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The 1-min animal test as a mental status screening examination in patients with diabetes

The 1-min animal test as a mental status screening examination in patients with diabetes Background: Detecting and treating dementia at an early stage are important. Although the Revised Hasegawa Dementia Scale (HDS-R) is commonly used to detect dementia, it takes about 10 min to complete. In contrast, the 1-min animal test (OMAT ) takes only 1 min to complete and may be a helpful screening test for general practitioners in deciding whether to proceed with administering further diagnostic tests such as the HDS-R. We sought to exam- ine the relationship between the OMAT and HDS-R scores, and determine the cut-off OMAT score that balanced the sensitivity and specificity in identifying HDS-R-positive patients. Methods: A total of 122 consecutive patients with diabetes who visited the outpatient clinic at the Fujiidera Munici- pal Hospital were enrolled. The patients underwent the OMAT and HDS-R on the same day. Tests were conducted in a single-blinded manner. The relationship between the OMAT and HDS-R scores was examined using Spearman’s rank correlation. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off score of OMAT that will determine whether to proceed with further diagnostic tests. Results: A strong positive correlation between the OMAT and HDS-R scores was observed (r = 0.70). The sensitivity and specificity of OMAT using cut-off scores of 12/13, 13/14, and 14/15 for HDS-R-positive patients were 0.87 and 0.66, 1.00 and 0.51, and 1.00 and 0.40, respectively among all the subjects. Similar results were obtained in a subgroup of subjects aged ≥ 65 years. Conclusions: A cut-off score of 13/14 on the OMAT balanced the sensitivity closest to 1.00 and allowed for the high- est specificity for the HDS-R not only among all the patients, but also among just the patients aged ≥ 65 years. The OMAT may be an optimal screening test to determine whether to proceed with further diagnosis using HDS-R. Trial registration UMIN UMIN000025260. This study is retrospectively registered on December 13th, 2016 Keywords: 1-min mental status examination, 1-min animal test, Dementia, Revised Hasegawa Dementia Scale, Screening *Correspondence: m2625696@med.osaka-cu.ac.jp Department of Medical Education and General Practice, Osaka City University Graduate School and Faculty of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 2 of 5 with diabetes as well as in just the diabetic patients aged Background 65 years or older. It has been estimated that one-seventh of elderly people aged 65  years or greater suffer from dementia in Japan Methods [1]. Ohara et al. have shown that diabetes is a significant A total of 122 consecutive patients with diabetes who risk factor for all-cause dementia [2]. In addition, the visited the outpatient clinic at Fujiidera Municipal Hos- prevalence of Alzheimer’s disease (AD), one of the lead- pital from January 2014 to June 2015 were enrolled in this ing causes of dementia, is on the rise [3]. Dementia is study. A diabetologist working at the hospital adminis- one of the leading sources of caregiver burden and has tered the OMAT and HDS-R tests. Tests were conducted emerged as a crucial public health, medical, economic, in a single-blinded manner on the same day. The study and social problem. protocols were in accordance with the Declaration of Several approaches to treat dementia including person- Helsinki, and were approved by the ethics committee of centered care, rehabilitation, training, or drugs, have the Osaka City University (number 3496). Informed con- recently become clinically available to prevent the pro- sent was obtained from all the subjects or their close rela- gression of dementia. Therefore, it is important to per - tives prior to participation. form screening tests for dementia at an early stage so that patients with dementia can be treated as early as possible 1‑min animal test to avert the progression of dementia-related behaviors The OMAT is a quick and simple examination for cat - and symptoms, and reduce medical, economic, and social egory fluency that asks subjects to list as many different burden alike. However, the early symptoms of dementia animals as possible in 1  min [7, 12]. A previous report are difficult to detect for not only the patients and their has shown that a cut-off score of 13/14 on the OMAT families, but also for general practitioners. In addition, it was able to distinguish patients with AD from control takes about 10 min to complete the frequently used tests subjects with a sensitivity of 0.91 and a specificity of 0.81. such as the Revised Hasegawa Dementia Scale (HDS-R) The number of animal names that could be verbally gen - [4, 5] or the Mini-Mental State Examination (MMSE) [6], erated by the subjects was measured in this study. which is often difficult to spare in busy out-patient clini - cal settings. Revised Hasegawa Dementia Scale Recently, the 1-min animal test (OMAT), which is a The HDS-R has been established in Japan and, like the 1-min mental status examination using animal names MMSE, is used as a common diagnostic test for demen- measuring verbal category fluency, has been developed. tia; the HDS-R has been demonstrated to be diagnosti- Verbal fluency can be classified into category fluency and cally more accurate compared to the MMSE [13]. The letter fluency. Previous studies have shown that category HDS-R consists of 9 simple questions with a maximum fluency tasks are better at discriminating between con - score of 30 points. Subjects are asked to state their age, trol subjects and patients with dementia or mild cogni- date, place, repeat 3 words, perform serial subtraction of tive impairment, when compared with letter fluency 7 starting at 100, recall digits backwards, recall 3 words, [7–9]. Moreover, the category “animals” is more appro- recall 5 objects, and state the names of vegetables [5]. priate than “vegetables” to measure semantic category The number of correct answers was measured and con - fluency because it is not confounded by sex-related dif - verted into scores based on the HDS-R assessment scale. ferences [10]. Therefore, we decided to use the OMAT. A score of 20/21 on the HDS-R has been shown to dis- Previous studies have validated the relationship between criminate between normal cognition and dementia with the OMAT and MMSE and demonstrated a positive cor- a sensitivity of 0.90 and a specificity of 0.82. Therefore, relation between OMAT and MMSE scores [7, 10, 11]. patients who scored less than 21 were defined as HDS-R- However, to the best of our knowledge, there has been positive in this study. no investigation into an association between the OMAT and HDS-R scores. The OMAT may be a helpful screen - Relationship between OMAT and HDS‑R ing test for general practitioners in deciding whether to In this study, we enrolled all consecutive patients with proceed with administering further diagnostic tests such diabetes who visited our hospital from January 2014 to as the HDS-R. June 2015. However, the prevalence of dementia in Japan We sought to examine the relationship between the has been reported to be 0.0476% among individuals OMAT and HDS-R scores, and also the cut-off score of younger than 65 years of age, and 15.75% among individ- OMAT that balanced the sensitivity closest to 1.00 and uals who are 65  years or older [1]. Therefore, we exam - enabled the highest specificity for the HDS-R-positive ined the correlation between the OMAT and HDS-R status; this would help us determine whether to proceed scores, as well as the OMAT cut-off score to determine with administering the HDS-R in all consecutive patients Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 3 of 5 whether to proceed with administering the HDS-R, not only among all the patients but also in a subgroup of patients aged 65 years or greater. Statistical analysis The Spearman’s rank correlation coefficient was used to determine the correlation between the OMAT and HDS-R scores. The receiver operating characteristics (ROC) curve analysis was used to determine the OMAT cut-off score that could identify HDS-R-positive patients [14]. The cut-off score was defined as that balancing the sensitivity closest to 1.00 while enabling the highest spec- ificity on the ROC curve in order for the OMAT to be an optimal screening test in deciding whether to proceed to administering the HDS-R. Results with p values less than 0.05 were considered statistically significant. The statisti - Fig. 1 Relationship between the 1-min animal test and Revised cal analyses were performed using IBM SPSS 22.0 (Chi- Hasegawa Dementia Scale scores. n = 31, the number of patients cago, IL, USA). with the 1-min animal test score < 14 and Revised Hasegawa’s dementia scale score < 21. n = 0, the number of patients with the Results 1-min animal test score ≥ 14 and Revised Hasegawa’s dementia scale The baseline characteristics of the 122 subjects used for score < 21. n = 45, the number of patients with the 1-min animal test score < 14 and Revised Hasegawa’s dementia scale score ≥ 21. n = 46, the analysis are shown in Table  1. We enrolled 122 con- the number of patients with the 1-min animal test score ≥ 14 and secutive patients with diabetes who visited the outpatient Revised Hasegawa’s dementia scale score ≥ 21. r = 0.70 (Spearman’s clinic at the Fujiidera Municipal Hospital in this study. rank correlation), p < 0.01 The age range of the study subjects was 40–89 years. The analyses were repeated in a subgroup of patients who were 65 years or older (n = 93; median age 75 years; inter- quartile range 70–80 years). 