Gpcog.com.au

CLINICAL REVIEW
What Is the Best Dementia Screening
Instrument for General Practitioners to Use?
Henry Brodaty, M.B.B.S., M.D., F.R.A.C.P., F.R.A.N.Z.C.P.,
Lee-Fay Low, B.Sc.(Psych.)Hons.,
Louisa Gibson, B.Sc.(Arch.), Grad. Dip. Psych., B.Sc.(Psych.)Hons.,
Kim Burns, R.N., B.Psych.(Hons.)
Objective: The objective of this study was to review existing dementia screening tools
with a view to informing and recommending suitable instruments to general prac-
titioners (GPs) based on their performance and practicability for general practice.
Method: A systematic search of pre-MEDLINE, MEDLINE, PsycINFO, and the Cochrane
Library Database was undertaken. Only available full-text articles about dementia
screening instruments written in English or with an English version were included. Articles using a translation of an English language instrument were excluded unless validated in a general practice, community, or population sample. Results: The
General Practitioner Assessment of Cognition (GPCOG), Mini-Cog, and Memory
Impairment Screen (MIS) were chosen as most suitable for routine dementia screen- ing in general practice. The GPCOG, Mini-Cog, and MIS were all validated in com- munity, population, or general practice samples, are easy to administer, and have administration times of 5 minutes or less. They also have negative predictive validity and misclassification rates, which do not differ significantly from those of the Mini-Mental Status Examination. Conclusions: It is recommended that GPs consider
using the GPCOG, Mini-Cog, or MIS when screening for cognitive impairment or for
case detection. (Am J Geriatr Psychiatry 2006; 14:391–400) Key Words: Diagnosis, dementia, screening, Alzheimer disease, primary care
Thedetectionandearlydiagnosisofdementiaare Early diagnosis may enable patients to plan for the becoming increasingly important as our popula- future while still competent, initiate enduring power tion ages. Delays to diagnosis of 8 –32 months from of attorney and guardianship, address safety con- symptom onset and caregivers’ dissatisfaction with cerns such as driving ability, and enable caregivers to their general practitioner’s (GP’s) knowledge and seek education sooner.3,4 Available pharmaceutical ability to diagnose dementia in its initial stages,1,2 treatments may slow dementia progress5 and reduce indicate a need for earlier diagnosis.
costs through delayed nursing home placement.4 Received December 8, 2005; revised December 22, 2005; accepted February 6, 2006. From the Academic Department for Old Age Psychiatry,Euroa Centre, Prince of Wales Hospital, Randwick, Australia (HB, LG); the School of Psychiatry, University of New South Wales, Sydney, Australia(HB, KB); and Centre for Mental Health Research Building 63, The National University, Canberra, Australia (L-FL). Send correspondence andreprint requests to Dr. Henry Brodaty, Academic Department for Old Age Psychiatry, Euroa Centre, Prince of Wales Hospital, Barker St., RandwickNSW 2031, Australia. e-mail: h.brodaty@unsw.edu.au 2006 American Association for Geriatric Psychiatry Cognitive Screening in Primary Care Open-label extension trials suggest that cholinester- general practice. In addition, we wanted to consider ase inhibitors are not as effective in stemming cog- psychometric properties in studies of populations of nitive decline if commencement is delayed.5 patients akin to those in primary care, i.e., distinct General practitioners may be best placed to detect from studies of distinct cognitively impaired and and treat dementia in its early stages. Wilkinson et normal samples, which maximize test performance al.2 found that 79% of people thought GPs were easily accessible, with 74% consulting a GP first afternoticing symptoms of cognitive decline. Despite theadvantages of early diagnosis, GPs fail to identify up to 91% of dementia cases depending on their sever-ity.6 Some reject routine screening7; however, a The review was conducted in three stages. First, a growing consensus recommends routinely screening literature search was undertaken to identify avail- patients for cognitive impairment when they are able screening instruments and validation studies.
over a certain age (e.g., 75 years) or when cognitive Second, instrument and study parameters were ob- tained for each instrument identified in the literature At present, only 39% of Australian GPs9 and 26% search. Third, suitable instruments were chosen for of Canadian GPs13 regularly screen for dementia.
