Bedside cognitive assessment:
instruments & applicability
(In house Skill Development Program, 30 Nov to 5 Dec, 2015)
Dr Rakesh Kumar Tripathi, M Phil, PhD
Assistant Professor & Clinical Psychologist
Department of Geriatric Mental Health
King George’s Medical University
Lucknow -226003 (India)
Bedside cognitive assessment:
instruments & applicability
Learning Objectives:
 Cognitive assessment
 Areas of cognitive assessment for elderly
 Practical exposure to assess Cognitive functions
 Basic skills for assessment
 Cognitive screening tools from India
2
Cognitive Assessment of Older Adults
Purpose of Bedside Assessment:
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To screen the pt for probable
diagnosis
To know differential diagnoses
For referral
Management/Rehabilitation
Improvement
Prognosis
3
Cognitive Assessment of Older Adults
Areas of assessment
 Cognition:
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Orientation,
Attention & Concentration,
Calculation,
Memory,
Language,
Visuospatial function,
Praxis,
Executive function & social behaviour
4
Folstein et al. 1975
Scoring:
0- 4: Severe,
5-14: Mod.
Normals can be expected to score > 2515-19: Mild
Dementia;
20-24: MCI,
However, even with > 25, if 0/3 or 1/3 25-28
for recent
Age
memory or problems with naming, repeating,
related Cog
Impairment,
writing or reading suggest focal deficits.
29-30:Normal
It is most sensitive to disturbances which
broadly effect function, it may miss subtle,
focal problems.
5
International Psychogeriatrics (2009),
21:1, 123–128 C 2008 International
Psychogeriatric Association
Applicability of the Mini-mental
State Examination (MMSE) and the
Hindi Mental State Examination
(HMSE) to the urban elderly in
India: a pilot study
...................................................................
....................................
S. C. Tiwari, Rakesh Kumar Tripathi
and Aditya Kumar
Department of Geriatric Mental Health, C.S.M.
Medical University (Uttar Pradesh), Lucknow,
India
Results:
Either HMSE is screening
more false negatives within the
urban literate population or MMSE is
screening more false positives within
the illiterate population.
6
Indian Journal of Geriatric Mental Health, 7(2), 83-96, 2011.
Hindi Cognitive Screening Test (HCST) (Tiwari and Tripathi, 2011)
No.
1.
2.
IAGMH/Intas Award 2011 at 3rd place.
ON HCST (items may change according to Literacy language and culture)
Areas (Score)
Total score: 30
Orientation to Time (5)
Items
Orientation to Place (5)
Either ‘which Place is this’, or ‘whose house is this’ depending on whether
the testing was conducted in a home or healthcare centre or other location in
the village/muhalla/town
Development of an Education and Culture
Fair Hindi Cognitive Screening Test (HCST)
for the Elderly Population of India
Year (of any calendar), weather, month, date, day
Police Station or Tehsil or Post office
3.
4.
5.
6.
7.
8.
Registration (3)
Attention and
Calculation (5)
District
State
Country
Mango (or any local fruit), Chair, Rupee
Items exchangeable to the literacy level:
 For illiterate: days backward
Serial subtractions:
 Up to 5th : 3 starting at 20.
 Up to 10th: 4 starting at 40 .
More than 10th : 7 starting at 100
Mango, Chair, Rupee
S. C. Tiwari and Rakesh Kumar Tripathi (2011)
Department of Geriatric Mental Health
Recall (3)
C. S. M. Medical
University, U P, Lucknow, India
Naming (2)
Pen, wristwatch/ Mobile phone
Repetition (1)
3 stage Follow
command (3)
‘Neither this nor that’
Give the individual a plain piece of paper and say, “Take the paper in your
hand, fold it in half, and put it on the floor.”
 Item exchangeable to the literacy level according to MMSE and HMSE
‘Close your eyes’ for Literate; and Examiner says ‘Look at me and do
exactly what I do’ and then closes his own eyes for three seconds for
illiterate.
Items exchangeable to the literacy level according to MMSE and HMSE.
Writing a sentence for literate and ‘Tell me something about your house’ for
illiterate
Items exchangeable to the literacy level according to MMSE and HMSE
Sensitivity: 0.93
Read & Follow
Command (1)
Specificity: 0.96
9.
Sentence (1)
10.
Copying (1)
Reliability (r): -0.87
with Brief Cognitive Rating Scale (Reisberg &
Ferris, 1988)
Up to 5th : Diamond
Total Score: 30
More than 5th: Two Pentagons
Cut off Score: At or below 23: Screen positive (Cognitive Impairment)
Score: 24 and above: No cognitive impairment
7
Page 1
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Page 1
Hindi Cognitive Screening Test ¼
HCST½(Tiwari & Tripathi 2011)
Department of Geriatric Mental Health, King George’s Medical University UP, Lucknow, India- 226003
Email : [email protected]; [email protected]
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17-3=14
14-3=11
11-3=8
8-3=5
40-4=36
36-4=32
32-4=28
28-4=24
24-4=20
100-7=93
93-7=86
86-7=79
79-7=72
72-7=65
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Score:
Cognitive Status:
8
Total Score=30. Cut off score: At or below 23: Cognitive Impairment; score 24 and above: No Cognitive Impairment
===============================================================================
Attention & Concentration

