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Cognitive Test and Questionnaire Forms, Instructions, and Normative Data for Evaluating Memory Loss, Alzheimer’s Disease, and Dementia
Screening for memory loss has become more and more common in both primary care and specialty practices. As discussed in Chapter 2 , there are a number of approaches to screening:
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Mental status tests: These tests are generally used to assess overall mental status and, as noted, can be used to screen for cognitive dysfunction.
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Single neuropsychological tests: Individual neuropsychological tests that can be used to screen for cognitive dysfunction.
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Brief screening batteries: Combining multiple single cognitive tests into a very brief (5–10 minutes) screening battery.
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Caregiver-completed questionnaires: Questionnaires that can be completed by someone who knows the patient well or, in some instances, by the patient.
Here we provide several examples of each of these categories of screening instruments for Alzheimer’s disease. Although we recognize that there are now many screening instruments that the clinician can use, we have selected several instruments that we feel are relatively easy and quick to administer and interpret, have been validated, are associated with normative data, and are readily accessible. In each case, we have provided a copy of the instrument that can be downloaded for use, normative data as well as occasional rules of thumb, and sources of additional information.
Mental Status Tests
The Blessed Dementia Scale
This scale has two parts. The Blessed Information, Memory, Concentration (BIMC or “right-side Blessed”) test measures orientation for time and place recent memory, and attention and concentration. It also measures orientation for person, as well as personal information (autobiographical memory). It does not, however, measure praxis or language. The left side of the Blessed is a caregiver scale measuring changes in everyday activities, personal habits, personality, interests, and drives ( ).
Scoring
The “Blessed” is reverse scored (higher numbers indicate poorer scores). Scores range from 0 (perfect score) to 37 on the BIMC test (right side) and from 0 to 28 on the caregiver scale (left side).
Accuracy
For the BIMC test (right side), most clinicians consider scores below 4 as normal, between 4 and 6 borderline, and above 6 as impaired. A study by found that fewer than 4 errors suggests no impairment, 4 to 10 errors suggests mild impairment, 11 to 16 errors suggests moderate impairment, and more than 16 errors suggests severe impairment, and that untreated patients decline approximately 3 or 4 points per year. For the caregiver scale (left side), scoring less than 4 suggests that the patient is unimpaired; a score from 4 to 9 suggests mild impairment; scores higher than 10 suggest moderate to severe impairment ( ).
Time to Administer/Training
In our experience, this instrument can be administered by most clinicians with a minimum of training in less than 10 minutes.
Notes
For the BIMC test (right side), if you give the name and address for the 5-Minutes Recall (section H) first it will be about five minutes when you get to it (better if timed). Ask patients to repeat the whole name and address together when learning it. Patients can be off by one on the “hour” and “date.” “Recognition of persons” is people they came with. Check personal memory data with caregiver or previous testing. Dates of World War I and World War II can be approximate. For the caregiver scale (left side) “coarsening of affect” is for you to judge.
Availability
There is currently no website support for this instrument. Clinicians typically reproduce the instrument for use.
The Montreal Cognitive Assessment
The Montreal Cognitive Assessment (MoCA) is an instrument ( ) that evaluates orientation, memory, attention, language (naming), executive function, and visuospatial function. In head-to-head studies with the Mini-Mental State Examination, the MoCA appears more sensitive in detecting patients with mild cognitive impairment and Alzheimer’s disease ( ).
Scoring
MoCA scores range from 0 to 30 (perfect score). Sums from each of the subscores are listed on the right-hand side of the document and the sum of the subscores yields the final score. One point is added for individuals who have less than 12 years of formal education.
Accuracy
Using a cutoff of 26 or lower, the sensitivity and specificity are both approximately 90%.
Time to Administer/Training
In our experience, this instrument can be administered by most clinicians with a minimum of training in less than 10 minutes.
Availability
The test and detailed instructions, as well as references, translations into more than 45 languages, and information are available at www.mocatest.org . There is no charge to use the test and permission is not required, although there is a fee for training and certification.
Single Neuropsychological Tests
Clock Drawing Test
In this routinely used neuropsychological test, the patient is asked to draw the face of a clock and to then draw the hands to indicate a specific time.
Scoring
The clock is scored from 0 to 7 (perfect score).
Accuracy
Using this scoring system and a cutoff of 5 or below the sensitivity and specificity are both above 80%.
Time to Administer/Training
In our experience, this instrument can be administered and scored by most clinicians with a minimum of training in less than five minutes.
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