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      Neuropsychiatric Disease and Treatment (submit here)

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      Screening for cognitive decline following single known stroke using the Mini-Mental State Examination

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          Abstract

          Background:

          Progressive cognitive decline develops in a nontrivial minority of stroke survivors. Although commonly used to identify cognitive decline in older stroke survivors, the usefulness of the Mini-Mental State Examination (MMSE) as a screening tool for post-stroke cognitive decline across a wider range of ages is not well established. This study therefore investigated the usefulness of the MMSE for this purpose.

          Methods:

          Twenty-seven subjects, aged 18–82 years, with a single known remote stroke were assessed using the MMSE. The frequency of cognitive impairment was determined by comparison of MMSE scores with population-based norms. Relationships between cognitive performance, motor impairments, age, gender, handedness, stroke laterality, and time since stroke also were explored.

          Results:

          Age-adjusted MMSE scores identified mild cognitive impairment in 22.2% and moderate-to-severe cognitive impairment in 7.4% of subjects. Raw and age-adjusted MMSE scores were inversely correlated with time since stroke, but not with other patient or stroke characteristics.

          Conclusion:

          A relationship between time since single known stroke and MMSE performance was observed in this study. The proportion of subjects identified as cognitively impaired in this group by Z-transformation of MMSE scores using previously published normative data for this measure comports well with the rates of late post-stroke cognitive impairment reported by other investigators. These findings suggest that the MMSE, when normatively interpreted, may identify cognitive decline in the late period following single known stroke. Additionally, the lack of a relationship between MMSE and Fugl-Meyer scores suggests that the severity of post-stroke motor impairments is unlikely to serve as a clinically useful indicator of the need for cognitive assessment. A larger study of stroke survivors is needed to inform more fully on the usefulness of normatively interpreted MMSE scores as a method of screening for post-stroke cognitive decline.

          Most cited references52

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          Population-based norms for the Mini-Mental State Examination by age and educational level.

          To report the distribution of Mini-Mental State Examination (MMSE) scores by age and educational level. National Institute of Mental Health Epidemiologic Catchment Area Program surveys conducted between 1980 and 1984. Community populations in New Haven, Conn; Baltimore, Md; St Louis, Mo; Durham, NC; and Los Angeles, Calif. A total of 18,056 adult participants selected by probability sampling within census tracts and households. Summary scores for the MMSE are given in the form of mean, median, and percentile distributions specific for age and educational level. The MMSE scores were related to both age and educational level. There was an inverse relationship between MMSE scores and age, ranging from a median of 29 for those 18 to 24 years of age, to 25 for individuals 80 years of age and older. The median MMSE score was 29 for individuals with at least 9 years of schooling, 26 for those with 5 to 8 years of schooling, and 22 for those with 0 to 4 years of schooling. Cognitive performance as measured by the MMSE varies within the population by age and education. The cause of this variation has yet to be determined. Mini-Mental State Examination scores should be used to identify current cognitive difficulties and not to make formal diagnoses. The results presented should prove to be useful to clinicians who wish to compare an individual patient's MMSE scores with a population reference group and to researchers making plans for new studies in which cognitive status is a variable of interest.
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            The role of cerebral ischemia in Alzheimer's disease.

            The Alzheimer type of dementia and stroke are known to increase at comparable rates with age. Recent advances suggest that vascular risk factors linked to cerebrovascular disease and stroke in the elderly significantly increase the risk of developing Alzheimer's disease (AD). These include atherosclerosis, atrial fibrillation, coronary artery disease, hypertension, and diabetes mellitus. Moreover, review of various autopsy series shows that 60-90% of AD cases exhibit variable cerebrovascular pathology. Although some vascular lesions such as cerebral amyloid angiopathy, endothelial degeneration, and periventricular white matter lesions are evident in most cases of AD, a third will exhibit cerebral infarction. Despite the interpretation of pathological evidence, longitudinal clinical studies suggest that the co-existence of stroke and AD occurs more than by chance alone. Strokes known to occur in patients with Alzheimer syndrome and most frequently in the oldest old substantially worsen cognitive decline and outcome, implicating some interaction between the disorders. Nevertheless, the nature of a true relationship between the two disorders seems little explored. What predisposes to strokes in underlying cognitive decline or AD? Is it possible that cerebral ischemia is a causal factor for AD? I examined several vascular factors and the vascular pathophysiology implicated in stroke and AD, and propose that cerebral ischemia or oligemia may promote Alzheimer type of changes in the aging brain. Irrespective of the ultimate pathogenetic mechanism, these approaches implicate that management of peripheral vascular disease is important in the treatment or prevention of Alzheimer's disease or mixed dementia.
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              Prospective follow-up study between 3 and 15 months after stroke: improvements and decline in cognitive function among dementia-free stroke survivors >75 years of age.

              Poststroke cognitive impairment is frequent. There are, however, few longitudinal studies examining delayed changes in poststroke cognition. As part of a longitudinal study of incident dementia after stroke, 115 older stroke survivors (>75 years of age) without dementia were evaluated at 3 and 15 months with a detailed neuropsychological evaluation (including memory, attention, executive performance, and language). we found that 9% of older stroke patients developed incident dementia, with significant deterioration in global cognition, memory, and attention. Only the severity of expressive language performance at 3 months was associated with dementia at follow-up. Conversely, 57 patients (50%) experienced some improvement in global cognition. None of the criteria for early cognitive impairment identified people at increased risk for dementia. Delayed dementia is frequent in older stoke patients, but current criteria for early cognitive impairment are not useful as predictors of cognitive deterioration. Improvement in cognition occurred in most patients.
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                Author and article information

                Journal
                Neuropsychiatr Dis Treat
                Neuropsychiatric Disease and Treatment
                Neuropsychiatric Disease and Treatment
                Dove Medical Press
                1176-6328
                1178-2021
                2011
                2011
                13 April 2011
                : 7
                : 189-196
                Affiliations
                [1 ]Brain Injury Rehabilitation Unit, HealthONE Spalding Rehabilitation Hospital, Aurora, CO, USA;
                [2 ]Neuropsychiatry Service, Department of Psychiatry, University of Colorado Health Sciences Center, Denver, CO, USA;
                [3 ]Behavioral Neurology Section, Department of Neurology, University of Colorado Health Sciences Center, Denver, CO, USA;
                [4 ]Neurology Service, Denver Veterans Affairs Medical Center, Denver, CO, USA
                Author notes
                Correspondence: David B Arciniegas, UCD Neurobehavioral Disorders Program, 13001 East 17th Place, Aurora, CO 80045, USA, Tel +1 303 724 4998, Fax +1 303 724 3594, Email david.arciniegas@ 123456ucdenver.edu
                Article
                ndt-7-189
                10.2147/NDT.S17886
                3090282
                21573080
                dbed219b-3687-45b7-a8bf-a0165b18e4e0
                © 2011 Arciniegas et al, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                History
                : 12 April 2011
                Categories
                Original Research

                Neurology
                mini-mental state examination,fugl-meyer evaluation,motor impairment,stroke,cognitive decline

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