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3ms scoring manualThe M odified M ini- M ental S tate ( 3MS ) test has incorporated:It can provide an estimated score of the MMSE, and can also be used to monitor cognitive change over time. By now a large body of literature has shown the usefulness of the 3MS test in both research and clinical studies.Thank you also for helping us to know more about who you are and your interest in the 3MS. If you are a student or are contacting us for a professional, the Request Form should be filled out by the professional supervisor and sent using his or her email address. Design: Psychometric and clinical comparison of the 3MS and MMSE. Setting: Neuropsychological clinic in the northeastern U.S. Participants: Older adults referred for cognitive concerns, 87 of whom were cognitively intact (CI) and 206 of whom were diagnosed with MCI. Measurements: The MMSE, the 3MS, and comprehensive neuropsychological evaluations. Results: Both instruments were significant predictors of diagnostic outcome (CI or MCI), with comparable odds ratios, but the 3MS explained more variance and showed improved classification accuracies relative to the MMSE. Additionally, compared to the MMSE, the 3MS shared more variance with neuropsychological composite scores in language and memory domains but not in attention, visuospatial, and executive domains. Finally, 65.5 MCI patients were classified as impaired (scoring ? 1 SD below the mean) using 3MS normative data, compared to only 11.7 of patients who were classified as impaired using MMSE normative data. Conclusions: Broadly speaking, our data strongly favor the widespread substitution of the MMSE with the 3MS in older adults with concerns for cognitive decline. Download full-text PDF Setting: Neuropsychological clinic in the northeaster n USA. Results: Both instruments were signi?cant predictors of diagnostic outcome (CI or MCI), with comparable odds ratios, but the 3MS explained more variance and showed improved classi?ca tion accuracies relative to the MMSE.http://www.wistco.co.kr/upload/editor/4-speed-manual-floor-shifter.xml
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Additionally, compared to the MMSE, the 3MS shared more variance with neuropsychological composite scores in Language and Memory domains but not in Attention, Visuospatial, and Executive domains. Finally, 65.5 MCI patients were classi?ed as impaired (scoring ? 1 SD below the mean) using 3MS normative data, compared to only 11.7 of patients who were classi?ed as impaired using MMSE normative data. Key words: mild cognitive impairment, aging, neuropsychological testing, cognitive assessment Introduction As technological innovation and scienti?c discovery continue to drive a reduction in disease prevalence across the lifespan and a concomitant increase in global life expectancy (Murray et al., 2015 ), attention is shifting toward preventativ e healthcare in older adults. Older adults are at high risk for pathological cognitive decline and the limited interventions currently available confer the greatest Correspondence should be addressed to: Ryan Van Patten, Neuropsychology Pro- gram, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.Although the gold standard for identifying cognitive decline in MCI and dementia is a comprehensive neuropsychological evaluation, such procedures are too costly and time consuming to be performed at a population level. Instead, brief screening measures provide cost-ef?cient estimates of older adults’ cognitive statuses. Man y. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Unfortunately, despite its widespread use, the MMSE also has many well- documented limitations. Importantly, its reported proportion of shared variance with neuropsychological tests has been inconsistent across studies (Mitrushina and Satz, 1991;G r a c e et al., 1995; Spencer et al., 2013 ), with the smaller coef?cients likely being due to a restriction in range of MMSE scores (T ombaugh and McIntyre, 1992 ).http://www.goteneplast.se/files/images/4-speed-manual-scooter.xml Broadly speaking, the MMSE is a useful tool in the detection of moderate to severe cognitive de?cits but it has repeatedly proven inadequate in the iden- ti?cation of subtle cognitive decline (T ombaugh and McIntyre, 1992 ), which is precisely the task that is of highest clinical signi?cance in aging populations. In response to the MMSE’s limitations, al- ternative cognitive screening measures have been developed. Several of these, including the Montreal Cognitive Assessment (MoCA; Nazem et al., 2009 ), and the Saint Louis University Mental Status examination (SLUMS; T ariq et al., 