Nilai abnormalitas

1. Tabel Abnormalitas

Parameter Rerata SD Rerata ± 2 SD Nilai abnormalitas

SGOT/SGPT 26.29 13.923
Hemoglobin 12.472 .3238
Trigliserid 115.31 20.047
Total Kolestrol 137.24 32.405
HDL 89.44 17.119
LDL 74.64 13.634

Statistics
SGOT/SGPT Total
Laki-laki Hemoglobin Trigliserid Kolestrol HDL LDL
N Valid 200 200 200 200 200 200
Missing 0 0 0 0 0 0
Mean 26.29 12.472 115.31 137.24 89.44 74.64
Std. Deviation 13.923 .3238 20.047 32.405 17.119 13.634

2. Clinical Scenario
a. Tabel P.I.C.O

P Older adult with early sign sympthom of cognitive impairment

I Mini-Cog Screening Test (yang baru, mau dicoba perbandingannya)
C Mini-Mental State Examination (MMSE) (pemeriksaan pada umumnya)
O Accurate diagnosis of Dementia or Alzheimer’s disease (Outcome)

b. Buatlah Clinical Question

In older adults with early sign-sympthom cognitive impairment, is the Mini-Cog Test
accurate as MMSE in diagnosis of Dementia or Alzheimer’s disease?

c. Buatlah Search Term/Search/Keyword

(Mini-Cog OR minicog) AND (mini-mental state exam OR MMSE) AND (Alzheimer
OR Dementia)

d. Lakukan Searching
Sumber: www.tripdatabase.com
Cognitive tests for dementia: MMSE, Mini-Cog and ACE-R
The way we diagnose and detect dementia, therefore, is by systematically assessing
the function of various brain regions by using cognitive tests.‘Cognitive’ here means
the ‘higher brain functions’ I alluded to earlier; things
like memory, numeracy, visual perception, personality change and planning, to
name a few.
The commonest cognitive test used is called the Mini-Mental State Examination
(MMSE). In this test you can score up to 30 points by answering a range of questions
that test your orientation to time and place, your memory, attention and so on. The
test itself takes about 10 minutes to complete. As the authors of this paper state, the
performance of the MMSE in detecting dementia as compared to other tests has not
been systematically assessed and so, that is what they set out to do. One of the
reasons to assess the relative merits of the MMSE is that it is a proprietary instrument,
owned by ‘Psychological Assessment Resources’ meaning that it is not actually free
for organisations to use.
Methods
The reviewers included studies that:
 Looked for patients with either Alzheimer’s, vascular dementia or Parkinson’s
disease in any clinical setting
 Assessed patients or carers face-to-face
 Used a standardised diagnostic criteria to diagnose dementia
 Published the outcome measures they were interested in.
Results
The initial search yielded 26,380 papers! After applying the inclusion/exclusion
criteria they were left with 149 studies, which covered 11 different diagnostic tests
and over 40,000 people from around the world.
MMSE
 The vast majority of the studies looked at MMSE (108 of 149)
 Sample size was 36,080 of whom 10,263 had dementia
 From these studies the:
o Mean sensitivity was 81% (CI was 78% to 84%)
o Mean specificity was 89% (CI was 87% to 91%)
 o All other markers also showed good diagnostic accuracy (LR+ = 7.45, LR- =
0.21, diagnostic OR was 35.4 and AUC was 92%)
Mini-Cog and ACE-R (the best of the rest)
 Of the 11 remaining tests, two stood out as being ‘better’ than the MMSE
o Mini-Cog (brief test <5 min): sensitivity of 91% and specificity of 86%
o ACE-R (20 min test): sensitivity of 92% and specificity of 89%
 However where the MMSE data was drawn from hundreds of studies:
o Mini-Cog data was drawn from just 9 studies
o ACE-R was drawn from just 13 studies
For all three of the above tests, there was found to be a high degree of heterogeneity.
In essence this is a statistical test telling us that between studies included in the
analyses, the results were quite different from one study to another. Heterogeneity is
not a good thing in systematic reviews.
Further analyses
The reviewers showed that the accuracy of the MMSE was not affected by
geographical location or clinical site (i.e. it was as effective for hospital patients as
community patients).
Finally they looked at the accuracy of diagnosing mild cognitive impairment (MCI);
a risk state that precedes dementia. They didn’t really go into much detail in the
methods of how they found the studies or how they defined MCI.
 Only 21 studies using MMSE were used to assess diagnostic accuracy for MCI
giving:
o a sensitivity of only 62%
o and a specificity of 87%.
 An alternative test, the MoCA, was found to perform better (in 9 studies) with:
o a sensitivity of 89%
o and a specificity of 75%
 No data was provided on the other tests presumably because there weren’t enough
studies.
Conclusions
 In short, the MMSE is not a bad screening tool for dementia but it is not miles better
than the rest; it’s just really commonly used, probably for historical reasons. The
ACE-R and the Mini-Cog are both free to use and may be viable alternatives.
The MMSE is less good in mild cognitive impairment.
Final thoughts
It’s important to add that whilst this paper focussed on cognitive screening tests,
which play an important part in diagnosis, a full clinical assessment of someone with
suspected dementia requires a much more detailed approach. Combining information
from the history, examination, investigations and cognitive tests greatly improve the
diagnostic accuracy. Also where the screening tests are not clear, patients can be
referred for much more detailed assessments of cognition performed by
neuropsychologists.
Also it is important to remember that the diagnosis of dementia requires evidence of a
progressive illness. This means that repeating cognitive tests and looking for change
is often more helpful than just a snapshot. This aspect was not covered in this
systematic review.

