Epidemiological dementia index: a screening instrument for Alzheimer's disease and other types of dementia suitable for use in populations with low education level

The Dementia Knowledge Assessment Scale, the Knowledge in Dementia Scale, and the Dementia Knowledge Assessment Tool 2: Which Is the Best Tool to Measure Dementia Knowledge in Greece?

Background

Measuring dementia knowledge can be a valuable tool for assessing the effectiveness of dementia awareness activities, identifying the potential benefits of dementia training programs, and breaking down common myths and stereotypes about dementia.

Objective

To compare the psychometric properties of three widely used dementia knowledge tools, the Dementia Knowledge Assessment Tool 2 (DKAT2-G), the Dementia Knowledge Assessment Scale (DKAS-G), and the Knowledge in Dementia Scale (KIDE-G) in the Greek adult population.

Methods

A convenience sample of 252 participants from the general population completed the survey online. Statistical analyses included Cronbach's internal reliability, retest reliability, factor analysis, concurrent and construct validity, and floor and ceiling effects.

Results

The DKAS-G had the most appropriate reliability levels (Cronbach's alpha  =  0.845; retest reliability  =  0.921), whereas the DKAT2-G had satisfactory indexes (Cronbach's α= 0.760; retest reliability  =  0.630). The KIDE-G showed unsatisfactory reliability (Cronbach's α= 0.419; retest reliability  =  0.619). Construct validity was confirmed for all questionnaires, showing that all of them detected participants with pre-existing knowledge of dementia. Confirmatory factor analysis revealed a four-factor model for the DKAS-G and proposed the removal of 5 items. Floor and ceiling effects were found for the DKAT2-G and the KIDE-G, mainly among those who had previously participated in dementia training.

Conclusions

The DKAS-G was found to have the highest levels of reliability and validity. The results prove that the DKAS-G meets the requirements for measuring dementia knowledge and evaluating dementia training programs in health professionals, caregivers, and the general population.

Translation, cultural adaptation, and validation of Cognistat for its use in Arabic-speaking population with acquired brain injury

BACKGROUND

The use of cognitive assessment tools is central to the detection of cognitive impairment in acquired brain injury patients. Cognistat is a commonly used cognitive screening tool that can detect cognitive deficits among patients with neurological and psychiatric conditions. Cognistat examines different major ability areas including level of language, construction, memory, calculation, reasoning, consciousness, orientation and attention. To date, Cognistat has not been translated/adapted for use in Arabic-speaking countries.

AIM

The aim of this paper is to provide normative data for the use of Cognistat in Arabic-speaking populations with acquired brain injury.

DESIGN

Cross-cultural validation study.

SETTING

Inpatient TBI and stroke rehabilitation ward in a rehabilitation hospital.

POPULATION

A total of 107 healthy Arabic-speaking adults and 62 acquired brain injury patients were involved in the study.

METHODS

After the completion of the cross-cultural adaptation process, psychometric properties of the adapted cognitive tool were evaluated.

RESULTS

The Arabic version of Cognistat was found to have acceptable internal consistency, and the test-retest reliability showed high stability of scores over time. For concurrent validity, patients' performance on the Arabic version of Cognistat and the Mini-Mental State Examination were compared with excellent correlations overall. Significant differences between the performance of patients and the control group were found on all sub-tests.

CONCLUSIONS

The Arabic version of Cognistat appears to be a valid and reliable cognitive screening tool. It is anticipated that the Arabic version of Cognistat will be widely used in the Arabic-speaking countries, allowing for a very precise evaluation of cognitive deficits in acquired brain injury patients.

CLINICAL REHABILITATION IMPACT

As part of the rehabilitation process, health care professionals are regularly required to test patients' cognitive abilities using appropriate measures. The findings of the study provide key solutions for the clinical assessment of Arabic populations: such cognitive tools could help improve the cognitive rehabilitation practice for the Arabic population by offering validated, reliable, and culturally adapted tests in the Arabic language.

