Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Brief Cognitive Testing in the Detection and Diagnosis of Clinical Alzheimer-Type Dementia

 

Am Fam Physician. 2021 Feb 1;103(3):183-185.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

In adults with suspected cognitive impairment, what is the utility of brief cognitive testing in detecting clinical Alzheimer-type dementia (ATD) and distinguishing it from mild cognitive impairment (MCI) or normal cognition?

Evidence-Based Answer

The Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), list learning memory test, list delayed recall memory test, and the semantic fluency language test have sensitivities and specificities that are 0.80 or greater in distinguishing clinical ATD from normal cognition. The MoCA is the only stand-alone test with sensitivity and specificity greater than 0.90 for this comparison. (Strength of Recommendation [SOR]: C, based on disease-oriented evidence.) Brief cognitive tests are less accurate in distinguishing clinical ATD from MCI compared with distinguishing it from normal cognitive function. (SOR: C, based on disease-oriented evidence.) Brief cognitive testing alone is insufficient to definitively detect or diagnose clinical ATD.1 (SOR: C, based on disease-oriented evidence.)

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CLINICAL BOTTOM LINE

Summary of Findings for Clinical Alzheimer-Type Dementia vs. Normal Cognition for Selected Brief Cognitive Tests and Metrics

Test categoryTest metricNo. of studiesMedian prevalence of clinical Alzheimer-type dementia (range)Median sensitivity (range)Median specificity (range)

Individual stand-alone tests

Clock drawing totals

8 (n = 1,022)

0.50 (0.15 to 0.64)

0.79 (0.36 to 0.93)

0.88 (0.42 to 1.0)

Mini-Mental State Examination total

7 (n = 1,724)

0.50 (0.15 to 0.71)

0.88 (0.56 to 1.0)

0.94 (0.59 to 1.0)

Montreal Cognitive Assessment total

2 (n = 864)

0.71 (0.60 to 0.71)

0.94 (0.93 to 0.96)

0.94 (0.91 to 1.0)

Brief multidomain batteries

Dementia rating scale total

2 (n = 507)

0.60 (0.50 to 0.71)

0.97 (0.96 to 0.97)

0.96 (0.92 to 0.99)

Memory

List learning, trials and totals

6 (n = 1,784)

0.21 (0.11 to 0.50)

0.82 (0.35 to 0.96)

0.96 (0.73 to 1.0)

List delayed recall and retention

5 (n = 937)

0.50 (0.16 to 0.50)

0.89 (0.62 to 0.96)

0.94 (0.76 to 0.98)

Prose recall and retention

3 (n = 895)

0.40 (0.11 to 0.54)

0.77 (0.71 to 0.87)

0.87 (0.81 to 0.89)

Executive

Trail Making Test part B, completion time

2 (n = 457)

0.33 (0.16 to 0.50)

0.86 (0.85 to 0.87)

0.86 (0.83 to 0.88)

Language

Semantic (category) fluency

9 (n = 1,586)

0.50 (0.15 to 0.68)

0.92 (0.35 to 1.0)

0.89 (0.81 to 1.0)

Phonemic (letter) fluency

4 (n = 830)

0.63 (0.15 to 0.68)

0.77 (0.72 to 0.89)

0.86 (0.69 to 0.93)

Boston Naming Test total

2 (n = 479)

0.50 (0.16 to 0.50)

0.65 (0.53 to 0.84)

0.92 (0.85 to 0.92)

Combinations

Wechsler Memory Scale logical memory; Wechsler Adult Intelligence Scale digital symbol; Boston Naming Test 60

2 (n = 302)

0.47 (0.44 to 0.50)

0.82 (0.68 to 0.95)

0.87 (0.74 to 1.0)


Adapted from Fink HA, Hemmy LS, Linskens EJ, et al. Diagnosis and treatment of clinical Alzheimer's-type dementia: a systematic review. Comparative effectiveness review no. 223. (Prepared by the Minnesota Evidence-based Practice Center under contract no. 290-2015-00008-I.) AHRQ publication no. 20-EHC003. Rockville, Md.: Agency for Healthcare Research and Quality; April 2020. Accessed June 3, 2020. https://effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_1.pdf

