-
CE/CME VÂÎPA S S O C I A T I O NC M E
The Clock Drawing Test is sensitive to early cognitive
changes,
simple to conduct, and highly predictive of driver safety.
CognitiveScreening ToolsFreddi Segai-Gidan, PA-C, PhD
As the US population ages, the need grows for clinicians in
all settings to be familiar with currently available
cognitive
screening tools. These tools, though not diagnostic, are
useful in the early recognition of cognitive changes and of
possible underlying dementia. No single cognitive screening
tool is appropriate for use in all settings or with all
populations. The components, scoring, and interpretation
of the more commonly used cognitive screening tools are
described here, with their respective benefits and
limitations.
CE/CME INFORMATION
TARGET AUDIENCE: lhis activity has been designed
to meet the educational needs of physician assistants
and nurse practitioners in primary care with patients at
risk for dementia, delirium, and other forms of cogni-
tive impairment.
• Original Release Date: January 2013
• Expiration Date: January 31, 2014
• Estimated Time to Complete This Activity: 1 hour
• Medium: Printed journal and online CE/CME
PROGRAM OVERVIEW: The primary objective of this
educational initiative is to provide clinicians in primary
care vAxh the most up-to-date information regarding
currently available screening tools for cognitive impair-
ment, in particular for use in elderly patients.
EDUCATIONAL OBJECTIVES: After completing this
activity, the participant should be better able to:
• Discuss factors that contribute to the growing incidence
of dementia in older adults and the ramifications of un-
diagnosed cognitive dysfunction in this age-group.
• Explain the importance of early detection of cogni-
tive changes as a first step toward accurate diagnosis
of dementia, delirium, or other forms of cognitive
dysfunction.
• Describe at least eight currently available cognitive
screening tools in terms of administration time, cogni-
tive functions assessed, and associated benefits for spe-
cific patient groups or administrative settings.
• Discuss associated clinical instruments used to
stage cognitive decline, assess function in cognitive-
ly impaired patients, and identify acute confusion
and delirium.
FACULTY: Ereddi Segal-Gidan, PA-C, PhD, is Director of
the Rancho/University of Southern California (USC) Cal-
ifornia Alzheimer's Disease Center in Downey, and is an
Assistant Clinical Professor in the departments of Neu-
rology and Family Medicine at the Keck School of Medi-
cine, USC, in Los Angeles, and an Assistant CUnical
Professor of Cerontology at the L. Davis School of Geron-
tology at USC. She is a member of the Clinician Reviews
editorial board.
ACCREDITATION STATEMENT:
PHYSICL\N ASSISTANTS
This program has been reviewed and is approved for a
maximum of 1.0 hour of American Academy of Physi-
cian Assistants (AAPA) Category I CME credit by the
Physician Assistant Review Panel. Approval is valid for
one year from the issue date of January 2013. Partici-
pants may submit the self-assessment at any time dur-
ing that period.
This program was planned in accordance with AAPA's
CME Standards for Enduring Material Programs and for
Commercial Support of Enduring Material Programs.
Successful completion of the self-assessment is re-
quired to earn Category I CME credit. Successful com-
pletion is deñned as a cumulative score of at least 70%
correct.
ACCREDITATION STATEMENT:
NURSE PRACTITIONERS
This program has been approved by the Nurse Practitio-
ner Association New York State (The NPA) for 1.0 con-
tact hour.
DISCLOSURE OF CONFLICTS OF INTEREST
The faculty reported the following financial relationships
or relationships to products or devices they or their
spouse/life parmer have with commercial interests related
to the content of this CME activity: Freddi Segal-Gidan,
PA-C, PhD, reported no significant financial relationship
with any commercial entity related to this activity.
METHOD OF PARTICIPATION: There is no fee for par
ticipating in and receiving CME credit for Clinician Re-
views'January 2013 CE/CME activity. Duringthe period
January 2013 through January 31, 2014, participants
must 1) read the learning objectives and faculty disclo-
sures; 2) study the educational activity; 3) go to www
.clinicianreviews.com/CECourses.aspx and follow
links to the posttest for this activity; 4) complete the
10-question posttest by recording the best answer to
each question; and 5) record their response to each of
the additional evaluation questions.