recommendation to GPs based on a set of selection General practitioners report limited time and lack of a cure and suitable screening tools as explanationsfor their failure to diagnose and screen for dementia,9 Systematic Literature Search
and many GPs do not attempt to screen patients evenwhen cognitive impairment is suspected.3 A systematic search of pre-MEDLINE and MED- The Mini-Mental Status Examination (MMSE14), LINE (between 1966 and January 2004), PsycINFO the most commonly used instrument,13 shows edu- (between 1974 and January 2004), and the Cochrane cation and language/cultural bias15 and is described Library Database was undertaken for English lan- by GPs as impractical3 because it takes 10 minutes to guage articles reporting development, validation, or administer.16 General practitioners have identified psychometric properties of dementia screening in- the need for a shorter instrument,9 and a Canadian struments. The key words “dementia” or “cognitive survey found that 93% would use a brief and simple impairment” combined with “screening” or “diagno- screening instrument.13 With average Western GP sis” and the MESH terms “Alzheimer disease/diag- consultation times ranging from 8 –11 minutes,17 nosis” or “dementia/diagnosis” combined with simple and effective instruments with administration “mass screening” and “neuropsychological tests/sta- times of five minutes or less seem most suitable for tistics and numerical data” were used, yielding 11,229 titles. The titles of individual scales were also Although the needs of GPs have been identified, entered individually as key words, and reference reviews of dementia screening instruments have lists of included articles were hand searched. A val- largely focused on individual scales such as the idation study from May 2004 was later included.
MMSE,19 the Clock Drawing Test (CDT20), and The Only papers available in full text and instruments Informant Questionnaire on Cognitive Decline in the written in English or with an English version avail- Elderly (IQCODE21). An exception is a review by able were included. Articles using a translation of an Lorentz et al.,18 which divided instruments accord- English language scale were excluded unless vali- ing to cognitive tests subdivided by administration dated in a general practice, community, or popula- time, informant or proxy-rated screening instru- ments, and remote (telephone and mail) dementiascreening instruments. Our article also aimed to 1) Instrument and Study Parameters
review existing dementia screening tools with a viewto informing and recommending instruments to GPs; One empiric paper was chosen to represent each and 2) consider specifically test performance, time instrument identified in the literature search. Articles taken, ease of administration, and practicability for that validated an instrument in a general practice, community, or population sample were preferen- 1. Overall study validity (quality)—reference stan- tially chosen. If no such article was available (or there dard used for diagnosis of dementia.
were several), the paper that contained the most a. Test blinding—were the reference standard and information about the instrument (in terms of the screening instrument administered/measured inde- screening parameters listed in Tables 1 and 2) was chosen. If information about the properties of the b. Avoidance of verification bias—was the choice of subjects who were assessed independent of the bias, test–retest reliability, internal consistency, or administration time) was not stated in the article, c. Was the screening instrument measured inde- they were referenced from another source when pendently of all other clinical information? possible. In particular, when test administration 2. Direct and indirect measures of applicability time was not stated, it was obtained from Burns et al.,16 with the exception of the BLT/Ash and Short IQCODE in which it was not reported in either Percentage of males (for complete sample); Quality and applicability information about each screening instrument was obtained according to a Percentage of subjects excluded because test was modified version (omitting information not relevant not feasible or the result was indeterminate; and to dementia screening instruments) of the Cochrane Performance of Instruments Validated in Two Distinct Samples or Inpatient or Outpatient Settings
Reliability
Reliability
Predictive d
Predictive #
Consistency
Validity
Instrument
Sensitivity
Specificity
Positive
Negative
Misclassification
Education
Language/Culture
Interrater
Test–Retest
Internal
(0.76–0.96) (0.88–0.97) (0.88–0.98) (0.87–1.00) (0.78–0.97) aDemonstrated to fulfill criterion adequately.
bDemonstrated to not fulfill this criterion.
cInsufficient/no published data on this criterion.
dCalculated using “DAGStat” program68 (when possible) if not reported in the article.
eFor severe language difficulties.
fBased on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition62 criteria requiring that instruments test memory and at least Cognitive Screening in Primary Care Performance of Instruments Validated in General Practice, Community or Population Samples
Reliability
Reliability
Predictive d
Predictive
Consistency
Validity
Instrument
Sensitivity
Specificity
Positive
Negative
Misclassification
Education
Language/Culture
Interrater
Test–Retest
Internal
aDemonstrated to fulfill criterion adequately.
bDemonstrated to not fulfill this criterion.
cInsufficient/no published data on this criterion.
dCalculated using the “DAGStat” program68 (when possible) if not reported in the article.
eFrom memory clinic sample.
fBased on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition62 criteria requiring that instruments test memory and at least gEstimated by the authors as taking 30 seconds to administer, because it theoretically only requires a test administrator to hand to the patient Selection of Instruments. The following selection Setting (e.g., two distinct samples, outpatient) criteria were used to determine the most suitable c. Primary care—was the setting within primary instruments for general practice from the full list of instruments identified by the literature search: d. Comorbid conditions for patients with dementia 1. Validated in a community, population, or gen- Further information was obtained about test bias and practical needs of GPs, sensitivity, specificity, area under the receiver operated characteristics 3. Administration time numerically Յ5 minutes.
curve (AUC), positive predictive validity (PPV), neg- 4. Misclassification rate numerically Յ MMSE.