3. Diagnosis
 Classification: MCI
100
90
80
70
60
Sensitivity (%)
50
Specificity (%)
40
30
20
10
0
40 50 60 70 80
Kreatinin Kinase

Kreatinin Kinase
100

80
Sensitivity

60

40

20
AUC = 0.973
P < 0.001
0
0 20 40 60 80 100
100-Specificity

ROC curve
Variable Kreatinin_kinase
Kreatinin Kinase
Classification variable MCI
MCI

Sample size
100

Positive group a 13 (13.00%)

Negative group b 87 (87.00%)

a
MCI = 1
b
MCI = 0

Disease prevalence (%) unknown

Area under the ROC curve (AUC)

Area under the ROC curve (AUC) 0.973

a
Standard Error 0.0140

b
95% Confidence interval 0.919 to 0.995

z statistic 33.901

Significance level P (Area=0.5) <0.0001

a
DeLong et al., 1988
b
Binomial exact

Youden index

Youden index J 0.9195

Associated criterion >69.1098

Sensitivity 100.00

Specificity 91.95
 Criterion values and coordinates of the ROC curve [Hide]

Criterion Sensitivity 95% CI Specificity 95% CI +LR -LR

≥40.0886 100.00 75.3 - 100.0 0.00 0.0 - 4.2 1.00

>69.1098 100.00 75.3 - 100.0 91.95 84.1 - 96.7 12.43 0.00

>70.1641 92.31 64.0 - 99.8 93.10 85.6 - 97.4 13.38 0.083

>72.9038 76.92 46.2 - 95.0 93.10 85.6 - 97.4 11.15 0.25

>73.2495 69.23 38.6 - 90.9 94.25 87.1 - 98.1 12.05 0.33

>75.2407 69.23 38.6 - 90.9 96.55 90.3 - 99.3 20.08 0.32

>76.5148 61.54 31.6 - 86.1 97.70 91.9 - 99.7 26.77 0.39

>76.8872 53.85 25.1 - 80.8 98.85 93.8 - 100.0 46.85 0.47

>77.4574 38.46 13.9 - 68.4 98.85 93.8 - 100.0 33.46 0.62

>77.995 30.77 9.1 - 61.4 100.00 95.8 - 100.0 0.69

>78.6751 0.00 0.0 - 24.7 100.00 95.8 - 100.0 1.00

Epicalc

Angka numerik 69,1098 – jadiin data kategorik (buat bertingakt) ada yg diatassama dengan itu dan ada
yg dibawah itu

kategori kreatinin kinase * MCI Crosstabulation

Count
MCI
MCI Negatif MCI Positif Total
kategori kreatinin kinase >69 9 13 22
<69 76 0 76
Total 85 13 98

Tables - 2-by-2 unstratified

11:20:44 AM, 5/24/2018

| + - | Total
 -------+-------------+-------
+ | 13 7 | 20
- | 0 80 | 80
-------+-------------+-------
Total | 13 87 | 100

Tests of significance
Fisher exact test (one tailed) : 0.000000
Fisher exact test (two tailed) : 0.000000
Uncorrected chi-square : 59.77
p-value : 0.000001
Yates corrected Chi-square : 54.16
p-value : 0.000001

Measures of exposure effect [95% CI]

Risk ratio : **** [****, ****]
Odds ratio : **** [****, ****]
Risk difference : 0.65 [0.44, 0.86]
Proportional attributable risk : **** [****, ****]
Population proportional attr. risk : **** [****, ****]

Vaccine efficacy [95% CI]

Vaccine efficacy : **** [****, ****]

Screening [95% CI]

Prevalence : 0.13 [0.07, 0.22]
Sensitivity : 1.00 [0.72, 0.99]
Specificity : 0.92 [0.84, 0.96]
Accuracy : 0.93 [0.86, 0.97]
Predictive value of +ve result : 0.65 [0.41, 0.84]
Predictive value of -ve result : 1.00 [0.94, 1.00]

Matched data
Z : 2.27
One-sided p-value : 0.011671
Two-sided p-value : 0.023342
McNemar Chi-square : 5.14
p-value : 0.023342
McNemar odds ratio [95% CI] : **** [1.28, 74.55]
Difference in proportions [95% CI] : 0.07 [0.02, 0.12]

Interpretasi:

Kesimpulan:

4. Data therapy bad outcome

 Kesimpulan: bermakna secara klinis karena nilai RRL 50%

Chi-Square Tests
Asymptotic
Significance (2- Exact Sig. (2- Exact Sig. (1-
Value df sided) sided) sided)
Pearson Chi-Square 3.184a 1 .074
Continuity Correctionb 2.339 1 .126
Likelihood Ratio 3.246 1 .072
Fisher's Exact Test .125 .062
Linear-by-Linear Association 3.152 1 .076
N of Valid Cases 100
a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 9.50.
b. Computed only for a 2x2 table

5. Data therapy Effectiveness

Kesimpulan: