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

2. 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”

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

4. 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 .

6. 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)

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

8. Mild Cognitive Impairmentis
NOT BENIGN

9. 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)

10. Families and physicians fail to recognize dementia.
50% of persons with mild to moderate dementia have not been diagnosed

11. Mini-Mental Status Examination
Folstein et al. 1975
Educationally dependent
Both false positives and false negatives
Minimal testing of visuospatial system

12. 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

13. William Untermohlen - self-portraits22 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

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

16. 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)

17. SLUMS took 7 minutes to complete

18. 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

19. ROC FOR MNCD FOR LESS THAN HIGH SCHOOL

20. 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

21. ROC FOR DEMENTIA WITH LESS THAN HIGH SCHOOL EDUCATION

22. 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

23. ROC FOR MNCD AND HIGH SCHOOL

24. 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

25. ROC FOR DEMENTIA WITH HIGH SCHOOL EDUCATION

26. 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 ( )
0.83
0.65 (
<.05
0.51 ( )
0.74
0.61 ( )
Year
0.52 (
0.68
0.59 ( )
0.13
0.84
0.57 ( )
0.09
State
0.50 ( )
1.00
0.56 ( )
0.36
0.50 ( )
0.54 ( )
0.28
Calculation Story problem money spent
0.52 ( )
0.69
0.67 ( )
<.01
0.53 ( )
0.62 )( )
Money Left
0.57 * )
0.16
0.78 ( )
<.001
0.57 ( )
0.71 ( )
Animal naming
0.62 ( )
0.85 ( )
0.66 ( )
0.84 ( )
Delayed recall -5 objects
0.74 ( )
0.91 ( )
0.75 ( )
0.92 ( )
Digit Span
0.65 ( )
0.72 ( )
0.63 ( )
0.80 ( )
Clock drawing- Numbers
0.54 ( )
0.35
0.81 ( )
0.56 ( )
0.70( )
Time
0.61 ( )
0.85 ( )
<0.56 ( )
0.82 ( )
Identification –triangle
0.53 ( )
0.49
0.55 ( )
0.43
0.77
0.55 ( )
0.26
Differentiation – Figure size
0.98
0.56 ( )
0.30
0.93
0.52 ( )
0.63
Immediate paragraph recall Who (Name)
.061 ( )
0.78 ( )
0.68 ( )
What (Work/Job)
0.62 ( )
0.84 ( )
0.58 ( )
0.72 ( )
When (returned to work)
0.72 ( )
0.81 ( )
0.61 ( )
0.78 ( )
Where (State Lived in)
0.68 ( )
0.83 ( )
0.69 ( )
0.76 ( )
*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.

28. 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