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Quick Reference Guide for Clinicians

Number 19

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Alzheimerls Disease

Related DementiasI

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U.S. Department of Health and Human Services

Public Health Service

Agency for Health Care Policy and Research

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The Clinical Pmclice Guideline on which this Quick Reference Guide for

Clinicians is based was developed by a multidisciplinary panel comprising health care professionals and consumer representatives sponsored by the Agency for Health Care Policy and Research (AHCPR). Panel members were: Paul T. Costa, Jr., PhD (Cochair)

T. Franklin Williams, MD, FACP

(Cochair)

Marilyn S. Albert, PhD

Nelson M. Butters, PhD (Deceased)

Marshal R Folstein, MD

Sid Oilman, MD

Barry J. Gurland, FRCPhys,

FRCPsych

Lisa P Gwyther, MSW, CCSW, ACSW

Consultants to the panel were: Kathryn Bayles, PhD

Elizabeth Q. Bulatao

Rupert Francis, MD

Catherine Mollis

John W. Kirk, MD

Douglas Lanska, MD

Albert Heyman, MD

Alfred W. Kaszniak, PhD, ABPP

Ira R. Katz, MD, PhD

Linda L. Levy, OTR/L

Nancy Emerson Lombardo, PhD

Nancy K. Orr-Rainey, MSG

Linda R. Phillips, PhD

Martha Storandt, PhD

Eric G. Tangalos, MD

May L. Wykle, PhD, FAAN

Dorothy Rice, PhD

Gary Stephenson, MS

Thomas V. Trainer

Gary V. VandenBos, PhD

Carol Weisman, PhD

The panel used an explicit, science-based methodology along with expert

clinical judgment to develop specific statements on recognition and initial assessment of Alzheimer's disease and related dementias. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence. Peer review was undertaken to evaluate the validity,

reliability, and utility of the guideline in clinical practice.

This Quick Reference Guide for Clinicians presents summary points from the Clinical Practice Guideline. The latter provides a description of the guideline

development process, analysis and discussion of the available research, strengthof-evidence ratings for recommendations, information for health care decisionmaking, a list of resources, and references. Decisions to adopt particular recommendations from either publication must be made by practitioners in light of

available resources and circumstances presented by individual patients.

AHCPR invites comments and suggestions from users. Please send written

comments to:

Director, Office of the Forum for Quality

and Effectiveness in Health Care

AHCPR, Willco Building, Suite 310

6000 Executive Boulevard

Rockville, MD 20852
Quick Reference Guide for Clinicians

Number 19

Early Identification of

Alzheimer's Disease and

Related Dementias

Purpose and Scope. ............................... 1 Recognizing Symptoms 1 Initiating an Assessment 3

Focused History 3

Focused Physical Examination .7

Functional Status Assessment ..................... 7

Mental Status Assessment ........................ 7

Assessing for Delirium and Depression 9

Delirium 9

Depression 10

Interpreting Findings. 11

Normal Results ................................ 11

Abnormal Results 11

Mixed Results 1

2

Confounding Factors ........................... 12

Role of Neuropsychological Testing. 13

Importance of Followup. 14

Selected Bibliography . 17

Attachments 19

U.S. Department of Health and Human Services

Public Health Service

Agency for Health Care Policy and Research

AHCPR Publication No. 97-0703

November 1996

^^
Abstract

This Quick Reference Guide for Clinicians contains highlights from

Recognition and Initial Assessment ofAlzheimer's Disease and Related

Dementias, Clinical Practice Guideline No. 19, which was developed by a

multidisciplinary panel composed of health care professionals and consumer

representatives. The Quick Reference Guide focuses on (1) symptoms that suggest the presence of a dementing disorder and (2) steps to follow in conducting an initial assessment for Alzheimer's disease or a related dementia, including use of specific mental and functional status tests on the basis of their efficacy

and clinical utility in discriminating early-stage dementia. It also addresses how

to interpret test results, the role of neuropsychological testing, and resources for patients and families facing a diagnosis of probable dementia.

Suggested Citation

This document is in the public domain and may be used and reprinted with- out special permission. AHCPR appreciates citation as to source, and the

suggested format is provided below:

Costa PT Jr, Williams TF, Somerfield M, et al. Early Identification of

Alzheimer's Disease and Related Dementias. Clinical Practice Guideline,

Quick Reference Guide for Clinicians, No. 19. Rockville, MD: U.S.

Department of Health and Human Services, Public Health Service, Agency

for Health Care Policy and Research. AHCPR Publication No. 97-0703.

November 1996.
Early Identification of

Alzheimer's Disease

and Related Dementias

Purpose and Scope

Dementia is a syndrome of progressive decline that relentlessly erodes

intellectual abilities, causing cognitive

and functional deterioration leading to impairment of social and occupational

functioning. Because Alzheimer's dis- ease is the most common dementing

illness in the United States, it is used as a prototype for dementia in this guide

unless otherwise stated. An estimated 5 to 10 percent of the U.S. adult population ages 65 and older

is affected by a dementing disorder,

and incidence doubles every 5 years

after age 65. Despite its prevalence,

dementia is often unrecognized or misdiagnosed in its early stages. Failure to identify early-stage dementia can result

in inappropriate treatment, hazardous

situations, and needless distress. Early

recognition of dementia, however, not only can prevent problems but also can Recognizing Symptoms

Certain "triggers" (clues, symptoms) should prompt a clinician to conduct an initial assessment for dementia rather than attribute apparent

signs of decline to aging. Examples of

such triggers appear in Table 1

.

Although the patient, family members,

or others often bring their concerns

about symptoms to the clinician's

attention, clinicians also should be

allow the patient and family to plan for the future and consider participation in

trials of promising new therapies as they are developed.

A number of characteristics distin- guish early-stage dementia from normal

aging and from other syndromes that involve cognitive problems, including

depression. This guide provides infor- mation to help clinicians recognize

those characteristics as symptoms

suggestive of a dementing disorder and

to conduct an initial assessment of mental and functional status. The recommendations are intended for use by primary

care clinicians, including but not limited

to family physicians, internists, geriatricians, psychologists, psychiatrists, nurses, and nurse practitioners. They are not intended to replace existing recommendations for a differential diagnosis once dementia has been identified.

alert to such signs during office visits. Table 1 is a clinical guide, not a val- idated test instrument. In asymptomatic

persons who have possible risk factors (see box), the clinician's judgment and

knowledge of the patient's cuiTcnt

condition, history, and social situation

(living aiTangements, support services,

isolation) must guide the decision to

initiate an assessment for dementia.
Table 1. Symptoms that may indicate dementia

Does the person have increased difficulty with any of the activities listed below?^

Learning and retaining new information. Is more repetitive; has trouble remembering recent conversations, events, appointments; frequently

misplaces objects.

