1. Bedside cognitive assessment: instruments & applicability
(In house Skill Development Program, 30 Nov to 5 Dec, 2015)
Dr Rakesh Kumar Tripathi, M Phil, PhD
Assistant Professor & Clinical Psychologist
Department of Geriatric Mental Health
King George’s Medical University
Lucknow (India)

2. Bedside cognitive assessment: instruments & applicability
Learning Objectives:
Cognitive assessment
Areas of cognitive assessment for elderly
Practical exposure to assess Cognitive functions
Basic skills for assessment
Cognitive screening tools from India

3. Cognitive Assessment of Older Adults
Purpose of Bedside Assessment:
To screen the pt for probable diagnosis
To know differential diagnoses
For referral
Management/Rehabilitation
Improvement
Prognosis

4. Cognitive Assessment of Older Adults
Areas of assessment
Cognition:
Orientation,
Attention & Concentration,
Calculation,
Memory,
Language,
Visuospatial function,
Praxis,
Executive function & social behaviour

5. Normals can be expected to score > 25
Folstein et al. 1975
Scoring:
0- 4: Severe,
5-14: Mod.
15-19: Mild Dementia;
20-24: MCI,
25-28 Age related Cog Impairment, 29-30:Normal
Normals can be expected to score > 25
However, even with > 25, if 0/3 or 1/3 for recent
memory or problems with naming, repeating,
writing or reading suggest focal deficits.
It is most sensitive to disturbances which
broadly effect function, it may miss subtle,
focal problems.

6. International Psychogeriatrics (2009), 21:1, 123–128 C 2008 International Psychogeriatric Association
Applicability of the Mini-mental State Examination (MMSE) and the Hindi Mental State Examination (HMSE) to the urban elderly in India: a pilot study
S. C. Tiwari, Rakesh Kumar Tripathi and Aditya Kumar
Department of Geriatric Mental Health, C.S.M. Medical University (Uttar Pradesh), Lucknow, India
Results:
Either HMSE is screening more false negatives within the urban literate population or MMSE is screening more false positives within the illiterate population.

7. Indian Journal of Geriatric Mental Health, 7(2), 83-96, 2011.
IAGMH/Intas Award 2011 at 3rd place.
Development of an Education and Culture Fair Hindi Cognitive Screening Test (HCST) for the Elderly Population of India
S. C. Tiwari and Rakesh Kumar Tripathi (2011)
Department of Geriatric Mental Health
C. S. M. Medical University, U P, Lucknow, India
Sensitivity: 0.93
Specificity: 0.96
Reliability (r): -0.87
with Brief Cognitive Rating Scale (Reisberg & Ferris, 1988)

9. Attention & Concentration
Spelling of a 5 word backwards e.g. ‘World’ or ‘Right’
100-Serial 7’s or 20-3’s
Vigilance test: "I am going to say a long series of letters. Whenever you hear the letter A, indicate by tapping the desk.“ Speak a random series of letters at a normal rate with A occurring regularly and sometimes repeating as in the following example:
“K T B A O S A W I E A A G H C A T A A A E ...”
Digit span
Localisation:
Normal attention and concentration requires optimal interaction between the reticular formation, thalamus and neocortex

10. Memory -not a Unitary Process
Sensory Memory
Short term memory
Long term memory
Recent memory
Remote memory
Working memory
Episodic memory
Semantic memory

11. Working Memory
Ability to temporarily maintain and manipulate information that one needs to keep on-line
Divided into components that process phonologic information (e.g. phone number in head) and components process visual (mentally following a route) with central executive
Poor working memory leads to faulty encoding
Overlap with attention
Bedside task- digit span test

12. Semantic Memory
Localisation

15. Localisation
In more than 98% of right handers the peri-sylvian language areas of the left hemisphere are responsible for language processing.
This includes Wernicke’s area, the arcuate fasciculus,Broca’s area and other associated cortical areas.
The right hemisphere is involved in other aspects of language such as humour, metaphor and determining the emotional state of the speaker.

