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Office- and Bedside-based Screening for Cognitive Impairment and the Dementias
Abstract
Elderly patients and their families are concerned about the patients' cognitive abilities, and cognitive screening is an efficient diagnostic tool, as long as clinicians administer the screens in a standardized manner and interpret the screen results accurately. The following brief summary reviews commonly used screening instruments and provides information about how to interpret screening test results. It concludes by showing how cognitive screening fits into a four-step process (Education, Screening, Follow-up, and Referral) of how to respond to patients with cognitive concerns.
... Early recognition of cognitive impairment allows for diagnosis and appropriate treatment, education, psychosocial support and engagement in shared decision-making regarding life planning, health care, involvement in research and financial matters [1]. It has been hard to meet the challenge of psychometrically sound, clinically feasible assessments, with some exceptions [2]. There is increasing recognition that the stimuli should not disadvantage any particular cultures [3]. ...
Cognitive impairment is a prevalent and debilitating symptom of multiple sclerosis (MS) but is not routinely addressed in clinical care. The Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) was developed in 2012 to screen and monitor MS patients’ cognition. This systematic review and meta-analysis aimed to identify, synthesise, and critically appraise current BICAMS’ international validations. The literature search was conducted using PubMed, PsycINFO and Web of Science electronic databases in August 2022. Quantitative, peer-reviewed adult studies, which followed the BICAMS international validation protocol and were published in English, were included. The search identified a total of 203 studies, of which 26 were eligible for inclusion. These reported a total of 2833 adults with MS and 2382 healthy controls (HC). The meta-analysis showed that BICAMS identified impaired cognitive functioning in adults with MS compared to HC for all three subtests: information processing speed (g = 0.854, 95% CI = 0.765, 0.944, p < 0.001), immediate verbal recall (g = 0.566, 95% CI = 0.459, 0.673, p < 0.001) and immediate visual recall (g = 0.566, 95% CI = 0.487, 0.645, p < 0.001). Recruitment sites and strategies limit the generalisability of results. BICAMS is a valid and feasible international MS cognitive assessment.
Objectives Effective identification and management of subclinical left ventricular (LV) dysfunction (LVD) and subclinical atrial fibrillation (AF) by screening elderly populations might be compromised by mild cognitive impairment (MCI). We sought to characterise the prevalence and profile of MCI and evaluate associations with LV and left atrial (LA) dysfunction and AF, in a trial of screening for subclinical LVD and AF.Design Cross-sectional.Setting Australian, community-based intervention trial.Participants Adults aged ≥65 years with ≥1 LVD risk factors without ischaemic heart disease (n=337).Outcome measures The Montreal cognitive assessment (MoCA) was obtained. Subclinical LVD was defined as echocardiographic global longitudinal strain ≤16%, diastolic dysfunction or LV hypertrophy; abnormal LA reservoir strain (LARS) was defined as <24%. Subclinical AF was detected using a single-lead portable electrocardiographic device in those without pre-existing AF who gave consent (n=293).Results Subclinical LVD was found in 155 (46%), abnormal LARS in 9 (3.6%) and subclinical AF in 11 (3.8%). MoCA score consistent with MCI (<26) was found in 101 (30%); executive function (69%) and delayed recall (93%), were the most frequently abnormal domains. Compared with normal cognition, MCI was associated with non-adherence to AF screening (25% vs 40%, p=0.01). In multivariable logistic regression modelling, educational achievement, systolic blood pressure, body mass index and waist-to-hip ratio were independently associated with MCI. However, neither subclinical AF nor any measure of cardiac dysfunction, were associated with MCI.Conclusions The 30% prevalence of MCI among elderly subjects with risk factors for subclinical LVD and AF has important implications for screening strategies and management. However, MCI is not associated with subclinical myocardial dysfunction nor subclinical AF.Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12617000116325).
Background:
We aimed to investigate the correlation of factors involved in the change of Mini-Mental State Examination (MMSE) and type 2 diabetes in the elderly.
Methods:
This study was a secondary analysis of a prospective cohort study. Type 2 diabetes patients aged > 55 years were recruited and assigned into three groups based on their glycated hemoglobin (HbA1c) levels: HbA1c < 7, 7% ≤ HbA1c < 8% and HbA1c ≥8%. MMSE decline was considered the endpoint. Factors related to MMSE decline were identified by univariate and multivariate regression analyses.
Results:
Altogether, 1519 subjects were included, 883 in the Low group, 333 in the Median group, and 303 in the High group. Age ≥ 75 years, education below elementary school level, not participating in seminars or consultation on healthcare, physical activity less than 30 min/day, cerebrovascular disease history, MMSE score at baseline, and HBA1c ≥8% were associated with cognitive decline by univariate and multivariate analysis. When the other factors were adjusted for, HBA1c ≥8% was independently associated with the severity of cognitive decline (β = 0.58, 95%CI:0.06-1.11, P = 0.029) and the occurrence of cognitive decline (odds ratio (OR) = 1.55, 95%CI:1.13-2.12, P = 0.007).
Conclusions:
In elderly patients with type 2 diabetes, HbA1c ≥8% is an independent factor for cognitive decline and is also associated with the severity of the cognitive decline.
Cognitive impairment is a common entity in patients with chronic kidney disease (CKD), which plays an important role in increasing the morbidity in these patients. This study was performed to evaluate cognitive dysfunction and its severity in different stages of CKD and identify the correlation with factors affecting this dysfunction. A cross-sectional design study was conducted on 100 patients with CKD Stage III to V-D fulfilling the eligibility criteria. Cognitive status was assessed using the mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) tests. The patients were divided into four groups according to their estimated glomerular filtration rate (eGFR); Group A with eGFR ranging between 30 and 59 mL/min/1.73 m2, Group B with eGFR between 15 and 29 mL/min/1.73 m2, Group C with eGFR
Objectives:
The focus of this study is the classification accuracy of the Montreal Cognitive Assessment (MoCA) for the detection of cognitive impairment (CI). Classification accuracy can be low when the prevalence of CI is either high or low in a clinical sample. A more robust result can be expected when avoiding the range of test scores within which most classification errors are expected, with adequate predictive values for more clinical settings.
