CLOCK DRAWING TEST (CDT)

Many clinicians use the drawing of the face of a clock as an “all-purpose” mental status screen. Indeed, clock drawing is incorporated into other mental status scales, from the Mini-Cog to the STMS, MoCA, RUDAS, SLUMS, and ACE-III. There are reasons for this. Drawing the face of an analog clock, with correct placement of numbers and a proscribed time, taps into multiple cognitive domains. The correct performance of the CDT requires not only visuospatial ability, but mental control (working memory), other executive functions, and numerical ability. Consequently, the CDT can be quite sensitive to cognitive impairment. The CDT is easy to administer and is less language or culture dependent than other tests. The examiner usually asks the patient to draw the face of a clock, place the numbers, and indicate the time by placing the hands, most commonly at “10 after 11” or “5 past 4.” Clinicians may experience variable results with the CDT in screening for dementia. One reason for this is that there are different systems for scoring and interpreting the CDT. Regardless of scoring systems, the examiner should consider exactly how the patient performed in spatial relationships, number order and location, and placement of the hands with designated time. Errors can range from left hemispatial neglect with omission of numbers on the left side to executive dysfunction with “concrete” placement of the hands, for example, the long hand on the “10” when asked to indicate “10 after 11.”

MEMORY IMPAIRMENT SCREEN (MIS)

As its name suggests, the MIS is strictly a memory screen; however, this instrument has the advantage of testing both free recall and cued recall. In this way, the MIS probes in greater depth for the presence of declarative episodic verbal memory loss, the earliest impairment in typical Alzheimer disease and other dementias. The examiner asks the patient to read aloud four items presented on a sheet of paper. Then the examiner gives a different category cue for each of the four items and asks the patient to indicate which items belong to which categories. This allows for subsequent cued and free recall after 2 to 3 minutes. The patient gets two points for each item spontaneously recalled and one point if they required cuing. Given its structure, the best use of the MIS is in screening for typical Alzheimer disease; it is not a screen for nonmemory areas of cognitive decline. The MIS is relatively robust to the effects of age and education and is one of the tools recommended for use in the Medicare Annual Wellness Visit by the Alzheimer’s Association.

MINI-COG

The Mini-Cog combines memory with the clock drawing task, thus combining the main elements of the CDT and MIS. Much of the earlier discussion on the CDT and the MIS applies to the Mini-Cog. Where this instrument differs from the CDT is in its simplified binary scoring system without consideration of hand length and other variables, and where it differs from the MIS is in the absence of a cued recall portion, limited only to free recall. An additional advantage of the Mini-Cog is that it has alternate word lists, which is helpful for longitudinal follow-up. An abnormal score of less than 3 occurs if the patient has an abnormal clock and misses one memory item or if the patient misses all three memory items. It is relatively robust to the effects of age and education and, like the MIS, is one of the tools recommended for use in the Medicare Annual Wellness, primarily as a screening test for Alzheimer disease.

SIX-ITEM SCREENER (SIS)

The SIS adds orientation for time (year, month, day of the week) to three memory words (free recall). The introduction of orientation items is helpful in detecting patients with dementia, who become disoriented to time from recent memory difficulty or from attentional problems. The examiner asks the orientation questions during the “interference” period between presentation of the memory words and request for recall. Each of the three memory words and three orientation questions gets one point (six total). The SIS has value in quickly screening for dementia, but it misses deficits in most cognitive domains including those involved in the clock drawing task.

SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ)

The SPMSQ greatly expands on testing for orientation to include orientation for place and personal information, as well as orientation for time. This instrument has 10 questions that extend to questions about the patient’s telephone number, age, place of birth, and mother’s maiden name. The SPMSQ does not include direct testing of episodic declarative memory, nor does it sample multiple areas of cognition. However, it has remote memory questions that ask for the names of the current and last presidents, and the last item samples mental control/attention by asking the patient to count backward from 20 by 3s. Patients must answer eight of the questions correctly for a normal score. The developers state that “One more error is allowed in the scoring if a patient has had a grade school education or less. One less error is allowed if the patient has had education beyond the high school level.” Like most of the brief (≤5 minute) scales, the SPMSQ is more accurate in identifying patients with moderately or severely impaired dementia rather than detecting those with mild impairment.

