Folstein Mini-Mental State Exam Research Articles

Terapia psicológica grupal y su efecto en ansiedad, depresión y niveles de BDNF en candidatos a trasplante renal

The objective of the present study is to describe the effect of a group intervention on the levels of anxiety and depression associated with the level of BDNF and cognitive impairment of patients who are candidates for kidney transplantationthrough a pre-experimental study. 25 adult patients of both gendersof a High Specialty Medical Unitparticipated in the study. The Beck depression and Golberg anxiety inventories and the Folstein Mini Mental State Exam were applied. At the beginning and end of the intervention, blood and urine samples were taken to analyze BDNF levels. A group intervention with a brief orientation cognitive behavioral approach was carried out. The results in the variables of anxiety (p = 0.002) and depression (p = 0.04) show significant differences before and after the interventionreducing the levels of these variables considerably; Regarding BDNF levels and cognitive impairment, no significant differences were found.This study shows the usefulness of group psychological therapies for the benefit of these patients as well as the need to carry out more studies that evaluate biological markers related to the pathologies presented.

Study on the Safety and Efficacy of Biological Target Radiotherapy Based on 11C-MET PET/CT in Patients with Newly Diagnosed Glioblastoma

<h3>Purpose/Objective(s)</h3> The purpose of this study was to evaluate the safety and efficacy of biological target area (BTV) defined by ¹¹C-methionine positron emission tomography / computed tomography (¹¹C-MET PET/CT) in postoperative radiotherapy for glioblastoma. <h3>Materials/Methods</h3> This study is a single-arm, open, single-center exploratory clinical study. Patients with newly diagnosed glioblastoma confirmed by pathology in our center were enrolled. The initial biological target area (BTV) was delineated on the basis of the area of high metabolism of ¹¹C-MET PET/CT. Finally, the BTV included the highly increased area of ¹¹C-MET PET/CT metabolism and comprehensively considered the abnormal signal areas on multimodal magnetic resonance imaging. BTV dose escalation with a simultaneous or increased in late course. Oral chemotherapy of temozolomide was given concurrently, and temozolomide adjuvant chemotherapy was given for 6 cycles after simultaneous radiotherapy and chemotherapy. The primary clinical study endpoints were safety, progression-free survival (PFS), and the secondary study endpoints were overall survival (OS) and 1 year survival (OS-1). The Common Terminology Criteria for Adverse Events (CTCAE) version 5. 0 was used to evaluate the adverse reactions. Folstein Mini-Mental Status Exam (MMSE) was used to evaluate the cognitive function of the patients. <h3>Results</h3> A total of 18 patients with assessable glioblastoma were enrolled from November 22, 2018 to June 2, 2021. The median follow-up period was 14.4 months (7.9months-37.2months). The median BTV dose was 74 Gy (64 Gy-75 Gy), and the median CTV dose was 60 Gy (50.1 Gy-60 Gy). The median dose of CTV1 was 46 Gy (30 Gy-50.1 Gy), and the median dose of CTV2 was 14 Gy (8 Gy-23.4 Gy). The median PFS was 10.1 months (95%CI:7.25-12.95). The main acute adverse events were hematological adverse events. Grade 1 leukopenia occurred in 5 patients (27.8%), and no grade 2 leukopenia was observed.4 patients (22.2%) developed grade 2 gastrointestinal reactions (nausea, vomiting, anorexia). One patient (5.6%) had advanced cognitive decline (MMSE score ≤ 26). No other hematological adverse events and non-hematological adverse events such as radiation brain necrosis were observed. OS-1 is 85.6%. The median OS was not reached. <h3>Conclusion</h3> BTV based on ¹¹C-MET PET/CT images guided dose-escalated radiotherapy has a good short-term effect in the treatment of newly diagnosed glioblastoma patients, and the incidence of adverse reactions is low, safe and tolerable. The long-term effect still needs longer follow-up and a large sample of clinical studies.

Utilizing timed categorical recall (naming US cities) for rapid bedside dementia screening.