Methods:
The classification methods have been applied to the MoCA data of 5019 patients in the Uniform Data Set of the University of Washington's National Alzheimer's Coordinating Center, to which 30 Alzheimer Disease Centers (ADCs) contributed.
Results:
The ADCs show sample prevalence of CI varying from 0.22 to 0.87. Applying an optimal cutoff score of 23, the MoCA showed for only 3 of 30 ADCs both a positive predictive value (PPV) and a negative predictive value (NPV) ≥0.8, and in 18 cases, a PPV ≥0.8 and for 13 an NPV ≥0.8. Overall, the test scores between 22 and 25 have low odds of true against false decisions of 1.14 and contains 55.3% of all errors when applying the optimal dichotomous cut-point. Excluding the range 22 to 25 offers higher classification accuracies for the samples of the individual ADCs. Sixteen of 30 ADCs showed both NPV and PPV ≥0.8, 25 show a PPV ≥0.8, and 21 show an NPV ≥0.8.
Conclusion:
In comparison to a dichotomous threshold, considering the most error-prone test scores as uncertain enables a classification that offers adequate classification accuracies in a larger number of clinical settings.
Background
Diabetes is a risk factor for cognitive impairment, but whether there is also a link between pre-diabetes and cognitive dysfunction is not yet fully established. The aim of this observational study was to investigate associations between pre-diabetes/diabetes and cognitive test results, and also between glucose levels measured during the Oral Glucose Tolerance Test (OGTT) and cognitive outcomes.
Methods
During 2007–2012, in all 2994 people (mean age 72 years), residing in Malmö, Sweden, underwent a clinical examination including the OGTT, cardiovascular measurements including carotid-femoral pulse wave velocity (c-f PWV) and two cognitive tests, the Mini Mental State Examination (MMSE), measuring global cognitive function, and A Quick Test of Cognitive Speed (AQT), measuring processing speed and executive functioning. Regression analyses were performed to investigate associations between: (a) categories of normal or impaired glucose metabolism, and (b) OGTT measurements, respectively, as exposure variables and cognitive test results as outcomes. Adjustments were made for demographics, lifestyle factors and cardiovascular risk factors.
Results
Participants with pre-diabetes and diabetes scored slightly worse cognitive test results compared to the control group. Results of participants with a long disease duration of diabetes since the baseline examination 13 years earlier were poorer (mean AQT test time 17.8 s slower than controls, p < 0.001). Linear associations were found between fasting and 2-h glucose and cognitive outcomes in the whole population, but also in a sub-analysis including only individuals without diabetes (for 2-h glucose and MMSE results: B = − 2.961, p = 0.005). Associations were stronger for older or less physically active individuals. When adjusting for cardiovascular risk factors, most correlations were non-significant.
Conclusions
Pre-diabetes and diabetes are associated with minor deficits in global cognitive function, processing speed and executive functioning. Long-standing diabetes is associated with bigger deficits. There appears to be a continuous inverse correlation between glucose levels and cognitive test results, also for people without diabetes. Associations are stronger in older and less physically active individuals. Cardiovascular factors are important mediating factors in the pathway between diabetes and cognitive dysfunction.
Introduction
Chronic obstructive pulmonary disease (COPD) is a complex multi-component disorder characterized by progressive irreversible respiratory symptoms and extrapulmonary comorbidities, including anxiety-depression and mild cognitive impairment (MCI). However, the prevalence of these impairments is still uncertain, due to non-optimal screening methods. This observational cross-sectional multicentre study aimed to evaluate the prevalence of anxiety-depressive symptoms and MCI in COPD patients, identify the most appropriate cognitive tests to screen MCI, and investigate specific cognitive deficits in these patients and possible predictive factors.
Materials and methods
Sixty-five stable COPD inpatients (n = 65, aged 69.9±7.6 years, mainly stage III–IV GOLD) underwent the following assessments: Hospital Anxiety and Depression Scale (HADS), Geriatric Depression Scale (GDS) or Beck Depression Inventory-II (BDI-II), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and a complete neuropsychological battery (ENB-2) including different cognitive domains (attention, memory, executive functions, and perceptive and praxis abilities).
Results
Moderate-severe anxiety was present in 18.5% of patients and depressive symptoms in 30.7%. The prevalence of MCI varied according to the test: 6.2% (MMSE), 18.5% (MoCA) and 50.8% (ENB-2). In ENB-2, patients performed significantly worse compared to Italian normative data on digit span (5.11±0.9 vs. 5.52±1.0, p = 0.0004), trail making test-B (TMT-B) (176.31±99.5 vs. 135.93±58.0, p = 0.004), overlapping pictures (26.03±8.9 vs. 28.75±8.2, p = 0.018) and copy drawing (1.370.6 vs. 1.61±0.5, p = 0.002). At logistic regression analysis, only COPD severity (p = 0.012, odds ratio, OR, 4.4 [95% CI: 1.4–14.0]) and anxiety symptoms (p = 0.026, OR 4.6 [1.2–17.7]) were significant and independent predictors of the deficit in copy drawing, which assesses visuospatial and praxis skills.
Conclusion
Given the prevalence of neuropsychological impairments in COPD patients, the routine adoption in rehabilitation of screening tools for mood and cognitive function, including digit span, TMT-B and copy drawing, may be useful to detect psychosocial comorbidities and personalize the rehabilitative program.
