Severe Mini-Mental State Examination Research Articles

Development and validation of the Music Cognitive Test: A music-based cognitive screening test

Specific tools to measure the cognitive benefits of music therapy and music-rehabilitation training available to music therapists are few and empirically weak: they are mostly psychometrically unrefined or based on unclear tasks and scoring protocols; they do not take into consideration distinct cognitive functions or are based on exclusively observational protocols. To overcome these limitations, we developed a 15-min cognitive screening tool suitable for music therapists, Music Cognitive Test (MCT), which assesses cognitive abilities stimulated by music-making activities (e.g., attentional, verbal, and executive functions, short- and long-term memory) by including music-based items. MCT was validated with 335 participants (aged 18–100 years old) presenting a range of cognitive levels, from healthy cognition to severe impairment. MCT correlated strongly and positively with well-known tests: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Severe Mini-Mental State Examination (SMMSE). MCT also displayed excellent sensitivity in identifying impaired individuals according to both MMSE and MoCA diagnostic criteria (99.4% and 93.0%, respectively), and excellent specificity in identifying healthy participants based on MMSE (93.5%) and MoCA (97.8%) criteria. Overall, results highlight the reliability of this novel brief music-focused cognitive screening test, to enable music therapists to independently and consistently monitor the effectiveness of their intervention on cognitive functions.

Clinical Trajectories of Neuropsychiatric Symptoms in Mild-Moderate to Advanced Dementia

Background: There is high prevalence of neuropsychiatric symptoms (NPS) among dementia patients. NPS are correlated with dementia progression, functional decline, early institutionalization, and death. There is scarce evidence on the progression of NPS in the latest stages of dementia. Objective: To describe the prevalence of NPS in mild-moderate to severe dementia and to reveal the progression of each NPS over time. Methods: We studied 317 patients (77.3% female, average age: 81.5 years) with a DSM-IV-TR diagnosis of dementia. This is a cross-sectional, and a prospective longitudinal study with 78-month follow-up. We assessed cognitive status (Mini-Mental State Examination and Severe Mini-Mental State Examination), dementia severity (Global Deterioration Scale and Clinical Dementia Rating), and psychopathological measures (Neuropsychiatric Inventory, APADEM-Nursing Home, Apathy Inventory, Cornell Scale for Depression in Dementia, and Cohen-Mansfield Agitation Inventory). Results: Overall prevalence of NPS was 94.6%, being apathy the most prevalent (66.7%) and the one whose severity increased the most with progression of dementia. Agitation/aggression, irritability, and sleeping and eating disorders also increased over time. Delusions and depressive symptoms decreased in severity with disease progression. In severe dementia, female displayed more depressive symptoms and eating disorders, while male displayed more agitation/aggression and sleep disturbances. Conclusion: NPS in dementia follow a heterogeneous course. Apathy is the most prevalent NPS and the one that worsens most significantly over time. The course of some NPS differs between sexes. Further research is required to understand the evolution of NPS at advanced stages of dementia.

APOE ε4 Carrier Status as Mediator of Effects of Psychotropic Drugs on Clinical Changes in Patients With Alzheimer's Disease.

Neuropsychiatric syndromes have been associated with memory dysfunction and risk of and earlier onset of dementia, but how psychotropic drugs affect clinical changes in Alzheimer's disease is not entirely clear. This study aimed to assess the prospective effects of psychotropic drugs on cognitive and functional changes in Alzheimer's disease according to APOE ε4 carrier status. The study included consecutive outpatients with late-onset Alzheimer's disease (N=193) and examined score variations at 1 year on the following tests: Clinical Dementia Rating sum of boxes, Mini-Mental State Examination, Severe Mini-Mental State Examination (SMMSE), Brazilian version of the Zarit Caregiver Burden Interview, Index of Independence in Activities of Daily Living, and Lawton's Instrumental Activities of Daily Living Scale. Analyses of score variations accounted for the use of psychotropic drugs or the number of different medications in use, as well as APOE ε4 carrier status, with significance at p<0.05. For APOE ε4 noncarriers (N=90), cholinesterase inhibitors were beneficial regarding caregiver burden (p=0.030) and basic functionality (p=0.046), memantine was harmful regarding SMMSE score changes (p=0.032), second-generation antipsychotics had nonsignificant harmful effects on SMMSE score changes (p=0.070), and antiepileptic therapy (p=0.001) and the number of different medications in use (p=0.006) were harmful in terms of basic functionality. APOE ε4 carriers (N=103) did not experience any effects of isolated psychotropic drugs on clinical changes, including antidepressants. Results support the harmful prospective effects of second-generation antipsychotics and antiepileptic drugs on cognitive and functional changes in Alzheimer's disease, particularly for APOE ε4 noncarriers, whereas antidepressants may be safer options for behavioral enhancement.