THE SHORT TEST OF MENTAL STATUS (STMS)

Up to this point, the brief mental status scales have involved a limited number of cognitive areas or included the clock drawing as a vehicle to screen multiple domains. The STMS is distinctly different in this regard. It is a well-constructed test that incorporates all elements of the other tests, such as clock drawing, memory (learning and delayed recall of four items), orientation (time and place), semantic memory (presidents, weeks/year, island definition), and mental control/attention (digits forward). The STMS further adds calculations (four problems), abstractions (three similarities), and the copy of a cube. In essence, this is a much expanded “short” test, which the authors reported as still having an administration time of approximately 5 minutes. It is probable that many patients take longer to complete the STMS given all of its items. Of the brief (≤5 minute) mental status scales described here, the STMS is the most sensitive to mild impairments in cognition. One concern is that it does not have a language subtest, as language and word-finding difficulty are the second most common cognitive impairments in early dementia.

MINI-MENTAL STATE EXAMINATION (MMSE)

The most widely used and prototypical cognitive scale has been the MMSE ( Table 16.2 ). There is extensive experience with this instrument, which has been in wide use since introduced in 1975. This 30-item instrument, which is also discussed in Chapter 15 , consists of 10 orientation items followed by 8 language and 5 mental control/attention items. There are only three memory items (plus three registration) and one visuospatial task. The MMSE takes an average of 12 minutes to administer, and it has high interrater and test-retest reliability. One of the best uses of the MMSE is in measuring and following the severity of the Alzheimer clinical syndrome over time. A total score of 23 or less suggests mild dementia (<19 for moderate and <10 for severe dementia). The three-word recall is the most sensitive to dementia followed by orientation to date and the drawing of the intersecting pentagons. The MMSE is less sensitive for patients with mild cognitive impairment and cannot distinguish different types of dementia. It has a prominent ceiling effect, which results in missing many mildly impaired patients. Age and education heavily influence MMSE scores, with some normal individuals over 85 years of age and lacking a grade school education scoring as low as 18. One unique psychometric problem with the MMSE is the alternate choice of either spelling “WORLD” backward or counting backward from 100 by 7s. These tasks are not comparable or interchangeable, even when both tasks are done and the examiner takes the best score. Another concern is that memory testing is limited to brief delayed recall and may miss a disturbance in declarative episodic memory. Finally, the MMSE does not assess executive functions in any of its subtests (except serial reversals), again limiting its sensitivity for mild cognitive impairments.

A special issue with the MMSE is the emergence of a copyright restriction after many years of free access. The MMSE has served as a common language allowing clinicians and researchers to understand the stage or severity of dementia patients across different times, patients, and populations. To use the MMSE now, a clinician or researcher needs to get permission from the copyright owner and pay a fee for using MMSE forms. This has led to either withdrawal from using the MMSE or the use of alternatives that have elements of the MMSE, such as the Sweet-16 and ACE-R. Clinicians need not be limited to this scale as there are new and better alternatives and choices.

MONTREAL COGNITIVE ASSESSMENT (MOCA)

The MoCA is another widely used screening test that gained in popularity as a replacement for the MMSE (also see Chapter 15). Like the MMSE, the MoCA is a 30-point scale, with items that include 6 for orientation, 5 for memory, 6 for language, 6 for mental control/attention, 3 for visuospatial, and 4 for executive abilities (including clock hands). This broad range of coverage allows for increased sensitivity to mild cognitive impairments, making the MoCA a much better instrument for detecting early cognitive changes in broad range of disorders. In fact, examiners can use the MoCA as a brief MSX screening of most cognitive domains. There has been disagreement about the initial cutoff score of 26 being overly strict for detecting dementia. A recommended alternative cutoff score that minimizes false positives for dementia is less than 23. A salient difference between the MoCA and the MMSE is that the MoCA is a harder test. It also has floor effects with little variance among very impaired patients. Unfortunately, similar to the MMSE, education strongly affects MoCA scores.

There are other pros and cons to the MoCA. It has increasingly available psychometric support with normative data. There is also the availability of videoconferencing and telephone (“Blind MoCA) adminisitration. Less favorable for clinical access is that, since September of 2019, there have been restrictions on the use of the MoCA. The copyright owner requires certification (with a fee) for use. Perhaps more problematic is the requirement to enter patient data into an online database, where the forms are scored. Patients, or their proxies, would have to give informed consent, an added process that is a disincentive to use the MoCA in routine clinical settings. Finally, unfortunately, the MoCA has been widely circulated in public and on the internet, thus potentially compromising its use.