If you have any questions, e-mail CR.evaluations@
qhc.com. Upon successful completion ofan online post-
test, with a score of 70% or better, and the completion of
the online activity evaluation form, a statement of credit
will be made available immediately.
DISCLOSURE OF UNLABELED USE: This educational
activity may contain discussion of published and/or in-
vestigational uses of agents that are not indicated by the
FDA. AAPA, The NPA, and Quadrant HealthCom Inc. do
not recommend the use of any agent outside of the la-
beled indications.
The opinions expressed in this educational activity are
those of the faculty and do not necessarily represent the
views of AAPA, The NPA, or Quadrant HealthCom Inc.
Please refer to the official prescribing information for
each product for discussion of approved indications,
contraindications, and warnings.
DISCLAIMER: Participants have an implied responsibil-
ity to use the newly acquired information to enhance pa-
tient outcomes and their own professional development.
The information presented in this activity is not meant to
serve as a guideline for patient management. Any proce-
dures, medications, or other courses of diagnosis or
tieatment discussed or suggested in this activity should
not be used by clinicians without evaluation of their pa-
tient's conditions and the possible contraindications or
dangers in use, review of any applicable manufacturer's
product information, and comparison with recommen-
dations of other authorities.
Clinician ReviewsJanuary 2013 • Vol 23, No 1
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CE/CME
As our elderly populationcontinues to grow, theissues of
screening forcognitive impairment
and early detection of dementiaare becoming increasingly
im-portant. Cognitive impairment,particularly in individuals
wholive alone, contributes to loss ofindependence, decreased
qual-ity of life, and increased healthcare costs.' There are
seriousand costly implications of un-recognized dementia,
includingdelayed treatment of reversibleconditions, medication
noncom-pliance for comorbid conditions,inaccurate and unreliable
report-ing by patients, safety concerns,potential catastrophes, and
in-creased risk for victimization.
Clinicians in all settings canexpect to care for
increasingnumbers of older adults—manywith various degrees of
cogni-tive difficulties. Such problems,especially if undetected,
can sig-nificantly impact the ongoingmanagement of both acute
andchronic medical problems. Inprimary care settings, it has
beenreported, between 50% and 65%
>PRIMARYPOINT
L
Cognitive changes may herald early
dementia (eg, Alzheimer's disease) or
functional decline, or reveal an increased
risk for delirium.
of patients found to have cogni-tive deficits meeting the
criteriafor dementia did not have a diag-nosis of dementia noted in
theirmedical record.^
The annual Wellness examina-tion provided for under the Pa-tient
Protection and AffordableCare Act-̂ (PPACA) for Medicare
Freddi Segal-Gidan is Director ofthe Rancho/University of
Southern
California (USC) California Alzheim-
er's Disease Center in Downey, and is
an Assistant Clinical Professor in the
departments of Neurology and Fam-
ily Medicine at the Keck School of
Medicine, USC, in Los Angeles, and an
Assistant Clinical Professor of Geron-
tology at the L. Davis School of Geron-
tology at USC. She is a member of the
Clinician Reviews editorial board.
beneficiaries is required to in-clude an assessment of
cogni-tive function,"" but the Centers forMedicare and Medicaid
(CMS)have not, to date, recommendedany specific screening
instru-ment; examiners are expected tobase their assessment on
obser-vation and reports from the pa-tient and other
informants.^
WHY DO TESTING?The purpose of cognitive screen-ing tests is to
aid the clinicianin early detection of cognitivechange as a first
step toward ac-curate diagnosis—a process thatrequires further
assessment.Such changes may herald thebeginning of a dementia,
suchas Alzheimer's disease, or mayindicate an increased risk
fordelirium, such as in the postop-erative setting,'' or functional
de-cline with accompanying safetyconcerns.^ Early identificationof
cognitive changes provides anopportunity for case finding, cri-sis
avoidance, and identificationof patients for earlier interven-tion
and management, includ-ing a discussion of goals with the
patient, and assur-ance that advancedirectives are com-plete and
accurate.