The illiterate brain and the neuropsychological assessment: From the past knowledge to the future new instruments

The lifetime learning of illiterate and low-educated individuals shapes their cognitive skills, which are challenging to grade by the current available neuropsychological tools. Eight hundred million of the global population are illiterate. It is very challenging to interpret the cognitive performance of this population by the available formal neuropsychological tests, mainly developed for higher educated people. From extensive literature investigation, we reviewed the cognitive process and performance of illiterate and low-educated population on various cognitive domains including language, executive function, memory, visual-related function, and motor skills. We also suggested the concept in the development of the appropriate tools for the cognitive assessment among this population. Finally, we provide the available cognitive screening tools validated in the illiterate and low-educated subjects within the last three decades.

Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations

BACKGROUND

The Mini Mental State Examination (MMSE) is a cognitive test that is commonly used as part of the evaluation for possible dementia.

OBJECTIVES

To determine the diagnostic accuracy of the Mini-Mental State Examination (MMSE) at various cut points for dementia in people aged 65 years and over in community and primary care settings who had not undergone prior testing for dementia.

SEARCH METHODS

We searched the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), LILACS (BIREME), ALOIS, BIOSIS previews (Thomson Reuters Web of Science), and Web of Science Core Collection, including the Science Citation Index and the Conference Proceedings Citation Index (Thomson Reuters Web of Science). We also searched specialised sources of diagnostic test accuracy studies and reviews: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). We attempted to locate possibly relevant but unpublished data by contacting researchers in this field. We first performed the searches in November 2012 and then fully updated them in May 2014. We did not apply any language or date restrictions to the electronic searches, and we did not use any methodological filters as a method to restrict the search overall.

SELECTION CRITERIA

We included studies that compared the 11-item (maximum score 30) MMSE test (at any cut point) in people who had not undergone prior testing versus a commonly accepted clinical reference standard for all-cause dementia and subtypes (Alzheimer disease dementia, Lewy body dementia, vascular dementia, frontotemporal dementia). Clinical diagnosis included all-cause (unspecified) dementia, as defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); International Classification of Diseases (ICD) and the Clinical Dementia Rating.

DATA COLLECTION AND ANALYSIS

At least three authors screened all citations.Two authors handled data extraction and quality assessment. We performed meta-analysis using the hierarchical summary receiver-operator curves (HSROC) method and the bivariate method.

MAIN RESULTS

We retrieved 24,310 citations after removal of duplicates. We reviewed the full text of 317 full-text articles and finally included 70 records, referring to 48 studies, in our synthesis. We were able to perform meta-analysis on 28 studies in the community setting (44 articles) and on 6 studies in primary care (8 articles), but we could not extract usable 2 x 2 data for the remaining 14 community studies, which we did not include in the meta-analysis. All of the studies in the community were in asymptomatic people, whereas two of the six studies in primary care were conducted in people who had symptoms of possible dementia. We judged two studies to be at high risk of bias in the patient selection domain, three studies to be at high risk of bias in the index test domain and nine studies to be at high risk of bias regarding flow and timing. We assessed most studies as being applicable to the review question though we had concerns about selection of participants in six studies and target condition in one study.The accuracy of the MMSE for diagnosing dementia was reported at 18 cut points in the community (MMSE score 10, 14-30 inclusive) and 10 cut points in primary care (MMSE score 17-26 inclusive). The total number of participants in studies included in the meta-analyses ranged from 37 to 2727, median 314 (interquartile range (IQR) 160 to 647). In the community, the pooled accuracy at a cut point of 24 (15 studies) was sensitivity 0.85 (95% confidence interval (CI) 0.74 to 0.92), specificity 0.90 (95% CI 0.82 to 0.95); at a cut point of 25 (10 studies), sensitivity 0.87 (95% CI 0.78 to 0.93), specificity 0.82 (95% CI 0.65 to 0.92); and in seven studies that adjusted accuracy estimates for level of education, sensitivity 0.97 (95% CI 0.83 to 1.00), specificity 0.70 (95% CI 0.50 to 0.85). There was insufficient data to evaluate the accuracy of the MMSE for diagnosing dementia subtypes.We could not estimate summary diagnostic accuracy in primary care due to insufficient data.

