CLINICAL REVIEW. What Is the Best Dementia Screening Instrument for General Practitioners to Use?

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1 CLINICAL REVIEW Wht Is the Best Dementi Sreening Instrument for Generl Prtitioners to Use? Henry Brodty, M.B.B.S., M.D., F.R.A.C.P., F.R.A.N.Z.C.P., Lee-Fy Low, B.S.(Psyh.)Hons., Louis Gison, B.S.(Arh.), Grd. Dip. Psyh., B.S.(Psyh.)Hons., Kim Burns, R.N., B.Psyh.(Hons.) Ojetive: The ojetive of this study ws to review existing dementi sreening tools with view to informing nd reommending suitle instruments to generl prtitioners (GPs) sed on their performne nd prtiility for generl prtie. Method: A systemti serh of pre-medline, MEDLINE, PsyINFO, nd the Cohrne Lirry Dtse ws undertken. Only ville full-text rtiles out dementi sreening instruments written in English or with n English version were inluded. Artiles using trnsltion of n English lnguge instrument were exluded unless vlidted in generl prtie, ommunity, or popultion smple. Results: The Generl Prtitioner Assessment of Cognition (GPCOG), Mini-Cog, nd Memory Impirment Sreen (MIS) were hosen s most suitle for routine dementi sreening in generl prtie. The GPCOG, Mini-Cog, nd MIS were ll vlidted in ommunity, popultion, or generl prtie smples, re esy to dminister, nd hve dministrtion times of 5 minutes or less. They lso hve negtive preditive vlidity nd mislssifition rtes, whih do not differ signifintly from those of the Mini-Mentl Sttus Exmintion. Conlusions: It is reommended tht GPs onsider using the GPCOG, Mini-Cog, or MIS when sreening for ognitive impirment or for se detetion. (Am J Geritr Psyhitry 2006; 14: ) Key Words: Dignosis, dementi, sreening, Alzheimer disese, primry re The detetion nd erly dignosis of dementi re eoming inresingly importnt s our popultion ges. Delys to dignosis of 8 32 months from symptom onset nd regivers disstisftion with their generl prtitioner s (GP s) knowledge nd ility to dignose dementi in its initil stges, 1,2 indite need for erlier dignosis. Erly dignosis my enle ptients to pln for the future while still ompetent, initite enduring power of ttorney nd gurdinship, ddress sfety onerns suh s driving ility, nd enle regivers to seek edution sooner. 3,4 Aville phrmeutil tretments my slow dementi progress 5 nd redue osts through delyed nursing home plement. 4 Reeived Deemer 8, 2005; revised Deemer 22, 2005; epted Ferury 6, From the Ademi Deprtment for Old Age Psyhitry, Euro Centre, Prine of Wles Hospitl, Rndwik, Austrli (HB, LG); the Shool of Psyhitry, University of New South Wles, Sydney, Austrli (HB, KB); nd Centre for Mentl Helth Reserh Building 63, The Ntionl University, Cnerr, Austrli (L-FL). Send orrespondene nd reprint requests to Dr. Henry Brodty, Ademi Deprtment for Old Age Psyhitry, Euro Centre, Prine of Wles Hospitl, Brker St., Rndwik NSW 2031, Austrli. e-mil: h.rodty@unsw.edu.u 2006 Amerin Assoition for Geritri Psyhitry Am J Geritr Psyhitry 14:5, My

2 Cognitive Sreening in Primry Cre Open-lel extension trils suggest tht holinesterse inhiitors re not s effetive in stemming ognitive deline if ommenement is delyed. 5 Generl prtitioners my e est pled to detet nd tret dementi in its erly stges. Wilkinson et l. 2 found tht 79% of people thought GPs were esily essile, with 74% onsulting GP first fter notiing symptoms of ognitive deline. Despite the dvntges of erly dignosis, GPs fil to identify up to 91% of dementi ses depending on their severity. 6 Some rejet routine sreening 7 ; however, growing onsensus reommends routinely sreening ptients for ognitive impirment when they re over ertin ge (e.g., 75 yers) or when ognitive deline is suspeted At present, only 39% of Austrlin GPs 9 nd 26% of Cndin GPs 13 regulrly sreen for dementi. Generl prtitioners report limited time nd lk of ure nd suitle sreening tools s explntions for their filure to dignose nd sreen for dementi, 9 nd mny GPs do not ttempt to sreen ptients even when ognitive impirment is suspeted. 