Rowland Universal Dementia Assessment Scale (RUDAS)

The RUDAS aims to be a mental status scale relatively free of educational, linguistic, and sociocultural effects. The RUDAS has six items, including delayed recall memory, visuospatial construction (copy of a cube), and semantic word fluency. Its other items are unique. They are left-right disorientation on body parts, probing of judgment involved in crossing a street (“safety question”), and alternating hand movements with fist and palm. These items are aimed at avoiding a multicultural bias, and the RUDAS is more robust to the effects of years of education and variations in native language compared with comparable scales. Most of the discriminability of the RUDAS, however, appears to be from its practical “shopping list” delayed recall items with up to five registration repetitions and its word fluency composed of generating a list of animals. It is unclear how much left-right disorientation and the judgment question add to the cognitive assessment. Left-right disorientation occurs from disturbance of a personal body map in the left parietal region (see Chapter 12 ) and is not a substitute for disorientation for time and place, which are disturbed from impairments in attention or memory. Paradoxically, the judgment question is one that may be extremely culturally dependent. The alternating motor movements are more a test of bradykinesia than of motor praxis and may be of value as an indicator of psychomotor slowing. The RUDAS has similar sensitivity for dementia but may be less sensitive for mild cognitive impairment than the MoCA, although more specific for both and much better overall than the MMSE.

SAINT LOUIS UNIVERSITY MENTAL STATUS EXAMINATION (SLUMS)

Like the MMSE, MoCA, and RUDAS, the SLUMS has a 30-point scale, which includes orientation, delayed recall memory, calculation, semantic word fluency, digit span backward, and clock drawing. It has two unique items: immediate story recall and visuospatial figure recognition-orientation. This instrument has the advantage of assessing most cognitive domains impacted by early dementia. The SLUMS is shorter than the MMSE, MoCA, or RUDAS, with a mean administration time of approximately 7 minutes. The cutoff scores for dementia are less than 20 if less than 12 years of education and less than 21 for high school graduates. Its most discriminative items appear to be the word fluency for animals, memory (delayed recall), digit span backward, and the immediate story recall. Preliminary data suggests that the SLUMS, at cutoffs of less than 20 for less than 12 years of education and less than 27 for high school graduates, may be one of the most sensitive mental status scales for mild cognitive impairment among scales of 15 minutes or less. The SLUMS, like the RUDAS, requires more research to validate its use and establish its value in screening for mild cognitive impairment.

ADDENBROOKE COGNITIVE EXAMINATION-III (ACE-III) AND ITS MINI-ACE DERIVATIVE

The ACE scales are comprehensive instruments that have shown great value in patient screening and assessment in studies throughout the world. They are noteworthy for their broad cognitive content and their applicability for assessing dementia syndromes beyond typical Alzheimer disease. Investigators have applied the ACE tests to distinguish typical Alzheimer disease (with decreased delayed recall memory and orientation) versus other disorders, such as frontotemporal dementia (with decreased phonemic verbal fluency). The original 100-item ACE contains delayed recall memory, language and verbal fluency measures, and the clock drawing combined with the elements of the MMSE. A revised version (ACE-R) defines cognitive subscales, and a further revision (ACE-III) removes the elements of the MMSE. Administration time for the ACE-III ranges from 15 to 20 minutes. The ACE-R and ACE-III are highly correlated thanks to the incorporation of items that replace the cognitive constructs of the MMSE. The further introduction of an abbreviated version of the ACE-III, the 30-point Mini-ACE, provides a 5-minute mental status scale with items for orientation, delayed recall of an address, a semantic word list, and clock drawing. The Mini-ACE is excellent for detecting Alzheimer disease and dementia but, like the other scales of 5 minutes or less, it is not as sensitive for mild cognitive impairment as longer scales.

SURVEY OF GENERAL MENTAL STATUS SCALES

There are a great many mental status scales, and it is not possible to individually review all of them in detail. In addition to the instruments covered in the first part of this chapter, there are a number of other scales that are worth mentioning. The reader can refer to the literature for the remaining mental status scales outlined in Tables 16.3 and 16.4 .

TABLE 16.3

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