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International neurological journal 8 (78) 2015

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Comparative Characteristic of Screening Scales for Cognitive Impairment Assessment

Authors: Milevska-Vovchuk L.S. - SHEE «Ternopil State Medical University named after I.Ya. Horbachevskyi» of Ministry of Health in Ukraine, Ternopil, Ukraine

Categories: Neurology

Sections: Clinical researches

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Summary

У роботі йдеться про результати виконаного порівняльного аналізу трьох скринінгових шкал для оцінки когнітивних порушень: Mini-Mental state examination (MMSE), Mini-Cog test, Montreal Cognitive Assessment (MoCA). Нейропсихологічне обстеження провели 25 пацієнтам із цереброваскулярними захворюваннями головного мозку. У результаті проведених досліджень було встановлено, що найменше часу потребує виконання тесту Mini-Cog (у середньому 3 хв), проведення MMSE займало близько 10 хв, а MoCA — 13–15 хв. Тривалість виконання тесту впливала на рівень втомлюваності та виснаження пацієнтів. Результати тесту Mini-Cog не залежали від вихідного рівня освіти, культури та мови. Проте даний тест виявився найменш чутливим і зміг діагностувати лише виражені когнітивні порушення. Перевагами тесту MMSE були можливість визначення рівня когнітивних порушень відповідно до кількості набраних балів та значно вища чутливість порівняно з тестом Mini-Cog. Найчутливішим скринінговим тестом виявився MoCA, проте система формалізованої оцінки даного тесту на сьогодні не передбачає градацію за тяжкістю порушень залежно від набраної кількості балів.
Отже, результати проведених досліджень доводять, що вибір нейропсихологічної методики повинен здійснюватися з урахуванням конкретної клінічної ситуації та умов, у яких вона застосовується. Даний порівняльний аналіз загальноприйнятих скринінгових шкал для визначення когнітивних порушень може бути застосований при плануванні діагностичного пошуку для забезпечення ранньої ефективної верифікації змін інтелектуально-мнестичних функцій.

В работе рассмотрены результаты проведенного сравнительного анализа трех скрининговых шкал для оценки когнитивных нарушений: Mini-Mental state examination (MMSE), Mini-Cog test, Montreal Cognitive Assessment (MoCA). Нейропсихологическое исследование было проведено 25 пациентам с цереброваскулярными заболеваниями головного мозга. В результате проведенных исследований было установлено, что меньше всего времени требует выполнение теста Mini-Cog (в среднем 3 мин), проведение MMSE занимает около 10 мин, а MoCA — 13–15 мин. Длительность выполнения теста влияла на уровень утомляемости и истощения пациентов. Результаты теста Mini-Cog не зависели от исходного уровня образования, культуры и языка. Но данный тест оказался наименее чувствительным и смог диагностировать только выраженные когнитивные нарушения. Преимуществами теста MMSE были возможность определения уровня когнитивных нарушений соответственно количеству набранных баллов и значительно большая чувствительность в сравнении с тестом Mini-Cog. Наиболее чувствительным скрининговым тестом оказался MoCA, но система формализированной оценки данного теста на сегодня не предусматривает градацию по уровню сложности в зависимости от набранного количества баллов.
Таким образом, результаты проведенных исследований доказывают, что выбор нейропсихологической методики должен осуществляться с учетом конкретной клинической ситуации и условий, в которых она применяется. Данный сравнительный анализ общепринятых скрининговых шкал для определения когнитивных нарушений можно использовать при планировании диагностического поиска для ранней эффективной верификации изменений интеллектуально-мнестических функций.

The paper describes the results of the comparative analysis of three cognitive screening scales: Mini-Mental state examination (MMSE), Mini-Cog test, Montreal Cognitive Assessment (MoCA). Neuropsychological examination was conducted in 25 patients with cerebrovascular diseases. It was found out that the performance of Mini-Cog test took 3 minutes approximately, while MMSE — 10 minutes, and MoCA — 13–15 min. The duration of the test impact the level of fatigue and exhaustion of patients. The results of Mini-Cog test do not depend on the initial level of education, culture and language. However, this test was the least sensitive and could only diagnose severe and moderate cognitive impairment. Among the advantages of MMSE were the possibility to determine the level of cognitive impairment according to the number of points and its higher sensitivity compared to Mini-Cog test. The most sensitive screening test was MoCA, but up to now formalized system of this test evaluation does not give possibility to rank the severity of cognitive impairments, according to the number of points.
Thus, the results of the research show that the neuropsychological methods should be selected taking into account the clinical situation and the conditions in which it is conducted. This comparative analysis of cognitive screening scales can be used in the preparation of diagnostic search for effective verification of the early changes in the intellectual and mental functions.