It is well docu-mented that de-mentia remainsunderrecognized
and may indeed be the "silent ep-idemic" of this century.^
Currentestimates are that the incidenceof new cases of Alzheimer's
dis-ease will double by 2050.̂ Addi-tionally, improvement in
strokesurvival rates means that therewill likely be increases in
vascu-lar and poststroke dementia, asone-third of stroke patients
havebeen found to develop a progres-sive dementia.'"
The early detection of cogni-tive change offers benefits forboth
patients and providers. Ifearly detection leads to a diag-nosis of
dementia (regardless ofetiology), this can provide an ex-planation
to patients and fami-lies regarding recent changes in
TABLE 1
Comparison of Sensitivity and Specificity of CognitiveScreening
Tools for Detection of Dementia^''^^
Screening tool
Mini-Mental State Exam (MMSE)
Modified Mini-Mental StateExam (3MS)
Mini-Cog
Montreal Cognitive Assessment(MoCA)
Saint Louis University MentalStatus (SLUMS)
General Practitioner Assessmentof Cognition (GPCOG)
Memory Impairment Screen (MIS)
Clock Drawing Test
Sensitivity
69% - 9 1 %
83%-94%
76% - 99%
100%
92%-95%
82%
80%
88%
Specificity
87% - 99%
85% - 90%
8 9 % - 9 3 %
87%
76% - 8 1 %
83%
96%
71%Sources: Cullen et al. J Neurol Neurosurg Psychiatr. 2007^'';
Smith et al. Can J Psychiatr.
2007^^; Tariq et a\. Am J Geriatr Psychiatry. 2006*; Brodaty et
al. i Am Geriatri Soc 2002";
Buschke et al. Neurology. 1999^"; Lessig et al. Int
Psychogeriatr. 2008.^'
function, mood, and behavior.A diagnosis of progressive
de-mentia (eg, Alzheimer's disease,Lewy body disease,
frontotem-poral dementia) provides an op-portunity for early
medicationmanagement, review and sim-plification of ongoing
chronicdisease management, and pre-vention of problems
commonlyassociated with mismanage-ment. More importantly,
earlydiagnosis of dementia enablespatients to be more involved
inplanning for their own futurecare needs, such as execution
ofadvance directives.
Cognitive screening may alsohelp in identification of the
at-risk driver or those who shouldundergo further assessment
forfitness to drive.'
WHO SHOULD BE SCREENED?There is no clear consensus onwho should
undergo cognitivescreening or how frequently itshould be carried
out. Screeningshould be targeted at individualswho are at greatest
risk for eitherprogressive dementia or deliri-um. Advancing age is
a knownrisk factor for dementia, but thereis no agreement on a
specificage at which to initiate cognitivescreening. In patients
older than80, there is a 25% to 50% preva-lence of dementia,'"'^
thus sug-
gesting that cognitive screeningshould be initiated before
thisage. Furthermore, clinicians whoprovide medical care for
patientsof advanced age must be increas-ingly attentive to the
possiblepresence of cognitive decline.
Individuals with subjectivememory complaints and thosewith a
history of depression havebeen identified as being at highrisk for
dementia.'^'" The Ameri-can Academy of Neurology rec-ommends
cognitive screeningin any patient in whom cogni-tive impairment is
suspected.'^This usually occurs when a fam-ily member or other
individualclose to the patient (eg, employ-er, friend) becomes
concernedabout changes in the patient'sthinking, behavior, or
function.Additionally, older individualswho have recently
undergonesurgery or been hospitalized area population at high risk
for acutecognitive changes and should beconsidered candidates for
mentalstatus screening.'"^^^
Another population for whomcognitive screening may be
ap-propriate is patients with certainmedical conditions known to
beassociated with dementia, as wellas any older person with
unex-plained functional decline. Ex-amples of conditions
associatedwith cognitive decline include
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COGNITIVESCREENINGTOOLSI
TABLE 2
Brief Cognitive Assessment Instruments^^-^^^''
Name ofinstrument
Mini-Mental StateExam (MMSE)
Modified Mini-Mental State (3MS)
Clock Drawing Test
Mini-Cog
Montreal CognitiveAssessment (MoCA)
Saint LouisUniversity MentalStatus(SLUMS)
Items
19
15
1
2
12
11
Maximumscore
30
100
4 - 10
5
30
30
Time toadminister
10 min
15 min
3 min3 - 5 min
10 min
7 min
Cognitive functions assessed
Orientation, registration, attention andcalculation; short-term
verbal recall; naming;repetition; three-step command;
reading;writing; visuospatial
Orientation; registration; attention andcalculation; short-term
verbal recall; delayedrecall; category fluency, executive
function,naming; repetition; 3-step command; reading;writing;
visuospatial
Visuospatial, executive functioning
Visuospatial, executive functioning, short-termrecall; includes
clock drawing
Visuospatial/executive functioning, naming,attention,
repetition, verbal fluency, abstraction,short-term verbal recall,
orientation; includesclock drawing
Orientation, verbal recall, calculation, naming,attention,
executive function; includes clockdrawing
Sources: Tariq et al. Am J Geriatr Psychiatry. 2006^''; Folstein
et al. i Psychiatr Res. 1975™; Teng and Chui. J Clin Psychiatiy.
1987^';
Sunderland et a\.J Am Geriatr Soc. 1989^ ;̂ Borson et al. IntJ
Geriatr Psychiatry. 2000^^; Nasreddine et al. 7 4m Geriatr Soc.
2005.3"
Parkinson's disease, a history ofstroke, and diabetes mellitus.̂
''̂ -'
Most patients with memorydifficulties and other
cognitiveproblems do not report thesecomplaints to their medical
pro-vider, and it is unrealistic to ex-pect them to do so. Often it
is afamily member or a coworkerwho becomes aware of a problemand
voices these concerns to theprovider; however, the providershould
not rely on this to ensureearly detection.
Clinicians must be pro-active
>PRIMARYPOINT
The ideal tool would have high sensitivity,specificity, and
positive predictive value,take minimal time to conduct, and be
easyto administer and score.
and maintain a high index of sus-picion for cognitive
difficulties,especially when treating adultsolder than 70 or 75.
Becoming fa-miliar v«th a variety of tools andusing one or more
regularly todetermine whether an individualdoes or does not have
cognitivechanges that might warrant fur-
ther assessment should be a rou-tine part of care.
WHICH TEST TO USE?There is no single, ideal cognitivescreening
tool that can be recom-mended for use in every clinicalsetting.
However, the ideal toolwould have high sensitivity (ie,the
proportion of those with im-pairment correctly classified
asimpaired), high specificity (theproportion of those who are
un-impaired correctly identified asnot having cognitive
problems;
see Table l,̂ ''-̂ ^page 13), and ahigh positive pre-dictive
value (pro-portion identifiedby screening asimpaired who re-ally
have cognitive
impairment). Additionally, sucha tool should be easy to
adminis-ter and score, and should take aminimum amount of time to
con-duct in our time-pressured clini-cal environment.
Many of the currently availablecognitive screening tests
overem-phasize memory to the neglect of
other areas of cognitive function,such as executive function,
lan-guage, and praxis, which can beimpacted in patients with
variousconditions. '̂' One review of cogni-tive screening tests
suggests that acomprehensive screening instru-ment should include
six core neu-ropsychologic domains that aremost commonly affected
in theearly stages of different dementias:
• Executive function• Abstract reasoning• Attention/working
memory• New verbal learning and re-
call• Expressive language• Visuospatial construction.^*
LIMITATIONS OF CURRENTSCREENING TESTSCognitive screening does
involvesome risk, and every tool hasknown limitations. A
significantbarrier can be the administrationtime required, possibly
rangingfrom five to 20 minutes. There isa potential for
false-positive re-sults, and there can be distressand stigma
associated with a di-agnosis of dementia, for both pa-tients and
families.
