CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

EDITORIAL EXPLORING OPTIONS WHEN PREVIOUSLY FREE OPEN ACCESS COGNITIVE SCREENING TOOLS SUCH AS THE MMSE AND MOCA BECOME PROPRIETARY AND CHARGE FOR USE AND/OR TRAINING

The opinions expressed below represent those of the author alone who

accepts full responsibility. The opinions do not reflect the opinions of the

Canadian Geriatrics Society nor of the Canadian Geriatrics Society

Journal of CME both of whom are indemnified. The purpose of this

editorial is to stimulate informed in-depth scholarly discussion.

Conflict of Interest: The author was the original developer of the

Ottawa 3DY (O3DY) cognitive screening tool employed in emergency

departments. The O3DY is not being promoted as a Primary Care

screening tool in this editorial.

This editorial was published in September 2019.

Dr. Frank Molnar

MSc, MDCM, FRCPC

Editor-in-chief,

Canadian Geriatrics Society

CME Journal

Key words:

cognition, dementia,

screening, MoCA,

primary care

Canadian Geriatrics Journal of CME is published two to three times a year by Secretariat Central, with office located

at 20 Crown Steel Drive, Unit 6, Markham, ON. The publisher and the Canadian Geriatrics Society Scholarship

Foundation and the Canadian Geriatrics Society shall not be liable for any of the views expressed by the authors

published in Canadian Geriatrics Society Journal of CME, nor shall these opinions necessarily reflect those of CGS,

the CGS Scholarship Foundation or the publisher. Every effort has been made to ensure the information provided

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To see other CME articles, go to: www. geriatricsjournal.ca

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MOLNAR, FRANK | EXPLORING OPTIONS WHEN PREVIOUSLY FREE OPEN ACCESS COGNITIVE SCREENING TOOLS SUCH AS THE MMSE AND MOCA BECOME PROPRIETARY AND CHARGE FOR USE AND/OR TRAINING

CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

The intellectual property rights for the MMSE were transferred to Psychological Assessment Resources in 2001.

When I heard that we would be charged for use of the MMSE I switched to the MoCA as it appeared to be a

superior test for my needs as a specialist and because I was not willing to pay for use of the MMSE.

Many others made the transition from the MMSE to the MoCA. In my opinion, the MoCA was not only a better

screen for Mild Cognitive Impairment but also, due to its executive function testing, could serve as a screen

for less common dementias that present with early executive dysfunction (e.g., Lewy Body Dementia,

Parkinson’s Dementia and Frontotemporal Lobar Degeneration). As the MoCA became more popular it came

to serve as a common point of reference (a common language) for Primary Care Practitioners and specialists

alike.

During my M.Sc. thesis work, which focused on the derivation and validation of cognitive screening tools,

I became highly sensitized to methodological issues surrounding cognitive screening tool development and

validation. I learned that when a cognitive screening test is modified, the modified version must be fully

re-validated with several studies demonstrating good psychometric properties in the population and setting

in which the tool is to be used (this includes translations of the original tool, which also require full

re-validation). I began to wonder if all the English versions of the MoCA and the many translations of the

MoCA were independently and fully re-validated. I was hoping to be able to set aside time to answer this

question when our reality shifted – one of the developers of the MoCA is planning to charge for access and

training. I was now faced with a familiar question, “Do I once again shift to another free open access test and,

if so, which one?”

This has created a major dilemma. It is unlikely that all Primary Care Practitioners will pay for training, and

many may stop using the MoCA as they did the MMSE. We therefore risk losing our common point of reference

(the common language that connected Primary Care Practitioners and specialists).

Furthermore, in this era of fiscal constraint, the reality is that many programs would not be able to afford the

new costs without laying off staff (i.e. budgets are already cut to the bone). Predictably, many have asked,

“What reasonable cognitive screening tools do we have in addition to the MoCA and MMSE?” I will attempt to

cover some important methodological and practical feasibility factors required to fully answer this question.

What factors affect psychometric properties of cognitive screening tests?

Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) can vary greatly as

the following change:

1. Spectrum of Disease (type and severity of dementia in population studied).

2. Prevalence of Disease (likely lower prevalence in Primary Care than in geriatric clinics or memory

clinics and Geriatric Day Hospitals). This means psychometric properties (e.g., sensitivity, specificity,

PPV, NPV) may be significantly different in such specialty clinics relative to values in Primary Care

settings.

3. Setting (e.g., community vs. primary care vs. emergency department vs. in-hospital vs. long-

term care).

4. Cut-off (cut-point) adopted – for tests where 0 indicates severe impairment and higher scores reflect

better cognition (e.g., MMSE and MoCA) as one raises the cut-off, the sensitivity increases (more

people with disease fall below the cut-off and are detected) and the specificity decreases (more people

free of disease fall below the cut-off and are falsely labelled as impaired). There is a predictable trade-

off of sensitivity vs. specificity; as one rises the other tends to drop.

5. Whether one applies the screen to all comers (the traditional definition of screening) or only to higher

risk individuals (e.g., only screen those with advanced age [>75 and >85 years old cut-offs have been

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CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

cited], vascular risk factors, late onset depression, family history, subjective memory complaints as

recommended by some Primary Care guidelines).

6. What one is screening for; dementia, MCI or cognitive impairment in general (due to dementia, MCI,

delirium and/or depression).

The bottom line is that sensitivity, specificity, PPV and NPV can vary widely from study to study (making

studies hard if not impossible to compare) and from clinical setting to clinical setting (making prediction of test

accuracy in one’s own clinical setting challenging as it may be very different from study psychometrics).

Sensitivity, specificity, PPV and NPV are not as stable or fixed as we like to believe but rather can be

very fluid.

For a more detailed review of methodological considerations I would suggest the Lorentz et al. article1 at

ww1.cpa-apc.org/Publications/Archives/CJP/2002/october/borson.pdf.

What are we screening for; dementia, MCI or cognitive impairment due to any cause?

It is reasonable to consider the focus of screening to be dementia in the Primary Care setting where patients

are relatively medically stable. In more acute settings such as emergency departments and acute care

hospitals where patients are often medically unstable, and where delirium is therefore more prevalent as a

confounder, it would be more reasonable to screen for cognitive impairment (which could be due to delirium,

depression, MCI and/or dementia). Screening specifically for dementia in acute care settings creates

unnecessary risk of false positive labelling due to concurrent delirium and/or depression. Dementia is best

diagnosed after patients have fully recovered from their acute illness (in my practice we follow up in 3-6

months after the patient is discharged from the hospital).

The pros and cons of screening for Mild Cognitive Impairment/Mild Neurocognitive Disorder is a complex topic

that I will not touch on in this editorial but that bears more in-depth review.

What screening tests have peer reviewed published reviews recommended for the detection of

dementia in Primary Care?

In this editorial I will focus on tests validated in English to screen for dementia based on reviews published in

peer reviewed journals.

Dementia screening tools fall into 3 main categories: (1) cognitive tests administered to patients (e.g., MMSE

and MoCA), (2) questions about cognition and function asked of proxy informants, and (3) functional

assessments that use direct observation-of-test tasks.1 In this editorial I will focus on (1) cognitive tests

administered to patients. Links have been provided in the References section to allow readers to access many

of the reviews mentioned below.

Early reviews often cited are Lorentz et al. (2002)1, Brodaty et al. (2006)2 and Milne et al. (2008),3 all three of

which independently recommended the same three screening tools: the Mini-Cog, the Memory Impairment

Screen (MIS) and the General Practitioner Assessment of Cognition (GPCOG).

Ismail et al. (2010)4 suggested that the Clock Drawing Test (CDT), the Montreal Cognitive Assessment (MoCA)

and the Rowland Universal Dementia Assessment Scale (RUDAS) be considered due to improvements in

sensitivity, the finding that they address frontal/executive functioning, and the possibility that they are less

susceptible to cultural and education biases.

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Lin et al. (2013)5 in ‘Screening for Cognitive Impairment in Older Adults: A Systematic review for the U.S.

