Test detects signs of dementia 6 months sooner than more commonly used exam
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The Self-Administered Gerocognitive Examination identified signs of dementia in patients 6 months earlier than the Mini-Mental State Examination, according to results from a cohort study published in Alzheimer's Research & Therapy.
Approximately two-thirds of older patients have cognitive scores in dementia ranges when first assessed, which may indicate less severe cognitive symptoms may have been occurring for years, according to the study authors.
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“It is critical for providers to more easily recognize symptoms of brain dysfunction at the mild cognitive impairment or early dementia stage,” they wrote.
“Clinical providers wish to provide the best assessments and care to their patients in a timely fashion within their existing time constraints,” Douglas Scharre, MD, director of the division of cognitive neurology at The Ohio State Wexner Medical Center, told Healio. “Administered tests like the [Mini-Mental State Examination (MMSE)] and others are more burdensome in busy clinical settings than the [Self-Administered Gerocognitive Examination (SAGE)] and consequently are less likely to be administered and repeated regularly over time.”
The MMSE was described as the “most commonly used office-based standard cognitive test” in a press release.
Scharre and colleagues conducted a retrospective chart review on 655 consecutive patients who attended a memory disorders clinic. The researchers excluded patients aged younger than 50 years; those with mental retardation, epilepsy, brain tumors, schizophrenia, ADHD and non-Alzheimer’s disease dementia or mixed dementia; and those with baseline MMSE or SAGE scores deemed “not meaningful for a change over time analysis” — leaving 424 patients with available data for the final analysis. This smaller group of patients was classified as either having subjective cognitive decline, mild cognitive impairment or Alzheimer’s disease dementia.
The researchers compared the patients’ SAGE test scores to those from the MMSE, which is administered by health care professionals. The SAGE test gauges the test taker’s orientation, language, calculations, memory, abstraction, executive and constructional abilities. It takes approximately 10 to 15 minutes for patients to complete. The MMSE does not gauge abstractions or executive abilities It takes about 7 to 10 minutes to administer. A lower score on either test indicates increased likelihood of cognitive decline.
The patients were followed for up to 8.8 years, the researchers said.
Scharre and colleagues reported that SAGE and MMSE scores declined at annual rates of 1.91 points annually (P < .0001) and 1.68 points annually (P < .0001) respectively, for patients with mild cognitive decline that converted to Alzheimer’s disease dementia over the course of the study. SAGE and MMSE scores dropped 1.82 points annually (P < .0001) and 2.38 points annually (P < .0001), respectively, for patients who had Alzheimer’s disease dementia. Both test scores remained stable for patients who did not progress to Alzheimer’s disease dementia. Statistically significant declines from baseline scores occurred at least 6 months earlier with SAGE vs. MMSE for patients with mild cognitive decline that converted to Alzheimer’s disease dementia (14.4 points vs. 20.4 points), patients with mild cognitive impairment that did not convert to non-Alzheimer’s disease dementia (14.4 points vs. 32.9 points) and patients with Alzheimer’s disease dementia (8.3 points vs. 14.4 points).
“If the clinical provider who is regularly obtaining SAGE assessments records a two- to three-point drop or more in 12 to 18 months, this represents a significant decline in their patient’s score and is predictive (over 80% specificity) that the individual will eventually develop dementia,” Scharre said. “This provides some time for intervention. Effective screening using a tool like SAGE leads to early identification of mild cognitive impairment, which allows the provider to consider more potential treatment options for the patient and to be able to treat earlier in the disease course, all of which typically provides improved patient outcomes.”
He recommended that primary care physicians administer SAGE when they or a caregiver notice that patients are “declining in their cognitive abilities from their usual baseline skills,” such as forgetting things more frequently, experiencing greater difficulty finding a word, “losing their sense of direction more easily, having more trouble using technology, or not making as wise decisions or judgments as they are accustomed to making.” Scharre also said that SAGE, which is available online or in paper form, should be administered every 6 months to monitor for changes in scores or when cognitive issues arise.