AUTHORS' CONCLUSIONS

The MMSE contributes to a diagnosis of dementia in low prevalence settings, but should not be used in isolation to confirm or exclude disease. We recommend that future work evaluates the diagnostic accuracy of tests in the context of the diagnostic pathway experienced by the patient and that investigators report how undergoing the MMSE changes patient-relevant outcomes.

Evaluation of the cholinergic hypothesis in Alzheimer's disease with neuropsychological methods

AIM

This study aimed at evaluating the cholinergic hypothesis in Alzheimer's disease (AD) patients utilizing the pupillometry method, cognitive tests and Hamilton Depression Rating Scale (HAM-D), as well as to examine whether a correlation between cognitive tests and pupillometry exists.

METHODS

Forty-two patients with mean age 69.2 ± 7.0 years and documented AD volunteered to participate in this study, while 33 healthy matched subjects served as controls. All subjects underwent a pupillometric measurement and performed the Wechsler Memory Scale (WMS) and Mini Mental State Examination (MMSE). Also, HAM-D was used to assess the severity of depressive symptoms. The pupillometric parameters studied were (1) latency for the onset of constriction (T1), (2) maximum constriction velocity (VCmax), and (3) maximum constriction acceleration (ACmax).

RESULTS

In AD patients MMSE and WMS score were correlated with ACmax (r = -0.409, p < 0.05 and r = -0.513, p < 0.05, respectively) and VCmax (r = -0.664, p < 0.05 and r = -0.771, p < 0.05), respectively. Moreover, T1 was found to be significantly increased by 23 % (p < 0.05) in AD patients compared to healthy subjects. Conversely, the mean scores of VCmax and ACmax were significantly decreased in AD patients by 46 % (p < 0.05) and by 47 % (p < 0.05), respectively, as compared to healthy subjects. There was no significant difference between the two groups for HAM-D. Additionally, AD patients showed decreased score in WMS by 40 % (p < 0.05) and in MMSE by 28.5 % (p < 0.05) compared to healthy subjects. Of the indices that were studied VCmax and ACmax are governed mainly by the action of the Parasympathetic Nervous System.

CONCLUSIONS

The results of this study demonstrated that there is a correlation between cognitive tests and pupillometry in AD patients. Thus, pupillometry could be considered as a sensitive technique for the investigation of cholinergic deficits, which indirectly lead to memory and cognitive disorders in AD patients.

Cultural adaptation, standardization and clinical validity of the test your memory dementia screening instrument in Greek

BACKGROUND/AIMS

To adapt and standardize the Test Your Memory (TYM) dementia screening instrument in Greek.

METHODS

Normative data on the Greek version of the TYM were obtained from a community sample of 239 adults aged 21-92 years. Clinical validity was assessed in a cohort of 134 Neurology Clinic patients. Concurrent validity was examined through comparisons with the Mini-Mental State Examination (MMSE) and the Greek Everyday Function Scale.

RESULTS

Correlations between the TYM and the MMSE were 0.73 and 0.82 in the community and patient samples, respectively. Scores on both tests were moderately associated with everyday functional capacity. Using age- and education-corrected cutoff scores ranging from 26/50 to 45/50 points, the sensitivity of the TYM for Alzheimer's disease detection was found to be higher than that of the MMSE (0.82 vs. 0.70), although its specificity was lower (0.71 vs. 0.90).

CONCLUSION

Findings are consistent with previous reports in a variety of cultural settings supporting the potential utility of the TYM as a dementia screening tool.

