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Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.24 no.7 Rio de Janeiro jul. 2019  Epub 22-Jul-2019

http://dx.doi.org/10.1590/1413-81232018247.20862017 

REVIEW

Cognitive assessment instruments used in elderly Brazilians in the last five years

Núbia Isabela Macêdo Martins1 
http://orcid.org/0000-0003-1132-9111

Priscila Romão Caldas2 
http://orcid.org/0000-0003-3492-2882

Etenildo Dantas Cabral3 
http://orcid.org/0000-0002-8446-7091

Carla Cabral dos Santos Accioly Lins3 
http://orcid.org/0000-0002-1018-5331

Maria das Graças Wanderley de Sales Coriolano3 
http://orcid.org/0000-0002-7937-7761

1 Programa de Pós-Graduação em Gerontologia, Centro de Ciências da Saúde (CCS), Universidade Federal de Pernambuco (UFPE). Av. Prof. Moraes Rego 1235, Cidade Universitária. 50670-901 Recife PE Brasil. nubiaamartins@hotmail.com

2 Departamento de Terapia Ocupacional, Centro de Biociências, UFPE. Recife PE Brasil.

3 Departamento de Anatomia, CCS, UFPE. Recife PE Brasil.

Abstract

Detecting and monitoring cognitive deficits in elderly populations are necessary, as they can impact individuals´ functionality. This integrative review aims to analyze the scientific production on the use of cognitive assessment instruments in Brazilian elderly individuals through articles published in the last five years, indexed in the Web of Science, Pubmed, Scopus and Bireme databases. Inclusion criteria were original articles published in English and Portuguese from 2012 to 2016, the age criterion to define elderly individuals and scores higher than 6 in the adapted CASP. The exclusion criterion was conference abstracts submitted for publication. The final sample consisted of 100 articles. Sixty-one cognitive assessment instruments were used in the studies, especially the Mini-Mental State Examination. This review features the use of cognitive instruments in the Brazilian literature, their different versions and domains evaluated. The literature includes a large number of instruments. The most used tests were the MMSE (version proposed by Brucki et al.), the Verbal Fluency Test (“animal” category) and the Digit Span Memory Test (forward span and backward span). The findings presented in this review are relevant not only for observational and experimental research but also for clinical practice.

Key words: Elderly; Geriatric assessment; Cognition

Introduction

Increasing life expectancy and aging of the Brazilian population, associated with their impacts, have been the focus of studies for years. According to the Brazilian Institute of Geography and Statistics (IBGE) census in 2010, older adults accounted for 11% of the Brazilian population and it is estimated that they will reach 13.4% by 20301.

Elderly people are exposed to functional losses due to aging (senescence) and/or age-related diseases (senility). In addition, some diseases have a higher prevalence in this age group, such as dementia. Alzheimer’s disease is the most common type of dementia, which is coupled with severe debilitating cognitive deficits2.

In order ensure reliable detection and monitoring of cognitive deficit, information from family members/caregivers should be provided, and patients’ follow up, identification of clinical history and standardized tests3 should also be performed. These tests may include imaging tests, biochemical exams and/or assessment instruments. The selection of a cognitive assessment instrument should be based on its reliability and whether its score results reflect the actual status of the patient without the influence of other factors, such as depressive symptoms, delirium, low level education or hearing impairment3.

With the objective of analyzing the recent scientific production on the use of cognitive assessment instruments in the Brazilian elderly population, the following question was addressed in this integrative review: Which instruments are currently used for cognitive assessment in the Brazilian elderly population? Based on the findings, the characteristics of the most used instruments were analyzed.

Method

After defining the guiding question, the instruments were assessed for eligibility according to the following steps: 1) specification of inclusion criteria (original articles published in English and Portuguese from 2012 to 2016, the age criterion to define elderly individuals and scores higher than 6 in the adapted CASP) and exclusion criteria (conference abstracts submitted for publication); 2) searches using the following Health Science Descriptors (DeCS) and Boolean operators: [“cognition” OR “dementia” AND “geriatric assessment”], in the Scopus, Bireme, Pubmed and Web of Science databases in November 2016; 3) pre-selection of articles by reading the titles and abstracts and excluding duplicates; 4) critical assessment of the articles after reading them in full; and 5) presentation and discussion of results. The screening process was conducted by two reviewers independently, and disagreements were resolved by a third reviewer.