Handling complex tasks. Has trouble following a complex train of thought

or performing tasks that require many steps such as balancing a checkbook

or cooking a meal. Reasoning ability. Is unable to respond with a reasonable plan to problems

at work or home, such as knowing what to do if the bathroom is flooded; shows uncharacteristic disregard for rules of social conduct.

Spatial ability and orientation. Has trouble driving, organizing objects

around the house, finding his or her way around familiar places.

Language. Has increasing difficulty with finding the words to express what

he or she wants to say and with following conversations.

Behavior. Appears more passive and less responsive; is more irritable than

usual; is more suspicious than usual; misinterprets visual or auditory stimuli.

In addition to failure to arrive at the right time for appointments, the clinician can look for difficulty discussing current events in an area of interest, and

changes in behavior or dress. It also may be helpful to follow up on areas of concern by asking the patient or family members relevant questions.

^ Positive findings In any of these areas generally indicate the need for further assessment for the presence of dementia. Source: Guideline panel.

For Alzheimer's disease, the only well-established risk factors are family history

of dementia and the presence of Down syndrome. Genetic studies show that autosomal-dominant forms of Alzheimer's disease are associated with early onset and early death. Recent research also suggests an association of certain apolipoprotein E (apoE) genotypes and late-onset Alzheimer's disease; however, apoE genotyping is not a definitive diagnostic tool.

Evidence also suggests the possibility of a modest but significant association

with earlier head trauma involving loss of consciousness.
Initiating an Assessment

To help determine whether a

patient's symptoms meet current crite- ria for dementia (see box), an initial assessment should combine information from several sources. The basic

components of this assessment are a focused history, a physical examination, a functional status assessment,

and a mental status assessment. The

recommended assessment process is presented in the Figure.

According to current criteria, a diagnosis of dementia requires evidence of decline from previous levels of functioning and impairment in multiple

cognitive domains (see Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], American

Psychiatric Association, 1994).

Focused History

A focused history is critical in the

assessment for dementia. It must identify signs and symptoms such as those

listed in Table 1 and document the

chronology of problems. Particularly

important are Mode of onset (abrupt versus

gradual).

Progression (stepwise versus continuous decline; worsening

versus fluctuating versus improving).

Duration of symptoms.

In addition to containing a

detailed description of the chief

complaint, a focused history should

include relevant medical, family.

social and cultural, and medication

history (including alcohol use).

Medical history. Ask about rele- vant systemic diseases; psychiatric

disorders; known neurological disorders, including history of head

trauma; alcohol or substance abuse;

and exposure to environmental toxins.

Because many medical conditions

may cause or contribute to cognitive

impairment, review information about

any intercurrent, infectious, or metabolic illness, such as pneumonia,

urinary tract infection, diabetes, or acute or chronic renal failure. Family history. Inquire about a family history of early-onset Alzheimer's disease or other rare genetic

conditions that lead to dementia, such

as Huntington's disease. Social and cultural history.

Include information about recent life events and social support networks,

education, literacy, and socioeconomic, ethnic, and cultural background.

These factors may affect performance on mental status tests; some studies

have found that they may affect the

risk for dementia as well. Medication history. This is a

critical component of the initial eval- uation, because drug toxicity is the

most common cause of dementias that can be resolved or significantly ameliorated. A wide range of drugs have

been associated with cognitive

changes (see Table 2). Consider any

drug, including over-the-counter medications and alcohol, as potentially

suspect. Encourage patients to bring

all medication botdes and pills to the

appointment.
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Table 2. Some medications that may cause cognitive

impairment

Type of medication and generic name ^ Antiarrhythmic agents: disopyramide, Antihistamines/decongestants:

quinidine, tocainide phenylpropanolamine, diphenhydramine.

chlorpheniramine, brompheniramine.

Antibiotics: cephalexin, cephalothin, pseudoephedrine

metronidazole, ciprofloxacin, ofloxacin Cardiotonic agents: digoxin

Anticholinergic agents: benztropine,

homatropine, scopolamine, tri- Corticosteroids: hydrocortisone,

hexyphenidyl prednisone

Antidepressants: amitryptyline. H2 receptor antagonists: cimetidine. imipramine, desipramine, fluoxetine ranitidine Anticonvulsants: phenytoin, valproic Immunosuppressive agents:

acid, carbamazepine cyclosporine, interferon Antiemetics: promethazine, hydroxy- Narcotic analgesics: codeine.

zine, metoclopramide, prochlorperazine hydrocodone, oxycodone, meperidine.

propoxyphene

Antihypertensive agents: propranolol.

metoprolol, atenolol, verapamil, methyl- Muscle relaxants: baclofen,

dopa, prazosin, nifedipine cyclobenzaprine, methocarbimol

Antineoplastic agents: chlorambucil, Nonsteroidal anti-inflammatory

cytarabine, interleukin-2 agents: aspirin, ibuprofen.

indomethacin, naproxen, sulindac

Antimanic agents: lithium Radiocontrast agents: metrizamide.

Anti-Parkinsonian agents: levodopa. iothalamate, iohexol

pergolide, bromocryptine

Sedatives: alprazolam, diazepam.

lorazepam, phenobarbital, butabarbital.

chloral hydrate

^ These are examples only; new medications appear regularly Many compounds contain other

active ingredients. Source: Guideline panel.

Informant reports. Whenever

possible, obtain the history from both

the patient and rehable informants,

such as family members or close

friends. Informant reports can supplement information from patients who

have experienced memory loss and

may lack insight into the severity of

their decline.

Reports from relatives, however,

may be influenced by the nature of the

relationship to the patient. For this reason, more than one family informant or a family consensus approach

can increase the accuracy of conclusions about the presence and range

of cognitive impairments in persons

suspected of having dementia.

When an informant is available:

Interview the patient alone first, to respect the patient's dignity.
Tell the patient that others will

be interviewed.

Interview informants separately

from the patient to increase the

likelihood of candor.

Consider the possibility of questionable motives in informant

reports. For example, symptoms

may be minimized if the family is concerned about the patient's being

denied admission to a nursing

home; conversely, symptoms may

be exaggerated or fabricated if an

informant is motivated by financial or other considerations.

Focused Physical

Examination

Use standard medical principles to guide a focused physical examination

conducted as part of an initial assess- ment for dementia: life-threatening or

rapidly progressing conditions must

be identified first. Life-threatening

conditions include mass lesions, vascular lesions, and infections. Assess

carefully for conditions that cause

delirium, which is a medical emer- gency requiring immediate attention. (see Assessing for Delirium section).

