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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
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
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)
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.
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 )
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%)
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)
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.
CDT)
y Brief components testing y Memory of recent events and orientation y Questionnaire in intermediate scores patients
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
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.*
cognitive impairment
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)
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
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
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
(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
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