Two instruments were used for the critical assessment of the articles: the adapted Critical Appraisal Skill Program (CASP), which classifies the quality of the article from 0 to 10, with a score ˃ 6 indicating good methodological quality and reduced bias; and the Agency for Healthcare and Research and Quality (AHRQ), which hierarchically ranks the level of evidence of the study in (I) systematic review or meta-analysis, (II) randomized clinical trials, (III) clinical trials without randomization, (IV) cohort and case-control studies, (V) systematic review of descriptive and qualitative studies and (VI) descriptive or qualitative study4,5.

Results

The screening process of articles from the Web of Science, Pubmed, Scopus and Bireme databases is summarized in Figure 1. The final sample consisted of 100 articles6-105, 80% of which are in English and 20% in Portuguese, selected according to the established criteria and after critical assessment.

Figure 1 Flowchart summarizing the article screening process. 

Most studies were conducted in the Southeast (72%) and the South (12%) of Brazil, with the highest publication frequency in 2014 (30%) and 2012 (23%). The predominant age criterion to define elderly individuals was ≥ 60 (64%). According to the AHRQ instrument, the level of evidence VI (68%) stood out, followed by level IV (16%).

Regarding the study design, the majority of the articles (84%) were observational, 68% of which were transversal, 14% were cohort and 2% were case-control. Of the clinical trials, 9% were non-randomized and 7% were randomized.

Sixty-one instruments were used for cognitive assessment of Brazilian elderly individuals in the last five years (Chart 1). Most tests were short, with application time of less than 20 minutes.

Chart 1 Cognitive assessment instruments used in studies with Brazilian elderly individuals between 2012 and 2016. 

