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Nov21InterventionPlan2 - MMSE

Nov21InterventionPlan2 - MMSE

No bias. No misinformation. No spin. Just what you need!Home » Posts » Mental health » dementia » Cognitive tests for dementia: MMSE, Mini-Cog and ACE-RIn this systematic review and meta-ysis, Tsoi and colleagues from Hong Kong aimed to assess the relative effectiveness of common cognitive tests at diagnosing dementia.Dementia is an umbrella term for a number of different brain diseases that progressively affect a person’s ability to think and function independently. Alzheimer’s disease, for example, is the commonest cause of dementia. The symptoms and the impairment caused by dementia are a result of progressive damage to the brain and a loss of brain cells and connections.The symptoms a particular person with dementia develops depends on where in the brain the disease is affecting. For example, early on in the disease course Alzheimer’s affects an area of the brain called the hippocampus, which is involved in storing memories about our lives. For this reason patients with Alzheimer’s disease get memory problems early on. By comparison, frontotemporal dementia affects the frontal area of the brain first and, as a result, these patients often have changes in personality and difficulties in planning long before they have difficulties with memory.The way we diagnose and detect dementia, therefore, is by systematically assessing the function of various brain regions by using cognitive tests. ‘Cognitive’ here means the ‘higher brain functions’ I alluded to earlier; things like memory, numeracy, visual perception, personality change and planning, to name a few.Obviously, an exhaustive assessment of a person’s cognitive function would take a very long time – hours, if not longer! While researchers may have hours to spend with patients, most busy clinicians do not and so the Holy Grail is finding a good, brief screening test of cognitive function that allows us to diagnose dementia.The commonest cognitive test used is called the Mini-Mental State Examination (MMSE). In this test you can score up to 30 points by answering a range of questions that test your orientation to time and place, your memory, attention and so on. The test itself takes about 10 minutes to complete. As the authors of this paper state, the performance of the MMSE in detecting dementia as compared to other tests has not been systematically assessed and so, that is what they set out to do. One of the reasons to assess the relative merits of the MMSE is that it is a proprietary instrument, owned by ‘Psychological Assessment Resources’ meaning that it is not actually free for organisations to use.In this paper, the authors completed a systematic review of the literature for studies that:This systematic review compares the MMSE with other tools for detecting dementia. [Interlocking-Pentagons used in the Mini-Mental State Exam]. The reviewers included studies that:They excluded:In terms of how the search was performed, it looks very thorough. They searched MEDLINE, EMBASE, PsychoINFO and Google Scholar from the earliest available dates stated in the individual databases until 1 Sep 2014. Two authors independently assessed the search results and used a standardised data extraction sheet. The studies were also screened for quality and bias.As outcomes they chose several different measures of diagnostic accuracy that can get a bit confusing. The perfect test should be able to tell you everyone who has the disease and correctly identify everyone who does not have the disease…easier said than done.To understand what the results of this paper mean it is worth running through an imaginary scenario.Let’s imagine 100 people come to a GP to get tested for ‘Disease X’. The GP decides to compare a new test he’s just bought with the gold-standard perfect test. Using the gold standard he finds out that 50 people have the dreaded ‘Disease X’ and 50 people do not. He then compares these results with his new test, which you can see in the table below.(n = 50)These are true positives (TP) – this is goodThese are false positives (FP) – this is bad.These are false negatives (FN) – this is really bad!These are true negatives (TN) – this is good too.From these kinds of tables you can work out how good a new/alternative diagnostic test is. As you can see from this imaginary scenario, the new test misdiagnosed 20 of the 100 people.In this paper, they chose to look at a number of different options for assessing the effectiveness of each of the cognitive tests they were interested in. It’s probably not worth going through all the measures they used, but it’s worth knowing about two: sensitivity and specificity.Sensitivity determines what proportion of people who actually have the disease get a positive test. Or as a formulaLikewise specificity determines what proportions of people who actually do not have the disease get a negative test. Or as a formula:For both sensitivity and specificity; the higher the number, the better.The paper also