Dementia Report

8/3/2019 Dementia Report

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Far Eastern UniversityInstitute of Nursing

Evidence- BasedNursing

Submitted by:

BSN203-Group 9A

Abadilla, Loise Anne M.

Ablaza, Jenalyn C.

Anies, Maria Alyssa C.

Antonio, Alvin Nel P.

Arrangquez, Precious Anne G.

Briones, Lester Paul M.

Submitted to:

Prof. Teodoro

Alejo MD, RN,MAN



I. Clinical Question What is the best

initial test assessmentin diagnosing

patients withdementia?



II. Citation

BMJ 2009; 338:b2030

doi:10.1136/bmj.b2030

(Published 4 June2009)



• Patients Included.

540 control participants with the agerange of 18 to 95 and 139 patientsattending a memory clinic with

dementia/amnestic mild cognitiveimpairment.• Interventions compared.

The study has compared a cognitive testdesigned to use minimal operator time and tobe suitable for non-specialist use called “Test Your Memory” (TYM) against two other

cognitive tests: Mini-Mental State Examination

III. Study Characteristics



• Outcomes monitored.

The test was independently marked by three different people: a

consultant experienced in the diagnosis of degenerative dementia, aneurology specialist registrar working in the memory clinic and a registeredgeneral nurse who received 10 minutes of tuition on marking the test, butwho had no specialised experience of patients with dementia. The patientsincluded in the test were assessed on the months of March to December of2009.

• Does the study focus on a significant problem in clinical

practice?

The study is focused on a significant problem in clinical practicesince dementia and other cognitive problems is a growing condition which

accounts for 24 million individuals worldwide and that number doubles every20 years. In addition, assessment is said to be a crucial part of manymedical consultations. Hence, these assessment tests are essential inproviding accurate data regarding patients’ condition.



• Methodology/ Design • Methodology Used.

In this cross sectional study, the researchers designed the TYM(Test Your Memory) to fulfil the requirements. The study was executedby allowing patients to fill in the test themselves with a minimal amountof time (5 minutes). The new “test your memory” test (TYM) was quickto use and detected 93% of cases of Alzheimer’s disease. Controlparticipants completed the TYM quickly and accurately.

The TYM is completed by the patient themselves and involves 10tasks with different scores for each. These are: orientation (10 points),ability to copy a sentence (two points), “semantic knowledge” on long-established knowledge about facts, objects and meanings of words(three points), calculation (four points), verbal fluency (four points),

similarities (four points), naming (five points), two tasks of visuospatialabilities (total seven points) and recall of a copied sentence (six points).The ability to perform the test was assigned a score of up to fivepoints. In total, those taking the test could score up to 50 points, with ahigher score indicating better memory and cognition.



The TYM was given to a control group of 540 peopleaged 18 to 95 who did not have dementia, 31 patients withnon- Alzheimer’s forms of dementia and 108 people withamnesic mild cognitive impairment or Alzheimer’s disease.Mild cognitive impairment (MCI) is likely to progress to Alzheimer’s in individuals with certain cognitive examinationscores.

Diagnoses of dementia were made by a neurologist, whoadministered the mini-mental state examination (MMSE)and the revised Addenbrooke’s cognitive examination(which includes the MMSE) and assessed the results of

brain imaging and blood tests. Many of the patients alsohad psychiatric and neuropsychological assessment.Diagnoses of Alzheimer’s were made using establishedcriteria, while other published criteria were used to diagnoseamnesic MCI.



The control group of people without dementia was recruited byselecting relatives of people attending the neurology clinic where

the study was being conducted and also from relatives of peopleattending neurology and medical outpatient departments at twoother hospitals. Three age-matched controls were selected fromthis larger group for each person with Alzheimer’s.

The researchers compared TYM scores for people with and

without Alzheimer’s disease with scores obtained using theMMSE and the revised Addenbrooke’s cognitive examination, tosee if there were any differences.