ative predictive validity (NPV), misclassification rate, education bias, language/culture bias, interra- The PPV was not considered, because all values ter reliability, test–retest reliability, internal consis- were generally low and were dependent on preva- tency, face validity, construct validity, time to ad- lence. Suitable instruments were chosen and then minister, ease of administration, and use of compared based on overall study validity, applica- bility, and psychometric and administration charac- teristics. We reviewed the literature on the perfor- however, only the RUDAS and CDT studies in- mance of the MMSE as a screening test in general cluded blinded measurement of the test and refer- practice or community populations. Rates of sensi- ence standard.41,43 Raters of the RUDAS and CDT tivity ranged from 64.8%–100%, specificity from were blinded to all other clinical information.41,43 81%Ϫ93.3%, and negative predictive values from Most instruments were validated on reasonably 91.1%–99.2%.19,23–27 We used the rates quoted by large sample sizes with a mean age (or age range) Wind et al.27 as representative (see subsequently) of representative of patients with dementia in the com- the values reported by others and because they were munity (65 years and over). The percentage of males obtained from consecutive patients attending general was not specified in several studies29,31,43–45; only practice, precisely the population for which we 22% of the RUDAS sample were male.41 The thresh- old for determining cognitive status was specified forall instruments, and the percentage excluded becausetesting was indeterminate or unfeasible was gener-ally low.
A validation sample with a higher prevalence of dementia than the demographic of interest can in-flate the performance of a screening instrument. The Systematic Literature Search
prevalence of dementia for people over 75 years, a Eighty-three full-text articles were obtained gener- putative key demographic for routine screening, is around 15%.46 The T&C, AMT, CAMCOG, CDT, 1. Seven-minute screen (7-Minute Screen28) short IQCODE, Mini-Cog, MIS, and SASSI were all 2. A Short Form of the IQCODE (Short IQCODE29) validated in studies with prevalence rates approxi- mately less than or equal to this value.29,34,37,43,45,47–49 4. Bowles-Langley Technology/Ashford Memory Many studies did not specify dementia severity and the 7-Minute Screen validation was specific to 5. Cambridge Cognitive Examination (CAMCOG32) Alzheimer disease.44 Only four instruments were 6. The CDT scored using the 10-point Sunderland validated within primary care settings.27,40,43,44 Ap- proximately half the instruments were validated in general practice, community, or population sam- ples,27,29,34,37,40,47–49 and their performance was tab- ulated separately (Table 2) to those validated in dis- tinct samples (Table 1). All studies, with the 11. Short and Sweet Screening Instrument (SASSI37) exception of the BLT/Ash, were rated by the authors as having construct validity based on available infor- 13. The 6-Item Cognitive Impairment Test (also mation (correlation with related and unrelated con- called The Short Blessed Test and The Short Orien- structs as well as ability to predict dementia). All tation–Memory–Concentration Test; 6CIT39) instruments except the 7-Minute Screen and the 14. The General Practitioner Assessment of Cogni- CAMCOG were judged to be easy to administer. The AMT, CAMCOG, and Short IQCODE were the only 15. The Rowland Universal Dementia Assessment Selection of Instruments
Of the instruments meeting the first of the selec- Instrument and Study Parameters
tion criteria (Table 2), the AMT, CDT, GPCOG, Short Tables 3 and 4 show the instruments’ quality and IQCODE, Mini-Cog, and MIS had administration applicability. Most studies used clinical diagnosis as times of 5 minutes or less. Each of these had a NPV the reference standard, and avoided verification bias; ՆMMSE (0.92). Only the GPCOG, Mini-Cog, and Cognitive Screening in Primary Care Overall Study Validity (quality)
Test Independent
Avoidance of
of All Other
Verification
Clinical
Instrument
Reference Standard
Blinding
Information
12–24 and/or clinicaldiagnosis (NINCDS-ADRDAcriteria) MMSE Ͻ20 with Ն6-monthcognitive symptoms aTest and reference standard blind to each other.
bTest and reference standard not blind to each other.
cInsufficient/no published data on this criterion.
CAMDEX: Cambridge Mental Disorders of the Elderly Examination59; DSM-III: Diagnostic and Statistical Manual of Mental Disorders, Third Edition60; DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised61; DSM-IV: Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition62; GMS-AGECAT: Geriatric Mental State–Automated Geriatric Examination for Computer AssistedTaxonomy63,64; mBDRS: Modified Blessed Dementia Rating Scale65; NINCDS-ADRDA: National Institute of Neurological and CommunicativeDisorders and Stroke–Alzheimer’s Disease and Related Disorders Association.66 MIS also had a misclassification rate Յ MMSE it may not perform as well in a general practice (15%29,34,40,43,48,49) and were therefore chosen as the most suitable instruments for use in general practice.
