Nonetheless, because false-positive results become a concern when applying this threshold to large populations with a low incidence of dementia, such as persons living independently in community, some experts prefer interpreting the MMSE score in three ranges (Dick et al., 1984 Kahle-Wrobleski et al., 2007). Assuming there is no evidence of delirium, a MMSE score of 23 or less increases the probability of dementia greatly, whereas a score of 24-30 decreases it. While the MMSE was originally developed to screen for dementia and delirium, many neurologists use this measure as a screening instrument for ‘cognitive impairment’ in hospitalized stroke patients (Nys et al., 2005). The MMSE was introduced by Folstein in 1975 as an 11-part bedside test requiring only 5-10 minutes to administer, a much briefer time compared with the 1-2 hour long formal tests for dementia (Gluhm et al., 2013). In the following sections using an evidence-based approach we explore important features of MMSE and MoCA and their significance in clinical and research settings. It is therefore important to consider factors such as inter-rater reliability which evaluates the consensus amongst clinicians to score patients in a similar fashion, and test-retest reliability which measures the consistency of the test over time as well as sensitivity and specificity of such tests before assign cutoff scores as requirement for admission and discharge. Just like an IQ score that can change the course of a child’s life or a credit score that can affect a family’s livelihood a cognitive score specifically in stroke population can directly affect the course of recovery or the choice of rehab institutions. We ought to realize that these scores are stored in patients medical records and are highly consequential parameters in the course of patients journey to treatment and recovery. This issue begs the following questions: Do we have appropriate institutional guidelines for the timeline of administration of such tests? when should cognitive tests be administered? Most stroke patients have much higher cognitive scores few weeks after the onset. We all are familiar with the post-stroke inflammatory processes and network reorganization that occur within the first few months after stroke. Based on my observations, many patients are labeled unworthy of rehab after stroke and sent to longterm care institutions because of a MoCA test that was administered 3 days after stroke. Despite training and certification in administering these tests Inter-rater reliability is one of the major treats, especially when there is a cutoff to determine if a patient is or is not cognitively competent. However, such approaches expose clinicians to bias and misinterpretation. This approach tends to stratify patients based on their scores and makes it easier to follow the progression of disease or in some cases efficacy of treatments and therapeutics.
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When a patient is seen by a neurologist or a physiatrist it is easier to look at the chart and see a test score assigned to the patient by previous clinicians. Given the fact that in our modern medicine each patient is assessed and treated by multiple clinicians developing clinical tests deemed necessary. From executive function to memory, attention and motor planning, cognitive ability of a patient is a strong determinant of longterm outcome and prognosis. Whether hemorrhagic or ischemic, stroke is the main cause of vascular cognitive impairment (VCI). 4- MMSE and MoCA forms to download (PDF- English & French).3- Montreal Cognitive Assessment (MoCA): Sensitivity, Specificity and Predictive Values.2- Mini-Mental Status Examination (MMSE): Sensitivity, Specificity and Predictive Values.Here, we argue that in clinical settings, despite their usefulness, these tests do not provide helpful information and potentially create a preconceived notion about patients cognitive status if administered in the first few weeks of stroke onset. These test are administered mainly to detect Mild Cognitive Impairment (MCI) in older population, but in recent years their utility has increased in the realm of stroke care and research.
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The need for stratification and a common scale amongst clinicians to evaluate and rate patients cognitive status has led to development of clinical scales and tests such as Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA)-as well as a dozen more tests.