VAMC/ST LOUIS UNIVERSITY SLUMS John E Morley Geriatrics Saint Louis University GRECC St Louis VAMC

no less powerful or pervasive “All Rivers Run to the Sea” “Memory is a passion no less powerful or pervasive than love.” Elie Wiesel “All Rivers Run to the Sea”

Dementia Prevalence 8% over 65 years + 8% MCI 47% at 85 years

The 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 .

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)

Mild Cognitive Impairment OUTCOMES Poor functional recovery from major event 30% dead within 5 years 30% develop Alzheimer’s disease within 5 years

Mild Cognitive Impairment is NOT BENIGN

Mild Cognitive Impairment WHO PROGRESSES? 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 Examination Folstein et al. 1975 Educationally dependent Both false positives and false negatives Minimal testing of visuospatial system

How clouds are transformed into fried eggs CH has always focused on painting realistic landscapes und protraits. CH‘s paintings regressed with relapse into primitive and infantile representations. Now few or only one colour was used. Maurer K, Froehlich L. How clouds are transformed into fried eggs. Alzheimer Insights, 2000, 6: 4-7 Carolus Horn

William Untermohlen - self-portraits 22 22 22 21 Crutch SJ, Isaacs R, Rossor MN. Some workmen can blame their tool: artistic changes in an individual with Alzheimer disease. Lancet, 2001, 357:2129 13 17

METHODS 705 veterans Age 60 or older DSM IV for mild neurocognitive disorder or dementia MMSE and SLUMS

Descriptive Data by Education and Cognitive Status (DSM-IV) Less Than High School High School or More Normal (n=137) MNCD (n=50) Dementia (n=27) Normal (n=303) MNCD (n=130) Dementia (n=55) Age, mean (SD) 74.6 (5.2) 77.8 (6.0) 79.1 (6.7) 74.2 (5.0) 75.6 (5.6) 77.8 (5.1) SLUMS, mean (SD) 25.7 (2.8) 20.2 (2.4) 11.3 (5.1) 26.9 (2.0) 22.3 (2.1) 14.9 (5.2) MMSE, mean (SD) 28.6 (1.7) 27.3 (2.4) 21.0 (7.4) 29.0 (1.3) 28.2 (1.7) 23.0 (5.0)

SLUMS took 7 minutes to complete

Cut-Off Score for Mild Neurocognitive Impairment (MNCD) in Patients with Less Than High School Education Cut-Off Test/Category Score (≤) Sensitivity Specificity PPV* NPV* SLUMS/MNCD 19.5 .040 0.98 0.91 0.82 20.5 0.56 0.96 0.86 21.5 0.70 0.74 0.89 22.5 0.78 0.67 23.5 0.92 0.81 0.64 0.97 24.5 0.57 25.5 1.00 0.55 0.45 26.5 0.40 0.38 27.5 0.29 0.34 MMSE/MNCD 21.0 0.02 1.0 0.04 0.99 0.75 0.20 0.62 0.77 0.24 0.52 0.30 0.87 0.46 0.79 0.44 0.80 28.5 0.60 0.65 29.5 0.39 0.33 *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 Than High School Education Test/Category Score (≤) Sensitivity Specificity PPV* NPV* SLUMS/MNCD 15.0 0.74 1.00 0.95 16.5 0.85 0.97 17.5 0.89 0.98 0.92 18.5 0.93 19.5 20.5 0.96 0.82 21.5 0.91 0.69 22.5 0.86 0.59 23.5 0.81 0.51 MMSE/MNCD 0.37 0.41 0.90 0.56 0.99 0.94 24.5 0.63 25.5 0.78 0.66 26.5 0.87 0.55 27.5 0.79 0.44 28.5 0.65 0.33 29.5 0.39 0.25 *PPV= positive predictive value; NPV= negative predictive value

