Brief cognitive assessment in a UK population sample -- distributional properties and the relationship between the MMSE and an extended mental state examination

Sex Differences in Dementia, Cognition, and Health in the Cognitive Function and Ageing Studies (CFAS)

Background

There is renewed interest in whether sex differences in dementia risk exist, and what influence social and biological factors have.

Objective

To review evidence from the Cognitive Function and Ageing Studies (CFAS), a multi-center population-representative cohort study in the UK; focusing on dementia and cognition, incorporating findings on participants' health and social circumstances.

Methods

After identifying all CFAS publications, the results of all sex-stratified primary analyses of CFAS data were narratively reviewed.

Results

Of 337 publications, 94 report results by sex (including null findings), which are summarized by theme: dementia epidemiology, cognition, mental health, health expectancy, social context and biological resource (including neuropathology).

Conclusions

Where differences are found they most commonly favor men; however, greater mortality in men may confound associations with age-related outcomes. This 'survival bias' may explain findings of greater risk of dementia and faster cognitive decline in women. Age-specific dementia incidence was similar between sexes, although reduced incidence across study generations was more pronounced in men. Mood disorders were more prevalent in women, but adjusting for disability and deprivation attenuated the association. Prominent findings from other cohorts that women have more Alzheimer's disease pathology and greater risk of dementia from the Apolipoprotein E ɛ4 allele were not observed, warranting further investigation. The 'male-female health-survival paradox' is demonstrated whereby women live longer but with more comorbidity and disability. Examining why health expectancies changed differently over two decades for each sex (interacting with deprivation) may inform population interventions to improve cognitive, mental and physical health in later life.

Outcome measures for Alzheimer's disease: A global inter-societal Delphi consensus

INTRODUCTION

We aim to provide guidance on outcomes and measures for use in patients with Alzheimer's clinical syndrome.

METHODS

A consensus group of 20 voting members nominated by 10 professional societies, and a non-voting chair, used a Delphi approach and modified GRADE criteria.

RESULTS

Consensus was reached on priority outcomes (n = 66), measures (n = 49) and statements (n = 37) across nine domains. A number of outcomes and measurement instruments were ranked for: Cognitive abilities; Functional abilities/dependency; Behavioural and neuropsychiatric symptoms; Patient quality of life (QoL); Caregiver QoL; Healthcare and treatment-related outcomes; Medical investigations; Disease-related life events; and Global outcomes.

DISCUSSION

This work provides indications on the domains and ideal pertinent measurement instruments that clinicians may wish to use to follow patients with cognitive impairment. More work is needed to develop instruments that are more feasible in the context of the constraints of clinical routine.

Decline in Cognition from Mid-Life Improves Specificity of Mini-Mental State Examination: Diagnostic Test Accuracy in Caerphilly Prospective Study (CaPs)

BACKGROUND

The merit of using baseline cognitive assessments in mid-life to help interpret cross-sectional cognitive tests scores in later life is uncertain.

OBJECTIVE

Evaluate how accuracy for diagnosing dementia is enhanced by comparing cross-sectional results to a midlife measure.

METHODS

Cohort study of 2,512 men with repeated measures of Mini-Mental State Examination (MMSE) over approximately 10 years. Index test MMSE at threshold of 24 indicating normal, as a cross-sectional measure and in combination with decline in MMSE score from mid-life. Reference standard consensus clinical diagnosis of dementia by two clinicians according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

RESULTS

1,150 men participated at phase 4 of whom 75 had dementia. A cross-sectional MMSE alone produced a sensitivity of 60% (50% to 70%) and specificity 95% (94% to 97%) with a threshold of≥24 points indicating normal. For lower-scoring men in late life, with cross sectional scores of < 22, combining cross-sectional AND a three-point or more decline over time had a sensitivity of 52% (39% to 64%) and specificity 99% (99% to 100%). For higher-scoring men in later life, with cross sectional scores < 26 combining cross-sectional OR decline of at least three points had a sensitivity of 98% (92% to 100%) and specificity 38% (32% to 44%).

CONCLUSION

It may be helpful in practice to formally evaluate cognition in mid-life as a baseline to compare with if problems develop in future, as this may enhance diagnostic accuracy and classification of people in later life.

Re-examining popular screening measures in neuro-oncology: MMSE and RBANS

BACKGROUND

The Mini-Mental Status Examination (MMSE) is routinely used in neuro-oncology clinics to rule out cognitive impairment. However, the MMSE is known to have poor sensitivity to mild cognitive impairment, raising concern regarding its continued use. More comprehensive cognitive screeners are available, such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and may be better able to assess for cognitive dysfunction.

METHODS

This retrospective cross-sectional study compared the relative rates of impairment using the MMSE-2 and RBANS in a sample of neuro-oncology patients (N = 81). A preliminary analysis of the sensitivity and specificity of the MMSE-2 to the level of cognitive impairment identified on the RBANS was conducted; in addition, we examined whether an adjustment of the MMSE-2 cut-off score improved consensus with a positive screening on the RBANS.

RESULTS

The MMSE-2 failed to identify over half of the patients with cognitive dysfunction that were identified on the RBANS. Further analysis showed limited sensitivity of the MMSE-2 to the level of impairment detected on the RBANS, and an adjustment of the cut-off score did not improve the sensitivity or specificity of the MMSE-2.

CONCLUSIONS

These results provide caution for neuro-oncology clinics using the MMSE. If providers continue to rely on the MMSE to screen for cognitive impairment alone, they may fail to identify individuals with mild cognitive impairments.

Neurophysiological and Brain Structural Markers of Cognitive Frailty Differ from Alzheimer's Disease