Also be alert to signs of abuse and

neglect of patients by caregivers, and

report suspected abuse to the proper

authorities. Functional Status

Assessment

Use a standardized test to evaluate

functional status. For evaluating complex or difficult cases, informant-based

scales are particularly important.

Among standardized tests, the

Functional Activities Questionnaire

(FAQ) is currently the best discriminator for early-stage dementia (see

Clinical Practice Guideline for details of meta-analyses). The FAQ is an

informant-based measure. Every effort should be made to find a reliable

informant. Components of the FAQ

and information on its administration

and scoring appear in Attachment A.

Mental Status Assessment

A quantitative mental status examination should be part of an initial assessment for dementia. Although a comprehensive mental status examination that provides a detailed cognitive

profile of the patient is desirable, it is impractical for most clinicians. Several brief, quantitative tests can

provide useful information about mental status. They feature systematic,

structured questions or tasks that can

be scored easily. Table 3 presents a summary of cognitive elements measured by several brief mental status

tests and their requirements for testing

(e.g., verbal ability or vision).

Brief mental status tests are not

diagnostic. They are used to: Develop a multidimensional clinical picture in conjunction with functional performance and the

patient's signs and symptoms.

Provide a baseline for monitoring

the course of cognitive impairment

over time.

Reassess mental status in persons

who have treatable delirium or depression on initial evaluation.

Document multiple cognitive

impairments, as required for a

diagnosis of dementia.

L
Table 3. Components of commonly used brief mental status

tests and requirements for testing

MMSE BIMC BOMC STMS

Components of cognition measured

(listed in the DSI\/I-IV criteria for dementia)

Immediate memory X X

Short-term recall X X X X

Abstract thinking X

Judgment

Aphasia X

Apraxia X

Agnosia X

Constructional ability X X

Additional components of cognition measured

Concentration X X X X

Spatial ability, orientation X X X X

Requirements for testing

Verbal responses X X X X

Reading ability X

Writing ability X X

Mathematical ability X X

Vision X X

Motor control skills X

Note: MMSE = Mini-Mental State Examination; BIMC = Blessed Information-Memory-Concentration

Test; BOMC = Blessed Orientation-Memory-Concentration Test; STMS = Short Test of Mental Status. Source: Adapted from White H, Davis PB. Cognitive screening tests: an aid in the care of elderly outpatients. J Gen Intern Med 1990;5:438-45. Copyright 1990, Society for Research and Education

in Primary Care Internal Medicine. Used with permission.

No single mental status test is clearly superior (see Clinical Practice

Guideline for details of meta-analyses). The following four brief mental

status tests are largely equivalent in their discriminative ability:

Mini-Mental State Examination

(MMSE).

The Blessed Information-MemoryConcentration Test (BIMC).

The Blessed Orientation-MemoiyConcentration Test (BOMC).

Short Test of Mental Status (STMS).

Information on administration

and scoring of these tests appears in

Attachments B through E. Any of

the tests is acceptable, if its utility is not limited by a patient's confounding

or comorbid conditions (see below).

The MMSE is the most widely used brief mental status test in the United States and the most comprehensive of the brief tests; however, several studies have

shown that it has differential sensitivity for various cognitive domains. On the basis

of these studies, an MMSE finding of impairments in memory and at least one

other cognitive area suggests dementia,

but a finding of impairment only in memory does not necessarily exclude

the possibility of dementia.

8
In diagnosing mild dementia, reli- able informants' accounts of minor

cognitive changes in a person suspected of dementia may be as important

as—or more important than—quantitative assessments, which can be

insensitive to mild impairment.

Confounding and comorbid

conditions. Visual and auditory

impairments and physical disabilities may affect performance on both mental status and neuropsychological

tests. Assess the patient for such conditions and consider them in the

selection of tests (see Table 3). For

example, the MMSE's praxis and

drawing portions make it unsuitable

for a patient who has impaired motor

control. In such cases, use other tests

(e.g., the BIMC).

When possible, correct visual

and auditory deficits before testing.

When this is not possible or when a physical disability is present, consider referral for neuropsychological

evaluation that uses the patient's

unimpaired faculties and capacities.

For testing any older adult, make

sure that the following conditions

are adequate: lighting, contrast of

visual stimuli, and volume and

distinctiveness of auditory stimuli.

Assessing for Delirium and Depression

During the focused history and

physical examination, look for evi- dence of an acute confusional state or

delirium, and for dysphoric mood suggesting depression. These conditions can be mistaken for, or coexist with,

dementia; they also can occur together.

Delirium and depression need

to be addressed promptly and

explicitly. If symptoms suggesting

dementia remain after the patient

has been treated for delirium or

depression, continue the assessment

for dementia.

Delirium

Although delirium is common in older persons with acute or chronic

illnesses, it is underrecognized in clinical settings. This underrecognition can have serious consequences,

because delirium is a medical emer- gency requiring immediate further

evaluation and treatment. Some of the

underlying causes (e.g., bacterial

meningitis or hypoglycemia) can be

fatal. If delirium is recognized early, it may be possible to prevent disability

and irreversible deterioration.

A person who displays the following symptoms is likely to have

delirium rather than uncomplicated

dementia:

Sudden onset of cognitive

impairment.

Disorientation.

Disturbances in attention. Decline in level of consciousness.

Perceptual disturbances (e.g.,

hallucinations). In addition to common medical

conditions, adverse effects of the

following types of medications are also common causes of delirium:

Anticholinergic agents.

Antipsychotic agents.
Antidepressants.

Digoxin.

H2-blocking agents.

Antihypertensive agents.

To improve recognition of deliri- um, use mental status tests to identify

patients with cognitive impairment,

and establish the symptoms' history

of onset and degree of fluctuations.

Several systematic methods of assess- ing for delirium have been found

effective (see Selected Bibliography).

Depression

Although depression is the most

common psychiatric illness in older per- sons, it is often underdiagnosed,

especially when physical illness is present. Diagnosis is complicated because

(a) depression is often mistaken for dementia and vice versa, (b) each may

present as the other, and (c) they may

coexist (e.g., DSM-IV categories of

dementia with depressed mood).

Changes in memory, attention, and

executive function suggest depression;

marked visuospatial or language impairment suggests a dementing process. Problems are associated with misdiagnosing dementia as depression. In

addition to the unnecessary expense,

inappropriate treatment for nonexistent

depression in a person with progressive

dementia may exacerbate the condition

because antidepressants that have anti- cholinergic properties may worsen

confusion or memory impairment. In persons with coexisting depression and

Alzheimer's disease, failure to diagnose

and treat the depression may cause unnecessary emotional, physical, and

social discomfort for both patient and

family.

