Brief cognitive screening instruments: an update

Transcription

1 REVIEW ARTICLE Brief cognitive screening instruments: an update Zahinoor Ismail 1,2,y, Tarek K. Rajji 1z and Kenneth I. Shulman 3x 1 Department of Psychiatry, Faculty of Medicine, University of Toronto, Geriatric Mental Health Program, Centre for Addiction and Mental Health, Canada 2 Department of Psychiatry, Faculty of Medicine, University of Calgary 3 Department of Psychiatry, Faculty of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Canada Correspondence to: Z. Ismail, MD, FRCPC, zahinoor@gmail.com y Assistant Professor at Department of Psychiatry, Faculty of Medicine, University of Toronto, Canada and also Head of Centre for Addiction and Mental Health Memory Clinic, Canada. z Fellow. Professor and Lewar Chair in Geriatric Psychiatry. Objective: To review the recent literature on cognitive screening with a focus on brief screening methods in primary care as well as geriatric services. Design: The Medline search engine was utilized using the keyword search terms cognitive screening, cognitive assessment, and dementia screening limiting articles to those published in English since Results: 679 abstracts were retrieved. Articles focusing on attitudes toward cognitive screening, current screening practices, promising new instruments and more recent updates contributing significant information on established instruments were retrieved and incorporated into this review. Reference lists were reviewed for relevant contributing articles. Instruments recommended from previous reviews of cognitive screening and those identified in surveys as most frequently used in primary care and geriatric settings were emphasized in this review. Conclusions: Dementia remains under-diagnosed in the elderly population. Despite significant limitations, the Mini Mental State Exam remains the most frequently used cognitive screening instrument. Its best value in the community and primary care appears to be for the purpose of ruling out a diagnosis of dementia. Instruments such as the Mini-Cog, Memory Impairment Screen (MIS), and the General Practitioner Assessment of Cognition (GPCOG) have consistently been recognized for utility in primary care. The clock drawing test (CDT) and newer instruments such as the Montreal Cognitive Assessment (MoCA) and the Rowland Universal Dementia Assessment Scale (RUDAS) are gaining credibility due to improvements in sensitivity, addressing frontal/executive functioning, and decreasing susceptibility to cultural and educational biases. Copyright # 2009 John Wiley & Sons, Ltd. Key words: dementia; screening; Alzheimer s disease; cognitive screening; cognitive assessment; dementia screening History: Received 21 January 2009; Accepted 26 March 2009; Published online 6 July 2009 in Wiley InterScience ( DOI: /gps.2306 Introduction Cognitive screening is a means to early detection of dementia, which carries a number of important benefits. A firm diagnosis of dementia helps to provide an explanation to patients and families regarding recent changes in instrumental activities of daily living, behavior, intellectual functioning, and mood. Once the diagnosis is established, patient and family can plan for important issues including powers of attorney for property and personal care, living wills for end of life care, planning for long-term care, and the preparation

2 112 Z. Ismail et al. of a last will and testament. Cognitive screening may help to identify at risk drivers and those who need further assessment of driving (Molnar et al., 2006) and delirium risk (Alagiakrishnan et al., 2007). Further, early diagnosis provides opportunity for medication management, if appropriate, with the hope of improving function, behavior, and cognition. Cognitive screening represents the initial step in a process of further assessment for dementia and can help identify potential cases for management. We use the term screening in this paper to refer to opportunistic case finding in the clinical setting (especially primary care) as opposed to the epidemiologic sense of screening asymptomatic individuals in the community. Screening should be carried out in individuals who have the greatest risk of developing the disorder. High-risk groups for developing dementia include those with subjective complaints of memory impairment (Wang et al., 2004; Reisberg and Gauthier, 2008) and those with a history of early or late onset depression (Ownby et al., 2006; Ballmaier et al., 2008; Geerlings et al., 2008). In those who are over the age of 85, the prevalence of dementia increases to greater than 25% (Ebly et al., 1994). Informants have been shown to be an important component of screening for dementia (Jorm, 1997). Older adults visit their primary care physicians on a regular basis and such visits represent an excellent opportunity to assess cognitive functioning. Geriatric specialist services which see high-risk older adults are also in a position of opportunistic case finding for dementia. However, cognitive screening is not a benign procedure. There is a risk of false positive results with concomitant distress and potential stigma for a person labeled with dementia. Furthermore, one needs to consider the capacity of local health care services to manage cases identified by screening and the economic burden of increased screening (Freyne, 2001; Brayne et al., 2007). Several recent reviews have assessed and evaluated cognitive screening instruments for dementia in primary care. Lorentz et al. (2002) compared brief dementia screening tests as candidates for routine use in primary care based on an administration time of 10 min or less and evaluation in at least one community sample. Based on these criteria as well as adequate psychometric properties, three tests showed the most promise for broad application in primary care settings: the Mini-Cog, the Memory Impairment Screen (MIS), and the General Practitioner Assessment of Cognition (GPCOG). Similarly, Brodaty et al. (2006) reviewed existing dementia screening tools with a view to informing and recommending suitable instruments to general practitioners based on performance and practicality. Studies were included based on an administration time of 5 min or less, validation in a community, population or general practice sample, and psychometric properties at least as good as the MMSE. The Mini-Cog, MIS, and GPCOG were identified as relevant to primary care and were recommended for use. Milne et al. (2008) reviewed 11 instruments chosen based on practicality, feasibility, range of applicability, and psychometric properties as they pertained to primary care. Graded on overall clinical utility, efficacy, and quality, the same three instruments Mini-Cog, MIS, and GPCOG were recommended as more appropriate for use in primary care than the MMSE. Synthesizing not only these recent reviews, but also relevant surveys of current screening practices, we aim to summarize current screening practices for dementia both in primary care and geriatric settings. Not only are the most recommended instruments reviewed, but also the most utilized, with some discussion around trends in screening practices and investigation of newer tools to address weaknesses of the current most commonly used tools. Current screening practices Milne et al. (2008) completed a primary care practice survey in the UK to determine whether, and if so, which screening instruments were used in primary care practices in Kent, England. Seventy nine per cent of practices used at least one dementia screening instrument including: the Folstein Mini-Mental State Examination (MMSE) and its variants (51%), the Abbreviated Mental Test (AMT) (11%), MMSE and AMT (10%), MMSE and Clock Drawing Test (CDT) (8%), MMSE and the 6-Item Cognitive Impairment Test (6-CIT) (6%), and the CDT (5%). Concerns raised in this survey were the limited availability of measures other than MMSE, a need for information about the full range of instruments, greater access to training and advice on screening and national guidance. A recent Canada-wide survey of individual family practitioners evaluated attitudes and practices of cognitive screening (Iracleous et al., 2009). The most frequently used assessment tools were: MMSE and its variants (76%), CDT (52%), Delayed Word Recall Test (52%), Alternating Sequences (13%), and Montreal Cognitive Assessment (5%). The need for a better primary care screening tool was identified, as were

3 Brief cognitive screening instruments 113 concerns about whether screening led to better outcomes. Inconsistent screening likely contributes to underdiagnosis and there remains a discrepancy between guidelines and practice in primary care (Stoppe et al., 2007). Obstacles to cognitive screening in general practice relate primarily to the lack of time and the potential for offending patients (Bush et al., 1997). For example, the MMSE takes approximately 10 min to administer and may be impractical in a busy general practice. A survey has since been developed to measure primary care patient attitudes about dementia screening. This survey assesses a patient s acceptance of dementia screening and their perceived harms and benefits of dementia screening (Boustani et al., 2008). Shulman et al. (2006) completed an international survey of geriatric specialists on behalf of the International Psychogeriatric Association (IPA). The goal was to determine which screening instruments were routinely used by clinicians with expertise in neuropsychiatric aspects of old age. The results revealed that only a small number of tests were used by the vast majority of specialists including: MMSE and its variants (100%), CDT (72%), Delayed Word Recall (56%), the Verbal Fluency Test (35%), Similarities (27%), and the Trail Making Test (25%). This sequence overlaps with that in the primary care setting. The specialists also reported ongoing challenges in the interpretation of cognitive screening including the influence of ethnicity/culture, language, education/literacy, and sensory factors. Given this survey information, an ideal cognitive screening instrument or battery in a primary care setting should be brief, acceptable to patients, independent of education/cultural/language confounds, simple to administer, psychometrically robust and broad in its coverage of cognitive domains (Shulman, 2000). We have chosen to review the most widely used screening batteries and those most recommended in previous reviews, while highlighting the most promising newer screening tests. The Mini Mental State Exam, CDT, Mini-Cog, MIS, GPCOG, AMT, Addenbrooke s Cognitive Examination, Montreal Cognitive Assessment, and Rowland Universal Dementia Assessment