Practical application of brief cognitive tests.

INTRODUCTION: Brief cognitive tests (BCT) may help detect cognitive impairment (CI) in the clinical setting. Several BCT have been developed and/or validated in our country, but we lack specific recommendations for use. DEVELOPMENT: Review of studies on the diagnostic accuracy of BCT for CI, using studies conducted in Spain with BCT which take less than 20 min. We provide recommendations of use based on expert consensus and established on the basis of BCT characteristics and study results. CONCLUSION: The Fototest, the Memory Impairment Screen (MIS) and the Mini-Mental State Examination (MMSE) are the preferred options in primary care; other BCT (Clock Drawing Test [CDT], test of verbal fluency [TVF]) may also be administered in cases of negative results with persistent suspected CI or concern (stepwise approach). In the specialised care setting, a systematic assessment of the different cognitive domains should be conducted using the Montreal Cognitive Assessment, the MMSE, the Rowland Universal Dementia Assessment, the Addenbrooke's Cognitive Examination, or by means of a stepwise or combined approach involving more simple tests (CDT, TVF, Fototest, MIS, Memory Alteration Test, Eurotest). Associating an informant questionnaire (IQ) with the BCT is superior to the BCT alone for the detection of CI. The choice of instruments will depend on the patient's characteristics, the clinician's experience, and available time. The BCT and IQ must reinforce - but never substitute - clinical judgment, patient-doctor communication, and inter-professional dialogue.

Should the mini-mental state examination be retired?

INTRODUCTION: Short cognitive tests are routinely used in clinical practice to detect and screen for cognitive impairment and dementia. These cognitive tests should meet minimum criteria for both applicability and psychometric qualities. DEVELOPMENT: The Mini-Mental State Examination (MMSE) is the most frequently applied short cognitive test, and the article introducing it remains a milestone in the history of medicine. Its main advantages are its widespread use and the extensive empirical evidence that supports it. However, the MMSE has important shortcomings, including lack of standardisation, its lack of suitability for illiterate subjects, the considerable effect of socio-educational variables on results, and its limited effectiveness for detecting cognitive impairment. Lastly, since the test is copyright-protected, using it is necessarily either costly or fraudulent. Newer available instruments do not share these shortcomings and have demonstrated greater diagnostic accuracy for detecting cognitive impairment and dementia, as well as being more cost-effective than the MMSE CONCLUSION: It is time to acknowledge the MMSE's important role in the history of medicine and grant it a deserved and honourable retirement. Its place will be taken by more effective instruments that require less time, are user-friendly and free of charge, can be applied to all individuals, and yield more equitable outcomes.

[Effectiveness of the Mini-Mental State for detection of cognitive impairment in primary care]. / Efectividad del Mini-Mental en la detección del deterioro cognitivo en Atención Primaria.

OBJECTIVE: To evaluate the diagnostic accuracy (DA) of the Mini-Mental State (MMS) for the detection of cognitive impairment (CI) in Primary Care (PC) and to determine the best conditions of use for that purpose. DESIGN: Pooled analysis of two prospective, double blind, studies on the evaluation of diagnostic tools with complete verification that were conducted in Madrid and Granada (Spain). SETTING: The MMS was administered in PC and the final cognitive diagnosis (gold standard) was made in Specialized Care. PARTICIPANTS: Subjects with cognitive complaints or suspected of having CI were consecutively recruited in the PC clinic. PRINCIPAL MEASURES: The DA of the MMS was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). The best cut-off point was selected according to the ratio of cases correctly classified (RCC) and to the kappa index. Direct (MMSd) and age- and education-adjusted (MMSa) total scores were analyzed separately. RESULTS: In the total sample of 360 subjects (214 CI), the DA of the MMSd was significantly superior to that of the MMSa (0.84±0.02 vs 0.82±0.02, p≤.001). The yield obtained by the best cut-off point of the MMSd (22/23) was modest (RCC 0.77, kappa 0.52±0.05) and was not improved by any MMSa cut-off point. CONCLUSION: The DA of the MMS for detection of CI in PC was modest and did not improve with adjustment of the score by age and education. The best cut-off point was 22/23, inferior to the usually recommended cut-off.