Instrument N (%) Use Domains assessed Versions n %
MMSE 90 (90%) Sample selection Screening Correlation with scores of other tests To evaluate effects of intervention To evaluate association and risk To aid in diagnostic procedures To compare means between groups To follow-up on the evolution of the disease Temporal orientation Spatial orientation Immediate and delayed memory Attention Calculation Language Constructive praxis Brucki et al., 2003 31 34,4
Bertolucci et al., 1994 15 16,7
Lourenço e Veras, 2006a 10 11,1
Folstein et al., 1975 8 8,9
Almeida, 1998 6 6,7
Icaza e Albala, 1999 5 5,6
Herrera et al., 2002 3 3,3
Castro-Costa et al., 2008 2 2,2
Bottino et al., 2001 2 2,2
Kochhann et al. 1 1,1
Nitrini et al., 2007 1 1,1
Nitrini et al., 1994 1 1,1
Seabra et al., 1990 1 1,1
Not mentioned 4 4,4
Verbal Fluency Test 24 (24%) Sample selection Screening Correlation with scores of other tests To evaluate effects of intervention To evaluate association and risk To aid in diagnostic procedures To compare means between groups To follow-up on the evolution of the disease To evaluate executive functions Language Semantic memory Executive functions Semantic (animals) 16 66,7
Semantic(animalsb and fruitsa) 2 8,3
Semantic (animals and supermarket) 1 4,2
Semantic (no category) 3 12,5
Phonemic(F,A,Sa) 4 16,7
Phonemic (A,F) 2 8,3
Phonemic (no categories) 1 4,2
Free choice 1 4,2
Not mentioned 1 4,2
Digit Span Memory Test a 15 (15%) Correlation with scores of other tests To evaluate effects of intervention To aid in diagnostic procedures To evaluate association To compare means between groups Attention Concentration Learning Working memory Executive functions - -
CAMCOG-Rb 13 (13%) Screening Correlation with scores of other tests To evaluate effects of intervention To aid in diagnostic procedures To evaluate association To compare means between groups Temporal orientation Spatial orientation Immediate and delayed memory Attention Calculation Language Executive functions Constructive praxis Praxis - -
CDRa 10 (10%) Sample selection Screening To aid in diagnostic procedures To classify severity of dementia Memory Orientation Executive function (problem solving) - -
CDT 10 (10%) Sample selection Screening Correlation with scores of other tests To compare means between groups To aid in diagnostic procedures To evaluate association Visuospatial skills Constructive praxis Executive functions Attention Sunderland et al., 1989a 5 50,0
Shulman et al., 1993a 3 30,0
Mendez et al., 1992b 2 20,0
Freedman et al., 1994 1 10,0
Shulman e Silver, 1986 1 10,0
Shulman, 2000 1 10,0
TMTb 9 (9%) Sample selection Screening To compare means between groups To aid in diagnostic procedures To evaluate association To evaluate effects of intervention To evaluate executive functions Attention Executive functions TMT A e B 8
TMT A 1
RAVLTa 8 (8%) To compare means between groups To aid in diagnostic procedures To evaluate effects of intervention To evaluate association Correlation with scores of other tests Recent memory Episodic memory Learning -
MoCAa 8 (8%) Screening To evaluate association To evaluate effects of intervention Correlation with scores of other tests Constructive praxis Attention Executive functions Immediate and delayed memory Language Orientation -
IQCODEa 8 (8%) Sample selection Screening To aid in diagnostic procedures To evaluate association To evaluate effects of intervention Correlation with scores of other tests Not applicable as it evaluates the cognitive decline through an interview with caregiver -
BCSBa 5 (5%) Screening To evaluate association To aid in diagnostic procedures Language Immediate and delayed memory Calculation Executive functions Constructive praxis -
RBMTa 4 (4%) Screening To evaluate association To evaluate effects of intervention Memory -
BNTa 4 (4%) To evaluate association To evaluate effects of intervention Language -
FOMEa 3 (3%) Screening To evaluate association Learning Episodic memory Language Executive functions -
WCSTa 3 (3%) To evaluate effects of intervention Executive functions -
List of words 3 (3%) To evaluate effects of intervention To evaluate association Immediate and delayed memory Learning -
LCTa 3 (3%) Sample selection Screening To evaluate association Orientation Language Immediate and delayed memory -
Vocabulary Subtest of the WAIS-III testa 3 (3%) To evaluate effects of intervention To evaluate association To aid in diagnostic procedures Language Semantic memory -
Digit Symbol-Coding subtest of WAIS-III testa 3 (3%) To evaluate effects of intervention Correlation with scores of other tests To aid in diagnostic procedures Attention Visuospatial skills Memory -
Corsi block-tapping test 2 (2%) To compare means between groups To evaluate effects of intervention Working memory Executive functions -
SKTa 2 (2%) Screening To evaluate association To evaluate effects of intervention Attention Concentration Executive functions Immediate and delayed memory Recognition -
FABa 2 (2%) Correlation with scores of other tests Executive functions -
MAC-Qb 2 (2%) To evaluate association To evaluate effects of intervention Prospective memory
MDRSb 2 (2%) To aid in diagnostic procedures Working memory Executive functions Attention Praxis -
SMMSEb 2 (2%) To evaluate association Constructive praxis Language Attention Memory Verbal fluency -
TN-LINa 2 (2%) To compare means between groups Correlation with scores of other tests Semantic memory Language -
Verbal Paired Associates of the WMS-Rb 2 (2%) To evaluate effects of intervention To evaluate association Immediate and delayed memory -
PDMT 2 (2%) To evaluate association and risk Immediate and delayed memory -
Stick Design Testb 2 (2%) To compare means between groups Correlation with scores of other tests Visuospatial skills -
Symbol search subtest of WAIS-IIIa 2 (2%) To evaluate effects of intervention Attention Executive functions -
Cookie Theft picture test of the Boston Diagnostic Aphasia Examination 2 (2%) To evaluate effects of intervention Language -
CANSMCI-BRa 1 (1%) Screening Memory Language Executive function -
ADAS-Cogb 1 (1%) Screening To evaluate association Immediate and delayed memory Language Visuospatial skills Ideomotor and constructive praxis -
CERADb 1 (1%) To evaluate association *Includes Verbal Fluency Tests; MMSE; Boston Naming Test; Word List: Visuoconstructive Skills -
The Arizona Battery for Communication Disorders of Dementia 1 (1%) To evaluate association Language Episodic memory Visuospatial skills Constructive praxis -
TROG-2 1 (1%) To evaluate association Language -
Community Screening Instrument for Dementia 1 (1%) Screening To evaluate association Language Memory Praxis Orientation -
Metamemory Adulthood Questionnairea 1 (1%) To evaluate effects of intervention Metamemory -
MSEQa 1 (1%) To evaluate effects of intervention Memory -
Raven’s Progressive Matrices Testb 1 (1%) To evaluate association Executive functions -
Stroop testa 1 (1%) To compare means between groups Executive functions -
Similarities subtest of WAIS-IIIa 1 (1%) To compare means between groups Language Executive functions -
Information subtest of WAIS-IIIa 1 (1%) To evaluate effects of intervention Immediate memory -
Cube design subtest of WAIS-IIIa 1 (1%) To evaluate association Visuospatial skills Executive functions -
Matrix reasoning subtest of WAIS-IIIa 1 (1%) To aid in diagnostic procedures Executive functions -
Comprehension subtest of WAIS-IIIa 1 (1%) To aid in diagnostic procedures Executive functions -
Arithmetic subtest of WAIS-IIIa 1 (1%) To evaluate effects of intervention Attention Calculation -
Letter-number sequencing subtest of WAIS-IIIa 1 (1%) To evaluate effects of intervention Working memory -
Logical memory subtest I and II of WMS-Rb 1 (1%) To evaluate effects of intervention Episodic memory Ability to recall -
Delay Visual Memory task 1 (1%) To evaluate association Episodic memory -
Short form of WAIS-IIIa 1 (1%) To evaluate association Attention Executive functions Working memory Episodic memory Calculation Language -
NEUPSILIN testa 1 (1%) To evaluate effects of intervention Attention Orientation Working memory Episodic, semantic and prospective memory Calculation Language Praxis Executive functions -
Groton Maze Learning Test; Set-Shifting test, One-back and Two-back tests 1 (1%) To evaluate effects of intervention Attention Working memory Executive functions -
Five-digit testa 1 (1%) To compare means between groups Executive functions -
Concentrated Attention Test (Toulouse-Piéron) b 1 (1%) To evaluate effects of intervention Attention -
Buschke Selective Reminding Test b 1 (1%) To evaluate association Episodic memory -
Token Test –short versiona 1 (1%) To compare means between groups Semantic memory Language -
Delayed recall of simple pictures 1 (1%) To aid in diagnostic procedures Delayed memory -
Labyrinth Test 1 (1%) To aid in diagnostic procedures - -
Tower of Hanoib 1 (1%) To evaluate association Executive functions -
Test of Variables of Visual Attention l 1 (1%) To evaluate association Attention -