3 The Mini-Mentl Sttus Exmintion (MMSE 14 ), the most ommonly used instrument, 13 shows edution nd lnguge/ulturl is 15 nd is desried y GPs s imprtil 3 euse it tkes 10 minutes to dminister. 16 Generl prtitioners hve identified the need for shorter instrument, 9 nd Cndin survey found tht 93% would use rief nd simple sreening instrument. 13 With verge Western GP onsulttion times rnging from 8 11 minutes, 17 simple nd effetive instruments with dministrtion times of five minutes or less seem most suitle for GPs. 18 Although the needs of GPs hve een identified, reviews of dementi sreening instruments hve lrgely foused on individul sles suh s the MMSE, 19 the Clok Drwing Test (CDT 20 ), nd The Informnt Questionnire on Cognitive Deline in the Elderly (IQCODE 21 ). An exeption is review y Lorentz et l., 18 whih divided instruments ording to ognitive tests sudivided y dministrtion time, informnt or proxy-rted sreening instruments, nd remote (telephone nd mil) dementi sreening instruments. Our rtile lso imed to 1) review existing dementi sreening tools with view to informing nd reommending instruments to GPs; nd 2) onsider speifilly test performne, time tken, ese of dministrtion, nd prtiility for generl prtie. In ddition, we wnted to onsider psyhometri properties in studies of popultions of ptients kin to those in primry re, i.e., distint from studies of distint ognitively impired nd norml smples, whih mximize test performne hrteristis. METHOD The review ws onduted in three stges. First, literture serh ws undertken to identify ville sreening instruments nd vlidtion studies. Seond, instrument nd study prmeters were otined for eh instrument identified in the literture serh. Third, suitle instruments were hosen for reommendtion to GPs sed on set of seletion riteri. Systemti Literture Serh A systemti serh of pre-medline nd MED- LINE (etween 1966 nd Jnury 2004), PsyINFO (etween 1974 nd Jnury 2004), nd the Cohrne Lirry Dtse ws undertken for English lnguge rtiles reporting development, vlidtion, or psyhometri properties of dementi sreening instruments. The key words dementi or ognitive impirment omined with sreening or dignosis nd the MESH terms Alzheimer disese/dignosis or dementi/dignosis omined with mss sreening nd neuropsyhologil tests/sttistis nd numeril dt were used, yielding 11,229 titles. The titles of individul sles were lso entered individully s key words, nd referene lists of inluded rtiles were hnd serhed. A vlidtion study from My 2004 ws lter inluded. Only ppers ville in full text nd instruments written in English or with n English version ville were inluded. Artiles using trnsltion of n English lnguge sle were exluded unless vlidted in generl prtie, ommunity, or popultion smple. Instrument nd Study Prmeters One empiri pper ws hosen to represent eh instrument identified in the literture serh. Artiles tht vlidted n instrument in generl prtie, 392 Am J Geritr Psyhitry 14:5, My 2006

3 Brodty et l. ommunity, or popultion smple were preferentilly hosen. If no suh rtile ws ville (or there were severl), the pper tht ontined the most informtion out the instrument (in terms of the sreening prmeters listed in Tles 1 nd 2) ws hosen. If informtion out the properties of the instrument (edution is, lnguge/ulturl is, test retest reliility, internl onsisteny, or dministrtion time) ws not stted in the rtile, they were referened from nother soure when possile. In prtiulr, when test dministrtion time ws not stted, it ws otined from Burns et l., 16 with the exeption of the BLT/Ash nd Short IQCODE in whih it ws not reported in either