Preventive Services Task Force’ indicated that publicly available instruments with adequate test performance

to detect dementia include the Clock Drawing test (CDT), the Memory Impairment Screen (MIS), the

Abbreviated Mental Test (AMT), the Short Portable Mental Status Questionnaire (SPMSQ), the Free and Cued

Selective Reminding Test (FCSRT) and the 7-Minute Screen.

Consistent with the above authors, Yokomizo et al. (2014)6 also supported the use of the Mini-Cog, the

Memory Impairment Screen (MIS), the General Practitioner Assessment of Cognition (GPCOG), the Montreal

Cognitive Assessment (MoCA), the Abbreviated Mental test (AMT) and the Short Portable Mental Status

Questionnaire (SPMSQ). Yokomizo et al.’s addition to the list was the 6 Item Cognitive Impairment Test

(6CIT), also known as the Short Blessed Test (SBT).

Most recently Tsoi et al. (2015)7 and Abd Razak et al. (2019)8 added Addenbrooke’s Cognitive Examination

(ACE) to the above list. The ACE has subsequently been modified (ACE-R and ACE III).

These findings are presented in Table 1.

Table 1. Dementia Screening Tools (cognitive tests administered to patients) for the Primary Care setting

recommended in peer reviewed published reviews.

Recommen-

ded by

(# refers to

Reference #)

Time to

administer

(range of

minutes

cited in

reviews)

Pros cited

in reviews

(partial list)

Cons cited

in reviews

(partial list)

Most

significant

barrier

identified

Mini-Cog 1, 2, 3, 5, 6, 7 2-4 May be less biased

by culture and

language1,3,4

Appear to have less

bias by education

and literacy.4

Memory

Impairment

Screen

(MIS)

1, 2, 3, 5, 6 4 Appear to have less

bias by age.1

Appear to have less

bias by education.1,3

No direct test of

executive function or

visuospatial skills.4

General

Practice

Assessment of

Cognition

(GPCOG)

1, 2, 3, 6 4-6 Combines cognitive

and informant data

(pro if informant

available).

Combines cognitive

and informant data

(unclear if a con if

informant not

available – need

psychometrics on

cognitive component

alone.)

Education bias.2

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MOLNAR, FRANK | EXPLORING OPTIONS WHEN PREVIOUSLY FREE OPEN ACCESS COGNITIVE SCREENING TOOLS SUCH AS THE MMSE AND MOCA BECOME PROPRIETARY AND CHARGE FOR USE AND/OR TRAINING

CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

Recommen-

ded by

(# refers to

Reference #)

Time to

administer

(range of

minutes

cited in

reviews)

Pros cited in

reviews

(partial list)

Cons cited in

reviews

(partial list)

Most

significant

barrier

identified

Clock Drawing

Test

(CDT)

4, 5 1-4 Ease of use.

Covers multiple

cognitive domains.1,4

Multiple scoring

methods with lack of

a single standard for

administration and

scoring1,4 –

consequently

psychometrics vary

widely.

Previous authors

have recommended

that the CDT not be

used alone as a

dementia screening

test.1

Variable

administration

and scoring.

Likely not a

stand-alone

test.

Montreal

Cognitive

Assessment

(MoCA)

4, 6 10-15 Sensitive for MCI.

>10 minutes.

Financial cost

for training

and re-

certification

(new

information –

not drawn

from a

publication).

Rowland

Universal

Dementia

Assessment

Scale

(RUDAS)

4 10-15 Decrease

susceptibility to

education and

cultural bias4 (i.e.

may be a good

supplement to other

tests when low

education, literacy

or language are felt

to adversely

influence other

tests)

Long time to

administer.

>10 minutes.

May be more

suited to

specialty

services to

assess low

literacy

patients.

Abbreviated

Mental Test

(AMT)

5, 6 3-10 Financial cost.3

Does not effectively

test frontal/executive

function.4

Financial cost.

