Mini-mental state examination as a predictor of mortality among older people referred to secondary mental healthcare

Digging into the intrinsic capacity concept: Can it be applied to Alzheimer's disease?

Historically, aging research has largely centered on disease pathology rather than promoting healthy aging. The World Health Organization's (WHO) policy framework (2015-2030) underscores the significance of fostering the contributions of older individuals to their families, communities, and economies. The WHO has introduced the concept of intrinsic capacity (IC) as a key metric for healthy aging, encompassing five primary domains: locomotion, vitality, sensory, cognitive, and psychological. Past AD research, constrained by methodological limitations, has focused on single outcome measures, sidelining the complexity of the disease. Our current scientific milieu, however, is primed to adopt the IC concept. This is due to three critical considerations: (I) the decline in IC is linked to neurocognitive disorders, including AD, (II) cognition, a key component of IC, is deeply affected in AD, and (III) the cognitive decline associated with AD involves multiple factors and pathophysiological pathways. Our study explores the application of the IC concept to AD patients, offering a comprehensive model that could revolutionize the disease's diagnosis and prognosis. There is a dearth of information on the biological characteristics of IC, which are a result of complex interactions within biological systems. Employing a systems biology approach, integrating omics technologies, could aid in unraveling these interactions and understanding IC from a holistic viewpoint. This comprehensive analysis of IC could be leveraged in clinical settings, equipping healthcare providers to assess AD patients' health status more effectively and devise personalized therapeutic interventions in accordance with the precision medicine paradigm. We aimed to determine whether the IC concept could be extended from older individuals to patients with AD, thereby presenting a model that could significantly enhance the diagnosis and prognosis of this disease.

Associations between mental health, blood pressure and the development of hypertension

Multiple studies have reported a link between mental health and high blood pressure with mixed or even contradictory findings. Here, we resolve those contradictions and further dissect the cross-sectional and longitudinal relationship between mental health, systolic blood pressure, and hypertension using extensive psychological, medical and neuroimaging data from the UK Biobank. We show that higher systolic blood pressure is associated with fewer depressive symptoms, greater well-being, and lower emotion-related brain activity. Interestingly, impending hypertension is associated with poorer mental health years before HTN is diagnosed. In addition, a stronger baseline association between systolic blood pressure and better mental health was observed in individuals who develop hypertension until follow-up. Overall, our findings offer insights on the complex relationship between mental health, blood pressure, and hypertension, suggesting that-via baroreceptor mechanisms and reinforcement learning-the association of higher blood pressure with better mental health may ultimately contribute to the development of hypertension.

Mini-Mental State Examination predicts mortality in patients on chronic hemodialysis

BACKGROUND

No available and easy to administer cognitive test has been evaluated for the prediction of mortality in prevalent patients on chronic hemodialysis. The aim of the present study was to determine if the Mini-Mental State Examination (MMSE) was predictor of mortality in patients on chronic hemodialysis.

METHODS

One hundred twenty-seven prevalent patients on chronic hemodialysis were studied. All patients underwent assessment of cognitive function through the MMSE. The MMSE was administered during a midweek hemodialysis session, avoiding the beginning and the end of each treatment to minimize the effects of fluctuations in uremic syndrome or blood pressure in accordance with a previous study. An MMSE score ≤23 was used as indicative of cognitive impairment. Demographic, clinical, and laboratory parameters were recorded for each patient.

RESULTS

Mean (SD) MMSE was 23.2 ± 4.1. Median MMSE was 24 (min-max: 2-30). MMSE was ≤23 in 72 patients and >23 in 55. With data updated in March 2021, after a mean follow-up of 58.8 ± 41 months (range: 2-156 months), 75 patients died, and 17 were transplanted. None was lost to follow-up or was transferred to another unit. Dead participants, as compared with alive ones, were significantly older, had a higher Charlson Index score, had lower Activities daily living and Instrumental activities daily living, and had a lower MMSE score and lower serum albumin levels. Kaplan-Meier analysis showed that survival was significantly lower in patients with MMSE ≤23 than in those with MMSE >23 (log-rank χ² : 8.825, p = 0.003). According to Cox regression analysis, mortality was associated with age and inversely associated with MMSE.