Swallowing in behavioral variant frontotemporal dementia.

Swallowing and feeding problems may occur with the progression of behavioral variant frontotemporal dementia (bvFTD) and can impair the anticipatory and oral preparatory phases of swallowing. To characterize swallowing problems and the feeding situation of patients with bvFTD and to correlate the swallowing problems with functionality, executive functions, cognitive and behavioral features. Consecutive outpatients with bvFTD in mild, moderate and severe dementia stages were recruited along with their caregivers. Patients and caregivers were screened with the following scales: "Mini-Mental State Examination", "Severe Mini-Mental State Examination", "FTLD-modified Clinical Dementia Rating", "Neuropsychiatric Inventory", "Frontal Assessment Battery", "Index of Independence in Activities of Daily Living", "Swallowing Rating Scale" and "Assessment of Feeding and Swallowing Difficulties in Dementia". Overall, thirty patients with bvFTD were included along with their caregivers. Patients with bvFTD showed feeding and swallowing difficulties such as: messy to eat, passivity, coughing and choking, difficulty with some food consistencies and with specific food. Swallowing problems in bvFTD correlated with impaired functionality (p<0.05) and cognition (p<0.05), executive dysfunction (p<0.01) and behavioral features (p<0.01). Caregivers had great difficulty in managing the feeding situation during mealtime, with different characteristics in each dementia stage. Patients with bvFTD had inappropriate speed eating, passivity, coughing and choking starting in the mild dementia stage, and these problems worsen in the severe stage. Such difficulties affected caregiver performance during mealtime. The correlations indicated that swallowing difficulties tend to follow cognitive and behavioral decline in patients with bvFTD.

Dealing with severe dementia in clinical practice: A validity and reliability study of Severe Mini-Mental State Examination in Greek population.

ObjectiveConsidering the floor effect problems of many cognitive instruments administered in patients with dementia, we aimed to evaluate the validity and reliability of the Severe Mini‐Mental State Examination (SMMSE) for monitoring patients with moderate to severe dementia in the Greek population.MethodsWe included 210 patients with dementia, mostly diagnosed with Alzheimer's disease, and administered the SMMSE, the Mini‐Mental State Examination (MMSE), the Global Deterioration Scale, and the Katz Activities of Daily Living Scale (ADL). Demographic effects on SMMSE, validity, and reliability properties were initially tested for the total sample; SMMSE diagnostic accuracy was examined between subgroups of patients according to their MMSE performance; longitudinal changes over a 6‐month period were assessed for a subgroup of 100 patients.ResultsNone of the demographic variables correlated with SMMSE score. Reliability analysis revealed high indices regarding internal consistency, inter‐rater, and test‐retest reliability. Validity analysis showed high correlation coefficients between SMMSE, MMSE, Global Deterioration Scale, and Katz Activities of Daily Living Scale (concurrent validity) and excellent discriminant validity of SMMSE to correctly categorize patients based on their MMSE score. In the longitudinal analysis, we found significant differences (1) only on SMMSE for patients with an MMSE = 0 to 6 at baseline and (2) both on SMMSE and MMSE for patients with an MMSE = 7 to 16 at baseline. No differences were detected for patients with an MMSE = 17 to 22 at baseline.ConclusionsWe suggest the SMMSE as quick, reliable, valid, and insensitive to demographic effects psychometric instrument to monitor cognitive changes in patients with profoundly severe dementia.