To look at how scores might vary depending on who markedthe test, they compared how a sample of 100 tests scored when

the test was independently marked by three different people: aconsultant experienced in the diagnosis of degenerativedementia, a neurology specialist registrar working in the memoryclinic and a registered general nurse who received 10 minutes oftuition on marking the test, but who had no specialised

experience of patients with dementia.



The researchers then assessed the sensitivity and specificity of the TYM test: • Sensitivity is the ability to accurately detect that someone does have Alzheimer’s disease, and • Specificity is the ability to accurately detect that someone does not have

Alzheimer’s.The researchers tested these factors by applying a range different cutoff

scores on the TYM results to see how well these cutoff scores could distinguishbetween those with Alzheimer’s disease or MCI that was likely to progress toAlzheimer's (total 92 patients) and those without the disease (282 randomly selectedage-matched controls), based on diagnosis by the neurologist.

This method was used to identify which cutoff score gave the best balanceof sensitivity and specificity. For the TYM, the optimal cutoff score was calculated tobe 42 or less.

The researchers also looked at how the sensitivity and specificity of the TYMcompared to that of the commonly used MMSE test. They did this by calculating thepercentage of patients with Alzheimer’s disease who were detected using the cutoff

score of 42 or less for the TYM and a score of 23 or less for the MMSE (the acceptedcutoff for dementia with this test).

The value of a test result in ruling in or out a disease (its positive or negativepredictive value) is affected by how common the disease is in the group tested (itsprevalence). The researchers therefore looked at what the positive or negativepredictive value of the TYM would be in populations with varying prevalence of

Alzheimer’s disease.



•Design.This was a cross-sectional study

designed to evaluate the ‘Test YourMemory’ (TYM) test as a potential methodfor identifying Alzheimer’s disease.

•Setting.The study was conducted at

outpatient departments in three hospitals,

including a memory clinic. QueenElizabeth Hospital, King’s Lynn, NorthCambridgeshire Hospital, Wisbech, and

Addenbrooke’s Hospital.



• Data sources. Ferri C, Prince M, Brayne C, Brodaty H, Fratiglioni L,

Ganguli M, et al. Global prevalence of dementia: a Delphiconsensus study.Lancet2006;366:2112-7. Graham JE, Rockwood K, Beattie BL, Eastwood R,Gauthier S, Tuokko H, et al. Prevalence and severity of

cognitive impairment with and without dementia in an elderlypopulation. Lancet1997;349:1793-6.Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patientsfor the clinician. J Psychiatr Res1975;12:189-98.Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges J. The Addenbrooke’s cognitive examination revised (ACE-R). Abrief cognitive test battery for dementia screening. Int JGeriatr Psychiatry2006;21:1078-85.



• Subject Selection. • Inclusion Criteria.

Patients were seen and diagnosed by a consultantneurologist with an interest in dementia in a dedicated

memory clinic at Addenbrooke’s Hospital. Controls were

recruited from relatives accompanying patients to the

memory clinic. Additional controls were recruited fromrelatives of patients attending neurology and medical

outpatients departments at two other hospitals. The study

also included some dermatology outpatients. Patients with

Alzheimer’s are included in the study if they werediagnosed without reference to the TYM test. Many also

had a psychiatric and neuropsychological assessment.



• Exclusion Criteria. The study excluded patients

whose cognitive problems were

thought to be substantially caused

by depression and also, people with

a history of neurological disease,memory problems, or brain injury.

• Has the original study

been replicated? No, because there were no

previous studies about this topic.



• What were the risks and benefits of the nursing action/intervention tested in the study?

Certain advantages and disadvantages can be pointed out in

the use of TYM. One benefit of this study is that there’s a brief but

rigorous scoring system. Ten-minute training and the scoring sheet

allows a nurse, without experience of memory clinics, to score the

TYM sheets as accurately as a specialist. The simplicity of the TYM

should allow it to be administered and scored in a different

language. It is currently being translated into four differentlanguages. The TYM was used successfully in patients outside this

study with more severe dementia or other physical disability. The

test is also useful for patients with hearing impairment who have

difficulty with verbal cognitive tests. The disadvantage of thememory test is the need for specially printed sheets; though, the

Addenbrooke’s cognitive examination-revised has a similar

requirement. A website is being developed to help to solve this

problem.



