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A New Bedside Test of Cognition for Patients with HIV Infection

Beverly N. Jones, MD; Evelyn Lee Teng, PhD; Marshal F. Folstein, MD; and Katharine S. Harrison, MD
[+] Article, Author, and Disclosure Information

From Johns Hopkins Hospital, Baltimore, Maryland. Requests for Reprints: Katharine S. Harrison, MD, Division of Infectious Diseases, Johns Hopkins Hospital, Ross Building 1159, 720 Rutland Avenue, Baltimore, MD 21205. Acknowledgments: The authors thank Dr. Charles Rohde for helping with the statistical analyses. Grant Support: Training grant AGO-149 from the National Institute of Aging.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(10):1001-1004. doi:10.7326/0003-4819-119-10-199311150-00006
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Objective: To compare the Mental Alternation Test, a new 60-second bedside test of cognition, with the Mini-Mental State Exam (MMSE) and the Trailmaking Test, parts A and B, in patients with human immunodeficiency virus (HIV) infection.

Design: Cohort study.

Participants: Sixty-two inpatients with HIV infection.

Setting: The AIDS service of a referral hospital.

Measurements: Scores on the MMSE; the Trailmaking Test, parts A and B; and the Mental Alternation Test were compared using correlation calculations and analyses of variance. Receiver operating curves were constructed to identify the best cutoff score on the Mental Alternation Test for detecting impaired performance on the MMSE and the Trailmaking Test.

Main Results: The Mental Alternation Test score correlated significantly with MMSE (r = 0.68, P < 0.01) and Trailmaking Test, part B, scores (r = 0.54,P < 0.01). The receiver operating curves showed that a Mental Alternation Test cutoff score of 15 yielded the best results for the detection of abnormal performance on the MMSE (sensitivity, 95% [95% CI, 90% to 100%]; specificity, 79% [CI, 69% to 89%]) and the Trailmaking Test, part B (sensitivity, 78% [CI, 68% to 88%]; specificity 93% [CI, 90% to 100%]). Patients making fewer than 15 alternations in 30 seconds were significantly more likely to have abnormal MMSE (P < 0.0001) and Trailmaking Test, part B, scores (P < 0.0001). The Mental Alternation Test had good reproducibility; analyses of reliability included test-retest correlation (r = 0.80) and inter-rater reliability (r = 0.85, = 0.84). Time of administration was approximately 60 seconds.

Conclusions: The Mental Alternation Test of cognition has good sensitivity and specificity and is easily administered. It is a valuable test to identify patients who may need further cognitive evaluation.


Grahic Jump Location
Figure 1.
Scatterplot of Mini-Mental State Exam (MMSE) scores versus Mental Alternation Test scores.
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Grahic Jump Location
Figure 2.
Receiver operating curve.

The usefulness of different cut-off values for defining abnormal performance on the Mental Alternation Test was determined by calculating the sensitivity and specificity of each cut-off score for abnormal Mini-Mental State Exam (MMSE) performance (MMSE score < 24).

Grahic Jump Location




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