# 10 - Bedside cognitive examination tools

# Bedside cognitive examination tools

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Bedside cognitive examination tools 
(This section is best read in conjunction with the section on neuropsychological tests in the Applied Neuroscience chapter and 
the chapter on Rating Scales) 
MMSE: The Mini-Mental State Examination (MMSE) is the standard screening instrument for 
dementia introduced by Folstein in 1976. It takes 5–10 minutes to administer and has a median 
positive Likelihood Ratio of 6.3 and a median Negative Likelihood Ratio of 0.19. 
 Brief tool for grading cognitive impairment in elderly and screening form dementia. 
 Not very sensitive to change, but used in anti-dementia drugs’ clinical trials. 
 ADAS-Cog may be better suited to detect change. 
 Practice effect may occur with MMSE. 
 It is a 30point scale 
 With less than 9 years of formal education, the cut off for suspecting dementia must be 21/22 
and not the usual 23/24. 
 Insensitive to early decline. 
 Doesn’t pick up frontal executive defects 
Bulbar Palsy 
Bulbar Palsy 
•LMN weakness of 9-12 cranial nerves 
•Wasted, fasciculating tongue 
•Nasal speech 
•Lost jaw jerk and gag reflex 
•emotional lability not seen 
•MND, polio, botulism, myasthenia 
gravis, muscular dystrophies 
Pseudobulbar palsy 
Pseudobulbar palsy 
•bilateral supranuclear (UMN) lesions 
of lower cranial nerves 
•Stiff tongue; wasting seen only in 
later stages 
•Donald-duck speech 
•Exaggerated jaw jerk; preserved gag 
reflex 
•emotional lability (pathological 
emotionalism) 
•MND, multiple sclerosis, 
multiinfarch dementia and severe 
head injury.

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ITEMS in MMSE 
o Orientation (10) 
o Registration (3) and recall (3) tasks (6 points total) 
o Attention task (5) 
o Multistep command (3) 
o Naming (2) 
o Repetition language (1) 
o Reading comprehension (close your eyes, 1 point) 
o Writing (1) 
o Visual construction (copy interlocking polygons, 1 point) 
Clinical interview with carers and patients is the best diagnostic tool for any disorder including 
dementia; overreliance on MMSE scores can be counterproductive. 
The clock drawing test: Clock drawing test requires verbal understanding (comprehension), 
short-term working memory to process the instruction and spatially coded knowledge in 
addition to constructive skills and planning (executive function). (It does not test orientation to 
time!) 
 Watson introduced a 7 scores screening method with a good degree of reliability. The 
placing of any three digits in a quadrant is considered to be correct. An error score of one is 
assigned to each of the first three quadrants containing any errors, and an error score of 
four is assigned for the fourth quadrant if it contains an error. Thus, a maximum error score 
of seven can be obtained. The normal range for the score is 0-3. A score of 4 or greater in 
this scoring system has a sensitivity of 87%, a specificity of 82% and a kappa value of 0.70 
for identifying dementia (according to the NINCDS-ADRDA criteria for probable 
dementia). 
 The test has a high correlation with the MMSE and other tests of cognitive dysfunction. 
 It can also be used in diagnosing unilateral neglect and inattention. 
 Subjects of low education, advanced age and depression perform more poorly. There are 
many methods of administering and scoring. 
 Normal clock-drawing ability reasonably excludes cognitive impairment 
 
Addenbrooke’s cognitive examination (ACE-Revised): 
 ACE-R evaluates six cognitive domains (orientation, attention, memory, verbal fluency, 
language and visuospatial ability). It is useful for detecting dementia and mild cognitive 
impairment.

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 Frontal tests such as verbal fluency are also included in the ACE, making it more sensitive 
to frontal types of dementia than MMSE. (Hodges R et al., 2000). It is also effective for 
differentiating the subtypes of dementia, such as Alzheimer’s disease, frontotemporal 
dementia, progressive supranuclear palsy, and other forms of dementia associated with 
parkinsonism (Rittman et al., 2013). 
 The normative data provided with ACE-R (revised version) states that there are two 
defined cut-offs (<88: sensitivity=0.94, specificity=0.89; <82: sensitivity=0.84, specificity=1.0). 
The likelihood ratio for a positive test of dementia at a cut-off of 82 is 100:1. 
 Language domain receives the major share of the scoring in ACE.