The availability of fast validated screening for dementia is a critical clinical need to improve neurologic examination time efficiency. This study validated a 1-minute timed categorical recall (TCR) method, naming as many US cities as possible and compared TCR to the Folstein Minimental Status Exam (MMSE) as a preliminary cognitive screening tool.Random uncompensated 349 volunteers were recruited ages 18 to 97 from local free clinics, retirement homes, university faculty, and students in Lynchburg, Virginia 2015 to 2020. Participants’ demographic and medical information were collected. After 1 minute preparation, participants were rapidly named as many US cities as possible until they were told to stop (1 minute). The time limitation was withheld in advance. Number of cities and organizational strategies were recorded. Folstein MMSE administration immediately after TCR was administered to 122 subjects recruited in the final 2 study years as a comparison benchmark. A multiple linear regression model and a regression tree model were used to identify important variables for the number of cities named and determine subgroups and their thresholds.TCR resulted in accuracy rate (0.80), sensitivity (0.78), and specificity (0.81). The global TCR threshold (9 cities named) is superseded by 4 subgroup thresholds, categorized by statistically important variables (age, education level, and number of states visited) as follows:For those visiting ≥8 states and1. 18 to 71 ages with a master’s degree or above, the threshold was naming 20 cities;2. 18 to 29 ages with a bachelor’s degree or below, the threshold was naming 17 cities;3. 30 to 71 ages with a bachelor’s degree or below, the threshold was naming 10 cities.For those visiting <8 states or for ages 72 to 97 (regardless of education levels and number of states visited), the threshold was naming 8 cities.American cities are common knowledge across ages and backgrounds, making it a useful bedside screen for dementia. In clinical practice, patients who report fewer cities than the threshold of 9 cities should receive further cognitive testing. If the patient meets the criteria for a subgroup, then the higher subgroup thresholds apply. TCR is a more time-efficient preliminary dementia screening tool with improved sensitivity and similar specificity compared with MMSE.

Developing and testing a South African Brief Cognitive Score in literate and illiterate people of mixed language groups.

BackgroundThe Folstein mini mental state exam (MMSE) is the most commonly administered assessment of cognitive functioning; however, its utility in illiterate individuals is limited. In South Africa, more than eight million adults are considered functionally illiterate and cognitive evaluation using standard scales is inaccurate. Other countries have developed adapted MMSE scales for their local purposes.AimThe first aim of this study was to develop a South African Brief Cognitive Score (SA BCS) for use in minimally literate or illiterate individuals. The second aim was to test this SA BCS against the original Folstein MMSE in patients with memory problems.SettingThe study was conducted in Tshilamba, Tshiombo, Tshifudi, Dzimauli and Pile in Venda as well as Rethabiseng and Zithobeni in Bronkhorstspruit for the illiterate study group, and Steve Biko Academic Hospital for the literate study groups.MethodsThe SA BCS was developed considering our local requirements and substituting questions needing literacy with items that did not. Both the original Folstein MMSE and the SA BCS were administered to groups of literate and illiterate normal individuals. Thereafter, the tests were repeated in groups of literate and illiterate patients with cognitive decline.ResultsFirstly, 33 illiterate and 31 literate subjects were assessed. The average original Folstein score was 29.29/30 for the literate subjects, and for the SA BCS 29.80. For the illiterate subjects, the average score for the original Folstein MMSE was 21.24/30 and for the SA BCS 27.45. Kruskall–Wallis equality of population rank test confirmed a significant improvement in the scores of the SA BCS in the illiterate group when compared to the original Folstein (p = 0.0001). In the second part of the study, 20 literate and 20 illiterate patients were assessed as before. In the literate group, the average original Folstein MMSE score was 20.5, while the average score for the South African BCS was 22.5. In the illiterate group, the average Folstein MMSE was 18.9; and the average score in the South African BCS was 22.8. The Kruskal–Wallis equality of population rank test showed a significant difference (p = 0.008) between the scores of the illiterate versus literate patients when the Folstein MMSE was used to assess cognition. With the SA BCS, no significant difference was found between the groups (p = 0.79).ConclusionThe SA BCS appears to have potential to be a more reliable scale when assessing cognition in illiterate or minimally literate subjects when compared to the original Folstein MMSE.