The GPCOG and MIS had high AUC values. The As well as fulfilling the selection criteria, the PPV of the GPCOG and MIS were also numerically GPCOG, Mini-Cog, and MIS had high sensitivity and superior to the MMSE. Only the GPCOG incorpo- specificity (Ն80%) and were validated in studies rated informant information and demonstrated good showing reasonable quality and applicability to gen- interrater reliability, test–retest reliability, and pa- eral practice (large sample size, clinical diagnosis tient and GP satisfaction in its validation.40 Unlike used as the reference standard). The GPCOG sample the MIS or Mini-Cog, the GPCOG shows education had a dementia prevalence of 29%,40 suggesting that bias and has not been assessed for language/cultural Dementia
Prevalence
Threshold
(complete
(complete
Instrument
Screening
(included
subjects)
Dementia
Severity
Applicability
Measures
Indirect
Instrument
Instrument
Screening
Clinical
Instrument
Cognitive Screening in Primary Care bias.34,40,48 The GPCOG has also been translated and despite concurrent upset, the majority of patients with dementia preferred to be informed of their di-agnosis.
Should global screening be undertaken for condi- tions for which there is no cure? Screening for hy- DISCUSSION
pertension and certain cancers are readily supported;however, if only modestly effective or symptomatic The GPCOG, Mini-Cog, and MIS were chosen as the treatments are available like in Alzheimer disease, is most suitable instruments for use in general practice.
routine cognitive testing justifiable? Clearly screen- This review found that these fulfilled criteria of being ing should not be contemplated for low-frequency quick and easy to administer while having psycho- conditions, but it may be worthwhile for GP attend- metric properties similar to the MMSE and con- ees aged 75 years or more in which prevalence ex- firmed the findings of Lorentz et al.18 despite using ceeds 15%, PPV is over 70%, and NPV exceeds 90%.
Even so, a positive screen is only a first step. It is Variations in study parameters alter the perfor- important that GPs carry out follow-up assessments mance of a screening instrument. It is a limitation of and referrals, appropriately educate and counsel pa- the review that all 16 instruments have not been tients and families, and have up-to-date treatment validated in the same study sample. Although many knowledge. False-positive screening results could newer instruments have been validated in only one lead to unnecessary treatment and cost, although or two studies, instruments such as the MMSE show these costs may be offset by financial gains from a range of performance over many studies. Positive early treatment of genuine cases.4 False-negative re- predictive validity of the MMSE has been shown to sults may give misleading reassurance, but these vary from 0.31–1.00, NPV from 0.43–1.00, sensitivity cases would not have been diagnosed without from 21%–100% and specificity from 46%–100%.19 screening, and continued screening would possibly Obtaining the performance of the MMSE from only one validation study may be a limitation; however, The families of patients must also be considered.
the screening parameters obtained from Wind et al.27 Earlier diagnosis may lead to better long-term out- (PPVϭ0.63, NPVϭ0.92, sensitivityϭ69%, specifici- comes for caregivers; education and earlier interven- tyϭ89%) show an overall bias in favor of the MMSE, tion for caregivers can reduce depression and psy- thus setting higher criteria against which to compare chologic, physical, social, and financial burden, and increase confidence and perceived competence.54,55 Routine screening could double the number of Whether or not GPs should adopt routine screen- patients with dementia identified by GPs,52 although ing for cognitive impairment remains a moot ques- these diagnoses cannot be made solely on the basis of tion. If answered in the affirmative, usually for an screening. Patients screening positive require further older population (e.g., 75 years or older) or when clinical evaluation to confirm a diagnosis of demen- cognitive impairment is suspected, then the GPCOG, tia and to exclude depression or acute medical ill- Mini-Cog, or MIS appears suitable for routine use.
nesses.12 Many GPs refer patients with cognitive im- The GPCOG should be further investigated for its pairment to specialists,9 and the final diagnosis of potential for language or cultural bias, although us- dementia is usually made by a neurologist, geriatri- ing the informant section alone appears to perform well across cultures and should be free of these bi- There is a broader debate about the use of screen- ases.57 The Mini-Cog and MIS should be the target of ing. Most patients identified are likely to have de- further research to ascertain their level of GP and mentia of mild or moderate severity.52 Although patient satisfaction. Computerized versions could be there are strong arguments for screening, these ben- made available in commonly used desktop pro- efits have not been directly assessed. Adverse effects grams. Routine screening needs to be supplemented such as increased anxiety and/or depression52 and by education about use of suitable instruments and the consequences of “labeling” are also possible from training on the management of dementia. Support screening positive, although Jha et al.53 found that from departments of health, GP divisions/col- leges, and pharmaceutical companies may also be Funding was provided by the New South Wales beneficial in encouraging GPs and increasing awareness of the advantages of testing with these The authors thank Dr. Kate Jackson and Dr. Robert Yeoh who provided advice about the project. References
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