vamc/st louis university slums john e morley geriatrics saint louis university grecc st louis vamc

VAMC/ST LOUIS UNIVERSITYSLUMS

John E MorleyGeriatrics

Saint Louis UniversityGRECC

St Louis VAMC

“Memory is a passionno less powerful or pervasive

than love.”

Elie Wiesel “All Rivers Run to the Sea”

“Memory is a passionno less powerful or pervasive

than love.”

Elie Wiesel “All Rivers Run to the Sea”

Dementia PrevalenceDementia Prevalence

8% over 65 years + 8% MCI

47% at 85 years

8% over 65 years + 8% MCI

47% at 85 years

The Economics of DementiaThe Economics of Dementia

Total Costs = $100 BILLION annually

Individual excess lifetime costs = $170,000

Patients in nursing homes with Alzheimer’s disease are more expensive to look after than those not afflicted .

Total Costs = $100 BILLION annually

Individual excess lifetime costs = $170,000

Patients in nursing homes with Alzheimer’s disease are more expensive to look after than those not afflicted .

Mild Cognitive Impairment Complaints and objective evidence of

memory problems

No defects in ADLs

Abnormal memory for age

Not demented

Not depressed

Mild Cognitive Impairment Complaints and objective evidence of

memory problems

No defects in ADLs

Abnormal memory for age

Not demented

Not depressed

(Winblad et al; J Int Med. 2004)(Winblad et al; J Int Med. 2004)

Mild Cognitive Impairment

OUTCOMES


OUTCOMES

o Poor functional recovery from major event

o 30% dead within 5 years

o 30% develop Alzheimer’s disease within 5 years

o Poor functional recovery from major event

o 30% dead within 5 years

o 30% develop Alzheimer’s disease within 5 years


is NOT BENIGN


is NOT BENIGN

Mild Cognitive ImpairmentWHO PROGRESSES?

Mild Cognitive ImpairmentWHO PROGRESSES?

• Small hippocampal volumes

• Decreased blood flow to posterior cingulate gyrus

• Increased CSF tau protein and decreased beta- amyloid (1-42)

• Small hippocampal volumes

• Decreased blood flow to posterior cingulate gyrus

• Increased CSF tau protein and decreased beta- amyloid (1-42)

Families and physicians fail to recognize dementia.

50% of persons with mild to moderate dementia have not been diagnosed

Mini-Mental Status ExaminationFolstein et al. 1975

1. Educationally dependent

2. Both false positives and false negatives

3. Minimal testing of visuospatial system

Mini-Mental Status ExaminationFolstein et al. 1975

1. Educationally dependent

2. Both false positives and false negatives

3. Minimal testing of visuospatial system

How clouds are transformed into fried How clouds are transformed into fried eggseggs

Maurer K, Froehlich L. How clouds are transformed into fried eggs. Alzheimer Insights, 2000, 6: 4-7

Carolus Horn

William Untermohlen - self-William Untermohlen - self-portraitsportraits

22 22

22 21

13 17

Crutch SJ, Isaacs R, Rossor MN. Some workmen can blame their tool: artistic changes in an individual with Alzheimer disease. Lancet, 2001, 357:2129

METHODSMETHODS

705 veterans705 veterans

Age 60 or olderAge 60 or older

DSM IV for mild neurocognitive disorderDSM IV for mild neurocognitive disorder

or dementiaor dementia

MMSE and SLUMS MMSE and SLUMS

Descriptive Data by Education and Descriptive Data by Education and Cognitive Status (DSM-IV)Cognitive Status (DSM-IV)Less Than High SchoolLess Than High School High School or MoreHigh School or More

Normal Normal (n=137)(n=137)

MNCD MNCD (n=50)(n=50)

DementiDementia (n=27)a (n=27)

Normal Normal (n=303)(n=303)

MNCD MNCD (n=130)(n=130)

DementiDementia (n=55)a (n=55)

Age, Age, mean mean (SD)(SD)

74.6 74.6 (5.2)(5.2)

77.8 77.8 (6.0)(6.0)

79.1 79.1 (6.7)(6.7)

74.2 74.2 (5.0)(5.0)

75.6 75.6 (5.6)(5.6)

77.8 77.8 (5.1)(5.1)

SLUMS, SLUMS, mean mean (SD)(SD)

25.7 25.7 (2.8)(2.8)

20.2 20.2 (2.4)(2.4)

11.3 11.3 (5.1)(5.1)

26.9 26.9 (2.0)(2.0)

22.3 22.3 (2.1)(2.1)

14.9 14.9 (5.2)(5.2)

MMSE, MMSE, mean mean (SD)(SD)

28.6 28.6 (1.7)(1.7)

27.3 27.3 (2.4)(2.4)

21.0 21.0 (7.4)(7.4)

29.0 29.0 (1.3)(1.3)

