Far Eastern University

Institute of Nursing

Evidence- Based Nursing

Submitted to: Prof. Teodoro Alejo MD, RN, MAN

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.

I. Clinical Question What is the best initial test assessment in diagnosing patients with dementia?

II. Citation
BMJ2009; 338:b2030

doi: 10.1136/bmj.b2030 (Published 4 June 2009)

III. Study Characteristics

Patients Included.

540 control participants with the age range of 18 to 95 and 139 patients attending a memory clinic with dementia/amnestic mild cognitive impairment.
Interventions compared.

The study has compared a cognitive test designed to use minimal operator time and to be suitable for non-specialist use called Test Your Memory (TYM) against two other cognitive tests: Mini-Mental State Examination

 Outcomes monitored. The test was independently marked by three different people: a consultant experienced in the diagnosis of degenerative dementia, a neurology specialist registrar working in the memory clinic and a registered general nurse who received 10 minutes of tuition on marking the test, but who had no specialised experience of patients with dementia. The patients included in the test were assessed on the months of March to December of 2009.

Does the study focus on a significant problem in clinical practice? The study is focused on a significant problem in clinical practice since dementia and other cognitive problems is a growing condition which accounts for 24 million individuals worldwide and that number doubles every 20 years. In addition, assessment is said to be a crucial part of many medical consultations. Hence, these assessment tests are essential in providing 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 executed by allowing patients to fill in the test themselves with a minimal amount of time (5 minutes). The new test your memory test (TYM) was quick to use and detected 93% of cases of Alzheimers disease. Control participants completed the TYM quickly and accurately. The TYM is completed by the patient themselves and involves 10 tasks with different scores for each. These are: orientation (10 points), ability to copy a sentence (two points), semantic knowledge on longestablished 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 visuospatial abilities (total seven points) and recall of a copied sentence (six points). The ability to perform the test was assigned a score of up to five points. In total, those taking the test could score up to 50 points, with a higher score indicating better memory and cognition.

The TYM was given to a control group of 540 people aged 18 to 95 who did not have dementia, 31 patients with non-Alzheimers forms of dementia and 108 people with amnesic mild cognitive impairment or Alzheimers disease. Mild cognitive impairment (MCI) is likely to progress to Alzheimers in individuals with certain cognitive examination scores. Diagnoses of dementia were made by a neurologist, who administered the mini-mental state examination (MMSE) and the revised Addenbrookes cognitive examination (which includes the MMSE) and assessed the results of brain imaging and blood tests. Many of the patients also had psychiatric and neuropsychological assessment. Diagnoses of Alzheimers were made using established criteria, while other published criteria were used to diagnose amnesic MCI.

The control group of people without dementia was recruited by selecting relatives of people attending the neurology clinic where the study was being conducted and also from relatives of people attending neurology and medical outpatient departments at two other hospitals. Three age-matched controls were selected from this larger group for each person with Alzheimers. The researchers compared TYM scores for people with and without Alzheimers disease with scores obtained using the MMSE and the revised Addenbrookes cognitive examination, to see if there were any differences. To look at how scores might vary depending on who marked the test, they compared how a sample of 100 tests scored when the test was independently marked by three different people: a consultant experienced in the diagnosis of degenerative dementia, a neurology specialist registrar working in the memory clinic and a registered general nurse who received 10 minutes of tuition 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 Alzheimers disease, and Specificity is the ability to accurately detect that someone does not have Alzheimers. The researchers tested these factors by applying a range different cutoff scores on the TYM results to see how well these cutoff scores could distinguish between those with Alzheimers disease or MCI that was likely to progress to Alzheimer's (total 92 patients) and those without the disease (282 randomly selected age-matched controls), based on diagnosis by the neurologist. This method was used to identify which cutoff score gave the best balance of sensitivity and specificity. For the TYM, the optimal cutoff score was calculated to be 42 or less. The researchers also looked at how the sensitivity and specificity of the TYM compared to that of the commonly used MMSE test. They did this by calculating the percentage of patients with Alzheimers 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 accepted cutoff for dementia with this test). The value of a test result in ruling in or out a disease (its positive or negative predictive value) is affected by how common the disease is in the group tested (its prevalence). The researchers therefore looked at what the positive or negative predictive value of the TYM would be in populations with varying prevalence of Alzheimers disease.

 Design. This was a cross-sectional study designed to evaluate the Test Your Memory (TYM) test as a potential method for identifying Alzheimers disease. Setting. The study was conducted at outpatient departments in three hospitals, including a memory clinic. Queen Elizabeth Hospital, Kings Lynn, North Cambridgeshire Hospital, Wisbech, and Addenbrookes Hospital.

 Data sources. Ferri C, Prince M, Brayne C, Brodaty H, Fratiglioni L, Ganguli M, et al. Global prevalence of dementia: a Delphi consensus 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 elderly population. Lancet1997;349:1793-6. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res1975;12:189-98. Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges J. The Addenbrookes cognitive examination revised (ACE-R). A brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry2006;21:1078-85.

 Subject Selection.
Inclusion Criteria.

