Brief cognitive battery in the diagnosis of mild Alzheimer's disease in subjects with medium and high levels of education

Nitrini, Ricardo; Caramelli, Paulo; Porto, Claudia Sellitto; Charchat-Fichman, Helenice; Formigoni, Ana Paula; Carthery-Goulart, Maria Teresa; Otero, Carla; Prandini, João Carlos

doi:10.1590/S1980-57642008DN10100006

Abstract

There has been an increasing trend to utilize short cognitive batteries for the diagnosis of dementia. Most of these batteries have been designed in countries with high standards of education and are less suitable for populations with low levels of education. We developed a battery that has been previously shown to be highly accurate in the diagnosis of dementia in individuals with low levels of education. The accuracy of this battery for patients with higher levels of education is unknown.

Objectives:

To evaluate the accuracy of a brief cognitive battery in the diagnosis of Alzheimer's disease (AD) in subjects with medium and high levels of schooling, and to develop a mathematical model that includes the most discriminative tests.

Methods:

Seventy-three mildly demented patients with probable AD and 94 control subjects were evaluated. Sixty patients and 60 controls were randomly selected to generate a mathematical model including the most discriminative tests of the battery using logistic regression. The model was back-tested for the remaining sample of patients and controls.

Results:

Delayed recall, learning and category fluency tests were included in a mathematical model that obtained an area of 0.917 in the ROC curve in the back-testing. Inter-rater reliabilities of these tests were high (kappa>0.8).

Conclusions:

This model showed a high accuracy for the diagnosis of mild AD in patients with medium and high educational levels. Future studies with more heterogeneously educated individuals are necessary to investigate whether the educational level (number of years at school) should also be included in the model.

Key words:
Alzheimers disease; dementia; diagnosis; education; brief cognitive battery; neuropsychological tests.

Resumo

Existe crescente tendência de se utilizarem baterias cognitivas breves no diagnóstico de demência. A maioria destas tem sido idealizada em países com altos níveis de escolaridade e é menos adequada para populações com baixa escolaridade. Desenvolvemos uma bateria que tem demonstrado alta acurácia no diagnóstico de demência em indivíduos com baixa escolaridade, mas a acurácia em indivíduos com escolaridade alta ainda não é conhecida.

Objetivos:

Avaliar a acurácia de uma bateria cognitiva breve no diagnóstico de doença de Alzheimer (DA) em indivíduos com escolaridade média ou alta, e desenvolver um modelo matemático que inclua os testes mais discriminativos.

Métodos:

Setenta e três pacientes com demência leve causada por DA provável e 94 controles foram avaliados com a bateria cognitiva breve. Sessenta pacientes e 60 controles foram selecionados aleatoriamente para gerar um modelo matemático com os testes mais discriminativos, empregando regressão logística. Este modelo foi retro-testado na amostra remanescente de pacientes e controles.

Resultados:

Os testes de memória tardia, aprendizado e fluência verbal foram incluídos no modelo matemático que obteve área sob a curva ROC de 0,917 no retro-teste. A confiabilidade inter-examinadores destes testes foi alta (kappa>0.8).

Conclusões:

Este modelo apresentou alta acurácia no diagnóstico de demência leve na DA em sujeitos com escolaridade média ou alta. Novos estudos com população

Palavras-chave:
doença de Alzheimer; demência; diagnóstico; educação; bateria cognitiva breve; testes neuropsicológicos.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

