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Clinical Screening and Assessment Tools

Aphasia: acquired language impairment

The Bilingual Aphasia Test is a comprehensive language test designed to assess the differential loss or sparing of various language functions in previously bilingual individuals. The individual is tested, separately, in each language he or she previously used, and then in the two languages simultaneously. The testing is multimodal -- sampling hearing, speaking, reading, and writing; and multidimensional -- testing various linguistic levels (phonological, morphological, syntactic, lexical, and semantic), tasks (comprehension, repetition, judgment, lexical access and propositionizing), and units (words, sentences, and paragraphs). The BAT is structured as follows:
  • To test a bilingual aphasic, you will need the following testing elements: the stimulus books for each of the languages in which the individual was formerly fluent, the single-language tests for each of these languages, as well as the bilingual test that links them. For example, if you are testing an English-French bilingual aphasic, you will need an English stimulus book, a French stimulus book, an English single-language test, a French single-language test, and an English-French bilingual test.
According to the Associazione Italiana Afasici, there are about 150,000 aphasics in Italy, and every year 20,000 new cases. This pathological process is devastating; in fact, they have lost that feature which makes us unique, namely language. Since, the first case of aphasia described by the French physician Paul Broca in 1861, science has made great strides. Many new theories have been proposed and have tried to explain how our brain processes language. Particularly, research on bilinguals has become interesting and important for our understanding of the neuroscientific bases of language. In this doctoral thesis, we are going to introduce and discuss, with the help of a clinical case study, one of the most plausible theories which tries to explain how our brain processes language. In addition, we are going to introduce Paradis’ Bilingual Aphasia Test, which we have adapted to Sardinian. It is very important that all languages of an aphasic patient are assessed with an equivalent instrument, not a simple translation of a standardized test from another language. The assessment of only one language is not enough, and in the worst case can even cause negative social and/or clinical results. The assessment of both languages through a standardized bilingual test allows us to compare the two languages and to ascertain which one is impaired and which recovers first and best. Based on these results, the clinician together with the patient’s family can decide which language should be treated.
  • Hambleton, R.K. 1994. Guidelines for adapting educational and psychological tests: A progress report. European Journal of Psychological Assessment, 10: 229-240.
  • Goldblum, M. C., & Paradis, M. (1989). The bilingual aphasia test, French adaptation.
Hillsdale, NJ: Lawrence Erlbaum Associates.
  • Hummel, K., & Libben, G. (1989). The bilingual aphasia test, English adaptation.
Hillsdale, NJ: Lawrence Erlbaum Associates.
  • Paradis, M., Libben, G., & Hummel, K. (1987). The bilingual aphasia test. Hillsdale, NJ:
Lawrence Erlbaum Associates.

