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©2010 Iowa Geriatric Education Center

========================================== March 2010 Vol. 12, No. 3 ========================================== Our Mission: Helping to prepare Iowa's health practitioners to care for our growing population of elders.

ENEWS is one of our methods of teaching through technology. Each month, ENEWS delivers abstracts from current multidisciplinary healthcare journal articles related to a specific geriatric topic. This month's ENEWS focuses on COGNITIVE SCREENING FOR OLDER ADULTS.



In this issue of the ENEWS, you will find abstracts for:

· · · · · · · · · A study that examines the validity of the Rowland Universal Dementia Assessment Scale (RUDAS) in a multicultural cohort of community-dwelling older adults with early dementia. A study that tests the accuracy of a brief cognitive assessment of nursing home residents. A study that assesses the efficacy of combining the Memory Impairment Screen (MIS) and the Isaacs Set Test (IST) to screen for cognitive change in older adults with questionable dementia. A study that compares the Telephone Interview for Cognitive Status (TICS) with the Mini-Mental State Examination (MMSE). A study that investigates the sensitivity of the Alzheimer's Disease Screen for Primary Care (ADS-PC) as compared to the Mini-Mental State Examination (MMSE). An article that reviews recent literature on various brief cognitive screening instruments. A study that evaluates critical clock-drawing errors for dementia screening. A study that discusses the use, efficacy, and quality of different dementia screening measures in primary care. A study that describes the development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia.



Basic D, Rowland JT, Conforti DA, Vrantsidis F, Hill K, LoGiudice D, Harry J, Lucero K, Prowse RJ. The validity of the Rowland Universal Dementia Assessment Scale (RUDAS) in a multicultural cohort of communitydwelling older persons with early dementia. Alzheimer Dis Assoc Disord. 2009 AprJun;23(2):1249.

The 6-item Rowland Universal Dementia Assessment Scale (RUDAS) is a simple, portable multicultural scale for detecting dementia. Items address executive function, praxis, gnosis, recent memory, and category fluency. It can be directly translated to other languages, without the need to change the structure or the format of any item. The RUDAS was administered to 151 consecutive, consenting, culturally diverse communitydwelling subjects of mean age 77 years, 72% of whom had an informant. Subjects were recruited from various clinics and healthcare programs. All were evaluated for cognitive impairment in a blinded manner by experienced clinicians in geriatric medicine. According to Diagnostic and Statistical Manual of Mental DisorderIV criteria, 40% of the subjects were normal, 22% had cognitive impairment (not otherwise specified), and 38% had dementia; 84% of whom had questionable or mild dementia. In the primary analysis (normal subjects vs. those with definite dementia), the RUDAS accurately identified dementia, with an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.88-0.97); at the published cut point of less than 23/30, the positive likelihood ratio (LR) for dementia diagnosis was 8.77, and the negative likelihood ratio was 0.14. Additional analyses showed that the RUDAS performed less well when subjects with cognitive impairment (not dementia) were included. In all logistic regression models, the RUDAS was an independent predictor of dementia (odds ratio 0.64, 95% confidence interval, 0.52-0.79, primary analysis model), after adjusting for age, sex, years of education, and cultural diversity, none of which were independent predictors. Further studies are needed across the full spectrum of early dementia syndromes, and in additional ethnic minority groups.


Chodosh J, Edelen MO, Buchanan JL, Yosef JA, Ouslander JG, Berlowitz DR, Streim JE, Saliba D. Nursing home assessment of cognitive impairment: development and testing of a brief instrument of mental status. J Am Geriatr Soc. 2008 Nov;56(11):206975.