CLINICAL BOTTOM LINE

Summary of Findings for Clinical Alzheimer-Type Dementia vs. Normal Cognition for Selected Brief Cognitive Tests and Metrics

Test categoryTest metricNo. of studiesMedian prevalence of clinical Alzheimer-type dementia (range)Median sensitivity (range)Median specificity (range)

Individual stand-alone tests

Clock drawing totals

8 (n = 1,022)

0.50 (0.15 to 0.64)

0.79 (0.36 to 0.93)

0.88 (0.42 to 1.0)

Mini-Mental State Examination total

7 (n = 1,724)

0.50 (0.15 to 0.71)

0.88 (0.56 to 1.0)

0.94 (0.59 to 1.0)

Montreal Cognitive Assessment total

2 (n = 864)

0.71 (0.60 to 0.71)

0.94 (0.93 to 0.96)

0.94 (0.91 to 1.0)

Brief multidomain batteries

Dementia rating scale total

2 (n = 507)

0.60 (0.50 to 0.71)

0.97 (0.96 to 0.97)

0.96 (0.92 to 0.99)

Memory

List learning, trials and totals

6 (n = 1,784)

0.21 (0.11 to 0.50)

0.82 (0.35 to 0.96)

0.96 (0.73 to 1.0)

List delayed recall and retention

5 (n = 937)

0.50 (0.16 to 0.50)

0.89 (0.62 to 0.96)

0.94 (0.76 to 0.98)

Prose recall and retention

3 (n = 895)

0.40 (0.11 to 0.54)

0.77 (0.71 to 0.87)

0.87 (0.81 to 0.89)

Executive

Trail Making Test part B, completion time

2 (n = 457)

0.33 (0.16 to 0.50)

0.86 (0.85 to 0.87)

0.86 (0.83 to 0.88)

Language

Semantic (category) fluency

9 (n = 1,586)

0.50 (0.15 to 0.68)

0.92 (0.35 to 1.0)

0.89 (0.81 to 1.0)

Phonemic (letter) fluency

4 (n = 830)

0.63 (0.15 to 0.68)

0.77 (0.72 to 0.89)

0.86 (0.69 to 0.93)

Boston Naming Test total

2 (n = 479)

0.50 (0.16 to 0.50)

0.65 (0.53 to 0.84)

0.92 (0.85 to 0.92)

Combinations

Wechsler Memory Scale logical memory; Wechsler Adult Intelligence Scale digital symbol; Boston Naming Test 60

2 (n = 302)

0.47 (0.44 to 0.50)

0.82 (0.68 to 0.95)

0.87 (0.74 to 1.0)


Adapted from Fink HA, Hemmy LS, Linskens EJ, et al. Diagnosis

Address correspondence to Aaron Saguil, MD, MPH, at aaron.saguil@usuhs.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Fink HA, Hemmy LS, Linskens EJ, et al. Diagnosis and treatment of clinical Alzheimer's-type dementia: a systematic review. Comparative effectiveness review no. 223. (Prepared by the Minnesota Evidence-based Practice Center under contract no. 290-2015-00008-I.) AHRQ publication no. 20-EHC003. Rockville, Md.: Agency for Healthcare Research and Quality; April 2020. Accessed June 3, 2020. https://effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_1.pdf...

2. Alzheimer's Association report. 2020 Alzheimer's disease facts and figures. Alzheimers Dement. 2020;16(3):391–460.

3. Administration for Community Living. 2019 profile of older Americans. July 2020. Accessed December 9, 2020. https://acl.gov/aging-and-disability-in-america/data-and-research/profile-older-americans

4. Hemmy LS, Linskens EJ, Silverman PC, et al. Brief cognitive tests for distinguishing clinical Alzheimer-type dementia from mild cognitive impairment or normal cognition in older adults with suspected cognitive impairment. Ann Intern Med. 2020;172(10):678–687.

5. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: mild cognitive impairment: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology. Neurology. 2018;90(3):126–135.

6. Patnode CD, Perdue LA, Rossom RC, et al. Screening for cognitive impairment in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(8):764–785.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review go to https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-223-clinical-alzheimers-type-dementia_0.pdf.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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