• Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: Early detection of dementia: Mild cognitive impairment (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001 May 8;56(9):1133-42. [47 references]

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed and is still considered to be current as of October 2003. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

• Dementia
• Alzheimer’s disease

Diagnosis
Screening

Family Practice
Geriatrics
Internal Medicine
Neurology
Psychiatry

Physicians

To determine whether screening different groups of elderly individuals in a general or specialty practice is beneficial in detecting dementia

Persons with mild cognitive impairment

General Cognitive Screening Instruments

1. Mini-Mental State Examination (MMSE)
2. Kokmen Short Test of Mental Status
3. Memory Impairment Screen
4. 7-Minute Screen

Brief Focused Screening Instruments

1. Clock Drawing Test
2. Time and Change Test

Neuropsychologic Batteries

1. Neuropsychologic Battery
2. Mattis Rating Scale
3. Halifax Mental Status Scale
4. Fuld Object Memory Test

Informant-Based Instruments

1. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
2. Clinical Dementia Rating (CDR)
3. Blessed Dementia Rating Scale (BDRS)

• Rates of conversion to dementia for persons classified as having mild cognitive impairment
• Sensitivity and specificity of screening instruments for detection of dementia/cognitive impairment
• Positive and negative predictive values of screening instruments for detection of dementia/cognitive impairment

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Panel selection. The Quality Standards Subcommittee identified two team leaders to select committee members to participate in the creation of one or more practice parameters on dementia. The committee determined that three practice parameters were needed: Detection of Dementia, Diagnosis of Dementia, and Management of Dementia. The three practice parameter committees coordinated their literature searches to include key words such as specific forms of dementia and databases that interrelate the three topics. All panel members provided comprehensive disclosures of any real or potential conflicts of interests.

Literature review process. Search terms. Key and index words used were as follows: dementia, pre-senile dementia, senile dementia, vascular dementia, Alzheimer’s disease, early detection, early diagnosis, early stages, early symptoms, health screening, psychologic screening inventory, geriatric assessment, longitudinal studies, retrospective studies, mild cognitive impairment, Mini-Mental State Examination, cognitive impairment, cognitive assessment, and memory tests.

Databases. MEDLINE, EMBASE, Current Contents, Psychological Abstracts, Psych Info, Cochrane Database, and CINAHL Database were searched.

Inclusion/exclusion criteria and process. For the searches, the authors of the guideline sought studies in all languages; however, other types of studies were limited to English only. Studies were restricted to human subjects. Longitudinal prospective studies that evaluated mildly impaired subjects and followed them to detect cognitive impairment from 1991 to early 2000 were reviewed. The authors of the guideline also examined reviews and their bibliographies published from 1994 to November 1999 to identify additional articles. In addition, the authors of the guideline evaluated studies of clinical testing instruments that could be used to identify subjects with cognitive impairment.

Number and disposition of articles. The authors of the guideline identified 1,933 abstracts, which yielded 120 articles. Application of appropriate inclusion/exclusion criteria yielded 74 articles that provided the evidence for this parameter.

74

Weighting According to a Rating Scheme (Scheme Given)

Classification of Evidence

Class I. Evidence provided by one or more well-designed, randomized, controlled clinical trials, including overviews (meta-analyses) of such trials.

Class II. Evidence provided by well-designed, observational studies with concurrent controls (e.g., case control or cohort studies).

Class III. Evidence provided by expert opinion, case series, case reports, and studies with historical controls.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Data extraction items. Articles were reviewed by at least two individuals and selected items were coded onto a data extraction form that had the following information: type of article, focus of article (e.g., diagnosis of dementia, early dementia), number of subjects, sex, subject selection method, method of patient characterization, screening instruments used, final diagnostic classification, gold standard for final diagnostic classification, quality of diagnostic methods, formal diagnostic criteria used, diagnostic criteria for Alzheimer’s disease (if applicable), age of population studied (if study dealt with test or instrument), name and value, sensitivity, specificity, positive predictive value, negative predictive value, and final classification of evidence.

Classification of evidence. Each article was assigned to a class of evidence based on a priori definitions. The class of evidence determined whether or not study results were ultimately translated into Standards, Guidelines, or Options.

Development of evidence tables. For all articles, evidences tables were developed. These tables indicate the author and year of the study, level of evidence, main purpose of the study, population, intervention, outcome measure, and result.

Not stated

Levels of Recommendation

Standard. Principle for patient management that reflects a high degree of clinical certainty. (Usually requires Class I evidence that directly addresses clinical questions, or overwhelming Class II evidence when circumstances preclude randomized clinical trials.)

Guideline. Recommendation for patient management that reflects moderate clinical certainty. (Usually requires Class II evidence or a strong consensus of Class III evidence.)

Option. Strategy for patient management for which clinical utility is uncertain (inconclusive or conflicting evidence or opinion).

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

The guidelines were approved by the American Academy of Neurology Quality Standards Subcommittee on November 11, 2000, by the American Academy of Neurology Practice Committee on January 6, 2001, and by the American Academy of Neurology Board of Directors on February 24, 2001.

Classification of evidence ratings, I-III, and the levels of recommendations (Standard, Guideline, Option) are defined at the end of the "Major Recommendations" field.