With increasing life span and prevalence of dementia, it is important to understand the mechanisms of cognitive aging. Here, we focus on a subgroup of the population we term "cognitively frail," defined by reduced cognitive function in the absence of subjective memory complaints, or a clinical diagnosis of dementia. Cognitive frailty is distinct from cognitive impairment caused by physical frailty. It has been proposed to be a precursor to Alzheimer's disease, but may alternatively represent one end of a nonpathologic spectrum of cognitive aging. We test these hypotheses in humans of both sexes, by comparing the structural and neurophysiological properties of a community-based cohort of cognitive frail adults, to people presenting clinically with diagnoses of Alzheimer's disease or mild cognitive impairment, and community-based cognitively typical older adults. Cognitive performance of the cognitively frail was similar to those with mild cognitive impairment. We used a novel cross-modal paired-associates task that presented images followed by sounds, to induce physiological responses of novelty and associative mismatch, recorded by EEG/MEG. Both controls and cognitively frail showed stronger mismatch responses and larger temporal gray matter volume, compared with people with mild cognitive impairment and Alzheimer's disease. Our results suggest that community-based cognitively frail represents a spectrum of normal aging rather than incipient Alzheimer's disease, despite similar cognitive function. Lower lifelong cognitive reserve, hearing impairment, and cardiovascular comorbidities might contribute to the etiology of the cognitive frailty. Critically, community-based cohorts of older adults with low cognitive performance should not be interpreted as representing undiagnosed Alzheimer's disease.SIGNIFICANCE STATEMENT The current study investigates the neural signatures of cognitive frailty in relation to healthy aging and Alzheimer's disease. We focus on the cognitive aspect of frailty and show that, despite performing similarly to the patients with mild cognitive impairment, a cohort of community-based adults with poor cognitive performance do not show structural atrophy or neurophysiological signatures of Alzheimer's disease. Our results call for caution before assuming that cognitive frailty represents latent Alzheimer's disease. Instead, the cognitive underperformance of cognitively frail adults could result in cumulative effects of multiple psychosocial risk factors over the lifespan, and medical comorbidities.

Predictors of dementia amongst newly diagnosed non-valvular atrial fibrillation patients

Atrial fibrillation (AF) confers a 2-to-3-fold increased risk of developing cognitive dysfunction and dementia, independent of age and past stroke. The purpose of study was to identify risk factors for developing dementia amongst AF patients in India. This was a single-centre, prospective, observational study wherein recently diagnosed, treatment naïve, persistent non-valvular AF patients were enrolled. All patients were screened for dementia using the Mini-Mental state exam. Amongst a total of 108 patients enrolled, 40 (37%) had dementia. The most common cognitive deficits were in attention and calculation followed by memory deficits. Factors independently contributing to dementia were advanced age, female sex, presence of diabetes, elevated pulmonary artery pressures and a lower serum albumin.

Adverse childhood experiences and cognitive function in adulthood: examining the roles of depressive symptoms and inflammation in a prospective cohort study

PURPOSE

Adverse childhood experiences (ACEs) have been associated with cognitive decline in adulthood. However, the underlying mechanisms implicated remain unclear. This study investigated depressive symptoms and systemic inflammation as potential mediators of the association between ACEs and later cognitive function.

METHODS

Participants were adults aged 50 + from the English Longitudinal Study of Ageing (N = 3029; 54.8% female). Measures included self-reported ACEs at wave 3 (2006-2007), C-reactive protein (CRP) and depressive symptoms at wave 4 (2008-2009), and cognitive function at waves 3 and 7 (2014-2015). Mediation analyses examined the direct associations between ACEs and cognitive function at wave 7 and the indirect associations via depressive symptoms and CRP at wave 4. In a first set of analyses, models were adjusted for sociodemographic factors and baseline cognitive function. In a second set of analyses, models were additionally adjusted for BMI and health behaviours (n = 1915).

RESULTS

Cumulative ACEs exposure positively predicted depressive symptoms (b = 0.184, s.e. = 0.034, p < .001), which in turn predicted poorer cognitive function at wave 7 (b =  - 0.035, s.e. = 0.008, p < .001). ACEs also positively predicted systemic inflammation as measured by CRP (b = 0.031, s.e. = 0.01, p = 0.0016). However, CRP did not mediate the association between ACEs and later cognitive function (b =  - 0.0002, 95% CI: - 0.002, 0.002).

CONCLUSION

These findings suggest that ACEs may be related to cognitive decline partly via depressive symptoms and corroborate prior research linking ACEs with systemic inflammation in adulthood.

Is there a dose-response relationship between musical instrument playing and later-life cognition? A cohort study using EPIC-Norfolk data

INTRODUCTION

Musical instrument playing provides intellectual stimulation, which is hypothesised to generate cognitive reserve that protects against cognitive impairment. Studies to date have classified musicianship as a binary entity. This investigation draws on the dataset of the European Prospective Investigation of Cancer Norfolk study to examine the effect of frequency of playing on later-life cognition.

METHODS

We compared three categorisations of self-reported musical playing frequency in late mid-life (12-month period) against cognitive performance measured after a 4-11 year delay, adjusted for relevant health and social confounders. Logistic regression models estimated the adjusted association between frequency of musical playing and the likelihood of being in the top and bottom cognitive deciles.

RESULTS

A total of 5,693 participants (745 musicians) provided data on music playing, cognition and all co-variables. Classification of musicianship by frequency of playing demonstrated key differences in socio-demographic factors. Musicians outperformed non-musicians in cognition generally. Compared with non-musicians, frequent musicians had 80% higher odds of being in the top cognitive decile (OR 1.80 [95% CI 1.19-2.73]), whereas musicians playing at any frequency had 29% higher odds (95% CI 1.03-1.62). There was evidence of a threshold effect, rather than a linear dose-response relationship.

DISCUSSION

This study supports a positive association between late mid-life musical instrument playing and later-life cognition, although causation cannot be assumed. Musicians playing frequently demonstrated the best cognition. 'Musicians' are a heterogeneous group and frequency of music playing seems a more informative measure than binary classification. Ideally, this more nuanced measure would be collected for different life course phases.

Television viewing and cognitive decline in older age: findings from the English Longitudinal Study of Ageing

There has been significant interest in the effects of television on cognition in children, but much less research has been carried out into the effects in older adults. This study aimed to explore whether television viewing behaviours in adults aged 50 or over are associated with a decline in cognition. Using data from the English Longitudinal Study of Aging involving 3,662 adults aged 50+, we used multivariate linear regression models to explore longitudinal associations between baseline television watching (2008/2009) and cognition 6 years later (2014/2015) while controlling for demographic factors, socio-economic status, depression, physical health, health behaviours and a range of other sedentary behaviours. Watching television for more than 3.5 hours per day is associated with a dose-response decline in verbal memory over the following six years, independent of confounding variables. These results are found in particular amongst those with better cognition at baseline and are robust to a range of sensitivity analyses exploring reverse causality, differential non-response and stability of television viewing. Watching television is not longitudinally associated with changes in semantic fluency. Overall our results provide preliminary data to suggest that television viewing for more than 3.5 hours per day is related to cognitive decline.