soure. Qulity nd ppliility informtion out eh sreening instrument ws otined ording to modified version (omitting informtion not relevnt to dementi sreening instruments) of the Cohrne riteri 22 : 1. Overll study vlidity (qulity) referene stndrd used for dignosis of dementi.. Test linding were the referene stndrd nd sreening instrument dministered/mesured independently of eh other?. Avoidne of verifition is ws the hoie of sujets who were ssessed independent of the results of the sreening instrument?. Ws the sreening instrument mesured independently of ll other linil informtion? 2. Diret nd indiret mesures of ppliility. Sreening instrument issues Totl smple size; Overll ge; Perentge of mles (for omplete smple); Threshold used for deteting dementi; Perentge of sujets exluded euse test ws not fesile or the result ws indeterminte; nd Dementi prevlene. Clinil issues TABLE 1. Performne of Instruments Vlidted in Two Distint Smples or Inptient or Outptient Settings Instrument Sensitivity (%) Speifiity (%) Are Under the Curve (95% CI) Positive Preditive Vlue d Negtive Preditive Vlue d (95% CI) # Mislssifition (%) d Edution Bis Lnguge/Culture Bis Interrter Reliility Test Retest Reliility Internl Consisteny Fe Vlidity f Time 6-Item Cognitive Impirment Test ( ) ( ) 7-Minute Sreen ( ) ( ) ( ) ( ) Bowles-Lngley Tehnology/ 1 67 Ashford Memory Test MAT s ( ) ( ) ( ) ( ) Rowlnd Universl Dementi Assessment Sle ( ) ( ) ( ) ( ) ( ) Short Test of Mentl Sttus e 5 ( ) ( ) ( ) ( ) Time nd Chnge Test s ( ) ( ) ( ) ( ) Demonstrted to fulfill riterion dequtely. Demonstrted to not fulfill this riterion. Insuffiient/no pulished dt on this riterion. d Clulted using DAGStt progrm 68 (when possile) if not reported in the rtile. e For severe lnguge diffiulties. f Bsed on Dignosti nd Sttistil Mnul of Mentl Disorders, Fourth Edition 62 riteri requiring tht instruments test memory nd t lest one other ognitive domin. CI: onfidene intervl. Am J Geritr Psyhitry 14:5, My

4 Cognitive Sreening in Primry Cre TABLE 2. Performne of Instruments Vlidted in Generl Prtie, Community or Popultion Smples Instrument Sensitivity (%) Speifiity (%) Are Under the Curve (95% CI) Positive Preditive Vlue d Negtive Preditive Vlue d (95% CI)# Mislssifition (%) d Edution Bis Lnguge/Culture Bis Interrter Reliility Test Retest Reliility Internl Consisteny Fe Vlidity f Time in Minutes Arevited Mentl Test , ( ) ( ) ( ) Cmridge Cognitive e Exmintion ( ) ( ) ( ) ( ) Clok Drwing Test ( ) ( ) ( ) ( ) Generl Prtitioner Assessment of Cognition ( ) ( ) ( ) ( ) ( ) Mini-Cog ( ) ( ) ( ) ( ) Memory Impirment Sreen ( ) ( ) ( ) ( ) Mini-Mentl Sttus ,19, Exmintion ( ) ( ) ( ) ( ) Short nd Sweet Sreening Instrument ( ) ( ) ( ) ( ) Short Informnt s, g Questionnire on Cognitive Deline in the Elderly ( ) ( ) ( ) ( ) Demonstrted to fulfill riterion dequtely. Demonstrted to not fulfill this riterion. Insuffiient/no pulished dt on this riterion. d Clulted using the DAGStt progrm 68 (when possile) if not reported in the rtile. e From memory lini smple. f Bsed on Dignosti nd Sttistil Mnul of Mentl Disorders, Fourth Edition 62 riteri requiring tht instruments test memory nd t lest one other ognitive domin. g Estimted y the uthors s tking 30 seonds to dminister, euse it theoretilly only requires test dministrtor to hnd to the ptient for self-ompletion. CI: onfidene intervl. Severity of dementi; nd Setting (e.g., two distint smples, outptient). Primry re ws the setting within primry re? d. Comorid onditions for ptients with dementi Further informtion ws otined out test is nd prtil needs of GPs, sensitivity, speifiity, re under the reeiver operted hrteristis urve (AUC), positive preditive vlidity (PPV), negtive preditive vlidity (NPV), mislssifition rte, edution is, lnguge/ulture is, interrter reliility, test retest reliility, internl onsisteny, fe vlidity, onstrut vlidity, time to dminister, ese of dministrtion, nd use of informnt dt. Seletion of Instruments. The following seletion riteri were used to determine the most suitle instruments for generl prtie from the full list of instruments identified y the literture serh: 1. Vlidted in ommunity, popultion, or generl prtie smple. 