Scale are discussed in this context. As cognitive screening evolves, this review will help succinctly summarize current practice and recent advances in order to help propel the field forward. Mini-Mental State Examination (MMSE) The development of the MMSE (Folstein et al., 1975) was a major advance on other screening instruments that tested only orientation and short-term memory and has since been cited on more than occasions in the medical literature. The MMSE was developed from items selected from different neuropsychological batteries and includes five sections: Orientation (10 points); Registration (3 points); Attention and Calculation (5 points); Recall (3 points), and Language (9 points) for a total of 30 points. However, there are a number of limitations that have emerged with widespread usage of the MMSE. Patients with high premorbid intelligence or education show a ceiling effect thus leading to false negatives. Great age, limited education, foreign culture, and sensory impairment can produce false positives. Consequently, MMSE score needs adjustment for age and education (Bravo and Hebert, 1997). In the Sao Paulo Ageing & Health Study, the MMSE was found to have an unacceptably high dementia misclassification for older illiterate adults at its regular cutoff point. Receiver operating characteristic analysis showed that the MMSE cutoff point of 14/15 was associated with 78.7% sensitivity and 77.8% specificity for the diagnosis of dementia amongst participants with no formal education (Scazufca et al., 2009). Fuzikawa et al. (2007) similarly found a modest correlation between the MMSE and the CDT in older adults with low levels of schooling. Folstein acknowledges the MMSE s limited sensitivity to frontal and subcortical changes and has recognized the need to add specific tests of frontal and executive function (Folstein, 1998) as detailed later in this review. The MMSE offers two tests of concentration, serial 7 s and spelling WORLD backwards, which are used interchangeably but may not have the same psychometric properties. These and other concerns about the administration and scoring of the MMSE have led to the developmental of variations including the standardized MMSE (SMMSE) (Molloy and Standish, 1997) and the modified MMSE (3MS) (Teng and Chui, 1987). The Standardized MMSE (SMMSE) The original publication of the MMSE provided little direction for test administration and much was left to the discretion of individual raters. This problem was highlighted in multi-site clinical trials where it was important to develop a uniform method of administration and scoring. Hence, Molloy and Standish (1997) developed the Standardized MMSE (SMME) with the following specific examples.

4 114 Z. Ismail et al. 1. The standardized approach recommends explicit time limits on all the tasks. 2. For orientation to place, items are asked in decreasing order from the largest unit size (e.g., country) to the smallest unit size (e.g., floor of the hospital). 3. The three-word memory and registration task is standardized to three specific words (apple, penny and table). The SMMSE also offers alternative three-word sets. 4. Attention and concentration is tested only by using the WORLD backwards task. Subjects are asked to spell WORLD forward first; however, and if not able to do this successfully, score zero. 5. The three-stage command provides the following specific instruction, Take this paper in your (non-dominant) hand, fold the paper in half once with both hands, and put the paper down on the floor. 6. For the copy design task (intersecting pentagons), a score of one point is awarded only if a four-sided figure is created by the overlapping of the two pentagons. By using a detailed and standardized approach, the authors were able to demonstrate improvements in intra and inter-rater variance and intraclass correlation. They were also able to reduce the average time for the administration of the test to just over 10 min. Meta-analytical methods have been used to assess the accuracy of the MMSE (Mitchell, 2009). In 34 dementia studies and 5 Mild Cognitive Impairment (MCI) studies, it was determined that the best value of the MMSE was for ruling out a diagnosis of dementia in community and primary care where negative predictive values were 98.5 and 95.7% respectively. The MCI studies demonstrated very little value of the MMSE in making a diagnosis of MCI against healthy controls and modest rule-out accuracy. It had similarly limited ability to help identify cases of AD against MCI. Despite its clear limitations, the MMSE has proved resilient in the clinical arena for over 25 years. However, clinicians must be careful not to confer more meaning to the MMSE score than is merited. Nonetheless, an abnormal score (<26/30) remains an important signal that more evaluation and investigations may be necessary to diagnose dementia. Clock Drawing Test (CDT) While the CDT was used originally by neurologists as a measure of parietal lobe function (Critchley, 1966), it has since become widely used as a screening instrument for dementia (Shulman, 2000). The CDT requires a wide range of intellectual and perceptual skills making it a good screening instrument that casts a wide net in capturing cognitive dysfunction. The cognitive domains include comprehension, planning, visual memory, visuospatial