Place orientation and visual construction subdomains of the Mini Mental State Examination test as predictors of rehabilitation outcome of post-acute hip-fractured patients

Comparison of the Brief Interview for Mental Status (BIMS) and Montreal Cognitive Assessment (MoCA) for identifying cognitive impairments and predicting rehabilitation outcomes in an inpatient rehabilitation facility

BACKGROUND

The Brief Interview for Mental Status (BIMS) is the Centers for Medicare and Medicaid Services' primary cognitive assessment for multiple health care settings. However, research suggests that the BIMS has low sensitivity in detecting mild cognitive impairment in community samples and nursing home residents.

OBJECTIVE

To determine the sensitivity of the BIMS in identifying patients with mild or moderate cognitive impairments in an inpatient rehabilitation setting and the relationship of BIMS and Montreal Cognitive Assessment (MoCA) scores with rehabilitation outcomes.

DESIGN

Retrospective cohort.

SETTING

Inpatient rehabilitation facility.

PATIENTS

A total of 2252 patients admitted for orthopedic or general rehabilitation.

METHODS

The sensitivity and specificity of the BIMS for identification of cognitive impairments were determined using validated cutoff scores on the MoCA as criterion. Multivariable ordinal regression was employed to determine if MoCA and BIMS scores were independent predictors of rehabilitation outcomes.

MAIN OUTCOME MEASUREMENTS

Functional independence at discharge (GG scores), rehabilitation efficiency (GG change per day), length of stay (LOS), and discharge destination.

RESULTS

The BIMS had low sensitivity in identifying moderate (0.384) or mild (0.257) cognitive impairment. Patients classified as having moderate cognitive impairment on the MoCA had lower GG scores at discharge (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.30 to 0.46) and rehabilitation efficiency (OR 0.43, CI 0.34 to 0.53) compared to individuals identified as impaired on the BIMS (GG scores: OR 0.63, CI 0.52 to 0.78; efficiency: OR 0.71, CI 0.58 to 0.86). LOS (OR 1.49, CI 1.19 to 1.85) and discharge destination (OR 0.47, CI 0.28 to 0.77) were uniquely predicted in patients identified as moderately impaired on the MoCA but not the BIMS (LOS: OR 0.99, CI 0.80 to 1.21; discharge home: OR 0.93, CI 0.62 to 1.38).

CONCLUSIONS

The BIMS had low sensitivity for detection of mild and moderate cognitive impairments. Compared to the MoCA, the BIMS was less effective at predicting rehabilitation outcomes.

[Multidisciplinary geriatric rehabilitation in the patient with hip fracture and dementia]

Hip fracture and dementia rates increase with age, and both groups of patients suffer increased morbidity and mortality and functional impairment. The management of these patients is a challenge for the orthogeriatric and rehabilitation team process, as despite the evidence on the benefit, the results analysed are still worse than in patients without cognitive impairment. For this reason, and due to the limitation in health resources, many of them have problems in accessibility to them, or are limited to a less intense rehabilitation. There are insufficient studies on the best rehabilitation interventions in this group of patients, but it is suggested: 1) to use a multidisciplinary rehabilitation model adapted to the patient with dementia, and 2) to redefine results of the rehabilitation of these patients not only in terms of functional improvement, without highlighting other concepts, such as quality of life, decrease in complications or improved social support.

General cognitive impairment as a risk factor for motor vehicle collision involvement: a prospective population-based study

This study examined whether cognitive impairment and decline as assessed by a brief mental status screening test is associated with future crash risk in a cohort of older drivers. A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers, aged 70 years and older. At the baseline visit, cognitive impairment was defined as <24 on the Mini Mental State Exam (MMSE). Decline was defined as those with a one-year change in MMSE scores in the lowest quartile (largest decrease). Motor vehicle collision involvement was obtained from the Alabama Department of Public Safety. Poisson regression was used to calculate crude and adjusted rate ratios (RR). There were 278 crashes during the follow-up period. Rates of crash involvement were higher for those with cognitive impairment (crude RR = 2.33) compared to those without impairment at baseline; adjustment for potential confounders namely age and visual processing speed attenuated this relationship (adjusted RR = 1.26, 95% confidence interval (CI) 0.65–2.44). Drivers who experienced a pronounced decline in estimated MMSE scores in one year were 1.64 (95% CI 1.04–2.57) times more likely to have a future at-fault crash, as compared to those whose scores did not decline. Evaluation of MMSE over time may provide important insight in an older driver’s future risk of at-fault crash involvement.

Relationship between areas of cognitive functioning on the Mini-Mental State Examination and crash risk

Previous studies have suggested that the pattern of cognitive impairment in crash-involved older drivers is different from non-crash-involved older drivers. This study assessed the relationship between seven areas of cognitive functioning (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction) on the Mini-Mental State Examination (MMSE) collected at baseline and rates of future crash involvement in a prospective population-based sample of older drivers. Motor vehicle collision (MVC) involvement was obtained from the Alabama Department of Public Safety. Poisson regression was used to calculate crude and adjusted rate ratios (RR). Older drivers having difficulties in place orientation were more than 6 times (95% CI 1.90–19.86) more likely to be involved in a future crash (adjusted RR = 6.14, 95% confidence interval (CI) 1.90–19.86) and at-fault crash (adjusted RR = 6.39, 95% CI 1.51–27.10). Impairment in the other cognitive areas was not associated with higher rates of crash or at-fault crash involvement. The findings were validated in an independent sample of high-risk older drivers and a similar pattern of results was observed. Spatial orientation impairment can help identify older drivers who are more likely to crash in the future.

Predictors of cognitive impairment assessed by Mini Mental State Examination in community-dwelling older adults: relevance of the step test

BACKGROUND

Several predictors of cognitive impairment assessed by Mini Mental State Examination (MMSE) have previously been identified. However, which predictors are the most relevant and what is their effect on MMSE categories remains unclear.

METHODS

Cross-sectional and longitudinal study using data from 1116 older adults (72.6 ± 5.6 years, 579 female), 350 of whom were followed for 7 years. At baseline, the following variables were collected: personal data, marital status, occupation, anthropometric measures, risk factors, previous cardiovascular events, self-rated health and physical activity during the last week. Furthermore, routine laboratory tests, abdominal echography and a step test (with measurement of the time needed to ascend and descend two steps 20 times) were performed. The associations of these variables with cross-sectional cognitive deficit (MMSE < 24) and longitudinal cognitive decline (decrease of MMSE score over 7 years of follow-up) were investigated using logistic regression models.

RESULTS

Cross-sectional cognitive deficit was independently associated with school education ≤ 5 years, prolonged step test duration, having been blue collar or housewife (P ≤ 0.0001 for all) and, with lower significance, with advanced age, previous stroke and poor recent physical activity (P < 0.05). Longitudinal cognitive decline was mainly associated with step test duration (P = 0.0001) and diastolic blood pressure (P = 0.0002). The MMSE categories mostly associated with step test duration were orientation, attention, calculation and language, while memory appeared to be poorly or not affected.

CONCLUSIONS

In our cohort of older adults, step test duration was the most relevant predictor of cognitive impairment.