2. Simple to dminister. 3. Administrtion time numerilly 5 minutes. 4. Mislssifition rte numerilly MMSE. 5. NPV numerilly MMSE. The PPV ws not onsidered, euse ll vlues were generlly low nd were dependent on prevlene. Suitle instruments were hosen nd then ompred sed on overll study vlidity, ppliility, nd psyhometri nd dministrtion hr- 394 Am J Geritr Psyhitry 14:5, My 2006

5 Brodty et l. teristis. We reviewed the literture on the performne of the MMSE s sreening test in generl prtie or ommunity popultions. Rtes of sensitivity rnged from 64.8% 100%, speifiity from 81% 93.3%, nd negtive preditive vlues from 91.1% 99.2%. 19,23 27 We used the rtes quoted y Wind et l. 27 s representtive (see susequently) of the vlues reported y others nd euse they were otined from onseutive ptients ttending generl prtie, preisely the popultion for whih we imed this review. RESULTS Systemti Literture Serh Eighty-three full-text rtiles were otined generting summries of 16 sles: 1. Seven-minute sreen (7-Minute Sreen 28 ) 2. A Short Form of the IQCODE (Short IQCODE 29 ) 3. Arevited Mentl Test (AMT 30 ) 4. Bowles-Lngley Tehnology/Ashford Memory Test (BLT/Ash 31 ) 5. Cmridge Cognitive Exmintion (CAMCOG 32 ) 6. The CDT sored using the 10-point Sunderlnd sle Memory Impirment Sreen (MIS 34 ) 8. Mentl Alterntion Test (MAT 35 ) 9. Mini-Cog MMSE Short nd Sweet Sreening Instrument (SASSI 37 ) 12. Short Test of Mentl Sttus (STMS 38 ) 13. The 6-Item Cognitive Impirment Test (lso lled The Short Blessed Test nd The Short Orienttion Memory Conentrtion Test; 6CIT 39 ) 14. The Generl Prtitioner Assessment of Cognition (GPCOG 40 ) 15. The Rowlnd Universl Dementi Assessment Sle (RUDAS 41 ) 16. Time nd Chnge Test (T&C 42 ) Instrument nd Study Prmeters Tles 3 nd 4 show the instruments qulity nd ppliility. Most studies used linil dignosis s the referene stndrd, nd voided verifition is; however, only the RUDAS nd CDT studies inluded linded mesurement of the test nd referene stndrd. 41,43 Rters of the RUDAS nd CDT were linded to ll other linil informtion. 41,43 Most instruments were vlidted on resonly lrge smple sizes with men ge (or ge rnge) representtive of ptients with dementi in the ommunity (65 yers nd over). The perentge of mles ws not speified in severl studies 29,31,43 45 ; only 22% of the RUDAS smple were mle. 41 The threshold for determining ognitive sttus ws speified for ll instruments, nd the perentge exluded euse testing ws indeterminte or unfesile ws generlly low. A vlidtion smple with higher prevlene of dementi thn the demogrphi of interest n inflte the performne of sreening instrument. The prevlene of dementi for people over 75 yers, puttive key demogrphi for routine sreening, is round 15%. 46 The T&C, AMT, CAMCOG, CDT, short IQCODE, Mini-Cog, MIS, nd SASSI were ll vlidted in studies with prevlene rtes pproximtely less thn or equl to this vlue. 29,34,37,43,45,47 49 Mny studies did not speify dementi severity nd the 7-Minute Sreen vlidtion ws speifi to Alzheimer disese. 44 Only four instruments were vlidted within primry re settings. 27,40,43,44 Approximtely hlf the instruments were vlidted in generl prtie, ommunity, or popultion smples, 27,29,34,37,40,47 49 nd their performne ws tulted seprtely (Tle 2) to those vlidted in distint smples (Tle 1). All studies, with the exeption of the BLT/Ash, were rted y the uthors s hving onstrut vlidity sed on ville informtion (orreltion with relted nd unrelted onstruts s well s ility to predit dementi). All instruments exept the 7-Minute Sreen nd the CAMCOG were judged to e esy to dminister. The AMT, CAMCOG, nd Short IQCODE were the only instruments to use informnt dt. Seletion of Instruments Of the instruments meeting the first of the seletion riteri (Tle 2), the AMT, CDT, GPCOG, Short IQCODE, Mini-Cog, nd MIS hd dministrtion times of 5 minutes or less. Eh of these hd NPV MMSE (0.92). Only the GPCOG, Mini-Cog, nd Am J Geritr Psyhitry 14:5, My