13/14 was able to balance the sensitivity closest to 1.00 Figure  1 displays the relationship between the OMAT while enabling the highest specificity in identifying HDS- and HDS-R scores. A strong positive correlation was R-positive patients. observed between the OMAT and HDS-R scores A strong positive correlation was observed between the (r = 0.70, p < 0.01). OMAT and HDS-R scores (r = 0.62; p < 0.01) in the sub Figure  2 displays the results of the ROC curve analysis group analysis as well. The ROC curve analysis showed to determine the optimal OMAT cut-off score that can that the OMAT scores of 12/13, 13/14, and 14/15 were identify HDS-R-positive individuals. The OMAT scores able to identify HDS-R-positive patients with sensitivities of 12/13, 13/14, and 14/15 identified HDS-R-positive of 0.87 (0.69–0.96; 95% CI), 1.00 (0.83–1.00; 95% CI), and patients with sensitivities of 0.87 (0.70–0.96; 95% CI, 1.00 (0.83–1.00; 95% CI), and with specificities of 0.56 confidence intervals), 1.00 (0.84–1.00; 95% CI), and 1.00 (0.43–0.68; 95% CI), 0.35 (0.23–0.48; 95% CI), and 0.25 (0.84–1.00; 95% CI), and with specificities of 0.66 (0.55– (0.15–0.38; 95% CI), respectively. Therefore, an OMAT 0.76; 95% CI), 0.51 (0.40–0.61; 95% CI), and 0.40 (0.30– score of 13/14 balanced the sensitivity closest to 1.00 0.50; 95% CI), respectively. Hence, the OMAT score of while enabling the highest specificity in identifying HDS- R-positive patients among subjects who were 65 years or older. Table 1 Baseline characteristics of  the  study sample (N = 122) Discussion Variable In the present study, a strong positive correlation was Men/women, n/n 63/59 observed between the OMAT and HDS-R scores among Age (years) 72 (65–78) all the enrolled patients with diabetes between 40 and 1-min animal test score 13 (10–16) 89  years of age. In addition, the OMAT cut-off score of 13/14 balanced the sensitivity closest to 1.00 while Revised Hasegawa’s dementia scale score 25 (20–28) enabling the highest specificity in identifying HDS-R- N total study sample size, n number of males/females in group a positive patients to determine whether to proceed with Values are expressed as median (interquartile range) Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 4 of 5 score of 13/14 was the common cut-off score to identify HDS-R-positive patients between both age groups tested, and thus may be a widely applicable index. There have been no previous studies comparing the dif - ference between implementing the OMAT in Japanese and any other language. The OMAT requires subjects to list as many different animals as possible in 1 min; there - fore, we speculate that any differences are unlikely. Fur - ther investigations are needed to confirm this. The present study has some limitations. First, the pos - sibility of dementia was considered based on the HDS-R score alone, and no other tests were administered to vali- date this assumption. The gold standards for the diagno - sis of dementia are the ICD-10, NIA-AA, and DSM-5 tests. Second, the HDS-R is an examination to assess the presence or absence of cognitive dysfunction, in particular, memory. It does not to distinguish between the different types of dementia. The OMAT is a simple examination to assess the presence or absence of cogni- Fig. 2 Receiver operating characteristic curve analysis. The receiver tive dysfunction. We did not examine the association operating characteristic curve analysis of the 1-min animal test for the between the different types of dementia and the results cut-off score of 20/21 on the Revised Hasegawa’s Dementia Scale of the HDS-R or the OMAT in this study. To the best of our knowledge, no previous studies have examined these administering the HDS-R among all the patients as well associations. Further studies are necessary to address as in the subgroup of patients who were 65 years or older. this issue. Third, the subjects of the present study were To our knowledge, ours is the first study to evaluate the all Japanese patients with diabetes from a single hospi- association between OMAT and HDS-R and show a pos- tal. Further studies involving non-diabetic patients or itive correlation between their scores. subjects of other ethnicities are required to improve the Although the MMSE has been commonly used as a validity of our results. Fourth, the tests were conducted screening test for dementia all over the world, it has sev- in a single-blinded manner. Further examinations using eral disadvantages. The assessment of dementia status by a double-blinded and independent study design are war- MMSE is prone to be influenced by the educational level ranted to confirm our findings. of the subjects [15]. Executive functions are not fully rep- resented in the MMSE. In addition, a previous study has shown that the HDS-R had a higher