2006 ) have outperformed the MMSE in head-to-head comparisons. Still, the MMSE continues to be widely used, likely due to familiarity with administration, scoring, and interpretation, as well as the availability of a vast literature delineating its optimal use in elderly populations. Consequently, rather than discarding the MMSE in favor of an entirely novel instrument, healthcare providers may be more receptive toward enhancements to the existing measure. In this vein, T eng and Chui ( 1987 ) developed the modi?ed Mini-Mental State Examination (3MS). The 3MS retains the same basic structure as the MMSE, while adding items measuring orientation to date and birthplace, nam- ing of body parts rather than pen and wristwatch, timed generation of four-legged animals, pairs of verbal similarities, and a second recall of the three words presented earlier in the task. Moreover, the scoring procedure was expanded from 30 to 100 total points to maximize variability across examinees, thereby allowing for more ?ne-grained discrimination among individuals. Still, no study to our knowledge has directly compared the MMSE and 3MS in MCI. The current study represents such an effort. Speci?http://www.drupalitalia.org/node/67568cally, we hypothesized that, in a sample of elderly individuals, (1) the 3MS would show better psychometric characteristics than the MMSE in the discrimination of MCI from intact cognition and (2) the 3MS would share more variance with neuropsychological tests than the MMSE.. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Materials and methods Participants Participants were 293 older adults who completed comprehensive clinical neuropsychological evalu- ations between 2010 and 2017 at a teaching hospital in the northeastern USA (see Table 1 for sociodemographic characteristics). Inclusion criteria for the entire sample were old age (de?ned as ? 55 years) and a referral for neuropsychological testing secondary to cognitive concerns. Based upon the neuropsychological assessment results, licensed psychologists con- cluded that 87 patients were cognitively intact (CI) and that 206 met diagnostic criteria for MCI. Given that the current study represents a retrospective analysis of an archival database, Institutional Review Board approval was granted following clinical data acquisition. Mirroring previous examinations of this database (e.g., Putcha and T remont, 2016 ), we calculated composite scores for each domain by transforming individual subtest raw scores into z -scores, normalized on the full sample, and averaging the z -scores for subtests within each domain. This procedure resulted in a single score re?ecting an individual participant’s overall performance for each of the ?ve neurocognitive abilities. The tests comprising the Attention sub- scale were the Dementia Rating Scale, 2nd edition (Jurica et al.http://drbillbaker.com/images/3mkd75dvm-service-manual.pdf, 2001 ) Attention scale, the W echsler Adult Intelligence Inventory, 4th edition (W AIS-IV; W echsler, 2008 ) Digit Span longest dig its forward and backward, the T rail Making T est (TMT; Reitan, 1992 ) part A, the W echsler Memory Scale, 3rd edition (W echsler, 1997 ) Mental Control task, and the W AIS-IV Coding subtest. The Language composite was a product of the Boston Naming T est (Kaplan et al., 1983 ) and category ?uenc y (animals; Gladsjo et al., 1999 ). The Visuospatial domain included the DRS-2 Construction scale, the Judgment of Line Orientation (Benton, 1994 ) test, and the Rey Complex Figure T est (RCFT; Stern et al., 1999 ), copy score. Memory was operationalized as the Hopkins V erbal Learning T est-Revised (Brandt and Benedict, 2001 ) T otal Learning and Delayed Recall scores, the Brief Visuospatial Memory T est-Revised (Benedict et al., 1996 ) T otal Learning and Delayed Recall scores. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Statistical analyses W e conducted all analyses using SPSS version 24.0. Prior to testing the study hypotheses, the data were examined for outliers and violations of test assump- tions. This conservative approach led to the identi?cation and modi?cation of only two values. As a test of Hypothesis 1, we conducted two hierarchical logistic regressions predicting diagnostic group (CI or MCI), with age, years of education, and the age.W e evaluated and compared model effect sizes, classi?cation accuracies, and odds ratios. Next, we examined the sensitivity and speci?city of the MMSE and 3MS by performing receiver operating characteristic (ROC) curves and evaluating the area under the curve (AUC) values. Given the importance of minimizing both false positives and false negatives, we