CONCLUSION

We show that the MMSE predicts mortality in prevalent patients on chronic hemodialysis.

Defining and assessing intrinsic capacity in older people: A systematic review and a proposed scoring system

INTRODUCTION

The World Health Organization has introduced the term 'intrinsic capacity' (IC) as a marker of healthy ageing. However, controversy exists on the definition and assessment of IC. We aimed to review the definitions and methods used for the assessment of IC in older adults. In addition, we proposed a new IC scoring method.

METHODS

A systematic search was performed in PubMed, Web of Science, Cochrane Library, Scopus and SPORTDiscus (up to February 10th, 2022) for studies assesing IC in older adults (>60 years).

RESULTS

Thirty-three studies were included. There is overall consensus on the definition of IC as well as on its different dimensions, that is: locomotion, vitality, sensory, cognition and psychological. However, the methods for assessing each of these five dimensions differ substantially across studies and there is no consensus on the best method to compute an eventual global compound score to evaluate IC taking into account all its different dimensions.

CONCLUSIONS

The IC represents a highly relevant clinical concept that has been unfortunately underutilized. We propose a standardization for the assessment of each dimension of IC, with a global 0 (worst) to 10 (highest) score.

The anticholinergic effect on cognition (AEC) scale-Associations with mortality, hospitalisation and cognitive decline following dementia diagnosis

OBJECTIVES

To investigate associations between central anticholinergic burden (determined through the anticholinergic effect on cognition [AEC] scale) and mortality, hospitalisation and cognitive decline in patients with dementia.

METHODS

The South London and Maudsley NHS Foundation Trust (SLaM) Clinical Records Interactive Search (CRIS) application was used to identify patients with a first diagnosis of dementia. Medication exposure was extracted through a natural language processing algorithm, allowing for calculations and comparisons of AEC scores. Data were linked to national mortality and hospitalisation data sources, and serially recorded Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline.

RESULTS

We identified 14 093 patients with dementia, 60.7% were female and the mean age at diagnosis was 79.8 years. Patients for whom a review of their medication was indicated (AEC score ≥ 2 for any individual drug or total AEC score ≥ 3) had an increased risk of mortality (hazard ratio 1.07; 95% confidence interval [CI]: 1.01-1.15) and emergency hospitalisation (1.10; 95% CI: 1.04-1.17), but there were no associations with duration of hospitalisation. Cognitive trajectory analyses showed that this exposure group had lower MMSE scores at diagnosis and a sharper increase in MMSE scores over the subsequent 6 months, but similar slopes for the 6 to 36 months period compared to the remainder of the sample.

CONCLUSIONS

Patients with dementia receiving medication with high central anticholinergic activity appear to have worse prognosis in terms of mortality and hospitalisation risk, but have, primarily, acutely impaired cognitive function, rather than longer-term differences in cognitive decline. J Am Geriatr Soc 68:-, 2020.

'Real time' monitoring of antipsychotic prescribing in patients with dementia: a study using the Clinical Record Interactive Search (CRIS) platform to enhance safer prescribing

BACKGROUND

The use of antipsychotic drugs in dementia has been reported to be associated with increased risk of cerebrovascular events and mortality. There is an international drive to reduce the use of these agents in patients with dementia and to improve the safety of prescribing and monitoring in this area.

OBJECTIVES

The aim of this project was to use enhanced automated regular feedback of information from electronic health records to improve the quality of antipsychotic prescribing and monitoring in people with dementia.

METHODS

The South London and Maudsley NHS Foundation Trust (SLaM) incorporated antipsychotic monitoring forms into its electronic health records. The SLaM Clinical Record Interactive Search (CRIS) platform provides researcher access to de-identified health records, and natural language processing is used in CRIS to derive structured data from unstructured free text, including recorded diagnoses and medication. Algorithms were thus developed to ascertain patients with dementia receiving antipsychotic treatment and to determine whether monitoring forms had been completed. We used two improvement plan-do-study-act cycles to improve the accuracy of the algorithm for automated evaluation and provided monthly feedback on team performance.

RESULTS

A steady increase in antipsychotic monitoring form completion was observed across the study period. The percentage of our sample with a completed antipsychotic monitoring form more than doubled from October 2017 (22%) to January 2019 (58%).