a: There are studies showing the accuracy of the instrument for the Brazilian elderly population; b: There are studies showing the accuracy of the instrument for the Brazilian population; MMSE: Mini-Mental State Examination; CAMCOG: Cambridge Cognitive Examination-Revised; CDR: Clinical Dementia Rating; CDT: Clock-Drawing Test; TMT: Trail Making Test; RAVLT: Rey Auditory Verbal Learning Test; MoCA: Montreal Cognitive Assessment; IQCODE: Informant Questionnaire on Cognitive Decline in the Elderly; BCSB: Brief Cognitive Screening Battery; RBMT: Rivermead Behavioral Memory Test; BNT: Boston Naming Test; FOME: Fuld Object Memory Evaluation; WCST: Wisconsin Card Sorting Test; LCT: Leganés cognitive test; WAIS_III: Wechsler Adult Intelligence Scale ; SKT: Syndrom-Kurztest ( Short Cognitive Performance Test); FAB: Frontal Assessment Battery; MAC-Q: Memory Complaint Questionnaire; MDRS: Mattis Dementia Rating Scale; SMMSE: Severe Mini-Mental State Examination; TN-LIN: Naming Test of the Laboratory of Neuropsychological Investigations; WMS-III: Weschler Memory Scale; PDMT: Picture drawings memory test; CANSMCI-BR: Computer-Administered Neuropsychological Screen For Mild Cognitive Impairment for Brazilian Portuguese; ADAS-Cog: The Alzheimer’s Disease Assessment Scale-Cognitive Subscale; CERAD: Consortium to Establish a Registry for Alzheimer’s Disease; TROG-2: Test for Reception of Grammar; MSEQ: Memory Self-Efficacy Questionnaire.

Most studies (90%) used at least the Mini-Mental State Examination (MMSE) for data collection. The most administered version was that proposed by Brucki et al. (2003) (34.4%), but twelve versions could also be observed during the analysis of the articles. The MMSE was followed by the Verbal Fluency Test (VFT) (24%), the Digit Span Memory Test (15%), the Cambridge Cognitive Examination- Revised (CAMCOG-R) (13%), the Clinical Dementia Rating (CDR) and the Clock-Drawing Test (CDT) (10%).

