IPA08 - Detection Of Dementia By General Practitioners [April 2008]

Which Cognitive Tests Are Validated for Detection of Dementia by General Practitioners?

A Pooled Analysis of 39 Primary Care Studies

Alex MitchellConsultant & Hon SnR Lecturer in Liaison Psychiatry, Leicester

IPA, Dublin 2008

0 10 20 30 40 50 60 70 80 90 100

Mini-mental State Exam (MMSE)

Clock Drawing Test

Delayed Word Recall

Verbal Fluency Test (FAS, Set test)

Similarities

Trail Making Test

Standardized MMSE (SMMSE)

Alternating Sequences

Modified MMS (3MS)

Go-no-go

IQCODE

Mini-Cog

7 Minute Screen

Short Portable Mental Status (SPMSQ)

Abbreviated Mental Test (AMT)

Memory Impairment Screen (MIS)

Neurobehavioral Cognitive Status Exam (NCSE)

Time and Change Test

Most Popular Cognitive Tests

GP Screening Preferences

• 74% of people consult a GP first after noticing symptoms of cognitive decline 3

• 82% of GPs say screening for dementia is worthwhile

– but 24% routinely screen (GPs)

– 39% psychiatrists use the MMSE1

• 93% would use a brief effective tool2

1 Gilbody, House Sheldon (2002) Br J Psychiatry2 Bush et al Can Fam Physician. 19973 Wilkinson et al (2004);

Gps neurol =>

How Accurate are GPs? (untrained, unassisted)

unass =>

Gold standard is probable dementia

Recognition Rate of Dementia by Severity

97%

73% 71%

46%

66%

33%

0

10

20

30

40

50

60

70

80

90

100

SevereDementia

(CI)

SevereDementia

(Dementia)

ModerateDementia

(CI)

ModerateDementia

(Dementia)

Milddementia

(CI)

Milddementia

(dementia)

Possible Diagnostic Methods

unass =>

Gold standard is probable dementia

Types of Assisted Recognition

• Clinician Prompts– GDS, CDR

• Simple (Bedside) Single Item Cognitive Tests– Verbal fluency, Name & Address, Orientation

• Short Batteries– MMSE

• Long Batteries– CAMCOG

• Criterion Standard– DSMIV, ICD10

domains =>

Types of Recognition

• Clinician Prompts– GDS, CDR

• Simple (Bedside) Single Item Cognitive Tests– Verbal fluency, Name & Address, Orientation

• Short Batteries– MMSE

• Long Batteries– CAMCOG

• Criterion Standard

domains =>

Accuracy of MMSE…what do we know?

unass =>

Gold standard is probable dementia

Pooled Accuracy of MMSE (n=5,892 x9 Primary Care)

Prevalence = 16%87.4% (Sp)77.2% (se)

95.2% (NPV)4328215MMSE No

53.9% (PPV)689727MMSE Yes

DementiaAbsent

DementiaPresent

ceiling =>

Theory of Diagnostic Tests

Dementia

Number ofIndividuals

False +veFalse +ve

True -veTrue -ve

Point of Partial Rarity

MMSE Cognitive Score

No Dementia

False -veFalse -ve

True +veTrue +ve

Theory of Diagnostic Tests

Dementia

Number ofIndividuals

False +veFalse +ve False -veFalse -ve

True -veTrue -ve

True +veTrue +ve

MMSE Cognitive Score

No Dementia

Theory of Diagnostic Tests

Dementia

Number ofIndividuals

False +veFalse +ve False -veFalse -ve

True -veTrue -ve

True +veTrue +ve

MMSE Cognitive Score

No Dementia

Hubbert et al (2005) BMC Geriatrics

MMSE scores for dementia (n=72)and non-dementia (n=2735)

Huppert et al BMC Geriatrc 2005

Animals named in 1 min (mms>19) - CERAD data set

0

2

4

6

8

10

12

0 10 20 30 40

number of animals named

perc

ent o

f tot

al

Normal Controls, CS = 1, n = 386

Alzheimer patients, CS = 0, n = 380

Methods

• Literature search– Electronic, manual, reverse (citation)

• Keywords– (cognitive, dementia) +(brief, short, rapid) +(screen,test)

• Inclusion criteria– Brief tests- max. 10 minutes– Sensitivity, specificity or raw data– Criterion Reference (DSM IIIR /IV, NINCDS-ADRDA)

• Exclusion– Study <200 participants

• Sample– 39x studies 25,400 individuals

poster =>

Srinivasa Malladi & Alex J Mitchell Liaison Psychiatry, Brandon Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW [email protected]

Aim: To identify brief and effective cognitive screening tools which may be practical and valid in the primary care settings.

Methods: An extensive literature search was performed electronically using keywords, abstract and citation searches. A full text search and manual search was also performed. A total of 56 articles were initially identified as “candidates.” Inclusion criteria were that the tool should be compared against a gold standard such as NINCDS-ADRDA, DSM IIIR/IV diagnostic criteria. A comparison with MMSE was desirable.