References

¹
Morris JC, Heyman A, Mohs RC, et al. The Consortium toestablish a registry for Alzheimer's disease (CERAD): Part I. clinical and neuropsychological assessment of Alzheimer's disease. Neurology 1989;39:1159-1165.
²
Meulen EF, Schmand B, van Campen JP, et al. The sevenminute screen: a neurocognitive screening test highly sensitive to various types of dementia. J Neurol Neurosurg Psychiatr 2004;75:700-705.
³
Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. Themini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatr 2000;15:1021-1027.
⁴
Lorentz WJ, Scanlan JM, Borson S. Brief screening tests fordementia. Can J Psychiatr 2002;47:723-733.
⁵
Nitrini R, Lefèvre BH, Mathias SC, et al. Neuropsychologicaltests of simple application for diagnosing dementia. Arq Neuropsiquiatr 1994;52:457-465.
⁶
Nitrini R, Caramelli P, Herrera E Jr, et al. Performance ofilliterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004; 10:634-638.
⁷
Takada LT, Caramelli P, Fichman HC, et al. Comparisonbetween two tests of delayed recall for the diagnosis of dementia. Arq Neuropsiquiatr 2006;64:35-40.
⁸
McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDSADRDA work group under the auspices of department of health and human services task force on Alzheimer's disease. Neurology 1984;34:939-944.
⁹
Folstein MF, Folstein SE, McHugh PR. »," ®,(r) §,§ , ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ Mini-mental State »," ®,(r) §,§ , ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ : a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
¹⁰
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.
¹¹
Mattis S. Dementia Rating Scale: professional manual. Florida: Psychol Assess Res; 1988.
¹²
Porto SC, Charchat-Fichman H, Caramelli P, Bahia VA,Nitrini R. Dementia Rating Scale - DRS - in the diagnosis of patients with Alzheimer's dementia. Arq Neuropsiquiatr 2003;61:339-345.
¹³
Weschler D. Weschler Memory Scale - revised manual. NewYork: Psychological Corporation; 1987.
¹⁴
Spreen O, Strauss E. A compendium of neuropsychologicaltests: administration, norms, and commentary. 2ª Ed. New York: Oxford Univ Press; 1998.
¹⁵
Diniz LFM, Cruz MF, Torres VM, Consenza RM. O teste deaprendizagem auditivo-verbal de Rey: normas para uma população brasileira. Rev Bras Neurol 2003;36:79-83.
¹⁶
Wechsler D. Test de inteligência para adultos (WAIS). Manual. 2nd ed. Buenos Aires: Paidos; 1993.
¹⁷
Hooper Visual Organization Test (VOT) Manual. LosAngeles: Western Psychological Services; 1983.
¹⁸
Kaplan E, Goodglass H, Weintraub S, Segal H. BostonNaming Test. Philadelphia: Lea & Febiger; 1983.
¹⁹
Mansur LL, Radanovic M, Araujo G de C, Taquemori LY,Greco LL. Boston Naming Test: performance of Brazilian population from Sao Paulo. Pro Fono 2006;18:13-20.
²⁰
Sunderland T, Hill JL, Mellow AM, et al. Clock drawing inAlzheimer's disease: a novel measure of dementia severity. J Am Geriatr Soc 1989;37: 725-729.
²¹
Buschke H, Kuslansky G, Katz M, Stewart WF, et al.Screening for dementia with the Memory Impairment Screen. Neurology 1999;52:231-238.
²²
Kilada S, Gamaldo A, Grant EA, Moghekar A, Morris JC,O'Brien RJ. Brief screening tests for the diagnosis of dementia: comparison with the mini-mental state exam. Alzheimer Dis Assoc Disord 2005;19:8-16.
²³
Welsh K, Butters N, Hughes J, Mohs R, Heyman A.Detection of abnormal memory decline in mild cases of Alzheimer's disease using CERAD neuropsychological measures. Arch Neurol 1991;48:278-281.
²⁴
Bertolucci PH, Okamoto IH, Brucki SM, Siviero MO,Toniolo Neto J, Ramos LR. Applicability of the CERAD neuropsychological battery to Brazilian elderly. Arq Neuropsiquiatr 2001;59:532-536.
²⁵
Canning SJD, Leach L, Stuss D, Ngo L, Black SE. Diagnosticutility of abbreviated fluency measures in Alzheimer disease and vascular dementia. Neurology 2004;62:556-562.
²⁶
Cummings JL. The one-minute mental status examination. Neurology 2004;62:534-535.
²⁷
Caramelli P, Carthery-Goulart MT, Porto CS, CharchatFichman H, Nitrini R. Category fluency as a screening test for Alzheimer's disease in illiterate and literate patients. Alzheimer Dis Assoc Disord (in press)
²⁸
Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281:545-551.
²⁹
Parker C, Philp I. Screening for cognitive impairmentamong older people in black and minority ethnic groups. Age Ageing 2004;33:447-452.

Publication Dates

Publication in this collection
Jan-Mar 2007

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Morris JC, Heyman A, Mohs RC, et al. The Consortium toestablish a registry for Alzheimer's disease (CERAD): Part I. clinical and neuropsychological assessment of Alzheimer's disease. Neurology 1989;39:1159-1165.

[2] ²
Meulen EF, Schmand B, van Campen JP, et al. The sevenminute screen: a neurocognitive screening test highly sensitive to various types of dementia. J Neurol Neurosurg Psychiatr 2004;75:700-705.

[3] ³
Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. Themini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatr 2000;15:1021-1027.

[4] ⁴
Lorentz WJ, Scanlan JM, Borson S. Brief screening tests fordementia. Can J Psychiatr 2002;47:723-733.