Objectives:
Screening tests play a crucial role in dementia diagnostics, thus they should be very sensitive for mild cognitive impairment (MCI) assessment. Nowadays, the MiniMental State Examination (MMSE) is the most commonly used scale in cognitive function evaluation, albeit it is claimed to be imprecise for MCI detection. The Montreal Cognitive Assessment (MoCA), was created as an alternative method for MMSE. Aim. MoCA vs. MMSE credibility assessment in detecting MCI, while taking into consideration the sensitivity and specificity by cut-off points.
Methods:
A systematic literature search was carried out by the authors using EBSCO host Web, Wiley Online Library, Springer Link, Science Direct and Medline databases. The following medical subject headings were used in the search: mild cognitive impairment, mini-mental state examination, Montreal cognitive assessment, diagnostics value. Papers which met inclusion and exclusion criteria were chosen to be included in this review. At the end, for the evaluation of MoCA 20, and MMSE 13 studies were qualified. Research credibility was established by computing weighted arithmetic mean, where weight is defined as population for which the result of sensitivity and specificity for the cut-off point was achieved. The cut-offs are shown as ROC curve and accuracy of diagnosis for MoCA and MMSE was calculated as the area under the curve (AUC).
Results:
ROC curve analysis for MoCA demonstrated that MCI best detection can be achieved with a cut-off point of 24/25 (n = 9350, the sensitivity of 80.48% and specificity of 81.19%). AUC was 0.846 (95% CI 0.823-0.868). For MMSE, it turned out that more important cut-off was of 27/28 (n = 882, 66.34% sensitivity and specificity of 72.94%). AUC was 0.736 (95% CI 0.718-0.767).
Conclusions:
MoCA test better meets the criteria for screening tests for the detection of MCI among patients over 60 years of age than MMSE.
Background:
The Mini Mental State Examination (MMSE) is a cognitive test that is commonly used as part of the evaluation for possible dementia.
Objectives:
To determine the diagnostic accuracy of the Mini-Mental State Examination (MMSE) at various cut points for dementia in people aged 65 years and over in community and primary care settings who had not undergone prior testing for dementia.
Search methods:
We searched the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), LILACS (BIREME), ALOIS, BIOSIS previews (Thomson Reuters Web of Science), and Web of Science Core Collection, including the Science Citation Index and the Conference Proceedings Citation Index (Thomson Reuters Web of Science). We also searched specialised sources of diagnostic test accuracy studies and reviews: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). We attempted to locate possibly relevant but unpublished data by contacting researchers in this field. We first performed the searches in November 2012 and then fully updated them in May 2014. We did not apply any language or date restrictions to the electronic searches, and we did not use any methodological filters as a method to restrict the search overall.
Selection criteria:
We included studies that compared the 11-item (maximum score 30) MMSE test (at any cut point) in people who had not undergone prior testing versus a commonly accepted clinical reference standard for all-cause dementia and subtypes (Alzheimer disease dementia, Lewy body dementia, vascular dementia, frontotemporal dementia). Clinical diagnosis included all-cause (unspecified) dementia, as defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); International Classification of Diseases (ICD) and the Clinical Dementia Rating.
Data collection and analysis:
At least three authors screened all citations.Two authors handled data extraction and quality assessment. We performed meta-analysis using the hierarchical summary receiver-operator curves (HSROC) method and the bivariate method.
Main results:
We retrieved 24,310 citations after removal of duplicates. We reviewed the full text of 317 full-text articles and finally included 70 records, referring to 48 studies, in our synthesis. We were able to perform meta-analysis on 28 studies in the community setting (44 articles) and on 6 studies in primary care (8 articles), but we could not extract usable 2 x 2 data for the remaining 14 community studies, which we did not include in the meta-analysis. All of the studies in the community were in asymptomatic people, whereas two of the six studies in primary care were conducted in people who had symptoms of possible dementia. We judged two studies to be at high risk of bias in the patient selection domain, three studies to be at high risk of bias in the index test domain and nine studies to be at high risk of bias regarding flow and timing. We assessed most studies as being applicable to the review question though we had concerns about selection of participants in six studies and target condition in one study.The accuracy of the MMSE for diagnosing dementia was reported at 18 cut points in the community (MMSE score 10, 14-30 inclusive) and 10 cut points in primary care (MMSE score 17-26 inclusive). The total number of participants in studies included in the meta-analyses ranged from 37 to 2727, median 314 (interquartile range (IQR) 160 to 647). In the community, the pooled accuracy at a cut point of 24 (15 studies) was sensitivity 0.85 (95% confidence interval (CI) 0.74 to 0.92), specificity 0.90 (95% CI 0.82 to 0.95); at a cut point of 25 (10 studies), sensitivity 0.87 (95% CI 0.78 to 0.93), specificity 0.82 (95% CI 0.65 to 0.92); and in seven studies that adjusted accuracy estimates for level of education, sensitivity 0.97 (95% CI 0.83 to 1.00), specificity 0.70 (95% CI 0.50 to 0.85). There was insufficient data to evaluate the accuracy of the MMSE for diagnosing dementia subtypes.We could not estimate summary diagnostic accuracy in primary care due to insufficient data.
Authors' conclusions:
The MMSE contributes to a diagnosis of dementia in low prevalence settings, but should not be used in isolation to confirm or exclude disease. We recommend that future work evaluates the diagnostic accuracy of tests in the context of the diagnostic pathway experienced by the patient and that investigators report how undergoing the MMSE changes patient-relevant outcomes.