Chart 2 presents a summary of the cognitive domains evaluated and which tests evaluated them.

Chart 2 Cognitive domains and respective instruments that evaluate these domains. 

Attention MMSE; Digit Span Memory Test; CAMCOG-R; CDT: TMT; MoCA; Digit Symbol-Coding Subtest, Symbol search and Arithmetic Subtest of WAIS-III; SKT; MDRS; SMMSE; CERAD; Short form of WAIS-III; NEUPSILIN test; Concentrated Attention Test of Toulouse-Piéron; Groton Maze Learning Test; Set-Shifting test, One-back and Two-back tests; Test of variables of Visual Attention
Orientation MMSE; CAMCOG-R; CDR: MoCA; LCT; CERAD; NEUPSILIN test; Community Screening Instrument for Dementia
Language MMSE; Verbal fluency Test; CAMCOG-R; MoCA; BCSB; BNT; FOME; LCT; SMMSE; TN-LIN; CANSMCI-BR; ADAS-Cog; CERAD; Cookie Theft picture test of the Boston Diagnostic Aphasia Examination; The Arizona Battery for Communication Disorders of Dementia; TROG-2; Community Screening Instrument for Dementia; Similarities subtest of WAIS-III; NEUPSILIN test; Short Form of WAIS-III; Token Test
Memory MMSE; Verbal fluency Test; Digit Span Memory Test; CAMCOG-R; CDR; RAVLT; MoCA; BCSB; RBMT; FOME- list of words; LCT; Vocabulary, Digit Symbol-Coding Subtest, Information, Number and Letter Sequencing subtests of WAIS-III; Corsi block-tapping test; SKT; MAC-Q; MDRS; SMMSE; TN-LIN; Verbal Paired Associates I and II and Logical Memory I and II of WMS-III; PDMT; CANSMCI-BR; CERAD; ADAS-Cog; The Arizona Battery for Communication Disorders of Dementia; Community Screening Instrument for Dementia; MSEQ; Metamemory in Adulthood Questionnaire; Delayed Visual Memory task; Short form of WAIS-III; NEUPSILIN test; Groton Maze Learning Test; Set-Shifting test, One-back and Two-back tests; Buschke Selective Reminding Test; Token Test; Delayed recall of simple pictures
Executive functions Verbal fluency Test; Digit Span Memory Test; CAMCOG-R; CDR; CDT; TMT; MoCA; BCSB; FOME; WCST; Corsi block-tapping test; SKT; FAB; MDRS; Symbol Search, Cube Design, Comprehension, Matrix reasoning subtests of WAIS-III; CANSMCI-BR; CERAD; Short term of WAIS-III; NEUPSILIN test; Groton Maze Learning Test; Set-Shifting test, One-back and Two-back tests; Five-digit test; Tower of Hanoi
Praxis MMSE; CDT; CAMCOG-R; MoCA; BCSB; MDRS; SMMSE; ADAS-Cog; CERAD; The Arizona Battery for Communication Disorders of Dementia; Community Screening Instrument for Dementia; NEUPSILIN test
Visuospatial skills CDT; Digit Symbol-Coding and Cube Design subtests of WAIS-III; Stick Design Test; ADAS-Cog; CERAD;
Calculation MMSE; CAMCOG-R; CERAD; Arithmetic subtest of WAIS-III; Short form of WAIS-III; NEUPSILIN test

MMSE: Mini-Mental State Examination; CAMCOG: Cambridge Cognitive Examination-Revised; CDR: Clinical Dementia Rating; CDT: Clock-Drawing Test; TMT: Trail Making Test; RAVLT: Rey Auditory Verbal Learning Test; MoCA: Montreal Cognitive Assessment; IQCODE: Informant Questionnaire on Cognitive Decline in the Elderly; BCSB: Brief Cognitive Screening Battery; RBMT: Rivermead Behavioral Memory Test; BNT: Boston Naming Test; FOME: Fuld Object Memory Evaluation; WCST: Wisconsin Card Sorting Test; LCT: Leganés cognitive test; WAIS_III: Wechsler Adult Intelligence Scale; SKT: Syndrom-Kurztest (Short Cognitive Performance Test); FAB: Frontal Assessment Battery; MAC-Q: Memory Complaint Questionnaire; MDRS: Mattis Dementia Rating Scale; SMMSE: Severe Mini-Mental State Examination; TN-LIN: Naming Test of the Laboratory of Neuropsychological Investigations; WMS-III: Weschler Memory Scale; PDMT: Picture drawings memory test; CANSMCI-BR: Neuropsychological Screen For Mild Cognitive Impairment for Brazilian Portuguese; ADAS-Cog: The Alzheimer’s Disease Assessment Scale-Cognitive Subscale; CERAD: Consortium to Establish a Registry for Alzheimer’s Disease; TROG-2: Test for reception of grammar; MSEQ: Memory Self-Efficacy Questionnaire.