EEG multifractal analysis correlates with cognitive testing scores and clinical staging in mild cognitive impairment

Alzheimer’s disease and mild cognitive impairment are increasingly prevalent global health concerns in aging industrialized societies. There are only limited non-invasive biomarkers for the cognitive and functional impairment associated with dementia. Multifractal analysis of EEG has recently been proposed as having the potential to be an improved method of quantitative EEG analysis compared to existing techniques (e.g., spectral analysis). We utilized an existing database of a study of healthy elderly patients (N = 20) who were assessed with cognitive testing (Folstein Mini Mental Status Exam; MMSE) and resting state EEG (4 leads). Each subject’s EEG was separated into two 30 s tracings for training and testing a statistical model against the MMSE scores. We compared multifractal detrended fluctuation analysis (MF-DFA) against Fourier Transform (FT) in the ability to produce an accurate classification and regression trees estimator for the testing EEG segments. The MF-DFA-based statistical model MMSE estimation strongly correlated with the actual MMSE when applied to the test EEG parameter dataset, whereas the corresponding FT-based model did not. Using a standardized cutoff value for MMSE-based clinical staging, the MF-DFA-based statistical model was both sensitive and specific for clinical staging of both mild Alzheimer’s disease and mild cognitive impairment. MF-DFA shows promise as a method of quantitative EEG analysis to accurately estimate cognition in Alzheimer’s disease.

Moderate alcohol consumption, intraoperative bleeding and postsurgical pain may increase the risk of postoperative delirium in patients undergoing radical retropubic prostatectomy

Background/Aim. The incidence of postoperative delirium (POD) after non-cardiac surgery is a problem not often recognized by many anesthesiologists. The objective of our study was to detect POD and its possible cause, in patients undergoing radical retropubic prostatectomy (RRP) under general anesthesia. Methods. After Ethical Committee approval, we enrolled 80 patients, ASA (the American Society of Anestesiology) status II, scheduled to undergo RRP un-der general anesthesia, in a prospective study. All patients completed MMSE tests (the Folstein Mini Mental State Ex-am) the evening before, and 48 hours after the surgery. Assessment for the presence and severity of delirium was per-formed using CAM (the Confusion Assessment Method), and an assessment of the degree of agitation and sedation using RASS (the Richmond Agitation and Sedation Scale). Results. The average preoperative MMSE score (28.59 ? 1.04) significantly decreased following the surgery (27.74 ? 1.52) (p &lt; 0.0001). The average postoperative MMSE score trend descended in correlation to intraoperative bleeding (p = 0.036). The patients with higher pain scores had significant decline in MMSE after the surgery (28.75 vs. 26.25; p &lt; 0.001). Five patients were considered positive for delirium, and four of them reported regular alcoholic drinks intake (&gt; 1 drink per day) preoperatively (p &lt; 0.0001). Based on RASS score, 13 patients (16.3%) were agitated or sedated, and they had statistically significantly higher intraoperative bleeding (p &lt; 0.001). Conclusion. Results of this study emphasize the importance of proper preoperative evaluation; especially regarding the alcohol consumption since all the patients that developed POD reported moderate alcohol consumption. Further-more, greater intraoperative bleeding and postoperative pain scores did not influence the occurrence of delirium, but resulted in lower postoperative MMSE scores, which high-lights the importance of adequate intraoperative treatment of patients during surgery and anesthesia in order to reduce the risk of developing POD.

Neurological, Cognitive, and Psychological Findings Among Survivors of Ebola Virus Disease From the 1995 Ebola Outbreak in Kikwit, Democratic Republic of Congo: A Cross-sectional Study

Clinical sequelae of Ebola virus disease (EVD) have not been described more than 3 years postoutbreak. We examined survivors and close contacts from the 1995 Ebola outbreak in Kikwit, Democratic Republic of Congo (DRC), and determined prevalence of abnormal neurological, cognitive, and psychological findings and their association with EVD survivorship. From August to September 2017, we conducted a cross-sectional study in Kikwit, DRC. Over 2 decades after the EVD outbreak, we recruited EVD survivors and close contacts from the outbreak to undergo physical examination and culturally adapted versions of the Folstein mini-mental status exam (MMSE) and Goldberg anxiety and depression scale (GADS). We estimated the strength of relationships between EVD survivorship and health outcomes using linear regression models by comparing survivors versus close contacts, adjusting for age, sex, educational level, marital status, and healthcare worker status. We enrolled 20 EVD survivors and 187 close contacts. Among the 20 EVD survivors, 4 (20%) reported at least 1 abnormal neurological symptom, and 3 (15%) had an abnormal neurological examination. Among the 187 close contacts, 14 (11%) reported at least 1 abnormal neurologic symptom, and 9 (5%) had an abnormal neurological examination. EVD survivors had lower mean MMSE and higher mean GADS scores as compared to close contacts (MMSE: adjusted coefficient: -1.85; 95% confidence interval [CI]: -3.63, -0.07; GADS: adjusted coefficient: 3.91; 95% CI: 1.76, 6.04). EVD survivors can have lower cognitive scores and more symptoms of depression and anxiety than close contacts more than 2 decades after Ebola virus outbreaks.