area under the ROC Conclusions curve than the MMSE while identifying patients with AD The present study showed a strong positive correlation [13]. Therefore, it would be useful to apply HDS-R as a between the OMAT and HDS-R scores. The OMAT cut- standard examination in the present study. off score of 13/14 balanced the sensitivity closest to 1.00 Though HDS-R has been established as a common while enabling the highest specificity in the identification diagnostic test for dementia, it consists of 9 questions, of HDS-R-positive patients. The OMAT may be used as takes approximately 10  min to complete, and is occa- an optimal screening test while deciding whether to pro- sionally difficult to implement in busy out-patient clini - ceed with administering further diagnostic tests such as cal settings. Meanwhile, OMAT consists of one simple the HDS-R not only among all the patients enrolled in question and is executed in 1  min. We found that the the study, but also in just the subgroup of patients aged OMAT cut-off score of 13/14 showed a sensitivity of 1.00 65 years or older. for identifying HDS-R-positive patients in this study. Authors’ contributions This indicates that all the patients with a score of 14 or SK participated in the study design and statistical analysis. ET, KF, HN, and SU more on the OMAT scored 21 or higher on the HDS-R, collected the data. MS, SN, TO, SH, and SU participated in the study design. Y T, Y T, MM, and TS helped draft the manuscript. All authors read and approved and that the HDS-R was negative for dementia when the the final manuscript. OMAT was negative for dementia. Therefore, the OMAT can be considered as an optimal screening test to deter- Author details Department of Medical Education and General Practice, Osaka City Univer- mine whether to proceed with the administration of fur- sity Graduate School and Faculty of Medicine, 1-4-3, Asahi-machi, Abeno-ku, ther diagnostic tests, such as the HDS-R. In addition, a Osaka 545-8585, Japan. Fujiidera Municipal Hospital, Fujiidera, Japan. Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 5 of 5 Acknowledgements 4. Katoh S, Shimogaki H, Onodera A, Ueda H, Oikawa K, Ikeda K, et al. Devel- Not applicable. opment of the revised version of Hasegawa’s Dementia Scale (HDS-R) (in Japanese). Jpn J Geriatr Psychiatry. 1991;2:1339–47. Competing interests 5. Imai Y, Hasegawa K. The Revised Hasegawa’s Dementia Scale (HDS-R)— The authors declare that they have no competing interests. evaluation of its usefulness as a screening test for dementia. J Hong Kong Call Psychiatr. 1994;4(Suppl 2):20–4. Availability of data and materials 6. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical The datasets used and/or analyzed during the current study available from the method for grading the cognitive state of patients for the clinician. J corresponding author on reasonable request. Psychiatr Res. 1975;12:189–98. 7. Hanyu H, Kume KK, Takada Y, Onuma T, Iwamoto T. The 1-minute Consent for publication mental status examination in the memory clinic. J Am Geriatr Soc. Not applicable. 2009;57:1130–1. 8. Monsch AU, Bondi MW, Butters N, Salmon DP, Katzman R, Thal LJ. Ethics approval and consent to participate Comparisons of verbal fluency tasks in the detection of dementia of the The study protocols were in accordance with the Declaration of Helsinki, and Alzheimer type. Arch Neurol. 1992;49:1253–8. were approved by the ethics committee of the Osaka City University (number 9. Canning SJ, Leach L, Stuss D, Ngo L, Black SE. Diagnostic utility of abbrevi- 3496). Informed consent was obtained from all the subjects or their close rela- ated fluency measures in Alzheimer disease and vascular dementia. tives prior to participation. Neurology. 2004;62:556–62. 10. Sakurai H, Hanyu H, Murakami M, Kume K, Takata Y, Onuma T, et al. The Funding category “animals” is more appropriate than the category “vegetables” to This was not an industry-supported study. measure semantic category fluency. Geriatr Gerontol Int. 2011;11:374–5. 11. Yajima K, Matsushita T, Sumitomo H, Sakurai H, Katayama T, Kanno K, et al. One-minute mental status examination for category fluency is more Publisher’s Note useful than mini-mental state examination to evaluate the reliability Springer Nature remains neutral with regard to jurisdictional claims in pub- of insulin self-injection in elderly diabetic patients. J Diabetes Investig. lished maps and institutional affiliations. 2014;5:340–4. 12. Cummings JL. The one-minute mental status examination. Neurology. Received: 20 December 2016 Accepted: 30 May 2018 2004;62:534–5. 13. Kim KW, Lee DY, Jhoo JH, Youn JC, Suh YJ, Jun YH, et al. Diagnostic accuracy of mini-mental status examination and revised hasegawa dementia scale for Alzheimer’s disease. Dement Geriatr Cogn Disord. 