Of the 100 articles, 39 mentioned only the use of the MMSE with three objectives in the Method section: screening, sample selection and evaluation of associations. The cut-off points for the MMSE varied mainly according to the individual´s level of education. The most commonly used cut-off points are listed as follows:

Brucki et al. (2003): < 20 points for illiterates; 25 points for individuals with 1 to 4 years of schooling; 26.5 for 5 to 8 years of schooling; 28 for 9 to 11 years of schooling; and 29 for more than 11 years of schooling;

Bertolucci et al. (1994): < 13 for illiterates (sensitivity: 82.4%, specificity: 97.5%); 18 for 1 to 8 years of schooling (sensitivity: 75.6%, specificity: 96.6%); and 26 for 9 or more years of schooling (sensitivity: 80%, specificity: 95.6%);

Lourenço & Veras (2006): < 18/19 for illiterates (sensitivity: 73.5%, specificity: 73.9%) and < 23/24 for individuals with one or more years of schooling (sensitivity: 75%, specificity: 69.7%).

Some authors conducted further analysis and adapted these cut-off points according to the design, studied population, objective, among others, which allowed differentiation of the studies and an increasing number of versions. The VFT and the Digit Span Memory Test were the second and third most used tests, respectively. The VFT was administered with several categories, and in this review, the semantic category of animals stood out. The Digit Span Memory Test has only one version and can be applied in forward span and backward span. The CDT was also addressed in six forms, and the versions proposed by Sunderland et al. (1989) and Shulman et al. (1993) were most commonly used.

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), used in eight articles, does not directly assess the patient - it is completed by the caregiver or someone close to the patient. The Leganés Cognitive Test (LCT) can be pointed out, as it was used in the assessment of cognitive function only in one Brazilian state (Rio Grande do Norte).

Two studies mentioned the use of the Comprehensive Geriatric Assessment (CGA), one in hospitalized elderly patients, and the other with elderly patients attending a geriatric outpatient clinic. When administering the CGA, both studies used the MMSE, but one of them associated it with the IQCODE.

Discussion

A considerable number of studies were included in this review, which indicates that cognition in the elderly population has been extensively addressed in the Brazilian literature. Most of the articles (72%) were published in the Southeast region. The distribution of stricto sensu postgraduate courses in Brazil in 2015 showed that the Southeast region accounted for 45.6% of the courses, followed by the South, Northeast, Midwest and North with 21.4%, 19.9%, 8.1% and 5% respectively106. This shows how the existing regional inequality impacts the Brazilian scientific production.

Regarding the numerical criterion used for a definition of elderly individuals, the World Health Organization (WHO) has accepted the chronological age of ≥ 60 years to refer to the older population in developing countries or 65 years in developed countries107. Most studies used the criterion ≥ 60 and the studies conducted in the Southeast, North and Northeast of the country used an older age for eligibility. Additionally, a pattern of use by region could not be observed.

A wide range of instruments could be identified, including brief tests and test batteries. The use of these instruments also ranged from screening to aid in diagnostic procedures. The administration of the instruments to monitor types of intervention (e.g., cognitive, motor, drug) provides data on the possible benefits of a specific physical stimulation for the cognition of elderly individuals.

In clinical practice, it is proposed that elderly individuals should be first evaluated with an instrument that provides a basic measure for cognitive function monitoring and/or an alert to the need for further investigation108. Through a systematic review, the authors identified diagnostic errors rates of over 10% in 16 diseases prevalent in elderly patients, mainly in dementias. Underdiagnosis of dementia appears more prevalent in older patients with poor access to health care, lower socioeconomic status and lower levels of education109. A Brazilian study found that only one third of the elderly individuals diagnosed with dementia by specialists had previous diagnosis of moderate to severe dementia110. The causes of low case detection were not indicated.