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment. DESIGN: Cross-sectional, independent cognitive screening tests with NH residents. SETTING: Six Department of Veteran Affairs nursing facilities. PARTICIPANTS: Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs. MEASUREMENTS: Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample. RESULTS: Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant-administered BIMS (BIMSR); 212 residents also received a facility nurse-administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient (r)=0.79 vs 0.62; P<.01 for difference). For the subset who received facility assessments, the BIMS-N was also more highly correlated with the 3MS (Pearson r=0.74 vs 0.65; P<.01 for difference). For any impairment (3MS<78), the area under the receiver operator characteristic curve (AUC) was 0.86 for the BIMS, versus 0.77 for the CPS. For severe impairment (3MS<48) the AUC was 0.94, versus 0.85 for the CPS. CONCLUSION: In this population, a brief cognitive test is a more accurate approach to cognitive assessment than the current observational methods employed using the MDS 2.0.


Chopard G, Vanholsbeeck G, Tio G, Pitard A, Binetruy M, Rumbach L, Galmiche J. Rapid screening of cognitive change in patients with questionable dementia using the Memory Impairment Screen and the Isaacs Set Test. J Am Geriatr Soc. 2009 Apr;57(4):7038.

OBJECTIVES: To assess the efficacy of combining the Memory Impairment Screen (MIS) and the Isaacs Set Test (IST) in predicting short-term development of dementia in a group of people with questionable dementia (QD) at baseline. DESIGN: Performances of the weighted sum of MIS and IST and the <<or>> rule were compared with each other and with the Mini-Mental State Examination. SETTING: Database of the Regional


Network for Diagnostic Aid and Management of Patients with Cognitive Impairment in the Franche-Comté geographical area in France. PARTICIPANTS: A cohort of 106 patients aged 65 and older with QD were followed up for a mean of 14.9 months (range 6-24 months). MEASUREMENTS: Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the combination of these two tests. RESULTS: The weighted sum had a sensitivity of 0.74 and a specificity of 0.84. The <<or>> rule (MIS<6 or IST<25) had a sensitivity of 0.74 and a specificity of 0.81. When range values were applied, low scores on the MIS and the IST (MIS<6 and IST<25) led to a high probability of dementia, whereas high scores (MIS>7 and IST>29) suggested a high probability of remaining dementia-free in the study follow-up. CONCLUSION: This quickly performed tool (5 minutes) is simple to use and score. When including cutscores (MIS<6 or IST<25) or range values, this test could be considered a useful screening procedure for all types of dementias.


Fong TG, Fearing MA, Jones RN, Shi P, Marcantonio ER, Rudolph JL, Yang FM, Kiely DK, Inouye SK. Telephone interview for cognitive status: Creating a crosswalk with the MiniMental State Examination. Alzheimers Dement. 2009 Nov;5(6):4927.

BACKGROUND: Brief cognitive screening measures are valuable tools for both research and clinical applications. The most widely used instrument, the Mini-Mental State Examination (MMSE), is limited in that it must be administered face-to-face, cannot be used in participants with visual or motor impairments, and is protected by copyright. Screening instruments such as the Telephone Interview for Cognitive Status (TICS) were developed to provide a valid alternative, with comparable cut-point scores to rate global cognitive function. METHODS: The MMSE, TICS-30, and TICS-40 scores from 746 community-dwelling elders who participated in the Aging, Demographics, and Memory Study (ADAMS) were analyzed with equipercentile equating, a statistical process of determining comparable scores based on percentile equivalents for different forms of an examination. RESULTS: Scores from the MMSE and TICS-30 and TICS-40 corresponded well, and clinically relevant cut-point scores were determined. For example, an MMSE score of 23 is equivalent to 17 and 20 on the TICS-30 and TICS-40, respectively. CONCLUSIONS: These findings indicate that TICS and MMSE scores can be linked directly. Clinically relevant and important MMSE cut points and the respective ADAMS TICS-30 and TICS-40 cut-point scores are included, to identify the degree of cognitive impairment among respondents with any type of cognitive disorder. These results will help in the widespread application of TICS in both research and clinical practice.


Grober E, Hall C, Lipton RB, Teresi JA. Primary care screen for early dementia. J Am Geriatr Soc. 2008 Feb;56(2):20613.