Association of Hospital Admission Risk Profile Score with Mortality in Hospitalized Older Adults.

ObjectivesTo evaluate the association of the Hospital Admission Risk Profile (HARP) score with mortality after discharge in a population of hospitalized older adults.DesignRetrospective cohort study.ParticipantsHospitalized patients aged 70 years or older.MeasurementsPatient age at the time of admission, modified Folstein Mini-Mental Status Exam score, and self-reported instrumental activities of daily living 2 weeks prior to admission were used to calculate a HARP score. The primary outcome assessed was overall mortality up to 365 days after hospital discharge. Cox proportional hazard analyses evaluated the association between HARP score and mortality adjusting for age, sex, and comorbidities associated with increased mortality.ResultsOf the 474 patients, 165 (34.8%) had a low HARP score, 177 (37.4%) had an intermediate, and 132 (27.8%) had a high score. HARP score was not associated with differences in 30-day readmission rates. High HARP score patients had higher mortality when compared to patients with low HARP scores at all time frames (30 days: 12.9% vs 1.8%, p < .05; 90 days: 19.7% vs 4.8%, p < .05; 365 days: 34.8% vs 16.9%, p < .05). In fully adjusted Cox proportional models, patients with high HARP scores had a 3.5 times higher odds of mortality when compared to low HARP score patients.ConclusionThe HARP score is a simple and easy to use instrument that identifies patients at increased risk for mortality after hospital discharge. Early identification of patients at increased risk for mortality has the potential to help guide treatment decisions following hospital discharge and provides additional information to providers and patients for shared decision making and may help in clarifying and achieving patient and family goals of care.

The write stuff

Clinicians often wonder if the single sentence from the Folstein Mini-Mental Status Exam (MMSE) offers meaningful information about the patient. We compared single sentences derived from the MMSE generated by 3 groups of participants — hospitalized medically-ill patients with psychiatric comorbidity, hospitalized medically-ill patients without psychiatric comorbidity, and non-hospitalized non-psychiatric participants. These sentences were analyzed for themes using manual thematic coding and a semi-automatic computerized method, the Meaning Extraction Method (MEM). We found that thematic content obtained from as little as a single sentence could differentiate between participant groups using both methods. Specifically, psychiatric patients used more power themes, focused on states other than the present, and were less interpersonally engaged than the other groups. Thematic content also indicated cognitive status through scores on the Clock Drawing Test (CDT) and MMSE. Our findings suggest that a single sentence can provide meaningful information about patients with medical and psychiatric comorbidity.

Geriatric day hospital improves quality of life: A before and after study

PurposeTo ascertain whether admission to a geriatric day hospital (GDH) modifies health self-perception and quality-of-life (QOL) dimensions using the Nottingham Health Profile (NHP) instrument, and to evaluate possible sex differences in these health dimensions. MethodsLongitudinal study including all patients admitted to and discharged from GDH. Evaluated parameters at admission and discharge were: Barthel and Lawton indexes, Folstein's Mini-Mental State Exam (MMSE), Charlson index, Geriatric Depression Scale (GDS), Timed Up&Go test, Tinetti walking test and NHP. ResultsOne hundred and ten of a total of 183 patients were included in the study (21 were excluded for different reasons and NHP was not registered at the time of discharge in 52); Barthel index, MMSE, GDS, Timed Up&Go and Tinetti walking test all improved significantly after the GDH intervention. A significant improvement was found in NHP scores (admission: 36.3±22.7 vs. discharge: 31.3±20.8, P=0.044), physical mobility (49.5±31.1 vs. 39.8±28.5, P=0.002) and emotional dimensions (36.4±29.1 vs. 29.4±25.7, P=0.042). Among women, NHP analysis revealed an improvement in physical mobility (48.7±32.9 vs. 37.2±27.1, P=0.008) and emotional dimensions (44.5±29.8 vs. 33.3±2.58, P=0.02), while only an improvement in pain dimension was observed (25.7±23.7 vs. 16.7±18.8, P=0.03) among men. ConclusionsGlobal health perception and QOL improved after admission to a GDH, particularly physical mobility and emotional dimensions. Women improved in physical mobility and emotion whereas men only improved in pain perception.

Faster Cognitive and Functional Decline in Dysexecutive versus Amnestic Alzheimer's Subgroups: A Longitudinal Analysis of the National Alzheimer's Coordinating Center (NACC) Database

ObjectiveTo compare the rate of cognitive and functional decline in dysexecutive, typical and amnestic subgroups of Alzheimer’s disease.Methods943 participants from the National Alzheimer’s Coordinating Center (NACC) database who had a diagnosis of probable AD were followed for a mean of 2.3 years. A dysexecutive subgroup (n = 165) was defined as having executive performance >1.5 SD worse than memory performance, an amnestic subgroup (n = 157) was defined as having memory performance >1.5 SD worse than executive performance and a typical subgroup (n = 621) was defined as having a difference in executive and memory performance of <1.5 SD. Generalized estimating equations (GEE) were used to model decline on the Folstein Mini Mental Status Exam (MMSE), rise on the Clinical Dementia Rating (CDR) sum of boxes and rise on the total Functional Assessment Questionnaire (FAQ).ResultsCompared with the amnestic subgroup, the dysexecutive subgroup declined 2.2X faster on the Folstein MMSE (p<.001), rose 42% faster on the CDR sum of boxes (p = .03) and rose 33% faster on the total FAQ (p = .01). Rate of change for the typical subgroup fell between that of the amnestic and dysexecutive subgroups for the MMSE, CDR sum of boxes and total FAQ. Among a subset of participants (n = 129) who underwent autopsy, the dysexecutive, amnestic and typical subgroups did not differ in odds of having an AD pathologic diagnosis, suggesting that variation in non-AD pathologies across subtypes did not lead to the observed differences.ConclusionsA dysexecutive subgroup of AD has a unique disease course in addition to cognitive phenotype.

Hypovitaminosis D in Psychiatric Inpatients: Clinical Correlation with Depressive Symptoms, Cognitive Impairment, and Prescribing Practices

The association of hypovitaminosis D with measures of depressive symptoms and cognitive impairment remains unclear. This correlation and subsequent prescribing practices of vitamin D supplementation were evaluated in a population of psychiatric inpatients. A retrospective study was conducted of 548 patients with a serum 25-hydroxyvitamin D [25(OH)D] level measured during hospitalization. Outcomes included the association of hypovitaminosis D with Patient Health Questionnaire (PHQ-9) and Folstein Mini-Mental State Exam (MMSE) scores, including an evaluation of vitamin D dosing upon hospital discharge. Two hundred three patients (37%) had hypovitaminosis D. The majority [183 (90%)] had moderate (10-24 ng/mL), while 20 (10%) had severe hypovitaminosis D (<10 ng/mL). There was no significant association between hypovitaminosis D and PHQ-9 or MMSE scores (p = 0.107 and p = 0.271, respectively). Overall, 33% of patients with moderate hypovitaminosis D and 45% of patients with severe hypovitaminosis D were newly prescribed vitamin D or received a dose increase. Initiation of vitamin D or increased vitamin D dose was significantly higher in patients with hypovitaminosis D (p < 0.001). No association was found between hypovitaminosis D and depressive symptoms or cognitive function. However, patients with hypovitaminosis D were more likely to be prescribed additional vitamin D at hospital discharge.

Mirror movements in essential tremor: prevalence and relationship to mini-mental status test scores.