The original validation study for the Montreal Cognitive Assessment (MoCA) suggests a cutoff score of 26; however, this may be too stringent for older adults, particularly for those with less education. Given the rapidly increasing number of older adults and associated risk of dementia, this study aims to provide appropriate age- and education-adjusted norms for the MoCA. Data from 205 participants in an ongoing longevity study were used to derive normative data. Individuals were grouped based on age (70-79, 80-89, 90-99) and education level (≤12 Years, 13-15, ≥16 Years). There were significant differences between age and education groups with younger and more educated participants outperforming their counterparts. Forty-six percent of our sample scored below the suggested cutoff of 26. These normative data may provide a more accurate representation of MoCA performance in older adults for specific age and education stratifications.
This study examined the Montreal Cognitive Assessment (MoCA) as a neurocognitive screener and its relationship with functional outcomes in a sample of outpatients diagnosed with severe mental illness (SMI). The MoCA, Brief Assessment of Cognition in Schizophrenia (BACS), UCSD Performance-Based Skills Assessment Test-2 (UPSA-2), and Global Assessment of Functioning (GAF) were administered to 28 SMI patients and 18 non-psychiatric controls. Patients obtained significantly lower scores on the MoCA, BACS, UPSA-2, and GAF compared to non-patients. The cutoff score <26 of the MoCA resulted in favorable sensitivity (89%) but lower specificity (61%) in classification of SMI patients. The MoCA was significantly correlated with UPSA scores but not GAF scores, whereas the BACS was not significantly correlated with UPSA or GAF scores. When entered into hierarchical regression analyses, the MoCA accounted for significant variance in UPSA scores above variance accounted for by the BACS. Both the MoCA and the BACS contributed unique variance in GAF scores. Overall, the MoCA demonstrated high sensitivity as a cognitive screener in SMI. Moreover, MoCA scores were related to performance-based measures of functional capacity.
Even those who do not experience dementia or mild cognitive impairment may experience subtle cognitive changes associated with aging. Normal cognitive changes can affect an older adult's everyday function and quality of life, and a better understanding of this process may help clinicians distinguish normal from disease states. This article describes the neurocognitive changes observed in normal aging, followed by a description of the structural and functional alterations seen in aging brains. Practical implications of normal cognitive aging are then discussed, followed by a discussion of what is known about factors that may mitigate age-associated cognitive decline.
The Montreal Cognitive Assessment (MoCA) is a brief yet comprehensive cognitive instrument used to assess level of impairment in neurological populations. The purpose of the present study was to assess the ability of the MoCA to detect cognitive impairment in a veteran patient population referred for neuropsychological testing and to determine optimal cutoff scores on the MoCA when compared with widely used neuropsychological measures.
Using receiver operator characteristic (ROC) analyses, the findings indicate that the optimal cutoff score to detect impairment (i.e., ≤20) in the present sample was notably lower than that suggested by others.
Use of the previously suggested cut score of <26 may overpathologize neurologically intact individuals. Further research utilizing ROC curve analysis should be conducted to establish appropriate cutoff scores for various populations which may differ from the present sample. Copyright © 2012 John Wiley & Sons, Ltd.
To provide normative and descriptive data for the Montreal Cognitive Assessment (MoCA) in a large, ethnically diverse sample.
The MoCA was administered to 2,653 ethnically diverse subjects as part of a population-based study of cardiovascular disease (mean age 50.30 years, range 18-85; Caucasian 34%, African American 52%, Hispanic 11%, other 2%). Normative data were generated by age and education. Pearson correlations and analysis of variance were used to examine relationship to demographic variables. Frequency of missed items was also reviewed.
Total scores were lower than previously published normative data (mean 23.4, SD 4.0), with 66% falling below the suggested cutoff (<26) for impairment. Most frequently missed items included the cube drawing (59%), delayed free recall (56%; <4/5 words), sentence repetition (55%), placement of clock hands (43%), abstraction items (40%), and verbal fluency (38%; <11 words in 1 minute). Normative data stratified by age and education were derived.
These findings highlight the need for population-based norms for the MoCA and use of caution when applying established cut scores, particularly given the high failure rate on certain items. Demographic factors must be considered when interpreting this measure.
Mild cognitive impairment (MCI) often presages development of Alzheimer's disease (AD). We recently completed a cross-sectional study to test the hypothesis that a combination of a brief cognitive screening instrument (Mini-Cog) with a functional scale (Functional Activities Questionnaire; FAQ) would accurately identify individuals with MCI and undiagnosed dementia. The Mini-Cog consists of a clock drawing task and 3-item recall, and takes less than 5 minutes to administer. The FAQ is a 30-item questionnaire completed by an informant. In addition to the Mini-Cog and FAQ, a traditional cognitive test battery was administered, and two neurologists and a neuropsychologist determined a consensus diagnosis of Normal, MCI, or Dementia. A classification tree algorithm was used to pick optimal cutpoints, and, using these cutpoints, the combined Mini-Cog and FAQ (MC-FAQ) predicted the consensus diagnosis with an accuracy of 83% and a weighted kappa of 0.81. When the population was divided into Normal and Abnormal, the sensitivity, specificity and positive predictive value were 89%, 90%, and 95%, respectively. The MC-FAQ discriminates individuals with MCI from cognitively normal individuals and those with dementia, and its ease of administration makes it an attractive screening instrument to aid detection of cognitive impairment in the elderly.
To validate a sensitive and specific screening test for AD and other dementias, assess its reliability and discriminative validity, and present normative data for its use in various applied settings.
To improve discrimination in screening for AD and dementia, we developed the Memory Impairment Screen (MIS), a 4-minute, four-item, delayed free- and cued-recall test of memory impairment. The MIS uses controlled learning to ensure attention, induce specific semantic processing, and optimize encoding specificity to improve detection of dementia.
Equivalent forms of the MIS were given at the beginning and end of the testing session to assess alternate forms reliability. Discriminative validity was assessed in a criterion sample of 483 aged individuals, 50 of whom had dementia according to Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised) criteria.