Evaluación cognitiva global en personas vascoparlantes con demencia en estadios avanzados. Validación al euskera de la escala Severe Mini Mental State Examination (SMMSE-eus)

IntroductionAdaptation and validation to the Basque language of tests to assess advanced cognitive impairment is a not covered need for Basque-speaking people. The present work shows the validation of the Basque version of the Severe Mini Mental State Examination (SMMSE). Material and methodsA total of 109 people with advanced dementia (MEC<15) took part in the validation study, and were classified as GDS 5-7 on the Geriatric Depression Scale (GDS). All participants were Spanish-Basque bilingual. ResultsIt was shown that SMMSE-eus has a high internal consistency (alpha=0.92), a good test-retest reliability (r=0.88; P<.01), and a high inter-rater reliability (CCI=0.99; P<.00) for the overall score, as well as for each item. ConclusionsBoth the high internal consistency and inter-rater reliability, and to a lesser extent, test-retest reliability, made the SMMSE-eus a valid test for the brief assessment of cognitive status in people with advanced dementia in Basque-speaking people. For this reason, the SMMSE-eus is a usable and reliable alternative for assessing Basque-speaking people in their mother-tongue, or preferred language.

Structural correlates of apathy in Alzheimer's disease: a multimodal MRI study.

Apathy is one of the most frequent symptoms of dementia, whose underlying neurobiology is not well understood. The objective was to analyze the correlations of apathy and its dimensions with gray and white matter damage in the brain of patients with advanced Alzheimer's disease (AD). The setting of the study was at the Alzheimer Center Reina Sofía Foundation Research Unit. Participants include 37 nursing home patients with moderate to severe AD, 78.4% were women, and mean Standard Deviation (SD) age is 82.7 (5.8). Several measurements were taken: severe mini-mental state examination and Global Deterioration Scale for cognitive and functional status, Neuropsychiatric Inventory for behavioral problems, and Apathy In Dementia-Nursing Home Version Scale for apathy, including total score and subscores of emotional blunting, deficit of thinking, and cognitive inertia. 3T magnetic resonance imaging measures (voxel-based morphometry, fluid-attenuated inversion recovery, and diffusion tensor imaging) were also conducted. Moderate levels of apathy (mean Apathy In Dementia-Nursing Home Version Scale: 31.1 ± 18.5) were found. Bilateral damage to the corpus callosum and internal capsule was associated with apathy severity (cluster size 2435, p < 0.0005, family-wise error [FWE]-corrected). A smaller and more anteriorly located region of the right internal capsule and corpus callosum was associated with higher emotional blunting (cluster size 334, p < 0.0005, FWE-corrected). Ischemic damage in the right periventricular frontal region was associated with higher deficit of thinking (cluster size 3805, p < 0.005, FWE-corrected). Brain damage related to apathy may have different features in the advanced stages of AD and differs between the three apathy dimensions. Besides atrophy, brain connectivity and vascular lesions are relevant in the study of apathy, especially in the more severe stages of dementia. Further magnetic resonance imaging studies should include multimodal techniques. Copyright © 2016 John Wiley & Sons, Ltd.

Social robots in advanced dementia.

Aims: Pilot studies applying a humanoid robot (NAO), a pet robot (PARO) and a real animal (DOG) in therapy sessions of patients with dementia in a nursing home and a day care center.Methods:In the nursing home, patients were assigned by living units, based on dementia severity, to one of the three parallel therapeutic arms to compare: CONTROL, PARO and NAO (Phase 1) and CONTROL, PARO, and DOG (Phase 2). In the day care center, all patients received therapy with NAO (Phase 1) and PARO (Phase 2). Therapy sessions were held 2 days per week during 3 months. Evaluation, at baseline and follow-up, was carried out by blind raters using: the Global Deterioration Scale (GDS), the Severe Mini Mental State Examination (sMMSE), the Mini Mental State Examination (MMSE), the Neuropsychiatric Inventory (NPI), the Apathy Scale for Institutionalized Patients with Dementia Nursing Home version (APADEM-NH), the Apathy Inventory (AI) and the Quality of Life Scale (QUALID). Statistical analysis included descriptive statistics and non-parametric tests performed by a blinded investigator.Results: In the nursing home, 101 patients (Phase 1) and 110 patients (Phase 2) were included. There were no significant differences at baseline. The relevant changes at follow-up were: (Phase 1) patients in the robot groups showed an improvement in apathy; patients in NAO group showed a decline in cognition as measured by the MMSE scores, but not the sMMSE; the robot groups showed no significant changes between them; (Phase 2) QUALID scores increased in the PARO group. In the day care center, 20 patients (Phase 1) and 17 patients (Phase 2) were included. The main findings were: (Phase 1) improvement in the NPI irritability and the NPI total score; (Phase 2) no differences were observed at follow-up.

