Focuses on cognitive assessment for

people with suspected dementia

Identification of 12 brief cognitive
impairment tests, of which 6 (MMSE, AMT,
CDT, Mini-cog, 6-CIT, MoCA) have been
sufficiently studied and can be
recommended for use in routine care
Dementia
Defined as a clinical syndrome
characterized by severe memory decline
and loss of function in at least one other
cognitive domain of sufficient severity to
interfere with social or occupational
functioning


DSM-IV criteria
A. The development of multiple cognitive deficits manifested by both:
1.Memory impairment (impaired ability to learn new information or to recall previously learned
information)

2.One or more of the following cognitive disturbances:
(a) aphasia (language disturbance)
(b) apraxia (impaired ability to carry out motor activities depite intact motor function)
(c) agnosia (failure to recognize or identify objects despite intact sensory function)
(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or
occupational functioning and represent a significant decline from a previous level of functioning.

C. The course is characterized by gradual onset and continuing cognitive decline.

D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
(1) other central nervous system conditions that cause progressive deficits in memory and
cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural
hematoma, normal-pressure hydrocephalus, brain tumor)
(2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic
acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)
(3) substance-induced conditions

E. The deficits do not occur exclusively during the course of a delirium.
Importance of brief cognitive tests
Reliable diagnosis of dementia integrates:
(1) Patient observations, (2) Informant
account, and (3) Formal cognitive
assessment
Cognitive tests aids in rapid assessment
and early diagnosis which facilitates timely
access to treatments and support services
An ideal test
Quick
Simple to score and interpret
Not require the use of special equipment or
training
High sensitivity
High inter-rater and re-test reliability
Patient acceptability
Provides a numerical value to objectively assess
disease severity and progression
Caution in people with:
Low educational backgrounds
Deafness
Depression
Communication impairment
High educational attainment (ceiling
effect)
Methodology
Search term: assessing cognitive ability in older
people
Over 4500 articles were screened and reduced
to 432 using the following inclusion and
exclusion criteria:
Inclusion: tests in English that had been developed to
screen for and identify dementia, primarily
Alzheimers disease
Exclusion: focus on a specific dementia, related to a
specific patient group, instruments designed to stage a
dementia, or instruments for which special equipment
was required
Size and population studied were noted
Proportion of study population with
dementia were also noted to ensure that
test performance was not overestimated
Instruments that required informant input
were excluded
The review only includes instruments that
were equivalent or shorter than the MMSE
score (delivery time approximately 10 min)
Limitations of the study
Many studies included used the MMSE
score as a reference standard
Caution should be exercised in the
interpretation, as a diagnosis based solely on
MMSE scores is potentially unreliable
Diagnostic criteria for dementia used in
different studies were not standardized
(DSM III/IV)
Results
135 articles reporting on 12 brief cognitive
assessment tests were retained for data
extraction

1. MMSE
30-Point Cognitive Assessment developed
by Folstein et al. in 1975
11 items
Tests for
Memory
Orientation
Attention
Language
Praxis impairments
1. MMSE
Cutoff
<24 points for considering dementia
21-24: Mild
10-20: Moderate
<10: Severe
Other proposed cutoffs from <26 to <22 have
been proposed based on population of
interest
1. MMSE
Meta-analysis of 34 dementia studies
show moderate sensitivity and specificity,
not as good as reported in original study
High dementia prevalence specialist settings
Sensitivity 77% and Specificity 90%
Low dementia prevalence specialist settings
Sensitivity 81% and Specificity 87%

1. MMSE
Strengths
Well validated
Quick (8 mins to complete)
Simple to score
Assesses most components required to
diagnose dementia
Objective, no inter-observer variability

1. MMSE
Limitations
Affected strongly by educational attainment
Strongest correlation Serial 7s and spelling
world backwards
Low ceiling May be less effective in
identifying MCI
Retrospective copyright enforced - Cost

1. MMSE
Local Context Modified Mini Mental State
Examination
Targeted at population of Singapore Chinese older
adults 55 years old
An optimal balance between sensitivity and specificity
was obtained at a cutoff score of 25, 27 and 29 for
subjects with nil, primary and secondary school and
above education levels, respectively.
For the whole sample (regardless of education level),
the optimal cutoff point was < 26