ROC FOR DEMENTIA WITH LESS THAN HIGH SCHOOL EDUCATION

Cut-Off Score for Mild Neurocognitive Impairment (MNCD) in Patients with High School Education or More Cut-Off Test/Category Score (≤) Sensitivity Specificity PPV* NPV* SLUMS/MNCD 21.5 038 1.00 0.75 22.5 0.55 0.99 0.79 23.5 0.68 0.95 0.96 0.84 24.5 0.85 0.87 25.5 0.76 0.74 0.93 26.5 0.98 0.61 0.63 27.5 0.42 0.52 28.5 0.22 29.5 0.12 0.35 MMSE/MNCD 0.03 0.71 0.05 0.64 0.08 0.65 0.14 0.47 0.72 0.27 0.86 0.45 0.73 0.43 0.48 0.38 0.82 *PPV= positive predictive value; NPV= negative predictive value

ROC FOR MNCD AND HIGH SCHOOL

Cut-Off Score for Dementia in Patients with High School Education or More Test/Category Score (≤) Sensitivity Specificity PPV* NPV* SLUMS/MNCD 17.5 0.58 1.00 0.93 18.5 0.78 0.96 19.5 0.99 20.5 21.5 0.98 22.5 0.95 23.5 0.77 24.5 0.87 25.5 0.76 0.42 MMSE/MNCD 0.27 0.88 0.38 0.90 0.45 0.91 0.53 0.92 0.67 0.86 0.94 26.5 0.68 27.5 0.89 28.5 0.75 0.40 29.5 0.48 0.25 *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 (DSM-IV) Less Than High School High School or More MNCD Dementia SLUMS Items Area under Curve (95% CI)* P Day of the week 0.51 (0.42-0.61) 0.83 0.65 (0.52-0.78 <.05 0.51 (0.45-0.57) 0.74 0.61 (0.52-0.70) Year 0.52 (0.42-0.62 0.68 0.59 (0.46-0.72) 0.13 0.84 0.57 (0.48-0.66) 0.09 State 0.50 (0.41-0.59) 1.00 0.56 (0.43-0.68) 0.36 0.50 (0.44-0.56) 0.54 (0.46-0.63) 0.28 Calculation Story problem money spent 0.52 (0.42-0.61) 0.69 0.67 (0.55-0.80) <.01 0.53 (0.47-0.59) 0.62 )(0.52-0.71) Money Left 0.57 *0.47-0.66) 0.16 0.78 (0.67-0.89) <.001 0.57 (0.51-0.63) 0.71 (0.62-0.79) Animal naming 0.62 (0.53-0.71) 0.85 (0.77-0.94) 0.66 (0.60-0.72) 0.84 (0.77-0.91) Delayed recall -5 objects 0.74 (0.66-0.82) 0.91 (0.86-0.96) 0.75 (0.70-0.80) 0.92 (0.87-0.96) Digit Span 0.65 (0.56-0.74) 0.72 (061-0.84) 0.63 (0.57-0.69) 0.80 (0.736-0.87) Clock drawing- Numbers 0.54 (0.45-0.64) 0.35 0.81 (0.72-0.91) 0.56 (0.50-0.62) 0.70(0.62-0.78) Time 0.61 (0.52-0.71) 0.85 (0.72-0.91) <0.56 (0.50-0.62) 0.82 (0.75-0.89) Identification –triangle 0.53 (0.44-0.63) 0.49 0.55 (0.42-0.67) 0.43 0.77 0.55 (0.46-0.64) 0.26 Differentiation – Figure size 0.98 0.56 (0.44-0.69) 0.30 0.93 0.52 (0.44-0.61) 0.63 Immediate paragraph recall Who (Name) .061 (0.52-0.71) 0.78 (0.66-0.89) 0.68 (0.59-0.77) What (Work/Job) 0.62 (0.52-0.71) 0.84 (0.75-0.93) 0.58 (0.52-0.64) 0.72 (6.64-0.81) When (returned to work) 0.72 (0.63-0.81) 0.81 (0.71-0.91) 0.61 (0.55-0.67) 0.78 (0.70-0.86) Where (State Lived in) 0.68 (0.58-0.77) 0.83 (0.73-0.92) 0.69 (0.63-0.75) 0.76 (0.68-0.84) *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.

CONCLUSION 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 CONCLUSION