Keywords

когнітивні порушення, Mini-Mental state examination, Mini-Cog test, Montreal Cognitive Assessment.

когнитивные нарушения, Mini-Mental state examination, Mini-Cog test, Montreal Cognitive Assessment.

cognitive impairment, Mini-Mental state examination, Mini-Cog test, Montreal Cognitive Assessment.

Introduction.

Analysis of cognitive functions is still an actual subject of studying for scientists and practitioners. Due to the cognitive functions one can get rational knowledge about the world and provide purposeful interaction with it [6, 17]. Of particular note is the fact that according to current national and international scientific and practical literature cognitive impairment should not be considered a normal aspect of aging [4, 18]. Scientists prove that with age may decrease the rate of cognitive process that manifest as slower assimilation of new skills and overall decreased speed of mental processes. However, having learned a new program or skill, an elderly person can use it as confident as his younger colleagues.

Numerous studies show that cognitive impairment, and related reduction in social, consumer and professional adaptation of different severity is always a manifestation of the disease: diabetes, hypothyroidism; heart rhythm disorders, episodes of atrial fibrillation; angina; heart surgery (coronary artery bypass surgery, stenting, angioplasty); insufficient blood supply to the brain due to heart disease and congestive heart failure; acute and chronic liver disease; uremia; chronic obstructive pulmonary disease; a number of exogenous intoxication (alcohol, drugs, smoking, intake of psychotropic drugs, use of medicines without taking into consideration their interaction); oncopathology (as a result of the direct effects of the tumor, and also due to the chemotherapy and radiation therapy); migraine; depression, etc. [3, 13]. That is why the term «Age-associated memory impairment», proposed by US psychiatrists in the 60-ies of the last century [16], nowadays is considered to be wrong and is not used in modern science and everyday clinical practice.

An objective way of cognitive functions assessment is neuropsychological testing [1, 2, 5]. Its goal is standardization of evaluation criteria, the possibility to compare the dynamics of the patient’s state in order to determine the effectiveness of treatment. Today there are numerous neuropsychological tests of different difficulty levels with precisely defined normative values ​​for a certain age, which makes it possible to compare the cognitive function in different domains [8, 9, 10], such as the perception of information (gnosis), processing and analysis of information (the so called visual-constructional and operational skills as well as voluntary attention, generalization, abstraction and ability to identify similarities and differences, formal-logical operations, establishing of associative relationships; making conclusions; memorization and storage (memory), information exchange, construction and implementation of action programs (called "expressive function", including language, verbal speed and skills of purposeful physical activity (praxis) [12, 15].

There are a number of well-proven standard test sets with quantitative assessment of results that allow to conduct rapid assessment of cognitive functions in a limited time and are widely used in daily clinical practice of neurologist, internist, endocrinologist and family physician. To them belong such screening scales as MMSE (Mini-Mental state examination), MoCA (Montreal Cognitive Assessment) [14], Mini Cog test, including the CDT (clock draw test) - Clock drawing test [7, 11].

The aim of this study was to compare the sensitivity, identify the advantages and disadvantages of different screening scales for its effective use in practical medicine.

Materials and methods.

The group of observation included 25 patients with cerebrovascular diseases (hypertensive encephalopathy, dyscirculative encephalopathy, chronic ischemia of the brain I.67.4 code in ICD-10), who were hospitalized in the Ternopil regional clinical municipal neuropsychiatric hospital. The average age of subjects was - 64,28 ± 1,28 years. The men were 56%. Higher education gained eight (25%) patients, specialized - 11 (44%) patients, remaining 6 (24%) subjects had incomplete secondary education. Study design provided a detailed medical history (concomitant diseases, bad habits, daily physical activity, marital status, surgery in anamnesis, degree of disability), conducting general clinical and neurological examination, selection of leading neurological syndrome or a combination of them.