1. MMSE
A summary of the modifications is shown below with
reasons/justifications in brackets.
1) The question on seasons was replaced with the question
Without looking at your watch, what time is it? (Q5,
there are no seasons in Singapore).
2) The question on city/town was replaced with the
question What area are we in? (Q8, Singapore is a city
country; for this question, the only correct answer is
Singapore).
3) The question on state/province was replaced with the
question Which part of Singapore is this place (North,
South, East, West or Central)? (Q10, Singapore is a
city country).
1. MMSE
4) For immediate recall (Q11Q13) and delayed
recall (Q19Q21),ball, flag, tree were used in
the English version and
(lemon, key, balloon) were used in the Chinese
version (in local Chinese language, ball, flag and
tree are single-syllable words).
5) For sentence repetition, no ifs, ands or buts in
the English version was used and
(forty-four stone lions) was used in the
Chinese version (Q24, direct translation of the
original English sentence is meaningless).
2. AMT
10-item assessment
81% sensitivity and 85% specificity with cut-off
score <8
Abnormal if: <7 points up to primary education;
<9 points higher than primary education
Assesses: memory, orientation, attention
Strengths: quick to perform (2 min), suitable for
patients with visual and/or motor deficits
2. AMT
Limitations:
Lower specificity and sensitivity than MMSE
Some questions are open to interpretation
bias, e.g. time, counting from 20-1, place
Address for recall and 2 persons identified are
not standardized
Question item drift

2. Shorter versions of the AMT
For cognitive assessment in time-sensitive acute
settings, e.g. ED
5-item and 7-item AMT with questions covering
recall, identification of 2 people, date of birth,
prime minister, 20-1, with or without time and
place
4-item AMT (AMT4) was developed specifically
for use in the ED; includes age, date of birth,
place and year
Predictive efficiency of 91% when compared to the
10-item AMT
3. Clock Drawing Test
3. Clock Drawing Test
CAMDEX scoring system:
0 No reasonable representation of a clock
No clock face drawn
Numbers not in correct position
Incorrect time
1 One of the 3 items mentioned in score 0 is
correct
2 Two of the 3 items mentioned in score 0 is
correct
3 All items are correctly represented
Failure on any item indicates
moderate/severe cognitive impairment
3. Clock Drawing Test
SHULMAN scoring system:
0 No reasonable representation of a clock
No attempts at all
No semblance of a clock at all
Writes a word or name
1 Severe level of disorganisation as described in 2
2 Moderate visuospatial disorganisation of times such that accurate denotation of 10 after 11
is impossible
Moderately poor spacing
Omits numbers
Perseverationrepeats circle or continues on past 12 to 13, 14, 15 etc.
Right-left reversalnumbers drawn counterclockwise
Dysgraphiaunable to write numbers accurately
3 Inaccurate representation of 10 after 11 when visiospatial organisation is perfect or shows
only minor deviations
Minute hand points to 10
Writes 10 after 11
Unable to make any denotation of time
4 Minor visuospatial errors
A mildly impaired spacing of times
Draws times outside circle
Turns page while writing numbers so that some numbers appear upside down
Draws in lines (spokes) to orient spacing
5 Perfect clock

3. Clock Drawing Test
Assesses: visuo-spatial impairment,
constructional apraxia, auditory
processing, memory, abstract thinking
Complementary to other tests
Strengths: quick to perform (under 1 min),
repeated testing provides visual log of
cognitive decline, readily acceptable to
patients
3. Clock Drawing Test
Limitations:
Lack of consistent scoring system
Explains the widely varying sensitivities (34-83%) and
specificities ( 13-97%)
Less reliable in detecting mild cognitive impairment
Not suitable for patients with visual and/or physical
disability
Increasing use of digital clocks may result in the CDT
becoming obsolete
Comprehensive review of the CDT reported
mean sensitivity of 85% and specificity of 85%
4. Montreal Cognitive Assessment
Incorporates frontal lobe executive function (vs MMSE)
8 cognitive domains with weighted scores
CDT, memory, cube copying, orientation, trail making, verbal fluency, sustained attention,
serial 7s naming objects
Scoring: 18-26 = mild / 10-17 = moderate / <10 = severe
Add 1 point if edu < 12 years (count from primary 1)
Strengths:
higher sensitivity than MMSE in detecting MCI (83-90% vs 17-18%) and mild
dementia (94-100% vs 25-78%). Validated in 55-85 year olds.
Singapore English/Malay/Hindi versions with standardised instructions available.
No significant learning effect even with retesting at 1 mth. Can use MoCA 7.2/7.3
if retesting frequently
Limitations:
lower specificity than MMSE (50-87% vs 100%)
severity thresholds have not been well studied
requires dexterity for 3 drawing tasks. Suggested by the authors to exclude the
drawing items and upscale the score e.g. 25 30. this has not been validated.

