Cognitive Screening Instruments: A Practical Approach
By A.J. Larner
()
About this ebook
Cognitive Screening Instruments: A Practical Approach provides a practical and structured overview of some of the most commonly used and easily available cognitive screening instruments applicable in the outpatient clinic and bedside setting. Dementia and cognitive disorders are now recognised as an increasing public health problem, both in terms of patient numbers and cost, as populations age throughout the world. Despite this, many patients with dementia never receive a formal diagnosis, with implications for their appropriate care and management. Diagnostic tests which identify cases of dementia therefore have an important role.
Expert authors from around the world equip the reader of Cognitive Screening Instruments: A Practical Approach with clear instructions on the usage of each screening instrument, its strengths and weaknesses, the time required for administration, and rules on scoring, such as how to correct for variations in the patient’s age or education, and suggested cut-off scores.
Cognitive Screening Instruments: A Practical Approach is a handy, illustrated guide and a valuable diagnostic aid for practitioners working closely with patients with dementia and mild cognitive impairment. This volume will be of use both to clinicians and to professionals in disciplines allied to medicine who are called upon to assess patients with possible cognitive disorders, including neurologists, old age psychiatrists, neuropsychologists, primary care physicians, dementia support workers, and members of memory assessment teams.
Related to Cognitive Screening Instruments
Related ebooks
Practical Biostatistics: A Friendly Step-by-Step Approach for Evidence-based Medicine Rating: 5 out of 5 stars5/5fMRI Neurofeedback Rating: 0 out of 5 stars0 ratingsEvidence-Based Laryngology Rating: 0 out of 5 stars0 ratingsNeurodevelopmental Disorders: Comprehensive Developmental Neuroscience Rating: 0 out of 5 stars0 ratingsExamining Neurocritical Patients Rating: 0 out of 5 stars0 ratingsNeuropathology Simplified: A Guide for Clinicians and Neuroscientists Rating: 0 out of 5 stars0 ratingsStem Cells: Scientific Facts and Fiction Rating: 0 out of 5 stars0 ratingsFinding the Nerve: The Story of Impedance Neurography Rating: 0 out of 5 stars0 ratingsClinical Neurotherapy: Application of Techniques for Treatment Rating: 5 out of 5 stars5/5Forensic Anthropology: Current Methods and Practice Rating: 4 out of 5 stars4/5Practical Oncologic Molecular Pathology: Frequently Asked Questions Rating: 0 out of 5 stars0 ratingsNeurosurgical Neuropsychology: The Practical Application of Neuropsychology in the Neurosurgical Practice Rating: 0 out of 5 stars0 ratingsImaging in Pediatric Oncology Rating: 0 out of 5 stars0 ratingsClinical Ophthalmic Oncology: Basic Principles and Diagnostic Techniques Rating: 0 out of 5 stars0 ratingsSignal Processing for Neuroscientists, A Companion Volume: Advanced Topics, Nonlinear Techniques and Multi-Channel Analysis Rating: 0 out of 5 stars0 ratingsClinician's Guide to Diagnostic Imaging Rating: 0 out of 5 stars0 ratingsCognitive Enhancement: Pharmacologic, Environmental and Genetic Factors Rating: 3 out of 5 stars3/5Intra-Operative Monitoring: A Comprehensive Approach Rating: 0 out of 5 stars0 ratingsMethods in Psychobiology: Specialized Laboratory Techniques in Neuropsychology and Neurobiology Rating: 0 out of 5 stars0 ratingsDetection of Malingering during Head Injury Litigation Rating: 0 out of 5 stars0 ratings12 Strokes: A Case-based Guide to Acute Ischemic Stroke Management Rating: 0 out of 5 stars0 ratingsNuclear Medicine Technology: Review Questions for the Board Examinations Rating: 0 out of 5 stars0 ratingsAdvances in Cell and Molecular Diagnostics Rating: 5 out of 5 stars5/5Cognitive Rehabilitation of Memory: A Clinical-Neuropsychological Introduction Rating: 0 out of 5 stars0 ratingsGuide to Research Techniques in Neuroscience Rating: 0 out of 5 stars0 ratingsClinical Ophthalmic Oncology: Orbital Tumors Rating: 0 out of 5 stars0 ratingsHigh-Quality Transesophageal Echocardiography Rating: 0 out of 5 stars0 ratingsNeurotechnology and Brain Stimulation in Pediatric Psychiatric and Neurodevelopmental Disorders Rating: 0 out of 5 stars0 ratingsExposure Science: Basic Principles and Applications Rating: 0 out of 5 stars0 ratingsMethodological Approaches for Sleep and Vigilance Research Rating: 0 out of 5 stars0 ratings
Medical For You