CONCLUSION

'Real time' monitoring and regular feedback to teams offer a time-effective approach, complementary to standard audit methods, to enhance the safer prescribing of high risk drugs.

Longitudinal Maintenance of Cognitive Health in Centenarians in the 100-plus Study

IMPORTANCE

Some individuals who reach ages beyond 100 years in good cognitive health may be resilient against risk factors associated with cognitive decline. Exploring the processes underlying resilience may contribute to the development of therapeutic strategies that help to maintain cognitive health while aging.

OBJECTIVE

To identify individuals who escape cognitive decline until extreme ages and to investigate the prevalence of associated risk factors.

DESIGN, SETTING, AND PARTICIPANTS

The 100-plus Study is a prospective observational cohort study of community-based Dutch centenarians enrolled between 2013 and 2019 who were visited annually until death or until participation was no longer possible. The centenarians self-reported their cognitive health, as confirmed by a proxy. Of the 1023 centenarians approached for study inclusion, 340 fulfilled the study criteria and were included in analyses. Data analysis was performed from April 2019 to December 2019.

MAIN OUTCOMES AND MEASURES

Cognition was assessed using the Mini-Mental State Examination (MMSE). To identify centenarians who escape cognitive decline, this study investigated the association of baseline cognition with survivorship and cognitive trajectories for at least 2 years of follow-up using linear mixed models, adjusted for sex, age, and education. This study investigated the prevalence of apolipoprotein E (APOE) genotypes and cardiovascular disease as risk factors associated with cognitive decline.

RESULTS

At baseline, the median age of 340 centenarians was 100.5 years (range, 100.0-108.2 years); 245 participants (72.1%) were female. The maximum survival estimate plateaued at 82% per year (95% CI, 77% to 87%) across centenarians who scored 26 to 30 points on the baseline MMSE (hazard ratio, 0.56; 95% CI, 0.42 to 0.75; P < .001), suggesting that an MMSE score of 26 or higher is representative of both cognitive and physical health. Among the 79 centenarians who were followed up for 2 years or longer, those with baseline MMSE score less than 26 experienced a decline in MMSE score of 1.68 points per year (95% CI, -2.45 to -0.92 points per year; P = .02), whereas centenarians with MMSE scores of 26 or higher at baseline experienced a decline of 0.71 point per year (95% CI, -1.08 to -0.35 points per year). For 73% of the centenarians with baseline MMSE scores of 26 or higher, no cognitive changes were observed, which often extended to ensuing years or until death. It is estimated that this group is representative of less than 10% of Dutch centenarians. In this group, 18.6% carried at least 1 APOE-ε4 allele, compared with 5.6% of the centenarians with lower and/or declining cognitive performance.

CONCLUSIONS AND RELEVANCE

Most centenarians who scored 26 or higher on the MMSE at baseline maintained high levels of cognitive performance for at least 2 years, in some cases despite the presence of risk factors associated with cognitive decline. Investigation of this group might reveal the processes underlying resilience against risk factors associated with cognitive decline.

Predicting high-cost care in a mental health setting

BACKGROUND

The density of information in digital health records offers new potential opportunities for automated prediction of cost-relevant outcomes.

AIMS

We investigated the extent to which routinely recorded data held in the electronic health record (EHR) predict priority service outcomes and whether natural language processing tools enhance the predictions. We evaluated three high priority outcomes: in-patient duration, readmission following in-patient care and high service cost after first presentation.

METHOD

We used data obtained from a clinical database derived from the EHR of a large mental healthcare provider within the UK. We combined structured data with text-derived data relating to diagnosis statements, medication and psychiatric symptomatology. Predictors of the three different clinical outcomes were modelled using logistic regression with performance evaluated against a validation set to derive areas under receiver operating characteristic curves.

RESULTS

In validation samples, the full models (using all available data) achieved areas under receiver operating characteristic curves between 0.59 and 0.85 (in-patient duration 0.63, readmission 0.59, high service use 0.85). Adding natural language processing-derived data to the models increased the variance explained across all clinical scenarios (observed increase in r2 = 12-46%).