4. Montreal Cognitive Assessment


5. 6-Item Cognitive Impairment
Test
Developed in 1983 by Katzman et al. using
regression analysis of the 26-Item Blessed
Information Memory Concentration Scale (BIMC)
6 Item test with an inversely weighted score
Tests for:
Memory
Orientation
Attention

5. 6-Item Cognitive Impairment
Test
Uses an inverse score and questions are
weighted to produce a total out of 28
0-7: Normal
>7: Significant

Or any other 5
component address
5. 6-Item Cognitive Impairment
Test
Strengths
Short time taken to administer (4 mins)
Correlates highly with the MMSE
More sensitive than the MMSE in detecting
mild dementia
Limitations
Difficult to administer
Does not assess as many domains


6. Seven Minute Screen Battery
Components
Cued recall
CDT
temporal orientation
category fluency

Strengths:
Higher sensitivity and specificity than MMSE, especially in MCI &
mild dementia.
High test-retest reliability and interrater reliability
Less affected by age, edu or age
Limitations:
Takes 9-13min to complete! Unlikely to be useful in the clinical
setting.

6. Seven Minute Screen Battery
ENHANCED CUED RECALL

"There is a piece of furniture on the card, what is it?"



There is a piece of stationery on the card, what is it?



There is an accessory on the card, what is it?



There is a communication device on the card, what is it?


CARD 1 OF 4
6. Seven Minute Screen Battery
ENHANCED CUED RECALL
Remove the card.
"I just showed you a piece of furniture / accessory/ stationery,
communication device, what was it?. Recall all 4 objects, 1 by 1.
If the subject misses 1 or more items, all items on the card are
presented a second time. Max 2 repeats per card.
Repeat above steps for all 4 cards.
Recall December to January
Free recall as many of the 16 pictures as possible
When the subject cannot recall any additional pictures, the examiner
provides the category cues for the remaining items (cued recall).
The score is the total number of items recalled in both free and cued
recall (range, 0-16).
6. Seven Minute Screen Battery
CATEGORY FLUENCY
Generate as many items as you can
from the category "animals" in 1
minute.
The total number of animals named
produces the score.
6. Seven Minute Screen Battery
BENTON TEMPORAL ORIENTATION TEST
Test:
(1) time1 error point for each 30-minute deviation to a
maximum of 5.
(2) day of week1 error point for each day to a
maximum of 3
(3) date1 error point for each date off to a maximum
of 15
(4) month5 error points for each month off to a
maximum of 30
(5) year10 error points for each year off to a
maximum of 60
The maximum total error score is 113
6. Seven Minute Screen Battery
CLOCK DRAWING
Provide subject with a pen and blank sheet
of paper
"I want you to draw a clock with all the
numbers on it. Make it large."
"Now draw the hands set at twenty to four."
Simplified version of Freedman et al. This
system requires the examiner to record the
presence of 7 attributes (not specified in
paper)
7. Mini-cog
Specifically developed to augment the narrow cognitive
domain focus of the CDT
Patients are
Given 3 items to remember (e.g. apple, watch, pen)
Complete CDT
Asked to recall of the 3 items
The clock is scored by awarding 2 points of the numbers,
hands and time are all correct, and 0 points in the
presence of any mistake
One point is awarded for each correct word recalled
Score ranges from 0-5 and a score of <5 implies
dementia
7. Mini-cog
Strengths: simple to use and score, quick to
perform (1.5 min), less influenced by culture and
education than the MMSE
Also increased the sensitivity of the CDT to
detect cognitive impairment from 79 to 99%
Limitations: not suitable for patients with visual
and/or physical disability
Sensitivity of 76% and specificity of 89% (VS
71% and 94% respectively for the MMSE)
8. Memory Orientation Screening
Test (MOST)
A further development of the Mini-cog
Temporal orientation (year, season, month,
date, day and time) and the recall of a 12-
item grocery list have been added
Strengths: quick to perform (4.5 min)
MOST outperformed the MMSE and Mini-
cog in a large-scale study of 1752
participants with a high dementia
prevalence of 74%
8. Memory Orientation Screening
Test (MOST)
Limitations: not well studied; but items
such as seasons and a 12-item grocery list
may not be applicable to the local
population
9. Brief Alzheimer Screen (BAS)
Shorter version of the MMSE
Developed to improve sensitivity to detect early
dementia
Identified MMSE items that optimized
discrimination between cognitively healthy
people and people with early dementia:
3-word recall
Date
Spelling world backwards
Verbal fluency (number of animals named in 30s)
95% sensitivity and 52% specificity when
assessed against the MMSE
10. Short Blessed Test (SBT)
Derived from the 26-item Blessed Information
Memory Concentration Scale
Comprises 6 questions assessing temporal
orientation, recall, counting backwards from 20-
1, and naming the months in reverse order
Scoring system is weighted with an emphasis on
the recall item, hence aiming to identify early
dementia
1 point is assigned for each incorrect item to a
maximum score of 28
>10 suggests dementia
10. Short Blessed Test (SBT)
Strengths: quick to perform (<10 min), less
influenced by education and literacy
attainment, low risk for interpreter bias
Limitations: need to calculate the score
(not for use in time-sensitive environment)
11. Time and Change test
Developed in the United States to assess
executive function based on a commonplace
daily task
Comprises of
Telling time: 1 min and 2 attempts to read the
time on a large clock set at 11:10
Making change: Participants are asked to make a
dollar from 3 quarters, 7 dimes and 7 nickels in 3
min
Failure of either task suggests cognitive
impairment

