Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis | Dementia and Cognitive Impairment | JAMA Internal Medicine | JAMA Network
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    2 Comments for this article
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    Query regarding the interpretation of best alternative screening tests
    Adam Bentvelzen (B Psych), Dr Katrin Seeher (PhD), and Professor Henry Brodaty (MBBS, MD, DSc) | Dementia Collaborative Research Centre, University of New South Wales, Sydney, Australia (Bentvelzen, Seeher, Brodaty)
    Dear Drs Tsoi, Chan, Hirai, Wong, and Kwok,

    A recently published meta-analysis of the effectiveness of different cognitive screens in detecting dementia stated that the Mini-Cog and the ACE-R are the best alternative screening tests to the MMSE due to their high pooled sensitivity and specificity compared to other alternative screens [4]. However the data are at odds with this conclusion.
    The Mini-Cog is reported to have pooled sensitivity and specificity values of 0.91 (0.80-0.96) and 0.86 (0.74-0.93), respectively. However, the reported values for the GPCOG are numerically higher with respective values of 0.92 (0.81-0.97) and 0.87 (0.83-0.90). In addition,
    while the confidence intervals are equally wide between the tests for sensitivity, for specificity they are narrower for the GPCOG than the Mini-Cog.
    In contrast to these reported measures, in the Methods the authors state that a diagnostic odds ratio (DOR) was used as a single indicator of test performance, to account for the trade-off between sensitivity and specificity in the context of different thresholds used across studies [5]. While we agree with this approach, this measure was not reported in the Abstract, Results or online Supplementary Material, so it is unclear to the reader how or if the DOR was actually used to support their conclusions independently of pooled sensitivity and specificity. Taking reported pooled sensitivity (Se) and specificity (Sp) alone [5], where DOR = (Se x Sp)/((1 – Se) x (1 – Sp)) the GPCOG (76.96) performs better than the Mini-Cog (62.11). Furthermore, the reported prevalence of dementia in the Mini-Cog studies (1182/4178; 28.3%) was slightly higher than that of the GPCOG (292/1082; 27.0%). Since a higher level of dementia prevalence positively biases the chances of detecting dementia, accounting for prevalence may have further increased the sensitivity and specificity of the GPCOG relative to the Mini-Cog.
    Unless the authors can demonstrate how their conclusions are supported by their data, we believe that the conclusion should have been revised to reflect that the Mini-Cog and GPCOG have at least equivalent diagnostic efficiency for detecting dementia.

    REFERENCES
    1. Lorentz WJ, Scanlan JM, Borson S. Brief screening tests for dementia. Can J Psychiatry. 2002;47(8):723-33.
    2. Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr. 2008;20(5):911-26.
    3. Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry. 2007;78(8):790.
    4. Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Int Med. 2015;175(9):1450-8.
    5. Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol. 2003;5600:1129-1135.
    CONFLICT OF INTEREST: Henry Brodaty is one of the authors of The General Practitioner Assessment of Cognition (Brodaty H, Pond D, Kemp NM, Luscombe G, Harding L, Berman K, et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc. 2002;50(3):530-4), which is mentioned in the article and in this comment.
    READ MORE
    Query regarding the interpretation of best alternative screening tests [corrected]
    Adam Bentvelzen, Katrin Seeher, and Henry Brodaty | Dementia Collaborative Research Centre, University of New South Wales, Sydney, Australia
    Dear Drs Tsoi, Chan, Hirai, Wong, and Kwok,

    Several recent reviews [1-3] of the relative utility of cognitive screening instruments have come to different conclusions. While two sets of reviews recommended the very brief Mini-Cog, GPCOG and MIS for use in general practice [1,2], another review recommended more comprehensive screens (3MS, CASI, SASSI, and ACE-R) [3]. A recently published meta-analysis of the effectiveness of different cognitive screens in detecting dementia stated that the Mini-Cog and the ACE-R are the best alternative screening tests to the MMSE due to their high pooled sensitivity and specificity compared to other alternative screens
    [4]. However the data are at odds with this conclusion.

    The Mini-Cog is reported to have pooled sensitivity and specificity values of 0.91 (0.80-0.96) and 0.86 (0.74-0.93), respectively. However, the reported values for the GPCOG are numerically higher with respective values of 0.92 (0.81-0.97) and 0.87 (0.83-0.90). In addition, while the confidence intervals are equally wide between the tests for sensitivity, for specificity they are narrower for the GPCOG than the Mini-Cog.

