standard. Two independent cohorts from the Baltimore Longitudinal Study of Aging and the Washington University Alzheimer's Disease Research Center were evaluated. We found that two brief and simple-to-administer tests appear to offer similar degrees of sensitivity and specificity to the MMSE. These are the recall of a five-item name and address, "John Brown 42 Market Street Chicago" and the one-minute verbal fluency for animals. Combining these two tests further improves sensitivity and specificity, surpassing the MMSE, to detect dementia in individuals with memory complaints.

Educational disadvantage impairs functional recovery after hospitalization in older persons

PURPOSE

To determine whether low educational level is associated with poor functional recovery after hospitalization in older adults.

METHODS

We followed 862 patients (374 with low education, defined as <high school) for 6 months after hospitalization. Poor functional recovery was defined as an Activities of Daily Living score that was lower 6 months after hospitalization than 1 month before hospitalization. People who died were also considered to have poor recovery.

RESULTS

Of the 862 participants, 351 (41%) experienced poor functional recovery: 124 died and 227 had declines in activities of daily living. There was a graded, statistically significant relation between level of education and poor functional recovery, regardless of impairment of activities of daily living at baseline. Poor functional recovery was more common in subjects with baseline impairment (50% [147/296]) than in those without baseline impairment (36% [204/566]). Independent predictors of poor functional recovery were low education, cognitive impairment, lack of social support, poor self-rated health, and high comorbidity. Sequential addition of demographic, economic, functional, psychosocial, and clinical factors to low education only modestly affected the association between low education and poor functional recovery.

CONCLUSION

Educational disadvantage impairs functional recovery after hospitalization in older persons.

Risk factors for development of delirium among oncology patients

To determine the occurrence of delirium in oncology inpatients and to identify and evaluate admission characteristics associated with the development of delirium during inpatient admission, a prospective observational study was conducted of 113 patients with a total of 145 admissions with histological diagnosis of cancer admitted to the oncology unit over a period of ten weeks. At the point of inpatient admission, all patients were assessed for the presence of potential risk factors for development of delirium. During the index admission patients were assessed daily for the presence of delirium using the Confusion Assessment Method. Delirium was confirmed by clinician assessment. Delirium developed in 26 of 145 admissions (18%) and 32 episodes of delirium were recorded with 6 patients having 2 episodes of delirium during the index admission. Delirium occurred on average 3.3 days into the admission. The average duration of an episode of delirium was 2.1 day. Four patients with delirium (15%) died. All other cases of delirium were reversed. Factors significantly associated with development of delirium on multivariate analysis were: advanced age, cognitive impairment, low albumin level, bone metastases, and the presence of hematological malignancy. Hospital inpatient admission was significantly longer in delirium group (mean: 8.8 days vs 4.5 days in nondelirium group, P<.01). Delirium among hospitalized oncology patients is a common condition. Identification of risk factors to delirium at the time of inpatient admission can be used to recognize those patients at the greatest risk and may aid prevention, early detection and treatment.

Community residential care: comparison of cognitively impaired and noncognitively impaired residents

Community residential care (CRC) is growing, with cognitive impairment the most common reason for CRC placement. We enrolled cognitively impaired and noncognitively impaired residents, informal caregivers, and providers in 219 CRC facilities for this study. Residents with cognitive impairment were older (p < .001), needed more activities of daily living (ADL) assistance (p < .001), and had a higher frequency of behavior problems (p < .001) than noncognitively impaired residents. Cognitively impaired and noncognitively impaired residents did not significantly differ in the facility-related factors they perceived as important or in the amount of control they felt they had over the decision to move. Including residents with cognitive impairment in future research and separately analyzing residents by cognitive status will give a more accurate picture of the needs of CRC residents.

Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial

STUDY OBJECTIVE

: We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone.

METHODS

The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately.

RESULTS

The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97).

CONCLUSION

In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.

Rapid emergency department intervention for older people reduces risk of functional decline: results of a multicenter randomized trial

OBJECTIVES

To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes.

DESIGN

Controlled trial, randomized by day of ED visit, with follow-up at 1 and 4 months.

SETTING

Four university-affiliated hospitals in Montreal.

PARTICIPANTS

Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk (ISAR) screening tool and their primary family caregivers. One hundred seventy-eight were randomized to the intervention, 210 to usual care.

INTERVENTION

The intervention consisted of disclosure of results of the ISAR screen, a brief standardized nursing assessment in the ED, notification of the primary care physician and home care providers, and other referrals as needed. The control group received usual care, without disclosure of the screening result.

MEASUREMENTS

Patient outcomes assessed at 4 months after enrollment included functional decline (increased dependence on the Older American Resources and Services activities of daily living scale or death) and depressive symptoms (as assessed by the short Geriatric Depression Scale). Caregiver outcomes, also assessed at baseline and 4 months, included the physical and mental summary scales of the Medical Outcomes Study Short Form-36. Patient and caregiver satisfaction with care were assessed 1 month after enrollment.