ability, motor programming and execution, abstraction, concentration, and response inhibition (i.e., the frontal pull of the hands to 10 in the instruction to set the time at 10 past 11 ). However, its complex nature also creates a challenge in terms of scoring and interpretation. The instruction for the CDT generally involves a pre-drawn circle (approximately 10 cm in diameter) with the following instruction: This is a clock face. Please fill in the numbers and then set the time to 10 past 11. This verbatim instruction is necessary in order to avoid the word hands, which may give the patient a clue when abstract ability is impaired Shulman (2000). There are numerous scoring systems of varying degrees of complexity available in the literature most of which report excellent psychometric properties (Garcia-Caballero et al., 2006b). A simple 4-point scoring system was used by the Consortium to Establish a Registry for Alzheimer s Disease (CERAD) (Morris et al., 1989). A score of 0 implies an intact clock, 1 ¼ mild impairment, 2 ¼ moderate impairment, and 3 ¼ severe impairment. Moreover, qualitative errors may be as important as a quantitative score in interpreting the CDT. One can observe preservation, poor planning, and concrete and conceptual deficits when attempting to denote the time as 10 after 11. Lessig et al. recently analyzed three scoring systems to identify 24 common clock-drawing errors in a sample of 364 subjects with 5 years of education or more. An algorithm using the six common errors of inaccurate time setting, no hands, missing numbers, number substitutions or repetitions, and failure to attempt clock drawing identified dementia with a specificity of 88% and a sensitivity of 71% (Lessig et al., 2008). CDT norms in cognitively healthy older adults have also been published using three scoring systems and indicate that normal CDT performance includes a wider distribution of scores than previously reported (Hubbard et al., 2008). Despite the plethora of CDT scoring systems published in the literature, its best value may lie in its qualitative assessment as normal or abnormal and as a visual analog for improvement or deterioration over time (see Figure 1). A variant of the CDT has been used to elicit frontal lobe/executive brain impairment. This was described by (Royall, 2000) and involves a first step (CLOX 1) where the patient is asked to draw a free-hand clock without any further instruction. If the patient is unable to do this accurately, he or she is then asked to copy a

5 Brief cognitive screening instruments 115 Figure 1 Sensitivity to deterioration in dementia (figure 4.3 from QCS). (Reproduced from Shulman, 2000, with permission from John Wiley & Sons Ltd.). completed clock (CLOX 2). Frontal lobe/executive impairment is suspected when CLOX 1 is impaired but CLOX 2 is intact, i.e., copying ability is retained. Figure 2 shows examples of this variant of the CDT. The CDT provides a user-friendly visual record of cognitive functioning that is appealing to busy clinicians. It takes less than a minute to conduct (compared to 10 min for the MMSE) and appears to have a high level of acceptability by patients. Another added feature of the CDT is the fact that it has a significant impact on caregivers who are often surprised to see the extent of the difficulty in clock drawing by their impaired dependents. The CDT is not immune to confounding by education and language but this appears to be less pronounced than other instruments such as the MMSE that rely more heavily on language (Shulman, 2000). Mini-Cog As a single screening instrument, the CDT does have limitations in terms of its sensitivity to cognitive impairment and in predictive validity. In response, the CDT was incorporated into a screening battery, the Mini-Cog, that also includes a simple 3-item delayed word recall test (Borson et al., 2000). Figure 3 provides an algorithm for screening for dementia using this simple two-step test. In a community sample of culturally, linguistically, and educationally heterogeneous older adults, the Mini-Cog had a sensitivity of 99% and correctly classified 96% of the subjects in the initial study of 249 subjects. Administration time was 3 min. The validation study showed the Mini-Cog to have comparable psychometric properties to the MMSE with a sensitivity of 76% (versus 79%) and a specificity of 89% (versus 88%) for dementia (Borson et al., 2003). The Mini-Cog was found to be equal or better than the MMSE in detecting dementia in multiethnic elderly individuals, easier to administer to non- English speakers, and was less biased by low education and literacy (Borson et al., 2005). Memory Impairment Screen (MIS) The MIS is a brief, four-item delayed free- and cuedrecall memory impairment test that uses controlled learning and cued recall to optimize encoding specificity (Buschke et al., 1999). Scoring is by hand using the formula [2 (free recall) þ (cued recall)] resulting in a score of 0 8. Time of administration is less than 5 min. In an English-speaking community sample, sensitivity for dementia was 80% and specificity was 96%. Negative predictive value and misclassification were at least equivalent to the MMSE. Age, education, and gender did not significantly affect performance. The MIS, however, has no direct test of executive function or visuospatial skills.