    In contrast to these reported measures, in the Methods the authors state that a diagnostic odds ratio (DOR) was used as a single indicator of test performance, to account for the trade-off between sensitivity and specificity in the context of different thresholds used across studies [5]. While we agree with this approach, this measure was not reported in the Abstract, Results or online Supplementary Material, so it is unclear to the reader how or if the DOR was actually used to support their conclusions independently of pooled sensitivity and specificity. Taking reported pooled sensitivity (Se) and specificity (Sp) alone [5], where DOR = (Se x Sp)/((1 – Se) x (1 – Sp)) the GPCOG (76.96) performs better than the Mini-Cog (62.11). Furthermore, the reported prevalence of dementia in the Mini-Cog studies (1182/4178; 28.3%) was slightly higher than that of the GPCOG (292/1082; 27.0%). Since a higher level of dementia prevalence positively biases the chances of detecting dementia, accounting for prevalence may have further increased the sensitivity and specificity of the GPCOG relative to the Mini-Cog.

    Unless the authors can demonstrate how their conclusions are supported by their data, we believe that the conclusion should have been revised to reflect that the Mini-Cog and GPCOG have at least equivalent diagnostic efficiency for detecting dementia.

    REFERENCES
    1. Lorentz WJ, Scanlan JM, Borson S. Brief screening tests for dementia. Can J Psychiatry. 2002;47(8):723-33.
    2. Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr. 2008;20(5):911-26.
    3. Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry. 2007;78(8):790.
    4. Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Int Med. 2015;175(9):1450-8.
    5. Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol. 2003;5600:1129-1135.
    CONFLICT OF INTEREST: Henry Brodaty is one of the authors of The General Practitioner Assessment of Cognition (Brodaty H, Pond D, Kemp NM, Luscombe G, Harding L, Berman K, et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc. 2002;50(3):530-4), which is mentioned in the article and in this comment.
    READ MORE
    Original Investigation
    September 2015

    Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin
    • 2Stanley Ho Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong, Shatin
    • 3Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin
    JAMA Intern Med. 2015;175(9):1450-1458. doi:10.1001/jamainternmed.2015.2152
    Abstract

    Importance  Dementia is a global public health problem. The Mini-Mental State Examination (MMSE) is a proprietary instrument for detecting dementia, but many other tests are also available.

    Objective  To evaluate the diagnostic performance of all cognitive tests for the detection of dementia.

    Data Sources  Literature searches were performed on the list of dementia screening tests in MEDLINE, EMBASE, and PsychoINFO from the earliest available dates stated in the individual databases until September 1, 2014. Because Google Scholar searches literature with a combined ranking algorithm on citation counts and keywords in each article, our literature search was extended to Google Scholar with individual test names and dementia screening as a supplementary search.

    Study Selection  Studies were eligible if participants were interviewed face to face with respective screening tests, and findings were compared with criterion standard diagnostic criteria for dementia. Bivariate random-effects models were used, and the area under the summary receiver-operating characteristic curve was used to present the overall performance.

    Main Outcomes and Measures  Sensitivity, specificity, and positive and negative likelihood ratios were the main outcomes.

    Results  Eleven screening tests were identified among 149 studies with more than 49 000 participants. Most studies used the MMSE (n = 102) and included 10 263 patients with dementia. The combined sensitivity and specificity for detection of dementia were 0.81 (95% CI, 0.78-0.84) and 0.89 (95% CI, 0.87-0.91), respectively. Among the other 10 tests, the Mini-Cog test and Addenbrooke’s Cognitive Examination–Revised (ACE-R) had the best diagnostic performances, which were comparable to that of the MMSE (Mini-Cog, 0.91 sensitivity and 0.86 specificity; ACE-R, 0.92 sensitivity and 0.89 specificity). Subgroup analysis revealed that only the Montreal Cognitive Assessment had comparable performance to the MMSE on detection of mild cognitive impairment with 0.89 sensitivity and 0.75 specificity.

    Conclusions and Relevance  Besides the MMSE, there are many other tests with comparable diagnostic performance for detecting dementia. The Mini-Cog test and the ACE-R are the best alternative screening tests for dementia, and the Montreal Cognitive Assessment is the best alternative for mild cognitive impairment.

    ×