Main Article: H.J. WOODFORD, J. GEORGE. Cognitive assessment in the elderly: a review of clinical methods.

Q J Med 2007; 100:469 484 Seminar May 09 Piyawat D., M.D. : speaker Nahathai W., Assis Prof., M.D. : supervisor

Introduction
y Distinguishing normal aging from the early stages of

an abnormal (disease) process

y Impact on social, functional or occupational activities

y Impairment not dementia (CIND) y Prevalence of dementia; y < 1% of people aged < 65 years y 3 11% of those aged 65 years y Up to 33% of those aged 85 years y Prevalence of CIND; 17% in people aged <65 years.

Introduction
y Multiple databases review (to August 2006) y Cinahl, Embase, Medline and PsychINFO y MMSE - most commonly used but time consuming

MMSE
y Distinguish organic from non-organic y Inter-user difference in scoring tests and variation y Cut-off points varies; y 23 for those who educated up to high school y 25 for those who underwent higher education y It has both a ceiling and floor effect y Limited capacity to y Test frontal : executive or visuospatial functions y Detected non-ADs, such as post-stroke cognitive impairment, frontotemporal or subcortical dementias

Abbreviated Mental Test (AMT)

y 10 questions with the components of; y short and long term memory y attention and orientation y Score of <8 is the usual cut-off y Quickly provide a severity assessment (~3mins) y Discriminatory ability to detect changes in cognition

associated with the post-operative delirium y Four-question version of the AMT (the AMT4)
y Cognitive assessment of elderly in busy hospital

AMT (en.wikipedia.org/wiki/Abbreviated_mental_test_score)

Six-Item Screener (SIS)

y 3 orientation questions and a 3-item recall task y Lower score signifying more cognitive impairment y Cut-off of 4

Example * y three-item recall (apple, table, penny)

y In CSI-D is boat, house, and fish

y three-item temporal orientation (day of the week,

month, year) * C. M. CALLAHAN, et al. Six-Item Screener to Identify Cognitive Impairment Among Potential
Subjects for Clinical Research: MEDICAL CARE Volume 40, Number 9, pp 771 781.

Six-Item Cognitive Impairment Test (6CIT)

y Short Orientation-Memory-Concentration Test y Constructed from six items y One memory, two calculation and three orientation y Weighting when scored (0 - 28) y Higher numbers representing more significant

cognitive impairment y Requirement for some mathematics y Scores of 0-7 are considered normal and 8 or more significant*
* Wilber ST, et al. The Six-Item Screener to detect cognitive impairment in older emergency department patients. Acad Emerg Med. 2008 Jul;15(7):613-6.

6-CIT
(www.patient.co.uk/leafl
ets/6_item_cognitive_im pairment_test.htm )

Clock Drawing Test (CDT)

y A screen for visiospatial, constructional praxis and

frontal/executive impairment y 10 past 11 y Many versions and at least 15 different scoring systems y Three-point scale
y one mark for each of: a correctly drawn circle; y appropriately spaced numbers; y and hands that show the right time

y Detect early, mild changes in cognition y Useful screening test (sensitivity/specificity ~ 85%)

Chula clock-drawing scoring system (CCSS)

(Buranee Kanchanatawan, et. al. Validity of Clock Drawing Test (CDT), Scoring by Chula Clock-Drawing Scoring System (CCSS) in Screening Dementia among Thai Elderly in Community. J Med Assoc Thai 2006; 89 (8): 1150-6.)

CDT
(http://www.dementiaguide.com/about dementia/understanding/praxis)

Mini-Cog
y Add a three-word recall test to the CDT y Having cognitive impairment if they are unable to; y Recall any of three words (correct complete clock) or, y Recall only 1 or 2 words and draw an abnormal clock (i.e. any of the circle, numbers and hands are incorrect) y Just a screening test (Present VS Absent)

The Mini-Cog Assessment Instrument for Dementia*

Administration 1. Instruct the patient to remember 3 unrelated words and then to repeat them. 2. Instruct the patient to draw the face of a clock with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time (These instructions can be repeated) 3. Ask the patient to repeat words. Scoring y Give 1 point for each recalled word after the CDT distractor. Score 1 3.
y A score of O indicates positive screen for dementia. y A score of 1 or 2 with an abnormal CDT indicates positive screen for

dementia. y A score of 1 or 2 with a normal CDT indicates negative screen for dementia.
*Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive vital signs measure for dementia screening in multi-lingual elderly. Int J Geriatr P s y c h i a t r y 2000; 15(11): 1021 1027.

The General Practitioner Assessment of Cognition (GPCOG)

y Similarities with the Mini-Cog (recall task

CDT)

y Brief components testing y Memory of recent events and orientation y Questionnaire in intermediate scores patients

Comparing brief assessment scales

Comparing brief assessment scales

y More capacities than MMSE; y CDT - frontal/executive cognitive abnormalities y 6CIT - milder cases of dementia in selected cases y Mini-Cog - ability to classify ethnically diverse groups y GPCOG outperform the MMSE in a GP-based sample y SIS better than Mini-Cog in ER setting y 2 reviews were recommended; y Mini-Cog, GPCOG, Memory Impairment Screen (MIS)

Recommendation
y SIS, 6CIT and Mini-Cog may be considered as quicker

yet sufficiently reliable alternatives to the MMSE y Choice of which is preferred may reflect the testing environment
y SIS

ER setting y 6CIT maths y Mini-Cog pen & paper (+non-Eng speaker)

Distinguishing causes of impairment

y The brief screening tests - little ability to distinguish y History of onset, progression and associated features y PE is also necessary to detect associated signs y Investigations to exclude reversible causes y Gold standard for the diagnosis of types of cognitive

impairment currently absence

y NINCDS-ADRDA criteria require autopsy proof for

definite ADs y DSM-IV criteria - limited differentiating ability between subtypes

Depression
y Gold standard - psychiatric interview y Brief screening y Geriatric Depression Score (GDS)
y y

A score > 5 points is suggestive of depression.* A score > 10 points is almost always indicative of depression.*

y Hospital Anxiety and Depression Scale (HADS)

y Validity may be impaired in patients with significant

cognitive impairment

Geriatric Depression Scale: Short Form*

(*http://www.stanford.edu/~yesavage/GDS.html)
1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO
y Score 1 point for each bolded answer.