Brief Cognitive Assessment Tools To Detect Dementia - A Systematic Review

Results: To date 31 papers have been analysed in detail, 15 papers were excluded and another 10 are under review. Sensitivity and specificity findings have been collated where data was presented. Preliminary results suggest that very short and ultra-short tests (Combined JB +VB; Rapid dementia screening test, the Memory impairment screen or the Mini-Cog) are more accurate and quicker than MMSE alone. A variety of tools including telephone interviews and informant questionnaires appear to be promising alternatives to MMSE which is not thought to be ideal for cognitive assessment in general practice. Several of the tools are also thought to be user friendly and potentially free of biases that can affect MMSE. Performance in different types of dementia has not been adequately tested.

Conclusions: Our preliminary data suggest that there appear to be a number of brief tools that are as effective as MMSE and several that may be more effective. These tools can also be combined where required.

Authors/year Test tool Criterion standard Sensitivity Specificity

Erkinjuntti et al 1988 BDS DSM IIIR 105 90% 84%

Albert M et al.1991 SPMSQ NINCDS-ADRDA. 3811 34.4% 94.3%

Albert M et al. 1991 EBMT NINCDS-ADRDA. 3811 47.8% 95.1%

Hooijer et al. 1992 SPMSQ GMS/AGECAT 24 100% 96.8%

Hooijer et al. 1992 MSQ GMS/AGECAT 18 92.3% 98.3%

Hooijer et al. 1992 AMTS GMS/AGECAT 28 92.3% 95.4%

Glosser et al..1993 Extended CCCE Clinical diagnosis 115 94% 99%

Stuss et al. 1996 DRS NINCDS-ADRDA 283 87% 84%

Stuss et al 1996 OMC NINCDS-ADRDA 283 95% 77%

Wind et al.1996 Set of items GMS/AGECAT 533 64.9% 96.4%

Tanya et al. 1998 T&C Test Clinical diagnosis 100 62.5% 96.4%

Solomon et al. 1998 7MS NINCDS-ADRDA 90 93.3% 96.6%

Bushke et al. 1999 MIS NINCDS-ADRDA 483 90% 81%

Belle,S.H.,(2000). SASSI CERAD CDR 1178 94% 91%

De Koning 2000 R-CAMCOG NINDS-AIREN 284 91% 90%

Borson S et al 2000 CASI NINCDS-ADRDA 249. 92% 96%

Derrer et al. 2001 WL+ LM+ VM NINCDS-ADRDA 74 100% 94.5%

Derrer et al. 2001 Word list NINCDS-ADRDA 74 95% 89%

Kirby et al.. 2001 CDT GMS-AGECAT 648 76% 80.5%

Kirby et al. 2001 MMSE + CDT GMS-AGECAT 648 95% 95%

Scanlan et al 2001 Mini Cog NINCDA-ADRDA 249 99% 93%

Brodaty et al. 2002 AMT DSM IV CAMDEX 375 42% 93%

Brodaty et al. 2002 GPCOG DSM IV CAMDEX 380 82% 83%

Salib E et al. 2002 MAT NINCDS-ADRDA 113 95% 81%

Kuslansky et al. 2002 MIS NINCDS-ADRDA 240. 86% 97%

DeYebenes et al. 2003 PCL DSM IV/IPA-WHO 375 93.9% 94.7%

Lipton et al. 2003 CF-T + MIS-T NINCDS-ADRDA 355 89% 93%

Lipton et al.. 2003 TICS NINCDS-ADRDA 355 83% 86%

Lin et al2003 3 Item CDT NINCDS-ADRDA 403 67% 75%

Kalbe et al. 2003 RDST NINCDS-ADRDA 490 72% 89%

Borson S et al. 2003 Mini-Cog NINCDR CERAD 1119 76% 89%

Robert et al. 2003 SCEB DSM IV 123 93.8% 85%

Meulen et al. 2004 7MS NINCDS-ADRDA 331 92.6% 93.5%

Brodaty et al. 2004 GPCOG DSM IV 283 85% 86%

Storey J et al. 2004 RUDAS DSM IV 90 89% 98%

Kalbe et al. 2004. DemTect NINCDS-ADRDA 363 100% 92%

Mahoney et al. 2005 TE4D-Cog DSM IV 203 100% 84%

Kilada S et al. 2005 C’bined JB + VF NINCDS-ADRDA 456 87% 90%

Galvin et al 2005. AD8 CDR 85% 86%

Abbreviations:MMSE- Mini mental state examination RUDAS-Rowland universal dementia assessment scale MIS-Memory impairment screen SCEB- Short cognitive evaluation battery MAT- Mental alternation test CCCE-Cross cultural cognitive examination PCL-Prueba cognitiva de leganes 7 MS- 7 minute screen TICS- Telephone instrument for cognitive status CF-T – Category fluency test MIS-T- Memory impairment screen by telephone RDST- Rapid dementia screening test CDT- Clock drawing testCombined VB+ JB- Combined verbal fluency and John brown address SASSI- Short and sweet screening instrument DRS-Dementia rating scale BDS- Blessed dementia scale MSQ- Mental status questionnaire SPMSQ- Short portable mental status questionnaire OMC- Orientation memory concentration test T&C test- Time and change test TE4D-Cog- Test for early detection of dementia from depression CASI- Cognitive abilities screening test AMT- Abbreviated mental test GPCOG-General practitioners assessment of cognition EBMT- East boston memory test WL+LM+VM- Word list + Logical memory + verbal memory