Understanding the relationship between cognition and death: a within cohort examination of cognitive measures and mortality

Despite several studies demonstrating an independent and inverse association between cognition and mortality, the nature of this association still remains unclear. To examine the association of cognition and mortality after accounting for sociodemographic, health and lifestyle factors and to explore both test and population characteristics influencing this relationship. In a population based cohort of 8585 men and women aged 48-92 years, who had cognitive assessments in 2006-2011 and were followed up till 2016 for mortality, we examined the relationship between individual cognitive tests as well as a global cognition score to compare their ability in predicting mortality and whether these differed by population characteristics. Risk of death was estimated using Cox proportional hazard regression models including sociodemographic, lifestyle and health variables, and self-reported comorbidities, as covariates in the models. Poor cognitive performance (bottom quartile of combined cognition score) was associated with higher risk of mortality, Hazard Ratio = 1.32 (95% Confidence Interval 1.09, 1.60); individual cognitive tests varied in their mortality associations and also performed differently in middle-age and older age groups. Poor cognitive performance is independently associated with higher mortality. This association is observed for global cognition and for specific cognitive abilities. Associations vary depending on the cognitive test (and domain) as well as population characteristics, namely age and education.

An individual differences approach to semantic cognition: Divergent effects of age on representation, retrieval and selection

Semantic cognition refers to the appropriate use of acquired knowledge about the world. This requires representation of knowledge as well as control processes which ensure that currently-relevant aspects of knowledge are retrieved and selected. Although these abilities can be impaired selectively following brain damage, the relationship between them in healthy individuals is unclear. It is also commonly assumed that semantic cognition is preserved in later life, because older people have greater reserves of knowledge. However, this claim overlooks the possibility of decline in semantic control processes. Here, semantic cognition was assessed in 100 young and older adults. Despite having a broader knowledge base, older people showed specific impairments in semantic control, performing more poorly than young people when selecting among competing semantic representations. Conversely, they showed preserved controlled retrieval of less salient information from the semantic store. Breadth of semantic knowledge was positively correlated with controlled retrieval but was unrelated to semantic selection ability, which was instead correlated with non-semantic executive function. These findings indicate that three distinct elements contribute to semantic cognition: semantic representations that accumulate throughout the lifespan, processes for controlled retrieval of less salient semantic information, which appear age-invariant, and mechanisms for selecting task-relevant aspects of semantic knowledge, which decline with age and may relate more closely to domain-general executive control.

Apolipoprotein E genotype does not moderate the associations of depressive symptoms, neuroticism and allostatic load with cognitive ability and cognitive aging in the Lothian Birth Cohort 1936

OBJECTIVES

In this replication-and-extension study, we tested whether depressive symptoms, neuroticism, and allostatic load (multisystem physiological dysregulation) were related to lower baseline cognitive ability and greater subsequent cognitive decline in older adults, and whether these relationships were moderated by the E4 allele of the apolipoprotein E (APOE) gene. We also tested whether allostatic load mediated the relationships between neuroticism and cognitive outcomes.

METHODS

We used data from the Lothian Birth Cohort 1936 (n at Waves 1-3: 1,028 [M age = 69.5 y]; 820 [M duration since Wave 1 = 2.98 y]; 659 [M duration since Wave 1 = 6.74 y]). We fitted latent growth curve models of general cognitive ability (modeled using five cognitive tests) with groups of APOE E4 non-carriers and carriers. In separate models, depressive symptoms, neuroticism, and allostatic load predicted baseline cognitive ability and subsequent cognitive decline. In addition, models tested whether allostatic load mediated relationships between neuroticism and cognitive outcomes.

RESULTS

Baseline cognitive ability had small-to-moderate negative associations with depressive symptoms (β range = -0.20 to -0.17), neuroticism (β range = -0.27 to -0.23), and allostatic load (β range = -0.11 to 0.09). Greater cognitive decline was linked to baseline allostatic load (β range = -0.98 to -0.83) and depressive symptoms (β range = -1.00 to -0.88). However, APOE E4 allele possession did not moderate the relationships of depressive symptoms, neuroticism and allostatic load with cognitive ability and cognitive decline. Additionally, the associations of neuroticism with cognitive ability and cognitive decline were not mediated through allostatic load.

CONCLUSIONS

Our results suggest that APOE E4 status does not moderate the relationships of depressive symptoms, neuroticism, and allostatic load with cognitive ability and cognitive decline in healthy older adults. The most notable positive finding in the current research was the strong association between allostatic load and cognitive decline.

Montreal Cognitive Assessment and Mini-Mental State Examination reliable change indices in healthy older adults

OBJECTIVE

Cognitive tests are used repeatedly to assess the treatment response or progression of cognitive disorders. The Montreal Cognitive Assessment (MoCA) is a valid screening test for mild cognitive impairment. The aim of our study was to establish 90% reliable change indices (RCI) for the MoCA together with the Mini-Mental State Examination (MMSE) in cognitively healthy older adults.

METHOD

We analyzed 197 cognitively healthy and functional independent volunteers aged 60-94 years, who met strict inclusion criteria for four consecutive years. The RCI methods by Chelune and Hsu were used.

RESULTS

For 1, 2, and 3 years, the 90% RCI for MoCA using Chelune's formula were -4 ≤, ≥4; -4 ≤, ≥4 and -5 ≤, ≥4 points, respectively, and -3 ≤, ≥3 for the MMSE each year. Ninety percent RCI for MoCA using Hsu's formula ranged from -6 to 0, respectively, and +3 to +8 dependent on the baseline MoCA.

CONCLUSION

Our study demonstrated RCI for the MoCA and MMSE in a 3-year time period that can be used for the estimation of cognitive decline or improvement in clinical settings. Copyright © 2016 John Wiley & Sons, Ltd.

Patterns and persistence of behavioural and psychological symptoms in those with cognitive impairment: the importance of apathy

OBJECTIVE

To study the stability and emergence of a range of behavioural and psychological symptoms (BPS), their association with mortality and the effect of covariates on these transitions in a population-based study of cognitively impaired older people with a long follow-up period and large sample size, with a particular focus on apathy.

METHODS

Data were from a population-based, longitudinal cohort study of ageing. Interviews were conducted at 0, 2, 6, 8 and 10 years with 3626 participants aged 65+. The persistence of 11 BPS and their association with mortality in those with cognitive impairment (MMSE 25 or below) was investigated using multi-state models, allowing us to take into account estimations of the probability of transitions that occurred in the time between interviews.