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MOLNAR, FRANK | EXPLORING OPTIONS WHEN PREVIOUSLY FREE OPEN ACCESS COGNITIVE SCREENING TOOLS SUCH AS THE MMSE AND MOCA BECOME PROPRIETARY AND CHARGE FOR USE AND/OR TRAINING

CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

Recommen-

ded by

(# refers to

Reference #)

Time to

administer

(range of

minutes

cited in

reviews)

Pros cited in

reviews

(partial list)

Cons cited in

reviews

(partial list)

Most

significant

barrier

identified

Short Portable

Mental Status

Questionnaire

(SPMSQ)

5, 6 3-6 Cut-off scores must

be adjusted for

education and

literacy.1

Free and Cued

Selective

Reminding

Test

(FCSRT)

5 6-10

7-Minute

Screen

5 7-12 Requires training and

computer to score.1

>10 minutes.

Complexity of

scoring.

6 Item

Cognitive

Impairment

Test

(6CIT) a.k.a.

Short Blessed

Test (SBT)

6 4-6 Score affected by age

and education.1

Addenbrooke’s

Cognitive

Examination

(ACE)

7, 8 12-20 >10 minutes.

We began with the question many have posed, “What reasonable cognitive screening tools do we have in

addition to the MoCA and MMSE?” If we remove those tests that have significant barriers identified in the last

column of Table 1 then we are left with 6 remaining alternative tests to explore further: the Mini-Cog, the

Memory Impairment Screen (MIS), the General Practitioner Assessment of Cognition (GPCOG), the Short

Portable Mental Status Questionnaire (SPMSQ), the Free and Cued Selective Reminding Test (FCSRT) and the

6 Item Cognitive Impairment Test (6CIT). Abd Razak et al.8 suggested the Saint Louis University Mental

Status (SLUMS), Rapid Cognitive Screen (RCS) and Brief Cognitive Assessment Tool (BCAT) show promise but

did not recommend them explicitly. We are converging on a manageable number of cognitive screens as a

starting point for more in-depth reviews. As some of these tests are proprietary, I am currently uncertain

which tests I can provide links to without breaching copyright and hence I have elected not to provide links

(this discomfort is a telling yet sad commentary on the field). Readers may be able to access the tests

themselves to get a sense of ease of use and face validity. This issue of copyright and restricted access bears

further review.

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Given the above information how can we go about selecting the best cognitive screening tests for

our clinical settings?

Some of the authors of the reviews cited above have provided guidance.

Lorentz et al. indicated “Brevity, effectiveness, freedom from biases irrelevant to dementia status, and

simplicity are the key characteristics of an effective dementia screening tool.”1

Milne et al.3 built on this by defining 16 criteria grouped into 4 key domains: practicality (3 criteria), feasibility

(6 criteria), range of applicability (4 criteria) and psychometric properties (3 criteria). To review the details of

these criteria go to:

www.researchgate.net/publication/5324747_Screening_for_dementia_in_primary_care_A_review_of_the_use

_efficacy_and_quality_of_measures.3

To these criteria I would add the following practical access criteria that should be studied in greater depth:

1. Ease of access; are the screening tools open access and can they be readily downloaded into a format

that can be immediately used by frontline clinicians?

2. Are there costs associated with using the tests?

3. Are there copyright issues that create a risk that a test that is currently free will be charged for in the

future (as we have experienced with the MMSE and MoCA)?

At this point I remain undecided regarding whether I will pay for training for the MoCA vs. whether I will

switch to another test. Before paying for the MoCA I would want to verify that all recommended English

versions have been independently re-validated (i.e. multiple validation studies of each version with good

psychometric properties in the clinical setting where the tests are to be used rather than incorrectly assuming

if one version is validated then modified versions are). Given that the MoCA is a language-based cognitive

test, I would also want to verify that all translated versions are also re-validated independently in each

language. Finally, I would want to examine the MoCA and the other tests suggested above through the lens of

the criteria mentioned in this section.

What is the true long-term dilemma we are facing (to use the hackneyed cliché is there an

“elephant in the room” that we should acknowledge)?