The MIS had good alternate forms reliability, high construct validity for memory impairment, and good discriminative validity in terms of sensitivity, specificity, and positive predictive value. We present normative data for use in settings with different base rates (prevalences) of AD and dementia.
The MIS provides efficient, reliable, and valid screening for AD and other dementias.
To test the Mini-Cog, a brief cognitive screening test, in an epidemiological study of dementia in older Americans.
A population-based post hoc examination of the sensitivity and specificity of the Mini-Cog for detecting dementia in an existing data set.
The Monongahela Valley in Western Pennsylvania.
A random sample of 1,119 older adults enrolled in the Monongahela Valley Independent Elders Survey (MoVIES).
The effectiveness of the Mini-Cog in detecting independently diagnosed dementia was compared with that of the Mini-Mental State Examination (MMSE) and a standardized neuropsychological battery.
The Mini-Cog, scored by an algorithm as "possibly impaired" or "probably normal," and the MMSE, at a cutpoint of 25, had similar sensitivity (76% vs 79%) and specificity (89% vs 88%) for dementia, comparable with that achieved using a conventional neuropsychological battery (75% sensitivity, 90% specificity).
When applied post hoc to an existing population, the Mini-Cog was as effective in detecting dementia as longer screening and assessment instruments. Its brevity is a distinct advantage when the goal is to improve identification of older adults in a population who may be cognitively impaired. Prior evidence of good performance in a multiethnic community-based sample further supports its validity in the ethnolinguistically diverse populations of the United States in which widely used cognitive screens often fail.
To estimate the prevalence of Alzheimer's disease (AD) and other dementias in the USA using a nationally representative sample.
The Aging, Demographics, and Memory Study sample was composed of 856 individuals aged 71 years and older from the nationally representative Health and Retirement Study (HRS) who were evaluated for dementia using a comprehensive in-home assessment. An expert consensus panel used this information to assign a diagnosis of normal cognition, cognitive impairment but not demented, or dementia (and dementia subtype). Using sampling weights derived from the HRS, we estimated the national prevalence of dementia, AD and vascular dementia by age and gender.
The prevalence of dementia among individuals aged 71 and older was 13.9%, comprising about 3.4 million individuals in the USA in 2002. The corresponding values for AD were 9.7% and 2.4 million individuals. Dementia prevalence increased with age, from 5.0% of those aged 71-79 years to 37.4% of those aged 90 and older.
Dementia prevalence estimates from this first nationally representative population-based study of dementia in the USA to include subjects from all regions of the country can provide essential information for effective planning for the impending healthcare needs of the large and increasing number of individuals at risk for dementia as our population ages.
Objective:
A progressive cognitive impairment is one of the frequent non-motor symptoms during Parkinson's disease (PD) course. A short and valid screening tool is needed to detect an incipient cognitive deficit at the mild cognitive impairment stage in Parkinson's disease (PD-MCI).
Method:
The present study aims to evaluate the classification accuracies of four cognitive screenings: Montreal Cognitive Assessment (MoCA), Mattis Dementia Rating Scale second edition (DRS-2), Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) in a cohort of PD patients (PD-MCI, n = 46; and Parkinson's disease with normal cognition, PD-NC, n = 95) and Controls (n = 66). All subjects underwent a standard neuropsychological battery as recommended by the International Parkinson and Movement Disorder Society and underwent all four screening tools.
Results:
In the detection of PD-MCI versus PD-NC, the MoCA showed a sensitivity of 84% and a specificity of 66% with a screening cutoff score at ≤25 points. The MoCA's AUC was 86% (95% CI 78.7-93.1). In the detection of PD-MCI versus Controls, the FAB displayed 84% sensitivity and 79% specificity with a cutoff ≤16 points, to screen. The FAB's AUC was 87% (79.0-95.0).
Conclusions:
Our results show that the MoCA is the most discriminative tool for screening MCI in the PD population.
Fibromyalgia is characterized by chronic, widespread musculoskeletal pain and associated fatigue, sleep disturbances, and other cognitive and somatic symptoms. For many patients, these symptoms persist for years and lead to frequent health care use; for some, fibromyalgia and its symptoms can be debilitating. Although many treatments are available, management remains challenging. This article highlights the clinical features of fibromyalgia, discusses diagnostic criteria and their evolution, and reviews treatment options.
Importance
Dementia (also known as major neurocognitive disorder) is defined by a significant decline in 1 or more cognitive domains that interferes with a person’s independence in daily activities. Dementia affects an estimated 2.4 to 5.5 million individuals in the United States, and its prevalence increases with age.
Objective
To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on screening for cognitive impairment, including mild cognitive impairment and mild to moderate dementia, in community-dwelling adults, including those 65 years or older residing in independent living facilities.
Population
This recommendation applies to community-dwelling older adults 65 years or older, without recognized signs or symptoms of cognitive impairment.
Evidence Assessment
The USPSTF concludes that the evidence is lacking, and the balance of benefits and harms of screening for cognitive impairment cannot be determined.
Recommendation
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults. (I statement)
Introduction
Vascular cognitive impairment (VCI) is common and important to detect as controlling risk factors, particularly hypertension, may slow onset and progression. There is no consensus as to which cognitive screening instrument (CSI) is most suitable for VCI. We systematically reviewed the psychometric properties of brief CSIs for vascular mild cognitive impairment (VMCI) and vascular dementia (VaD).
Methods
Literature searches were performed using scholarly databases from inception until May 31, 2018. Studies were eligible if participants were aged ≥18, interviewed face‐to‐face and standard diagnostic criteria for VCI were applied, excluding those specifically identifying post‐stroke dementia. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.