Mirror movements (MM) are mirror reversals of contralateral, voluntary alternating or repetitive limb movements. MM have been described in age-related neurological diseases, including essential tremor (ET). MM could represent a motor release sign. Cognitive dysfunction (especially executive dysfunction) and dementia have also been reported among ET patients. It is conceivable that MM and cognitive dysfunction in ET arise from the same underlying anatomical or physiological substrate. Hence, the underlying clinical question is whether MM are a simple and easily elicited motor marker for incipient cognitive change or dementia in ET? Identifying such a marker would have value to clinicians, and we are unaware of prior studies that have assessed this issue. The Folstein Mini-Mental State Exam (FMMSE) and the Modified Mini-Mental Status Examination (mMMSE) were administered to 148 ET cases enrolled in a cross-sectional clinical study. MM were present in 115 out of 148 (77.7%) ET cases. In analyses that considered age, there were no differences in FMMSE or mMMSE scores between participants with vs. without MMs (all p values >0.05). These data suggest that MM, while present in a considerable number of ET cases, would not be a useful motor marker for incipient cognitive change in ET cases.

An initial study of modifiable and non-modifiable factors for late-life psychosis.

To determine rates of psychotic symptoms and associated modifiable and non-modifiable factors among elderly long term nursing home residents without prior history of psychiatric illness. A cross-sectional design using the Scale for the Assessment of Positive Symptoms (SAPS) to measure psychotic symptoms, the Folstein's Mini-Mental State Exam (MMSE), and Mattis Dementia Rating Scale (DRS) to evaluate cognitive impairment. Frequency and rates of global psychotic symptoms and hallucinations, delusions, formal thought disorder, and bizarre behavior were calculated. Logistic regression was used to examine modifiable (e.g., medication use) and non-modifiable clinical characteristics (e.g., older age) associated with late-life psychosis. There were 15.9% of subjects reporting delusions and 7.3% reporting hallucinations. History of stroke, poorer cognition, and receiving multiple medications showed significant association with late-life psychosis. Only stroke (OR = 9.12; 95% CI: 1.58-52.74) and receiving different classes of medications (benzodiazepines, neuroleptics, and antidepressants) (OR = 13.17; 95% CI: 2.10-85.82) remained significantly associated with psychosis after adjusting for Mattis DRS total score. Further analyses excluding subjects with MMSE scores of 24 or lower (n = 24) showed essentially the same results but subjects with better cognitive function suffered a less severe form of psychosis, essentially constituted by one symptom type (i.e., visual hallucinations). Rates of late-life psychosis in this sample of nursing home residents without previous psychiatric history were high. Simultaneous use of medications including antidepressants, sedatives, and stimulants may be a clinically relevant modifiable factor to be targeted in prevention studies. Severity and type of psychosis is dependent on the severity of cognitive impairment.

Cognitive Impairment in Mental Illness: An SSA Blind Spot?

