Focuses on cognitive assessment for people with suspected dementiaIdentification 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

DementiaDefined 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 criteriaA. 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 testsReliable diagnosis of dementia integrates: (1) Patient observations, (2) Informant account, and (3) Formal cognitive assessmentCognitive tests aids in rapid assessment and early diagnosis which facilitates timely access to treatments and support services

An ideal testQuickSimple to score and interpretNot require the use of special equipment or trainingHigh sensitivityHigh inter-rater and re-test reliabilityPatient acceptabilityProvides a numerical value to objectively assess disease severity and progression

Caution in people with:Low educational backgroundsDeafnessDepressionCommunication impairmentHigh educational attainment (ceiling effect)

MethodologySearch term: assessing cognitive ability in older peopleOver 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 diseaseExclusion: 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 notedProportion of study population with dementia were also noted to ensure that test performance was not overestimatedInstruments that required informant input were excludedThe review only includes instruments that were equivalent or shorter than the MMSE score (delivery time approximately 10 min)

Limitations of the studyMany studies included used the MMSE score as a reference standardCaution 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)

Results135 articles reporting on 12 brief cognitive assessment tests were retained for data extraction

1. MMSE30-Point Cognitive Assessment developed by Folstein et al. in 197511 itemsTests for MemoryOrientationAttentionLanguagePraxis impairments

1. MMSECutoff

1. MMSEMeta-analysis of 34 dementia studies show moderate sensitivity and specificity, not as good as reported in original studyHigh dementia prevalence specialist settings Sensitivity 77% and Specificity 90%Low dementia prevalence specialist settings Sensitivity 81% and Specificity 87%

1. MMSEStrengthsWell validatedQuick (8 mins to complete)Simple to scoreAssesses most components required to diagnose dementiaObjective, no inter-observer variability

1. MMSELimitationsAffected strongly by educational attainmentStrongest correlation Serial 7s and spelling world backwardsLow ceiling May be less effective in identifying MCIRetrospective copyright enforced - Cost

1. MMSELocal Context Modified Mini Mental State ExaminationTargeted at population of Singapore Chinese older adults 55 years oldAn 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. MMSEA 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. MMSE4) 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. AMT10-item assessment 81% sensitivity and 85% specificity with cut-off score

2. AMTLimitations: Lower specificity and sensitivity than MMSESome questions are open to interpretation bias, e.g. time, counting from 20-1, placeAddress for recall and 2 persons identified are not standardizedQuestion item drift

2. Shorter versions of the AMTFor 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 place4-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 TestCAMDEX scoring system:0 No reasonable representation of a clock No clock face drawnNumbers not in correct positionIncorrect time1 One of the 3 items mentioned in score 0 is correct2 Two of the 3 items mentioned in score 0 is correct3 All items are correctly representedFailure on any item indicates moderate/severe cognitive impairment

3. Clock Drawing TestSHULMAN scoring system:0 No reasonable representation of a clockNo attempts at allNo semblance of a clock at allWrites a word or name1 Severe level of disorganisation as described in 22 Moderate visuospatial disorganisation of times such that accurate denotation of 10 after 11 is impossibleModerately poor spacingOmits numbersPerseverationrepeats circle or continues on past 12 to 13, 14, 15 etc.Right-left reversalnumbers drawn counterclockwiseDysgraphiaunable to write numbers accurately3 Inaccurate representation of 10 after 11 when visiospatial organisation is perfect or shows only minor deviationsMinute hand points to 10Writes 10 after 11Unable to make any denotation of time4 Minor visuospatial errorsA mildly impaired spacing of timesDraws times outside circleTurns page while writing numbers so that some numbers appear upside downDraws in lines (spokes) to orient spacing5 Perfect clock

3. Clock Drawing TestAssesses: visuo-spatial impairment, constructional apraxia, auditory processing, memory, abstract thinking Complementary to other testsStrengths: quick to perform (under 1 min), repeated testing provides visual log of cognitive decline, readily acceptable to patients

3. Clock Drawing TestLimitations:Lack of consistent scoring systemExplains the widely varying sensitivities (34-83%) and specificities ( 13-97%)Less reliable in detecting mild cognitive impairmentNot suitable for patients with visual and/or physical disabilityIncreasing use of digital clocks may result in the CDT becoming obsoleteComprehensive review of the CDT reported mean sensitivity of 85% and specificity of 85%

4. Montreal Cognitive AssessmentIncorporates frontal lobe executive function (vs MMSE)8 cognitive domains with weighted scoresCDT, memory, cube copying, orientation, trail making, verbal fluency, sustained attention, serial 7s naming objectsScoring: 18-26 = mild / 10-17 = moderate /