2005;19:324–30. References 14. Akobeng AK. Understanding diagnostic tests 3: receiver operating char- 1. Asada T. Prevalence of dementia in Japan: past, present and future. Clin acteristic curves. Acta Paediatr. 2007;96:644–7. Neurol. 2012;52:962–4. 15. O’Bryant SE, Humphreys JD, Smith GE, Ivnik RJ, Graff-Radford NR, Petersen 2. Ohara T, Doi Y, Ninomiya T, Hirakawa Y, Hata J, Kanba S, et al. Glucose RC, et al. Detecting dementia with the mini-mental state examination in tolerance status and risk of dementia in the community: the Hisayama highly educated individuals. Arch Neurol. 2008;65:963–7. study. Neurology. 2011;77:1126–34. 3. Honda H, Sasaki K, Hamasaki H, Shijo M, Koyama S, Ohara T, et al. Trends in autopsy-verified dementia prevalence over 29 years of the Hisayama study. Neuropathology. 2016;36:383–7. Ready to submit your research ? 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Abstract

Background: Detecting and treating dementia at an early stage are important. Although the Revised Hasegawa Dementia Scale (HDS-R) is commonly used to detect dementia, it takes about 10 min to complete. In contrast, the 1-min animal test (OMAT ) takes only 1 min to complete and may be a helpful screening test for general practitioners in deciding whether to proceed with administering further diagnostic tests such as the HDS-R. We sought to exam- ine the relationship between the OMAT and HDS-R scores, and determine the cut-off OMAT score that balanced the sensitivity and specificity in identifying HDS-R-positive patients. Methods: A total of 122 consecutive patients with diabetes who visited the outpatient clinic at the Fujiidera Munici- pal Hospital were enrolled. The patients underwent the OMAT and HDS-R on the same day. Tests were conducted in a single-blinded manner. The relationship between the OMAT and HDS-R scores was examined using Spearman’s rank correlation. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off score of OMAT that will determine whether to proceed with further diagnostic tests. Results: A strong positive correlation between the OMAT and HDS-R scores was observed (r = 0.70). The sensitivity and specificity of OMAT using cut-off scores of 12/13, 13/14, and 14/15 for HDS-R-positive patients were 0.87 and 0.66, 1.00 and 0.51, and 1.00 and 0.40, respectively among all the subjects. Similar results were obtained in a subgroup of subjects aged ≥ 65 years. Conclusions: A cut-off score of 13/14 on the OMAT balanced the sensitivity closest to 1.00 and allowed for the high- est specificity for the HDS-R not only among all the patients, but also among just the patients aged ≥ 65 years. The OMAT may be an optimal screening test to determine whether to proceed with further diagnosis using HDS-R. Trial registration UMIN UMIN000025260. This study is retrospectively registered on December 13th, 2016 Keywords: 1-min mental status examination, 1-min animal test, Dementia, Revised Hasegawa Dementia Scale, Screening *Correspondence: m2625696@med.osaka-cu.ac.jp Department of Medical Education and General Practice, Osaka City University Graduate School and Faculty of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 2 of 5 with diabetes as well as in just the diabetic patients aged Background 65 years or older. It has been estimated that one-seventh of elderly people aged 65  years or greater suffer from dementia in Japan Methods [1]. Ohara et al. have shown that diabetes is a significant A total of 122 consecutive patients with diabetes who risk factor for all-cause dementia [2]. In addition, the visited the outpatient clinic at Fujiidera Municipal Hos- prevalence of Alzheimer’s disease (AD), one of the lead- pital from January 2014 to June 2015 were enrolled in this ing causes of dementia, is on the rise [3]. Dementia is study. A diabetologist working at the hospital adminis- one of the leading sources of caregiver burden and has tered the OMAT and HDS-R tests. Tests were conducted emerged as a crucial public health, medical, economic, in a single-blinded manner on the same day. The study and social problem. protocols were in accordance with the Declaration of Several approaches to treat dementia including person- Helsinki, and were approved by the ethics committee of centered care, rehabilitation, training, or drugs, have the Osaka City University (number 3496). Informed con- recently become clinically available to prevent the pro- sent was obtained from all the subjects or their close rela- gression of dementia. Therefore, it is important to per - tives prior to participation. form screening tests for dementia at an early stage so that patients with dementia can be treated as early as possible 1‑min animal test to avert the progression of dementia-related behaviors The OMAT is a quick and simple examination for cat - and symptoms, and reduce medical, economic, and social egory fluency that asks subjects