28.2 28.2 (1.7)(1.7)

23.0 23.0 (5.0)(5.0)

SLUMSSLUMStooktook

7 minutes 7 minutes toto

completecomplete

Cut-Off Score for Mild Neurocognitive Impairment Cut-Off Score for Mild Neurocognitive Impairment (MNCD) in Patients with Less Than High School (MNCD) in Patients with Less Than High School

EducationEducationCut-OffCut-Off

Test/Test/CategoryCategory

Score (Score (≤)≤) SensitivitSensitivityy

SpecificitSpecificityy

PPV*PPV* NPV*NPV*

SLUMS/MNCDSLUMS/MNCD 19.519.5 .040.040 0.980.98 0.910.91 0.820.82

20.520.5 0.560.56 0.960.96 0.820.82 0.860.86

21.521.5 0.700.70 0.910.91 0.740.74 0.890.89

22.522.5 0.780.78 0.860.86 0.670.67 0.910.91

23.523.5 0.920.92 0.810.81 0.640.64 0.970.97

24.524.5 0.960.96 0.740.74 0.570.57 0.980.98

25.525.5 1.001.00 0.550.55 0.450.45 1.001.00

26.526.5 1.001.00 0.400.40 0.380.38 1.001.00

27.527.5 1.001.00 0.290.29 0.340.34 1.001.00

MMSE/MNCDMMSE/MNCD 21.021.0 0.020.02 1.001.00 1.01.0 0.740.74

22.522.5 0.040.04 1.001.00 1.01.0 0.740.74

23.523.5 0.040.04 0.990.99 0.750.75 0.740.74

24.524.5 0.200.20 0.960.96 0.620.62 0.770.77

25.525.5 0.240.24 0.920.92 0.520.52 0.770.77

26.526.5 0.300.30 0.870.87 0.450.45 0.770.77

27.527.5 0.460.46 0.790.79 0.440.44 0.800.80

28.528.5 0.600.60 0.650.65 0.380.38 0.820.82

29.529.5 0.820.82 0.390.39 0.330.33 0.860.86

*PPV= positive predictive value; NPV= negative predictive value

ROC FOR MNCD FOR LESS THAN HIGH SCHOOL

Cut-Off Scores for Dementia in Patients with Less Cut-Off Scores for Dementia in Patients with Less Than High School EducationThan High School Education

Cut-OffCut-Off




PPV*PPV* NPV*NPV*

SLUMS/MNCDSLUMS/MNCD 15.015.0 0.740.74 1.001.00 1.001.00 0.950.95

16.516.5 0.850.85 1.001.00 1.001.00 0.970.97

17.517.5 0.890.89 0.980.98 0.920.92 0.980.98

18.518.5 0.930.93 0.980.98 0.930.93 0.980.98

19.519.5 1.001.00 0.980.98 0.930.93 1.001.00

20.520.5 1.001.00 0.960.96 0.820.82 1.001.00

21.521.5 1.001.00 0.910.91 0.690.69 1.001.00

22.522.5 1.001.00 0.860.86 0.590.59 1.001.00

23.523.5 1.001.00 0.810.81 0.510.51 1.001.00


22.522.5 0.410.41 1.001.00 1.001.00 0.900.90

23.523.5 0.560.56 0.990.99 0.940.94 0.920.92

24.524.5 0.630.63 0.960.96 0.740.74 0.930.93

25.525.5 0.780.78 0.920.92 0.660.66 0.950.95

26.526.5 0.810.81 0.870.87 0.550.55 0.960.96

27.527.5 0.850.85 0.790.79 0.440.44 0.960.96

28.528.5 0.890.89 0.650.65 0.330.33 0.970.97

29.529.5 1.001.00 0.390.39 0.250.25 1.001.00*PPV= positive predictive value; NPV= negative predictive value

ROC FOR DEMENTIA WITH LESS THAN HIGH SCHOOL EDUCATION

Cut-Off Score for Mild Neurocognitive Impairment Cut-Off Score for Mild Neurocognitive Impairment (MNCD) in Patients with High School Education or (MNCD) in Patients with High School Education or