Combined Alzheimer's disease and cerebrovascular staging explains advanced dementia cognition

IntroductionThe absence of a consensus system for full neuropathological evaluation limits clinicopathological studies and comparability between laboratories. Combined staging for Alzheimer's type and cerebral vascular pathology may allow a better classification of cases for clinical and cognitive correlation. MethodsCognitive and postmortem neuropathological data were obtained from 70 brains donated to the Tissue Bank of the Centro de Investigación de Enfermedades Neurológicas (CIEN) Foundation according to recently developed staging schemes for Alzheimer's type and vascular pathology. Subjects belonged to a cohort of institutionalized patients with moderate or severe dementia and a mean follow-up period of 7 years. ResultsCases were classified into three groups: Alzheimer's predominant (64.1%), vascular predominant (6.3%) and mixed pathology (29.6%). Significant differences were observed in Severe Mini-Mental State Examination and verbal fluency between the vascular predominant and the other groups of patients. DiscussionThe combination of scales measuring cerebral vascular and Alzheimer's type pathology allowed a classification of patients that reveals differences between groups in premortem cognitive features.

Clinical Effectiveness of Assessments of Cognitive Ability for Severely Demented Patients

The Mini Mental State Examination (MMSE) is the most commonly used cognitive assessment in clinical practice. However, in severely demented patients, the MMSE has noted floor effects. The gold standard of cognitive assessment of severely demented patients is the Severe Impairment Battery (SIB) but it takes 20 minutes to administer. The objective of this study is to examine 5 different cognitive assessments, SIB, Severe Impairment Battery-8 (SIB-8), Brief Interview of Mental Status (BIMS), MMSE, and Severe Mini Mental State Examination (sMMSE) to determine the validity and utility of shorter scales for clinical practice based upon scores, time of administration, and the administrator's impression of the patient frustration, comprehension, fatigue, and ability to attend to task.

Is there correlation between cognition and functionality in severe dementia? the value of a performance-based ecological assessment for Alzheimer's disease.

Besides significant cognitive decline, patients in later stages of Alzheimer's disease (AD) also present global functional impairment, usually reported by their caregivers. This study searched for preserved activities of daily living by investigating correlations among specific instruments for severe dementia with a performance-based functional scale. A sample of 95 moderate to severe AD patients and their caregivers underwent a neuropsychological battery consisting of screening tools, the Functional Assessment Staging Test (FAST), the Severe Mini-Mental State Examination (MMSEsev) and a performance-based ecological scale, the Performance Test of Activities of Daily Living (PADL). Consistent findings emerged from the comparisons among tests. PADL showed significant statistical correlation with MMSEsev (ρ<0.001), according to FAST subdivisions. Upon suspicion of unreliable caregiver reports, ecological scales may be useful for disease staging. Variable degrees of functionality and cognition may be present even in later stages of AD, requiring proper assessment.

Educational bias in the assessment of severe dementia: Brazilian cutoffs for severe Mini-Mental State Examination.