For these reasons, assessing for depression is an important part of the

initial evaluation of any older adult suspected of cognitive impairment,

especially for persons who complain

of memory difficulty.

When taking the history, look for

symptoms consistent with the DSMIV definition of depression. If depression is suspected, (a) evaluate

further, (b) treat appropriately (depression in older adults often responds to treatment with antidepressants, psychotherapy, electroconvulsive therapy, or all of the above), and then (c) reassess the patient for dementia.

Clinical interview. The clinical interview is the mainstay for evaluating and diagnosing depression in older

adults. The DSM-IV provides some

guidance on obtaining relevant information and observations. In applying

DSM-IV criteria, however, be aware

that physical conditions or behavioral

changes common among older persons

may account for many DSM-IV symptoms of major depression, such as: Changes in sleep pattern or

appetite.

Fatigue.

Behavioral slowing or agitation.

Complaints of diminished ability to think or concentrate. Drug interactions that result from

polypharmacy also can produce depression or depression-related symptoms

and contribute to cognitive impairment.

Depression assessment

instruments. Brief self-report

questionnaires can facilitate initial screening for depression. The following two self-report instruments have

established reliability and validity:

The Geriatric Depression Scale

(GDS), developed specifically for use with older adults, is a 30-item

10
questionnaire that has a simple

yes/no format and takes only 8 to 10 minutes to administer. A 15- item form of the GDS is also

available.

The Centerfor Epidemiological

Studies Depression Scale (CES-D)

is a 20-item questionnaire that can

be administered in 5 to 8 minutes.

Self-report instruments have

shown lower frequencies of depression-related symptoms in patients with

Alzheimer's disease compared with

informant sources or trained clinical observers. They should be used with

caution for persons suspected of having dementia. Depression screening in

patients suspected of dementia should

include information from both a

patient self-report and a caregiver

(or informant) report, as well as direct

clinician observation of the patient's

behavior. A good time to ask about

other symptoms (see box) is right

after the functional assessment. Memory difficulty, agitation, disrupted

sleep-wake cycle, and personality

changes (e.g., apathy, increased

dependence) are classic symptoms of Alzheimer's disease that may be mistaken for depressive signs of poor

concentration, decreased interest, changes in psychomotor activity sleep

disturbance, and fatigue.

Interpreting Findings

The combination of findings from

the assessments of mental and functional status can yield three possible results:

(a) normal, (b) abnormal, and (c) mixed.

The following recommendations, geared

to each of these results, provide a framework for clinical decisions and should

be used in conjunction with patientspecific circumstances.

Normal Results

If findings from both the mental and

the functional assessment are normal,

reassure the patient and concemed family

members or friends and suggest reassess- ment in 6 to 12 months (or whenever

further concems develop). If concerns

remain, consider referral for a second

opinion or for further chnical evaluation: For concern about the adequacy of

the mental status test, refer for fur- ther neuropsychological testing.

For concern about possible depression or other emotional problems,

refer for further psychiatric or psychological evaluation.

For concern about possible loss of

social and instrumental functioning

caused by a neurological disorder not detected in the functional

assessment, refer to a neurologist.

Abnormal Results

If findings from both the mental

and the functional assessment are abnormal, the patient is likely to have a dementing illness and should

have further clinical evaluation. This

evaluation should include differential

diagnosis, treatment, and continuing

care as indicated. The Selected

Bibliography lists guidelines for

further clinical evaluation.

11
Laboratory tests may be appropriate when specific medical conditions

are suspected. However, a laboratory

test should not be used as a screening

procedure solely to identify probable

early- stage dementia or as a routine

part of an initial assessment for

dementia.

Mixed Results

Mixed results—abnormal findings on the mental status test with no

abnormalities in functional assessment

or vice versa—call for further evaluation. For example:

Patients who have abnormal

results on only the mental status

test require more complete neu- ropsychological testing. If results indicate possible neuropsychiatric

or systemic neurological problems

as well, refer to an appropriate specialist. Patients who have declining

function but normal mental status

test results require either (a) further neurological evaluation for systemic

neurological diseases or (b) psychiatric or psychological evaluation,

if evidence suggests depression or

other emotional problems.

Clinical presentations that could

produce mixed results include:

A person with lifelong borderline

or retarded intellectual functioning

who has learned to perform routine

activities of daily living (ADLs)

adequately.

A person with a dementing illness who lives in an environment where

functional supports mask evidence

of significant functional impairment.

A person with high intelligence

and education who scores within

the normal range on a mental sta- tus test but shows clear functional

decline, especially on demanding

tasks (e.g., instrumental activities of daily living [lADLs]).

Importance of Cognitive Baselines

Because cognitive performance can

vary from day to day, an initial assess- ment of cognitive impairment needs to be verified by reassessment. A cognitive baseline is an important benchmark for confirming cognitive decline and evaluating its nature and magnitude. A baseline measure is especially useful for: Persons of initially high cognitive

ability whose early decline may be

difficult to find on initial testing. Persons found to have only mild impairment who require several examinations conducted weeks or months apart to document stable or progressing cognitive problems. Persons who minimize or deny

problems because of lack of insight or denial. Confounding Factors

Assess confounding factors such

as age, educational level, and cultural influences and consider them in the

interpretation of mental status test scores. Age and educational

influences. Both age and education can affect performance on most

mental status and neuropsychological

tests. On the MMSE, for example,

significant correlations have been

found between MMSE scores and

12
both age and years of schooling.

Evidence suggests that: Low education increases the likeh- hood that an unimpaired person will

test as cognitively impaired (false- positive error), especially for those

who have fewer than 9 years of

education.

A high educational level increases

the likelihood that a cognitively

impaired person will test as unimpaired (false-negative error).

Age- and education-stratified data

are available only for the MMSE (see

Attachment B). If the MMSE is the

mental status test used, refer to these

stratified data in interpreting test results. For other brief mental status tests, take

these factors into account in setting the

threshold for dementia for test results. As always, the clinician's knowledge of

each patient should guide consideration

of these confounding factors. Cultural influences. Primary

language, race, ethnicity, and cultural

bias also can affect performance on

mental status tests and some neuropsychological tests. Research suggests that several neuropsychological tests (e.g., some

Wechsler Adult Intelligence Scale

Revised [WAIS-R] subtests, the FAS

Controlled Oral Word Association Test)

may place Hispanic persons and possibly

members of other racial or ethnic groups

at a disadvantage, particularly in the use

of culturally inappropriate norms or cutpoints. The Consortium to Establish a

Registry for Alzheimer's Disease

(CERAD) has developed Spanishlanguage versions of its clinical and neuropsychological assessments. Copies are

available from CERAD (see Table 4). Use the focused history and physical examination to evaluate English

language ability. Then determine

whether it is appropriate to administer an English-language version of a mental status test or make a referral to someone who is competent in the

patient's primary language.