The Song of the Cell: An Exploration of Medicine and the New Human Rating: 4 out of 5 stars4/5The Vagina Bible: The Vulva and the Vagina: Separating the Myth from the Medicine Rating: 5 out of 5 stars5/5What Happened to You?: Conversations on Trauma, Resilience, and Healing Rating: 4 out of 5 stars4/5Mediterranean Diet Meal Prep Cookbook: Easy And Healthy Recipes You Can Meal Prep For The Week Rating: 5 out of 5 stars5/5The Emperor of All Maladies: A Biography of Cancer Rating: 5 out of 5 stars5/5Brain on Fire: My Month of Madness Rating: 4 out of 5 stars4/5Mating in Captivity: Unlocking Erotic Intelligence Rating: 4 out of 5 stars4/5Holistic Herbal: A Safe and Practical Guide to Making and Using Herbal Remedies Rating: 4 out of 5 stars4/5Herbal Healing for Women Rating: 4 out of 5 stars4/5Gut: The Inside Story of Our Body's Most Underrated Organ (Revised Edition) Rating: 4 out of 5 stars4/5Adult ADHD: How to Succeed as a Hunter in a Farmer's World Rating: 4 out of 5 stars4/5WomanCode: Perfect Your Cycle, Amplify Your Fertility, Supercharge Your Sex Drive, and Become a Power Source Rating: 4 out of 5 stars4/5Living Daily With Adult ADD or ADHD: 365 Tips o the Day Rating: 5 out of 5 stars5/5Women With Attention Deficit Disorder: Embrace Your Differences and Transform Your Life Rating: 5 out of 5 stars5/5The Diabetes Code: Prevent and Reverse Type 2 Diabetes Naturally Rating: 4 out of 5 stars4/5"Cause Unknown": The Epidemic of Sudden Deaths in 2021 & 2022 Rating: 5 out of 5 stars5/5The People's Hospital: Hope and Peril in American Medicine Rating: 4 out of 5 stars4/5As Nature Made Him: The Boy Who Was Raised as a Girl Rating: 4 out of 5 stars4/5The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet Rating: 4 out of 5 stars4/5The Amazing Liver and Gallbladder Flush Rating: 5 out of 5 stars5/5Peptide Protocols: Volume One Rating: 4 out of 5 stars4/5Summary of Dr. Gundry's Diet Evolution: Turn off the Genes That Are Killing You and Your Waistline Rating: 3 out of 5 stars3/5Tight Hip Twisted Core: The Key To Unresolved Pain Rating: 4 out of 5 stars4/5Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner Rating: 4 out of 5 stars4/5The 40 Day Dopamine Fast Rating: 4 out of 5 stars4/5
Reviews for Cognitive Screening Instruments
0 ratings0 reviews
Book preview
Cognitive Screening Instruments - A.J. Larner
A. J. Larner (ed.)Cognitive Screening Instruments2013A Practical Approach10.1007/978-1-4471-2452-8_2© Springer-Verlag London 2013
2. The Mini-Mental State Examination (MMSE): An Update on Its Diagnostic Validity for Cognitive Disorders
Alex J. Mitchell¹, ²
(1)
Department of Psycho-oncology, Leicestershire Partnership Trust, Leicester, UK
(2)
Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
Alex J. Mitchell
Email: ajm80@le.ac.uk
2.1 Introduction: History and Development
2.2 Structure and Reliability of the MMSE
2.3 Diagnostic Validity in Unselected Dementia
2.4 Diagnostic Validity in Early Dementia
2.5 Diagnostic Validity in Specific Dementias
2.6 Diagnostic Validity in MCI
2.7 Diagnostic Validity in Delirium
2.8 Conclusion: Implementation
References
Abstract
The Mini-Mental State Examination (MMSE) is the most commonly used brief cognitive tool in the assessment of a variety of cognitive disorders. The tool comprises a short battery of 20 individual tests covering 11 domains and totalling 30 points. Typical completion time is 8 min in cognitively unimpaired individuals rising to 15 min in those with dementia. Internal consistency appears to be moderate and test-retest reliability good. However, the main psychometric issue concerns the MMSE’s diagnostic validity against dementia, mild cognitive impairment, and delirium. This chapter updates previous meta-analytic summary analyses for the performance of the MMSE in specialist and nonspecialist settings. Summary sensitivity, specificity, positive, and negative predictive values are presented. Results suggest against dementia, mild cognitive impairment, and delirium it did not perform well as a confirmatory (case-finding) tool, but it did perform adequately in a rule-out (screening) capacity. In clinical practice, this means that a high score on the MMSE would lead to about a 10 % false negative rate, and further, a low (positive) score must be followed by more extensive neuropsychological or clinical evaluation. The MMSE is neither the most accurate nor more efficient tool with which to evaluate cognitive disorders, but it has provided a benchmark against which all newer tools can be measured.