RESULTS

Most BPS were persistent. Apathy was one of the most stable symptoms; in those with apathy, the probability of still having apathy after 1 year is 62%. Apathy, sleep problems, depression, irritability and wandering were most likely to develop. BPS are associated with mortality; in those with apathy, mortality is 3.1 times more likely than in those without apathy. Low cognitive function and dementia were associated with emergence of new symptoms.

CONCLUSIONS

This population-based, multi-centre study with a follow-up period of 10 years showed that BPS are associated with mortality and most symptoms are persistent. Apathy was characterised by a high prevalence, a high persistence and a strong association with mortality, and has a negative impact on disability, management of other disease and caregiver burden.

Cross Sectional Associations between Socio-Demographic Factors and Cognitive Performance in an Older British Population: The European Investigation of Cancer in Norfolk (EPIC-Norfolk) Study

BACKGROUND

Cognition covers a range of abilities, such as memory, response time and language, with tests assessing either specific or generic aspects. However differences between measures may be observed within the same individuals.

OBJECTIVE

To investigate the cross-sectional association of cognitive performance and socio-demographic factors using different assessment tools across a range of abilities in a British cohort study.

METHODS

Participants of the European Prospective Investigation of Cancer (EPIC) in Norfolk Study, aged 48-92 years, underwent a cognitive assessment between 2006 and 2011 (piloted between 2004 and 2006) and were investigated over a different domains using a range of cognitive tests.

RESULTS

Cognitive measures were available on 8584 men and women. Though age, sex, education and social class were all independently associated with cognitive performance in multivariable analysis, different associations were observed for different cognitive tests. Increasing age was associated with increased risk of a poor performance score in all of the tests, except for the National Adult Reading Test (NART), an assessment of crystallized intelligence. Compared to women, men were more likely to have had poor performance for verbal episodic memory, Odds Ratio, OR = 1.99 (95% Confidence Interval, 95% CI 1.72, 2.31), attention OR = 1.62, (95% CI 1.39, 1.88) and prospective memory OR = 1.46, (95% CI 1.29, 1.64); however, no sex difference was observed for global cognition, OR = 1.07 (95%CI 0.93, 1.24). The association with education was strongest for NART, and weakest for processing speed.

CONCLUSION

Age, sex, education and social class were all independently associated with performance on cognitive tests assessing a range of different domains. However, the magnitude of associations of these factors with different cognitive tests differed. The varying relationships seen across different tests may help explain discrepancies in results reported in the current literature, and provides insights into influences on cognitive performance in later life.

Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations

BACKGROUND

The Mini Mental State Examination (MMSE) is a cognitive test that is commonly used as part of the evaluation for possible dementia.

OBJECTIVES

To determine the diagnostic accuracy of the Mini-Mental State Examination (MMSE) at various cut points for dementia in people aged 65 years and over in community and primary care settings who had not undergone prior testing for dementia.

SEARCH METHODS

We searched the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), LILACS (BIREME), ALOIS, BIOSIS previews (Thomson Reuters Web of Science), and Web of Science Core Collection, including the Science Citation Index and the Conference Proceedings Citation Index (Thomson Reuters Web of Science). We also searched specialised sources of diagnostic test accuracy studies and reviews: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). We attempted to locate possibly relevant but unpublished data by contacting researchers in this field. We first performed the searches in November 2012 and then fully updated them in May 2014. We did not apply any language or date restrictions to the electronic searches, and we did not use any methodological filters as a method to restrict the search overall.

SELECTION CRITERIA

We included studies that compared the 11-item (maximum score 30) MMSE test (at any cut point) in people who had not undergone prior testing versus a commonly accepted clinical reference standard for all-cause dementia and subtypes (Alzheimer disease dementia, Lewy body dementia, vascular dementia, frontotemporal dementia). Clinical diagnosis included all-cause (unspecified) dementia, as defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); International Classification of Diseases (ICD) and the Clinical Dementia Rating.

DATA COLLECTION AND ANALYSIS

At least three authors screened all citations.Two authors handled data extraction and quality assessment. We performed meta-analysis using the hierarchical summary receiver-operator curves (HSROC) method and the bivariate method.

MAIN RESULTS

We retrieved 24,310 citations after removal of duplicates. We reviewed the full text of 317 full-text articles and finally included 70 records, referring to 48 studies, in our synthesis. We were able to perform meta-analysis on 28 studies in the community setting (44 articles) and on 6 studies in primary care (8 articles), but we could not extract usable 2 x 2 data for the remaining 14 community studies, which we did not include in the meta-analysis. All of the studies in the community were in asymptomatic people, whereas two of the six studies in primary care were conducted in people who had symptoms of possible dementia. We judged two studies to be at high risk of bias in the patient selection domain, three studies to be at high risk of bias in the index test domain and nine studies to be at high risk of bias regarding flow and timing. We assessed most studies as being applicable to the review question though we had concerns about selection of participants in six studies and target condition in one study.The accuracy of the MMSE for diagnosing dementia was reported at 18 cut points in the community (MMSE score 10, 14-30 inclusive) and 10 cut points in primary care (MMSE score 17-26 inclusive). The total number of participants in studies included in the meta-analyses ranged from 37 to 2727, median 314 (interquartile range (IQR) 160 to 647). In the community, the pooled accuracy at a cut point of 24 (15 studies) was sensitivity 0.85 (95% confidence interval (CI) 0.74 to 0.92), specificity 0.90 (95% CI 0.82 to 0.95); at a cut point of 25 (10 studies), sensitivity 0.87 (95% CI 0.78 to 0.93), specificity 0.82 (95% CI 0.65 to 0.92); and in seven studies that adjusted accuracy estimates for level of education, sensitivity 0.97 (95% CI 0.83 to 1.00), specificity 0.70 (95% CI 0.50 to 0.85). There was insufficient data to evaluate the accuracy of the MMSE for diagnosing dementia subtypes.We could not estimate summary diagnostic accuracy in primary care due to insufficient data.

AUTHORS' CONCLUSIONS

The MMSE contributes to a diagnosis of dementia in low prevalence settings, but should not be used in isolation to confirm or exclude disease. We recommend that future work evaluates the diagnostic accuracy of tests in the context of the diagnostic pathway experienced by the patient and that investigators report how undergoing the MMSE changes patient-relevant outcomes.

Cognitive function in a general population of men and women: a cross sectional study in the European Investigation of Cancer-Norfolk cohort (EPIC-Norfolk)

Background

Although ageing is strongly associated with cognitive decline, a wide range of cognitive ability is observed in older populations with varying rates of change across different cognitive domains.