CONCLUSIONS

EHR data offer the potential to improve routine clinical predictions by utilising previously inaccessible data. Of our scenarios, prediction of high service use after initial presentation achieved the highest performance.

Psychiatric comorbidity as a risk factor for the mortality of people with bulimia nervosa

BACKGROUND

Bulimia nervosa (BN) is associated with increased mortality. Frequent comorbidities of BN include substance use disorders, affective disorders and personality disorders (PD). These comorbidities may add an additional risk for mortality.

METHODS

We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders over an observation period from January 2007 to March 2016 for 1501 people with BN using anonymised health records data from the South London and Maudsley NHS Foundation Trust (SLaM), retrieved through its Clinical Records Interactive Search (CRIS) data resource. Mortality was ascertained through monthly linkages to the nationwide tracing system administered by the Office for National Statistics (ONS). We used Cox proportional hazards regression to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Multivariable analyses were also performed to estimate effects when controlling for confounding of age, sex, ethnicity, borough, marital status and deprivation score.

RESULTS

A total of 18 patients with BN died during the observation period. The standardised mortality ratio (SMR) for our study cohort (against the population of England and Wales in 2012 as a standard) was 2.52 (95% CI 1.49-3.97). Cox regressions revealed significant associations of mortality with older age and male gender. Comorbid PD (HR: 3.36; 95% CI 1.05-10.73) was significantly associated with all-cause mortality, even after controlling for demographic and socioeconomic covariates.

CONCLUSIONS

These results highlight increased mortality in patients with BN and the importance of recognising and treating PDs in patients with BN.

Psychiatric comorbidity as a risk factor for mortality in people with anorexia nervosa

Anorexia nervosa (AN) is found associated with increased mortality. Frequent comorbidities of AN include substance use disorders (SUD), affective disorders (AD) and personality disorders (PD). We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders in the observation window between January 2007 and March 2016 for 1970 people with AN, using data from the case register of the South London and Maudsley (SLaM) NHS Foundation Trust, an almost monopoly-secondary mental healthcare service provider in southeast London. We retrieved data from its Clinical Records Interactive Search (CRIS) system as data source. Mortality was ascertained through nationwide tracing by the UK Office for National Statistics (ONS) linked to CRIS database on a monthly basis. A total of 43 people with AN died during the observation period. Standardized Mortality Ratio (SMR) with England and Wales population in 2012 as standard population for our study cohort was 5.21 (95% CI 3.77, 7.02). In univariate analyses, the comorbidity of SUD or PD was found to significantly increase the relative risks of mortality (HRs = 3.10, 95% CI 1.21, 7.92; and 2.58, 95% CI 1.23, 5.40, respectively). After adjustment for demographic and socioeconomic covariates as confounders, moderately but not significantly elevated risks were identified for SUD (adjusted HR = 1.39, 95% CI 0.53, 3.65) and PD (adjusted HR = 1.58, 95% CI 0.70, 3.56). These results suggest an elevated mortality in people with AN, which might be, at least partially, explained by the existence of the comorbidities SUD or PD.

Association of socioeconomic status and health-related behavior with elderly health in China

Previous health studies have focused on the correlation between socioeconomic status (SES) and health. We pooled data from the Chinese Longitudinal Healthy Longevity Survey (N = 9765) conducted in 2011, and examined the association of SES and health-related behavior with elderly health in China. The cumulative health disadvantage of the elderly caused by SES can be relieved by lifelong health-related behavior. In the same SES, the odds of self-rated health (SRH) as “good,” mini-mental state examination (MMSE) as “not impaired,” and activities of daily living (ADLs) as “not impaired” among the elderly who exercised regularly, were 46.9%, 28.6%, and 62.3% lower for the elderly who rarely exercised. The elderly who started doing regular exercise from 30 years old, achieved higher SRH, ADL, and MMSE scores to some extent. The health improvement advantage for the elderly who started doing regular exercises after 60 years old, was reduced. However, the odds of SRH as “good,” MMSE as “not impaired,” and ADLs as “not impaired” were still 3.4%, 12.5%, and 17.8%, respectively, higher than the respondents who never exercised. The health-related behaviors not only promote elderly health improvement, but its duration has also been found to be associated with the extent of health improvement.