11. Time and Change test
Study was conducted comparing T&C test,
MMSE and modified Blessed Dementia
Rating Scale (mBDRS)
T&C did not meet desirable standards for
dementia detection
Attempted to improve performance
Time: Time limit of 3s <- 1 min
Change: One attempt in 10s <- 3 min
Lead to sensitivity of 98% but specificity of
only 24%
11. Time and Change test
Strengths
Fast, takes only 23s to complete
Easy to administer
Good acceptability rates by patients, only 5%
refusal
Reliable, inter-rater agreement of 88%
Limitations
Poor specificity
Not suitable to detect MCI
Not tailored for Singapore population
Does not assess as many domains

12. Hopkins Verbal Learning Test
Developed by Brandt in 1991
Brief assessment of verbal recall and recognition
Involves providing participants with a list of words
to remember
3 trials to freely recall the words are allowed
Patient supplied with words from semantic categories
to provide cues
Each form consists of a list of 12 nouns (targets) with
four words drawn from each of three semantic
categories. The semantic categories differ across the
six forms, but the forms are very similar in their
psychometric properties.

12. Hopkins Verbal Learning Test
Raw scores are derived for Total Recall,
Delayed Recall, Retention (% retained), and a
Recognition Discrimination Index.
Software available to generate 5 specific reports
from the scores
2 studies performed one with focus on
detecting mild dementia and another heavily
weighted with dementia patients showed good
specificity and sensitivity when correlated to
MMSE

12. Hopkins Verbal Learning Test
Strengths
Good specificity and sensitivity
High test-retest reliability
Available in many languages
Relatively short duration of administration
Limitations
Has to be purchased
Not widely used
Not well studied
Assesses limited domains only



Conclusion
Role of brief cognitive impairment test
To screen for the possibility of dementia in
a time-constrained clinical encounter
Tests are not diagnostic diagnosis
requires detailed assessment with the
DSM IV / V criteria (Memory Clinics)
Conclusion
Increasing interest detecting mild cognitive
impairment
Special advantage in MoCA test due to its
high sensitivity and specificity to both MCI and
early dementia. Incorporates CDT.
Accurate diagnosis of MCI still requires
detailed neurocognitive assessment
Conclusion
12 brief cognitive assessments were reviewed
6 of which (BAS, SBT, T&C, HVLT, MOST) are
insufficiently well studied
MMSE, AMT, CDT, Mini-cog, 6-CIT and MoCA are
recommended for use in routine care
Practitioners should be familiar and competent with
just a few instruments, with selection based on local
context to maximise communication between teams
and services
Conclusions
Quick screen in <5min:
AMT + CDT

Detailed screening
(MMSE + CDT) OR MoCA alone

Keep in mind pseudodementia
GDS 15