Methods

Cognitive function was measured as part of the third health examination of the European Prospective Investigation of Cancer in Norfolk (EPIC-Norfolk 3) between 2006 and 2011 (including measures from the pilot phase from 2004 to 2006). This was done using a battery consisting of seven previously validated cognitive function tests assessing both global function and specific domains. The battery included a shortened version of the Extended Mental State Exam (SF-EMSE); letter cancellation task; Hopkins Verbal Learning Test (HVLT); Cambridge Neuropsychological Test Automated Battery Paired Associates Learning Test (CANTAB-PAL); Visual Sensitivity Test (VST); Shortened version of the National Adult Reading Test (Short-NART) and a task to test for prospective memory. We report the distribution of cognitive function in different cognitive domains by age and sex and compare the utility of a number of assessment tests in a general population of older men and women.

Results

Cognitive test data were available for 8585 men and women taking part in EPIC-Norfolk 3. Increasing age was generally associated with declining mean cognitive function, but there was a wide range observed within each age group as well as variability across different cognitive domains. Some sex differences were also observed.

Conclusion

Descriptive data are presented for this general population sample of older men and women. There is a wide range of cognitive performance seen in this population. Though average performance declines with age, there is large individual variability across different cognitive domains. These variations may provide insights into the determinants of cognitive function in later life.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2318-14-142) contains supplementary material, which is available to authorized users.

Openness predicts cognitive functioning in bipolar disorder

OBJECTIVES

Openness to experience (O) is a well-established personality factor and is associated with cognitive performance. Little is known about the personality-cognitive relationship in bipolar disorder, an illness with significant variability in mood. Cognitive evaluation is essential in psychopathology assessment as it may reflect underlying disease processes and psychosocial functional capacity. Screening using a proxy personality variable may identify those in need of comprehensive cognitive testing. We hypothesized that O and measures of cognition would associate in both the Bipolar Disorder (BD) and healthy control (HC) samples, whereas neuroticism and extraversion would correlate with cognition only in the BD sample.

METHODS

Data from a longitudinal study of BD were used to study the association between personality factors and cognitive measures of attention, executive functioning, memory and fine motor skills. Regression analyses were used to determine the variables that account for the association between personality and cognition.

RESULTS

Aspects of O explained significant cognitive variance (~5%) in both groups; this persisted when demographic variables (including BD versus HC status) were considered. Neuroticism and extraversion did not consistently correlate with cognitive performance in either group.

LIMITATIONS

There were more females in the HC group who were slightly younger compared to the BD group. We lack direct measures of positive affect, and there is a reliance on a single measure of personality.

CONCLUSIONS

BD Individuals scoring low on self-reported Openness are potential candidates for more comprehensive cognitive assessments (which represent a limited resource).

Calibration and validation of an innovative approach for estimating general cognitive performance

OBJECTIVE

To evaluate a new approach for creating a composite measure of cognitive function, we calibrated a measure of general cognitive performance from existing neuropsychological batteries.

METHODS

We applied our approach in an epidemiological study and scaled the composite to a nationally representative sample of older adults. Criterion validity was evaluated against standard clinical diagnoses. Convergent validity was evaluated against the Mini-Mental State Examination (MMSE).

RESULTS

The general cognitive performance factor was scaled to have a mean of 50 and standard deviation of 10 in a nationally representative sample of older adults. A cutoff point of approximately 45, corresponding to an MMSE of 23/24, optimally discriminated participants with and without dementia (sensitivity = 0.94, specificity = 0.90, area under the curve = 0.97). The general cognitive performance factor was internally consistent (Cronbach's α = 0.91) and provided reliable measures of functional ability across a wide range of cognitive functioning. It demonstrated minimal floor and ceiling effects, which is an improvement over most individual cognitive tests.

CONCLUSIONS

The cognitive composite is a highly reliable measure, with minimal floor and ceiling effects. We calibrated it using a nationally representative sample of adults over the age of 70 in the USA and established diagnostically relevant cutoff points. Our methods can be used to harmonize neuropsychological test results across diverse settings and studies.

The presence of behavioural and psychological symptoms and progression to dementia in the cognitively impaired older population

OBJECTIVE

Behavioural and psychological symptoms (BPS) are common in the older population and may be an indication of early dementia. We explored the predictive effect of the presence of BPS on the 2-year progression to dementia in a cognitively impaired population aged 65 years and over without dementia at baseline.

METHODS

Twelve symptoms were measured in 2024 participants without dementia at baseline as part of a population-based longitudinal study of ageing. The risk of progression to dementia was predicted in those with cognitive impairment for each individual BPS and using a BPS composite score.

RESULTS

Wandering and persecution were independently associated with progression to dementia after adjustment for socio-demographic factors, cognitive domains and other BPS. When stratifying by cognitive function, those with low cognition (MMSE 0-18) and 4 or more BPS were more likely to progress to dementia than those without BPS.

CONCLUSIONS

We have shown that some psychiatric symptoms are associated with increased short-term progression to dementia in those with low cognition. The predictive effect of BPS in dementia progression has implications for risk stratification of those at high risk of progression to dementia, along with memory impairment, other cognitive impairment and health variables.

Analysing cognitive test data: Distributions and non-parametric random effects

An important assumption in many linear mixed models is that the conditional distribution of the response variable is normal. This assumption is violated when the models are fitted to an outcome variable that counts the number of correctly answered questions in a questionnaire. Examples include investigations of cognitive decline where models are fitted to Mini Mental State Examination scores, the most widely used test to measure global cognition. Mini Mental State Examination scores take integer values in the 0–30 range, and its distribution has strong ceiling and floor effects. This article explores alternative distributions for the outcome variable in mixed models fitted to mini mental state examination scores from a longitudinal study of ageing. Model fit improved when a beta-binomial distribution was chosen as the distribution for the response variable.