Role of Neuropsychological Testing

Neuropsychological assessment

can make an important contribution to identification of mild dementia, particularly when delayed recall is measured. It can Give information about the specific nature of strengths and deficits in cognitive functions.

Assist in diagnosis, particularly in cases of mild impairment, high

premorbid intellectual ability, or an

unusual combination of cognitive

impairments.

Contribute to recommendations

for treatment and management of

behavior problems.

Provide a baseline measurement

for judging the effects of treatment

or disease progression.

Neuropsychological tests can measure performance across different

domains of cognition, including orientation and attention, language functions, visual motor constructional

ability (praxis), memory, abstract and

conceptional reasoning, and executive

functions (formulating goals, planning, and executing plans). A person's

pattern of performance across such

tests can help in (a) identifying

dementia among persons with high

premorbid intellectual funcdoning.

13
(b) discriminating patients with a dementing illness from those with focal cerebral disease, and (c) differentiating

among certain causes of dementia.

Neuropsychological evaluation may

be useful in certain circumstances: (a) when the mental status test is abnormal

but the functional assessment is nor- mal; (b) when a family member

expresses concern or dementia is sus- pected and results of mental status tests are within the normal range and the

patient has more than a high school

education or an occupation that indi- cates high premorbid intelligence; and

(c) when mental status test results indi- cate cognitive impairment and when

any of the following circumstances

apply to the patient:

Low level of formal education.

Evidence of long-term low

intelligence (more than 10 years).

Inadequate command of English

for the test. Minority racial or ethnic

background.

Impairment in only one cognitive area on mental status tests. No evidence of cognitive impairment for more than 6 months.

No evidence of functional

impairments.

Neuropsychological evaluation must

be interpreted within the context of

other clinical information, such as infor- mant-based history of cognitive decline; evidence of impairment in lADLs; educational background; assessment for depression; sensory impairment; and

factors other than dementia that may

account for impaired performance (see

Confounding Factors).

Importance of Follpwup

Followup, with assessment of

declining mental function, may be the

most useful diagnostic procedure for

differentiating Alzheimer's disease from

normal aging. For this reason, repeat

the mental status test over a period of 6

to 12 months and note change or stability of scores. (For the MMSE,

a change of four points per year is expected in scores of persons with

Alzheimer's disease.) In cases of referral, make sure test results and medical

records follow the patient from the specialist back to the referring clinician. When a diagnosis of dementia is made, the patient and family members

have serious issues to consider. The

progressive nature of cognitive impairment makes followup especially

important for persons with Alzheimer's

disease or a related disorder; however,

followup cannot be ensured. For this reason, the visit during which the diagnosis is given is an appropriate time for the clinician to discuss relevant issues

with the patient and family or close

friends, for example:

The patient's competence to drive

and carry out other routine functions that raise issues of safety

(e.g., cooking); manage finances;

supervise or care for grandchildren.

Financial, legal, and medical

planning, including execution of

a durable power of attorney for health care. The list of resources in Table 4, provided in take-home form, can be

14
helpful to families when they are ready to confront the many implications of a diagnosis of dementia. A

consumer education version of this guideline is also available (see inside

back cover for ordering information).

Table 4. Resources for health professionals, patients,

and families

Name of Organization Explanation

Administration on Aging

330 Independence Avenue, SW

Washington, DC 20201

(202)619-1006

Fax: (202)619-7586

Internet: http://www.aoa.dhhs.gov

The Administration on Aging (AoA)

coordinates delivery of services specified

by the Older Americans Act. Services

are coordinated and provided through 57

State agencies and 657 areas. The

range of services provided by these Agencies on Aging (AAA) varies, but all include nutrition, access, in-home, and

community services. Addresses and

phone numbers of State and local AAAs

are available from the national office. The Elder Care Locator (800-667-1116)

provides a toll-free access number to locate State agency networks. Alzheimer's Association

919 North Michigan Avenue

Suite 100

Chicago, IL 60611-1676

(312)335-8700

800-272-3900 for information and

local chapter referrals nationwide

(24-hour telephone line)

Internet: http://www.alz.org

The Alzheimer's Association is a national voluntary organization with 220 local chapters and more than 2,000 support

groups. The Alzheimer's Association funds research, promotes public awareness, advocates legislation for patients and

families, and provides support services,

including support groups, adult day care programs, respite care programs, and telephone helplines through its national, chapter, and volunteer network. Alzheimer's Disease Centers

(access through ADEAR;

see next entry)

The National Institute on Aging, part of the National Institutes of Health, supports

28 Alzheimer's Disease Centers across

the country. This program provides clinical services, conducts basic and clinical research, disseminates professional

and public information, and sponsors

educational activities. A growing number

of satellite clinics associated with this program are helping to expand diagnostic

and treatment services in rural and

minority communities and collect research data from a more diverse

population.

15
Table 4 (continued)

Name of Organization Explanation

Alzlieimer's Disease Education and

Referral Center

P.O. Box 8250

Silver Spring, MD 20907-8250

800-438-4380

Fax:(301)495-3334

Internet: adear@alzheimers.org

The Alzheimer's Disease Education and

Referral (ADEAR) Center, a service of the National Institute on Aging, provides

information and publications on Alzheimer's disease for health professionals, people

with Alzheimer's disease and their families, and the public. The ADEAR Center

serves as a national resource for information on diagnosis, treatment issues, patient care, caregiver needs, long-term care, education, research, and ongoing

programs. In addition, the Center provides

referrals to national and State resources.