• Results of the Study. Control participants completed the TYM with an average

score of 47/50. Some low scoring controls aged over 70 show a

typical pattern for mild Alzheimer’s and might be in the earlystages (they were still included in the control group). Patients with Alzheimer’s disease scored an average of 33/50. The patients withmild cognitive impairment scored an average of 45/50 on the TYM,with a trend towards problems in anterograde memory; they

scored well in other subtests of the test. The TYM score showsexcellent correlation with the two standard tests. A score of ≤42/50had a sensitivity of 93% and specificity of 86% in the diagnosis of Alzheimer’s disease. The TYM was more sensitive in detection of Alzheimer’s disease than the mini-mental examination, detecting

93% of patients compared with 52% for the mini-mental stateexxamination. The negative and positive predictive values of theTYM with the cut off of ≤42 were 99% and 42% with a prevalenceof Alzheimer’s disease of 10%. Thirty one patients with non-Alzheimer dementias scored an average of 39/50.



TYM VERSUS mini-mental state examination The mini-mental state examination has been the

standard short cognitive test for 30 years. It has provedvaluable in the assessment of patients with establisheddementia. It has many strengths but fails three of therequirements for a brief screening test for the non-specialist: minimal operator time, testing a wide range ofcognitive domains, and sensitivity to mild Alzheimer’s. The

mini-mental state examination takes an average of eightminutes to administer. In addition, mini-mental state is saidto be insensitive in the detection of mild Alzheimer’s.

The TYM seems more sensitive than the mini-mental

state examination in screening for non- Alzheimer’s dementias. In the small group of such patients in our studythe average mini-mental score was 25, close to theaverage for the population. The TYM score in the samegroup was 39, eight points below the average control

score.



TYM VERSUS Addenbrooke’s cognitive

examination The original and revised Addenbrooke’s

examinations are sensitive and specific in thediagnosis of degenerative dementia. major

drawback of the revised examination is that itfails to fulfil the time requirement for a test fornon-specialists, taking 20 minutes toadminister and score. It tests a similar

number of cognitive domains to the TYM andis sensitive to mild Alzheimer’s.



• Author’s Conclusion/ Recommendations. • What contribution to the client healthstatus does the nursing action / intervention

make?This carefully conducted research assessed the

validity of a new, brief, self-administered test fordementia by trialing it in people who had clinicallyconfirmed Alzheimer’s or other types of dementia aswell as a large number of people who did not havedementia. The test has contributed to clients' earlydetection. And as we all know early detection is betterin order to slow down the gradual and irreversible

decline in memory. That is why it is a must for anindividual to consult the doctor annually, to detect earlycertain illnesses, implement appropriate interventionsand prevent them from worsening.



• What overall contribution to nursing

knowledge does the study make?

Cognitive tests aid the diagnosis of dementia and areimportant in the medical and social management of patientsand in the assessment of their capacity. TYM test emphasizesthe importance of assessment of a patient’s cognition. Also, itstresses that nurses are known to be a crucial part of the

assessment phase in diagnosing a disease. Moreover, this testhas instilled another means that is suitable for use in primary care and by non-specialists. Even without the proper trainingor experience, nurses are able to supervise the test. With this,

nurses will acquire more information regarding how thedisease is being assessed and diagnosed and therefore be ableto apply earlier the appropriate interventions and counselingthe client needs.



VII. Applicability • Does the study provide a direct enough answer to

your clinical question in terms of type of patients,

intervention and outcome?

The study provides a direct enough answer in terms of patient,intervention and outcome. The results of the study answer that “Test Your

Memory” test is the best and quickest assessment test in diagnosing dementia.

In terms of patient, the study had covered various groups, one group which

consists of patients with the actual disease and a control group. The study has

claimed that the study can detect dementia more accurately compared to other

two cognition tests. • Is it feasible to carry out the nursing

action in the real world?