Cognitive assessment in advanced stages of Alzheimer's disease (AD) is limited by the imprecision of most instruments. To determine objective cognitive responses in moderate and severe AD patients by way of the Severe Mini-Mental State Examination (SMMSE), and to correlate performances with Mini-Mental State Examination (MMSE) scores. Consecutive outpatients in moderate and severe stages of AD (Clinical Dementia Rating 2.0 or 3.0) were evaluated and compared according to MMSE and SMMSE scores. Overall 400 patients were included, 67.5% females, mean age 76.6±6.7 years-old. There was no significant impact of age or gender over MMSE or SMMSE scores. Mean schooling was 4.4±2.5 years, impacting SMMSE scores (p=0.008). Scores on MMSE and SMMSE were significantly correlated (F-ratio=690.6325, p<0.0001). The SMMSE is influenced by schooling, but not by age or gender, and is an accurate test for assessment of moderate and severe AD.

Correlation and adaptation among functional and cognitive instruments for staging and monitoring Alzheimer?s disease in advanced stages

Background : Although Alzheimer’s disease (AD) is the most prevalent form of dementia, little is known about cognitive and functional aspects in its advanced stages. Objective : This study aimed the adaptation and correlation among specific instruments for AD in advanced stages with regard to cognition objectively weighted, besides the comparison between static and ecological aspects of functional capacity. Methods : 95 moderate, moderatly severe and severe AD patients (33 men and 62 women) underwent the scales CDR (Clinical for Dementia Rating), FAST (Functional Assessment Scale), MMSE (Mini-Mental State Exame), MMSEsev (Severe Mini-Mental State Examination), SIB-8 (Severe Impairment Battery) and TSI (Test for Severe Impairment), for the comparison with a golden-standard ecological scale the PADL (Performance Activities of Daily Living). Results : The evidence suggests an increasing and statistically significant linear correlation between the ecological functional scale and cognitive tests according to the stratification of AD stages once weighted by static functional scale. Discussion : The results indicate that for patients in advanced stages of AD, appropriate cognitive tests and performance-based functional scales are useful in more accurate assessment of disease staging and monitoring its progression.

A Useful and Brief Cognitive Assessment for Advanced Dementia in a Population with Low Levels of Education

Background/Aims: Almost half of community-dwelling patients and 59.6% of institutionalized residents with dementia are in moderate or severe stages of this disease. The Mini-Mental State Examination (MMSE) has limited applicability to these patients due to floor effects. We aimed to determine the correlation between the MMSE and the Severe Mini-Mental State Examination (SMMSE), as well as SMMSE association with functional scales in patients having moderate to severe dementia and low levels of education. Methods: A cross-sectional study of patients 60 years or older attending an outpatient clinic was conducted. The MMSE, SMMSE and functional scales were applied. Clinical and demographic data from medical records were reviewed. Results: Seventy-five patients with a mean of 4.1 ± 3.6 years of education were analyzed. The mean scores on the MMSE and SMMSE were 7.8 ± 7.0 and 17.8 ± 9.4, respectively. The results indicated that the MMSE and SMMSE correlated only in patients who had an MMSE score of less than 10 (r = 0.87; p < 0.001). In addition, significant correlations were found between the SMMSE and functional scales (p < 0.001). It was observed that educational level did not interact with SMMSE performance. Conclusion: The SMMSE is a useful and reliable tool for a brief cognitive assessment of advanced dementia patients with low educational levels.

Montreal Cognitive Assessment (MoCA): Diagnostic Utility in a Cognitive Clinic Population

Background: Severe dementia (SD) is relatively neglected, and its prevalence is unclear, but it is estimated that one-third of dementia patients are in the severe stages. There is a lack of assessment tools for cognition with standardized neuropsychological tests and patients are labelled “untestable”. Behavioral symptoms are responsible for most distress that both sufferers and caregivers experience and decline in functional autonomy is a major component. Our aim is to present a pilot study of a protocol to evaluate cognition, behavior and functionality in patients with SD. Methods: 30 subjects with SD were assessed in one year (2010). SD was defined based on scores on global rating scales, observation of subjects’ residual abilities and interview with the patient’s caregiver. According with the literature, we defined SD as a score of 3 or higher in the Clinical Dementia Rating (CDR); or categories 6a to 7f in the Functional Assessment Staging Test (FAST); or a score of 6 or 7 in the Global Deterioration Scale (GDS). The protocol we applied includes the Mini-Mental State Examination (MMSE) and Severe Mini-Mental State Examination (SMMSE) to evaluate cognitive functions; CDR and FASTas two different staging systems; Katz scale for functional assessment; Neuropsychiatric Inventory (NPI) for behavior. A nutritional evaluation was also applied; the Functional Outcome Questionnaire for Aphasia (FOQ-A) and a Brazilian version of the Southampton Assessment of Mobility (SAM-BR). Our intention with this study is to evaluate the performance in different types of dementia and make correlations to determine the best tools for followup. Results: Our results showed that most of patients were AD’s women with apathy or agitation/aggression as more frequently behavior disturbs. SMMSE was better than MMSE to evaluate cognition in this population. Conclusions: In severe cognitive impairment, differential diagnosis is often difficult. A complete multidisciplinary group is essential to make it possible. Without a good multidisciplinary group and a comprehensive non-pharmacological intervention it is not possible to treat patients in this stage. With our extend protocol we expect to study all these functions and make a correct disease and problems diagnosis to improve treatment and follow-up.