to list as many different burden alike. However, the early symptoms of dementia animals as possible in 1  min [7, 12]. A previous report are difficult to detect for not only the patients and their has shown that a cut-off score of 13/14 on the OMAT families, but also for general practitioners. In addition, it was able to distinguish patients with AD from control takes about 10 min to complete the frequently used tests subjects with a sensitivity of 0.91 and a specificity of 0.81. such as the Revised Hasegawa Dementia Scale (HDS-R) The number of animal names that could be verbally gen - [4, 5] or the Mini-Mental State Examination (MMSE) [6], erated by the subjects was measured in this study. which is often difficult to spare in busy out-patient clini - cal settings. Revised Hasegawa Dementia Scale Recently, the 1-min animal test (OMAT), which is a The HDS-R has been established in Japan and, like the 1-min mental status examination using animal names MMSE, is used as a common diagnostic test for demen- measuring verbal category fluency, has been developed. tia; the HDS-R has been demonstrated to be diagnosti- Verbal fluency can be classified into category fluency and cally more accurate compared to the MMSE [13]. The letter fluency. Previous studies have shown that category HDS-R consists of 9 simple questions with a maximum fluency tasks are better at discriminating between con - score of 30 points. Subjects are asked to state their age, trol subjects and patients with dementia or mild cogni- date, place, repeat 3 words, perform serial subtraction of tive impairment, when compared with letter fluency 7 starting at 100, recall digits backwards, recall 3 words, [7–9]. Moreover, the category “animals” is more appro- recall 5 objects, and state the names of vegetables [5]. priate than “vegetables” to measure semantic category The number of correct answers was measured and con - fluency because it is not confounded by sex-related dif - verted into scores based on the HDS-R assessment scale. ferences [10]. Therefore, we decided to use the OMAT. A score of 20/21 on the HDS-R has been shown to dis- Previous studies have validated the relationship between criminate between normal cognition and dementia with the OMAT and MMSE and demonstrated a positive cor- a sensitivity of 0.90 and a specificity of 0.82. Therefore, relation between OMAT and MMSE scores [7, 10, 11]. patients who scored less than 21 were defined as HDS-R- However, to the best of our knowledge, there has been positive in this study. no investigation into an association between the OMAT and HDS-R scores. The OMAT may be a helpful screen - Relationship between OMAT and HDS‑R ing test for general practitioners in deciding whether to In this study, we enrolled all consecutive patients with proceed with administering further diagnostic tests such diabetes who visited our hospital from January 2014 to as the HDS-R. June 2015. However, the prevalence of dementia in Japan We sought to examine the relationship between the has been reported to be 0.0476% among individuals OMAT and HDS-R scores, and also the cut-off score of younger than 65 years of age, and 15.75% among individ- OMAT that balanced the sensitivity closest to 1.00 and uals who are 65  years or older [1]. Therefore, we exam - enabled the highest specificity for the HDS-R-positive ined the correlation between the OMAT and HDS-R status; this would help us determine whether to proceed scores, as well as the OMAT cut-off score to determine with administering the HDS-R in all consecutive patients Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 3 of 5 whether to proceed with administering the HDS-R, not only among all the patients but also in a subgroup of patients aged 65 years or greater. Statistical analysis The Spearman’s rank correlation coefficient was used to determine the correlation between the OMAT and HDS-R scores. The receiver operating characteristics (ROC) curve analysis was used to determine the OMAT cut-off score that could identify HDS-R-positive patients [14]. The cut-off score was defined as that balancing the sensitivity closest to 1.00 while enabling the highest spec- ificity on the ROC curve in order for the OMAT to be an optimal screening test in deciding whether to proceed to administering the HDS-R. Results with p values less than 0.05 were considered statistically significant. The statisti - Fig. 1 Relationship between the 1-min animal test and Revised cal analyses were performed using IBM SPSS 22.0 (Chi- Hasegawa Dementia Scale scores. n = 31, the number of patients cago, IL, USA). with the 1-min animal test score < 14 and Revised Hasegawa’s dementia scale score < 21. n = 0, the number of patients with the Results 1-min animal test score ≥ 14 and Revised Hasegawa’s dementia scale The baseline characteristics of the 122 subjects used for score < 21. n = 45, the number of patients with the 1-min animal test score < 14 and Revised Hasegawa’s dementia scale score ≥ 21. n = 46, the analysis are shown in Table  1. We enrolled 122 con- the number of patients with the 1-min animal test score ≥ 14 and secutive patients with diabetes who visited the outpatient Revised Hasegawa’s dementia scale score ≥ 21. r = 0.70 (Spearman’s clinic at the Fujiidera Municipal Hospital in this study. rank correlation), p < 0.01 The age range of the study subjects was 40–89 years. The analyses were repeated in a subgroup of patients who were 65 years or older (n = 93; median age 75 years; inter- quartile range 70–80 years). 