OBJECTIVES: To determine whether the Alzheimer's Disease Screen for Primary Care (ADS-PC) is more sensitive to early dementia than the Mini-Mental State Examination (MMSE) and whether it has as high a misclassification rate in minority patients and patients with limited education. DESIGN: Cross-sectional validation study. SETTING: Urban geriatric primary care practice. PARTICIPANTS: Three hundred sixteen African-American and Caucasian patients, including 55 patients with early dementia (Clinical Demential Rating of 0.5). MEASUREMENTS: The ADS-PC is a two-stage strategy for identifying early dementia that consists of a brief high-sensitivity dementia screen, applied to all patients aged 65 and older, and a second stage to identify memory impairment, applied to patients who fail the first stage. Differences in the sensitivities or specificities of the ADS-PC and the MMSE were evaluated using the McNemar test. RESULTS: Receiver operating characteristic curves were used to examine differences in the operating characteristics of the ADSPC across a range of cutscores. When the specificities of both tests were equated (0.90), the sensitivities were significantly different (ADS-PC, 0.75; MMSE, 0.56). The MMSE failed to identify five times as many cases of dementia as the ADS-PC. When the sensitivities were equated, the specificities differed significantly (ADS-PC, 0.95; MMSE, 0.73). The MMSE misclassified five times as many noncases as the ADS-PC. This pattern of significantly higher sensitivity and specificity for the ADS-PC than for the MMSE was repeated in the results according to race and for individuals with high school or more education but not in individuals with less education. CONCLUSION: The ADS-PC outperformed the MMSE in identifying early dementia in a racially and educationally diverse primary care cohort.

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Ismail Z, Rajji TK, Shulman KI. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry. 2010 Feb;25(2):11120.

OBJECTIVE: To review the recent literature on cognitive screening with a focus on brief screening methods in primary care as well as geriatric services. DESIGN: The Medline search engine was utilized using the keyword search terms 'cognitive screening', 'cognitive assessment', and 'dementia screening' limiting articles to those published in English since 1998. RESULTS: 679 abstracts were retrieved. Articles focusing on attitudes toward cognitive screening, current screening practices, promising new instruments and more recent updates contributing significant information on established instruments were retrieved and incorporated into this review. Reference lists were reviewed for relevant contributing articles. Instruments recommended from previous reviews of cognitive screening and those identified in surveys as most frequently used in primary care and geriatric settings were emphasized in this review. CONCLUSIONS: Dementia remains under-diagnosed in the elderly population. Despite significant limitations, the Mini Mental State Exam remains the most frequently used cognitive screening instrument. Its best value in the community and primary care appears to be for the purpose of ruling out a diagnosis of dementia. Instruments such as the Mini-Cog, Memory Impairment Screen (MIS), and the General Practitioner Assessment of Cognition (GPCOG) have consistently been recognized for utility in primary care. The clock drawing test (CDT) and newer instruments such as the Montreal Cognitive Assessment (MoCA) and the Rowland Universal Dementia Assessment Scale (RUDAS) are gaining credibility due to improvements in sensitivity, addressing frontal/executive functioning, and decreasing susceptibility to cultural and educational biases.


Lessig MC, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clockdrawing errors for dementia screening. Int Psychogeriatr. 2008 Jun;20(3):45970.