[5] ⁵
Nitrini R, Lefèvre BH, Mathias SC, et al. Neuropsychologicaltests of simple application for diagnosing dementia. Arq Neuropsiquiatr 1994;52:457-465.

[6] ⁶
Nitrini R, Caramelli P, Herrera E Jr, et al. Performance ofilliterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004; 10:634-638.

[7] ⁷
Takada LT, Caramelli P, Fichman HC, et al. Comparisonbetween two tests of delayed recall for the diagnosis of dementia. Arq Neuropsiquiatr 2006;64:35-40.

[8] ⁸
McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDSADRDA work group under the auspices of department of health and human services task force on Alzheimer's disease. Neurology 1984;34:939-944.

[9] ⁹
Folstein MF, Folstein SE, McHugh PR. »," ®,(r) §,§ , ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ Mini-mental State »," ®,(r) §,§ , ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ : a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.

[10] ¹⁰
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.

[11] ¹¹
Mattis S. Dementia Rating Scale: professional manual. Florida: Psychol Assess Res; 1988.

[12] ¹²
Porto SC, Charchat-Fichman H, Caramelli P, Bahia VA,Nitrini R. Dementia Rating Scale - DRS - in the diagnosis of patients with Alzheimer's dementia. Arq Neuropsiquiatr 2003;61:339-345.

[13] ¹³
Weschler D. Weschler Memory Scale - revised manual. NewYork: Psychological Corporation; 1987.

[14] ¹⁴
Spreen O, Strauss E. A compendium of neuropsychologicaltests: administration, norms, and commentary. 2ª Ed. New York: Oxford Univ Press; 1998.

[15] ¹⁵
Diniz LFM, Cruz MF, Torres VM, Consenza RM. O teste deaprendizagem auditivo-verbal de Rey: normas para uma população brasileira. Rev Bras Neurol 2003;36:79-83.

[16] ¹⁶
Wechsler D. Test de inteligência para adultos (WAIS). Manual. 2nd ed. Buenos Aires: Paidos; 1993.

[17] ¹⁷
Hooper Visual Organization Test (VOT) Manual. LosAngeles: Western Psychological Services; 1983.

[18] ¹⁸
Kaplan E, Goodglass H, Weintraub S, Segal H. BostonNaming Test. Philadelphia: Lea & Febiger; 1983.

[19] ¹⁹
Mansur LL, Radanovic M, Araujo G de C, Taquemori LY,Greco LL. Boston Naming Test: performance of Brazilian population from Sao Paulo. Pro Fono 2006;18:13-20.

[20] ²⁰
Sunderland T, Hill JL, Mellow AM, et al. Clock drawing inAlzheimer's disease: a novel measure of dementia severity. J Am Geriatr Soc 1989;37: 725-729.

[21] ²¹
Buschke H, Kuslansky G, Katz M, Stewart WF, et al.Screening for dementia with the Memory Impairment Screen. Neurology 1999;52:231-238.

[22] ²²
Kilada S, Gamaldo A, Grant EA, Moghekar A, Morris JC,O'Brien RJ. Brief screening tests for the diagnosis of dementia: comparison with the mini-mental state exam. Alzheimer Dis Assoc Disord 2005;19:8-16.

[23] ²³
Welsh K, Butters N, Hughes J, Mohs R, Heyman A.Detection of abnormal memory decline in mild cases of Alzheimer's disease using CERAD neuropsychological measures. Arch Neurol 1991;48:278-281.

[24] ²⁴
Bertolucci PH, Okamoto IH, Brucki SM, Siviero MO,Toniolo Neto J, Ramos LR. Applicability of the CERAD neuropsychological battery to Brazilian elderly. Arq Neuropsiquiatr 2001;59:532-536.

[25] ²⁵
Canning SJD, Leach L, Stuss D, Ngo L, Black SE. Diagnosticutility of abbreviated fluency measures in Alzheimer disease and vascular dementia. Neurology 2004;62:556-562.

[26] ²⁶
Cummings JL. The one-minute mental status examination. Neurology 2004;62:534-535.

[27] ²⁷
Caramelli P, Carthery-Goulart MT, Porto CS, CharchatFichman H, Nitrini R. Category fluency as a screening test for Alzheimer's disease in illiterate and literate patients. Alzheimer Dis Assoc Disord (in press)

[28] ²⁸
Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281:545-551.

[29] ²⁹
Parker C, Philp I. Screening for cognitive impairmentamong older people in black and minority ethnic groups. Age Ageing 2004;33:447-452.

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