Results
Fifteen studies were identified including eight types of CSIs (27 subtests/variants) and 4,575 participants (1,105 with VCI), mean age range: 51.6‐75.5 years. Most studies compared more than one instrument. Five papers examined Clock‐drawing, four the Montreal Cognitive Assessment (MoCA) and Mini‐Mental State Examination (MMSE) and three used the Brief Memory and Executive Test (BMET). The MoCA (AUC >0.90) and MMSE (AUC 0.86‐0.99) had excellent accuracy in differentiating VaD from controls; the MoCA had good internal consistency (Cronbach's‐alpha 0.83‐0.88). The MoCA (AUC 0.87‐0.93) and BMET (AUC 0.94) had the greatest accuracy in separating VMCI from controls. Most studies had low‐moderate risk of bias in all domains of the QUIPS. Data were heterogeneous, precluding a meta‐analysis.
Conclusions
Although few studies were available and further research is required, data suggests that the MoCA is accurate and reliable for differentiating VaD and VMCI from controls.
Objective:
There is ongoing concern about the impact of electroconvulsive therapy (ECT) on cognition in patients with late-life depression (LLD), especially in patients for whom pretreatment Mini-Mental State Exam (MMSE) scores are low. Our aim was to examine the evolution of cognitive effects of ECT, using the MMSE in a large group of patients with LLD.
Methods:
One hundred nine patients aged 55 years and older with unipolar depression, referred for ECT, were included in our study. The MMSE was assessed before, during, immediately after, and 6 months after ECT.
Results:
MMSE scores improved significantly during the course of ECT and remained stable during the 6-month period after ending ECT for the total group. In the group of patients with a low MMSE score (<24) at baseline, the MMSE score improved significantly during ECT, whereas in the group of patients with a normal MMSE score (≥24) at baseline, the score did not change significantly during ECT. In both groups, MMSE scores still increased slightly after ECT was discontinued.
Conclusion:
ECT does not cause deleterious cognitive effects, as measured with the MMSE, during and for 6 months after the ECT course in patients with LLD. In the event of a baseline cognitive impairment, MMSE scores tend to improve significantly during and for 6 months after the ECT course. The presence of pretreatment cognitive impairment should not lead clinicians to withhold ECT in older patients with severe depression.
Background:
Alzheimer's disease and other forms of dementia are becoming increasingly common with the aging of most populations. The majority of individuals with dementia will first present for care and assessment in primary care settings. There is a need for brief dementia screening instruments that can accurately diagnose dementia in primary care settings. The Mini-Cog is a brief, cognitive screening test that is frequently used to evaluate cognition in older adults in various settings.
Objectives:
To determine the diagnostic accuracy of the Mini-Cog for diagnosing Alzheimer's disease dementia and related dementias in a primary care setting.
Search methods:
We searched the Cochrane Dementia and Cognitive Improvement Register of Diagnostic Test Accuracy Studies, MEDLINE, Embase and four other databases, initially to September 2012. Since then, four updates to the search were performed using the same search methods, and the most recent was January 2017. We used citation tracking (using the databases' 'related articles' feature, where available) as an additional search method and contacted authors of eligible studies for unpublished data.
Selection criteria:
We only included studies that evaluated the Mini-Cog as an index test for the diagnosis of Alzheimer's disease dementia or related forms of dementia when compared to a reference standard using validated criteria for dementia. We only included studies that were conducted in primary care populations.
Data collection and analysis:
We extracted and described information on the characteristics of the study participants and study setting. Using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria we evaluated the quality of studies, and we assessed risk of bias and applicability of each study for each domain in QUADAS-2. Two review authors independently extracted information on the true positives, true negatives, false positives, and false negatives and entered the data into Review Manager 5 (RevMan 5). We then used RevMan 5 to determine the sensitivity, specificity, and 95% confidence intervals. We summarized the sensitivity and specificity of the Mini-Cog in the individual studies in forest plots and also plotted them in a receiver operating characteristic plot. We also created a 'Risk of bias' and applicability concerns graph to summarize information related to the quality of included studies.
Main results:
There were a total of four studies that met our inclusion criteria, including a total of 1517 total participants. The sensitivity of the Mini-Cog varied between 0.76 to 1.00 in studies while the specificity varied between 0.27 to 0.85. The included studies displayed significant heterogeneity in both methodologies and clinical populations, which did not allow for a meta-analysis to be completed. Only one study (Holsinger 2012) was found to be at low risk of bias on all methodological domains. The results of this study reported that the sensitivity of the Mini-Cog was 0.76 and the specificity was 0.73. We found the quality of all other included studies to be low due to a high risk of bias with methodological limitations primarily in their selection of participants.
Authors' conclusions:
There is a limited number of studies evaluating the accuracy of the Mini-Cog for the diagnosis of dementia in primary care settings. Given the small number of studies, the wide range in estimates of the accuracy of the Mini-Cog, and methodological limitations identified in most of the studies, at the present time there is insufficient evidence to recommend that the Mini-Cog be used as a screening test for dementia in primary care. Further studies are required to determine the accuracy of Mini-Cog in primary care and whether this tool has sufficient diagnostic test accuracy to be useful as a screening test in this setting.
Objective:
The Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) is a cognitive screening tool that aims to differentiate healthy cognitive aging from Mild Cognitive Impairment (MCI). Several validation studies have been conducted on the MoCA, in a variety of clinical populations. Some studies have indicated that the originally suggested cutoff score of 26/30 leads to an inflated rate of false positives, particularly for those of older age and/or lower education. We conducted a systematic review and meta-analysis of the literature to determine the diagnostic accuracy of the MoCA for differentiating healthy cognitive aging from possible MCI.
Methods:
Of the 304 studies identified, nine met inclusion criteria for the meta-analysis. These studies were assessed across a range of cutoff scores to determine the respective sensitivities, specificities, positive and negative predictive accuracies, likelihood ratios for positive and negative results, classification accuracies, and Youden indices.