de?ned an optimal cut-off value as the score with the largest sum of sensitivity and speci?city (Y ouden, 1950 ). Additionally, due to the importance of educational attainment when setting cut-offs for the MMSE and 3MS (T ombaugh and McIntyre, 1992; T ombaugh et al., 1996; Jones et al., 2002 ), we conducted ROC curves for the entire sample and split by years of education. As an initial test of Hypothesis 2, we statistically compared partial correlations between each of the two screening measures and neurocognitive composite scores, controlling for age and years of education. That is, we examined t -test signi?cance for the differences in dependent (i.e. from the same sample) correlation coef?cients, as outlined in Field ( 2009 ). These analyses were performed in the entire sample to avoid restricting the range of values, as would occur if we examined relationships by group. Moreover, w e were interested in shared variance between the cognitive screening measures and neuropsychological test performance, inde- pendent of group membership (CI or MCI), as clinicians must choose appropriate screeners for patients prior to knowing the subsequent diagnosis. Finally, we also examined the proportion of MCI participants who were normatively impaired for the MMSE and 3MS. For the purposes of this analysis, we de?ned “impaired” in a liberal fashion, as those participants scoring ? 1 SD below the mean. For the MMSE, normative data were taken from Crum et al. ( 1993 ) and for the 3MS, normative data were taken from Jones et al. ( 2002 ). Results T able 1 shows sociodemographic characteristics. Analyses were ?rst conducted separately by MCI subgroup (aMCI and naMCI). No differences emerged between these groups; therefore, MCI participants were examined as a single cohort for all subsequent analyses. Due to group (CI and MCI) differences in age and years of education, we included these variables as covariates in relevant analyses. With respect to Hypothesis 1, both the MMSE and 3MS ( T able 2 ) were signi?cant predictors of diagnostic outcome (CI or MCI) in hierarchical logistic regression models, with comparable odds ratios. Results of ROC analyses are presented in T able 3 and Figure 1. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Given differences by group in age and years of education, we also conducted the ROC analyses using predicted probabilities from the hierarchical logistic regression models, while controlling for these sociodemographic factors. Results mirrored those presented above; for the sake of parsimony and interpretability, only the results from the raw scores are presented. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Discussion W e examined the proper ties of the MMSE and 3MS in a sample of older adults classi?ed as MCI or CI. Although previous researchers investigated these measures in other populations (Grace et al., 1995; T ombaugh et al., 1996; McDowell et al., 1997 ), the current study is the ?rst to our know- ledge to make the comparison in MCI. Consistent with a priori hypotheses, the 3MS outperformed the MMSE across several metrics. First, relative to the MMSE, the 3MS explained more variance and showed better classi?cation accuracies in logistic regression analyses, primarily by reducing f alse positive errors. Similarly, it resulted in a larger ROC AUC parameter (0.85) than the MMSE (0.74), further suppor ting improved discriminatory power. Second, the 3MS shared more variance than the MMSE with neuropsychological composite scores in Language (28 vs. 9, respectively) and Memory (38 vs. 22, respectively) domains, suggesting stronger construct validity. Finally, results suggested that normative impairment on the 3MS facilitates enhanced clinical identi?cation of MCI (65.5 impaired) relative to the MMSE (11.7 impaired). Although the MMSE is widely used in both clin- ical and scienti?c contexts, it is plagued by a variety of limitations, including low sensitivity in detecting predementia syndromes, poor content validity in assessing language, visuospatial, and executive functions, and ceiling effects. W e demonstrated that the alterations incorporated into the 3MS (T eng and Chui, 1987 ) successfully address several of these limitations. In particular, the sensitivity of the 3MS was substantially higher than that of the MMSE (0.58) at optimal cut-off values, suggesting enhanced detection of early cognitive decline in older adults. Therefore, it is imperative that idiographic interpretation account for sociodemographic characteristics and suspected clinical syndromes. Second, our data revealed that the 3MS assessed neuropsychological language functions better than the