While it is true that the new cost associated with use of the MoCA has created a short-term dilemma, this will

be sorted out in time. There is, unfortunately, a more long-term dilemma that many do not mention or even

recognize. We have all witnessed cognitive tests used incorrectly and inappropriately – tests administered,

scored and interpreted incorrectly and inconsistently; screening tests inappropriately used as the sole grounds

upon which diagnoses are made. It is not surprising therefore that there have been calls for “greater access to

training and advice on screening.”3

The attempt to standardize practice through education is to be commended. To maintain fidelity (to use tests

appropriately and consistently) significant training and education resources will be required. The reality is such

training/education resources will incur significant cost. Who will pay the cost and maintain the training

resources? Who will lead this education? Should education be led by individual companies such as those that

own the MMSE and MoCA, or should this be a task for professional societies such as the NIA, AGS, BGS and

CGS to take on (perhaps as a multi-national collaboration) via training videos and workshops (for

nonproprietary screening tools that remain free and full open access)?

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CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

Future Directions

There appear to be more than enough screening tools to study as alternatives to tests such as the MMSE and

the MoCA. Future research and exploration would seem to include:

1. Performing a more formal Rapid Review (a more in-depth, methodologically rigorous review) of

cognitive screening tools that can be used in Primary Care. This is currently underway: stay tuned for

more.

2. Determining what tests should be used in other settings:

a. Emergency departments face a different reality (high volume, less time, acute illness limiting

ability to perform physical aspects of tests such as sitting up and writing, confounding by high

rates of delirium mandating screening for more global cognitive impairment of any cause rather

than dementia, etc.) and hence have different needs for cognitive screening. To learn more

regarding cognitive screening in emergency departments go to Carpenter et al.’s study at

www.ncbi.nlm.nih.gov/pmc/articles/PMC3080244/.9

b. Hospitalized patients – realities and needs may overlap with those of emergency department

patients mentioned above.

c. Specialty clinics (Geriatric or Memory) or Geriatric Day Hospitals with different types,

prevalence and severity of dementia. Different spectrum of disease with greater prevalence can

dramatically alter the psychometrics of the screening tools used in comparison to Primary Care.

Consequently, the psychometrics of screening tools cannot be extrapolated from Primary Care

studies to these specialty settings but must be derived in these clinic populations directly. Given

the great variability in spectrum of disease in specialty services, validation of screening tools

across such settings may prove challenging if not impossible. Validation often refers to

validation of cut-offs. If screens cannot be validated in these highly variable settings, then

perhaps the best advice I can suggest is to employ tools in a disaggregate fashion – do not

worry about the scores or cut-offs but rather look at the specific errors and ask if these are

meaningful, and which domains are impaired (“the devil is in the details” approach).

3. Studying creative non-traditional approaches to screening such as sequential/serial testing (e.g., very

brief and sensitive tests followed by longer and more specific tests for those who fail the very brief

test), trichotomization and serial trichotomization – see Figures 1 and 2 in

www.researchgate.net/publication/26626265_The_Derivation_and_Validation_of_the_Ottawa_3D_and

_Ottawa_3DY_Three-_and_Four-Question_Screens_for_Cognitive_Impairment.10

A golden opportunity for growth – we are at a crossroads.

The bottom line is that this is an exciting time in the field of cognitive screening and dementia care where we

are challenged to reconsider our options. The changes in access to the MoCA should be viewed as a positive

catalyst as we may have become too complacent in focusing on one test. We need to decide what tests are

reasonable to use in which settings, how to maintain free open access to those tests, how we can best fund

education on the use of these tools and who should lead such education.

My hope is that the ideas and links embedded in this article will stimulate creative thinking and debate by

opening the field to everyone who is interested and by creating a common foundation of understanding.

If readers are aware of any English language cognitive screening tools for dementia that are validated in

multiple studies published in peer review journals, that are not captured by the above reviews, please send

those peer review studies (identifiers, links etc.) to cognitivescreen@gmail.com for our Rapid Review team to

follow up on. Please do not send cognitive screening tools that do not meet these criteria.