Keywords
Mini-Mental State Examination (MMSE)DementiaMild cognitive impairmentDeliriumDiagnostic accuracyReliabilitySensitivityClinical utility
2.1 Introduction: History and Development
The Mini-Mental State Examination (MMSE) was published in 1975 by Folstein et al. [1] as a practical method of grading cognitive impairment and has become the most commonly used rapid cognitive screening instrument [2]. While it is true that the MMSE may never have been intended as a diagnostic tool, it has been very extensively investigated as a diagnostic test of dementia and related cognitive disorders. Many are attracted by the brevity of the instrument and the belief that it offers broad coverage of cognitive domains. Its ubiquitous use was no doubt helped by its royalty free distribution up to 2001 when copyright was acquired by Psychological Assessment Resources (http://www.minimental.com/). In clinical practice, the main applications of the MMSE are to help clinicians in the diagnosis of dementia and delirium [3]. It has been investigated in a case-finding role (i.e. confirmatory diagnosis) as well as in a screening role (largely rule-out application designed to minimize false negatives). Recent work has also investigated its performance in detecting mild cognitive impairment (MCI). A subsidiary aim, not discussed here, is grading severity of cognitive impairment in those with known disorders [4]. It is worth noting that while a typical application time of 10 min seems short to neuropsychologists, many working in primary care would consider this much too long [5, 6].
At least 100 validation studies exist, but most are underpowered and many lack an adequate criterion standard and, hence, can give a misleading impression of accuracy [7]. For example, Folstein, Folstein, and McHugh validated the MMSE in two samples of patients which included only 38 with dementia [1]. However, it can be argued that even with suboptimal accuracy, the large evidence base surrounding the MMSE is advantageous because scores on the MMSE are fairly well understood by health professionals. This is most applicable to normative data. Folstein et al. [1] tested a population sample in Baltimore and found 4.2 % of those aged 18–64 scored <24/30 compared to 20.8 % of those over 65. Crum et al. [8] tested an extensive group of 18,056 participants in US Epidemiologic Catchment Area (ECA) study and presented distributions by age and educational levels. Some groups have provided norms for each item on the MMSE by age group [9]. Yet there remains controversy about its clinical applications in case finding and screening, as well as the optimal cut-off threshold [10, 11]. A cut-off of <24/30 was recommended as significant by Folstein and colleagues in persons with at least 8 years of education [1]. But in reality, individuals with early dementia but with a background of extensive education are likely to experience a ceiling effect with the MMSE (see Sect. 2.4 on early dementia). Numerous other cut-offs have been calculated from receiver operating characteristic curve (ROC) analysis of specific populations together with adjustments for age and education [12, 13]. Here, I will review the accuracy of the MMSE when considering one of the common cognitive disorders in clinical practice: dementia, mild cognitive impairment, and delirium.