MMSE, likely due to the addition of a semantic ?uency item, a verbal similarities task, and an expansion of the original confrontation naming task (T eng and Chui, 1987 ). W e contend that this represents a clinically meaningful improvement, given the insensitivity of the MMSE language items (Mitrushina and Satz, 1991 ), together with the potential for certain neurodegenerative illnesses (e.g. primary prog ressive aphasias; Harciarek and Kertesz, 2011 ) and acquired brain injuries (e.g. stroke; Sinanovic et al., 2011 ) to lead to language- speci?c impairments. The 3MS also shared more variance than did the MMSE with the composite Memory score, likely due to the additional recall of three words and the expanded scoring system. This ?nding is commensurate with Loewenstein et al.( 2000 ), who showed that a similar second. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Notably, the relationships betw een both screening measures and the executive composite were near zero, suggesting that the addition of the verbal abstraction and ?uency items to the 3MS do not improve coverage of this content area. Ex ecutive functions are considered a particularly complex and elusive construct to measure with traditional neuropsychological instruments (Barkley, 2012 ), yet they are vulnerable to a wide variety of disease states, including Alzheimer’s disease (AD; P er ry and Hodges, 1999 ), depression Snyder, 2013 ), and schizophrenia (Perlstein et al., 1998 ), among others. Results of our study suggest that examiners consider supplementing the 3MS with additional measures such as the TMT (Reitan, 1992 ) or the Wisconsin Card Sorting test (Berg, 1948 ) when dysexecutive symptomatology is suspected. Broadly speaking, our ?ndings make a strong argument for the clinical utility of the 3MS over the MMSE in detecting MCI. Adding to the aforementioned results, a follow-up analysis of published normative data demonstrated that MCI patients were substantially more likely to exhibit impairment on the 3MS compared to the MMSE. This is particularly noteworthy, given that MCI is generally considered to be too subtle to be measured by brief screening instruments (Strauss et al., 2006 ). While we do not contend that the 3MS should replace comprehensive neuropsychological evaluations, its brevity, user- friendliness, and extensive empirical support make it an ideal screening measure in large empirical investigations and routine clinical practice. In short, we believe that our data strongly favor the widespread substitution of the MMSE with the 3MS in older adults with concerns for cognitive decline. Several limitations should be considered when interpreting the current study results. First, our sample was comprised primarily of highly educated Caucasians, all of whom were referred for clinical neuropsychological evaluations in the context of potential pathological cognitive decline. It is noteworthy that the restricted range in years of education may explain why, inconsistent with prior research (T ombaugh and McIntyre, 1992; To m b a u g h et al., 1996; Jones et al., 2002 ), our MMSE and 3MS cut-off values were not moderated by level of educational attainment. Second, we did not have access to item-lev el data, so we were unable to examine domain-speci?c contributors to the differences between the MMSE and 3MS. Third, two different normative samples were used to compare proportions impaired on the MMSE (Crum et al., 1993 ) and 3MS (Jones et al., 2002 ). Consequently, we cannot rule out sample differences as a potential contributor to these results. Finally, sev eral other alter native screening measures (e.g. the SLUMS; T ariq et al., 2006 and the MoCA; Nazem et al., 2009 ) have outperformed the MMSE in head-to-head comparisons but these measures were not part of our clinical battery, so we are unable to comment on their psychometric properties relative to the 3MS. The MoCA is a particularly popular cognitive screening instrument and no study to our knowledge has compared the psychometric properties of the 3MS and MoCA. On the other hand, the 3MS includes a second memory recall item, raising the possibility that it is more sensitive to amnestic syndromes (e.g. AD). W e leave these questions to future investigations. Overall, results of the current study show substantial improvements of the 3MS over the MMSE in the discrimination of MCI from intact cognition in older adults. While many examiners have been hesitant to stray from the familiarity and vast empirical literature on the MMSE, even in the face of instruments with better psychometric properties, we contend that the 3MS circumvents these barriers, while substantially enhancing clinical and scienti?c utility and adding little in the way of administrative burden. Giv en the importance of cognitive screening in older adults in populations across the globe, together with the widespread use of the MMSE across languages and cultures, these results have the potential for far- reaching improvements in the early identi?cation of pathological cognitive decline in the elderly. Con?ict of interest None. Description of authors’ roles R. V an Patten participated in research question formulation and study design. R. Van P atten also conducted data analysis and wrote the paper. K. Britton participated in data collection and edited. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at G Tremont also supervised data analysis and edited the paper. Acknowledgments The authors would like to thank the providers and staff from the Rhode Island Hospital Neuropsycho- logy Program for their contributions to this project. Refe re nce s Barkley, R. A. (2012). Executive Functions: What They Are, How They W ork, and Why They Evolved. New Y ork, NY: Guilford Press. Benedict, R. H., Schretlen, D., Groninger, L., Dobraski, M. and Shpritz, B. (1996). Revision of the brief visuospatial memory test: studies of normal perfor mance, reliability, and validity. New Y ork: Oxford University Press. Berg, E. A. (1948). A simple objective technique for measuring ?exibility in thinking. Odessa, FL: Psychological Assessment Resources. Bravo, G. and Hebert, R. (1997). Age and education speci?c reference values for the mini-mental and modi?ed mini-mental state examinations derived from a non-demented elderly population. Thousand Oaks, CA: Sage Publications. Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. Harciarek, M. and Kertesz, A. (2011). Primar y progressive aphasias and their contribution to the contemporary knowledge about the brain-language relationship. Odessa, FL: Psychological Assessment Resources. Kaplan, E., Goodglass, H. and W eintraum, S. (1983). The Boston Naming T est. New Y ork: NY: Oxford University Press. Loewenstein, D. A. et al. (2000). Utility of a modi?ed mini-mental state examination with extended delayed recall in screening for mild cognitive impairment and dementia among community dwelling elders. Downloaded from. IP address: 66.75.242.89, on 21 Jul 2018 at 23:21:03, subject to the Cambridge Core terms of use, available at Reitan Neuropsychology Laboratory, T ucson. Sinanovi ? c, O., Mrkonji ? c, Z., Zuki ? c, S., Vidovi ? c, M. and Imamovi ? c, K. (2011). Post-stroke language disorders. Odessa, FL: Psychological Assessment Resources. Stern, R. A. and White, T. (2003). Neuropsycholo gical Assessment Battery: Administration, Scoring, and Interpretation Manual. T ombaugh, T. N., McDow ell, I., Kristjansson, B. and Hubley, A. M. (1996). Mini-mental state examination (MMSE) and the modi?ed MMSE (3MS): a psychometric comparison and normative data. T ombaugh, T. N. and McIntyre, N. J. (1992). The mini-mental state examination: a comprehensive review. San Antonio, TX: The Psychological Corporation. San Antonio, TX: Pearson. Y o u d e n,W.J. (1950). Index for rating diagnostic tests.Various tests were used by the selected studies, including the MMSE, Modified MMSE (3MS), and Digit Symbol-Coding subtest of the WAIS-III. Second?order multistage regression was identified as the best?fit model for the association between the probability of cognitive impairment and serum folate levels based on data generated by randomly sampling probabilistic distributions with parameters estimated based on summarized information reported in relevant publications. The findings indicate a “J?shape” effect of serum folate levels on the occurrence of cognitive impairment. In particular, an excessive level of folate exposure is predicted to be associated with a higher risk of cognitive impairment, albeit with greater uncertainty than the association between low folate exposure and cognitive impairment. View Show abstract. In addition, the participants were a clinically-based sample of participants recovering from a hip fracture, which may not be reflective of the broader population living with cognitive impairment. In addition, the MMSE although used widely in clinical settings has increasingly been out-performed by alternative instruments, and particularly those sensitive enough to monitor the degree of change in cognitive impairment within populations over time (Jorm et al., 1995; Van Patten et al., 2018). For example the Psychogeriatric Assessment Scales -Cognitive Impairment Scale (or PAS-CIS) was developed specifically in a population of 1045 older Australians living in the community or in institutions