The majority of cognitivescreening tests were developedand
validated using cohorts ofEnglish-speaking patients. Whenused in
other populations, suchas those vwth English as a sec-ond (or
third) language, or whenused in translation, the resultsmay not be
valid. Similarly, manytests have an inherent educa-tional bias,
presuming attain-ment of an eighth-grade level orhigher—again
calling results intoquestion when the test is con-ducted in people
with less for-mal education. Further, most ofthe currently
available tools areinsensitive to small changes, asthey were
designed for screening,not to detect changes in a patientover
time.
Screening tests may have aceiling effect, that is, they maybe
insensitive to changes amongpatients with high intelligence orhigh
levels of education premor-bidity. Some tests may also havea fioor
effect, lacking the abilityto assess for change in patientsbelow a
certain level of educationor intelligence. The summaryscores of
these tests have cut-offsfor normal and may allow broad-range
classification of levels ofimpairment as mild, moderate,or severe;
this is not very useful indistinguishing different patternsof
cognitive loss.
COGNITIVE SCREENING TOOLSA variety of tools are available
forbedside/clinical assessment ofcognition (see Table 2'^^'^-^).
Theiradministration can be learnedwithout difficulty, and they
canbe conducted with relative easeto provide insight into a
patient'scognitive abilities and deficits.
Mini-Mental State ExamThe most commonly used cog-nitive
screening tool is the Fol-stein Mini-Mental State Exam(MMSE).̂ "
With administrationtaking about 15 minutes, theMMSE includes
assessment ofattention, orientation, registra-tion,
recall/short-term memory,language, and visuospatial con-struction.
Clinicians will find
Clinician ReviewsJanuary 2013 • Vol 23, No 1
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CE/CME
this tool most useful in assess-ing the individual with
suspect-ed early dementia and to followprogression through the
earlyand middle stages of cognitivedecline in those with
Alzheim-er's disease and related dement-ing disorders.
The maximum score is 30points, with impairment suspect-ed in
suhjects whose score is 25or lower. The MMSE is highly de-pendent
on verhal memory, andit does not include any tests ofexecutive
function; performancecan he influenced hy educationand cultural
background. A for-mula has been developed thattakes age and
education into ac-count, allov«ng for correctionof the score" (see
Table 3"^''). TheMMSE is currently a proprietarydocument requiring
payment forits use.
The Modified Mini-MentalState Exam (3MS)̂ ' expandsupon the MMSE
with the addi-tion of items that address remotememory, delayed
recall, list gen-eration, and judgment and rea-soning. With a
maximum score of100 points, it allows for partiallycorrect
responses to be scored.For example, on verbal recall,cuing and
choices are provided,with subsequent correct answersawarded partial
points (ie, 1 or 2points out of a 3-point maximumscore per recall
item). Cognitiveimpairment is defined by a scoreof 85 points or
less.
The 3MS may be more sensitivein identification of early
demen-fia than is the MMSE. The 3MS'sexpanded item scoring may
behelpful in differentiating betweensome ofthe clinical dementia
sub-types, such as Alzheimer's versusvascular dementia.-̂ ''
Clock Drawing Test
The Clock Drawing Test (CDT) isperhaps the simplest test to
ad-minister.̂ '̂̂ ^ The patient is givena blank sheet of paper and
askedto draw a large circle, then to writenumbers inside the circle
so that itresembles a face of a clock. Oncethis is completed, the
patient is in-structed to "draw the hands on the
clock to read ten past eleven."There are multiple scoring
sys-
tems for the CDT,-̂ '22,37 ̂ ^^^^ points
given for accuracy of placement ofthe numbers and the size and
po-sition of the hands. Lower scoresgenerally indicate greater
impair-ment. The advantages of the CDTare that it is not very
threatening, itis very sensitive to changes in ear-ly Alzheimer's
disease, and its ad-ministration requires little train-ing.̂ ^ It
has also been shovm to behighly predictive of driver safety.̂ ^
The CDT is most appropriatefor screening in busy practicesand
other settings (eg, healthfairs) where further evaluationcan be
relied upon to identity anyfalse-positive test results.