Delirium
y CAM - screening test to detect delirium y Compared it to the DSM-IV criteria, the sensitivity and

specificity were 81% and 84%, respectively y present or absent result y Delirium Rating Scale (DRS)

Delirium Index (DI)

(McCusker J. The delirium index, a measure of the severity of delirium: new findings on reliability, validity, and responsiveness. J Am Geriatr Soc. 2004 Oct;52(10):1744-9.)

Dementia
y Hachinski Ischaemic score VaD y < 4 suggests primary dementia (eg, Alzheimer's disease) y 4 7 = indeterminate y > 7 suggests vascular dementia y Dementia of Alzheimer Type (DAT) inventory AD

Modified Hachinski Ischemic Score

(http://www.merck.com/mmpe/sec16/ch213/ch213c.html)

Informant questionnaires
y Ask for an impression of change y Give an impression of general decline rather than specific domains of cognitive impairment y Influenced by factors regarding y The informant s state of mind y Relationship with the patient y Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) y 26 questions based on change in cognitive function over a 10year period y sensitivities/specificities - 100% /86% comparing with MMSE

Frontal lobe testing

y Frontal/Subcortical Assessment Battery (FSAB) y Luria sequencing task y go/no go test y Cortical dementia (AD) also scored poorly in the FSAB and the additional use of the MMSE y Frontal Lobe Score (FLS) y sensitivity of 78 92% / specificity of 100%

Frontal lobe testing

y Frontal Assessment Battery (FAB) y Briefer screening tool of frontal/executive function y Effective at distinguishing patients with frontal lobe impairment from normal controls y Ability to distinguish frontal impairment from other cognitive deficits (e.g. AD) is unknown y Lower scores -more severe impairment (score 0 18) y Executive Interview (EXIT25) y AD also score poorly on the EXIT25 y Combination with the MMSE - greater discriminatory value

Extended versions of the MMSE

y Addenbrooke s Cognitive Examination (ACE) y 100-point scale with more detailed components for memory and frontal/executive functioning y Distinguish between AD and FTD y Includes the questions from MMSE and CDT y Score of <87 indicated a significant impairment y Modified Mini Mental Status Examination (3MS) y Additional verbal fluency and extended memory testing y sensitivity/specificity = 86%/87% (cut-off <78)

Extended versions of the MMSE

y Cognitive Abilities Screening Instrument (CASI) y Cambridge Mental Disorders of the Elderly

Examination (CAMDEX) y Cambridge Cognitive Examination (CAMCOG)

y Additional cognitive aspects (mainly praxis, abstract

thinking and perception) y Sensitivity of 92% and specificity of 96% to detect organic y Combination of the CDT with the MMSE offered equivalent sensitivity and specificity

Extended versions of the MMSE

y Middlesex Elderly Assessment Memory Score

(MEAMS)
y Used by occupational therapists than doctors y Designed to assess frontal and right parietal lobe

function (verbal fluency, motor perseveration and fragmented letter perception) y Cut off 47 (lower scores - more cognitive impairment) y Benefit in the MEAMS for detecting non-dementia, isolated cognitive impairments.

Qualitative assessments
y Attention y Recite reverse sequences y Serial 7s y Digit span testing y Characteristically impaired in patients with delirium y Memory y Long- and short-term elements y Short-term memory - limbic system (temporal lobes) y Long-term memory - cortical processes

Qualitative assessments
y Memory y Episodic memory is related to personal experiences y Semantic memory to impersonal facts y Procedural memory to performing actions y Working memory is the capacity to briefly y Three words (MMSE) y Name and address to recall (ACE) y Subcortical dementias - likely to recall information when given clues than those with cortical deficits y Visuospatial memories - non-dominant parietal lobe

Qualitative assessments
y Language y Dominant hemisphere y Subcortical dementia - Loss of prosody, Reduced verbal fluency, Dysarthria y Repeat complex phrases y Repeat complex commands y Naming y Visuospatial skills y Either hemisphere, but tend to be more severe when the non-dominant hemisphere y Copy diagrams

Qualitative assessments
y Frontal/executive function y Mainly derived from the frontal lobe (also involving y y y y

subcortical connections with the basal ganglia) Planning, abstract thought, and judgement Trail-making tests List as many words in a 1-min (at least 15 words) go/no go tests

Rating severity of disorder, and monitoring disease progression

y AD is typically associated with an annual decline on

the MMSE of 3 4 points

y 18

23 = mild y 17 and below = severe

y Instrumental activities of daily living (IADLs)

Summary
y Brief tests with a reasonable sensitivity and specificity

include the 6CIT, Mini-Cog and SIS y Longer tests may have a small additional benefit in sensitivity and specificity to detect cognitive impairment, but their main roles may be to help define patterns of cognitive loss and to rate severity y Use suitable tests for purposes and environment