I look forward to a lively and productive discussion going forward.

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CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

Respectfully yours,

Frank Molnar M.Sc., MDCM, FRCPC

Editor-in-chief, Canadian Geriatrics Society CME Journal (www.geriatricsjournal.ca)

Immediate Past-President, Canadian Geriatrics Society (www.canadiangeriatrics.ca)

Co-chair, Regional Geriatric Programs of Ontario (www.rgps.on.ca)

Professor of Medicine, University of Ottawa

fmolnar@toh.ca

REFERENCES:

1. Lorentz WJ, Scanlan JM, Borson S. Brief Screening Tests for Dementia. Can J Psychiatry 2002;

47(8):723-733. ww1.cpa-apc.org/Publications/Archives/CJP/2002/october/borson.pdf

2. Brodaty H, Low LF, Gibson L, Burns K. What is the Best Dementia Screening Instrument for General

Practitioners to Use? Am J Geriatr Psychiatry 2006; 14(5): 391-399.

http://gpcog.com.au/uploads/ckfinder/userfiles/files/Brodaty%20et%20al%20What%20is%20the%20b

est%20dementia%20screening%20instrument.pdf

3. 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. International Psychogeriatrics 2008; 20(5); 911-926.

www.researchgate.net/publication/5324747_Screening_for_dementia_in_primary_care_A_review_of_t

he_use_efficacy_and_quality_of_measures

4. Ismail Z, Rajji TK, Shulman KI. Brief Cognitive Screening Instruments: an update. Int J Geriatr

Psychiatry 2010; 25: 111-120. https://onlinelibrary.wiley.com/doi/pdf/10.1002/gps.2306

5. Lin JS, O’Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for Cognitive Impairment in Older

Adults: A Systematic Review for the U.S. Preventive Services Task Force. Annals of Internal Medicine

2013; 159(9); 601-612. https://annals.org/aim/fullarticle/1763246/screening-cognitive-impairment-

older-adults-systematic-review-u-s-preventive

6. Yokomizo JE, Sanz Simon S, Machado de Campos Bottino C. Cognitive Screening for Dementia in

Primary Care: A Systematic Review. International Psychogeriatrics 2014; 26(11): 1783-1804.

www.researchgate.net/publication/263934479_Cognitive_screening_for_dementia_in_primary_care_A_

systematic_review

7. Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive Tests to Detect Dementia: A

Systematic review and meta-analysis. JAMA Internal Med June 8, 2015: E1-E9.

Doi.10.1001/jamainternmed.2015.2152

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2301149

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CGS JOURNAL OF CME | SPECIAL EDITION (EDITORIAL) SEPTEMBER 2019

8. Abd Razak MA, Ahmad NA, Chan YY, Mohamad Kasim N, Yusof M, Abdul Ghani MKA, Omar M. Abd Aziz

FA, Jamaluddin R. Validity of Screening Tools for Dementia and Mild Cognitive Impairment Among the

Elderly in Primary Health Care: A Systematic Review. Public Health 2019; 1619: 84-92.

www.sciencedirect.com/science/article/pii/S0033350619300010

9. Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four Sensitive screening

Tools to Detect Cognitive Dysfunction in Geriatric Emergency Department Patients: Brief Alzheimer’s

Screen, Short Blessed Test, Ottawa 3DY and the Caregiver-completed AD8. Acad Emerg Med 2011;

18(4). wwwaemj.org doi: 10.1111/j.1553-2712.2011.01040.x

www.ncbi.nlm.nih.gov/pmc/articles/PMC3080244/

10. Molnar FJ, Wells GA, McDowell I. The Derivations and Validation of the Ottawa 3D and Ottawa 3DY

Three- and Four-Question Screens for Cognitive Impairment. Clinical Medicine: Geriatrics 2008: 2; 1-

11.www.researchgate.net/publication/26626265_The_Derivation_and_Validation_of_the_Ottawa_3D_a

nd_Ottawa_3DY_Three-_and_Four-Question_Screens_for_Cognitive_Impairment

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