[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.

Effectiveness and costs of phototest in dementia and cognitive impairment screening.

BACKGROUND: To assess and compare the effectiveness and costs of Phototest, Mini Mental State Examination (MMSE), and Memory Impairment Screen (MIS) to screen for dementia (DEM) and cognitive impairment (CI). METHODS: A phase III study was conducted over one year in consecutive patients with suspicion of CI or DEM at four Primary Care (PC) centers. After undergoing all screening tests at the PC center, participants were extensively evaluated by researchers blinded to screening test results in a Cognitive-Behavioral Neurology Unit (CBNU). The gold standard diagnosis was established by consensus of expert neurologists. Effectiveness was assessed by the proportion of correct diagnoses (diagnostic accuracy [DA]) and by the kappa index of concordance between test results and gold standard diagnoses. Costs were based on public prices and hospital accounts. RESULTS: The study included 140 subjects (48 with DEM, 37 with CI without DEM, and 55 without CI). The MIS could not be applied to 23 illiterate subjects (16.4%). For DEM, the maximum effectiveness of the MMSE was obtained with different cutoff points as a function of educational level [k = 0.31 (95% Confidence interval [95%CI], 0.19-0.43), DA = 0.60 (95%CI, 0.52-0.68)], and that of the MIS with a cutoff of 3/4 [k = 0.63 (95%CI, 0.48-0.78), DA = 0.83 (95%CI, 0.80-0.92)]. Effectiveness of the Phototest [k = 0.71 (95%CI, 0.59-0.83), DA = 0.87 (95%CI, 0.80-0.92)] was similar to that of the MIS and higher than that of the MMSE. Costs were higher with MMSE (275.9 ± 193.3€ [mean ± sd euros]) than with Phototest (208.2 ± 196.8€) or MIS (201.3 ± 193.4€), whose costs did not significantly differ. For CI, the effectiveness did not significantly differ between MIS [k = 0.59 (95%CI, 0.45-0.74), DA = 0.79 (95%CI, 0.64-0.97)] and Phototest [k = 0.58 (95%CI, 0.45-0.74), DA = 0.78 (95%CI, 0.64-0.95)] and was lowest for the MMSE [k = 0.27 (95%CI, 0.09-0.45), DA = 0.69 (95%CI, 0.56-0.84)]. Costs were higher for MMSE (393.4 ± 121.8€) than for Phototest (287.0 ± 197.4€) or MIS (300.1 ± 165.6€), whose costs did not significantly differ. CONCLUSION: MMSE is not an effective instrument in our setting. For both DEM and CI, the Phototest and MIS are more effective and less costly, with no difference between them. However, MIS could not be applied to the appreciable percentage of our population who were illiterate.

Utility of the mini-cog for detection of cognitive impairment in primary care: data from two spanish studies.

Objectives. To study the utility of the Mini-Cog test for detection of patients with cognitive impairment (CI) in primary care (PC). Methods. We pooled data from two phase III studies conducted in Spain. Patients with complaints or suspicion of CI were consecutively recruited by PC physicians. The cognitive diagnosis was performed by an expert neurologist, after formal neuropsychological evaluation. The Mini-Cog score was calculated post hoc, and its diagnostic utility was evaluated and compared with the utility of the Mini-Mental State (MMS), the Clock Drawing Test (CDT), and the sum of the MMS and the CDT (MMS + CDT) using the area under the receiver operating characteristic curve (AUC). The best cut points were obtained on the basis of diagnostic accuracy (DA) and kappa index. Results. A total sample of 307 subjects (176 CI) was analyzed. The Mini-Cog displayed an AUC (±SE) of 0.78 ± 0.02, which was significantly inferior to the AUC of the CDT (0.84 ± 0.02), the MMS (0.84 ± 0.02), and the MMS + CDT (0.86 ± 0.02). The best cut point of the Mini-Cog was 1/2 (sensitivity 0.60, specificity 0.90, DA 0.73, and kappa index 0.48 ± 0.05). Conclusions. The utility of the Mini-Cog for detection of CI in PC was very modest, clearly inferior to the MMS or the CDT. These results do not permit recommendation of the Mini-Cog in PC.