Tiie Corporation for National Service

Office of Public Liaison 1201 New York Avenue, NW

Washington, DC 20525

(202) 606-5000

Fax: (202) 565-2794

The Corporation for National and

Community Service is a public corporation

that administers Federal service programs,

including AmeriCorps, the Foster Grandparent Program, and the Senior

Companion Program (SCP), which provides

supportive services to adults with physical,

emotional, and health limitations. A major

SCP emphasis is preventing or delaying

institutionalization. Foster Grandparent

volunteers work with children, including those with disabilities. AmeriCorps members

address a range of local health issues. Other Resources

American Association of Retired Persons (AARP)

Washington, DC

(202) 434-2277

800-424-3410

AARP Pharmacy Price Quote Center

800-456-2226,

(open 24 hours a day)

American Bar Association Commission

on Legal Problems of the Elderly

Washington, DC

(202) 662-8690

Children of Aging Parents

Levittown, PA

(215)945-6900

Consortium to Establish a Registry for Alzheimer's Disease (CERAD)

Durham, NC,

(919) 286-6406 or 6405

Insurance Consumer Helpline

Washington, DC

800-942-4242

Medicare Beneficiaries Defense Fund

New York, NY

(212)869-3850

800-333-4114

Medicare Hotline Baltimore, MD

800-638-6833

16
Table 4 (continued)

other Resources

National Association for Continence

Spartanburg, SC

800-BLADDER

(800-252-3337)

National Stroke Association Englewood, CO

(303)771-1700

800-STROKES

National Citizen's Coalition for Nursing Home Reform

Washington, DC

(202) 332-2275

National Hospice Organization

Arlington, VA

(703) 243-5900

800-658-8898

Social Security Information 800-772-1213

(open 7 am-7 pm in all time zones)

U.S. Department of Veterans Affairs Regional Office, Veterans Assistance

Washington, DC

(202)418-4343

800-827-1000

National Parkinson's Foundation

East Coast: Miami, FL

800-327-4545

West Coast: Encino, CA

800-522-8855

Selected Bibliography

American Psychiatric Association.

Diagnostic and statistical manual of

mental disorders. 4th ed. (DSM-IV).

Washington (DC): American

Psychiatric Association; 1994. 886 p. Bleecker ML, BoUa-Wilson K, Kawas

C, et al. Age-specific norms for the

Mini-Mental State Exam. Neurology

1988;38:1565-8.

Crum RM, Anthony JC, Bassett SS,

et al. Population-based norms for the

Mini-Mental State Examination by

age and educational level. JAMA

1993;269:2386-91.

Folstein MF, Folstein SE, McHugh

PR. "Mini-Mental State": a practical

method for grading the cognitive state of patients for the clinician. J PsychiatrRes 1975;12:189-98.

Katzman R, Brown T, Fuld P, et al. Validation of a short orientationmemory-concentration test of cognitive impairment. Am J Psychiatry

1983;140:734-9.

Kokmen E, Naessens JM, and Offord

KP. A short test of mental status: description and preliminary results. Mayo Clin Proc 1987:62;281-8

Morrison RL, Katz IR. Drug-related

cognitive impairment: current progress and recurrent problems.

Annu Rev Gerontol Geriatr

1989;9:232-79.

Pfeffer RI, Kurosaki TT, Harrah C, et

al. Measurement of functional activities in older adults in the community.

J Gerontol 1982;37:323-9.

17
White H, Davis PB. Cognitive screen- ing tests: an aid in the care of elderly

outpatients. J Gen Intern Med

1990;5:438-45.

Assessing for Delirium

Albert MS, Levkoff SE, Reilly C, et

al. The delirium symptoms interview: an interview for the detection of

delirium symptoms in hospitalized

patients. J Geriatr Psychiatry Neurol

1992;5:14-21.

Anthony JC, LeResche LA, Von Korff

MR, et al. Screening for delirium on a general medical ward: the tachistoscope and a global accessibility rating.

Gen Hosp Psychiatry 1985;7:36-42.

Gottlieb GL, Johnson J, Wanich C, et al. Delirium in the medically ill elderly:

operationalizing the DSM-in criteria. Int Psychogeriatr 1991;3:181-96.

Inouye SK, van Dyck CH, Alessi CA, et

al. Clarifying confusion: the Confusion

Assessment Method—a new method for detection of delirium. Ann Intern Med

1990;113:941-8.

Inouye SK, Viscoli CM, Horwitz RI,

et al. A predictive model for delirium

in hospitalized elderly medical patients

based on admission characteristics. Ann Intern Med 1993;119:474-81.

Assessing for Depression

Brink TL, Yesavage JA, Lum O, et al. Screening tests for geriatric depression.

Clin Gerontologist 1982;1:37-43.

National Institutes of Health.

Consensus Development Panel on

Depression in Late Life. Diagnosis

and treatment of depression in late

life. JAMA 1992;268:1018-24.

Radloff LS. The CES-D scale: a self- report depression scale for research in

the general population. Appl Psychol

Measurement 1977;1:385-401.

Rush JA, Golden WE, Hall GW, et al. Depression in primary care: Volume 1. Detection and diagnosis. Clinical

Practice Guideline No. 5. AHCPR

Publication No. 93-0550. Rockville,

MD: Agency for Health Care Policy

and Research, Public Health Service,

U.S. Department of Health and

Human Services. April 1993.

Yesavage JA. Geriatric depression scale. Psychopharmacol Bull 1988;24:709-11.

Further Evaluation

American Academy of Neurology.

Practice parameters for diagnosis and

evaluation of dementia (summary

statement): report of the Quality

Standards Subcommittee of the

American Academy of Neurology.

Neurology 1994;44:2203-6.

Clarfield AM. Canadian consensus

conference on the assessment of

dementia, 5-6 October 1989.

Montreal, Quebec: Canadian

Consensus Conference on the

Assessment of Dementia; 1991.

McKhann G, Drachman D, Folstein M,

et al. Clinical diagnosis of Alzheimer's

disease: report of the NINCDS-ADRDA

Work Group under the auspices of

Department of Health and Human

Services Task Force on Alzheimer's

Disease. Neurology 1984;34:939-44.

National Institutes of Health. Differential diagnosis of dementing diseases. Consensus Development Conference

Statement 1987 (July);6(ll):l-9.

U.S. Department of Veterans Affairs. Dementia: guidelines for diagnosis

and treatment, 1989 (revised). VA

Publication No. IB 18-3. 107 p.

18
Attachment A. Functional Activities Questionnaire (FAQ):

Administration and Scoring

The FAQ is an informant-based measure of functional abilities. Informants provide

performance ratings of the target person on 10 complex, higher-order activities. Individual Items of the Functional Activities Questionnaire

1

.

Writing checks, paying bills, balancing a checkbook.

2. Assembling tax records, business affairs, or papers.

3. Shopping alone for clothes, household necessities, or groceries.

4. Playing a game of skill, working on a hobby.

5. Heating water, making a cup of coffee, turning off the stove.

6. Preparing a balanced meal.

7. Keeping track of current events.

8. Paying attention to, understanding, discussing a TV show, book, or magazine.

9. Remembering appointments, family occasions, holidays, medications.

10. Traveling out of the neighborhood, driving, arranging to take buses.

The levels of performance assigned range from dependence to independence, and

are rated as follows: Dependent = 3

Requires assistance = 2

Has difficulty but does by self = 1 Normal = Two other response options can also be scored: Never did [the activity], but could do now = Never did and would have difficulty now = 1 A total score for the FAQ is computed by simply summing the scores across the 10

items. Scores range from to 30; the higher the score the poorer the function, i.e., the greater the impairment. A outpoint of "9" (dependent in three or more activities)

is recommended.