Prognosis of Treatment Outcomes by Cognitive and Physical Scales

The aim of this study was to assess the possibility of using scales for measuring cognitive and physical functions for a prognosis of care outcomes in elderly patients. Methodology. The survey was carried out in one of the Vilnius City Hospitals for Nursing and Support Treatment. A total number of 177 respondents were involved in the study. The Mini–Mental State Examination (MMSE), The Barthel Index (BI) and The Morse Fall Scale were used. Results. A statistically significant correlation was revealed between the scores of MMSE and BI (Pearson R = 0.41, p < 0.01); those with severe cognitive impairment were more dependent. A statistically significant correlation (Pearson R = −0.181, p < 0.01) was reported between the scores of MMSE and the Morse Fall Scale – the risk of falling was higher in patients with severe cognitive impairment. Conclusions. The Morse Fall Scale was not suitable for the prognosis of outcomes. The MMSE was suitable for the prognosis of a patient’s discharge. The Barthel Index should be considered as the most suitable tool for the prognosis of care outcomes: the sum-score of the Barthel Index above 25 may suggest that the patient would be discharged home; the sum-score below this level was associated with a higher likelihood of patient death.

Joint modelling of longitudinal 3MS scores and the risk of mortality among cognitively impaired individuals

Background

Modified Mini-Mental State Examination (3MS) is an instrument administered by trained personnel to examine levels of participants’ cognitive function. However, the association between changes in scores over time and the risk of death (mortality) is not known. The aims of this study are to examine the association between 3MS scores and mortality via cognitive impairment among older women and to determine individuals’ risk of changes in scores to better predict their survival and mortality rates.

Methods

We propose a Bayesian joint modelling approach to determine mortality due to cognitive impairment via repeated measures of 3MS scores trajectories over a 21-year follow-up period. Data for this study are taken from the Osteoporotic Fracture longitudinal study among women aged 65+ which started in 1986–88.

Results

The standard relative risk model from the analyses with a baseline 3MS score after adjusting for all the significant covariates demonstrates that, every unit decrease in a 3MS score corresponds to a non-significant 1.059 increase risk of mortality with a 95% CI of (0.981, 1.143), while the extended model results in a significant 0.09% increased risk in mortality. The joint modelling approach found a strong association between the 3MS scores and the risk of mortality, such that, every unit decrease in 3MS scores results in a 1.135 (13%) increased risk of death via cognitive impairment with a 95% CI of (1.056, 1.215).

Conclusion

It has been demonstrated that a decrease in 3MS results has a significant increase risk of mortality due to cognitive impairment via joint modelling, but insignificant when considered under the standard relative risk approach.

Identification of the delivery of cognitive behavioural therapy for psychosis (CBTp) using a cross-sectional sample from electronic health records and open-text information in a large UK-based mental health case register

OBJECTIVE

Our primary objective was to identify cognitive behavioural therapy (CBT) delivery for people with psychosis (CBTp) using an automated method in a large electronic health record database. We also examined what proportion of service users with a diagnosis of psychosis were recorded as having received CBTp within their episode of care during defined time periods provided by early intervention or promoting recovery community services for people with psychosis, compared with published audits and whether demographic characteristics differentially predicted the receipt of CBTp.

METHODS

Both free text using natural language processing (NLP) techniques and structured methods of identifying CBTp were combined and evaluated for positive predictive value (PPV) and sensitivity. Using inclusion criteria from two published audits, we identified anonymised cross-sectional samples of 2579 and 2308 service users respectively with a case note diagnosis of schizophrenia or psychosis for further analysis.

RESULTS

The method achieved PPV of 95% and sensitivity of 96%. Using the National Audit of Schizophrenia 2 criteria, 34.6% service users were identified as ever having received at least one session and 26.4% at least two sessions of CBTp; these are higher percentages than previously reported by manual audit of a sample from the same trust that returned 20.0%. In the fully adjusted analysis, CBTp receipt was significantly (p<0.05) more likely in younger patients, in white and other when compared with black ethnic groups and patients with a diagnosis of other schizophrenia spectrum and schizoaffective disorder when compared with schizophrenia.

CONCLUSIONS

The methods presented here provided a potential method for evaluating delivery of CBTp on a large scale, providing more scope for routine monitoring, cross-site comparisons and the promotion of equitable access.