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Spelling of a 5 word backwards e.g. ‘World’ or ‘Right’
100-Serial 7’s or 20-3’s
Vigilance test: "I am going to say a long series of letters.
Whenever you hear the letter A, indicate by tapping the
desk.“ Speak a random series of letters at a normal rate with
A occurring regularly and sometimes repeating as in the
following example:
 “K T B A O S A W I E A A G H C A T A A A E ...”
Digit span
Localisation:
Normal attention and concentration
requires optimal interaction between
the reticular formation, thalamus and
neocortex
9
Memory
-not a Unitary Process
Sensory Memory
Short term memory
Long term memory
Recent memory
Remote memory
Working memory
Episodic memory
Semantic memory
10
Working Memory

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Ability to temporarily maintain and manipulate information
that one needs to keep on-line
Divided into components that process phonologic
information (e.g. phone number in head) and components
process visual (mentally following a route) with central
executive
Poor working memory leads to faulty encoding
Overlap with attention
Bedside task- digit span test
11
Semantic Memory
Localisation
12
13
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Localisation
 In more than 98% of right handers the peri-sylvian language areas of the
left hemisphere are responsible for language processing.
 This includes Wernicke’s area, the arcuate fasciculus,Broca’s area and
other associated cortical areas.
 The right hemisphere is involved in other aspects of language such as
humour, metaphor and determining the emotional state of the speaker.
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16
17
Executive Function
A complex set of cognitive abilities that are involved in
planning and multitasking
Localisation


The frontal cortices are involved in
executive functioning and it connects
closely with subcortical structures.
These
connections
form
loops
projecting from the frontal cortex to
the
striatum,
globus
pallidus,
thalamus and back to the frontal
cortex.
Lesioning in any part of this circuit will
result
in
deficits
that
are
indistinguishable from a frontal
cortical injury. The anterior cingulate
has many connections with the frontal
lobes and are also involved in
executive functioning.
Frontal cortices
Subcortical structures
Frontal cortex
Striatum
Globus pallidus
Thalamus
Anterior cingulate
18
Frontal lobe test
19
Frontal lobe
test contd.
20
Friends! Please follow the instructions and do
mistakes to learn scoring



