Effectiveness and costs of phototest in dementia and cognitive impairment screening

<p>Abstract</p> <p>Background</p> <p>To assess and compare the effectiveness and costs of Phototest, Mini Mental State Examination (MMSE), and Memory Impairment Screen (MIS) to screen for dementia (DEM) and cognitive impairment (CI).</p> <p>Methods</p> <p>A phase III study was conducted over one year in consecutive patients with suspicion of CI or DEM at four Primary Care (PC) centers. After undergoing all screening tests at the PC center, participants were extensively evaluated by researchers blinded to screening test results in a Cognitive-Behavioral Neurology Unit (CBNU). The gold standard diagnosis was established by consensus of expert neurologists. Effectiveness was assessed by the proportion of correct diagnoses (diagnostic accuracy [DA]) and by the kappa index of concordance between test results and gold standard diagnoses. Costs were based on public prices and hospital accounts.</p> <p>Results</p> <p>The study included 140 subjects (48 with DEM, 37 with CI without DEM, and 55 without CI). The MIS could not be applied to 23 illiterate subjects (16.4%). For DEM, the maximum effectiveness of the MMSE was obtained with different cutoff points as a function of educational level [k = 0.31 (95% Confidence interval [95%CI], 0.19-0.43), DA = 0.60 (95%CI, 0.52-0.68)], and that of the MIS with a cutoff of 3/4 [k = 0.63 (95%CI, 0.48-0.78), DA = 0.83 (95%CI, 0.80-0.92)]. Effectiveness of the Phototest [k = 0.71 (95%CI, 0.59-0.83), DA = 0.87 (95%CI, 0.80-0.92)] was similar to that of the MIS and higher than that of the MMSE. Costs were higher with MMSE (275.9 ± 193.3€ [mean ± sd euros]) than with Phototest (208.2 ± 196.8€) or MIS (201.3 ± 193.4€), whose costs did not significantly differ. For CI, the effectiveness did not significantly differ between MIS [k = 0.59 (95%CI, 0.45-0.74), DA = 0.79 (95%CI, 0.64-0.97)] and Phototest [k = 0.58 (95%CI, 0.45-0.74), DA = 0.78 (95%CI, 0.64-0.95)] and was lowest for the MMSE [k = 0.27 (95%CI, 0.09-0.45), DA = 0.69 (95%CI, 0.56-0.84)]. Costs were higher for MMSE (393.4 ± 121.8€) than for Phototest (287.0 ± 197.4€) or MIS (300.1 ± 165.6€), whose costs did not significantly differ.</p> <p>Conclusion</p> <p>MMSE is not an effective instrument in our setting. For both DEM and CI, the Phototest and MIS are more effective and less costly, with no difference between them. However, MIS could not be applied to the appreciable percentage of our population who were illiterate.</p

The comparative diagnostic accuracy of the Mini Mental State Examination (MMSE) and the General Practitioner assessment of Cognition (GPCOG) for identifying dementia in primary care: a systematic review protocol

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Incidence and clinical impact of infective endocarditis after transcatheter aortic valve implantation

Aims: To describe the characteristics of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). Methods and results: This study was performed using the GAMES database, a national prospective registry of consecutive patients with IE in 26 Spanish hospitals. Of the 739 cases of IE diagnosed during the study, 1.3% were post-TAVI IE, and these 10 cases, contributed by five centres, represented 1.1% of the 952 TAVIs performed. Mean age was 80 years. All valves were implanted transfemorally. IE appeared a median of 139 days after implantation. The mean age-adjusted Charlson comorbidity index was 5.45. Chronic kidney disease was frequent (five patients), as were atrial fibrillation (five patients), chronic obstructive pulmonary disease (four patients), and ischaemic heart disease (four patients). Six patients presented aortic valve involvement, and four only mitral valve involvement; the latter group had a higher percentage of prosthetic mitral valves (0% vs. 50%). Vegetations were found in seven cases, and four presented embolism. One patient underwent surgery. Five patients died during follow-up: two of these patients died during the admission in which the valve was implanted. Conclusions: IE is a rare but severe complication after TAVI which affects about 1% of patients and entails a relatively high mortality rate. IE occurred during the first year in nine of the 10 patients

Should the Mini-Mental State Examination be retired?

