A 67-year-old retired college professor comes to the office for evaluation of memory loss. The patient has had intermittent episodes of misplacing objects and forgetting appointments. He also reports difficulty concentrating. The patient performs most activities of daily living independently. He has a history of well-controlled hypertension. Family history is significant for dementia in his mother. Vital signs are within normal limits. Mini-Mental State Examination is administered to screen for cognitive impairment. Which of the following factors may limit validity of the screening tool in this patient?

Question

A 67-year-old retired college professor comes to the office for evaluation of memory loss.  The patient has had intermittent episodes of misplacing objects and forgetting appointments.  He also reports difficulty concentrating.  The patient performs most activities of daily living independently.  He has a history of well-controlled hypertension.  Family history is significant for dementia in his mother.  Vital signs are within normal limits.  Mini-Mental State Examination is administered to screen for cognitive impairment.  Which of the following factors may limit validity of the screening tool in this patient?

Quizplus · Accepted Answer

Patients who report memory loss should undergo a thorough mental status examination, which commonly includes a cognitive screening tool such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment. The MMSE is a 30-point scale that assesses orientation, memory, concentration, language, and visuospatial function. A cutoff score of ≤23 is most commonly used as an indicator of cognitive impairment. However, educational level should be taken into account when evaluating a patient's performance. An individual with high educational attainment, such as this college professor, may score in the unimpaired range despite experiencing clinically significant cognitive decline compared to his baseline, thereby limiting the validity of the test. When the history is inconsistent with the results of a screening test, more detailed or formal neuropsychological testing is indicated. (Choice A) Impaired attention may be present in mild cognitive impairment/mild dementia. It can be detected by the MMSE, which includes a test of attention/concentration. (Choice B) Family history is a risk factor for dementia, but it would not impact the validity of the MMSE screening tool. (Choice D) Cutoffs for cognitive screening tools are typically established using cohorts age 65-80. The patient's educational level, not his age, risks limiting the validity of the MMSE results. (Choice E) The ability to perform activities of daily living is one factor that can help differentiate normal age-related cognitive changes from mild cognitive impairment/dementia, but it does not limit the validity of the MMSE. Educational objective: Interpretation of cognitive screening tests should take educational level into account. Individuals with high educational levels may score in the unimpaired range despite experiencing clinically significant cognitive decline. References: Sensitivity of neuropsychological tests to identify cognitive decline in highly educated elderly individuals: 12 months follow up. (http://www.ncbi.nlm.nih.gov/pubmed/26484925) Diagnostic accuracy of the MMSE in detecting probable and possible Alzheimer's disease in ethnically diverse highly educated individuals: an analysis of the NACC database. (http://www.ncbi.nlm.nih.gov/pubmed/22396476)

A 67-Year-Old Retired College Professor Comes to the Office for Evaluation