Screening and case finding tools for the detection of dementia. Part I: evidence-based meta-analysis of multidomain tests

AIM

To evaluate the diagnostic accuracy of all brief multidomain alternatives to the Mini-Mental State Examination (MMSE) in the detection of dementia.

METHODS

A literature search, critical appraisal, and meta-analysis were conducted of robust diagnostic validity studies involving cognitive batteries. Twenty-nine distinct brief batteries were tested in 44 large-scale analyses. Twenty studies took place in specialist settings (11 in memory clinics and 9 in secondary care), ten studies were conducted in primary care, and 14 in the community.

RESULTS

In community settings with a low prevalence of dementia, short screening methods of no more than 10 minutes had an overall sensitivity of 72.0% (95% confidence interval [CI] = 60.4%-82.3%) and a specificity of 88.2% (95% CI = 83.0%-92.5%). The optimal individual tests were the Telephonic interview based on MSQ, Category fluency/Memory impairment screen-Telephonic interview and 6 item Cognitive Impairment Test (6-CIT), but data were limited by the absence of multiple independent confirmation for any individual test. In primary care where the prevalence of dementia is usually modest, the optimal individual tools were the Abbreviated mental test score/Mental status questionnaire (MSQ), and Prueba cognitive de leganes (PCL). Furthermore, the Abbreviated mental test score (AMTS) was superior to the MMSE for case finding, but for screening the MMSE was optimal. If length is not a major consideration, the MMSE may remain the best tool for primary care clinicians who want to rule in and rule out a diagnosis. In specialist settings where the prevalence of dementia is often high, the optimal individual tools were the DEMTECT, Montreal cognitive assessment (MOCA), Memory Alteration test, and MINI-COG. Two tools were potentially superior to the MMSE for rule in and rule out, namely the 6-CIT and MINI-COG. Only four analyses looked specifically at accuracy in early-stage dementia, and each showed at least equivalent diagnostic accuracy, suggesting these methods might be applicable to early identification.

CONCLUSION

A large number of alternatives to the MMSE have now been validated in large samples with favorable rule-in and rule-out accuracy. Evidence to date suggests for those wishing to use brief battery tests then the original MMSE or the AMTS should be considered in primary care and either the 6-CIT or the MINI-COG should be considered in specialist settings.

Cambridge Cognitive Examination: performance of healthy elderly Brazilians with low education levels

This study aimed to estimate the quartile distribution on the cognitive assessment of normal elderly with low education as measured by the Cambridge Cognitive Examination (CAMCOG). A sample of 292 elderly (> 65 years of age), screened for dementia and depression, were assessed using the CAMCOG. The CAMCOG scores of normal subjects (n = 206) were stratified according to age (65-69, 70-74, 75-79, > 80) and schooling (illiterate, 1-4, and > 5 years of formal education). Mean age was 72.8 (± 3.5) and mean schooling was 3.5 years (± 3). The mean score on the CAMCOG was 71 (± 12.7). The scores at the first quartile for illiterate/1-4 years of schooling were 58/62 (65-69 years), 52/63 (70-74 years), 48/67 (75-79 years) and 46/64 (> 80 years), respectively. There was a significant difference in the CAMCOG quartiles according to education and age. This study provides normative data on the CAMCOG of elderly people with low educational levels which may be clinically useful.