All patients had a thorough neuropsychological examination using standard screening scales:

· MMSE (Mini-Mental state examination) was developed in 1975 (Folstein MF, Folstein SE & McHugh RP, 1975) "A practical method for grading the cognitive state of patients for the clinician" Journal of psychiatric research 12 (3): 189- 98. It includes 30 questions to assess the orientation in time and place, perception, concentration, short-term and long-term memory, language, reading, writing, design and praxis. Total score from 30 to 28 means the absence of pathological changes, the rate 27 to 24 – cognitive decline, 23 - 20 - mild dementia, 19 - 11 - moderate dementia, 10 and less - severe dementia.

· Mini-Cog test (Borson, S., Scanlan, J., Brush, M., Vitallano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive "vital signs" measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15 (11), 1021-1027), which includes the clock drawing test and verification of memory by storing three words, each of which is estimated at 1 point. Clock drawing test is evaluated in 2 points in case of correct position of figures on the dial and accurately reproduced time. Thus the total score from 0 to 2 means cognitive decline, score from 3 to 5 points is regarded as the absence of cognitive decline.

· MoCA (Montreal Cognitive Assessment) (Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H., 2005) The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr; 53 (4): 695-9. The test assesses different cognitive domains: attention and concentration, executive functions, memory, language, visual-constructive skills, conceptual thinking, calculations, and orientation. The total possible score - 30 points. Score of 26 and above is considered normal. This test is used in more than 100 countries (MoCA website Stats 2013), available in 45 languages ​​and dialects, including five versions of Chinese (2014).

All these scales meet the requirements of psychological tests developed in psychometry, such as reliability, validity and sensitivity, and are simple in usage and do not require special conditions and special training.

Results and discussion.

Among the main complaints of patients were: impaired memory (76%), low concentration (60%), difficulty in remembering new information (72%), increased fatigue and rapid depletion (88%).

Analysis of the results of MMSE scale revealed the presence of cognitive decline in 20 (80%) patients – cognitive decline (mean score was 25,5 ± 0,58) were observed in 4 (16%) patients; mild dementia (21,8 ± 0,53 points) was diagnosed in 5 (20%) patients; 9 (36%) subjects had moderate (17,5 ± 0,53 points) and 2 (8%) patients - severe dementia (9,5 ± 0,41). According to MMSE scale the weakest domains were memory (56%), attention and calculating properties (32%).

Screening Scale Mini-Cog test revealed the presence of cognitive decline in 11 (44%) patients, the average score for this group was 1,63 ± 0,15. According to the results of this test weak domain were memory (40%) and visual-spatial perception (12%).

MoCA test diagnosed cognitive disorders in 22 (88%) persons. An average score was 18,95 ± 1,01. The test revealed disorders of visual-constructional and executive skills (56%), memory storage (64%), attention (44%), verbal speed (40%), abstraction (60%) long term memory (72%) and orientation (4%).

Thus, a comparative analysis of standard neuropsychological scales found out that the least time was spent on Mini-Cog test (3 minutes in average), while MMSE test took about 10 minutes, and MoCA - 13-15 min in accordance. The duration of the test affects the level of fatigue and exhaustion of patients. It should be noted that the results of the Mini-Cog test did not depend on the level of education, culture and language. However, this test was the least sensitive and could only diagnose severe cognitive decline.

The advantages of MMSE test include the possibility of establishing the grade of cognitive impairment according to the number of points and much more higher sensitivity compared to Mini-Cog test.

It should be noted that the results of MoCA test can determine the necessity in narrow neuropsychological methods for more careful assessment of specific subdomains, such as:  California test of studying the words, REYAVLT (Rey Auditory Verbal Learning Test), test of 10 words by Luria; Bourdon-Anfimova test, Schulte tables, account according to Krepelin, Trail making test; Wisconsin card sorting test; phonetic and semantic associations test, Boston naming test, etc. However, the system of formal assessment used in MoCA test currently does not provide a ranking for grades, depending on the number of points.

Conclusions.

The studies show that the selection of neuropsychological methods should be carried out taking into account the clinical situation and the conditions in which it is conducted. This comparative analysis of general accepted screening scales for determination of cognitive decline can be used in diagnostic search for effective early verification of changes in the intellectual and mental functions.


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