What cognitive test is best for an elderly patient with abnormal Saint Louis University Mental Status (SLUMS) scores but normal Brief Interview for Mental Status (BIMS) scores?

Best Cognitive Test for Elderly Patient with Discrepant BIMS and SLUMS Scores

The Montreal Cognitive Assessment (MoCA) would be the most appropriate cognitive test for an elderly patient who scored 15/15 on BIMS but 22/30 on SLUMS, as it offers superior sensitivity for detecting mild cognitive impairment while providing comprehensive domain assessment. 1, 2

Understanding the Discrepancy

This patient presents with an interesting clinical scenario:

• BIMS score of 15/15 indicates intact cognition on this brief screening tool
• SLUMS score of 22/30 suggests possible cognitive impairment
• This discrepancy requires further evaluation with a more sensitive instrument

Why This Discrepancy Exists:

• BIMS is a very brief assessment (focuses primarily on orientation and memory) with significant ceiling effects 3
• SLUMS examines more cognitive domains but has limited psychometric validation compared to other tests 4
• The discrepancy likely represents subtle cognitive deficits that BIMS cannot detect due to its limited scope

Recommended Cognitive Assessment: MoCA

The MoCA is the optimal choice for this scenario because:

1. Superior sensitivity for mild cognitive impairment (MCI):

   • Detects 90% of MCI cases compared to only 18% with MMSE 2
   • Less ceiling effect than other brief cognitive tests (18.1% vs 71.4% for MMSE) 5

2. Comprehensive domain assessment:

   • Evaluates multiple cognitive domains including attention, memory, language, visuospatial abilities, and executive function 1
   • Takes only 10-15 minutes to administer 1

3. Well-validated with clear cutoff scores:

   • Cutoff score of ≥26 indicates normal cognition (95% sensitivity) 6
   • Scores 21-25 suggest possible MCI 5, 6
   • Scores <21 may indicate dementia 6

Alternative Options to Consider

If MoCA is not available or appropriate, consider:

1. Short Test of Mental Status (STMS):

   • Takes 10-15 minutes
   • More sensitive than MMSE for detecting MCI
   • Superior to MMSE in detecting subtle cognitive deficits 3

2. Addenbrooke's Cognitive Examination (ACE-III):

   • Takes 20-30 minutes
   • Provides detailed assessment of multiple cognitive domains
   • Particularly useful for differential diagnosis 3

Implementation Approach

1. Administer the MoCA:

   • Use the standard version (not the basic or telephone version)
   • Ensure proper administration according to standardized protocols
   • Account for education level (add one point if education ≤12 years)

2. Interpret results in context:

   • Compare MoCA score with previous BIMS and SLUMS results
   • A MoCA score <26 with normal BIMS strongly suggests MCI 2, 6
   • Consider educational level, language, and cultural factors when interpreting results 1

3. Supplement with functional assessment:

   • Use Functional Activities Questionnaire (FAQ) to help distinguish between MCI and dementia 5
   • Abnormal FAQ scores are more common in dementia than MCI

Common Pitfalls to Avoid

• Don't rely solely on screening tests for diagnosis: Cognitive tests should be part of a comprehensive evaluation 1
• Avoid using translated versions without validation: Use professionally translated versions when needed 1
• Don't ignore educational and cultural factors: These can significantly impact test performance 1
• Beware of practice effects: If serial testing is needed, use alternate versions when available

The MoCA will provide the most comprehensive assessment to clarify the discrepancy between the BIMS and SLUMS scores, allowing for better clinical decision-making regarding this patient's cognitive status.