BACKGROUND: Clock-drawing tests are popular components of dementia screens but no single scoring system has been universally accepted. We sought to identify an optimal subset of clock errors for dementia screening and compare them with three other systems representative of the existing wide variations in approach (Shulman, Mendez, Wolf-Klein), as well as with the CDT system used in the Mini-Cog, which combines clock drawing with delayed recall. METHODS: The clock drawings of an ethnolinguistically and educationally diverse sample (N = 536) were analyzed for the association of 24 different errors with the presence and severity of dementia defined by independent research criteria. The final sample included 364 subjects with > or = 5 years of education, as preliminary examination suggested different error patterns in subjects with 0-4 years of education and inadequate numbers of normal controls for reliable analysis. RESULTS: Eleven of 24 errors were significantly associated with dementia in subjects with > or = 5 years of education, and six were combined to identify dementia with 88% specificity and 71% sensitivity: inaccurate time setting, no hands, missing numbers, number substitutions or repetitions, or refusal to attempt clock drawing. Time setting was the most prevalent error at all dementia stages, refusal occurred only in moderate and severe dementia; and ethnicity and language of administration had no effect. All critical errors increased in frequency with dementia stage. This simplified scoring system had much better specificity than two other systems (88% vs 39% for Mendez's system - 63% for Shulman's) and much better sensitivity than Wolf-Klein's (71% vs 51%). Stepwise logistic regression found the simplified system to be more strongly predictive of dementia than the three other CDT systems of dementia. Substituting the new CDT algorithm for that used in the original CDT Mini-Cog improved the Mini-Cog's specificity from 89 to 93% with minimal change in sensitivity. CONCLUSIONS: Only six errors need be assessed to capture most of the power of clock drawing to discriminate between people with dementia and normal subjects, and improves specificity over older systems in subjects with > or = 5 years of education. These errors require minimal conceptual classification and are easily detected and scored by non-specialists.


Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr. 2008 Oct;20(5):91126.

BACKGROUND: Despite evidence that early identification of dementia is of growing policy and practice significance in the U.K., limited work has been done on evaluating screening measures for use in primary care. The aim of this paper is to offer a clinically informed synthesis of research and practice-based evidence on the utility, efficacy and quality of dementia screening measures. METHOD: The study has three elements: a review of research literature, a small-scale survey of measures employed in three primary care trusts, and a


systematic clinical evaluation of the most commonly used screening instruments. The study integrates data from research and clinical sources. RESULTS: The General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS), and the Mini-Cognitive Assessment Instrument (Mini-Cog) were found to be brief, easy to administer, clinically acceptable, effective, and minimally affected by education, gender, and ethnicity. All three have psychometric properties similar to the Mini-mental State Examination (MMSE).CONCLUSIONS: Although the MMSE is widely used in the U.K., this project identifies the GPCOG, MIS and Mini-Cog as clinically and psychometrically robust and more appropriate for routine use in primary care. A coherent review of evidence coupled with an in-depth evaluation of screening instruments has the potential to enhance ability and commitment to early intervention in primary care and, as part of a wider educational strategy, improve the quality and consistency of dementia screening.


Steenland NK, Auman CM, Patel PM, Bartell SM, Goldstein FC, Levey AI, Lah JJ. Development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia. J Alzheimers Dis. 2008 Nov;15(3):41927.

Mild cognitive impairment (MCI) often presages development of Alzheimer's disease (AD). We recently completed a cross-sectional study to test the hypothesis that a combination of a brief cognitive screening instrument (Mini-Cog) with a functional scale (Functional Activities Questionnaire; FAQ) would accurately identify individuals with MCI and undiagnosed dementia. The Mini-Cog consists of a clock drawing task and 3item recall, and takes less than 5 minutes to administer. The FAQ is a 30-item questionnaire completed by an informant. In addition to the Mini-Cog and FAQ, a traditional cognitive test battery was administered, and two neurologists and a neuropsychologist determined a consensus diagnosis of Normal, MCI, or Dementia. A classification tree algorithm was used to pick optimal cutpoints, and, using these cutpoints, the combined MiniCog and FAQ (MC-FAQ) predicted the consensus diagnosis with an accuracy of 83% and a weighted kappa of 0.81. When the population was divided into Normal and Abnormal, the sensitivity, specificity and positive predictive value were 89%, 90%, and 95%, respectively. The MC-FAQ discriminates individuals with MCI from cognitively normal individuals and those with dementia, and its ease of administration makes it an attractive screening instrument to aid detection of cognitive impairment in the elderly.




Next Month's Issue: Management of Depression and Anxiety in Older Adults


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