Dementia ascertainment using existing data in UK longitudinal and cohort studies: a systematic review of methodology

BACKGROUND

Studies investigating the risk factors for or causation of dementia must consider subjects prior to disease onset. To overcome the limitations of prospective studies and self-reported recall of information, the use of existing data is key. This review provides a narrative account of dementia ascertainment methods using sources of existing data.

METHODS

The literature search was performed using: MEDLINE, EMBASE, PsychInfo and Web of Science. Included articles reported a UK-based study of dementia in which cases were ascertained using existing data. Existing data included that which was routinely collected and that which was collected for previous research. After removing duplicates, abstracts were screened and the remaining articles were included for full-text review. A quality tool was used to evaluate the description of the ascertainment methodology.

RESULTS

Of the 3545 abstracts screened, 360 articles were selected for full-text review. 47 articles were included for final consideration. Data sources for ascertainment included: death records, national datasets, research databases and hospital records among others. 36 articles used existing data alone for ascertainment, of which 27 used only a single data source. The most frequently used source was a research database. Quality scores ranged from 7/16 to 16/16. Quality scores were better for articles with dementia ascertainment as an outcome. Some papers performed validation studies of dementia ascertainment and most indicated that observed rates of dementia were lower than expected.

CONCLUSIONS

We identified a lack of consistency in dementia ascertainment methodology using existing data. With no data source identified as a "gold-standard", we suggest the use of multiple sources. Where possible, studies should access records with evidence to confirm the diagnosis. Studies should also calculate the dementia ascertainment rate for the population being studied to enable a comparison with an expected rate.

Biomarkers of Aging: From Function to Molecular Biology

Aging is a major risk factor for most chronic diseases and functional impairments. Within a homogeneous age sample there is a considerable variation in the extent of disease and functional impairment risk, revealing a need for valid biomarkers to aid in characterizing the complex aging processes. The identification of biomarkers is further complicated by the diversity of biological living situations, lifestyle activities and medical treatments. Thus, there has been no identification of a single biomarker or gold standard tool that can monitor successful or healthy aging. Within this short review the current knowledge of putative biomarkers is presented, focusing on their application to the major physiological mechanisms affected by the aging process including physical capability, nutritional status, body composition, endocrine and immune function. This review emphasizes molecular and DNA-based biomarkers, as well as recent advances in other biomarkers such as microRNAs, bilirubin or advanced glycation end products.

Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register: current status and recent enhancement of an Electronic Mental Health Record-derived data resource

PURPOSE

The South London and Maudsley National Health Service (NHS) Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register and its Clinical Record Interactive Search (CRIS) application were developed in 2008, generating a research repository of real-time, anonymised, structured and open-text data derived from the electronic health record system used by SLaM, a large mental healthcare provider in southeast London. In this paper, we update this register's descriptive data, and describe the substantial expansion and extension of the data resource since its original development.

PARTICIPANTS

Descriptive data were generated from the SLaM BRC Case Register on 31 December 2014. Currently, there are over 250,000 patient records accessed through CRIS.

FINDINGS TO DATE

Since 2008, the most significant developments in the SLaM BRC Case Register have been the introduction of natural language processing to extract structured data from open-text fields, linkages to external sources of data, and the addition of a parallel relational database (Structured Query Language) output. Natural language processing applications to date have brought in new and hitherto inaccessible data on cognitive function, education, social care receipt, smoking, diagnostic statements and pharmacotherapy. In addition, through external data linkages, large volumes of supplementary information have been accessed on mortality, hospital attendances and cancer registrations.

FUTURE PLANS

Coupled with robust data security and governance structures, electronic health records provide potentially transformative information on mental disorders and outcomes in routine clinical care. The SLaM BRC Case Register continues to grow as a database, with approximately 20,000 new cases added each year, in addition to extension of follow-up for existing cases. Data linkages and natural language processing present important opportunities to enhance this type of research resource further, achieving both volume and depth of data. However, research projects still need to be carefully tailored, so that they take into account the nature and quality of the source information.

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.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study

PURPOSE

People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.

METHODS

E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.

RESULTS

In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).

CONCLUSIONS

There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.