6 Cognitive Sreening in Primry Cre TABLE 3. Overll Study Vlidity (qulity) Instrument Soure Referene Stndrd 6-Item Cognitive Impirment Test Brooke nd Bullok 57 Clinil dignosis 7-Minute Sreen Solomon nd Clinil dignosis (NINCDS-ADRDA Pendleury 44 riteri) Arevited Mentl Test Srsquet et l. 49 Clinil dignosis (DSM-IV) Bowles-Lngley Tehnology/ Bowles-Lngley Ashford Memory Test Tehnology 31 Cmridge Cognitive Lolk et l. 47 Clinil dignosis (DSM-III nd Exmintion NINCDS-ADRDA riteri) Clok Drwing Test Kiry et l. 43 GMS-AGECAT Generl Prtitioner Assessment Brodty et l. 40 Clinil dignosis (CAMDEX nd of Cognition DSM-IV) Mentl Alterntion Test Sli nd MCrthy 58 Mini-Mentl Sttus Exmintion nd/or linil dignosis (NINCDS-ADRDA riteri) Mini-Cog Borson et l. 48 Clinil dignosis (DSM-III-R nd NINCDS-ADRDA riteri) Memory Impirment Sreen Bushke et l. 34 Clinil dignosis (DSM-III-R nd NINCDS-ADRDA riteri) Mini-Mentl Sttus Exmintion Wind et l. 27 GP dignosis (CAMDEX nd GMS- AGECAT) Rowlnd Universl Dementi Storey et l. 41 Clinil dignosis y geritriin Assessment Sle Short nd Sweet Sreening Belle et l. 37 Clinil dignosis plus Instrument MMSE/memory tests nd test Short Informnt Questionnire on Cognitive Deline in the Elderly Jorm 29 Test Blinding Avoidne of Verifition Bis Test Independent of All Other Clinil Informtion ttery Clinil dignosis (DSM-III-R) Short Test of Mentl Sttus Kokmen et l. 38 Clinil dignosis (DSM-III nd NINCDS-ADRDA riteri) Time nd Chnge Test Froehlih et l. 45 mbdrs 4, or mbdrs 2 nd MMSE 20 with 6-month ognitive symptoms Test nd referene stndrd lind to eh other. Test nd referene stndrd not lind to eh other. Insuffiient/no pulished dt on this riterion. CAMDEX: Cmridge Mentl Disorders of the Elderly Exmintion 59 ; DSM-III: Dignosti nd Sttistil Mnul of Mentl Disorders, Third Edition 60 ; DSM-III-R: Dignosti nd Sttistil Mnul of Mentl Disorders, Third Edition, Revised 61 ; DSM-IV: Dignosti nd Sttistil Mnul of Mentl Disorders, Fourth Edition 62 ; GMS-AGECAT: Geritri Mentl Stte Automted Geritri Exmintion for Computer Assisted Txonomy 63,64 ; mbdrs: Modified Blessed Dementi Rting Sle 65 ; NINCDS-ADRDA: Ntionl Institute of Neurologil nd Communitive Disorders nd Stroke Alzheimer s Disese nd Relted Disorders Assoition. 66 MIS lso hd mislssifition rte MMSE (15% 29,34,40,43,48,49 ) nd were therefore hosen s the most suitle instruments for use in generl prtie. As well s fulfilling the seletion riteri, the GPCOG, Mini-Cog, nd MIS hd high sensitivity nd speifiity ( 80%) nd were vlidted in studies showing resonle qulity nd ppliility to generl prtie (lrge smple size, linil dignosis used s the referene stndrd). The GPCOG smple hd dementi prevlene of 29%, 40 suggesting tht it my not perform s well in generl prtie setting where prevlene is lower. The GPCOG nd MIS hd high AUC vlues. The PPV of the GPCOG nd MIS were lso numerilly superior to the MMSE. Only the GPCOG inorported informnt informtion nd demonstrted good interrter reliility, test retest reliility, nd ptient nd GP stisftion in its vlidtion. 40 Unlike the MIS or Mini-Cog, the GPCOG shows edution is nd hs not een ssessed for lnguge/ulturl 396 Am J Geritr Psyhitry 14:5, My 2006