4. Montreal Cognitive Assessment

5. 6-Item Cognitive Impairment TestDeveloped 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 scoreTests for:MemoryOrientationAttention

5. 6-Item Cognitive Impairment TestUses an inverse score and questions are weighted to produce a total out of 280-7: Normal>7: Significant

Or any other 5 component address

5. 6-Item Cognitive Impairment TestStrengthsShort time taken to administer (4 mins)Correlates highly with the MMSEMore sensitive than the MMSE in detecting mild dementiaLimitationsDifficult to administerDoes not assess as many domains

6. Seven Minute Screen BatteryComponentsCued recallCDTtemporal orientationcategory fluency

Strengths: Higher sensitivity and specificity than MMSE, especially in MCI & mild dementia. High test-retest reliability and interrater reliabilityLess affected by age, edu or ageLimitations: 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 RECALLRemove 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 JanuaryFree recall as many of the 16 pictures as possibleWhen 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 BatteryCATEGORY FLUENCYGenerate 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 BatteryBENTON TEMPORAL ORIENTATION TESTTest:time1 error point for each 30-minute deviation to a maximum of 5. day of week1 error point for each day to a maximum of 3 date1 error point for each date off to a maximum of 15month5 error points for each month off to a maximum of 30 year10 error points for each year off to a maximum of 60The maximum total error score is 113

6. Seven Minute Screen BatteryCLOCK DRAWINGProvide 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-cogSpecifically developed to augment the narrow cognitive domain focus of the CDTPatients are Given 3 items to remember (e.g. apple, watch, pen)Complete CDTAsked 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 mistakeOne point is awarded for each correct word recalledScore ranges from 0-5 and a score of

7. Mini-cogStrengths: simple to use and score, quick to perform (1.5 min), less influenced by culture and education than the MMSEAlso increased the sensitivity of the CDT to detect cognitive impairment from 79 to 99%Limitations: not suitable for patients with visual and/or physical disabilitySensitivity 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-cogTemporal orientation (year, season, month, date, day and time) and the recall of a 12-item grocery list have been addedStrengths: 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 MMSEDeveloped to improve sensitivity to detect early dementiaIdentified MMSE items that optimized discrimination between cognitively healthy people and people with early dementia:3-word recallDateSpelling world backwardsVerbal 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 orderScoring system is weighted with an emphasis on the recall item, hence aiming to identify early dementia1 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 (

11. Time and Change testDeveloped in the United States to assess executive function based on a commonplace daily taskComprises ofTelling time: 1 min and 2 attempts to read the time on a large clock set at 11:10Making change: Participants are asked to make a dollar from 3 quarters, 7 dimes and 7 nickels in 3 minFailure of either task suggests cognitive impairment

11. Time and Change testStudy was conducted comparing T&C test, MMSE and modified Blessed Dementia Rating Scale (mBDRS)T&C did not meet desirable standards for dementia detectionAttempted to improve performanceTime: Time limit of 3s

11. Time and Change testStrengthsFast, takes only 23s to completeEasy to administerGood acceptability rates by patients, only 5% refusalReliable, inter-rater agreement of 88%LimitationsPoor specificityNot suitable to detect MCINot tailored for Singapore populationDoes not assess as many domains

12. Hopkins Verbal Learning TestDeveloped by Brandt in 1991Brief assessment of verbal recall and recognitionInvolves providing participants with a list of words to remember3 trials to freely recall the words are allowedPatient supplied with words from semantic categories to provide cuesEach 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 TestRaw scores are derived for Total Recall, Delayed Recall, Retention (% retained), and a Recognition Discrimination Index.Software available to generate 5 specific reports from the scores2 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 TestStrengthsGood specificity and sensitivityHigh test-retest reliabilityAvailable in many languagesRelatively short duration of administrationLimitationsHas to be purchasedNot widely usedNot well studiedAssesses limited domains only

ConclusionRole of brief cognitive impairment test To screen for the possibility of dementia in a time-constrained clinical encounterTests are not diagnostic diagnosis requires detailed assessment with the DSM IV / V criteria (Memory Clinics)

ConclusionIncreasing interest detecting mild cognitive impairmentSpecial 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

Conclusion12 brief cognitive assessments were reviewed6 of which (BAS, SBT, T&C, HVLT, MOST) are insufficiently well studiedMMSE, AMT, CDT, Mini-cog, 6-CIT and MoCA are recommended for use in routine carePractitioners should be familiar and competent with just a few instruments, with selection based on local context to maximise communication between teams and services

ConclusionsQuick screen in