MoreMoreCut-OffCut-Off




PPV*PPV* NPV*NPV*

SLUMS/MNCDSLUMS/MNCD 21.521.5 038038 1.001.00 1.001.00 0.750.75

22.522.5 0.550.55 0.990.99 1.001.00 0.790.79

23.523.5 0.680.68 0.950.95 0.960.96 0.840.84

24.524.5 0.850.85 0.870.87 0.850.85 0.870.87

25.525.5 0.950.95 0.760.76 0.740.74 0.930.93

26.526.5 0.980.98 0.610.61 0.630.63 0.990.99

27.527.5 0.990.99 0.420.42 0.520.52 0.990.99

28.528.5 1.001.00 0.220.22 0.420.42 0.990.99

29.529.5 1.001.00 0.120.12 0.350.35 1.001.00


24.524.5 0.050.05 0.990.99 0.640.64 0.710.71

25.525.5 0.080.08 0.980.98 0.650.65 0.710.71

26.526.5 0.140.14 0.930.93 0.470.47 0.720.72

27.527.5 0.270.27 0.860.86 0.450.45 0.730.73

28.528.5 0.450.45 0.760.76 0.430.43 0.760.76

29.529.5 0.750.75 0.480.48 0.380.38 0.820.82

*PPV= positive predictive value; NPV= negative predictive value

ROC FOR MNCD AND HIGH SCHOOL

Cut-Off Score for Dementia in Patients with High Cut-Off Score for Dementia in Patients with High School Education or MoreSchool Education or More

Cut-OffCut-Off




PPV*PPV* NPV*NPV*

SLUMS/MNCDSLUMS/MNCD 17.517.5 0.580.58 1.001.00 1.001.00 0.930.93

18.518.5 0.780.78 1.001.00 1.001.00 0.960.96

19.519.5 0.930.93 1.001.00 1.001.00 0.990.99

20.520.5 0.960.96 1.001.00 1.001.00 0.990.99

21.521.5 0.980.98 1.001.00 1.001.00 1.001.00

22.522.5 0.980.98 0.990.99 0.950.95 1.001.00

23.523.5 0.980.98 0.950.95 0.770.77 1.001.00

24.524.5 0.980.98 0.870.87 0.580.58 1.001.00

25.525.5 0.980.98 0.760.76 0.420.42 1.001.00


22.522.5 0.380.38 1.001.00 1.001.00 0.900.90

23.523.5 0.450.45 1.001.00 1.001.00 0.910.91

24.524.5 0.530.53 0.990.99 0.880.88 0.920.92

25.525.5 0.670.67 0.980.98 0.860.86 0.940.94

26.526.5 0.760.76 0.930.93 0.680.68 0.960.96

27.527.5 0.890.89 0.860.86 0.530.53 0.980.98

28.528.5 0.940.94 0.750.75 0.400.40 0.990.99

29.529.5 0.960.96 0.480.48 0.250.25 0.990.99*PPV= positive predictive value; NPV= negative predictive value

ROC FOR DEMENTIA WITH HIGH SCHOOL EDUCATION

SLUMS Item Discrimination as a Function of Education and Cognitive Status SLUMS Item Discrimination as a Function of Education and Cognitive Status (DSM-IV(DSM-IV))

Less Than High SchoolLess Than High School High School or MoreHigh School or More

MNCDMNCD DementiaDementia MNCDMNCD DementiaDementia

SLUMS ItemsSLUMS Items Area under Area under Curve (95% Curve (95% CI)*CI)*

PP Area under Area under Curve (95% Curve (95% CI)*CI)*



PP

Day of the weekDay of the week 0.51 (0.42-0.51 (0.42-0.61)0.61)

0.830.83 0.65 (0.52-0.65 (0.52-0.780.78

<.05<.05 0.51 (0.45-0.57)0.51 (0.45-0.57) 0.740.74 0.61 (0.52-0.70)0.61 (0.52-0.70) <.05<.05

YearYear 0.52 (0.42-0.52 (0.42-0.620.62

0.680.68 0.59 (0.46-0.59 (0.46-0.72)0.72)

0.130.13 0.51 (0.45-0.57)0.51 (0.45-0.57) 0.840.84 0.57 (0.48-0.66)0.57 (0.48-0.66) 0.090.09

StateState 0.50 (0.41-0.50 (0.41-0.59)0.59)

1.001.00 0.56 (0.43-0.56 (0.43-0.68)0.68)

0.360.36 0.50 (0.44-0.56)0.50 (0.44-0.56) 1.001.00 0.54 (0.46-0.63)0.54 (0.46-0.63) 0.280.28

Calculation Story problem Calculation Story problem money spentmoney spent

0.52 (0.42-0.52 (0.42-0.61)0.61)

0.690.69 0.67 (0.55-0.67 (0.55-0.80)0.80)

<.01<.01 0.53 (0.47-0.59)0.53 (0.47-0.59) 0.360.36 0.62 )(0.52-0.62 )(0.52-0.71)0.71)

<.01<.01

Money LeftMoney Left 0.57 *0.47-0.57 *0.47-0.66)0.66)

0.160.16 0.78 (0.67-0.78 (0.67-0.89)0.89)

<.00<.0011

0.57 (0.51-0.63)0.57 (0.51-0.63) <.05<.05 0.71 (0.62-0.79)0.71 (0.62-0.79) <.00<.0011

Animal namingAnimal naming 0.62 (0.53-0.62 (0.53-0.71)0.71)

<.01<.01 0.85 (0.77-0.85 (0.77-0.94)0.94)