6 116 Z. Ismail et al. Figure 2 CLOX Test. Qualitative differences in CLOX performance, in a normal elderly control, a patient with Alzheimer s disease, and a patient with non-cortical vascular disease. (A) An 82-year-old elderly control. EXIT25 ¼ 08/50 (scores > 5/50 impaired), MMSE ¼ 29/30 (scores < 24/30 impaired). (B) A 74-year-old married white woman with Alzheimer s disease. EXIT25 ¼ 21/50(24/50) comparable with six-year-old children or residents requiring skilled nursing), MMSE ¼ 12/30. (C) A 74-year-old right-handed white man with a history of coronary artery disease (status post myocardial infarction), hypertension, non-insulin dependent diabetes mellitus, and falls. EXIT22 ¼ 24/50, MMSE ¼ 28/30. (Reproduced from Royall et al., 1998, with permission from the BMJ Publishing Group.) Figure 3 Mini-Cog. Mini-Cog scoring algorithm. (Reproduced from Borson et al., 2000, with permission from John Wiley & Sons Ltd.).

7 Brief cognitive screening instruments 117 The General Practitioner Assessment of Cognition (GPCOG) Designed for primary care, the GPCOG includes nine cognitive items including assessment of time orientation, a clock drawing task, report of a recent event, and a word recall task as well as six informant questions assessing changes in the patient compared to a few years ago (Brodaty et al., 2002). Patient administration time is approximately 4 min and informant screening approximately 2 min. In an English-speaking nonrandom sample of subjects aged 75 or older and those with memory complaints, sensitivity was 0.85 and specificity 0.86, which was comparable to the MMSE in this sample. The GPCOG has the benefit of brief administration time and the incorporation of informant input. It is a relatively new instrument and may take time to be reflected in surveys of commonly used instruments. Abbreviated Mental Test (AMT) The AMT is a very brief test used largely in Europe that assesses orientation, attention, and memory (Hodkinson, 1972). A score of < 8 differentiates normal from abnormal cognition, including delirium with a sensitivity of 91% and a specificity of 75% (Jitapunkul et al., 1991). With respect to diagnosis of dementia, the AMT at a score of < 7 had a sensitivity, and specificity of 81 and 84% respectively, NPVof 99%, but poor PPV of 25% (Antonelli Incalzi et al., 2003). The AMT was shown to be correlated to MMSE score (Swain et al., 1999) and has been validated in a Spanish speaking sample (Sarasqueta et al., 2001). Although brief, the AMT does not effectively test frontal/executive function. Addenbrooke s Cognitive Examination (ACE) ACE (Mathuranath et al., 2000) and ACE-R (Mioshi et al., 2006) are multi-domain tests taking min to administer. ACE-R clusters the items into five cognitive domains with comparable contribution to the total score of 100. The five domains are: attention/ orientation, fluency, language, memory, and visuospatial function. ACE at a cutoff of 88 had high reliability, construct validity, and sensitivity (93%) in detecting patients with early dementia (Mathuranath et al., 2000). These findings were replicated in both Spanish (Garcia-Caballero et al., 2006a) and French speaking samples (Bier et al., 2005). ACE was also shown to distinguish between cognitive impairment due to major depression from that due to dementia. The former was characterized by mildly low total scores and low scores on memory and letter but not category fluency (Dudas et al., 2005). ACE and ACE-R are relatively newly developed cognitive screening tools. Although they have gained popularity internationally, further studies by different research groups will be required to establish their strengths and limitations. One such limitation of the ACE-R is that its scores did not correlate with scores of basic and instrumental activities of daily living among patients with different types of dementias such as AD and FTD (Mioshi et al., 2007). The Montreal Cognitive Assessment (MoCA) Initially designed as a brief screening tool for MCI, the Montreal Cognitive Assessment evaluates multiple domains of cognitive functioning that are affected in dementia (Nasreddine et al., 2005) (Figure 4). The test is available at and is a one-page 30- point test that takes 10 min to administer as follows: 1. Short-term memory: recall of five nouns after 5 min (5 points). 