A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment

The MMSE is the most widely used cognitive test but its accuracy and clinical utility in diagnosing cognitive disorders is not fully known. A meta-analysis of 34 dementia studies and five mild cognitive impairment (MCI) studies was conducted, separated into high and low prevalence settings. In memory clinic settings the MMSE had a pooled sensitivity (Se) of 79.8%, a specificity (Sp) of 81.3%, a positive predictive value (PPV) of 86.3% and a negative predictive value (NPV) of 73.0%. In mixed specialist hospital settings the Se, Sp, PPV and NPV were 71.1%, 95.6%, 94.2% and 76.4%, respectively. In non-clinical community settings the MMSE had a pooled Se of 85.1%, a Sp of 85.5%, a PPV of 34.5% and an NPV of 98.5%. In those studies conducted purely in primary care the Se, Sp, PPV and NPV were 78.4%, 87.8%. 53.6% and 95.7%, respectively. Thus the case-finding ability of the MMSE was best when confirming a suspected diagnosis in specialist settings with correct identification made in 27/30 positive results. It was modestly effective at ruling-out dementia in specialist settings. Conversely, in non-specialist settings, the MMSE was best at ruling out dementia, achieving about 29/30 correct reassurances with less than three false negatives out of every 100 screens. Regarding use of the MMSE in identifying MCI, limited evidence was found with only five robust studies comparing MCI with healthy subjects and three comparing Alzheimer's disease with MCI. Provisionally, the MMSE had very limited value in making a diagnosis of MCI against healthy controls and modest rule-out accuracy. It had similarly limited ability to help identify cases of Alzheimer's disease against MCI. In conclusion the MMSE offers modest accuracy with best value for ruling-out a diagnosis of dementia in community and primary care. For all other used it should be combined with or replaced by other methods.

Validation of the Cognitive Assessment of Later Life Status (CALLS) instrument: a computerized telephonic measure

BACKGROUND

Brief screening tests have been developed to measure cognitive performance and dementia, yet they measure limited cognitive domains and often lack construct validity. Neuropsychological assessments, while comprehensive, are too costly and time-consuming for epidemiological studies. This study's aim was to develop a psychometrically valid telephone administered test of cognitive function in aging.

METHODS

Using a sequential hierarchical strategy, each stage of test development did not proceed until specified criteria were met. The 30 minute Cognitive Assessment of Later Life Status (CALLS) measure and a 2.5 hour in-person neuropsychological assessment were conducted with a randomly selected sample of 211 participants 65 years and older that included equivalent distributions of men and women from ethnically diverse populations.

RESULTS

Overall Cronbach's coefficient alpha for the CALLS test was 0.81. A principal component analysis of the CALLS tests yielded five components. The CALLS total score was significantly correlated with four neuropsychological assessment components. Older age and having a high school education or less was significantly correlated with lower CALLS total scores. Females scored better overall than males. There were no score differences based on race.

CONCLUSION

The CALLS test is a valid measure that provides a unique opportunity to reliably and efficiently study cognitive function in large populations.

Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study

CONTEXT

The Mini-Mental State Examination (MMSE) is commonly used as a screening tool to detect dementia. However, it performs poorly in identifying persons with mild neurocognitive disorder. The Saint Louis University Mental Status (SLUMS) examination is a 30-point screening questionnaire that tests for orientation, memory, attention, and executive functions.

OBJECTIVE

The objective of this study was to compare SLUMS and the MMSE for detecting dementia and mild neurocognitive disorder (MNCD) using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.

METHODS

Patients at the Veterans' Affairs Geriatric Research, Education and Clinical Center, St. Louis, MO (N = 702) were clinically classified as having normal cognitive functioning, MNCD, or dementia based on DSM-IV criteria. The SLUMS and MMSE were administered for comparison.

RESULTS

Mean age was 75.3 years (standard deviation: 5.5). Regarding education, 62.4% of the sample had at least completed high school and 30.6% had not. Sensitivity and specificity were calculated and receiver operator curves (ROCs) generated for SLUMS and MMSE as a function of diagnosis (MCND versus dementia) and education. Both the SLUMS and MMSE produced acceptable ROCs for the diagnosis of dementia, but the ROCs for SLUMS were better than the MMSE for the diagnosis of MNCD in both education groups.

CONCLUSION

These results suggest that the SLUMS and MMSE have comparable sensitivities, specificities, and area under the curve in detecting dementia. Although the definition of MNCD is controversial, the authors believe that the SLUMS is possibly better at detecting mild neurocognitive disorder, which the MMSE failed to detect, but this needs to be further investigated.