Diagnostic performance of brief cognitive tests in cognitive impairment screening.

INTRODUCTION AND OBJECTIVES: This study aims to assess and compare the diagnostic performance of brief cognitive tests for cognitive impairment (CI) screening recommended by the Spanish guidelines for the integral care of people with Alzheimer's disease and other dementias. MATERIAL AND METHODS: We performed a phase iii study into the accuracy of diagnostic tests, including patients with suspected CI in a primary care setting. All patients completed the Mini-Mental State Examination (MMSE), the Mini Examen Cognoscitivo (MEC), the Short Portable Mental Status Questionnaire (SPMSQ), the Memory Impairment Screen (MIS), the Clock Drawing Test (CDT), the Eurotest, the Fototest, and the Memory Alteration Test (M@T). CI was diagnosed independently by researchers blinded to scores on these tests. Diagnostic performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC). RESULTS: The study included 141 individuals (86 with CI). The Eurotest and M@T (AUC±SE: 0.91±0.02 and 0.90±0.02, respectively) took longer to administer (mean [SD]: 7.1 [1.8] and 6.8 [2.2]min, respectively) and have significantly better diagnostic performance compared to the MMSE, MEC, SPMSQ, and CDT, but not compared to MIS or Fototest (both with an AUC of 0.87±0.03), with the latter taking less than half as long to administer (2.8 [0.8]min). The M@T and MIS only evaluate memory, and the latter cannot be administered to illiterate people. CONCLUSION: The most advisable tests for CI screening in primary care are the Eurotest, M@T, and Fototest, with the latter being the most efficient as it takes half as long to administer.

Normative data for the Fototest from neurological patients with no cognitive impairment.

OBJECTIVES: To contribute normative data for the Fototest from neurological patients with no cognitive impairment, including disaggregated data on each domain of the test (naming, free recall, total recall, and naming fluency). MATERIAL AND METHODS: We performed a cross-sectional study in which neurological patients with no cognitive impairment were tested with the Fototest; we recorded total and domain scores. We performed a descriptive study of the total and domain scores, with data disaggregated by sex, age (over/under 65 years), and level of education (primary education completed/not completed; further study completed). RESULTS: We included a sample of 1055 patients, who were mainly women (57.1%), aged over 65 (60.6%), and had a low level of education (38.6% had not completed primary education). Sex, age, and level of education influence total Fototest score (34.6 ±â€¯5.3; P10: 28; P5: 27) and free recall (8.5 ±â€¯2.2; 6; 4), total recall (10.0 ±â€¯1.5; 8; 7), and naming fluency scores (18.7 ±â€¯4.9; 13; 12). For total score, the multivariate analysis revealed values of 1.5 ±â€¯0.3 (ß ±â€¯SD) for sex (female), -2.4 ±â€¯0.3 for age (>65), and -1.6 ±â€¯0.4 and 3.3 ±â€¯0.4 for incomplete primary education and completed post-primary education, respectively (completed primary study was used as a reference). CONCLUSIONS: We provide normative data for total and domain Fototest results for each of the groups defined according to sex, age, and level of education. We also provide a percentile distribution of scores. We hope that these normative data will translate into increases in efficiency in Fototest administration in the clinical setting.

Brief cognitive tests as a decision-making tool in primary care. A population and validation study.