2. Visuospatial: clock-drawing (3 points) and cube copying (1 point). 3. Executive: modified Trail making B task (1 point), phonemic fluency (1 point), and 2 item verbal abstraction (2 points). 4. Attention, concentration, and working memory: target detection using tapping (1 point), serial subtraction (3 points), and digits forward and backward (2 points). 5. Language: animal naming of low-familiarity animals (lion, camel, rhinoceros; 3 points) and sentence repetition (2 points). 6. Orientation to time and place (6 points). A cutoff score of 26 (25 or below indicating impairment) was used for sensitivity and specificity calculation. The MoCA exhibited excellent sensitivity in identifying MCI and AD (90 and 100%) respectively (compared to the relatively poor performance of the MMSE of 18 and 78%). In terms of specificity, the MoCA correctly identified 87% of normal controls (versus 100% for the MMSE). With its test retest reliability, internal consistency, and content validity, the MoCA is an excellent screen

8 118 Z. Ismail et al. Figure 4 Montreal Cognitive Assessment. for MCI. The authors suggest the following algorithm for assessing cognitive impairment. Patients who present with both cognitive complaints and functional decline are more likely to suffer from dementia and should be screened with the MMSE. If the MMSE is normal (>25) then the MoCA should be administered (100% of patients with AD had an abnormal MoCA score). For patients with cognitive complaints without functional impairment, the MoCA should be administered first, as these patients are either normal or have MCI and may not be identified by the MMSE. As such, the MoCA provides an effective method for screening for MCI and distinguishing it from cognitively intact elderly. As identified in the IPA survey, the MoCA incorporates 5/6 of the most often used tools in screening for dementia. Its psychometric properties have since been validated in a British memory clinic population (Smith et al., 2007), a Southeastern United

9 Brief cognitive screening instruments 119 States population (Luis et al., 2009), and a Korean version in an elderly outpatient population (Lee et al., 2008). Rowland Universal Dementia Assessment Scale (RUDAS) Specifically and thoroughly designed as a portable and multi-cultural cognitive assessment scale, the RUDAS (Storey et al., 2004) was validated in an Australian community sample using the following domains: 1. Memory: 4 item grocery list recall (8 points). 2. Gnosis: body orientation via pointing to various body parts (5 points). 3. Praxis: fist-palm alternating task (2 points). 4. Visuospatial: cube copying (3 points). 5. Judgment: the patient describes how they would cross a busy street and the examiner scores for mention of safety and looking for traffic (4 points). 6. Language: animal generation in 1 min (8 points). Scored out of 30 points, a cut-off score of 23 is found to have sensitivity and specificity of 89 and 98% respectively and high inter-rater and test retest reliability. The RUDAS seems to be relatively unaffected by gender, years of education, and language of preference. However, in a South Indian sample with the RUDAS translated into Malayalam, an educational bias did emerge (Iype et al., 2006). In this study, fewer patients had less than 6 years of education compared to the original Australian sample. The RUDAS has potential for increased utility into broader patient populations and further studies are warranted. Key Points The Mini Mental State Exam remains the most frequently used cognitive screening instrument. Instruments such as the Mini-Cog, MIS, and the GPCOG have consistently been recognized for utility in primary care. The CDT and newer instruments such as the Montreal Cognitive Assessment and the Rowland Universal Dementia Assessment Scale are gaining credibility due to improvements in sensitivity, addressing frontal/executive functioning, and decreasing susceptibility to cultural and educational biases. Summary Although there is no specific Alzheimer s test, we are doing a better job of identifying the many facets of dementia. As early detection becomes more clinically relevant, screening tools will also gain in importance. While novel approaches are unlikely to supplant the MMSE in the foreseeable