Development of a short form of Mini-Mental State Examination for the screening of dementia in older adults with a memory complaint: a case control study

<p>Abstract</p> <p>Background</p> <p>Primary care physicians need a brief and accurate screening test of dementia. The objective of this study was to determine whether a short form of Mini-Mental State Examination (SMMSE) was as accurate as the Mini-Mental State Examination (MMSE) in screening dementia.</p> <p>Methods</p> <p>Based on case control design study, SMMSE and MMSE were assessed in 184 community-dwelling older adults (mean age 81.3 ± 6.5 years, 71.7% women) with memory complaint sent by their primary care physician to a memory clinic. Included participants were separated into two groups: cognitively healthy individuals and demented individuals.</p> <p>Results</p> <p>The trade-off between sensitivity and specificity of the SMMSE for clinically diagnosed dementia was 4. Based on the cut-off value ≤ 4 for SMMSE and a cut-off value ≤ 24 for MMSE, the sensitivity of both tests was similar (89.5% for SMMSE versus 90.0% for MMSE), whereas the specificity, the positive predictive values (PPV) and the negative predictive values (NPV) were higher for SMMSE compared to MMSE (85.4 versus 75.5% for specificity; 95.5% versus 92.8% for PPV; 70.0 versus 68.9 for NPV). The positive and negative Likehood Ratio (LR) of SMMSE were higher than those of MMSE (respectively, 6.1 versus 3.7; 8.1 versus 7.7). In addition, odds ratio (OR) for dementia was higher for the SMMSE compared to the MMSE (OR = 49.8 with 95% confident interval (CI) [18.0; 137.8] versus OR = 28.6 with 95% CI [11.6; 70.3]).</p> <p>Conclusions</p> <p>SMMSE seems to be an efficient short screening test for dementia among community-dwelling older adults with a memory complaint. Further research is needed to confirm its predictive values among unselected primary care older patients.</p

“I Can't Afford That!”: Dilemmas in the Care of the Uninsured and Underinsured

When patients lack sufficient health care insurance, financial matters become integrally intertwined with biomedical considerations in the process of clinical decision making. With a growing medically indigent population, clinicians may be compelled to bend billing or reimbursement rules, lower standards, or turn patients away when they cannot afford the costs of care. This article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (1) whether to refer the individual to a safety net provider, such as a public clinic; (2) whether to forgo indicated tests and therapies because of cost; and (3) whether to reduce fees by fee waivers or other adjustments in billing. Clinicians' responses to these dilemmas impact on quality of care, continuity, safety net providers, and the liability risk of committing billing violations or offering nonstandard care. Caring for the underinsured in the current health care climate requires an understanding of billing regulations, a commitment to informed consent, and a beneficent approach to finding individualized solutions to each patient care/financial dilemma. To effect change, however, physicians must address issues of social justice outside of the office through political and social activism

The Severe Impairment Battery

The term dementia is an umbrella term used to describe a clinical syndrome that consists, primarily, of significant, progressive and irreversible deterioration of cognitive functioning (learning and memory, language, perception, executive functioning, attention) from a higher level of premorbid functioning, which is of significant severity to interfere with independent living skills across a range of domains (instrumental, domestic, self-care, social). Decline in cognitive functioning can also be accompanied by behavioural and personality changes [1, 2]. The National Institute for Health and Care Excellence [3] defines dementia as “a progressive and largely irreversible clinical syndrome that is characterised by a widespread impairment of mental function … as [dementia] progresses [people] can experience some or all of the following: memory loss, language impairment, disorientation, changes in personality, difficulties with activities of daily living, self-neglect, psychiatric symptoms and out-of-character behaviour” (p. 5). There are many different types of dementia caused by a number of diseases of the brain (for example Alzheimer’s disease, Frontotemporal degeneration, lewy body disease, vascular disease), the most common cause being Alzheimer’s disease [3]. In the most recently published diagnostic manuals [2] the ‘dementias’ are subsumed within the category of Major and Mild neurocognitive disorders