Sample Size

Individual Results : MMSE (Mean) Sensitivity= 83% Specificity= 85.9%As accurate as MMSE=21As accurate + quicker than MMSE = 7: Mini-Cog Combined (VF+JB) MIS AD8 GPCOG Word list acquisition CCCE

As accurate + as quick as MMSE = 3: RUDAS DemTect 7MS

Head to head comparison with MMSE:More accurate + quicker = 6: MiniCog RDST MIS GPCOG Set of items(Time+ PM+ Address) CCCEMore accurate +as quick = 3 :TE4D-Cog DemTect 7MSAs accurate+ quicker =3:Word list acquisition MAT OMC As accurate but longer=3:SASSI (MMSE+CDT) DRS

Less accurate but quicker=1: CDT Tools not compared =6: SCEB TICS (CF-T + MIS-T) AD8 RUDAS PCL

Royal College of Psychiatrists Faculty of Old Age Psychiatry Annual Residential Conference Radisson SAS Hotel, Glasgow, 1st – 3rd March 2006

Simple Battery Methods tests

unass =>

Gold standard is probable dementia

SPMSQ

6-CIT =>

Results - Ranking

unass =>

Primary Care Battery Ranking

• Overall Accuracy (PSI)

– SPMSQ = 0.55

– MMSE = 0.49

– Battery = 0.59

– AMTS = 0.52

– CDT = 0.25

Simple Single domain tests

unass =>

Gold standard is probable dementia

Pooled Analysis of Single Items (N=13,247 16x primary care)

10,43996073640

86511279Test -ve

9562361Test +ve

DementiaABSENT

DementiaPRESENT

Sensitivity64.9%

PPV 71%

Specificity90%

NPV 87%

Prevalence27.5%

Pooled Accuracy of MMSE (n=5,892 x9 Primary Care)

Prevalence = 16%87.4% (Sp)77.2% (se)

95.2% (NPV)4328215MMSE No

53.9% (PPV)689727MMSE Yes

DementiaAbsent

DementiaPresent

ceiling =>

More on Single Items

• 2 Specific Tests perform well– Memory

• Memory Impairment Screen (MIS), the East Boston Memory Test (EBMT) and 3 word recall

– Verbal fluency• Animals, Supermarket

• On meta-analysis verbal fluency was no less accurate in terms of sensitivity than the MMSE itself and individual memory tests were no less accurate than the MMSE itself in terms of specificity.

Is Recall Alone better MMSE?

AUCs

RI 48 Test: 98.5CERAD immediate recall: 96.5CERAD delayed recall: 95.2MMSE: 85.3

9.7

6.7

10.5

12.3

13.2

12.9

58.8

76

64.2

49.9

62.7

31.5

30.4

13.5

23.5

36.9

24.4

62.9

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

MMSE

Battery No MMSE

6-CIT

Blessed

SPMSQ

AMTS

False NegativesAccurate DiagnosesFalse Positives

NPV

NPV

PPV

Where? =>

Where Can I Find these scales?

• Many Scales are here

– www.neurotransmitter.net/alzheimerscales.html

– www.medal.org

Extras

unass =>

29.1DSM-III

17.3DSM-IIIR

13.7DSM-IV

5.0ICD-9

4.9CAMDEX

3.1ICD-10

% of CSHA populationCriteria (n=1879)Canadian Study of Health and Aging (CSHA)

Erkinjuntti T, Ostbye T, Steenhuis R, Hachinski V. The effect of different diagnostic criteria on the prevalence of dementia. NEJM 1997 337(23):1667-74.

Diagnostic criteria & dementia prevalence

Diagnostic criteria & dementia prevalence

Diagnostic criteria & dementia prevalence

Accuracy of Trained Clinicians

1000190810

160 Total _ve10060Test -ve

840 Total +ve90750Test +ve

ALZHEIMER’SABSENT

ALZHEIMER’SPRESENT

Sensitivity93%

PPV 90%

Specificity55%

NPV 64%

Prevalence81%True n= 2188,

GS = pathologyMayeux et al (1998)

Credits / Acknowledgments

For more slides www.psycho-oncology.info/slides

Alex J Mitchell © 2008