Establishing the limits of the Mini-Mental State. Examination of 'subtests'.

It has been suggested that the Mini-Mental State examination can be used to examine a patient's cognitive profile. We therefore examined the validity of Mini-Mental State subtests and individual items. The memory item, attention-concentration items, and constructional item had satisfactory sensitivity-specificity and correlated significantly with scores on neuropsychological tests. In contrast, four of the five Mini-Mental State language items had very low sensitivity, and three of five failed to correlate with neuropsychological test scores. These findings establish limits with regard to the ability of the Mini-Mental State to generate a cognitive profile. Our data also provide information regarding validity, difficulty level, and optimal cutoff scores for widely used mental status tasks.

Factors attenuating the validity of the Geriatric Depression Scale in a dementia population.

OBJECTIVE: The validity of the Geriatric Depression Scale (GDS) in cognitively impaired patients has been questioned. We investigated possible factors (memory loss, dementia severity, unawareness of illness) attenuating the validity of the GDS in patients with dementia. PATIENTS: Eighty-three patients who met research diagnostic criteria for "probable Alzheimer's disease." Subjects with major depressive disorder were excluded. Dementia severity ranged from mild to moderate. SETTING: Outpatient clinics, including institutional settings and private research settings. MEASUREMENTS: Depression--GDS; Hamilton Depression Scale. Memory--Wechsler Memory Scale; Benton Visual Retention Test. Dementia severity--Mini-Mental State Examination. Self-awareness of cognitive deficits--Difference score between a self-report memory questionnaire and an informant-rated memory questionnaire. RESULTS: Multiple regression analysis revealed that Hamilton scores were the major predictor of GDS scores. Memory scores and self-awareness scores were also significant predictors. Dementia severity scores were not a significant predictor. CONCLUSIONS: The GDS is a valid measure of mild-to-moderate depressive symptoms in Alzheimer patients with mild-to-moderate dementia. However, Alzheimer patients who disavow cognitive deficits also tend to disavow depressive symptoms, and the GDS should be used with caution in such patients. Finally, the argument that memory impairment precludes accurate self-report of recent mood is negated by our finding that many patients accurately reported depressive symptoms and that worse memory was associated with more self-reported depressive symptoms.

Memory self-report in Alzheimer's disease and in age-associated memory impairment.

We investigated memory self-report in Alzheimer's disease (AD) and age-associated memory impairment (AAMI). AD and AAMI patients and healthy elderly subjects were administered a self-report memory questionnaire, memory tests, a family-rated memory questionnaire, and a depression scale. The AD group reported worse memory than the control group, but many individual AD subjects reported normal memory. This finding confirms clinical observations that unawareness of memory loss is common in AD but variable across patients. Multiple regression analysis revealed that worse memory self-ratings were associated with greater dementia severity and higher depression scores. In the AAMI group, memory self-ratings were predicted by family ratings of memory ability but not by memory test scores. There was a nonsignificant trend for depression scores to predict memory self-ratings. Finally, level of self-reported memory ability did not differ for AD and AAMI, contradicting clinical lore that memory complaint is a useful diagnostic indicator.

Progressive nonfluent aphasia with dementia: a case report.

We report a patient with progressive nonfluent aphasia and mild dementia. On 9-month follow-up evaluation, there was significant deterioration in both language and cognition. Unlike in Alzheimer's disease, the aphasia was of the Broca's type. In contrast with primary progressive aphasia, a dementia was present and the cognitive and language decline showed a rather rapid course.

Other neurologic diseases with dementia as a sequela.

Less-common causes of dementia are briefly discussed. Disorders covered include Pick's disease, primary progressive aphasia, progressive supranuclear palsy, Huntington's disease, olivopontocerebellar atrophies, closed head injury, dementia pugilistica, and Creutzfeldt-Jakob disease. Pseudodementia is also discussed. These disorders are compared and contrasted with the more common etiologies of dementia that are reviewed in other articles in the issue. Topics covered include treatment, differential diagnosis, clinical features, and pathogenesis.

Mental status assessment of insight and judgment.

Although a traditional part of the mental status examination, assessment of insight and judgment has received scant attention from researchers and clinicians. This is unfortunate, because few abilities are more crucial to decisions about whether a patient can continue to live independently or what level of supervision is needed. The authors discuss current and evolving methods for the assessment of insight and judgment, and also address neuroanatomic substrates and theoretical conceptions of these functions.

Recurrent fluent aphasia associated with a seizure focus.

The relationship between dominant hemisphere seizure activity and aphasia is unclear. Although speech arrest, expressive speech problems, and comprehension difficulties have often been associated with temporal lobe seizure activity, neologistic, paraphasic speech is rare. We report a patient with seizures following encephalitis who had recurrent episodes of fluent, severely aphasic speech with impaired comprehension which correlated with continuous, high voltage spike and slow wave activity in the left temporal region. During a several-day period of intermittent electrographic seizure activity, he had fluctuating receptive aphasia, and he developed transient paranoid psychosis following treatment. We discuss the behavioral manifestations of his left temporal seizures and correlate the changing nature of his behavior with therapeutic interventions. This case, as well as a review of others, suggests that paroxysmal fluent aphasia results from a partially treated electrographic seizure focus in the dominant temporal lobe.

Assessment of memory complaint in age-associated memory impairment: the MAC-Q.

Few brief self-report memory questionnaires are available, and non has been well validated. We designed a brief questionnaire, the MAC-Q, to assess age-related memory decline. Validity and reliability of the MAC-Q were assessed in 232 subjects meeting diagnostic criteria for age-associated memory impairment (AAMI). Concurrent validity of the MAC-Q was supported by a significant correlation (r = .41, p < .001) with a lengthy, well-validated memory questionnaire. Multiple regression analysis indicated that memory test scores were significant predictors of MAC-Q scores. MAC-Q scores were not predicted by Hamilton Depression Scale scores, suggesting that memory complaint in AAMI is not related to affective status. Internal consistency and test-retest reliability of the MAC-Q were satisfactory. Our data support the validity and reliability of the MAC-Q, a new brief memory questionnaire. The MAC-Q is of particular relevance to the assessment of AAMI, but should also prove useful in any clinical or research setting requiring a brief index of memory complaint.

Baylor profound mental status examination: a brief staging measure for profoundly demented Alzheimer disease patients.

There is no brief patient-derived rating scale for staging and following profoundly demented Alzheimer disease (AD) patients. We developed the Baylor Profound Mental Status Examination (BPMSE) modeled after the Mini-Mental State Examination (MMSE) to meet this need. The BPMSE consists of 25 cognitive questions that assess orientation, language, attention, and motor functioning; 10 examiner ratings of presence or absence of problem behaviors; and 2 qualitative observations of language and social interaction. Two hundred eight probable or possible AD patients (MMSE scores of 20 or less) received the BPMSE. Some were also rated on the clinical dementia rating (CDR) and Lawton activities of daily living (ADL). A ceiling effect occurred at MMSE scores above 11. BPMSE cognitive scores and MMSE scores correlated significantly (r = 0.76, p < 0.0001). Subareas of the BPMSE also intercorrelated significantly. The BPMSE correlated with both CDR and ADL scores (p < 0.001). Internal consistency, interrater reliability, and test-retest stability were excellent. There was no floor effect, and BPMSE scores continued to decline after the MMSE reached 0. The BPMSE is a quick and easy staging tool with excellent validity and test-retest stability that measures cognitive function successfully in patients with MMSE scores below 12. The scale is sensitive to longitudinal change and continues to assess decline when performance has reached the lowest levels on conventional measures.