future, they are addressing important needs and complement this standard screen. Whether the needs be greater sensitivity and/or assessment of executive function (MoCA), validity regardless of culture or education (RUDAS), simplicity of administration (CDT), utility in primary care (Mini-Cog, MIS or GPCOG), these important issues in screening for dementia are now being addressed. Further iterations of the IPA and primary care surveys and further clinical advances in management may illuminate new directions for cognitive screening for dementia. Conflict of interest None. References Alagiakrishnan K, Marrie T, Rolfson D, et al Simple cognitive testing (Mini-Cog) predicts in-hospital delirium in the elderly. J Am Geriatr Soc 55(2): Antonelli Incalzi R, Cesari M, Pedone C, Carosella L, Carbonin PU Construct validity of the abbreviated mental test in older medical inpatients. Dement Geriatr Cogn Disord 15(4): Ballmaier M, Narr KL, Toga AW, et al Hippocampal morphology and distinguishing late-onset from early-onset elderly depression. Am J Psychiatry 165(2): Bier JC, Donckels V, Van Eyll E, et al The French Addenbrooke s cognitive examination is effective in detecting dementia in a Frenchspeaking population. Dement Geriatr Cogn Disord 19(1): Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A The mini-cog: a cognitive vital signs measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11): Borson S, Scanlan JM, Chen P, Ganguli M The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 51(10): Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M Simplifying detection of cognitive impairment: comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample. J Am Geriatr Soc 53(5): Boustani M, Perkins AJ, Monahan P, et al Measuring primary care patients attitudes about dementia screening. Int J Geriatr Psychiatry 23(8): Bravo G, Hebert R Age- and education-specific reference values for the Mini-Mental and modified Mini-Mental State Examinations derived from a non-demented elderly population. Int J Geriatr Psychiatry 12(10): Brayne C, Fox C, Boustani M Dementia screening in primary care: is it time? Jama 298(20):

10 120 Z. Ismail et al. Brodaty H, Low LF, Gibson, L, Burns K What is the best dementia screening instrument for general practitioners to use? Am J Geriatr Psychiatry 14(5): Brodaty H, Pond D, Kemp NM, et al The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc 50(3): Buschke H, Kuslansky G, Katz M, et al Screening for dementia with the memory impairment screen. Neurology 52(2): Bush C, Kozak J, Elmslie T Screening for cognitive impairment in the elderly. Can Fam Physician 43: Critchley M The Parietal Lobes. Hafner Publishing Company: New York. Dudas RB, Berrios GE, Hodges JR The Addenbrooke s cognitive examination (ACE) in the differential diagnosis of early dementias versus affective disorder. Am J Geriatr Psychiatry 13(3): Ebly EM, Parhad IM, Hogan DB, Fung TS Prevalence and types of dementia in the very old: results from the Canadian Study of Health and Aging. Neurology 44(9): Folstein M Mini-mental and son. Int J Geriatr Psychiatry 13(5): Folstein MF, Folstein SE, McHugh PR Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12(3): Freyne A Screening for dementia in primary care - a viable proposition? Irish J Psych Med 18(2): Fuzikawa C, Lima-Costa MF, Uchoa E, Shulman K Correlation and agreement between the Mini-mental State Examination and the Clock Drawing Test in older adults with low levels of schooling: the Bambui Health Aging Study (BHAS). Int Psychogeriatr 19: Garcia-Caballero A, Garcia-Lado I, Gonzalez-Hermida J, et al. 2006a. Validation of the Spanish version of the Addenbrooke s Cognitive Examination in a rural community in Spain. Int J Geriatr Psychiatry 21(3): Garcia-Caballero A, Recimil MJ, Garcia-Lado I, et al. 2006b. ACE clock scoring: a comparison with eight standard correction methods in a population of low educational level. J Geriatr Psychiatry Neurol 19(4): Geerlings MI, den Heijer T, Koudstaal PJ, Hofman A, Breteler MM History of depression, depressive symptoms, and medial temporal lobe atrophy and the risk of Alzheimer disease. Neurology 70(15): Hodkinson HM Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1(4): Hubbard EJ, Santini V, Blankevoort CG Clock drawing performance in cognitively normal