Mini-Cog Test
The Mini-Cog Test (with instruc-tions available at
http://geriatrics.uthscsa.edu/tools/MINICog.pdf ) includes the
clock-draw-ing task and a three-word recall,with a simple scoring
algorithm.^'Ability to recall all three words, orto recall one or
two words withnormal results on the clock test,represents a
negative screeningresult for dementia. Conversely,an inability to
recall any of thethree words, or ability to recallonly one or two
words with an ab-
>PRIMARYPOINT
TABLE 3Formula Correction for MMSE (MMSE Adjusted,or
MMSAdj = Raw MMS - [0.471 x (education - 12)] H- [0.131 x (age -
70)]Example: A 78-year-old patient with 9 years of education
scores 21/30 on MMSE.
MMSAdj = 21 - [0.471 x (9 - 12)] + [0.131 x (78 - 70)]
= 21 -[0.471 x(-3)]-H [0.131 x(8)]
= 21-(-1.413) H-(1.048)
= 21 4- 1.413 + 1.048
= 23.461
Source: Mungas et al. Neurology. 1995.̂
lates easily for use in other lan-guages,33,39
Tbough not diagnostic, these tools detect
early cognitive change, representing a
first step toward accurate diagnosis of
dementia or other impairment.
normal clock test, is considered apositive screen for dementia.
TheMini-Cog is a good tool for identi-fication of early dementia,
but notuseful for following changes in in-dividuals identified vwth
cognitiveimpairment.
The Mini-Cog has been shownto have sensitivity and specific-ity
similar to those of the MMSE,but it is much briefer and easier
toadminister. It is also less prone tolanguage or ethnic bias,
makingit appropriate for patients with awide variety of backgrounds
andeducational levels, and it trans-
Montreal CognitiveAssessment
The Montreal Cognitive Assess-ment (MoCA) was originallydesigned
as a brief screeninginstrument for mild cognitiveimpairment.̂ "* It
is a single-page,30-point test, available in mul-tiple languages
(with several ver-sions in some languages) at www.mocatest.org. The
MoCA includesassessment of short-term memo-ry, visuospafial
ability, executivefunction, attention, concentra-tion, working
memory, language,and orientation. A score of 25 or
lower is consideredsubnormal.
By design, theMoCA is useful fordetecting subtledeficits that
may be
i missed in patientswho are highly
educated, who score within thenormal range on MMSE (> 25),
orwho have prominent executivedysfunction. The test has beenshown
to have excellent sensitiv-ity in identification of
early/mildcognitive changes and high test-retest reliability, and
it is consid-ered an excellent screening toolfor detection of
cognitive impair-ment in a busy clinical setting.'"'
Saint Louis UniversityMental StatusThe Saint Louis University
Men-tal Status (SLUMS) has also been
shown to have better sensitivitythan the MMSE for early
cog-nitive changes.-** This 11-itemtool, with a maximum score of30
points, includes assessmentof seven cognitive domains:
ori-entation, recall, attention, cal-culation, fiuency, language,
andvisuospatial construction. Thefive-item delayed recall in
theSLUMS has been shown to be anexcellent discriminator of
thosewith normal cognition ver-sus mild cognitive change. It
isavailable for general use with nofee; currently, it is widely
usedby the Veterans Administrationsystem.'"
General PractitionerAssessment of Cognition
The General Practitioner Assess-ment of Cognition (GPCOC)̂ ^ isa
unique two-part tool that in-cludes questions for the patientand
for someone who knows thepatient well ("informant"). Thepatient
items include memory/recall, orientation, and visuo-spatial tasks.
The six informantquestions ask about recall, lan-guage, and
functional abilities.The GPCOG has been shown tohave sensitivity
and specificitysimilar to those ofthe MMSE '̂; asits name
indicates, it is designedand best suited for screening in afamily
medicine or general inter-nal medicine practice.
