1
2
3
4
5
6
Background note:  The DSC identified 7 priority topics.  We did evidence reviews on the top

3.  

These were the other 4 topics:

4.  Evidence‐based functional maintenance programs      

5.  Co‐occurring dementia and depression        

6.  Management of vascular risk factors

7.  Neuroimaging    

7
8
9
Regardless of the controversies surrounding dementia screening, there may be

opportunities to improve case‐finding approaches.  

10
11
12
Full names of tests:

Blessed Orientation‐Memory‐Concentration (BOMC) Test

Mini‐Cog

Montreal Cognitive Assessment (MoCA)

General Practitioner Assessment of Cognition (GPCOG)

St. Louis University Mental Status (SLUMS) Exam

Short Test of Mental Status (STMS)   

13
14
15
16
17
18
19
20
21
Examples of items in the QUADAS tool:  Is the reference standard likely to correctly classify

patients?

Is time period between reference standard and test in question short enough?

Did patients receive the same reference standard regardless of test result?

Were index test results interpreted without knowledge of the results of the reference

standard?  

22
23
24
25
Eliciting SMC means the investigators asked patients and/or caregivers whether or not they

had experienced memory loss over a certain time period.  There were various methods for

eliciting SMC, most involving 1‐3 brief questions.  As applied in these studies, the elicitation

of SMC is, in a sense, a form of screening.  

26
We relied on one systematic review by Mitchell et al from 2008.  They used reliable

methods to identify studies, however, they were more inclusive than we would have been

in selecting studies.  

27
Before we move on to selected results, I just wanted to briefly review some basic

terminology.  

28
These are the three best conducted and most representative of the SMC studies.  The first

two studies assessed self‐reported SMC, while the third study by Carr et al assessed a

single‐item informant‐reported SMC question.  The table shows their sensitivity/specificity

and then the predictive values of the test based on theoretic prevalence assumptions.  As

you can see, when the prevalence of dementia is low – as might be seen in a younger,

primary care practice, a negative test result is very good at identifying patients without

dementia.  However, the value of a positive test result is much less, except in very high

prevalence prevalence populations populations.  The informant informant‐reported reported SMC study found the best performance performance,

but this has not been widely studied.  

29
In general, neuropsychiatric symptoms were poorly sensitive but moderately to highly

specific for dementia. Some methodologic issues – two of the studies included a portion of

cohort with + MMSE screen Æ higher dementia prevalence rates.  One of the studies used

a non‐demented patient population from a different cohort.  

30
Inability to perceive the form of an object by sense of touch.  

Inability to recognize writing on the skin by sense of touch alone.  

31
32
All 6 measures test for recall ability.

A clock drawing test is included in all tests except BOMC.

Assessment of other cognitive domains, such as orientation, abstraction, math, and

language skills, varies among the 6 measures.

33
Among the 6 tests, the Mini‐Cog has the shortest administration time (2 to 4 minutes).

The BOMC was evaluated in a bi‐racial population sample, and was found to misclassify

more blacks than whites as impaired.  Specificity varied widely among studies of the

BOMC.

34
Example of brief cognitive measure:  excerpt from the MoCA

35
Excerpt is 2nd half of MoCA.  Shows scoring method and adjustment for education.

36
Among the 6 tests, the Mini‐Cog has the shortest administration time, and has been

studied in a large population sample as well as in multi‐ethnic samples.  Sensitivity and

specificity were high in 2 studies, while poor specificity in a third study may have resulted

from inclusion of subjects with MCI.  

The SLUMS examination had very high sensitivity and specificity in a VA population, and it

allows for adjustment for education.  However, the SLUMS has a longer administration time

(approximately 7 minutes) compared with other tests, and has only been evaluated in 1

study.  

The other 4 tests had various strengths and limitations.  The STMS had high sensitivity and

specificity in a primary care setting, but has been evaluated in only 2 studies.  The GPCOG is

unique in that it allows for the input of an informant; however, the specificity of the

informant section by itself was low (49‐66%).  The BOMC was evaluated in a bi‐racial

population sample, and was found to misclassify more blacks than whites as impaired.  

Specificity varied widely among studies of the BOMC.  The MoCA has the longest

administration time among the 6 tests, and had low specificity (35‐50%) in 2 of 3 studies.

37
38
For example, in one study, only 57% of respondents would agree to routine testing for

dementia.  

Of note, these were mainly studies about dementia screening and are not 100% applicable

to our key questions.  

39
We excluded studies of MCI patients only and most studies did not include populations

with very mild or very early dementia.  

40
41
Clinical utility Æ provider satisfaction, workflow, time to completion, ease of use etc.   

42
43