Diagnostic accuracy, effectiveness and cost for cognitive impairment and dementia screening of three short cognitive tests applicable to illiterates.

BACKGROUND: Illiteracy, a universal problem, limits the utilization of the most widely used short cognitive tests. Our objective was to assess and compare the effectiveness and cost for cognitive impairment (CI) and dementia (DEM) screening of three short cognitive tests applicable to illiterates. METHODS: Phase III diagnostic test evaluation study was performed during one year in four Primary Care centers, prospectively including individuals with suspicion of CI or DEM. All underwent the Eurotest, Memory Alteration Test (M@T), and Phototest, applied in a balanced manner. Clinical, functional, and cognitive studies were independently performed in a blinded fashion in a Cognitive Behavioral Neurology Unit, and the gold standard diagnosis was established by consensus of expert neurologists on the basis of these results. Effectiveness of tests was assessed as the proportion of correct diagnoses (diagnostic accuracy [DA]) and the kappa index of concordance (k) with respect to gold standard diagnoses. Costs were based on public prices at the time and hospital accounts. RESULTS: The study included 139 individuals: 47 with DEM, 36 with CI, and 56 without CI. No significant differences in effectiveness were found among the tests. For DEM screening: Eurotest (k = 0.71 [0.59-0.83], DA = 0.87 [0.80-0.92]), M@T (k = 0.72 [0.60-0.84], DA = 0.87 [0.80-0.92]), Phototest (k = 0.70 [0.57-0.82], DA = 0.86 [0.79-0.91]). For CI screening: Eurotest (k = 0.67 [0.55-0.79]; DA = 0.83 [0.76-0.89]), M@T (k = 0.52 [0.37-0.67]; DA = 0.80 [0.72-0.86]), Phototest (k = 0.59 [0.46-0.72]; DA = 0.79 [0.71-0.86]). There were no differences in the cost of DEM screening, but the cost of CI screening was significantly higher with M@T (330.7 ± 177.1 €, mean ± sd) than with Eurotest (294.1 ± 195.0 €) or Phototest (296.0 ± 196. 5 €). Application time was shorter with Phototest (2.8 ± 0.8 min) than with Eurotest (7.1 ± 1.8 min) or M@T (6.8 ± 2.2 min). CONCLUSIONS: Eurotest, M@T, and Phototest are equally effective. Eurotest and Phototest are both less expensive options but Phototest is the most efficient, requiring the shortest application time.

Efectividad del Mini-Mental en la detección del deterioro cognitivo en Atención Primaria / Effectiveness of the Mini-Mental State for detection of cognitive impairment in Primary Care

Objetivo: Evaluar la utilidad diagnóstica (UD) del Mini-Mental (MMS) en la detección del deterioro cognitivo (DC) en Atención Primaria (AP) y determinar las mejores condiciones de aplicación para este fin. Diseño: Análisis conjunto de 2 estudios de evaluación de pruebas diagnósticas prospectivos con selección consecutiva y sistemática, verificación completa y doble cegamiento, realizados en Madrid y Granada. Emplazamiento: El MMS fue aplicado en AP y el diagnóstico de referencia en Atención Especializada. Participantes: Se seleccionaron de forma consecutiva y sistemática sujetos con quejas o sospecha de DC atendidos en AP. Mediciones principales: La UD del MMS se evaluó mediante el área bajo la curva ROC (AUC) y se consideró mejor punto de corte el que ofrecía la mayor tasa de aciertos diagnósticos (TAD) y el mayor índice kappa. Se analizó de forma independiente la UD para las puntuaciones directas (MMSd) y ajustadas por edad y nivel educativo (MMSa). Resultados: En la muestra total de 360 sujetos (214 DC), la UD de MMSd fue significativamente superior a la de MMSa (0,84 ± 0,02 vs 0,82 ± 0,02, p ≤ 0,001). El rendimiento diagnóstico conseguido por el MMSd con el mejor punto de corte (22/23) fue discreto (TAD 0,77, kappa 0,52 ± 0,05), pero no fue mejorado por ningún punto de corte del MMSa. Conclusión: El Mini-Mental tiene una UD discreta para la detección de DC en AP que no mejora con la corrección de las puntuaciones por edad y nivel educativo; el mejor punto de corte es 22/23, inferior al habitualmente recomendado (AU)