RESULTS

The intervention increased the rate of referral to the primary care physician and to home care services. The intervention was associated with a significantly reduced rate of functional decline at 4 months, in both unadjusted (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.36-0.99) and adjusted (OR = 0.53, 95% CI = 0.31-0.91) analyses. There was no intervention effect on patient depressive symptoms, caregiver outcomes, or satisfaction with care.

CONCLUSION

A two-stage ED intervention, consisting of screening with the ISAR tool followed by a brief, standardized nursing assessment and referral to primary and home care services, significantly reduced the rate of subsequent functional decline.

Cognitive screening and neuropsychological assessment in early Alzheimer's disease

Cognitive screening and detailed neuropsychological assessment provide a reliable means of detecting dementia in its earliest stages, tracking the progression of cognitive decline over time, and aiding in the differential diagnosis of various dementing disorders. In addition, recent studies have shown that mild cognitive changes, and particularly declines in memory function, are evident in the "preclinical" phase of Alzheimer's disease and may help to identify elderly individuals who are likely to develop dementia in the near future. Until effective and easily obtainable biological markers for detecting the onset and progression of Alzheimer's disease are developed, neuropsychological assessment will continue to have an important role in the dementia evaluation.

The role of tests of frontal executive function in the detection of mild dementia

OBJECTIVE

To compare the performance of patients with mild dementia (Mini Mental State Examination (MMSE) >23), depression (Montgomery-Asberg depression rating scale (MADRS) >12) and controls on tests of frontal executive function (FEF), to see if simple tools could be an adjunct to early recognition of dementia in primary care.

DESIGN

Subjects were required to score above 23 on the MMSE, and to be non-depressed unless in the depression group. Tests of FEF used were a letter based verbal fluency test, a cognitive estimates test, trail marking parts A and B, and a Stroop colour word test. Subjects were followed up at one year to assess long-term outcomes.

SETTING

The Thornhill Unit, an old age psychiatry unit, Moorgreen Hospital, Southampton, UK.

PATIENTS

Sixteen patients with a clinical diagnosis of dementia but with normal or borderline MMSE scores, 16 subjects with depression and 19 healthy control subjects.

RESULTS

Subjects with mild dementia scored significantly worse than control subjects on all FEF tests used other than verbal fluency. Subjects with mild dementia were only found to score worse than depressed subjects on the cognitive estimates test and Stroop test, with the Stroop test providing better discrimination between these groups. At follow-up, MMSE scores of both dementia and depression groups were worse.

CONCLUSIONS

Many simple tests of FEF can distinguish subjects with mild dementia from controls, although caution must be taken in the presence of depression. Of these tests, the cognitive estimates test may provide a simple test which can be used in conjunction with screening tests for dementia, such as the MMSE. The Stroop colour test was the most successful at distinguishing subjects with mild dementia from those with depression, but was more difficult to use. The depression group remained cognitively impaired at follow-up, despite improvements in depressive symptoms.

The Short Orientation-Memory-Concentration Test: a study of its reliability and validity

OBJECTIVE

To establish the limits of intra-observer test-retest reliability of the Short Orientation-Memory-Concentration Test (SOMC), and to investigate the relationship of performance on the SOMC with a test of verbal memory.

DESIGN

Each patient was assessed twice by the same assessor over an interval of 3-7 days.

SETTING

Two specialist rehabilitation units concerned with patients with severe and/or complex disability arising from neurological disease.

SUBJECTS

Thirty-eight patients aged 17-63 years, 25 being men, with a variety of neurological diseases. The Barthel Activities of Daily Living Index score ranged from 0 to 20, median 10.5.

MEASURES

The Short Orientation-Memory-Concentration Test, the Barthel Activities of Daily Living Index and the paragraph recall subtest of the Rivermead Behavioural Memory Test (RBMT).

RESULTS

There was a slight but statistically significant (p <0.01) improvement in the score of 2 points (out of 28) between the two test occasions, but this was not related to the interval between testing or to the mean score of the two tests. The scores differed by as much as +10 to -8, but most patients (n = 35; 92%) showed a difference between -2 and +6 points. The SOMC scores were correlated with the RBMT paragraph recall immediate and delayed scores (r = 0.74) but the scatterplot showed considerable variation.

CONCLUSION

If used by the same observer, changes in the SOMC score are likely to reflect a real difference if it increases by more than 6 points or decreases by more than 2 points. The SOMC does seem to reflect verbal memory.

Equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire and the Orientation-Memory-Concentration test

OBJECTIVE

To determine the equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire (SPMSQ) and the Orientation-Memory-Concentration (OMC) test.

DESIGN

The design was cross-sectional and longitudinal.

SETTING

Four rural and one urban county in the Piedmont region of North Carolina (n = 3210).

PARTICIPANTS

A stratified random cluster sample (n = 3210) of people 68 years of age and older.

MEASUREMENTS

SPMSQ and OMC at the fourth wave of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE); disability, depression, and death measurements from the fourth through seventh waves of EPESE; demographic characteristics.