Results:
Meta-analysis revealed a cutoff score of 23/30 yielded the best diagnostic accuracy across a range of parameters.
Conclusions:
A MoCA cutoff score of 23, rather than the initially recommended score of 26, lowers the false positive rate and shows overall better diagnostic accuracy. We recommend the use of this cutoff score going forward. Copyright © 2017 John Wiley & Sons, Ltd.
There is a clear need for brief, but sensitive and specific, cognitive screening instruments as evidenced by the popularity of the Addenbrooke's Cognitive Examination (ACE).
We aimed to validate an improved revision (the ACE-R) which incorporates five sub-domain scores (orientation/attention, memory, verbal fluency, language and visuo-spatial).
Standard tests for evaluating dementia screening tests were applied. A total of 241 subjects participated in this study (Alzheimer's disease=67, frontotemporal dementia=55, dementia of Lewy Bodies=20; mild cognitive impairment-MCI=36; controls=63).
Reliability of the ACE-R was very good (alpha coefficient=0.8). Correlation with the Clinical Dementia Scale was significant (r=-0.321, p<0.001). Two cut-offs were defined (88: sensitivity=0.94, specificity=0.89; 82: sensitivity=0.84, specificity=1.0). Likelihood ratios of dementia were generated for scores between 88 and 82: at a cut-off of 82 the likelihood of dementia is 100:1. A comparison of individual age and education matched groups of MCI, AD and controls placed the MCI group performance between controls and AD and revealed MCI patients to be impaired in areas other than memory (attention/orientation, verbal fluency and language).
The ACE-R accomplishes standards of a valid dementia screening test, sensitive to early cognitive dysfunction.
Background:
Accumulating evidence points to the superiority of the MoCA over the MMSE as a cognitive screening tool. To facilitate the transition from the MMSE to the MoCA in clinical and research settings, authors have developed MMSE-MoCA conversion tables. However, it is unknown whether a conversion table generated from Alzheimer's disease (AD) patients would apply to patients with other dementia subtypes like vascular dementia or frontotemporal dementia. Furthermore, the reliability and accuracy of MMSE-MoCA conversion tables has not been properly evaluated.
Method:
We retrospectively examined the MMSE-MoCA relationship in a large multicenter sample gathered from 3 Memory Clinics in Quebec, Canada (1492 patients). We produced an MMSE-MoCA conversion table using the equi-percentile method with log-linear smoothing. We then cross-validated our conversion table with the ADNI dataset (1202 patients) and evaluated its accuracy for future predictions.
Results:
The MMSE-MoCA conversion table is consistent with previously published tables and has an intra-class correlation of 0.633 with the ADNI sample. However, we found that the MMSE-MoCA relationship is significantly modified by diagnosis (P < .01), with dementia subtypes associated with a dysexecutive syndrome showing a trend towards higher MMSE than other dementia syndromes for a given MoCA score. The large width of 95% confidence interval (CI) for a new prediction suggests questionable reliability for clinical use.
Conclusion:
In this study, we validated a conversion table between MMSE and MoCA using a large multicenter sample. Our results suggest caution in interpreting the tables in heterogeneous clinical populations, as the MMSE-MoCA relationship may be different across dementia subtypes.
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the diagnostic accuracy of the Mini-Cog for detecting AD dementia and related dementias in a primary care setting. To investigate the heterogeneity of test accuracy in the included studies and potential sources of heterogeneity. These potential sources of heterogeneity will include the baseline prevalence of dementia in study samples, thresholds used to determine positive test results, the type of dementia (Alzheimer's disease dementia or all causes of dementia), and aspects of study design related to study quality. We will also identify gaps in the evidence where further research is required.
AimTo assess the relationship between cognitive status and self-reported symptoms of depression, anxiety and stress of older adults living in an underserved rural South American population.Methods
Community-dwelling Atahualpa residents aged ≥60 years were identified during a door-to-door census, and evaluated with the Depression Anxiety Stress Scale-21 (DASS-21) and the Montreal Cognitive Assessment (MoCA). We explored whether positivity in each of the DASS-21 axes was related to total and domain-specific MoCA performance after adjustment for age, sex and education.ResultsA total of 280 persons (59% women; mean age, mean age 70 ± 8 years) were included. Based on established cut-offs for the DASS-21, 12% persons had depression, 15% had anxiety and 5% had stress. Mean total MoCA scores were significantly lower for depressed than for not depressed individuals (15.9 ± 5.5 vs 18.9 ± 4.4, P < 0.0001). Depressed participants had significantly lower total and domain-specific MoCA scores for abstraction, short-term memory and orientation. Anxiety was related to significantly lower total MoCA scores (17 ± 4.7 vs 18.8 ± 4.5, P = 0.02), but not to differences in domain-specific MoCA scores. Stress was not associated with significant differences in MoCA scores.Conclusion
The present study suggests that depression and anxiety are associated with poorer cognitive performance in elderly residents living in rural areas of developing countries. Geriatr Gerontol Int 2015; 15: 508-514.
Assessment of visuospatial function is an integral part of most neuropsychological assessments and is frequently assessed by visuoconstructional tests. A significant impact of limited schooling and illiteracy has been found on numerous neuropsychological tests and it can be difficult to interpret test results from illiterate individuals. In this study, quantitative and qualitative aspects of performance of elderly cognitively healthy illiterate and literate Turkish immigrants were compared on five commonly used visuoconstructional tests. Significantly poorer performances of illiterate compared to literate subjects were found in copying of two- and three-dimensional geometric designs, and in Clock Drawing Test performance. A systematic qualitative analysis found lacking three-dimensionality, "curved angles", omissions, distorted relation between elements, and spatial disorganization to be common error types in illiterate subjects. Performances were not found to be influenced by duration of residence in Denmark or level of acculturation. The results warrant caution in the interpretation of visuoconstructional test performances in illiterate subjects, as they can easily be misinterpreted as signs of cognitive dysfunction.