7 Brodty et l. TABLE 4. Diret nd Indiret Mesures of Appliility nd Qulity Sreening Instrument Issues Instrument Soure Smple Size (inluded sujets) Smple Age in Yers (omplete smple) Perent Mles (omplete smple) Threshold Used Dementi Prevlene (%) Sreening Instrument Issues 6-Item Cognitive Impirment Test Brooke nd Bullok Men / Minute Sreen Solomon nd 120 Men Proility 0.9 from logisti regression 50 Pendleury 44 Arevited Mentl Test Srsquet et l /8 12 Bowles-Lngley Tehnology/Ashford Memory Test Bowles-Lngley Tehnology 31 90% Cmridge Cognitive Exmintion Lolk et l Clok Drwing Test Kiry et l Men Generl Prtitioner Assessment of Cognition Brodty et l Men ptient setion, or 5 8 ptient 3 informnt Mentl Alterntion Test Sli nd MCrthy Mini-Cog Borson et l. 48 1,179 Men rell 0 or rell 3 nd norml lok 6 Memory Impirment Sreen Bushke et l Men Mini-Mentl Sttus Exmintion Wind et l Men rml 24 30, devint Rowlnd Universl Dementi Assessment Storey et l Men Sle Short nd Sweet Sreening Instrument Belle et l. 37 1,178 Men Mini-Mentl Sttus Exmintion 27 nd verl flueny 23 or temporl orienttion 2 Short Informnt Questionnire on Cognitive Deline in the Elderly Jorm / Short Test of Mentl Sttus Kokmen et l Men Time nd Chnge Test Froehlih et l vlidity, Any inorret response reliility Clinil Issues Instrument Soure Severity of Dementi Setting Primry Cre 6-Item Cognitive Impirment Brooke nd Bullok 57 Mild 2 7-Minute Sreen Solomon nd Alzheimer disese 2 Pendleury 44 Arevited Mentl Test Srsquet et l. 49 C Bowles-Lngley Tehnology/Ashford Memory Test Bowles-Lngley Tehnology 31 2 Cmridge Cognitive Exmintion Lolk et l. 47 Mild moderte P Clok Drwing Test Kiry et l. 43 GP Generl Prtitioner Assessment of Cognition Brodty et l. 40 Mild severe GP Mentl Alterntion Test Sli nd MCrthy 58 Mild severe 2 Mini-Cog Borson et l. 48 P Memory Impirment Sreen Bushke et l. 34 C Mini-Mentl Sttus Exmintion Wind et l. 27 Miniml severe GP Rowlnd Universl Dementi Assessment Sle Storey et l. 41 Mild severe 2 Short nd Sweet Sreening Instrument Belle et l. 37 C Jorm 29 C Short Informnt Questionnire on Cognitive Deline in the Elderly Short Test of Mentl Sttus Kokmen et l. 38 Mild moderte O Time nd Chnge Test Froehlih et l. 45 O 29 6 Demonstrted to fulfill riterion dequtely. Demonstrted to not fulfill this riterion. Insuffiient/no pulished dt on this riterion. 2: two distint smples; I: inptient; O: outptient; C: ommunity; P: popultion; GP: generl prtie. Am J Geritr Psyhitry 14:5, My

8 Cognitive Sreening in Primry Cre is. 34,40,48 The GPCOG hs lso een trnslted nd vlidted in Frenh 50 nd Itlin. 51 DISCUSSION The GPCOG, Mini-Cog, nd MIS were hosen s the most suitle instruments for use in generl prtie. This review found tht these fulfilled riteri of eing quik nd esy to dminister while hving psyhometri properties similr to the MMSE nd onfirmed the findings of Lorentz et l. 18 despite using differing methodology. Vritions in study prmeters lter the performne of sreening instrument. It is limittion of the review tht ll 16 instruments hve not een vlidted in the sme study smple. Although mny newer instruments hve een vlidted in only one or two studies, instruments suh s the MMSE show rnge of performne over mny studies. Positive preditive vlidity of the MMSE hs een shown to vry from , NPV from , sensitivity from 21% 100% nd speifiity from 46% 100%. 19 Otining the performne of the MMSE from only one vlidtion study my e limittion; however, the sreening prmeters otined from Wind et l. 27 (PPV 0.63, NPV 0.92, sensitivity 69%, speifiity 89%) show n overll is in fvor of the MMSE, thus setting higher riteri ginst whih to ompre the other instruments. Routine sreening ould doule the numer of ptients with dementi identified y GPs, 52 lthough these dignoses nnot e mde solely on the sis of sreening. Ptients sreening positive require further linil evlution to onfirm dignosis of dementi nd to exlude depression or ute medil illnesses. 