References
Scharre DW, et al. Alzheimer's Res Therp. 2021;doi:10.1186/s13195-021-00930-4.
Self-administered cognition test predicts early signs of dementia sooner. https://news.osu.edu/self-administered-cognition-test-predicts-early-signs-of-dementia-sooner/. Published Dec. 7, 2021. Accessed Dec. 7, 2021.
Perspective
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Heather Snyder, PhD
This is an interesting study looking at a self-administered cognitive test and its ability to identify individuals who will go on to develop dementia. While it is good to see this research was done longitudinally over 8 years, the study population was relatively small for what we’d need to see with this sort of evaluation. It is important to study this test in much larger, more diverse populations to better understand how it works in a real-world setting.
If clinicians are asked about the test studied by Scharre and colleagues by their patients, or about self-testing in general, they should explain that testing for Alzheimer's should be done in a medical office to ensure that the process of assessment and diagnosis is done accurately through a qualified health care professional. Clinicians can also play a role in educating their patients about how an Alzheimer's diagnosis is currently made, including neurological exams, mental cognitive status testing and, if appropriate, brain imaging.
The Alzheimer's Association strongly supports efforts for early detection, although at this time we encourage evaluation to take place in a medical setting with appropriately validated testing tools. Medical professionals can either detect cognitive impairment or establish a baseline measurement of memory and thinking abilities and track change over time (eg, as part of a patient’s Medicare Annual Wellness Visit).
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Back to TopPierre N. Tariot, MD
The main point of this retrospective study by Scharre and colleagues is that a self-administered cognitive assessment appears to perform as well as or better than a rater-performed cognitive assessment, when both are administered serially over time, in detecting progression from mild cognitive impairment to overt dementia. The main thrust of the paper otherwise is the case made for the advantages of using a self-administered assessment.
As Scharre and colleagues’ paper states, “The cognitive domains tested with the 11-item SAGE include orientation, language, calculations, memory, abstraction, executive, and constructional abilities. The MMSE does not test abstractions nor executive abilities. On average it takes about 7 to 10 minutes to administer the MMSE and about 10 to 15 minutes for patients to take the SAGE on their own. The SAGE has four interchangeable forms designed to reduce learning effects from multiple administrations.” I would suggest that one part of the MMSE requires at least some executive abilities.
A limitation of SAGE is that the single objective measure of memory is built into the form as a written answer at the beginning of the test with recall of that at the end of the test, and a correct answer is obtainable just by looking back at what was written earlier. This relative liability is not addressed in the paper but may have been addressed elsewhere.
The MMSE has more than one memory-related question, and the type of solution that the Self-administered Gerocognitive Examination offers is not possible since there is no way to look back at earlier responses. While patients can access the SAGE online or have it administered in an office; the MMSE is only available via a tester. The MMSE is also more widely used, scores are generally well-understood, and it has less of a floor effect. For research clinics, it has a relative advantage of being more useful for research referral (since many studies have MMSE criteria). The MMSE also has the disadvantages of requiring a tester and, if one believes this is enforceable, a user fee.
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Sharon A. Brangman, MD
Although PCPs are well-positioned to notice signs of cognitive decline among older patients, they face the challenge of having enough time or having enough resources to conduct the very time-consuming process of cognitive screening.
Therefore, Scharre and colleagues’ paper is very interesting in that it appears to show SAGE as a viable, effective screening tool when placed in the hands of the right health care professionals who hopefully then turn it over to patients who can benefit most from its use. It also appears SAGE is better than the MMSE at picking up early changes in cognition. Every little bit of extra time in patients with cognitive decline is helpful, in that perhaps we can steer them towards successful treatments or maybe even enroll them in a trial exploring the potential of a possible treatment.
I would hope there are plans to turn the tool over the patients who would benefit most from its use, such as African Americans and Latinos, who have higher rates of Alzheimer’s disease than other populations. I would also hope the tool is made available to patients in rural areas, since there are so many people in these locations who are not normally reached.
Director, Center for Excellence for Alzheimer’s Disease
Upstate Medical University, New York
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