Draw a clock face (large circle)
mark the hours (numbers in the circle)
draw a time 10 past 11
21
Bedside Cognitive Assessment of Older Adults
Clock drawing Test
Score≥ 3: Cognitive deficit
Score
Error(s)
1
No error
2
Minor visuospatial error
3
Inaccurate
representation of “10
past 11”
4
Moderate visuospatial
disorganization of
times
5
Several disorganization
6
No reasonable
representation of a
clock
22
Bedside Cognitive Assessment of Older Adults
23
Basic communication Skill for Assessment
»
»
»
»
»
»
»
»
»
»
»
»
Calm, reassuring tone of voice
Explain what you are going to do prior to moving into the
patient’s personal space to implement care/assessment
Use a non-threating posture
Do not approach the patient from behind
Touch and care should be in a respectful, careful and
unhurried manner
Use short words and simple sentences
Ask one question at a time
Don’t ask ‘why’
Give adequate time for response
Repeat questions and instructions if necessary
Speak slowly and clearly
Use of aids (hearing, vision, physical) by the patient
Sing I & Tripathi SM (2013). Management of BPSD. In Tiwari SC & Pandey NM (eds.) Geriatric Mental
Health at a Glance ,pp 81-95. Ahuja Publishing House , New Delhi , India.
Psychological Assessment of Older Adults
Screening

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Mini Mental State Examination (MMSE) (Folstein et al. 1975)
Hindi Mental State Examination (HMSE) (Ganguli et al. 1995)
Hindi Cognitive Screening Test (Tiwari and Tripathi, 2011)
St. Louis University Mental State (SLUMS) Exm. (JE Morley, 2000)
Clock Drawing Test (CDT) (Shulman et al. 1993)
Bender Gestalt Test (BGT) (Lauretta Bender, 1938)
Hachinski Ischemic Scale (1975)
7 Minute Neurocognitive Screening Battery (Solomon et al. 1998)
Short Portable Mental State Questionnaire (E. Pfieffer, 1975)
Community Screening Instrument for Dementia (Hall et al. 1993)
Brief Cognitive Rating Scale (BCRS) (Reisberg and Ferris, 1998)
Functional Assessment Staging (FAST) (Reisberg, 1988)
Global Deterioration Scale (GDS) (Reisberg, 1988)
Cognistat (Northern California Neurobehavioural Group, 1995 )
Indian adaptation of Cognistat (Gupta and Kumar, 2009)
Addenbrooke’s Cognitive Examination (2005 to 2012)
Montreal Cognitive Assessment (Nasreddine, 1996)
25
Bedside Cognitive Assessment of Older Adults
St. Louis University Mental State Examination (SLUMS
Exam.) Morley JE, 2000
• It is a simple 11 items tool
High School
Education
Clinical
Condition
Less Than
High School
Education
27-30
Normal
25-30
21-26
MNCD*
20-24
1-20
Dementia
1-19
* Mild Neurocognitive Disorder
•Takes about 5-10 minutes in
administration
• SLUMS is more sensitive in detecting
MCI and dementia than Mini Mental
State Examination
26
Bedside Cognitive Assessment of Older Adults
Hachinski Ischemic Scale (1975)
Features
Score
1. Abrupt
2
2. Stepwise deterioration
Features
Score
1
9. History or presence of
hypertension
1
3. Fluctuating course
2
10. History of strokes
2
4. Nocturnal confusion
1
1
5. Relative preservation of
personality
1
11. Evidence of associated
atherosclerosis
2
6. Depression
1
12. Focal neurologic
symptoms
7. Somatic Complaints
1
13. Focal neurologic sign
2
8. Emotional incontinence
1
Total Score
18
Scoring
0-4: Alzheimer's Dementia;
5-6: diagnosis unclear;
7 or more : Vascular Dementia
Montreal Cognitive Assessment
(Nasreddine, 1996)
10-15 minutes
•Score / 30
•Better sensitivity than MMSE for
MCI
•Needs more clarity about cutoff
scores?
•Mean score of normal population
26-27
•Cutoff at 26 gives high sensitivity
but low specificity
•Suggested guide is <22 for MCI,
AD < 17
28
Cognitive screening tools from India
29
Cognitive screening tools from India (contd.)
Adaptation
Tiwari & Tripathi,
Community
2011
based
KGMU,Lucknow
, UP
Like MMSE
300
60
&+
Bias
Free
Hindi
In
Progress
Yes
30
31
King George’s Medical University,
Lucknow, U.P., INDIA
Contact: R K Tripathi [email protected]
91+9454202905
32
33
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