Patients were seen and diagnosed by a consultant neurologist with an interest in dementia in a dedicated memory clinic at Addenbrookes Hospital. Controls were recruited from relatives accompanying patients to the memory clinic. Additional controls were recruited from relatives of patients attending neurology and medical outpatients departments at two other hospitals. The study also included some dermatology outpatients. Patients with Alzheimers are included in the study if they were diagnosed 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 theres 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 different languages. 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 the memory test is the need for specially printed sheets; though, the Addenbrookes 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 Alzheimers and might be in the early stages (they were still included in the control group). Patients with Alzheimers disease scored an average of 33/50. The patients with mild 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 shows excellent correlation with the two standard tests. A score of 42/50 had a sensitivity of 93% and specificity of 86% in the diagnosis of Alzheimers disease. The TYM was more sensitive in detection of Alzheimers disease than the mini-mental examination, detecting 93% of patients compared with 52% for the mini-mental state exxamination. The negative and positive predictive values of the TYM with the cut off of 42 were 99% and 42% with a prevalence of Alzheimers disease of 10%. Thirty one patients with nonAlzheimer 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 proved valuable in the assessment of patients with established dementia. It has many strengths but fails three of the requirements for a brief screening test for the nonspecialist: minimal operator time, testing a wide range of cognitive domains, and sensitivity to mild Alzheimers. The mini-mental state examination takes an average of eight minutes to administer. In addition, mini-mental state is said to be insensitive in the detection of mild Alzheimers. The TYM seems more sensitive than the mini-mental state examination in screening for non-Alzheimers dementias. In the small group of such patients in our study the average mini-mental score was 25, close to the average for the population. The TYM score in the same group was 39, eight points below the average control score.

TYM VERSUS Addenbrookes cognitive examination The original and revised Addenbrookes examinations are sensitive and specific in the diagnosis of degenerative dementia. major drawback of the revised examination is that it fails to fulfil the time requirement for a test for non-specialists, taking 20 minutes to administer and score. It tests a similar number of cognitive domains to the TYM and is sensitive to mild Alzheimers.

 Authors Conclusion/ Recommendations. What contribution to the client health status does the nursing action / intervention make?
This carefully conducted research assessed the validity of a new, brief, self-administered test for dementia by trialing it in people who had clinically confirmed Alzheimers or other types of dementia as well as a large number of people who did not have dementia. The test has contributed to clients' early detection. And as we all know early detection is better in order to slow down the gradual and irreversible decline in memory. That is why it is a must for an individual to consult the doctor annually, to detect early certain illnesses, implement appropriate interventions and prevent them from worsening.

 What overall contribution to nursing knowledge does the study make?

Cognitive tests aid the diagnosis of dementia and are important in the medical and social management of patients and in the assessment of their capacity. TYM test emphasizes the importance of assessment of a patients cognition. Also, it stresses that nurses are known to be a crucial part of the assessment phase in diagnosing a disease. Moreover, this test has instilled another means that is suitable for use in primary care and by non-specialists. Even without the proper training or experience, nurses are able to supervise the test. With this, nurses will acquire more information regarding how the disease is being assessed and diagnosed and therefore be able to apply earlier the appropriate interventions and counseling the client needs.

 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.

VII. Applicability

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 specialization on 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.

 Reviewers Conclusions/ Commentary Assessment of a patients cognition is a crucial part of many medical consultations. Cognitive tests aid the diagnosis of dementia and are important in the medical and social management 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-specialistthat is, take minimal operator time to administer, test a reasonable range of cognitive functions, and are sensitive to mild Alzheimers 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 tests accuracy against Addenbrookes and MMSE in identify dementia is higher. Thus, the use of this is more appropriate and beneficial for both the patient and the doctor. Advantageous for the client in the sense that he/she is provided with a test that is able to assess dementia most effectively, allowing for early interventions and care thereby aiding in the slowing down of the gradual decline in memory, language skills, perception of time and space, and, eventually, the ability to care for oneself. It is likewise beneficial for the physician because the test is finished for 5 minutes only, letting him/her diagnose the client for 2 minutes only. This test will truly be a big help on medical professionals because it saves time and is uncomplicated. Furthermore, this study provides more meaningful directions for future public health initiatives.

Evaluating the Nursing Care Practices

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 a supervision 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, with the noted number of advantages from the TYM test as compared to the other two, it will most likely be recognized by many hospital institutions.
Effectiveness

The result of the test confirms the effectiveness of TYM. It was stated in the article that TYM has arrived to a more valid findings than the two tests being compared to it. In addition nurses provision of the tests resulted to a more effective conduct of the study because of the knowledge and qualities in handling assessments.

 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 or without any cognitive problems can undergo the test. Efficiency The TYM is a powerful and valid screening test for the detection of dementia. The usefulness of screening tests varies according and suits to clinical setting, and develop experience in its use to improve the identification of patients with early dementia. Accessibility The 'Test your Memory' is a newly made test completed in 2009. Thus, many health providers have not implemented yet the use of this, especially in poor clinical 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 cognition test being compared to the TYM ?

5.) TRUE or FALSE

TYM test is effective in assessing and detecting Alzheimers and Mild Alzheimers disease.