Using the Folstein Mini Mental State Exam (MMSE) to explore methodological issues in cognitive aging research

Cognitive scales are used frequently in geriatric research and practice. These instruments are constructed with underlying assumptions that are a part of their validation process. A common measurement scale used in older adults is the Folstein Mini Mental State Exam (MMSE). The MMSE was designed to screen for cognitive impairment and is used often in geriatric research. This paper has three aims. Aim one was to explore four potential threats to validity in the use of the MMSE: (1) administering the exam without meeting the underlying assumptions, (2) not reporting that the underlying assumptions were assessed prior to test administration, (3) use of variable and inconsistent cut-off scores for the determination of presence of cognitive impairment, and (4) failure to adjust the scores based on the demographic characteristics of the tested subject. Aim two was to conduct a literature search to determine if the assumptions of (1) education level assessment, (2) sensory assessment, and (3) language fluency were being met and clearly reported in published research using the MMSE. Aim three was to provide recommendations to minimalize threats to validity in research studies that use cognitive scales, such as the MMSE. We found inconsistencies in published work in reporting whether or not subjects meet the assumptions that underlie a reliable and valid MMSE score. These inconsistencies can pose threats to the reliability of exam results. Fourteen of the 50 studies reviewed reported inclusion of all three of these assumptions. Inconsistencies in reporting the inclusion of the underlying assumptions for a reliable score could mean that subjects were not appropriate to be tested by use of the MMSE or that an appropriate test administration of the MMSE was not clearly reported. Thus, the research literature could have threats to both validity and reliability based on misuse of or improper reported use of the MMSE. Six recommendations are provided to minimalize these threats in future research.

Using the Folstein Mini Mental State Exam (MMSE) to explore methodological issues in cognitive aging research

Cognitive scales are used frequently in geriatric research and practice. These instruments are constructed with underlying assumptions that are a part of their validation process. A common measurement scale used in older adults is the Folstein Mini Mental State Exam (MMSE). The MMSE was designed to screen for cognitive impairment and is used often in geriatric research. This paper has three aims. Aim one was to explore four potential threats to validity in the use of the MMSE: (1) administering the exam without meeting the underlying assumptions, (2) not reporting that the underlying assumptions were assessed prior to test administration, (3) use of variable and inconsistent cut-off scores for the determination of presence of cognitive impairment, and (4) failure to adjust the scores based on the demographic characteristics of the tested subject. Aim two was to conduct a literature search to determine if the assumptions of (1) education level assessment, (2) sensory assessment, and (3) language fluency were being met and clearly reported in published research using the MMSE. Aim three was to provide recommendations to minimalize threats to validity in research studies that use cognitive scales, such as the MMSE. We found inconsistencies in published work in reporting whether or not subjects meet the assumptions that underlie a reliable and valid MMSE score. These inconsistencies can pose threats to the reliability of exam results. Fourteen of the 50 studies reviewed reported inclusion of all three of these assumptions. Inconsistencies in reporting the inclusion of the underlying assumptions for a reliable score could mean that subjects were not appropriate to be tested by use of the MMSE or that an appropriate test administration of the MMSE was not clearly reported. Thus, the research literature could have threats to both validity and reliability based on misuse of or improper reported use of the MMSE. Six recommendations are provided to minimalize these threats in future research.

Trajectories of cognitive decline over 10 years in a Brazilian elderly population: the Bambuí cohort study of aging

Few population-based studies have examined long term cognitive trajectory, and these studies were conducted in high income countries. We investigated the association of age, gender and education with 10-year cognitive trajectory in a well-defined population of elderly using data from the Bambuí Cohort Study of Aging, in Brazil. Cognition was measured using the Mini- Mental State Examination (MMSE). Cohort members underwent annual follow-ups. This analysis was based on 12,206 MMSE measurements from 1,461 (91%) baseline participants. We used mixed effects models to study MMSE as outcome. The key findings from this analysis are that women and people with a higher schooling level at baseline had high scores of MMSE, while older participants started off lower. Regarding cognitive decline, women, older people and those with a higher schooling level declined faster.

Optimizing mild cognitive impairment for discriminating dementia risk in the general older population

BACKGROUND

Criteria for mild cognitive impairment (MCI) predict dementia risk in the clinic. Dementia risk in the population is different and whether there is an optimal MCI-derived threshold for discriminating at-risk from not-at-risk cases in the general older population is not known.

METHODS

Data were from the Medical Research Council Cognitive Function and Ageing Study. Two risk thresholds were derived from each of seven different concepts of MCI including: Mayo Clinic-defined amnestic, nonamnestic, multiple, and revised MCI, MCI based on Mini-Mental State Examination derived categories, and the definitions of Cognitive Impairment No Dementia and Age-Related Cognitive Decline (ARCD). Receiver operating characteristic analysis was used to compare the predictive validity of 2-year incident dementia for each risk threshold across the different MCI definitions.

FINDINGS

MCI-derived risk thresholds varied in their ability to predict dementia. MCI thresholds were accurate in identifying individuals not at-risk of dementia progression (false-negative range: 0%–3.4%). No MCI-derived threshold accurately identified an at-risk group with a 2-year progression rate greater than 20%. Criteria for ARCD defined the threshold with the highest sensitivity and specificity for dementia conversion.

INTERPRETATION

MCI-derived thresholds do not reliably identify individuals at-risk of incident dementia at 2 years when applied in the general population. A large subpopulation of individuals not at-risk was more reliably identified. What is considered a sufficient level of accuracy for identification of individuals at increased risk of dementia depends on the motivation for screening and on the safety and efficacy of available interventions.

Alterations of matrix metalloproteinases in the healthy elderly with increased risk of prodromal Alzheimer's disease

Introduction

Matrix metalloproteinases (MMP) are believed to be involved in the pathologic processes behind Alzheimer's disease (AD). In this study, we aimed to examine the cerebrospinal fluid (CSF) levels of MMPs and tissue inhibitors of metalloproteinase-1 (TIMP-1) in individuals with AD dementia and cognitively healthy elderly individuals, and to investigate their relationship with established CSF biomarkers for Alzheimer's disease.

Methods

CSF was collected from 38 individuals with AD dementia and 34 cognitively healthy elderly individuals. The CSF was analyzed for MMP-1, MMP-3, MMP-9, TIMP-1, β-amyloid_1-42 (Aβ42), total tau protein (T-tau) and phosphorylated tau protein (P-tau). MMP/TIMP-1 ratios were calculated. APOE genotype was determined for the participants.

Results

AD patients had higher MMP-9/TIMP-1 ratios and lower TIMP-1 levels compared to cognitively healthy individuals. In AD patients, the MMP-9/TIMP-1 ratio correlated with CSF T-tau, a marker of neurodegeneration. Interestingly, the cognitively healthy individuals with risk markers for future AD, i.e. AD-supportive CSF biomarker levels of T-tau, P-tau and Aβ42 or the presence of the APOE ε4 allele, had higher CSF MMP-3 and MMP-9 levels and higher CSF MMP-3/TIMP-1 ratios compared to the healthy individuals without risk markers. The CSF levels of MMP-3 and -9 in the control group also correlated with the CSF T-tau and P-tau levels.