Source: Pfeffer Rl, Kurosaki TT, Harrah CH, et al. Measurement of functional activities of older

adults in the community J Gerontol 1982;37:323-9. Copyright 1982, Gerontological Society of America. Used with permission.

19
Attachment B. Mini-Mental State Examination

Maximum

Score

5

5

Score

( ) ( )

( )

( )

( )

( )

Orientation What is the (year) (season) (day) (month)?

Where are we: (state) (county) (town) (hospital) (floor) Registration

Name 3 unrelated objects, allow 1 second to say each. Then ask the patient to repeat all 3 after you have said them. Give 1 point for each correct answer. Repeat

them until he learns all 3. Count trials and record.

Trials: Attention and calculation Ask patient to count backwards from 100 by sevens.

1 point for each correct answer. Stop after 5 answers.

Alternatively spell "world" backwards.

Recall Ask patient to recall the 3 objects previously stated. Give 1 point for each correct. Language

Show patient a wrist watch; ask patient what it is. Repeat for a pencil. (2 points).

Ask patient to repeat the following: "No its, ands or buts" (1 point). Follow a 3-stage command:

"Take a paper in your right hand, fold it in half, and put it on the floor" (3 points).

Ask patient to read and obey the following sentence

which you have written on a piece of paper. "Close your eyes" (1 point).

Ask patient to write a sentence (1 point).

Ask patient to copy a design (1 point).

_Total Score

ASSESS level of consciousness along a continuum

Alert Drowsy Stupor Coma

20
Attachment B (continued)

Instructions for Administration of l\/lini-i\/lental State Examination

Orientation

(1) Ask for the date. Then ask specifically for parts omitted, e.g., "Can you also tell me what season it is?" One point for each correct.

(2) Ask in turn "Can you tell me the name of this hospital?" (town, county, etc.). One point for each correct. Registration

Ask the patient if you may test his memory. Then say the names of 3 unrelated

objects, clearly and slowly, about one second for each. After you have said all 3, ask

him to repeat them. This first repetition determines his score (0-3) but keep saying

them until he can repeat all 3, up to 6 trials. If he does not eventually learn all 3, recall cannot be meaningfully tested. Attention and calculation Ask the patient to begin with 100 and count backwards by 7. Stop after 5 subtractions (93, 86, 79, 72, 65). Score the total number of correct answers. If the patient cannot or will not perform this task, ask him to spell the word "world" backwards. The

score is the number of letters in correct order, e.g., dirow = 5, dIonA/ = 3. Recall Ask the patient if he can recall the 3 words you previously asked him to remember.

Score 0-3. Language

Naming-. Show the patient a wrist watch and ask him what it is. Repeat for pencil.

Score 0-2. Repetition: Ask the patient to repeat the sentence after you. Allow only one trial. Score or 1

.

3-Stage command: Give the patient a sheet of blank paper and repeat the command.

Score 1 point for each part correctly executed.

Reading: On a blank piece of paper print the sentence "Close your eyes," in letters large enough for the patient to see clearly. Ask him to read it and do what it says. Score 1 point only if he actually closes his eyes.

Writing: Give the patient a blank piece of paper and ask him/her to write a sentence. Do not dictate a sentence, it is to be written spontaneously. The sentence must contain a

subject and verb and be sensible. Correct grammar and punctuation are not necessary. Copying: On a clean piece of paper, draw intersecting pentagons, each side about 1 in., and ask him to copy it exactly as it is. All 10 angles must be present and 2 must

intersect to score 1 point. Ignore tremor and rotation.

21
Attachment B (continued)

Estimate the patient's level of sensorium along a continuum, from alert on the left to coma on the right. Reprinted from the Journal of Psychiatric Research, volume 12, Folstein MF, Folstein SE,

McHugh PR. Mini-Mental State: A practical method for grading the cognitive state of patients

for the clinician. 196-8, 1975. Used with kind permission from Elsevier Science, Ltd., The

Boulevard, Langford Lane, Kidlington OX5 1GB UK.

Median Mini-Mental State Examination

Score by Age and Educational Level

Education

0-4y 5-8y 9-1 2y >12y Total 18-24 23 28 29 30 29

25-29 25 27 29 30 29

30-34 26 26 29 30 29

35-39 23 27 29 30 29

40-44 23 27 29 30 29

45-49 23 27 29 30 29

50-54 22 27 29 30 29

55-59 22 27 29 29 29

60-64 22 27 28 29 28

65-69 22 27 28 29 28

70-74 21 26 28 29 27

75-79 21 26 27 28 26

80-84 19 25 26 28 25

>85 20 24 26 28 25

Total 22 26 29 29 29

Source: Adapted from Crum RM, Anthony JC, Bassett SS, et al. Population- based norms for the mini-mental state examination by age and educational

level. JAMA 1993;269:2386-91. Copyright 1993, American Medical

Association. Used with permission.

22
Attachment C. The Blessed Orientation-MemoryConcentration Test

Overview

The six-item Blessed Orientation-Memory-Concentration (BOMC) test was devel- oped by Katzman and colleagues (Katzman, Brown, Fuld, et al., 1983) from the longer (29 item) Blessed Information-Memory-Concentration (BIMC) test (Blessed,

Tomlinson, and Roth, 1968). Katzman et al. selected 6 of the original 29 BIMC items

based on a series of statistical analyses. The scores from each of the six items are

multiplied as detailed below to yield a weighted score. Possible total scores on the BOMC range from (all items answered correctly) to 28 (all items answered incorrectly). Weighted error scores greater than 10 are consistent with dementia,

according to Katzman et al. (1983).

Items Maximum

Error Score Weight

1 What year is it now?

What month is it now?

1

1

XX4 =

2 3 = memory

phrase

Repeat this phrase after me: John Brown, 42 Market Street, Chicago

About what time is it? (within 1 hour)

Count backwards 20 to 1 Say the months in reverse order Repeat the memory phrase

X 2 =

X 2 =

X 2 =

Score of 1 for each incorrect response; maximum weighted score = 28.

Source: Katzman R, Brown T, Fuld P, et al. Validation of a short orientation-memory-concentration

test of cognitive impairment. Am J Psychiatry 1983;140:734-9. Copyright 1983, American Psychiatric Association. Used with permission.