INTRODUCTION AND OBJECTIVES: Brief cognitive tests (BCT) are used in primary care (PC) for the detection of cognitive impairment (CI). Still, there are little data on their diagnostic utility (DU) in a community setting. This work evaluates the DU at the population level of Fototest, T@M, AD8 questionnaire and MMSE. It provides new cut-off points (CoP) validated in a CI early detection program. MATERIAL AND METHODS: In the population and validation samples, the evaluation was carried out in two phases, a first of screening and administration of BCT and a second of clinical diagnosis, blinded to the results of the BCT, applying the current NIA-AA criteria. The DU of BCT in the population sample was evaluated with the area under the ROC curve (aROC). Youden index and the CoP with the best specificity that ensured a sensitivity of 80% were used to decide on the most appropriate CoP. The sensitivity, specificity, and predictive values for these CoP were calculated in the validation sample. RESULTS: 260 participants (23.1% with CI) from the population sample and 177 (42.4% with CI) from the validation sample were included. The Fototest has the best UD at the population level (aROC 0.851), which improves with the combination of Fototest and AD8 (aROC 0.875). The proposed CoP are AD8 ≥ 1, Fototest ≤ 35, T@M ≤ 40, and MMSE ≤ 26. CONCLUSION: BCT are helpful in detecting CI in PC. This work supports the use of more demanding PoC.

Diagnostic performance of brief cognitive tests in cognitive impairment screening. / Utilidad diagnóstica de test cognitivos breves en el cribado de deterioro cognitivo.

INTRODUCTION AND OBJECTIVES: This study aims to assess and compare the diagnostic performance of brief cognitive tests for cognitive impairment (CI) screening recommended by the Spanish guidelines for the integral care of people with Alzheimer's disease and other dementias. MATERIAL AND METHODS: We performed a phase iii study into the accuracy of diagnostic tests, including patients with suspected CI in a primary care setting. All patients completed the Mini-Mental State Examination (MMSE), the Mini Examen Cognoscitivo (MEC), the Short Portable Mental Status Questionnaire (SPMSQ), the Memory Impairment Screen (MIS), the Clock Drawing Test (CDT), the Eurotest, the Fototest, and the Memory Alteration Test (M@T). CI was diagnosed independently by researchers blinded to scores on these tests. Diagnostic performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC). RESULTS: The study included 141 individuals (86 with CI). The Eurotest and M@T (AUC ± SE: 0.91 ± 0.02 and 0.90 ± 0.02, respectively) took longer to administer (mean [SD]: 7.1 [1.8] and 6.8 [2.2] min, respectively) and have significantly better diagnostic performance compared to the MMSE, MEC, SPMSQ, and CDT, but not compared to MIS or Fototest (both with an AUC of 0.87 ± 0.03), with the latter taking less than half as long to administer (2.8 [0.8] min). The M@T and MIS only evaluate memory, and the latter cannot be administered to illiterate people. CONCLUSION: The most advisable tests for CI screening in primary care are the Eurotest, M@T, and Fototest, with the latter being the most efficient as it takes half as long to administer.

Normative data for the Fototest from neurological patients with no cognitive impairment. / Valores normativos del Fototest en pacientes neurológicos sin deterioro cognitivo.

OBJECTIVES: To contribute normative data for the Fototest from neurological patients with no cognitive impairment, including disaggregated data on each domain of the test (naming, free recall, total recall, and naming fluency). MATERIAL AND METHODS: We performed a cross-sectional study in which neurological patients with no cognitive impairment were tested with the Fototest; we recorded total and domain scores. We performed a descriptive study of the total and domain scores, with data disaggregated by sex, age (over/under 65 years), and level of education (primary education completed/not completed; further study completed). RESULTS: We included a sample of 1,055 patients, who were mainly women (57.1%), aged over 65 (60.6%), and had a low level of education (38.6% had not completed primary education). Sex, age, and level of education influence total Fototest score (34.6 ± 5.3; P10: 28; P5: 27) and naming (5,9±0,3; 6; 5), free recall (8.5 ± 2.2; 6; 4), total recall (10.0 ± 1.5; 8; 7), and naming fluency scores (18.7 ± 4.9; 13; 12). For total score, the multivariate analysis revealed values of 1.5 ± 0.3 (ß ± SE) for sex (female), -2.4 ± 0.3 for age (> 65), and -1.6 ± 0.4 and 3.3 ± 0.4 for incomplete primary education and completed post-primary education, respectively (completed primary study was used as a reference). CONCLUSION: We provide normative data for total and domain Fototest results for each of the groups defined according to sex, age, and level of education. We also provide a percentile distribution of scores. We hope that these normative data will translate into increases in efficiency in Fototest administration in the clinical setting.