RESULTS

On the SPMSQ and the OMC (r = .80), 15.3% and 38.4%, respectively, of those tested were rated cognitively impaired. Poorer scores were associated with older age, black race, and less education. These associations were attenuated on the dichotomized SPMSQ but not on the OMC. Both measures predicted disability and depressive symptomatology currently and 3 years hence and death.

CONCLUSIONS

The SPMSQ and OMC, although highly correlated, are not equivalent. Association with race and education are greater for the OMC, whereas an association with age exists for both measures. The milder level of impairment identified by the OMC increases predictive capacity.

A critique of instruments and methods to detect, diagnose, and rate delirium

This document reviews existing instruments for evaluation of delirium. Instruments have been grouped into four categories: tests that screen for cognitive impairment, delirium diagnostic instruments, delirium-specific numerical rating scales, and laboratory and paraclinical exams. Analysis of instruments was based on comparison of their psychometric properties as well as subjective judgment. Guidelines are suggested for choosing the appropriate instrument according to the type of clinical evaluation or delirium research envisaged. Important factors in choosing an instrument, besides the appropriateness of its psychometric characteristics, include administration time constraints, level of rater expertise, and patient capabilities. By familiarizing investigators with the variety of evaluation instruments available, this work should permit more appropriate instrument selection in future studies on delirium.

Raven's colored progressive matrices: a normative study of a random sample of healthy adults

Raven's Colored Progressive Matrices Test (RCPM) was administered to 894 normal healthy adults who were randomly selected in six Italian cities and in the Republic of San Marino. Gender, age, and education significantly influenced overall test performance, and performance on different RCPM subsets. Findings from this large random sample provide demographic corrections to test scores for use in clinical practice.

The mini-mental state examination: a comprehensive review

OBJECTIVE

The purpose of this paper is to provide a comprehensive review of information accumulated over the past 26 years regarding the psychometric properties and utility of the Mini-Mental State Examination (MMSE).

PARTICIPANTS

The reviewed studies assessed a wide variety of subjects, ranging from cognitively intact community residents to those with severe cognitive impairment associated with various types of dementing illnesses.

MAIN OUTCOME MEASURES

The validity of the MMSE was compared against a variety of gold standards, including DSM-III-R and NINCDS-ADRDA criteria, clinical diagnoses, Activities of Daily Living measures, and other tests that putatively identify and measure cognitive impairment.

RESULTS

Reliability and construct validity were judged to be satisfactory. Measures of criterion validity showed high levels of sensitivity for moderate-to-severe cognitive impairment and lower levels for mild degrees of impairment. Content analyses revealed the MMSE was highly verbal, and not all items were equally sensitive to cognitive impairment. Items measuring language were judged to be relatively easy and lacked utility for identifying mild language deficits. Overall, MMSE scores were affected by age, education, and cultural background, but not gender.

CONCLUSIONS

In general, the MMSE fulfilled its original goal of providing a brief screening test that quantitatively assesses the severity of cognitive impairment and documents cognitive changes occurring over time. The MMSE should not, by itself, be used as a diagnostic tool to identify dementia. Suggestions for the clinical use of the MMSE are made.

Mini-Mental State Examination (MMSE): sensitivity in an Italian sample of patients with dementia

The sensitivity of the Mini-Mental State Examination (MMSE) was assessed in a sample of patients with dementia of the Alzheimer type or vascular dementia. The MMSE identified the majority of pts with diffuse cognitive impairment but did not discriminate between the two types of dementia. If failed to detect mild deterioration or forms in which only some cognitive functions were impaired. The test is therefore not sufficient for distinguishing deteriorated from non deteriorated pts, although it is still useful in mass screening or for a quick assessment of deterioration in the course of clinical neurological examination.

Reliability and validity of the Mini-Mental State Exam in neurologically intact elderly

Reliability and validity of MMSE were explored in a sample of 122 healthy, community-residing elderly volunteers between the ages of 57 and 85, who were tested with a battery of neuropsychological tests over three annual probes. Test-retest reliability ranged between .45 and .50 over a 1-year interval and was .38 over a 2-year period. Change on the MMSE of more than 5 points over a 2-year period was associated with a neurological disorder. Significant correlations were found with many neuropsychological measures, especially with a measure of verbal learning.

Development of an "early" detection battery for dementia of the Alzheimer type

1. To develop a diagnostic battery sensitive to and specific for the early detection of Alzheimer disease (AD) dementia, the authors reviewed over 400 journal articles dealing with the diagnosis of A.D. or senile dementia and cognitive assessment in organic brain dysfunction and closed head injury. 2. We culled those studies that met our criteria for solid, reliable and statistically significant results and recommend the testing paradigms that most often produced good discrimination of mild AD dementia from normal senescence. 3. These include tests of language, verbal and non-verbal memory, perception, praxis, attention and reasoning. 4. The battery we assembled takes less than 1 hour to administer, requires no special equipment, and was designed as an early screen for use by psychologists, psychiatrists and other trained health care professionals; it is not intended for repeated administration, as in pharmacological or longitudinal studies.