elderly. Arch Clin Neuropsychol 23(3): Iracleous P, Nie JX, Tracy CS, et al Primary care physicians attitudes toward cognitive screening: findings from a national postal survey. Int J Geriatr Psychiatry. Iype T, Ajitha BK, Antony P, et al Usefulness of the Rowland Universal Dementia Assessment scale in South India. J Neurol Neurosurg Psychiatry 77(4): Jitapunkul S, Pillay I, Ebrahim S The abbreviated mental test: its use and validity. Age Ageing 20(5): Jorm AF Methods of screening for dementia: a meta-analysis of studies comparing an informant questionnaire with a brief cognitive test. Alzheimer Dis Assoc Disord 11(3): Lee JY, Dong Woo L, Cho SJ Brief screening for mild cognitive impairment in elderly outpatient clinic: validation of the korean version of the montreal cognitive assessment. J Geriatr Psychiatry Neurol 21(2): Lessig MC, Scanlan JM, Nazemi H, Borson S Time that tells: critical clock-drawing errors for dementia screening. Int Psychogeriatr 20(3): Lorentz WJ, Scanlan JM, Borson S Brief screening tests for dementia. Can J Psychiatry 47(8): Luis CA, Keegan AP, Mullan M Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. Int J Geriatr Psychiatry. Mathuranath PS, Nestor PJ, Berrios GE, Rakowicz W, Hodges JR A brief cognitive test battery to differentiate Alzheimer s disease and frontotemporal dementia. Neurology 55(11): Milne A, Culverwell A, Guss R, Tuppen J, Whelton R Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr 20: Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR The Addenbrooke s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 21(11): Mioshi E, Kipps CM, Dawson, K, et al Activities of daily living in frontotemporal dementia and Alzheimer disease. Neurology 68(24): Mitchell AJ A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment. J Psychiatr Res 43: Molloy DW, Standish TI A guide to the standardized Mini-Mental State Examination. Int Psychogeriatr 9 (Suppl 1): 87 94; discussion Molnar FJ, Patel A, Marshall SC, Man-Son-Hing M, Wilson KG Clinical utility of office-based cognitive predictors of fitness to drive in persons with dementia: a systematic review. J Am Geriatr Soc 54(12): Morris JC, Heyman A, Mohs RC, et al The Consortium to Establish a Registry for Alzheimer s Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer s disease. Neurology 39(9): Nasreddine ZS, Phillips NA, Bedirian V, et al The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53(4): Ownby RL, Crocco E, Acevedo A, et al Depression and risk for Alzheimer disease: systematic review, meta-analysis, and metaregression analysis. Arch Gen Psychiatry 63(5): Reisberg B, Gauthier S Current evidence for subjective cognitive impairment (SCI) as the pre-mild cognitive impairment (MCI) stage of subsequently manifest Alzheimer s disease. Int Psychogeriatr 20(1): Royall DR Executive cognitive impairment: a novel perspective on dementia. Neuroepidemiology 19(6): Sarasqueta C, Bergareche A, Arce A, et al The validity of Hodkinson s Abbreviated Mental Test for dementia screening in Guipuzcoa, Spain. Eur J Neurol 8(5): Scazufca M, Almeida OP, Vallada HP, Tasse WA, Menezes PR Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status: results from the Sao Paulo Ageing & Health Study. Eur Arch Psychiatry Clin Neurosci 259: Shulman KI Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 15(6): Shulman KI, Herrmann N, Brodaty H, et al IPA survey of brief cognitive screening instruments. Int Psychogeriatr 18: Smith T, Gildeh N, Holmes C The Montreal Cognitive Assessment: validity and utility in a memory clinic setting. Can J Psychiatry 52(5): Stoppe G, Haak S, Knoblauch A, Maeck L Diagnosis of dementia in primary care: a representative survey of family physicians and neuropsychiatrists in Germany. Dement Geriatr Cogn Disord 23(4): Storey JE, Rowland JT, Basic D, Conforti DA, Dickson HG The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. Int Psychogeriatr 16(1): Swain DG, O Brien AG, Nightingale PG Cognitive assessment in elderly patients admitted to hospital: the relationship between the Abbreviated Mental Test and the Mini-Mental State Examination. Clin Rehabil 13(6): Teng EL, Chui HC The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 48(8): Wang L, van Belle G, Crane PK, et al Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc 52(12):