Memory Impairment Screen
The Memory Impairment Screenuses a four-item mem-
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TABLE 4
Clinical Dementia Rating Stac
None0*
Questionabledementia
0.5*
Milddementia
1*
Moderate
dementia2*
Severedementia
3*
Profounddementia
4*
Terminaldementia
5*
Memory
Little to nomemory loss;slight, inconsistent
forgetfulness
Consistent,slight ("benign")
forgetfulness.partial recollectionof events
Moderate memory
loss, more markedwith recent events;defect interferes
with everydayactivities
Severe memoryloss; only well-learned materialretained; new
material rapidlylost
Severe memoryloss; only
fragments remain
Even fragmentsof memorygenerally lost;memory testingmade
difficult byunintelligible orirrelevant speech
No meaningfulmemoryfunction; oftenuncomprehendingor obtunded
1^547-49
Orientation
Fully oriented
Fully oriented
except forslight difficultywith timerelationships
Moderate
difficulty withtime relationships;
oriented for spaceat examination.may
havegeographicdisorientation
elsewhere
Severe difficultywith timerelationships;usually
disoriented totime, often to
place
Orientation toperson only
Occasionallyresponds to ownname
No recognition
of self
Judgment andproblem solving
Solves everydayproblems, handlesbusiness/financial
affairs well;judgment good
in relation to pastperformance
Slight impairment
in solvingproblems.similarities.and differences
Moderate
difficulty inhandling
problems.similarities, anddifferences; socialjudgment
usuallymaintained
Severe impairmentin handlingproblems.similarities, and
differences; socialjudgment usually
impaired
Unable to makejudgments orsolve problems
Unable to followeven simpleinstructions or
commands
Unaware ofproblems, nocomprehension of
surroundings
Communityaffairs
Independentfunction at
usual level inwork, shopping.
volunteering.
social groups
Slight
impairment inthese activities
Unable tofunctionindependently at
these activitiesbut may be
engaged insome; appears
normal to casualinspection
No pretense at
independentfunction outsidethe home;
appears wellenough to beaccompanied to
functions outsidethe home
No pretense ofindependent
function outside
the home;appears too illto be taken tofunctions outsidethe
home
Unable to
participatemeaningfully inany social setting
Completely
unable toengage in any
activity
Home andhobbies
Home life.hobbies.
intellectualinterests well
maintained
Slight
impairmentin home life.
hobbies.intellectual
interests
Mild but
definitefunctional
impairment athome; abandons
more difficultchores, as well
as hobbiesand previous
interests
Only simple
chorespreserved;very restricted
interests, poorlymaintained
No significant
function in the
home
Unable to
participatemeaningfully inany hobby or
home activity
Completely
unable toengage in any
activity
Personalcare
Fully capable ofself-care
Fully capable
of self-care
Needs
prompting
Requires
assistancein dressing.hygiene.
maintainingpersonal effects
Requires
much help
with personal
care; frequentincontinence
May attempt
to dress orfeed self;nonambulatory
without
assistance;
mostlyincontinent
Needs to
be fed; isbedridden.
incontinent
* Numbers represent patient scores on the Clinical Dementia
Rating."'
Sources: Morris. Neurology. 1993"'; Hughes et al. BrJ
Psychiatry. 1982*; Heyman et al. Neurology 1987.""
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TABLE 5
Comparison of Cognitive Screening Tool Scores byImpairment
Level/Stage^O'̂ ^^^^^
Screening tool
Mini-Mental State Exam (MMSE)
Modified Mini-Mental State Exam (3MS)
Montreal Cognitive Assessment (MoCA)
Clinical Dementia Rating (CDR)
Preclinical
26-30
92-100
22-26
0.5
Mild/early
19-25
80-91
16-21
1.0
Moderate/middle
1 0 - 18
61 - 7 9
5 - 1 5
2.0
Severe/late
< 10
-
COGNITIVESCREENINGTOOLSI
dent dementia attributable to surgery or gen-
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RADIOLOGYREVIEW» continued from page 8
ANSWERThe radiograph demonstrates lateral dislocation ofthe
patella, with
no evidence of an acute fracture of any surrounding bones.
The
patella was easily reduced in the emergency department, and
the
patient was placed in a knee immobilizes Orthopedic
consultation
was obtained. CR
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