cognitive tests

Brief questionnaire for dementia progression validated

August, 2012

A new tool that should help in the managing of dementia symptoms is designed to be easily and quickly employed, and is a reliable and sensitive measure of dementia change (over 3 months).

Dementia is a progressive illness, and its behavioral and psychological symptoms are, for caregivers, the most difficult symptoms to manage. While recent research has demonstrated how collaborative care can reduce these symptoms and reduce stress for caregivers, the model requires continuous monitoring of the symptoms. What’s needed is a less arduous way of monitoring changes in symptoms.

A new questionnaire for assessing dementia progression has now been validated. The Healthy Aging Brain Care Monitor is simple, user-friendly and sensitive to change in symptoms. Its 31 items cover cognitive, functional, and behavioral and psychological symptoms of the patient, as well as caregiver quality of life, and takes about six minutes for a caregiver to complete.

Some of the specific items that may be of interest include:

  • Repeating the same things over and over
  • Forgetting the correct month or year
  • Handling finances
  • Planning, preparing or serving meals
  • Learning to use a tool, appliance, or gadget

You can see the full questionnaire at http://www.indydiscoverynetwork.org/HealthyAgingBrainCareMonitor.html. The HABC Monitor and scoring rules are available without charge.

The four factors (cognitive; functional; behavioral and psychological; caregiver quality of life) were all significantly correlated, with one exception: cognitive and caregiver quality of life.

The validating study involved 171 caregivers, of whom 52% were the children of the patients, 34% were spouses, 6% were siblings, and 4% were grandchildren. The participant group included 61% identifying as white, 38% African-American, and 1% other. Only 1% was Hispanic.

The study found good internal consistency (0.73–0.92); good correlations with the longer and more detailed Neuropsychiatric Inventory (NPI) total score and NPI caregiver distress score; and greater sensitivity to three-month change compared with NPI “reliable change” groups.

The value of this new clinical tool lies in its brevity. Described as a ‘blood pressure cuff’ for dementia symptoms, the one-page questionnaire is designed to fit into a health visit easily.

The researchers note some caveats, including the fact that it was validated in a memory care practice setting and not yet in a primary care setting, and (more importantly) only over a three-month period. Future projects will assess its sensitivity to change over longer periods, and in primary care.

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Identifying those with cognitive impairment

March, 2012

A brief questionnaire designed to identify those with Alzheimer’s has been found to be useful in also identifying those with MCI. A large study confirms the value of such tools but also points to their limitations

New data from the ongoing validation study of the Alzheimer's Questionnaire (AQ), from 51 cognitively normal individuals (average age 78) and 47 aMCI individuals (average age 74), has found that the AQ is effective in identifying not only those with Alzheimer’s but also those older adults with mild cognitive impairment.

Of particular interest is that four questions were strong indicators of aMCI. These related to:

  • repeating questions and statements,
  • trouble knowing the date or time,
  • difficulties managing finances, and
  • decreased sense of direction.

The AQ consists of 21 yes/no questions designed to be answered by a relative or carer. The questions fall into five categories: memory, orientation, functional ability, visuospatial ability, and language. Six of these questions are known to be predictive of AD and are given extra weighting, resulting in a score out of 27. A score above 15 was indicative of AD, and between 5 and 14 of aMCI. Scores of 4 or lower indicate that the person does not have significant memory problems.

The questionnaire is not of course definitive, but is intended as an indicator for further testing. Note, too, that all participants in this study were Caucasian.

The value and limitations of brief cognitive screenings

The value of brief cognitive screenings combined with offering further evaluation is demonstrated in a recent large VA study, which found that, of 8,342 Veterans aged 70+ who were offered screening (the three-minute Mini-Cog), 8,063 (97%) accepted, 2,081 (26%) failed the screen, and 580 (28%) agreed to further evaluation. Among those accepting further evaluation, 93% were found to have cognitive impairment, including 75% with dementia.

Among those who declined further evaluation, 17% (259/1,501) were diagnosed with incident cognitive impairment through standard clinical care. In total, the use of brief cognitive screenings increased the numbers with cognitive impairment to 11% (902/8,063) versus 4% (1,242/28,349) in similar clinics without this program.

Importantly, the limits of such questionnaires were also demonstrated: 118 patients who passed the initial screen nevertheless requested further evaluation, and 87% were found to have cognitive impairment, including 70% with dementia.

This should not be taken as a reason not to employ such cognitive tests! There are two points that should, I think, be taken from this:

  • Routine screening of older adults is undoubtedly an effective strategy for identifying those with cognitive impairment.
  • Individuals who pass such tests but nevertheless believe they have cognitive problems should be taken seriously.

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Which 'Senior moments' may signal mental decline

October, 2011

A very large survey of older women indicates which type of memory difficulties may signal age-related cognitive impairment possibly leading to dementia.

A telephone survey of around 17,000 older women (average age 74), which included questions about memory lapses plus standard cognitive tests, found that getting lost in familiar neighborhoods was highly associated with cognitive impairment that might indicate Alzheimer’s. Having trouble keeping up with a group conversation and difficulty following instructions were also significantly associated with cognitive impairment. But, as most of us will be relieved to know, forgetting things from one moment to the next was not associated with impairment!