2.2 Structure and Reliability of the MMSE
The MMSE has an internal structure of 20 individual tests covering 11 domains including orientation, registration, attention or calculation (serial sevens or spelling), recall, naming, repetition, comprehension (verbal and written), writing, and construction. Internal consistency appears to be moderate with Cronbach alpha scores reported between 0.6 to 0.9 [14, 15]. Test-retest reliability has been examined in several studies and in those where re-examination took place within 24-h reliability by Pearson correlation was usually above 0.85. Scoring emphasizes orientation (time – 5 points; place – 5 points) and attention/concentration/calculation (5 points) with lower emphasis on registration memory (3 points) and recall (3 points). Little weight is placed on naming (2 points), repetition (1 point), following a three-stage command (3 points), reading (1 point), writing (1 point), or copying intersecting pentagons (1 point). Factor-analytic and item-response studies suggest up to five factors [16, 17]. Using Rasch analysis, it is possible to grade the completion difficulty of each item on the MMSE. Relatively difficult items are the recall of three words, citing the correct date, coping the pentagon design, and spelling world backwards or completing serial sevens. Conversely, relatively simple items are naming the correct country, registering three words, following the command and naming an object (pencil).
A significant issue is that the individual questions are not particularly applied, which reduces acceptability of the test to those who suspect impairment. In other words, uptake of the test may be low in those with impairment. It is generally accepted that much of the content of the MMSE was derived from existing instruments [18]. All questions are designed to be asked in the order listed, with omissions scored as errors giving a maximum score of 30. However, there is some ambiguity in several items leading to the Standardized Mini-Mental State Examination from Molloy et al. [19] (see Sect. 3.2.1). The MMSE has helped in the development of newer potentially improved cognitive instruments discussed in other chapters (e.g. Chap. 4).
2.3 Diagnostic Validity in Unselected Dementia
This is probably the MMSE’s most common application and hence the most important question. Does the MMSE enable clinicians to accurately rule-in or rule-out dementia? Further, does this depend on prevalence of dementia, for example, when dementia is less common such as in primary care settings? O’Connor et al. [20] conducted one of the first adequately powered tests of the MMSE using a cut-off <24/30 in 2,302 primary care patients; 586 received a CAMDEX/CAMCOG interview as a gold standard (criterion reference). O’Connor et al. found that sensitivity of the MMSE was 86 % and specificity 92 % [20]. There have been at least eight other primary studies, and these documented somewhat differing results (see Table 2.1).
To clarify uncertainty, our group undertook a meta-analysis of MMSE dementia studies published prior to 2009 [21]. In the original paper, after excluding studies relying upon modified forms of the MMSE, as well as those focussing on specific sub-tests, there were 34 diagnostic validity studies against dementia (typically using DSM criteria, not robust post-mortem data). This is now updated to 45 studies (Table 2.1; [20, 22–64]) comprising 12 community studies, 7 primary care studies and 26 from specialist settings where the prevalence of dementia is relatively high. It is important to remember that the prevalence of a condition strongly influences test performance. High prevalence settings favor few false positives but at the expense of false negatives. Three studies were difficult to classify as they were conducted in the community but recruited from primary care lists. The most common reference standard in making a diagnosis of dementia was used in 20 studies. These results are now updated in Table 2.1 with the addition of eight new studies. A random effects meta-analysis model was used to calculate summary sensitivity, specificity, and PPV and NPV calculated using a prevalence of 25 %.
Table 2.1
Diagnostic validity of MMSE in diagnosing dementia
Updated from [21]
DSM-IV Diagnostic and Statistical Manual of Mental Disorders (DSM IV), CERAD Consortium to Establish a Registry for Alzheimer’s Disease, CDR Clinical Dementia Rating
Looking at specialist settings, meta-analysis showed that the MMSE’s sensitivity for diagnosing dementia was 76.9 % (95 % CI = 70.1–83.1 %) and its specificity was 89.9 % (95 % CI = 82.5–95.4 %). More meaningfully, that converts into a positive predictive value (PPV) of 89.3 % and a negative predictive value (NPV) of 74.8 % at a prevalence of 55 %, but 71.7 % (PPV) and 92.1 % (NPV) at 25 %. Thus, there would be a 25 % false negative rate for every 24 or above MMSE score in clinics where the prevalence of dementia was high, but only an 8 % error rate when prevalence was low. Clinical utility can be considered to be a function of both occurrence and discrimination of a test. MMSE may be suitable to be used as a first step screening tool in specialist