23
Attachment D. The Blessed Information-MemoryConcentration Test

"Now I'd like to give you a short memory test that will take about five minutes.

Some questions will be easy, some will be more difficult. Are you ready?"

Correct Error

1 1.2.

3.

4.

5.

6.

7.

Name

1 Aae

1 When born

1 Where born

1 Name of this place

1 What street is it on

1 How lonq have vou been here (How long today)

1 8. Name of this city

1 9. 10.

11. 12.

Today's date

1 Month

1 Year

1 Day of week

1 13. Part of day

1 14. Time (Best guess) (Actual time: )

1 15. hrase after Season

Repeat this p me: John Brown, 42 Market Street, Chicago.

1

1

16.

17.

18.

Mother's first name NamP of nnp qrhnnl ynii attPnHpH fl^^^^H

1 What kind of work have you done

1 19. 20. Who is the president now

1 Who was the last president

1 21.

22.

23.

Date of World War 1

1 Date of World War II

1 Months of the year backwards. (Start with December)

D N S A Jl Jn M Ap M F Ja

1 24. Count from 1 to 20

1 25. Count backwards 20 to 1

.

20 19 18 17 16 15 14 13 12 11 10 9 8 76 5432 1 12345 26. Recall name and address: John Brown

42 Market Chicago j (Cue with "John Brown" only. Score up to 5 errors) TOTAL SCO =(E: (The sum of the scores for all 26 questions. Total number

of errors.)

24
Attachment D (continued)

Instructions for Scoring of the Blessed

Information-Memory-Concentration (BIMC) Test

Information Test Score each item "1" for incorrect response; "0" for correct response.

Item 5: Possible answers include: home, hospital, etc. Item 7: Answer can be given in number of hours, days, etc. Item 9: The date must be the actual date of the month, within a day, e.g., the

16th, 5th, etc. Item 13: One of the following must be selected: morning, afternoon, evening, night. Item 14: Score as correct if within one hour of the actual time. Memory Test Score each item "1" for incorrect response, "0" for correct response (except Item 27, see below). Item 3: Item 4: Item 19: Item 20

Item 21 Item 22

Item 26

Items

23-25:

The month and year must both be given correctly.

City and state must be given; town is optional. If foreign born,

country is sufficient. The name of the current president must be given; the last name is sufficient. The name of the past president must be given; the last name is sufficient. One of the years WWI took place must be given: 1914 to 1918. One of the years WWII took place must be given: 1939 to 1945.

If no cue is necessary and the patient recalls both name and address, score "0." If patient cannot spontaneously recall the name and address, cue with "John Brown" one time only. If this cue is necessary, the

patient automatically has 2 errors. Score 1 point for each subsequent

"unit" the participant cannot recall. The three units are: 42; Market

Street; Chicago.

Concentration Test

For uncorrected errors, score "2"; for self-corrected errors, score "1 For no errors, score "0." Indicate all errors and self corrections.

Source: Katzman R, Brown T, Fuld P, et al. Validation of a short orientation-memory-concentration

test of cognitive impairment. Am J Psychiatry 1983;140:734-9. Copyright 1983, American Psychiatric Association. Used with permission.

25
Attachment E. A Short Test of Mental Status (STMS)

"I would now like to examine your memory and related items. Please relax, pay

attention to the questions I am asking, and answer them as best as you can." Orientation

(8) Attention

(7)

Immediate recall

(4)

Calculation

(4) Abstraction

(3) Construction

(2) Copy

(2)

Name, address, current location (building),

city, state, date (day), month, year

Digit span (present 1/sec; record longest

correct span) 2-9-6-8-3, 5-7-1-9-4-6, 2-1-5-9-3-6-2 Four unrelated words: "apple," "Mr. Johnson,

"charity," "tunnel" Number of trials needed to learn all four: 5x13; 65 -7; 58 -2; 29 + 11

Similarities: orange/banana, dog/horse,

table/bookcase

Draw clock face showing 11:15

Information

(4) Recall

(4) Total Score:

(38)

President; first President; define an island; number of weeks per year The four words: "apple," "Mr. Johnson,"

"charity," "tunnel" [Raw Score - (number of learning trials - 1)]

26
Attachment E (continued)

Instructions for Administration and Scoring of tlie Short Test of l\/Iental Status (STMS)

Orientation Each correct response is worth 1 point. The maximum score is 8. Attention Usually a span of five digits is given to the patient. If the patient responds correctly, the span is increased to six and then to seven. The patient's best performance is then

recorded. If the patient is able to repeat seven digits forward, the test is terminated. The number of digits correctly repeated is the score; the maximal score is 7, and the minimal score is 0. Immediate Recall

If the patient learns the words on the first trial, then the next subtest is given. If the

patient is unable to learn all four words, the investigator repeats them for a maximum of 4 trials and records the number of trials that the patient requires to learn all 4 words. If the patient is unable to learn all four words by the end of the fourth trial, the patient's best performance is recorded (the number of words learned and the number of trials required). Learning is scored in two part. A point is earned for each word learned (a maximum of 4 points). One less than the number of trials (a maximum of 4) required to learn the words was subtracted from the score. Thus, the values that were subtracted were between and 3. Calculation Each correct answer earns 1 point, and the maximal score is 4. Abstraction

One point for each word pair is given only for definitely abstract interpretations (for example, horse/dog = animal). Concrete interpretations or inability to see a similarity earns points for that word pair. The maximal score is 3. Construction and Copying

The patient is able to view the diagram of a cube while drawing his or her own version. For each construction, an adequate conceptual drawing is scored as 2, a less than complete drawing earns a score of 1 , and inability to perform the task earns a score of

0. The maximum score for the construction tasks is 4. Information Each correct answer earns 1 point, and the maximal score is 4.

27
Attachment E (continued)

Recall At the end of the test, the patient is asked to recall the four words from the immediate

recall subtest. No cues or reminders are provided. The patient earns 1 point for each

word recalled, and the maximal score is 4. Total Score

Total score = sum of subtest scores - (number of trials for acquisition - 1). For example, if a patient learned all four words on the first trial, nothing was subtracted from the sum of the subtest scores. If a patient required four trials to learn some or all four words, then 3 was subtracted from the sum of the subtest scores.

Source: Kokmen E, Naessens JM, Offord KP. A short test of mental status: description and prelim- inary results. Mayo Clinic Proc 1987;62:281-8. Copyright 1987, Mayo Clinic Foundation. Used

with permission.

28
Notes
Notes

n
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U.S. Department of Health and Human Services

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2101 East Jefferson Street, Suite 501

Rockville, MD 20852

AHCPR Publication No. 97-0703

November 1996