- Cognitive Screening Instruments - A Practical Approach | Andrew Larner | Springer
- Cognitive Screening Instruments Practical
- Cognitive Screening Instruments, A Practical Approach, Second Edition
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Cognitive Screening Instruments - A Practical Approach | Andrew Larner | Springer
Criterion diagnosis was by judgment of an experienced clinician based on diagnostic criteria but did not use CSI scores in order to avoid review bias. The following three forms of data analysis were performed, some based on previously published results, 11,30 others requiring re-analysis of individual study data. Firstly, significance testing based on the null hypothesis was undertaken comparing mean test scores for patients with dementia versus MCI, and for patients with MCI versus no cognitive impairment. Significance tests are, of course, post hoc, based on aggregate data once diagnoses have been made, and hence are of limited use in clinical practice where diagnosis is not known beforehand, and parameters such as sensitivity, specificity, predictive values and likelihood ratios are more typically used.
Hence the second analysis was to calculate these measures of discrimination for MCI diagnosis versus SMC, since this would most likely correspond to treatment threshold if any disease-modifying therapy were available. All these descriptors of outcome are dependent on the cut-off, cut point, threshold or dichotomisation point of the test scores selected by the investigator s , which choice may have a major impact on these values.
Cognitive Screening Instruments Practical
This measure is independent of test cut-off chosen, and may be qualified effect sizes of 0. Table 2. Dementia versus MCI: significance testing based on null hypothesis for test scores from pragmatic diagnostic test accuracy studies examining various short cognitive screening instruments; adapted from reference Table 3. MCI versus no cognitive impairment SMC : significance testing based on null hypothesis for test scores from pragmatic diagnostic test accuracy studies examining various short cognitive screening instruments; adapted from reference Measures of discrimination were calculated for diagnosis of MCI versus SMC using specified test cut-offs for those short CSIs reaching or tending to statistical significance on null hypothesis testing see Table 4.
Table 4. Table 5. Of course, this approach is not without its shortcomings.
Pragmatic studies, broadly inclusive with respect to patient age and comorbidity, lack the power of proof-of-concept studies with patient groups pre-selected by diagnosis, although the latter approach is of course alien to day-to-day clinical practice. Moreover, these pragmatic studies were cross-sectional, again the idiom of clinical practice, rather than longitudinal, with consequent risk of inaccurate criterion diagnosis, particularly when attempting to separate MCI and SMC.
Furthermore, the use of purely quantitative aggregate measures may not necessarily be helpful clinically see the Materials and methods section above : since MCI patients may be anticipated to do well on certain aspects of CSIs and poorly on others eg memory recall in amnestic MCI , so the qualitative pattern of impairment on these tests may also be useful clinically, rather than simply using the overall test scores. Nevertheless, pragmatic studies, as analysed in this report, may give indications of potential test utility as a support for MCI diagnosis, or the requirement for further patient investigation or longitudinal assessment.
It was not the purpose of this analysis directly to compare the different CSIs, since the different studies from which the data were taken were not and never could be exactly comparable. Nevertheless, the studies being examined shared a similar setting, methodology eg application of reference standard for diagnosis and analysis, thereby minimising variability, although this could not be entirely excluded eg dementia prevalence, based on the case mix seen in series of unselected consecutive patients.
Cognitive Screening Instruments, A Practical Approach, Second Edition
However, the high false positive rate associated with high sensitivity would argue against the use of these instruments for use in clinical trials where high specificity and low false positive rate is more desirable. In conclusion, a number of short performance-based CSIs may be helpful in clinical practice as a first step to screen for the diagnosis of MCI. Dependent upon their results, more detailed assessment including sophisticated biomarker studies and formal cognitive assessment may be indicated to establish or refute the diagnosis of MCI.
Lancet Neurol ;—29 [Erratum Lancet Neurol ;]. Lancet Neurol ;— Mov Disord ; — Stroke ; — Frontotemporal mild cognitive impairment. J Alzheimers Dis ;—9. Rate of progression of mild cognitive impairment to dementia — meta-analysis of 41 robust inception cohort studies.
Acta Psychiatr Scand ;— Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet ;—6. Kozora E, Filley CM. Cognitive dysfunction and white matter abnormalities in systemic lupus erythematosus. J Int Neuropsychol Soc ;— This has occurred despite the recognized shortcomings of the MMSE, one problem being the time required for its administration.
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In one such modification reported by Belmin et al. In a validation study in elderly people, taking categories C and D as indicators of dementia Belmin et al. Despite these encouraging initial findings, no further validation study of the diagnostic utility of Codex appears to have been published.
Therefore, a pragmatic prospective study to examine Codex screening utility in an independent patient cohort was undertaken. This involved patients attending a cognitive disorders clinic and afforded not only the opportunity to examine Codex utility in the diagnosis of dementia but also of milder forms of cognitive impairment insufficient to reach a criterion diagnosis of dementia. Cognitive screening instruments which are sufficiently sensitive to identify not only cases of dementia but also of MCI are therefore considered desirable in clinical practice.
The aims of the current study were to test the diagnostic utility of Codex in screening for dementia and for cognitive impairment dementia and MCI in day-to-day clinical practice in a large cohort of patients with cognitive complaints of unknown etiology. Dementia in clinical practice: a neurological perspective. Criterion diagnosis was by judgment of an experienced clinician based on diagnostic criteria. Evaluating dementia screening tests. Taking Codex categories C and D as indicators of cognitive impairment cases of dementia and of MCI combined , Codex sensitivity declined 0. In this study, the Codex decision tree proved easy to use; no patient failed to be categorized according to Codex.
The results confirmed the good sensitivity and specificity of Codex for the diagnosis of dementia, although the figures 0. Positive predictive value was poorer 0. There were very few false negative diagnoses 5 , but of note these included both FTD cases.