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Psychiatrists may be daunted by the prospect of undertaking a neurological examination. In this article we briefly review the neurological signs that may be seen in the context of some common neurological disorders of cognition and movement which may present with neurobehavioural symptoms and therefore may be seen initially by psychiatrists. This approach emphasises that neurological examination is not simply an operationalised procedure but an interpretative process. We propose a minimum neurological examination suitable for use by psychiatrists. Many of the signs included are relatively simple to observe or elicit, require no special equipment, and the examination techniques involved are easy to master.
The six-item cognitive impairment test (6CIT) is a brief cognitive screening instrument (CSI) recommended for use in primary care settings. There are very few studies of 6CIT performance in secondary care settings.
We undertook a pragmatic diagnostic accuracy study of 6CIT in consecutive patients referred over the course of one year to a neurology-led cognitive function clinic, and compared its performance for the diagnosis of dementia and mild cognitive impairment (MCI) to that of the simultaneously administered Mini-Mental State Examination (MMSE).
In a cohort of 245 patients with dementia prevalence around 20%, 6CIT proved quick and easy to use and acceptable to patients. It had good sensitivity (0.88) and specificity (0.78) for dementia diagnosis; it was more sensitive than MMSE (0.59) but less specific (0.85). For MCI diagnosis, 6CIT was again more sensitive (0.66) than MMSE (0.51) but less specific (0.70 vs. 0.75). Weighted comparisons showed net benefit for 6CIT compared to MMSE for both dementia and MCI diagnosis. 6CIT effect sizes (Cohen's d) were large for dementia diagnosis and moderate for MCI diagnosis.
6CIT is an acceptable and accurate test for the assessment of cognitive problems, its performance being more sensitive than the MMSE. 6CIT use should be considered as a viable alternative to MMSE in the secondary care setting.
The Addenbrooke's Cognitive Examination (ACE) and its Revised version (ACE-R) are relatively new screening tools for cognitive impairment that may improve upon the well-known Mini-Mental State Examination (MMSE) and other brief batteries. We systematically reviewed diagnostic accuracy studies of ACE and ACE-R.
Published studies comparing ACE, ACE-R and MMSE were comprehensively sought and critically appraised. A meta-analysis of suitable studies was conducted.
Of 61 possible publications identified, meta-analysis of qualifying studies encompassed 5 for ACE (1,090 participants) and 5 for ACE-R (1156 participants); of these, 9 made direct comparisons with the MMSE. Sensitivity and specificity of the ACE were 96.9% (95% CI = 92.7% to 99.4%) and 77.4% (95% CI = 58.3% to 91.8%); and for the ACE-R were 95.7% (95% CI = 92.2% to 98.2%) and 87.5% (95% CI = 63.8% to 99.4%). In a modest prevalence setting, such as primary care or general hospital settings where the prevalence of dementia may be approximately 25%, overall accuracy of the ACE (0.823) was inferior to ACE-R (0.895) and MMSE (0.882). In high prevalence settings such as memory clinics where the prevalence of dementia may be 50% or higher, overall accuracy again favored ACE-R (0.916) over ACE (0.872) and MMSE (0.895).
The ACE-R has somewhat superior diagnostic accuracy to the MMSE while the ACE appears to have inferior accuracy. The ACE-R is recommended in both modest and high prevalence settings. Accuracy of newer versions of the ACE remain to be determined.
Understanding the cognitive aspects of neurological disorders is essential to manage effectively patients suffering from these conditions. This book begins by outlining the various cognitive domains and how these can be tested, before covering in depth the cognitive deficits seen in prototypical neurodegenerative cognitive disorders (Alzheimer's disease, frontotemporal dementias, Huntington's disease, prionoses) and other common neurological disorders that may be complicated by cognitive impairment (stroke, multiple sclerosis, Parkinson's disease, brain tumours). This second edition has been completely revised and updated, with new material added throughout, including two new chapters: 'Sleep-Related Disorders' and 'Psychiatric Disorders in the Cognitive Function Clinic'. This an essential reference for all neurologists, not just for those with an interest in cognitive disorders. General physicians and specialists who deal with endocrine, metabolic, vascular or infective disorders that may compromise cognitive function, and allied health professionals who work with cognitively impaired patients, will also find this text useful.