Back to table of contents Previous article Next article LettersFull AccessCognitive Impairment in Mental Illness: An SSA Blind Spot?Mark A. Amdur, M.D.Mark A. AmdurSearch for more papers by this author, M.D.Published Online:1 Jun 2011AboutSectionsView articleSupplemental MaterialPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleTo the Editor: The field now recognizes that our patients, particularly those with a diagnosis of schizophrenia, have significant co-occurring cognitive impairment (1). Unfortunately, in our experience at Thresholds, the disability determination process used by the Social Security Administration (SSA) often does not recognize cognitive impairment of individuals with schizophrenia and similar conditions otherwise considered stable (the exception is for the category of patients with dementia, delirium, or amnestic disorders, for whom cognitive impairment is taken into account). SSA does not recognize the importance of cognitive impairment in most mental disorders as a vocational impairment in determining disability.The current SSA guidelines for determining disability focus heavily on the overt signs and symptoms of mental impairments but do not focus on cognitive impairment. Proposed new rules would deemphasize the signs and symptoms, but there is no evidence of concern about cognitive impairment in schizophrenia and other psychiatric disorders in the proposed rules. The actual vocational disability that results from these disorders is often unrelated to delusions, hallucinations, sadness, or anxiety. Our patients, even when their symptoms have remitted, are left with cognitive impairments that interfere with concentration, attention, visuospatial function, language, memory, and executive function. These are the enduring and disabling features of serious mental illness. There is no good way to demonstrate these impairments unless you test for them.The Montreal Cognitive Assessment (MoCA) was designed as a rapid test for “mild cognitive impairment” among elderly persons (2). Like the Folstein Mini-Mental State Exam, scores on the MoCA range from 0 to 30. The MoCA takes about 12 minutes to administer. For persons with no cognitive impairment, MoCA scores averaged 27.4±2.2. Persons with known dementia of the Alzheimer type had MoCA scores that averaged 16.2±4.8. Persons with “mild cognitive impairment” had MoCA scores that averaged 22.1±3.1.In a 2010 study at Thresholds, we administered the MoCA and the Folstein Mini-Mental State Exam to 112 stable individuals with schizophrenia (Wilkniss S, Teachout A, Robin L, et al., unpublished manuscript, 2010). The mean±SD MoCA score of persons with schizophrenia was 22.7±4.3. This score falls squarely into the “mild cognitive impairment” range observed with an elderly sample. On the Folstein Mini-Mental State Exam, the same individuals had a score of 27.1±2.5, which is in the normal range.As part of preparing a report for SSA, we also administered the MoCA to 224 individuals seen for consecutive psychiatric evaluations. The group had a wide range of diagnoses. We cannot validate the representativeness of the sample with respect to all individuals who apply to SSA for disability benefits; however, we did nothing to specially select the sample. We were surprised by the high rates of cognitive impairment across all diagnostic categories. [A table with mean MoCA scores for patients in the main diagnostic categories is available in an online supplement to this letter at ps.psychiatryonline.org.]On the basis of our experience, we propose that SSA recognize cognitive impairment as a common work-related impairment in a wide range of mental disorders not confined to dementia, delirium, or amnestic disorders. Failure to do so risks inappropriate denials of disability benefits. Physicians reporting to SSA need to perform more sophisticated cognitive testing. The SSA guidelines should accommodate the concept of co-occurring cognitive impairment in all diagnostic categories. Adjudicators and administrative law judges need to be educated about this phenomenon. At the same time, strategies to facilitate recovery and exit from the disability roll must target cognitive impairment and remediation of cognitive deficits.Dr. Amdur is senior psychiatric consultant at Thresholds, Chicago.Acknowledgments and disclosuresThe author reports no competing interests.References1 Keefe RSE , Fenton WS : How should DSM-V criteria for schizophrenia include cognitive impairment? Schizophrenia Bulletin 33:912–920, 2007 Crossref, Medline, Google Scholar2 Nasreddine ZS , Phillips NA , Bédirian V , et al.: The Montreal Cognitive Assessment (MoCA): a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society 53:695–699, 2005 Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 62Issue 6 June 2011Pages 682-682 Metrics Acknowledgments and disclosuresThe author reports no competing interests.PDF download History Published online 1 June 2011 Published in print 1 June 2011

How can we improve targeting of frail elderly patients to a geriatric day-hospital rehabilitation program?

BackgroundThe optimal patient selection of frail elderly persons undergoing rehabilitation in Geriatric Day Hospital (GDH) programs remains uncertain. This study was done to identify potential predictors of rehabilitation outcomes for these patients.MethodsThis study is a retrospective cohort analysis of patients admitted to the rehabilitation program of our GDH, in Montreal, Canada, over a five year period. The measures considered were: Barthel Index, Older Americans Resources and Services, Folstein Mini Mental Status Exam, Timed Up & Go (TUG), 6-minute walk test (6 MWT), Gait speed, Berg Balance, grip strength and the European Quality of life - 5 Dimensions. Successful improvement with rehabilitation was defined as improvement in three or more tests of physical function. Logistic regression analysis using the Bayesian Information Criterion (BIC) was employed to select the optimal model for making predictions of rehabilitation success.ResultsA total of 335 patients were studied, but only 233 patients had a complete data set suitable for the predictive model. Average age was 81 years and patients attended the GDH an average of 24 visits. Significant changes were found in several measures of physical performance for many patients ranging from improved gait speed in 21.3% to improved TUG in 62.7% of the cohort. Fifty-eight percent of patients attained successful improvement with rehabilitation by our criteria. This group was characterized by lower test scores on admission. Using BIC, the best predictor model was the 6 MWT [OR: 0.994 per meter walked (95% CI: 0.990-0.997)].ConclusionsThe GDH rehabilitation program is effective in improving patients' physical performance. Although no single measure was found to be sufficiently predictive to help target candidates appropriately, the 6 MWT showed a trend to significance. Further research will be done to elucidate the utility of a composite 'rehab appropriateness index' and the role of International Classification of Function concepts for targeting frail elderly to GDH rehabilitation services.