Cognitive impairment screening in the context of dementia or stroke

OBJECTIVES: To develop a 10-minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first-line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia. DESIGN: Validation study. SETTING: A community clinic and an academic center. PARTICIPANTS: Ninety-four patients meeting MCI clinical criteria supported by psychometric measures, 93 patients with mild Alzheimer's disease (AD) (Mini-Mental State Examination (MMSE) score > or =17), and 90 healthy elderly controls (NC). MEASUREMENTS: The MoCA and MMSE were administered to all participants, and sensitivity and specificity of both measures were assessed for detection of MCI and mild AD. RESULTS: Using a cutoff score 26, the MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild AD group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively). CONCLUSION: MCI as an entity is evolving and somewhat controversial. The MoCA is a brief cognitive screening tool with high sensitivity and specificity for detecting MCI as currently conceptualized in patients performing in the normal range on the MMSE. Sarah T. Pendlebury, MRCP, DPhil; Fiona C. Cuthbertson, MCSP; Sarah J.V. Welch, RGN; Ziyah Mehta, DPhil; Peter M. Rothwell, FRCP, FMedSci From the Stroke Prevention Research Unit (S.T.P., F.C.C., S.J.V.W., Z.M., P.M.R.), University Department of Clinical Neurology, John Radcliffe Hospital and the University of Oxford, Oxford, UK; and the National Institute of Health Research Biomedical Research Centre (S.T.P.), John Radcliffe Hospital, Oxford, UK. Correspondence to Sarah T. Pendlebury, MRCP, DPhil, Stroke Prevention Research Unit, Level 6 West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK. E-mail [email protected] Background and Purpose— The Mini-Mental State Examination (MMSE) is insensitive to mild cognitive impairment and executive function. The more recently developed Montreal Cognitive Assessment (MoCA), an alternative, brief 30-point global cognitive screen, might pick up more cognitive abnormalities in patients with cerebrovascular disease. Methods— In a population-based study (Oxford Vascular Study) of transient ischemic attack and stroke, the MMSE and MoCA were administered to consecutive patients at 6-month or 5-year follow-up. Accepted cutoffs of MMSE <27 and MoCA <26 were taken to indicate cognitive impairment. Results— Of 493 patients, 413 (84%) were testable. Untestable patients were older (75.5 versus 69.9 years, P<0.001) and often had dysphasia (24%) or dementia (15%). Although MMSE and MoCA scores were highly correlated (r2=0.80, P<0.001), MMSE scores were skewed toward higher values, whereas MoCA scores were normally distributed: median and interquartile range 28 (26 to 29) and 23 (20 to 26), respectively. Two hundred ninety-one of 413 (70%) patients had MoCA <26 of whom 162 had MMSE 27, whereas only 5 patients had MoCA 26 and MMSE <27 (P<0.0001). In patients with MMSE 27, MoCA <26 was associated with higher Rankin scores (P=0.0003) and deficits in delayed recall, abstraction, visuospatial/executive function, and sustained attention. Conclusion— The MoCA picked up substantially more cognitive abnormalities after transient ischemic attack and stroke than the MMSE, demonstrating deficits in executive function, attention, and delayed recall. Key Words: cognitive impairment • dementia • stroke • vascular cognitive impairment The majority of patient with post-stroke Vascular Cognitive Impairment (VCI) have Vascular Cognitive Impairment No Dementia (VCIND). The Mini-Mental State Examination (MMSE) has been criticized as a poor screening test for VCIND due to insensitivity to visuospatial and executive function impairments. The Montreal Cognitive Assessment (MoCA) was designed to be more sensitive to such deficits and may therefore be a superior screening instrument for VCIND. Stable patients within 14days of their index stroke without significant physical disability, aphasia, dysarthria, active psychiatric illness or pre-existing dementia were eligible. Cognitive and neurological measures were administered after informed consent. 100 patients were recruited. Of the 57 patients with unimpaired MMSE scores, 18 (32%) patients had an impaired MoCA score. By comparison, only 2 out of the 41 (4.9%) patients with unimpaired MoCA scores had impaired MMSE scores. Moreover, MMSE domain subtest scores could not differentiate between groups of differing screening test results, whilst MoCA domain subtest scores (Visuospatial/Executive Function, Attention and Recall) could. The MoCA is more sensitive than the MMSE in screening for cognitive impairment after acute stroke. Longitudinal studies are required to establish the prognostic value of MoCA and MMSE evaluation in the acute post-stroke period for cognitive impairment as defined by the standard method of formal neuropsychological evaluation 3–6months after stroke.
  • Wong A, Xiong YY, Kwan PW, Chan AY, Lam WW, Wang K, et al. The validity, reliability and clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease. Dement Geriatr Cogn Disord. 2009;28:81–87
garbageThe Assessment of Bilingual Aphasia By Michel Paradis, and Gary Libben

The Bilingual Aphasia Test is a comprehensive language test designed to assess the differential loss or sparing of various language functions in previously bilingual individuals. The individual is tested, separately, in each language he or she previously used, and then in the two languages simultaneously. The testing is multimodal -- sampling hearing, speaking, reading, and writing; and multidimensional -- testing various linguistic levels (phonological, morphological, syntactic, lexical, and semantic), tasks (comprehension, repetition, judgment, lexical access and propositionizing), and units (words, sentences, and paragraphs).

The BAT is structured as follows:

  • To test a bilingual aphasic, you will need the following testing elements: the stimulus books for each of the languages in which the individual was formerly fluent, the single-language tests for each of these languages, as well as the bilingual test that links them. For example, if you are testing an English-French bilingual aphasic, you will need an English stimulus book, a French stimulus book, an English single-language test, a French single-language test, and an English-French bilingual test.
  • Zanetti, Dario (2009) Bilingual aphasia: adaptation of the Bilingual Aphasia Test (BAT) to sardinian and study of a clinical case. Doctoral Thesis. Universita' degli studi di Sassari.
According to the Associazione Italiana Afasici, there are about 150,000 aphasics in Italy, and every year 20,000 new cases. This pathological process is devastating; in fact, they have lost that feature which makes us unique, namely language. Since, the first case of aphasia described by the French physician Paul Broca in 1861, science has made great strides. Many new theories have been proposed and have tried to explain how our brain processes language. Particularly, research on bilinguals has become interesting and important for our understanding of the neuroscientific bases of language. In this doctoral thesis, we are going to introduce and discuss, with the help of a clinical case study, one of the most plausible theories which tries to explain how our brain processes language. In addition, we are going to introduce Paradis’ Bilingual Aphasia Test, which we have adapted to Sardinian. It is very important that all languages of an aphasic patient are assessed with an equivalent instrument, not a simple translation of a standardized test from another language. The assessment of only one language is not enough, and in the worst case can even cause negative social and/or clinical results. The assessment of both languages through a standardized bilingual test allows us to compare the two languages and to ascertain which one is impaired and which recovers first and best. Based on these results, the clinician together with the patient’s family can decide which language should be treated. Hillsdale, NJ: Lawrence Erlbaum Associates.
  • Hummel, K., & Libben, G. (1989). The bilingual aphasia test, English adaptation.
Hillsdale, NJ: Lawrence Erlbaum Associates.
  • Paradis, M., Libben, G., & Hummel, K. (1987). The bilingual aphasia test. Hillsdale, NJ:
Lawrence Erlbaum Associates.