looks at other measures of the diagnostic accuracy but they are derived from the sensitivity and specificity. Without going into detail, the paper also reports Likelihood Ratios, diagnostic odds ratio and ‘AUC’ or area-under-the-curve.Accurate diagnostic tests have high sensitivity and high specificity.The initial search yielded 26,380 papers! After applying the inclusion/exclusion criteria they were left with 149 studies, which covered 11 different diagnostic tests and over 40,000 people from around the world.For all three of the above tests, there was found to be a high degree of heterogeneity. In essence this is a statistical test telling us that between studies included in the yses, the results were quite different from one study to another. Heterogeneity is not a good thing in systematic reviews.The reviewers showed that the accuracy of the MMSE was not affected by geographical location or clinical site (i.e. it was as effective for hospital patients as community patients).Finally they looked at the accuracy of diagnosing mild cognitive impairment (MCI); a risk state that precedes dementia. They didn’t really go into much detail in the methods of how they found the studies or how they defined MCI.The freely available ACE-R and Mini-Cog instruments may be viable alternatives to the MMSE for detecting dementia.In short, the MMSE is not a bad screening tool for dementia but it is not miles better than the rest; it’s just really commonly used, probably for historical reasons. The ACE-R and the Mini-Cog are both free to use and may be viable alternatives.The MMSE is less good in mild cognitive impairment.It’s important to add that whilst this paper focussed on cognitive screening tests, which play an important part in diagnosis, a full clinical assessment of someone with suspected dementia requires a much more detailed approach. Combining information from the history, examination, investigations and cognitive tests greatly improve the diagnostic accuracy. Also where the screening tests are not clear, patients can be referred for much more detailed assessments of cognition performed by neuropsychologists.Also it is important to remember that the diagnosis of dementia requires evidence of a progressive illness. This means that repeating cognitive tests and looking for change is often more helpful than just a snapshot. This aspect was not covered in this systematic review.A full clinical assessment of someone with suspected dementia involves much more than a simple cognitive test.Tsoi KF, Chan JC, Hirai HW, Wong SS, Kwok TY. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-ysis. JAMA Intern Med. Published online June 08, 2015. doi:10.1001/jamainternmed.2015.2152. [Abstract]Alzheimer’s Society. The Mini Mental State Examination (MMSE). Website last accessed 27 Jan 2016.Share this post: More posts CommentNameEmailNot publishedWebsite Cognitive tests for dementia: MMSE, Mini-Cog and ACE-R https://t.co/iGCfQH5vu7 #MentalHealth https://t.co/eUt9D5IkeoNow using ACE-IIIToday @_a_nair asks: Which cognitive test is best for detecting dementia & mild cognitive impairment? https://t.co/KPUC8iyFqWMeta- ysis of cognitive tests for dementia: MMSE, Mini-Cog and ACE-R https://t.co/2e8X4QOqAY @Mental_ElfSR suggests freely available ACE-R & Mini-Cog instruments may be viable alternatives to MMSE for detecting dementia https://t.co/KPUC8iyFqW@Mental_Elf Do you mean the ACE-III? The ACE-R was replaced because it *included* the MMSE and therefore breached copyright.Cognitive tests for dementia: MMSE, Mini-Cog and ACE-R https://t.co/pYDeszrsjaCognitive #tests for #dementia: MMSE, Mini-Cog & ACE-R https://t.co/BMw1TMPNs2 @Mental_Elf looks at the #evidence from a #systematicreviewRead our summary of a systematic review & meta-ysis of cognitive tests to detect #dementia https://t.co/KPUC8iyFqW‘MMSE:not a bad screening tool for dementia but it is not miles better than the rest; it’s just really commonly used’https://t.co/FA7IQlQRd0El Mini-Cog y ACE-R [de acceso libre] pueden ser alternativas viables al mini-mental para la detección de demencias https://t.co/aDXToC5ADAStruggling to understand diagnostic tests? #JargonBin sensitivity & specificity. Our blog today will help you! https://t.co/KPUC8iyFqWDon’t miss: Cognitive tests for dementia – MMSE, Mini-Cog and ACE-R https://t.co/KPUC8iyFqW@_a_nair explores the results of a systematic review of cognitive tests for #dementia & mild cognitive impairment https://t.co/KPUC8iQgiuAnd RBANS :)Cognitive tests for dementia: MMSE, Mini-Cog and ACE-R https://t.co/RhH73UUKigThank you for reminding us as you go about the statistical definitions you’re using. That really helps, and you do it without getting in the way of your discussion. Other Elf bloggers, please note.Hi @_a_nair Here’s a #StatsBadger for yr blog abt cognitive tests for dementia. Great work! https://t.co/KPUC8iyFqW https://t.co/KTkQZeWEj8 Sign up now. It’s free! Or Sign in We can help you:Do you have a suggestion for a paper? Then let us know.Click here



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