Severe Mini-Mental State Examination: a brief cognitive assessment for patients with moderate and severe dementia

Severe Mini-Mental State Examination: a brief cognitive assessment for patients with moderate and severe dementia

Evaluación breve del estado cognitivo de la demencia en estadios avanzados: resultados preliminares de la validación española del Severe Mini-Mental State Examination

Introduction The cognitive assessment of patients with advanced dementia needs proper screening instruments that allow obtain information about the cognitive state and resources that these individuals still have. The present work conducts a Spanish validation study of the Severe Mini Mental State Examination (SMMSE). Material and methods Forty-seven patients with advanced dementia (Mini-Cognitive Examination [MEC]<11) were evaluated with the Reisberg's Global Deterioration Scale, MEC, SMMSE and Severe Cognitive Impairment Profile scales. Results All test items were discriminative. The test showed high internal ( α = 0.88), test-retest (0.64 to 1.00, P < .01) and between observers reliabilities (0.69-1.00, p < 0.01), both for scores total and for each item separately. Construct validity was tested through correlations between the instrument and MEC scores (r = 0.59, P < 0.01). Further information on the construct validity was obtained by dividing the sample into groups that scored above or below 5 points in the MEC and recalculating their correlations with SMMSE. The correlation between the scores in the SMMSE and MEC was significant in the MEC 0-5 group (r = 0.55, P < .05), but not in the MEC>5 group. Additionally, differences in scores were found in the SMMSE, but not in the MEC, between the three GDS groups (5, 6 and 7) (H = 11.1, P < .05). Conclusions The SMMSE is an instrument for the assessment of advanced cognitive impairment which prevents the floor effect through an extension of lower measurement range relative to that of the MEC. From our results, this rapid screening tool and easy to administer, can be considered valid and reliable.

The Severe Mini-Mental State Examination: a new neuropsychologic instrument for the bedside assessment of severely impaired patients with Alzheimer disease.

The bedside and office assessment of cognitive abilities in moderately to severely impaired patients with Alzheimer disease could be enhanced by a well-standardized instrument. The authors' group has developed such an instrument (i.e., Severe Mini-Mental State Examination; SMMSE) to assess this population. Based on the Folstein Mini-Mental State Examination (MMSE), the SMMSE, which totals 30 points, was designed to briefly assess cognitive domains relatively preserved in moderate to severe Alzheimer disease. One hundred eighty-two patients with possible or probable Alzheimer disease were administered both the MMSE and SMMSE. Performances on the SMMSE and MMSE were found to correlate significantly only when MMSE fell below 9 points (p < 0.0001). However, as performance on the MMSE approached floor levels, patients continued to score at half maximal levels on the SMMSE. Functional staging with the Clinical Dementia Rating Scale and the Global Deterioration Scale also were found to significantly correlate with performance on the SMMSE (p < 0.001). Test-retest performance on both the SMMSE and MMSE was relatively stable over a period of 5 months. Inter-rater reliability of the SMMSE was excellent. These results suggest that the SMMSE has both construct and criterion validity for assessing severely impaired Alzheimer disease patients. Our results also suggest that the SMMSE may be a useful instrument for assessing severely impaired patients at the bedside and in the office.