Cognitive impairment screening in the context of dementia or stroke

OBJECTIVES: To develop a 10-minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first-line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia. DESIGN: Validation study. SETTING: A community clinic and an academic center. PARTICIPANTS: Ninety-four patients meeting MCI clinical criteria supported by psychometric measures, 93 patients with mild Alzheimer's disease (AD) (Mini-Mental State Examination (MMSE) score > or =17), and 90 healthy elderly controls (NC). MEASUREMENTS: The MoCA and MMSE were administered to all participants, and sensitivity and specificity of both measures were assessed for detection of MCI and mild AD. RESULTS: Using a cutoff score 26, the MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild AD group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively). CONCLUSION: MCI as an entity is evolving and somewhat controversial. The MoCA is a brief cognitive screening tool with high sensitivity and specificity for detecting MCI as currently conceptualized in patients performing in the normal range on the MMSE. Sarah T. Pendlebury, MRCP, DPhil; Fiona C. Cuthbertson, MCSP; Sarah J.V. Welch, RGN; Ziyah Mehta, DPhil; Peter M. Rothwell, FRCP, FMedSci From the Stroke Prevention Research Unit (S.T.P., F.C.C., S.J.V.W., Z.M., P.M.R.), University Department of Clinical Neurology, John Radcliffe Hospital and the University of Oxford, Oxford, UK; and the National Institute of Health Research Biomedical Research Centre (S.T.P.), John Radcliffe Hospital, Oxford, UK.

Correspondence to Sarah T. Pendlebury, MRCP, DPhil, Stroke Prevention Research Unit, Level 6 West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK. E-mail [email protected]

Background and Purpose— The Mini-Mental State Examination (MMSE) is insensitive to mild cognitive impairment and executive function. The more recently developed Montreal Cognitive Assessment (MoCA), an alternative, brief 30-point global cognitive screen, might pick up more cognitive abnormalities in patients with cerebrovascular disease.

Methods— In a population-based study (Oxford Vascular Study) of transient ischemic attack and stroke, the MMSE and MoCA were administered to consecutive patients at 6-month or 5-year follow-up. Accepted cutoffs of MMSE <27 and MoCA <26 were taken to indicate cognitive impairment.

Results— Of 493 patients, 413 (84%) were testable. Untestable patients were older (75.5 versus 69.9 years, P<0.001) and often had dysphasia (24%) or dementia (15%). Although MMSE and MoCA scores were highly correlated (r2=0.80, P<0.001), MMSE scores were skewed toward higher values, whereas MoCA scores were normally distributed: median and interquartile range 28 (26 to 29) and 23 (20 to 26), respectively. Two hundred ninety-one of 413 (70%) patients had MoCA <26 of whom 162 had MMSE 27, whereas only 5 patients had MoCA 26 and MMSE <27 (P<0.0001). In patients with MMSE 27, MoCA <26 was associated with higher Rankin scores (P=0.0003) and deficits in delayed recall, abstraction, visuospatial/executive function, and sustained attention.

Conclusion— The MoCA picked up substantially more cognitive abnormalities after transient ischemic attack and stroke than the MMSE, demonstrating deficits in executive function, attention, and delayed recall.

Key Words: cognitive impairment • dementia • stroke • vascular cognitive impairment

The majority of patient with post-stroke Vascular Cognitive Impairment (VCI) have Vascular Cognitive Impairment No Dementia (VCIND). The Mini-Mental State Examination (MMSE) has been criticized as a poor screening test for VCIND due to insensitivity to visuospatial and executive function impairments. The Montreal Cognitive Assessment (MoCA) was designed to be more sensitive to such deficits and may therefore be a superior screening instrument for VCIND. Stable patients within 14days of their index stroke without significant physical disability, aphasia, dysarthria, active psychiatric illness or pre-existing dementia were eligible. Cognitive and neurological measures were administered after informed consent. 100 patients were recruited. Of the 57 patients with unimpaired MMSE scores, 18 (32%) patients had an impaired MoCA score. By comparison, only 2 out of the 41 (4.9%) patients with unimpaired MoCA scores had impaired MMSE scores. Moreover, MMSE domain subtest scores could not differentiate between groups of differing screening test results, whilst MoCA domain subtest scores (Visuospatial/Executive Function, Attention and Recall) could. The MoCA is more sensitive than the MMSE in screening for cognitive impairment after acute stroke. Longitudinal studies are required to establish the prognostic value of MoCA and MMSE evaluation in the acute post-stroke period for cognitive impairment as defined by the standard method of formal neuropsychological evaluation 3–6months after stroke.
  • Wong A, Xiong YY, Kwan PW, Chan AY, Lam WW, Wang K, et al. The validity, reliability and clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease. Dement Geriatr Cogn Disord. 2009;28:81–87
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