and to be sensitive enough to capture changes in cognitive impairment over time (Jorm et al., 1995).. Assessing quality of care in nursing homes using discrete choice experiments: How does the level of cognitive functioning impact upon older people's preferences. Article Aug 2019 SOC SCI MED Rachel Milte Elisabeth Huynh Julie Ratcliffe Traditionally older people with mild to moderate cognitive impairment have been excluded from preference elicitation studies in health economics. We assessed the impact of the level of cognitive functioning on preference and scale heterogeneity in a discrete choice experiment undertaken with 126 older people living in residential aged care homes in Australia between January 2015 and February 2016. The Swait-Louviere test was undertaken to formally test for differences in preference and scale between the two groups. Overall, the findings provide support for the more widespread inclusion of older people with mild to moderate cognitive impairment in such studies. Participants between the ages of 18yrs and 50yrs were recruited through the University of California, Los Angeles and local community advertisements. The sample was comprised of 186 right-handed participants (84 males and 102 females), with the absence of significant medical or psychiatric conditions.. History of Early Life Adversity is Associated with Increased Food Addiction and Sex?specific Alterations in Reward Network Connectivity in Obesity Article Full-text available Jul 2019 Vadim Osadchiy Emeran A Mayer Ravi R. Bhatt Arpana Gupta Background. Neuroimaging studies have identified obesity-related differences in the brain's resting state activity. An imbalance between homeostatic and reward aspects of ingestive behaviour may contribute to obesity and food addiction. The interactions between early life adversity (ELA), the reward network and food addiction were investigated to identify obesity and sex-related differences, which may drive obesity and food addiction. Methods. Participants completed questionnaires to assess ELA (Early Traumatic Inventory) and food addiction (Yale Food Addiction Scale). A tripartite network analysis based on graph theory was used to investigate the interaction between ELA, brain connectivity and food addiction. Interactions were determined by computing Spearman rank correlations, thresholded at q View Show abstract. It was not surprising that the MMSE was the most commonly used measure in the included studies as it has been reported to be the most frequently applied cognitive test worldwide (Carnero-Pardo 2014). The widespread use of the MMSE can be controversial due to threats to validity and reliability resulting from misuse of the assessment (Monroe and Carter 2012), its lack of sensitivity to mild deficits and classification inaccuracies (Van Patten et al. 2019), and the considerable effect of socio-educational variables on results (Carnero-Pardo 2014). That said, the advantage of the widespread use of the MMSE in cognitive research is that it allows direct comparisons to be made across studies and contributes to homogeneity in meta-analyses.. The Impact of Adherence to the Traditional Mediterranean Diet and Sex Differences on Global Cognitive Functioning: a Systematic Review and Meta-analysis Article Jul 2019 Michelle E. Kelly David Loughrey Joanna Power Brian Pennie Contradictory findings in reviews that assess the relationship between the Mediterranean Diet (MedDiet) and cognitive functioning have been attributed to heterogeneity in the criteria used to assess MedDiet and cognition, and differences in the location or cultural habits of the populations studied. Few reviews have examined the relationship between dietary adherence and cognition or considered the impact of sex differences. We included isolated data from Mediterranean regions and considered differential outcomes based on sex. The primary outcome of interest was global cognitive functioning. Results are compared to those of prior meta-analyses, and the impact of sources of heterogeneity is considered. The potential influence of sex and gender, as biological and social constructs, on dietary adherence is discussed. View Show abstract Aging as “Time-Related Dysfunction”: A Perspective Article Full-text available Jul 2020 Marios Kyriazis View Fusion of ULS Group Constrained High- and Low-Order Sparse Functional Connectivity Networks for MCI Classification Article Apr 2019 NEUROINFORMATICS Yang Li Jingyu Liu Ziwen Peng Dinggang Shen Functional connectivity networks, derived from resting-state fMRI data, have been found as effective biomarkers for identifying mild cognitive impairment (MCI) from healthy elderly.