Yes, it is feasible to carry out the nursing action in the real world

since the supervision of the test does not necessarily require a specializationon dementia. Moreover, the study on TYM test arrived to the result that it is

more effective and easy to use than other cognition tests. Hence, it will be most

likely to implement the use of this in many clinical settings. In addition, the

resources are sufficient in various hospitals in different countries. However,

there is no information indicating that the TYM is already available for usage

in the Philippines.



• Reviewer’s Conclusions/ Commentary Assessment of a patient’s cognition is a crucial part of

many medical consultations. Cognitive tests aid the diagnosis

of dementia and are important in the medical and socialmanagement of patients and in the assessment of their

capacity.

Many cognitive tests are available but only the TYM has

met the three critical requirements for widespread use by a

non-specialist—that is, take minimal operator time toadminister, test a reasonable range of cognitive functions,

and are sensitive to mild Alzheimer’s disease.

Unlike any other tests made, the TYM is the only test that

able to produce a diagnosis after 5 minutes of test, needing no

special training in improvising the intervention. This test will

truly be a big help on medical professionals because it saves

time and is uncomplicated. Moreover, this study provides

more meaningful directions for future public health

initiatives.



The TYM test, in our perpective, can replace other

cognition tests one reason for this is that the test’s accuracyagainst Addenbrooke’s and MMSE in identify dementia is higher.

Thus, the use of this is more appropriate and beneficial for boththe patient and the doctor. Advantageous for the client in thesense that he/she is provided with a test that is able to assessdementia most effectively, allowing for early interventions and care

thereby aiding in the slowing down of the gradual decline inmemory, language skills, perception of time and space, and,eventually, the ability to care for oneself. It is likewise beneficial forthe physician because the test is finished for 5 minutes only,letting him/her diagnose the client for 2 minutes only. This test willtruly be a big help on medical professionals because it saves timeand is uncomplicated. Furthermore, this study provides moremeaningful directions for future public health initiatives.



Evaluating the Nursing CarePractices

• Safety This study was performed under ethical approval

from Cambridgeshire 2 research ethics committee. All

participants signed an informed consent prior to

execution. Furthermore, all clients were under asupervision of a non-specialist, most likely a nurse.

• Competence of the care provider As stated earlier, it does not take a specialist in order to

provide and supervise the TYM test. In addition, the study

was successfully accomplished, therefore implying that

the care providers were competent in the research

process.



• Acceptability Since prior tests have already been used to

diagnose dementia, it may probably take time to

implement the use of TYM test. However, withthe noted number of advantages from the TYMtest as compared to the other two, it will mostlikely be recognized by many hospitalinstitutions.

• Effectiveness The result of the test confirms the

effectiveness of TYM. It was stated in the articlethat TYM has arrived to a more valid findings

than the two tests being compared to it. Inaddition nurses’ provision of the tests resultedto a more effective conduct of the study becauseof the knowledge and qualities in handlingassessments.



• Appropriateness The test is suitable to administer in all clinical settings

since it does not necessitate a specialization. Aside from

that, individuals with or without dementia or with orwithout any cognitive problems can undergo the test.• Efficiency

The TYM is a powerful and valid screening test for thedetection of dementia. The usefulness of screening tests

varies according and suits to clinical setting, and developexperience in its use to improve the identification of patients with early dementia.

• Accessibility The 'Test your Memory' is a newly made test completedin 2009. Thus, many health providers have notimplemented yet the use of this, especially in poorclinical settings.





Q.U.I.Z



1.) What does TYM stands

for?

a.) Test Your Mind

b.) Time Your Memory

c.) Take Your Medicine

d.) Test Your Memory



2.) How Long can TYM test be

completed?

a.) 5 mins.

b.) 8 mins.

d.) 10 mins.

d.) 20 mins.



3.) What is the highest score

in TYM?

a.) 10

b.) 20

c.) 50

d.) 100



4.) What are the

two cognitiontest being

compared to the

TYM ?



5.) TRUE or FALSE

TYM test is effective

in assessing and

detecting Alzheimer’s

and Mild Alzheimer’s

disease.

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