Prevalence of dementia and Alzheimer's disease in elders of nursing homes and a senior center of Durango City, Mexico

BACKGROUND

Epidemiological reports about dementia and Alzheimer's disease (AD) in elderly people from developing countries are scarce. Therefore, we sought to determine the prevalences of dementia and AD in a population of nursing home residents and senior center attendees of Durango City, Mexico, and to determine whether any socio-demographic characteristics from the subjects associated with dementia or AD exist.

METHODS

One hundred and fifty-five residents of two nursing homes and 125 attendees of a senior center were examined for dementia and Alzheimer's disease. All subjects were tested by the mini-mental state examination, and those who scored twenty-four or less underwent psychiatric and neurological evaluations. Diagnosis of dementia, AD and vascular dementia (VaD) was based on the DSM-IV criteria. Socio-demographic characteristics from each participant were also obtained.

RESULTS

Residents of nursing homes found to suffer from dementia were 25 out of 155 (16.1%). Eighteen of them (11.6%) had AD, and seven (4.5%) had VaD. None of the attendees of the senior center suffered from dementia. Dementia (pooled AD and VaD cases) correlated with white ethnicity (OR = 3.2; 95%CI = 1.28-8.31), and a history of unemployment (OR = 6.46; 95%CI = 1.42-25.97), while AD correlated with journeymen occupations (OR = 4.55; 95%CI = 1.00-19.29).

CONCLUSION

Prevalence of dementia in residents of nursing homes found in this study is much lower than reported from more industrialized countries. AD was more frequent than VaD. Ethnicity and occupation showed effects on the prevalence figures. The prevalence of dementia found has implications for the optimum kind of health care that nursing homes should provide to their residents.

Special characteristics affecting the neuropsychologic assessment of the elderly in Greece

An important element in the diagnostic approach to psychogeriatric patients is the neuropsychologic assessment. Most instruments have been developed in the United States or the United Kingdom, but their appropriateness for culturally different populations is still an open question. Validation studies in Greece revealed certain difficulties both for the Mini-Mental State Examination and the Cambridge Cognitive Examination for the Elderly. These results were probably due to the functional illiteracy of elderly people in Greece, the coexistence of mood disorders, restricted access to news over past decades, and low levels of cooperation between the subject and the examiner The need for a more suitable diagnostic instrument for this kind of population led to the development of the Epidemiological Dementia Index. Data from developing countries support the possibility that research results from Europe and the United States are not directly applicable to the whole world; thus, the need for data from non-English speaking countries is evergrowing. Our understanding of psychogeriatric disorders in the developing world is like an iceberg: The larger portion is hidden because of the lack of relevant data.

Changes in pupil reaction to light in Alzheimer's disease patients: a preliminary report

The aim of this preliminary study was to compare the pupil reaction to light in Alzheimer's disease (AD) patients before and after treatment and in normal controls. Ten AD patients diagnosed according to DSM-IV and NINCDS-ADRDA criteria (five medication-free and five under anticholinesterase treatment) and five age- and gender-matched controls took part in the study. Drug-free patients and all control subjects were free of any medication for at least four weeks. An optical method was used to assess the pupil reaction to a single flash. Medication-free AD patients manifested shorter latency and lower amplitude of maximum response to light in comparison to controls. These findings are in agreement with the presence of a cholinergic deficit in AD patients. Pharmacological treatment with donepezil, which is an anticholinesterase agent partially improves this deficit. The results of this preliminary investigation suggest that dynamic pupillometry could be a useful adjunct to assist the diagnosis of early AD, and the differential diagnosis between different types of dementia. AD patients seem to manifest a specific pattern of pupil reaction to light, and some characteristics of this pattern are detectable even in patients receiving anticholinesterase medication. However, this is only a preliminary report and further research is mandatory.