Tuesday, March 15, 2011

The Past is Hard to Forget when Evaluating New Dementia Screening Tests | GeriPal - Geriatrics and Palliative Care Blog

If we care about primary care physicians actually using the screening tests we develop, then we should care about their accessibility to those clinicians. To put it simply, the more barriers we put in place, the less likely anyone will use them to assess cognitive status in the elderly.

The prior gold standard for cognitive screening was the mini-mental status exam (MMSE). This test used to be freely available online, in books, and on pocket cards that were distributed to medical students and residents throughout the country. This all changed in March of 2001 when MiniMental, LLC (the current owners of the MMSE copyright) granted Psychological Assessment Resources (PAR) the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE. Suddenly, after decades of neglect, PAR began enforcing the copyright on the MMSE (see "stealth patents"). Now physicians would have to pay about $1 per test, and importantly, another barrier to cognitive screening was erected.

In the wake of the MMSE copyright enforcement, several new and improved cognitive screens began hitting the geriatrics store shelves. One excellent example is the Montreal Cognitive Assessment (MoCA). This is a free, brief, and validated screening tool with high sensitivity and specificity for detecting MCI and dementia (http://www.mocatest.org). It’s easy to use, but does require one to print out the actual test in order to administer it to patients.

What about a test that requires no props and no special forms? This months Archives of Internal Medicine released a study on the Sweet 16. The article describes the creation of this new brief cognitive assessment tool, and its comparison to the MMSE in a cohort of patients. A long story made short: the Sweet 16 was found to be at least equivalent to, and possibly superior to that of the MMSE (at least in this cohort of patients). Some of the results included:
  • The average time to complete the test was 1.4 to 2.9 minutes
  • When compared to the IQCODE, a Sweet 16 score of less than 14 demonstrated a sensitivity of 80% and a specificity of 70%, whereas an MMSE score of less than 24 showed a sensitivity of 64% and a specificity of 86%.
  • When compared with clinical diagnosis, a Sweet 16 score of less than 14 showed a sensitivity of 99% and a specificity of 72% in contrast to an MMSE score with a sensitivity of 87% and a specificity of 89%.
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