Introduction: Short cognitive tests are routinely used in clinical practice to detect and screen for cognitive impairment and dementia. These cognitive tests should meet minimum criteria for both applicability and psychometric qualities. Development: The Mini-Mental State Examination (MMSE) is the most frequently applied short cognitive test, and the article introducing it remains a milestone in the history of medicine. Its main advantages are its widespread use and the extensive empirical evidence that supports it. However, the MMSE has important shortcomings, including lack of standardisation, its lack of suitability for illiterate subjects, the considerable effect of socio-educational variables on results, and its limited effectiveness for detecting cognitive impairment. Lastly, since the test is copyright-protected, using it is necessarily either costly or fraudulent. Newer available instruments do not share these shortcomings and have demonstrated greater diagnostic accuracy for detecting cognitive impairment and dementia, as well as being more cost-effective than the MMSE. Conclusion: It is time to acknowledge the MMSE's important role in the history of medicine and grant it a deserved and honourable retirement. Its place will be taken by more effective instruments that require less time, are user-friendly and free of charge, can be applied to all individuals, and yield more equitable outcomes. Resumen: Introducción: Los test cognitivos breves (TCB) son instrumentos de uso habitual en la práctica clínica para la detección y el cribado del deterioro cognitivo y demencia. Los TCB deben reunir unas características de aplicabilidad y psicométricas mínimas. Desarrollo: El Mini-Mental es el TCB más utilizado y el artículo en el que se describe es un hito en la historia de la Medicina. Su principal ventaja es la amplia difusión de su uso y el extenso soporte empírico que la apoya. No obstante, el Mini-Mental tiene numerosas e importantes limitaciones, fundamentalmente la falta de estandarización, el no poder ser aplicado a analfabetos, la gran influencia en sus resultados de las variables socioeducativas y la discreta utilidad para la detección de DC; además, este instrumento está protegido por copyright por lo que su uso es gravoso o fraudulento. En la actualidad, hay TCB disponibles que no cuentan con estas limitaciones y que han mostrado una mayor utilidad diagnóstica e incluso un mayor coste-efectividad que el Mini-Mental en la detección de deterioro cognitivo y demencia. Conclusión: Es hora de reconocerle al Mini-Mental el importante papel que ha desempeñado en la historia de la Medicina y concederle una merecida y honrosa jubilación, dando paso a instrumentos más breves, fáciles y baratos, que puedan ser aplicados libremente a todos los individuos y que sean más eficientes y justos. Keywords: Mini-Mental, Screening test, Short cognitive test, Dementia, Cognitive impairment, Abbreviated cognitive evaluation, Palabras clave: Mini-Mental, Test de cribado, Test cognitivos breves, Demencia, Deterioro cognitivo, Evaluación cognitiva abreviad

¿Es hora de jubilar al Mini-Mental?

Resumen: Introducción: Los test cognitivos breves (TCB) son instrumentos de uso habitual en la práctica clínica para la detección y el cribado del deterioro cognitivo y demencia. Los TCB deben reunir unas características de aplicabilidad y psicométricas mínimas. Desarrollo: El Mini-Mental es el TCB más utilizado y el artículo en el que se describe es un hito en la historia de la Medicina. Su principal ventaja es la amplia difusión de su uso y el extenso soporte empírico que la apoya. No obstante, el Mini-Mental tiene numerosas e importantes limitaciones, fundamentalmente la falta de estandarización, el no poder ser aplicado a analfabetos, la gran influencia en sus resultados de las variables socioeducativas y la discreta utilidad para la detección de DC; además, este instrumento está protegido por copyright por lo que su uso es gravoso o fraudulento. En la actualidad, hay TCB disponibles que no cuentan con estas limitaciones y que han mostrado una mayor utilidad diagnóstica e incluso un mayor coste-efectividad que el Mini-Mental en la detección de deterioro cognitivo y demencia. Conclusión: Es hora de reconocerle al Mini-Mental el importante papel que ha desempeñado en la historia de la Medicina y concederle una merecida y honrosa jubilación, dando paso a instrumentos más breves, fáciles y baratos, que puedan ser aplicados libremente a todos los individuos y que sean más eficientes y justos. Abstract: Introduction: Short cognitive tests are routinely used in clinical practice to detect and screen for cognitive impairment and dementia. These cognitive tests should meet minimum criteria for both applicability and psychometric qualities. Development: The Mini-Mental State Examination (MMSE) is the most frequently applied short cognitive test, and the article introducing it remains a milestone in the history of medicine. Its main advantages are its widespread use and the extensive empirical evidence that supports it. However, the MMSE has important shortcomings, including lack of standardisation, its lack of suitability for illiterate subjects, the considerable effect of socio-educational variables on results, and its limited effectiveness for detecting cognitive impairment. Lastly, since the test is copyright-protected, using it is necessarily either costly or fraudulent. Newer available instruments do not share these shortcomings and have demonstrated greater diagnostic accuracy for detecting cognitive impairment and dementia, as well as being more cost-effective than the MMSE Conclusion: It is time to acknowledge the MMSE's important role in the history of medicine and grant it a deserved and honourable retirement. Its place will be taken by more effective instruments that require less time, are user-friendly and free of charge, can be applied to all individuals, and yield more equitable outcomes. Palabras clave: Mini-Mental, Test de cribado, Test cognitivos breves, Demencia, Deterioro cognitivo, Evaluación cognitiva abreviada, Keywords: Mini-Mental, Screening test, Short cognitive test, Dementia, Cognitive impairment, Abbreviated cognitive evaluatio