Unsurprisingly, the more memory complaints a woman had, the more likely she was to score poorly on the cognitive test.

The 7 memory lapse questions covered:

  • whether they had recently experienced a change in their ability to remember things,
  • whether they had trouble remembering a short list of items (such as a shopping list),
  • whether they had trouble remembering recent events,
  • whether they had trouble remembering things from one second to the next,
  • whether they had difficulty following spoken or written instructions,
  • whether they had more trouble than usual following a group conversation or TV program due to memory problems,
  • whether they had trouble finding their way around familiar streets.

Because this survey was limited to telephone tests, we can’t draw any firm conclusions. But the findings may be helpful for doctors and others, to know which sort of memory complaints should be taken as a flag for further investigation.

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New brief tool to screen for cognitive impairment in elderly patients

December, 2010

A 2-minute questionnaire does an excellent job of indicating older adults with cognitive impairment.

A simple new cognitive assessment tool with only 16 items appears potentially useful for identifying problems in thinking, learning and memory among older adults. The Sweet 16 scale is scored from zero to 16 (with 16 representing the best score) and includes questions that address orientation (identification of person, place, time and situation), registration, digit spans (tests of verbal memory) and recall. The test requires no props (not even pencil and paper) and is easy to administer with a minimum of training. It only takes an average of 2 minutes to complete.

A score of 14 or less correctly identified 80% of those with cognitive impairment (as identified by the Informant Questionnaire on Cognitive Decline in the Elderly) and correctly identified 70% of those who did not have cognitive impairment. In comparison, the standard MMSE correctly identified 64% of those with cognitive impairment and 86% of those who were not impaired. In other words, the Sweet 16 missed diagnosing 20% of those who were (according to this other questionnaire) impaired and incorrectly diagnosed as impaired 30% of those who were not impaired, while the MMSE missed 36% of those who were impaired but only incorrectly diagnosed as impaired 14% of those not impaired.

Thus, the Sweet 16 seems to be a great ‘first cut’, since its bias is towards over-diagnosing impairment. It should also be remembered that the IQCDE is not the gold standard for cognitive impairment; its role here is to provide a basis for comparison between the new test and the more complex MMSE. In comparison with a clinician’s diagnosis, Sweet 16 scores of 14 or less occurred in 99% of patients diagnosed by a clinician to have cognitive impairment and 28% of those without such a diagnosis.

The great benefit of the new test is of course its speed and simplicity, and it seems to offer great promise as an initial screening tool. Another benefit is that it supposedly is unaffected by the patient’s education, unlike the MMSE. The tool is open access.

The Sweet 16 was developed using information from 774 patients who completed the MMSE, and then validated using a different group of 709 older adults.

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Friends, family detect early Alzheimer's signs better than traditional tests

October, 2010

Cognitive tests only test you at a particular moment in time; early signs of Alzheimer's are more evident in declines in everyday behavior that are most visible to other people.

Confirming earlier research, a study involving 257 older adults (average age 75) has found that a two-minute questionnaire filled out by a close friend or family member is more accurate that standard cognitive tests in detecting early signs of Alzheimer’s.

The AD8 asks questions about changes in everyday activities:

  • Problems with judgment, such as bad financial decisions;
  • Reduced interest in hobbies and other activities;
  • Repeating of questions, stories or statements;
  • Trouble learning how to use a tool or appliance, such as a television remote control or a microwave;
  • Forgetting the month or year;
  • Difficulty handling complicated financial affairs, such as balancing a checkbook;
  • Difficulty remembering appointments; and
  • Consistent problems with thinking and memory.

Problems with two or more of these are grounds for further evaluation. The study found those with AD8 scores of 2 or more were very significantly more likely to have early biomarkers of Alzheimer’s (abnormal Pittsburgh compound B binding and cerebrospinal fluid biomarkers), and was better at detecting early stages of dementia than the MMSE. The AD8 has now been validated in several languages and is used in clinics around the world.

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New Alzheimer's test offers better opportunities for early detection

March, 2010

A computerized self test (CST) has been developed that is 96% accurate in diagnosing Alzheimer’s and MCI (compared to 71% for the MMSE and 69% for the Mini-Cognitive — tests currently in use).

A computerized self test (CST) has been developed that is 96% accurate in diagnosing Alzheimer’s and MCI-A (compared to 71% for the MMSE and 69% for the Mini-Cognitive — tests currently in use). Moreover, the test accurately classified 91% of the six experimental groups (control, MCI, early Alzheimer's, mild to moderate, moderate to severe, and severe) as compared to 54% for the MMSE and 48% for the Mini-Cog. The brief, interactive online test is designed to be used in the primary care setting, where physicians may not have detailed training in recognizing cognitive impairments.

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Dougherty, J.H. Jr. et al. 2010. The Computerized Self Test (CST): An Interactive, Internet Accessible Cognitive Screening Test For Dementia. Journal of Alzheimer's Disease, 20 (1), 185-195.
The journal article is available at http://iospress.metapress.com/content/a1242x878323454x/fulltext.pdf

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