Cognition, copyright, and the classroom

Comparing Detection of Alzheimer's and Vascular Disease-Related Cognitive Impairment With Brief Cognitive Screens

Objectives: The study compared the accuracy of the Mini-Mental State Examination (MMSE) with its modified version (3MS) in distinguishing healthy older adults from adults with cognitive impairment due to suspected Alzheimer’s disease (AD) or vascular disease (VaD). Method: Participants were 98 veterans who underwent comprehensive neuropsychological evaluation due to concern for cognitive decline. Participants were selected via retrospective chart review on the basis of diagnosis. They had diagnoses of mild or major neurocognitive disorder due to suspected AD (N=20), mild or major neurocognitive disorder due to suspected VaD (N=44), or no neurocognitive diagnosis (i.e., healthy adult comparisons; HC, N=34). Results: The 3MS demonstrated superior detection of cognitive impairment. The extent of this enhanced detection was influenced by the suspected etiology of cognitive impairment. The 3MS and MMSE had comparable discrimination of AD and HC. With respect to VaD, the 3MS showed superior discriminability compared to the MMSE. Conclusions: Overall, results support the adoption of the 3MS over that of the MMSE. The 3MS is a superior (and free) tool for detecting cognitive impairment in geriatric populations. Its use is recommended for first-line screening of cognitive symptoms in older adult populations, especially those with concern for VaD.

Which figure copy test is more sensitive for cognitive impairment in Parkinson's disease: Wire cube or interlocking pentagons?

BACKGROUND

Performance on figure copy tests has been shown to predict progressive cognitive decline in Parkinson's disease (PD). Historically, the interlocking pentagons from the Mini Mental State Exam (MMSE) have been the figure copy test most commonly used during cognitive screening evaluations. However, the wire cube from the Montreal Cognitive Assessment (MoCA) is increasingly being used.

OBJECTIVE

To evaluate which of these figure copy tests is more sensitive for cognitive impairment in PD.

METHODS

Sixty-three PD patients from UK and USA completed the MMSE and MoCA. Logistic regression and sensitivity/specificity analyses were used to evaluate the utility of each figure copy test for detecting global cognitive impairment.

RESULTS

The wire cube was a significant indicator of cognitive impairment (OR=4.79, 95% CI=1.63-14.07, p=0.004), with a sensitivity/specificity of 0.74/0.63 in our sample. In contrast, interlocking pentagons were not a significant indicator of cognitive impairment (OR=1.88, 95% CI=0.54-6.50, p=0.32), with a sensitivity/specificity of 0.26/0.84.

CONCLUSION

The wire cube is more sensitive to cognitive impairment in PD, most likely related to its greater complexity. The results have implications for clinicians who may have time for just one figure copying task as part of a brief screen for cognitive impairment in busy clinics and for researchers applying the PD mild cognitive impairment diagnostic criteria necessitating two tests of visuospatial function to be administered.

Validity of the montreal cognitive assessment as a screen for mild cognitive impairment and dementia in African Americans

The validity of the Montreal Cognitive Assessment (MoCA) as a screen for mild cognitive impairment (MCI) and dementia was evaluated in African Americans attending an urban outpatient memory disorders clinic. Eighty one patients ≥50 years old were administered the MoCA and neuropsychological tests. Clinicians, blinded to the MoCA scores, reviewed the neuropsychological findings and reports of instrumental activities of daily living and they assigned a diagnosis of normal cognition (NC; N = 16), MCI (N = 38), or dementia (N = 27). The MoCA scores of the 3 groups were significantly different (NC > MCI > dementia). Using cutoff scores of ≤24 points for MCI and ≤22 points for dementia, the MoCA had .95 sensitivity and .63 specificity for MCI and .96 sensitivity and .88 specificity for dementia. The MoCA is a valid and cost-effective screen for cognitive impairment in African Americans but with a higher likelihood of falsely classifying persons with NC as having MCI.

Practical assessment of delirium in palliative care

CONTEXT

Delirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging.

OBJECTIVES

This review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings.

METHODS

In addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990-2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care.

RESULTS

Of the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes.

CONCLUSION

Given the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.

Should the mini-mental state examination be retired?

INTRODUCTION

Short cognitive tests are routinely used in clinical practice to detect and screen for cognitive impairment and dementia. These cognitive tests should meet minimum criteria for both applicability and psychometric qualities.

DEVELOPMENT

The Mini-Mental State Examination (MMSE) is the most frequently applied short cognitive test, and the article introducing it remains a milestone in the history of medicine. Its main advantages are its widespread use and the extensive empirical evidence that supports it. However, the MMSE has important shortcomings, including lack of standardisation, its lack of suitability for illiterate subjects, the considerable effect of socio-educational variables on results, and its limited effectiveness for detecting cognitive impairment. Lastly, since the test is copyright-protected, using it is necessarily either costly or fraudulent. Newer available instruments do not share these shortcomings and have demonstrated greater diagnostic accuracy for detecting cognitive impairment and dementia, as well as being more cost-effective than the MMSE CONCLUSION: It is time to acknowledge the MMSE's important role in the history of medicine and grant it a deserved and honourable retirement. Its place will be taken by more effective instruments that require less time, are user-friendly and free of charge, can be applied to all individuals, and yield more equitable outcomes.

LOINC® - A Universal Catalog of Individual Clinical Observations and Uniform Representation of Enumerated Collections

In many areas of practice and research, clinical observations are recorded on data collection forms by asking and answering questions, yet without being represented in accepted terminology standards these results cannot be easily shared among clinical care and research systems. LOINC contains a well-developed model for representing variables, answer lists, and the collections that contain them. We have successfully added many assessments and other collections of variables to LOINC in this model. By creating a uniform representation and distributing it worldwide at no cost, LOINC aims to lower the barriers to interoperability among systems and make this valuable data available across settings when and where it is needed.

Screening for memory disorders, dementia and Alzheimer’s disease

Dementia and its most common cause, Alzheimer’s disease, affect memory and occur predominantly in the elderly. Dementia has become increasingly prevalent in the world as health has improved and life expectancy has increased. However, the fields of clinical care have not responded adequately to develop diagnostic tools and treatments for this rapidly increasing group of conditions. While scientists search for cures for the numerous causes of dementia, improvement of diagnostic measures are needed now and should begin with screening elderly populations for memory difficulties and other cognitive problems. This review examines the history of cognitive screening tests, the numerous excellent tests that are currently available and ready for use, and directions and methods that will lead to progressively better evaluations.