13/14 was able to balance the sensitivity closest to 1.00 Figure  1 displays the relationship between the OMAT while enabling the highest specificity in identifying HDS- and HDS-R scores. A strong positive correlation was R-positive patients. observed between the OMAT and HDS-R scores A strong positive correlation was observed between the (r = 0.70, p < 0.01). OMAT and HDS-R scores (r = 0.62; p < 0.01) in the sub Figure  2 displays the results of the ROC curve analysis group analysis as well. The ROC curve analysis showed to determine the optimal OMAT cut-off score that can that the OMAT scores of 12/13, 13/14, and 14/15 were identify HDS-R-positive individuals. The OMAT scores able to identify HDS-R-positive patients with sensitivities of 12/13, 13/14, and 14/15 identified HDS-R-positive of 0.87 (0.69–0.96; 95% CI), 1.00 (0.83–1.00; 95% CI), and patients with sensitivities of 0.87 (0.70–0.96; 95% CI, 1.00 (0.83–1.00; 95% CI), and with specificities of 0.56 confidence intervals), 1.00 (0.84–1.00; 95% CI), and 1.00 (0.43–0.68; 95% CI), 0.35 (0.23–0.48; 95% CI), and 0.25 (0.84–1.00; 95% CI), and with specificities of 0.66 (0.55– (0.15–0.38; 95% CI), respectively. Therefore, an OMAT 0.76; 95% CI), 0.51 (0.40–0.61; 95% CI), and 0.40 (0.30– score of 13/14 balanced the sensitivity closest to 1.00 0.50; 95% CI), respectively. Hence, the OMAT score of while enabling the highest specificity in identifying HDS- R-positive patients among subjects who were 65 years or older. Table 1 Baseline characteristics of  the  study sample (N = 122) Discussion Variable In the present study, a strong positive correlation was Men/women, n/n 63/59 observed between the OMAT and HDS-R scores among Age (years) 72 (65–78) all the enrolled patients with diabetes between 40 and 1-min animal test score 13 (10–16) 89  years of age. In addition, the OMAT cut-off score of 13/14 balanced the sensitivity closest to 1.00 while Revised Hasegawa’s dementia scale score 25 (20–28) enabling the highest specificity in identifying HDS-R- N total study sample size, n number of males/females in group a positive patients to determine whether to proceed with Values are expressed as median (interquartile range) Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 4 of 5 score of 13/14 was the common cut-off score to identify HDS-R-positive patients between both age groups tested, and thus may be a widely applicable index. There have been no previous studies comparing the dif - ference between implementing the OMAT in Japanese and any other language. The OMAT requires subjects to list as many different animals as possible in 1 min; there - fore, we speculate that any differences are unlikely. Fur - ther investigations are needed to confirm this. The present study has some limitations. First, the pos - sibility of dementia was considered based on the HDS-R score alone, and no other tests were administered to vali- date this assumption. The gold standards for the diagno - sis of dementia are the ICD-10, NIA-AA, and DSM-5 tests. Second, the HDS-R is an examination to assess the presence or absence of cognitive dysfunction, in particular, memory. It does not to distinguish between the different types of dementia. The OMAT is a simple examination to assess the presence or absence of cogni- Fig. 2 Receiver operating characteristic curve analysis. The receiver tive dysfunction. We did not examine the association operating characteristic curve analysis of the 1-min animal test for the between the different types of dementia and the results cut-off score of 20/21 on the Revised Hasegawa’s Dementia Scale of the HDS-R or the OMAT in this study. To the best of our knowledge, no previous studies have examined these administering the HDS-R among all the patients as well associations. Further studies are necessary to address as in the subgroup of patients who were 65 years or older. this issue. Third, the subjects of the present study were To our knowledge, ours is the first study to evaluate the all Japanese patients with diabetes from a single hospi- association between OMAT and HDS-R and show a pos- tal. Further studies involving non-diabetic patients or itive correlation between