Conclusions

This study indicates that MMP-3 and MMP-9 might be involved in early pathogenesis of AD and that MMPs could be associated with neuronal degeneration and formation of neurofibrillary tangles even prior to development of overt cognitive dysfunction.

Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision

Background

Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision.

Methods

We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes.

Results

Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data.

This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication.

There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06).

Conclusions

Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful.

Trial registration

Trial registration: ISRCTN86057119.

[A population-based study on factors associated with performance on the Mini-Mental State Examination in the elderly: the Bambuí Study]

The aim of this study was to examine factors associated with cognitive functioning in community-dwelling older adults with low schooling. 1,588 subjects residing in Bambuí, Minas Gerais State, Brazil, and aged > 60 years participated in this cross-sectional study. Multivariate ordinal logistic regression was used to assess associations between exploratory variables and the Mini-Mental State Examination score (MMSE): < 13 (below the 5th percentile), 14-21 (between the 5th percentile and the lowest quintile), and > 22. Lower MMSE scores were significantly and independently associated with age > 80 years (OR: 2.20; 95%CI: 1.52-3.48), male gender (OR: 2.20; 95%CI: 1.52-3.38), < 3 complete years of schooling (OR: 5.92; 95%CI: 3.92-8.94), lack of spouse (OR: 1.91; 95%CI: 1.39-2.62), vegetable and fruit consumption less than 5 times a week (OR: 1.94; 95%CI: 1.39-2.62), and depressive symptoms (OR: 1.94; 95%CI: 1.39-2.62). The results suggest that individuals with poor MMSE performance also have other markers of vulnerability.

A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment

The MMSE is the most widely used cognitive test but its accuracy and clinical utility in diagnosing cognitive disorders is not fully known. A meta-analysis of 34 dementia studies and five mild cognitive impairment (MCI) studies was conducted, separated into high and low prevalence settings. In memory clinic settings the MMSE had a pooled sensitivity (Se) of 79.8%, a specificity (Sp) of 81.3%, a positive predictive value (PPV) of 86.3% and a negative predictive value (NPV) of 73.0%. In mixed specialist hospital settings the Se, Sp, PPV and NPV were 71.1%, 95.6%, 94.2% and 76.4%, respectively. In non-clinical community settings the MMSE had a pooled Se of 85.1%, a Sp of 85.5%, a PPV of 34.5% and an NPV of 98.5%. In those studies conducted purely in primary care the Se, Sp, PPV and NPV were 78.4%, 87.8%. 53.6% and 95.7%, respectively. Thus the case-finding ability of the MMSE was best when confirming a suspected diagnosis in specialist settings with correct identification made in 27/30 positive results. It was modestly effective at ruling-out dementia in specialist settings. Conversely, in non-specialist settings, the MMSE was best at ruling out dementia, achieving about 29/30 correct reassurances with less than three false negatives out of every 100 screens. Regarding use of the MMSE in identifying MCI, limited evidence was found with only five robust studies comparing MCI with healthy subjects and three comparing Alzheimer's disease with MCI. Provisionally, the MMSE had very limited value in making a diagnosis of MCI against healthy controls and modest rule-out accuracy. It had similarly limited ability to help identify cases of Alzheimer's disease against MCI. In conclusion the MMSE offers modest accuracy with best value for ruling-out a diagnosis of dementia in community and primary care. For all other used it should be combined with or replaced by other methods.

Review of normative data for common screening measures used to evaluate cognitive functioning in elderly individuals

When conducting neuropsychological evaluations of the elderly, it is important to compare patients' test scores to appropriate normative data to maximize diagnostic and descriptive accuracy. Many sets of normative data are now available for screening measures that assess cognitive functioning in the elderly. This article systematically reviewed available norms for 6 widely used screening measures of cognitive functioning in elderly patients. Details regarding the sample characteristics and data collection methods are provided for each set of norms, thereby providing a useful reference for clinicians.

Thyroid function and cognitive decline in the MRC Cognitive Function and Ageing Study

Hypothyroidism and subclinical hyperthyroidism have both been associated with cognitive impairment and dementia. The association between thyroid stimulating hormone (TSH), free thyroid hormone or thyroxine (FT4) levels and cognition was investigated at baseline and after a 2 year follow-up in 1047 participants over 64 years of age, without physical frailty or severe cognitive impairment at baseline. Results indicated that high log transformed TSH levels were associated with lower MMSE performance (B=-0.24 (S.E.=0.09), 95% CI=-0.41 to -0.07) at baseline, independent of FT4, age, sex, education and mood, and, in separate analyses, cardiovascular (risk) factors. Importantly, half of all hypothyroid cases were untreated and unaware of having this disorder. In analyses which excluded cases with thyroid disorders, stroke and those suspected of possible dementia/cognitive impairment (MMSE less than 25) or psychiatric mood disorders at baseline, high-normal FT4 levels were associated with worse MMSE performance and a greater risk for a drop of at least 4 points on the MMSE after 2 years (per pmol/l O.R.=1.13, 95% C.I.=1.03-1.22). In conclusion, elderly patients with cognitive impairment should always be assessed for hypothyroidism. It is unclear why high normal FT4 levels were independently associated with accelerated cognitive decline in those without overt thyroid disease. Other studies found that thyroxine can generate oxidative stress and damage neurons. Treatment with thyroxine in those without thyroid disease (as is sometimes done in anti-ageing clinics) is thus not recommended on the basis of these data and the optimal therapeutic level in the elderly may be lower than is assumed.

Cerebrospinal fluid biomarkers predict decline in subjective cognitive function over 3 years in healthy elderly

OBJECTIVE

To investigate whether cerebrospinal fluid (CSF) biomarkers can predict cognitive decline in healthy, elderly individuals as they have been shown to do in cognitively impaired patient samples.

METHODS

In this study, 57 controls were tested for CSF biomarkers at baseline and then cognitively followed over 3 years.

RESULTS

Low levels of baseline beta-amyloid 1-42 (Abeta42) were associated with development of subjective memory impairment affecting quality of life (memQoL), with a worse Mini Mental Status Examination score and with inability to live in regular housing at follow-up (p < 0.05). The combination of baseline Abeta42 and phosphorylated tau (P-tau) was found to predict development of pathological memQoL with a sensitivity of 71.4% and a specificity of 75.7 (<0.01).

CONCLUSION

Low Abeta42 and combined Abeta42 and P-tau predicted subjective cognitive decline in healthy individuals. In summary, this study shows that already in the clinically normal population Alzheimer-disease-related biological signs might be detectable.