The concept of cognitive reserve provides an explanation for differences between individuals in susceptibility to age-related brain changes or pathology related to Alzheimer's disease, whereby some people can tolerate more of these changes than others and maintain function. Epidemiological studies suggest that lifelong experiences, including educational and occupational attainment, and leisure activities in later life, can increase this reserve. For example, the risk of developing Alzheimer's disease is reduced in individuals with higher educational or occupational attainment. Reserve can conveniently be divided into two types: brain reserve, which refers to differences in the brain structure that may increase tolerance to pathology, and cognitive reserve, which refers to differences between individuals in how tasks are performed that might enable some people to be more resilient to brain changes than others. Greater understanding of the concept of cognitive reserve could lead to interventions to slow cognitive ageing or reduce the risk of dementia.
The Mini-Mental State Examination (MMSE) is insensitive to mild cognitive impairment and executive function. The more recently developed Montreal Cognitive Assessment (MoCA), an alternative, brief 30-point global cognitive screen, might pick up more cognitive abnormalities in patients with cerebrovascular disease.
In a population-based study (Oxford Vascular Study) of transient ischemic attack and stroke, the MMSE and MoCA were administered to consecutive patients at 6-month or 5-year follow-up. Accepted cutoffs of MMSE <27 and MoCA <26 were taken to indicate cognitive impairment.
Of 493 patients, 413 (84%) were testable. Untestable patients were older (75.5 versus 69.9 years, P<0.001) and often had dysphasia (24%) or dementia (15%). Although MMSE and MoCA scores were highly correlated (r(2)=0.80, P<0.001), MMSE scores were skewed toward higher values, whereas MoCA scores were normally distributed: median and interquartile range 28 (26 to 29) and 23 (20 to 26), respectively. Two hundred ninety-one of 413 (70%) patients had MoCA <26 of whom 162 had MMSE > or =27, whereas only 5 patients had MoCA > or =26 and MMSE <27 (P<0.0001). In patients with MMSE > or =27, MoCA <26 was associated with higher Rankin scores (P=0.0003) and deficits in delayed recall, abstraction, visuospatial/executive function, and sustained attention.
The MoCA picked up substantially more cognitive abnormalities after transient ischemic attack and stroke than the MMSE, demonstrating deficits in executive function, attention, and delayed recall.
Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established.
A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained.
Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect).
The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.
The population-based Helsinki Aging Study was comprised of three age groups: 75-, 80- and 85-year-olds. A random sample of 511 subjects completed the Mini Mental State Examination (MMSE) and were assessed on the Clinical Dementia Rating-scale (CDR). According to the CDR results 446 subjects were screened as non-demented. Of these subjects 30% scored below or at 24 MMSE points. Age, education and social group had a significant effect on the MMSE scores, even after excluding the demented cases. Together they explained 10% of the total variance within the MMSE. Social group correlated with education. The MMSE scores were corrected according to age and education. Adjustment of the originally used cutpoint of 24 resulted in cutpoints of 25 and 26 among the 75-year-olds, in the low and high education groups respectively; 23 and 26 in the 80-year-olds; 22 and 23 in the 85-year-olds.
To design and test a brief, efficient dementia-screening instrument for use by general practitioners (GPs).
The General Practitioner Assessment of Cognition (GPCOG) consists of cognitive test items and historical questions asked of an informant. The validity of the measure was assessed by comparison with the criterion standard of diagnoses of dementia derived from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition).
Primary care doctors' offices.
Sixty-seven GPs administered the GPCOG to 283 community-dwelling patients aged 50 to 74 with memory complaints or aged 75 and older.
The Cambridge Mental Disorder of the Elderly Examination, the Abbreviated Mental Test (AMT), the Mini-Mental State Examination (MMSE), the 15-item Geriatric Depression Scale, and the 12-item Short-Form Health Survey.
The GPCOG was reliable and superior to the AMT (and possibly to the MMSE) in detecting dementia. The two-stage method of administering the GPCOG (cognitive testing followed by informant questions if necessary)had a sensitivity of 0.85, a specificity of 0.86, a misclassification rate of 14%, and positive predictive value of 71.4%. Patient interviews took less than 4 minutes to administer and informant interviews less than 2 minutes. The instrument was reported by GPs to be practical to administer and was acceptable to patients.
The GPCOG is a valid, efficient, well-accepted instrument for dementia screening in primary care.
To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition.
Survey of physicians and review of medical records.
Health maintenance organization in southern California.
Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study).
Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia.
Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04-1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03-1.45) or stroke (RR=1.37, 95% CI=1.04-1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23-0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09-0.88) or cancer (RR=0.49, 95% CI=0.18-0.90).
Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia.
To develop a 10-minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first-line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia.
Validation study.
A community clinic and an academic center.
Ninety-four patients meeting MCI clinical criteria supported by psychometric measures, 93 patients with mild Alzheimer's disease (AD) (Mini-Mental State Examination (MMSE) score > or =17), and 90 healthy elderly controls (NC).
The MoCA and MMSE were administered to all participants, and sensitivity and specificity of both measures were assessed for detection of MCI and mild AD.
Using a cutoff score 26, the MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild AD group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively).
MCI as an entity is evolving and somewhat controversial. The MoCA is a brief cognitive screening tool with high sensitivity and specificity for detecting MCI as currently conceptualized in patients performing in the normal range on the MMSE.
Screening for cognitive impairment in older adults: US preventive Services task Force recommendation statement.
- US Preventive Services Task Force
- Owens D.K.
- Davidson K.W.