their scores. subjects of other ethnicities are required to improve the Although the MMSE has been commonly used as a validity of our results. Fourth, the tests were conducted screening test for dementia all over the world, it has sev- in a single-blinded manner. Further examinations using eral disadvantages. The assessment of dementia status by a double-blinded and independent study design are war- MMSE is prone to be influenced by the educational level ranted to confirm our findings. of the subjects [15]. Executive functions are not fully rep- resented in the MMSE. In addition, a previous study has shown that the HDS-R had a higher area under the ROC Conclusions curve than the MMSE while identifying patients with AD The present study showed a strong positive correlation [13]. Therefore, it would be useful to apply HDS-R as a between the OMAT and HDS-R scores. The OMAT cut- standard examination in the present study. off score of 13/14 balanced the sensitivity closest to 1.00 Though HDS-R has been established as a common while enabling the highest specificity in the identification diagnostic test for dementia, it consists of 9 questions, of HDS-R-positive patients. The OMAT may be used as takes approximately 10  min to complete, and is occa- an optimal screening test while deciding whether to pro- sionally difficult to implement in busy out-patient clini - ceed with administering further diagnostic tests such as cal settings. Meanwhile, OMAT consists of one simple the HDS-R not only among all the patients enrolled in question and is executed in 1  min. We found that the the study, but also in just the subgroup of patients aged OMAT cut-off score of 13/14 showed a sensitivity of 1.00 65 years or older. for identifying HDS-R-positive patients in this study. Authors’ contributions This indicates that all the patients with a score of 14 or SK participated in the study design and statistical analysis. ET, KF, HN, and SU more on the OMAT scored 21 or higher on the HDS-R, collected the data. MS, SN, TO, SH, and SU participated in the study design. Y T, Y T, MM, and TS helped draft the manuscript. All authors read and approved and that the HDS-R was negative for dementia when the the final manuscript. OMAT was negative for dementia. Therefore, the OMAT can be considered as an optimal screening test to deter- Author details Department of Medical Education and General Practice, Osaka City Univer- mine whether to proceed with the administration of fur- sity Graduate School and Faculty of Medicine, 1-4-3, Asahi-machi, Abeno-ku, ther diagnostic tests, such as the HDS-R. In addition, a Osaka 545-8585, Japan. Fujiidera Municipal Hospital, Fujiidera, Japan. Kinuhata et al. Asia Pac Fam Med (2018) 17:6 Page 5 of 5 Acknowledgements 4. Katoh S, Shimogaki H, Onodera A, Ueda H, Oikawa K, Ikeda K, et al. Devel- Not applicable. opment of the revised version of Hasegawa’s Dementia Scale (HDS-R) (in Japanese). Jpn J Geriatr Psychiatry. 1991;2:1339–47. Competing interests 5. Imai Y, Hasegawa K. The Revised Hasegawa’s Dementia Scale (HDS-R)— The authors declare that they have no competing interests. evaluation of its usefulness as a screening test for dementia. J Hong Kong Call Psychiatr. 1994;4(Suppl 2):20–4. Availability of data and materials 6. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical The datasets used and/or analyzed during the current study available from the method for grading the cognitive state of patients for the clinician. J corresponding author on reasonable request. Psychiatr Res. 1975;12:189–98. 7. Hanyu H, Kume KK, Takada Y, Onuma T, Iwamoto T. The 1-minute Consent for publication mental status examination in the memory clinic. J Am Geriatr Soc. Not applicable. 2009;57:1130–1. 8. Monsch AU, Bondi MW, Butters N, Salmon DP, Katzman R, Thal LJ. Ethics approval and consent to participate Comparisons of verbal fluency tasks in the detection of dementia of the The study protocols were in accordance with the Declaration of Helsinki, and Alzheimer type. Arch Neurol. 1992;49:1253–8. were approved by the ethics committee of the Osaka City University (number 9. Canning SJ, Leach L, Stuss D, Ngo L, Black SE. Diagnostic utility of abbrevi- 3496). Informed consent was obtained from all the subjects or their close rela- ated fluency measures in Alzheimer disease and vascular dementia. tives prior to participation. Neurology. 2004;62:556–62. 10. Sakurai H, Hanyu H, Murakami M, Kume K, Takata Y, Onuma T, et al. The Funding category “animals” is more appropriate than the category “vegetables” to This was not an industry-supported study. measure semantic category fluency. Geriatr Gerontol Int. 2011;11:374–5. 11. 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Asia Pacific Family MedicineSpringer Journals

Published: Jun 7, 2018

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