Using the Mini-Mental State Examination for tracking cognition in the older population based on longitudinal data

OBJECTIVES

To estimate population norms for use in assessment of individuals in relation to their age-matched peers using true longitudinal patterns of decline.

DESIGN

Longitudinal study of 10 years of follow-up data from the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) on the most commonly used cognitive test across clinical and research settings.

SETTING

England and Wales.

PARTICIPANTS

Thirteen thousand four people were seen in five sites at baseline, with follow up at 2, 5, and 10 years.

MEASUREMENTS

Mini-Mental State Examination (MMSE) score at three interviews over 10 years. A total of 42,777 MMSE scores were used in the analysis.

RESULTS

MMSE norms are presented according to age and split according to sex using longitudinal data. Potential cohort effects and dropout of individuals with low MMSE scores have been accounted for.

CONCLUSION

It is likely that the cognitive MMSE scale will continue to be used in many settings and across the age range. The figures presented here can be used to plot individual performance and chart where there is change in the relative position of one individual compared with others.

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.

Psychosocial and biochemical interactions in aging: preliminary results from an Italian old sample of "Zincage" project

The study of the interactions among biological factors and psychosocial conditions is a very innovative field, because data are lacking in the scientific literature. Among biological aspects, zinc is an essential element in the elderly, especially in relation to one of the proteins, such as albumin, involved in zinc transport into the cells. In this study, the aim is the assessment of the interrelationship between albumin value (used as an index of the body zinc status) and some psychosocial dimensions in elderly Italian sample recruited for ZINCAGE project, supported by the European Commission in the "Sixth Framework Programme". Some tests and questionnaires were administered to older people included in the trial: the "life-style questionnaire"; the mini mental state examination (MMSE); the geriatric depression scale (GDS-15 items). On the basis of the Senieur Protocol for gerontological studies, a sample of 291 Italian healthy old subjects has been recruited in Central Italy and divided into 3 age groups: (a) 125 subjects aged from 65 to 74 years, (b) 89 subjects aged from 75 to 84 years, (c) 77 subjects aged >or=85 years (classified like successful old people). No cognitive impairment assessed by MMSE was observed in 67.5% of the sample; 64.0% had GDS score less than 5, indicating no depression, whereas the prevalence of biological albumin deficiency (<3.5 g/dl) found in Italian old people was 21.0%. Sixty one percent of subjects with albumin deficiency displayed higher values of GDS (>or=5). These preliminary results showed an interrelationship among serum albumin value and psychosocial aspects in Italian old population, suggesting that low albumin values may be involved in impaired psychological dimensions.

Relationship between cognitive impairment and oral health: results of the Health 2000 Health Examination Survey in Finland

OBJECTIVE

The aim was to study oral health in relation to cognitive impairment in the general population.

MATERIAL AND METHODS

The study population comprised 2320 persons aged 55 years or older who participated in a nationally representative Health 2000 Health Examination Survey in Finland. The data were collected by interviews and clinical oral examinations. Cognition was assessed using a shortened version of the Mini-Mental State Examination (score 0-16). Poisson regression models were used to estimate the relative risk (RR) for continuous variables and logistic regression models to estimate the odds ratio (OR) for dichotomized variables.

RESULTS

The results show that individuals with cognitive impairment have more carious teeth (MMSE 11-10: RR: 1.3, CI: 0.9-1.7, MMSE 9-0: RR: 1.5 CI: 1.0-2.4) than healthy persons. Furthermore, compared to cognitively healthy subjects, those with MMSE 9-0 more often have no teeth and no dentures (OR: 5.2, CI: 1.0-26.6) and less often good denture hygiene (OR: 0.4, CI: 0.2-0.7).

CONCLUSION

Cognitively impaired subjects among older adults in Finland have more carious teeth, are more often edentulous without using a denture, and have poorer denture hygiene than cognitively healthy persons.

Mini-Mental State Examination norms in a community-dwelling sample of elderly with low schooling in Brazil

The objective of this study was to assess Mini-Mental State Examination norms of a functionally normal sample of community-dwelling elderly. Illiterate and low-educated subjects who scored less than 5 on the Pfeffer Functional Activities Questionnaire (PFAQ) [n = 397; female = 269; mean age = 72.15 (SD = 7.24) years] had the 5th, 25th, 50th, and 75th percentiles calculated according to age (65-74; 75-84 years). Overall MMSE score was 21.97 (SD = 4.48). Mean MMSE for illiterate younger individuals was 19.46 (SD = 3.47), and the quartile distribution was 14, 17, 19, and 21. MMSE of subjects with 1-8 years of schooling was 23.90 (3.87), and the distribution was 15, 22, 24, and 27. MMSE of older illiterate subjects was 18.11 (SD = 3.63), and the distribution of scores was 13, 16, 18, and 20, whereas subjects with 1-8 years of schooling scored 23.81 (SD = 4.01) and the distribution was 15, 22, 24, and 27. These MMSE normative data may help improve the detection of cognitive impairment in Brazil, mainly in the primary clinical setting.

Predicting driving cessation over 5 years in older adults: psychological well-being and cognitive competence are stronger predictors than physical health

OBJECTIVES

To examine psychological, medical, and sensorimotor risk factors that predict driving cessation in older adults.

DESIGN

Prospective cohort study including five waves of data collected in 1992, 1993, 1994, 1995, and 1997.

SETTING

The Australian Longitudinal Study of Aging.

PARTICIPANTS

One thousand four hundred sixty-six men and women aged 70 and older drawn from the electoral roll and including 753 drivers at baseline.

MEASUREMENTS

Interviews, including assessments of self-rated health (indicating general well-being); medical conditions; driving status; and clinical assessments of vision, hearing, cognitive function, and grip strength, were conducted in 1992 (baseline) and 1994. Information on current driving status was obtained at baseline and four subsequent waves (1993, 1994, 1995, and 1997). Drivers and nondrivers were compared at baseline. Risk factors for driving cessation were identified using logistic regression.

RESULTS

Drivers were younger and more likely to be male and had better self-rated health, vision, hearing, and cognitive performance than nondrivers at baseline. Seventeen percent of drivers in the study had vision of 6/18 or worse, and 7.3% were classified as possibly cognitively impaired. In those identified as drivers at baseline, subsequent cessation was associated with increasing age, low grip strength, poorer cognitive performance, and poorer self-rated health.

CONCLUSION

Self-rated health and cognitive function were more important than medical conditions or sensory function for predicting driving cessation.