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 (AU)

Oftalmoplejía dolorosa recurrente secundaria a displasia fibrosa poliostótica del seno maxilar con afectación de la hendidura esfenoidal / Recurrent painful ophthalmoplegia secondary to polyostotic fibrous dysplasia of the maxillary sinuses with involvement of the superior orbital fissure

Introducción. La displasia fibrosa es una enfermedad ósea benigna que suele cursar con lesiones asintomáticas pero que en ocasiones puede dar manifestaciones neurológicas por afectación de los huesos craneofaciales. Caso clínico. Mujer de 25 años, con antecedentes de migraña, que consultó a los 18 años por un cuadro de dolor en la región maxilar y retrocular derecha de características diferentes de las de su migraña habitual y que asocia oftalmoparesia ipsolateral; presenta un curso autolimitado con buena respuesta a corticoides, aunque recidivante. La exploración puso de manifiesto un intenso dolor a la palpación en el seno maxilar derecho y parálisis incompleta del III par craneal ipsolateral con ptosis palpebral. Los estudios complementarios fueron normales, salvo la resonancia magnética craneal y la tomografía axial computarizada facial, donde se evidenció una lesión expansiva con afectación del seno maxilar superior derecho y el ala mayor del esfenoides, con probable afectación de la hendidura esfenoidal, compatible con el diagnóstico de displasia fibrosa, que fue confirmado mediante estudio anatomopatológico. Conclusiones. La displasia fibrosa es un trastorno óseo benigno cuya etiología se desconoce y que consiste en la sustitución del tejido óseo normal por tejido conjuntivo amorfo. En ocasiones, existe afectación craneofacial y se forma una masa ósea hipertrófica que puede ocupar los senos paranasales y la órbita, y dar lugar a exoftalmos y alteraciones visuales. Hasta el momento, no se ha descrito en la bibliografía científica la manifestación de esta enfermedad en forma de brotes de oftalmoparesia dolorosa recurrente con respuesta a corticoides, como ocurre en nuestra paciente (AU)

Introduction. Fibrous dysplasia is a bone disease that is usually accompanied by asymptomatic lesions but which may sometimes display neurological manifestations due to the involvement of the craniofacial bones. Case report. A 25-year-old female, with a history of migraines, who visited at the age of 18 due to pain in the right retro-ocular and maxillary region, although with characteristics that were unlike those of her usual migraines, and which was associated with ipsilateral ophthalmoparesis. The condition had a self-limiting course and responded well to corticoids, although it was recurring. Examination revealed intense pain on palpation of the right-hand maxillary sinus and incomplete paralysis of the ipsilateral oculomotor nerve with palpebral ptosis. Results of complementary studies were normal, except for magnetic resonance imaging of the head and computerised axial tomography of the face, which revealed an expansive lesion with involvement of the right superior maxillary sinus and the greater wing of the sphenoid bone, with probable compromise of the superior orbital fissure, consistent with the diagnosis of fibrous dysplasia, which was confirmed by means of a pathology study. Conclusions. Fibrous dysplasia is a benign bone disorder, of unknown causation, in which normal bone tissue is replaced by amorphous conjunctive tissue. There is sometimes craniofacial involvement and a hypertrophic bone mass is formed which can fill the paranasal sinuses and the orbit, resulting in exophthalmus and visual disorders. To date the scientific literature does not include any reports of this disease manifesting as bouts of recurrent painful ophthalmoparesis which responds to corticoids, as happened in the case of our patient (AU)