12 Mny GPs refer ptients with ognitive impirment to speilists, 9 nd the finl dignosis of dementi is usully mde y neurologist, geritriin, or psyhogeritriin. 2 There is roder dete out the use of sreening. Most ptients identified re likely to hve dementi of mild or moderte severity. 52 Although there re strong rguments for sreening, these enefits hve not een diretly ssessed. Adverse effets suh s inresed nxiety nd/or depression 52 nd the onsequenes of leling re lso possile from sreening positive, lthough Jh et l. 53 found tht despite onurrent upset, the mjority of ptients with dementi preferred to e informed of their dignosis. Should glol sreening e undertken for onditions for whih there is no ure? Sreening for hypertension nd ertin ners re redily supported; however, if only modestly effetive or symptomti tretments re ville like in Alzheimer disese, is routine ognitive testing justifile? Clerly sreening should not e ontemplted for low-frequeny onditions, ut it my e worthwhile for GP ttendees ged 75 yers or more in whih prevlene exeeds 15%, PPV is over 70%, nd NPV exeeds 90%. Even so, positive sreen is only first step. It is importnt tht GPs rry out follow-up ssessments nd referrls, ppropritely edute nd ounsel ptients nd fmilies, nd hve up-to-dte tretment knowledge. Flse-positive sreening results ould led to unneessry tretment nd ost, lthough these osts my e offset y finnil gins from erly tretment of genuine ses. 4 Flse-negtive results my give misleding ressurne, ut these ses would not hve een dignosed without sreening, nd ontinued sreening would possily identify them in the future. The fmilies of ptients must lso e onsidered. Erlier dignosis my led to etter long-term outomes for regivers; edution nd erlier intervention for regivers n redue depression nd psyhologi, physil, soil, nd finnil urden, nd inrese onfidene nd pereived ompetene. 54,55 Whether or not GPs should dopt routine sreening for ognitive impirment remins moot question. If nswered in the ffirmtive, usully for n older popultion (e.g., 75 yers or older) or when ognitive impirment is suspeted, then the GPCOG, Mini-Cog, or MIS ppers suitle for routine use. The GPCOG should e further investigted for its potentil for lnguge or ulturl is, lthough using the informnt setion lone ppers to perform well ross ultures nd should e free of these ises. 57 The Mini-Cog nd MIS should e the trget of further reserh to sertin their level of GP nd ptient stisftion. Computerized versions ould e mde ville in ommonly used desktop progrms. Routine sreening needs to e supplemented y edution out use of suitle instruments nd trining on the mngement of dementi. Support from deprtments of helth, GP divisions/ol- 398 Am J Geritr Psyhitry 14:5, My 2006

9 Brodty et l. leges, nd phrmeutil ompnies my lso e enefiil in enourging GPs nd inresing wreness of the dvntges of testing with these instruments. Funding ws provided y the New South Wles Deprtment of Helth. The uthors thnk Dr. Kte Jkson nd Dr. Roert Yeoh who provided dvie out the projet. Referenes 1. Bond J, Stve C, Sgng A, et l: Inequlities in dementi re ross Europe: key findings of the Fing Dementi Survey. Int J Clin Prt 2005; 59 (suppl): Wilkinson D, Stve C, Keohne D, et l: The role of generl prtitioners in the dignosis nd tretment of Alzheimer s disese: multintionl survey. J Int Med Res 2004; 32: Boise L, Cmiioli R, Morgn DL, et l: Dignosing dementi: perspetives of primry re physiins. Gerontologist 1999; 39: Ashford JW: Developing pprohes to Alzheimer sreening. Sreening for Alzheimer s disese: Generl priniples. Interntionl Psyhogeritri Assoition s Eleventh Interntionl Congress. 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