1. Does the presence of mild cognitive impairment predict the development of dementia?

   Conclusion: Studies indicate that individuals characterized as being cognitively impaired but not meeting clinical criteria for dementia or Alzheimer's disease (mild cognitive impairment) have a high risk of progressing to dementia or Alzheimer's disease. If the figures for incident Alzheimer's disease from the general population are used (Table 4 in the original guideline document), one can see that the rates range from 0.2% in the 65 to 69 year age rage to 3.9% in the 85 to 89 year range. The studies of mild cognitive impairment indicate that the rate of progression to dementia of Alzheimer's disease is between 6 and 25% per year.

   Practice Recommendation: Patients with mild cognitive impairment should be recognized and monitored for cognitive and functional decline due to their increased risk for subsequent dementia (Guideline).

2. Does screening at-risk subjects with a specific instrument in a specific setting accurately lead to the diagnosis of dementia?

   General Cognitive Screening Instruments

   Conclusion: General cognitive screening instruments, which include the Mini-Mental State Examination, Kokmen Short Test of Mental Status, 7-Minute Screen, and Memory Impairment Screen, are useful for the detection of dementia when used in patient populations with an elevated prevalence of cognitive impairment either due to age or presence of memory dysfunction.

   Practice Recommendation: General cognitive screening instruments (e.g., Mini-Mental State Examination) should be considered for the detection of dementia in individuals with suspected cognitive impairment (Guideline).

   Brief Focused Screening Instruments

   Conclusion: Recently, attempts have been made to develop useful screening tools that can be administered in a brief time frame. Caution must be exercised because of the limited scope of these tools.

   Practice Recommendation: Brief cognitive assessment instruments that focus on limited aspects of cognitive function (i.e., Clock Drawing Test, Time and Change Test) may be considered when screening patients for dementia (Option).

   Neuropsychologic Batteries

   Conclusion: Neuropsychologic batteries are useful instruments in identifying patients with dementia, particularly when administered to an increased-risk (by virtue of memory impairment) population. Those neuropsychologic instruments that emphasize memory function are most useful.

   Practice Recommendation: Neuropsychologic batteries should be considered useful in identifying patients with dementia, particularly when administered to a population at increased risk of cognitive impairment (Guideline).

   Informant-based Batteries

   Conclusion: Interview-based techniques (i.e., Blessed Dementia Rating Scale, Clinical Dementia Rating, Informant Questionnaire on Cognitive Decline in the Elderly) may be useful in identifying patients with dementia, particularly when administered to patients who are at increased risk of developing dementia by virtue of age or memory impairment. These instruments emphasize the importance of obtaining information concerning the cognitive and functional status of persons from an informed source.

   Practice Recommendation: Interview-based techniques may be considered in identifying patients with dementia, particularly in a population at increased risk for cognitive impairment (Option).

Definitions:

Classification of Evidence

Class I. Evidence provided by one or more well-designed, randomized, controlled clinical trials, including overviews (meta-analyses) of such trials.

Class II. Evidence provided by well-designed, observational studies with concurrent controls (e.g., case control or cohort studies).

Class III. Evidence provided by expert opinion, case series, case reports, and studies with historical controls.

Levels of Recommendation

Standard. Principle for patient management that reflects a high degree of clinical certainty. (Usually requires Class I evidence that directly addresses clinical questions, or overwhelming Class II evidence when circumstances preclude randomized clinical trials.)

Guideline. Recommendation for patient management that reflects moderate clinical certainty. (Usually requires Class II evidence or a strong consensus of Class III evidence.)

Option. Strategy for patient management for which clinical utility is uncertain (inconclusive or conflicting evidence or opinion).

None provided

The recommendations are based on a review of the literature. The type of supporting evidence is identified and graded for each recommendation on the early detection of dementia (see "Major Recommendations" field).

Improved detection of dementia in persons with signs of mild cognitive impairment

Not stated

This statement is provided as an educational service of the American Academy of Neurology. It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use specific procedures. Neither is it intended to exclude any reasonable alternative methodologies. The American Academy of Neurology recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all the circumstances involved.

An implementation strategy was not provided.

Staying Healthy

Effectiveness

• Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: Early detection of dementia: Mild cognitive impairment (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001 May 8;56(9):1133-42. [47 references]

Not applicable: Guideline was not adapted from another source.

2001 May (reviewed 2003)

American Academy of Neurology - Medical Specialty Society

American Academy of Neurology (AAN)

Quality Standards Subcommittee

Authors: R.C. Petersen, PhD, MD; J.C. Stevens, MD; M. Ganguli, MD, MPH; E.G. Tangalos, MD; J.L. Cummings, MD; and S.T. DeKosky, MD

All panel members provided comprehensive disclosures of any real or potential conflicts of interest.

American Association of Neuroscience Nurses - Professional Association
American Geriatrics Society - Medical Specialty Society

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed and is still considered to be current as of October 2003. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

This NGC summary was completed by ECRI on February 12, 2002. The information was verified by the guideline developer on September 22, 2003.

This NGC summary is based on the original guideline, which is copyrighted by the American Academy of Neurology.