18. Executive Function
A complex set of cognitive abilities that are involved in planning and multitasking
Frontal cortices
Localisation
The frontal cortices are involved in executive functioning and it connects closely with subcortical structures. These connections form loops projecting from the frontal cortex to the striatum, globus pallidus, thalamus and back to the frontal cortex.
Lesioning in any part of this circuit will result in deficits that are indistinguishable from a frontal cortical injury. The anterior cingulate has many connections with the frontal lobes and are also involved in executive functioning.
Subcortical structures
Frontal cortex
Striatum
Globus pallidus
Thalamus
Anterior cingulate

19. Frontal lobe test

20. Frontal lobe test contd.

21. Draw a clock face (large circle)
Friends! Please follow the instructions and do mistakes to learn scoring
Draw a clock face (large circle)
mark the hours (numbers in the circle)
draw a time 10 past 11

22. Bedside Cognitive Assessment of Older Adults
Clock drawing Test
Score
Error(s) 1
No error 2
Minor visuospatial error 3
Inaccurate representation of “10 past 11” 4
Moderate visuospatial disorganization of times 5
Several disorganization 6
No reasonable representation of a clock
Score≥ 3: Cognitive deficit

23. Bedside Cognitive Assessment of Older Adults

24. Basic communication Skill for Assessment
Calm, reassuring tone of voice
Explain what you are going to do prior to moving into the patient’s personal space to implement care/assessment
Use a non-threating posture
Do not approach the patient from behind
Touch and care should be in a respectful, careful and unhurried manner
Use short words and simple sentences
Ask one question at a time
Don’t ask ‘why’
Give adequate time for response
Repeat questions and instructions if necessary
Speak slowly and clearly
Use of aids (hearing, vision, physical) by the patient
Sing I & Tripathi SM (2013). Management of BPSD. In Tiwari SC & Pandey NM (eds.) Geriatric Mental Health at a Glance ,pp Ahuja Publishing House , New Delhi , India.

25. Psychological Assessment of Older Adults
Screening
Mini Mental State Examination (MMSE) (Folstein et al. 1975)
Hindi Mental State Examination (HMSE) (Ganguli et al. 1995)
Hindi Cognitive Screening Test (Tiwari and Tripathi, 2011)
St. Louis University Mental State (SLUMS) Exm. (JE Morley, 2000)
Clock Drawing Test (CDT) (Shulman et al. 1993)
Bender Gestalt Test (BGT) (Lauretta Bender, 1938)
Hachinski Ischemic Scale (1975)
7 Minute Neurocognitive Screening Battery (Solomon et al. 1998)
Short Portable Mental State Questionnaire (E. Pfieffer, 1975)
Community Screening Instrument for Dementia (Hall et al. 1993)
Brief Cognitive Rating Scale (BCRS) (Reisberg and Ferris, 1998)
Functional Assessment Staging (FAST) (Reisberg, 1988)
Global Deterioration Scale (GDS) (Reisberg, 1988)
Cognistat (Northern California Neurobehavioural Group, 1995 )
Indian adaptation of Cognistat (Gupta and Kumar, 2009)
Addenbrooke’s Cognitive Examination (2005 to 2012)
Montreal Cognitive Assessment (Nasreddine, 1996)

26. Bedside Cognitive Assessment of Older Adults
St. Louis University Mental State Examination (SLUMS Exam.) Morley JE, 2000
It is a simple 11 items tool
High School Education
Clinical Condition
Less Than
High School
Education
27-30
Normal
25-30
21-26
MNCD*
20-24
1-20
Dementia
1-19
* Mild Neurocognitive Disorder
Takes about 5-10 minutes in administration
SLUMS is more sensitive in detecting MCI and dementia than Mini Mental
State Examination

27. Hachinski Ischemic Scale (1975)
Bedside Cognitive Assessment of Older Adults
Hachinski Ischemic Scale (1975)
Features
Score
Abrupt 2
2. Stepwise deterioration 1
3. Fluctuating course
4. Nocturnal confusion
5. Relative preservation of personality
Depression
7. Somatic Complaints
8. Emotional incontinence
Features
Score
9. History or presence of hypertension 1
10. History of strokes 2
11. Evidence of associated atherosclerosis
12. Focal neurologic symptoms
13. Focal neurologic sign
Total Score 18
Scoring
0-4: Alzheimer's Dementia;
5-6: diagnosis unclear;
7 or more : Vascular Dementia

28. Montreal Cognitive Assessment
(Nasreddine, 1996)
10-15 minutes
•Score / 30
•Better sensitivity than MMSE for MCI
•Needs more clarity about cutoff scores?
•Mean score of normal population 26-27
•Cutoff at 26 gives high sensitivity but low specificity
•Suggested guide is <22 for MCI, AD < 17

29. Cognitive screening tools from India

30. Cognitive screening tools from India (contd.)
Adaptation
Community based
Tiwari & Tripathi, 2011
Like MMSE
300
60 &+
KGMU,Lucknow, UP
Bias Free
In Progress
Hindi
Yes

32. King George’s Medical University,
Lucknow, U.P., INDIA
Contact: R K Tripathi
Thank you