In relation to the area of research, choosing an adequate instrument and establishing a cut-off point are necessary to avoid mistakes due to false-positive and false-negative test results. Researchers are able to find a cut-off point that best suits their sample111 by retrieving published studies with samples containing related profiles, also taking into account the specificity and sensitivity of the test.

The analysis of the most used test in the Brazilian studies with elderly individuals - the MMSE- still shows no standardized administration of the test. The different versions and cut-off points support this statement. These issues display the cultural, educational and age biases that influence the test score. Although these different cut-off points are created to minimize bias and establish criteria for normality for the Brazilian population, the level of education is a variable that influences the MMSE score, and may generate false-negative results in individuals with higher levels of education94,112.

It should be noted that, although the MMSE does not evaluate all cognitive domains, it is quick to administer and it is the most widely studied instrument for cognitive screening not only in Brazil but worldwide. The MMSE is also used as a gold standard and reference for validation of other assessment instruments. In Brazil, the first version was proposed almost 23 years ago108.

The Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) includes batteries of test covering all cognitive domains, but it was used in only one study. It requires longer administration time, which may be a negative factor for its use in research. Also, it does not have criteria for normality for the individuals´ level of education.

As for the other instruments more commonly used, the Verbal Fluency Test and Digit Span Memory Test do not assess global cognition and are more specific for certain functions. The VFT focuses on the evaluation of executive functions and consists in recalling the greatest number of words during a pre-established time - usually one minute. The score is calculated by counting the total of produced words. In the phonemic fluency test, the individuals are requested to produce words beginning with a certain letter, for example, “F”, “A”, “S”. The semantic fluency consists of naming words within a category, such as animals. Studies show that it is an instrument with good accuracy in the detection of cognitive deficits in the elderly population113-115.

In the articles here, the semantic verbal fluency test of animal category was the most common test in association with other instruments. The semantic task, in addition to evaluating executive functions and language, has the advantage of accessing declarative semantic memory. The cut-offs points for the Brazilian versions varied according to levels of education and age116,117.

The Digit Span Subtest of the Wechsler Adult Intelligence Scale (WAIS-III) consists of two tasks of repeating a sequence of numbers in forward span and backward span, especially used in the evaluation of attention. Although both tasks can be administered independently, the studies included in this review used both tasks. The backward version is also widely used to evaluate working memory. The cut-off point was not cited. The VFT and the Digit Span Memory Test can be used in association with the MMSE for an enhanced cognitive assessment, provided that it is the goal of the professional and/or researcher. The combined use of instruments may be beneficial to avoid false diagnosis in the elderly population118.

The CDT is a cognitive screening instrument used to evaluate executive function, praxis and visuospatial skills. It also presents several versions with different scores. In the most used version, the patient is asked to draw the face of a clock and place the hands to designate a specific time, e.g., 11h10min119. Combined with the MMSE, the CDT has a sensitivity of 84.9% and specificity of 90.4% in the screening for cognitive impairment in elderly populations120. But, individuals with symptoms such as tremor and motor coordination deficits may show lower scores, or even fail to perform a task due to these motor impairments.

As for the instrument administration time, frail or multimorbid elderly individuals may need more time to complete the evaluation. Individuals who require hearing aids, glasses and dental prostheses should be using them during the evaluation121.

A limitation of the study lies in the fact that after the application of the eligibility criteria, the whole Brazilian literature was not evaluated, given that dissertations and theses were not included. This could have increased the variation of the instruments used.

Conclusion

The variability of cognitive deficits due to aging or associated pathological process points to the need to address the issue of how to identify these deficits earlier and whether this early identification influences the course of the disease and the quality of life of the individuals and their relatives.

This integrative review addresses the use of cognitive assessment instruments in the Brazilian literature, their different versions and domains evaluated. The recent literature includes a large number of instruments. The most used tests were the MMSE (version proposed by Brucki et al.), the Verbal Fluency Test (animal category) and the Digit Span Memory Test (forward span or backward span). The findings presented in this review are relevant not only for observational and experimental research but also for clinical practice.

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Received: April 03, 2017; Revised: October 02, 2017; Accepted: October 04, 2017

Collaborations

NIM Martins designed, outlined, analyzed and interpreted the data and drafted the article. PR Caldas conducted data analysis. ED Cabral performed the critical review of the article. CCSA Lins contributed to the article design and critical review. MGWS Coriolano contributed to the concept, design, interpretation of data and critical review of the article.

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