<.00<.0011

0.66 (0.60-0.72)0.66 (0.60-0.72) <.00<.0011

0.84 (0.77-0.91)0.84 (0.77-0.91) <.00<.0011

Delayed recall -5 objectsDelayed recall -5 objects 0.74 (0.66-0.74 (0.66-0.82)0.82)

<.001<.001 0.91 (0.86-0.91 (0.86-0.96)0.96)

<.00<.0011

0.75 (0.70-0.80)0.75 (0.70-0.80) <.00<.0011

0.92 (0.87-0.96)0.92 (0.87-0.96) <.00<.0011

Digit SpanDigit Span 0.65 (0.56-0.65 (0.56-0.74)0.74)

<.01<.01 0.72 (061-0.72 (061-0.84)0.84)

<.00<.0011

0.63 (0.57-0.69)0.63 (0.57-0.69) <.00<.0011

0.80 (0.736-0.80 (0.736-0.87)0.87)

<.00<.0011

Clock drawing- NumbersClock drawing- Numbers 0.54 (0.45-0.54 (0.45-0.64)0.64)

0.350.35 0.81 (0.72-0.81 (0.72-0.91)0.91)

<.00<.0011

0.56 (0.50-0.62)0.56 (0.50-0.62) <.05<.05 0.70(0.62-0.78)0.70(0.62-0.78) <.00<.0011

TimeTime 0.61 (0.52-0.61 (0.52-0.71)0.71)

<.05<.05 0.85 (0.72-0.85 (0.72-0.91)0.91)

<.00<.0011

<0.56 (0.50-<0.56 (0.50-0.62)0.62)

<.01<.01 0.82 (0.75-0.89)0.82 (0.75-0.89) <.00<.0011

Identification –triangleIdentification –triangle 0.53 (0.44-0.53 (0.44-0.63)0.63)

0.490.49 0.55 (0.42-0.55 (0.42-0.67)0.67)

0.430.43 0.51 (0.45-0.57)0.51 (0.45-0.57) 0.770.77 0.55 (0.46-0.64)0.55 (0.46-0.64) 0.260.26

Differentiation – Figure sizeDifferentiation – Figure size 0.50 (0.41-0.50 (0.41-0.59)0.59)

0.980.98 0.56 (0.44-0.56 (0.44-0.69)0.69)

0.300.30 0.50 (0.44-0.56)0.50 (0.44-0.56) 0.930.93 0.52 (0.44-0.61)0.52 (0.44-0.61) 0.630.63

Immediate paragraph recall Immediate paragraph recall Who (Name)Who (Name)

.061 (0.52-.061 (0.52-0.71)0.71)

<.05<.05 0.78 (0.66-0.78 (0.66-0.89)0.89)

<.00<.0011

0.57 (0.51-0.63)0.57 (0.51-0.63) <.05<.05 0.68 (0.59-0.77)0.68 (0.59-0.77) <.00<.0011

What (Work/Job)What (Work/Job) 0.62 (0.52-0.62 (0.52-0.71)0.71)

<.05<.05 0.84 (0.75-0.84 (0.75-0.93)0.93)

<.00<.0011

0.58 (0.52-0.64)0.58 (0.52-0.64) <.01<.01 0.72 (6.64-0.81)0.72 (6.64-0.81) <.00<.0011

When (returned to work)When (returned to work) 0.72 (0.63-0.72 (0.63-0.81)0.81)

<.001<.001 0.81 (0.71-0.81 (0.71-0.91)0.91)

<.00<.0011

0.61 (0.55-0.67)0.61 (0.55-0.67) <.00<.0011

0.78 (0.70-0.86)0.78 (0.70-0.86) <.00<.0011

Where (State Lived in)Where (State Lived in) 0.68 (0.58-0.68 (0.58-0.77)0.77)

<.001<.001 0.83 (0.73-0.83 (0.73-0.92)0.92)

<.00<.0011

0.69 (0.63-0.75)0.69 (0.63-0.75) <.00<.0011

0.76 (0.68-0.84)0.76 (0.68-0.84) <.00<.0011

*Based on receiver operator curve (ROC) plots of sensitivity and I-Specificity. Area under the curve (AUC) and 95% confidence interval (CI) were estimated using the non-parametric approach.

CONCLUSIONCONCLUSION

The SLUMS is an acceptable alternative to the MMSE

It also identifies MNCD

Copyright belongs to the US Government as it was developed by St Louis GRECC Clinicians

The SLUMS is an acceptable alternative to the MMSE

It also identifies MNCD

Copyright belongs to the US Government as it was developed by St Louis GRECC Clinicians

vamc/st louis university slums john e morley geriatrics saint louis university grecc st louis vamc

Documents

dementia n

mncd n

morenormal n

positive predictive

high schoolhigh school

moderate dementia

mild neurocognitive

alzheimers disease