A Prospective Observational Study of Decisional Capacity Determinations in an Academic Medical Center

The main goals, of this observational study were to clarify and categorize decisional capacity assessments performed by a psychosomatic medicine (PSM) consult service at an academic medical center. Areas of investigation included types of decisional capacity requests, the relationship between Folstein Mini-Mental State Exam (MMSE) and PSM decisional capacity determination, psychiatric diagnoses of patients, and the agreement between primary clinician capacity assessment and that of the PSM clinician. This was a prospective study of 100 consecutive decisional capacity consultations. Twelve requests were for second consultations for patients previously seen, for a net of 88 patients. In 77 cases, patients lacked decisional capacity. Assessments for capacity to leave against medical advice (AMA), capacity to accept medical/surgical procedures, capacity to refuse medical/surgical procedures, and capacity to participate in discharge planning were nearly equally frequent. An MMSE cutoff score of < 21 was found to be 100% specific and 69% sensitive for identifying the patients without capacity, while a cutoff of < 24 was found to be 83% sensitive and 90% specific for identifying patients without capacity. The primary psychiatric diagnosis was a cognitive disorder in 52 cases. In 38 of the 39 cases where the primary team believed the patient lacked capacity, the PSM service agreed. In only two of the seven cases where primary teams believed patients had capacity did the PSM team agree. The MMSE was a useful predictor of capacity determination by PSM personnel, but using MMSE alone results in a number of erroneous determinations. Cognitive disorders were the most common primary psychiatric diagnoses in decisional capacity cases. Primary teams tended to be more accurate when they found patients to lack capacity.

Olfaction and apathy in Parkinson's disease

Background Olfactory deficits are frequent among patients with idiopathic Parkinson's disease (PD). Additionally, apathy (as quantified by the Apathy Evaluation Scale), is more prevalent in PD patients compared to the general population. Olfactory impairment and apathy are associated with dysfunction in overlapping brain regions. Neuroimaging studies indicate that the anterior cingulate gyrus and medial orbitofrontal cortex are hypoactive in apathetic patients and are also involved in secondary olfactory processing. However, no study until this point has been published investigating whether there is any association between olfactory dysfunction and apathy in PD patients. Methods In our study seventy consecutive patients with PD took the Brief Smell Identification Test (B-SIT), completed the Apathy Evaluation Scale (AES) and were administered the Folstein Mini-Mental Status exam (MMSE). Results Apathetic PD patients performed poorly on the B-SIT compared with non-apathetic PD patients and olfactory impairment correlated with apathy. The simultaneous disruption of olfaction and emotion in Parkinson's could be the result of disease pathology in brain regions involved in both olfactory and emotional processing and reinforces the idea that this link between olfaction and emotions may have clinical consequences.

The Effect of Music on the Cognition of Older Adults Undergoing Hip and Knee Surgery

The purpose of this study was to determine the effects of music listening on the acute confusion that is common in older adults after hip or knee surgery. Music listening is an activity that does not require active physical partic- ipation from the patient but provides an environment for healing. This study used a random control experimental design with a music-listening group and control group for 22 older adults undergoing hip or knee surgery. The experimental group listened to music at the bedside for at least 4 hours daily. The NEECHAM Acute Confusion Scale and the Folstein Mini-Mental State Exam were used to measure cognition and acute confusion. Find- ings demonstrate that the music-listening group had higher levels of cognitive function and less confusion than those who did not listen to music.

Mirror Writing and a Dissociative Identity Disorder

Individuals with dissociative identity disorder (DID) have been known to show varied skills and talents as they change from one dissociative state to another. For example, case reports have described people who have changed their handedness or have spoken foreign languages during their dissociative states. During an interview with a patient with DID, a surprising talent emerged when she wrote a sentence for the Folstein Mini-Mental State Exam—mirror writing. It is not known whether her mirror writing had a deeper level of meaning; however, it does emphasize the idiosyncratic nature of dissociative identity disorder.