Self administered cognitive screening test (TYM) for detection of Alzheimer’s disease: cross sectional study
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2030 (Published 10 June 2009) Cite this as: BMJ 2009;338:b2030
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Although I primarily perform Orthopoedic consultantations, I am
interested in this test and reasonably would employ it in my practice. I
have read several pages about it but no method of directly obtaining it
for review.
In my opinion, it probably deserves a place in office practice and
should be considered as a valuable screening asset for practitioners.
I would like to review it for my own practice.
Pleasse advise me how to obtain a copy of the TYM test
Thank you
Robert K Johnson MD
KY 41892
USA
Competing interests:
None declared
Competing interests: No competing interests
Congratulations to Drs. Brown et al. for bringing out what will prove
to be a prototype for easily administered screening test for a looming
epidemic of cognitive diseases in the elderly. All the comments are valid
criticisms and point towards the difficulty of any tests of this kind.
What we need is a well validated test across different languages
educational levels age groups and cultures which can be easily
administered and non-confrontational.
With the availability of new gadgets like the iphone, it would quite
conceivable to develop such a test as a freely downloadable application in
different language forms and include tests for attention, reaction time
etc. which can be significant for diseases such as Lewy Body Dementia
(DLB), which ranks second to Alzheimer disease in the over 75s. I agree
that interpretation should be left to clinicians and the results should be
referred back to a central reference databank where they can be analysed
against age, gender and ethnic norms, and reported only as within a
certain percentile of the normal range.
It is about time tests such as the MMSE are replaced - the gold standard
lining the pockets of the copyright holders.
Competing interests:
None declared
Competing interests: No competing interests
There has been much interest in the publication of the new cognitive
test “Test Your Memory (TYM)”.
We have received many positive comments but there has been some
misinterpretation of our findings. The TYM test is intended to be self-
administered by the patient and this is a central feature – as it allows
testing of 10 cognitive skills in minimal operator time. The TYM test
needs to be overseen and interpreted by a health professional. The test is
therefore self-administered but not for self diagnosis. It is hard to
choose an alternative title which clarifies this without being too long.
As a result of the publicity concerning self testing we have delayed the
launch of the website tymtest.com until we can ensure easy access for
professionals whilst discouraging self testing.
The TYM test has been validated in a single study in a single
population who have presented with cognitive problems. It shows great
promise as a screening tool in this setting. Some of the replies highlight
problems that would occur with indiscriminate screening of asymptomatic
patients, where the number of false positives would cause many problems.
We would agree that such testing is not appropriate. A low TYM score
suggests the need to look for a cause (which can be as simple as leaving
spectacles at home), it does not mean the patient has Alzheimer’s disease.
We agree that the TYM test needs to be validated in other populations.
Longitudinal data is crucial and is being collected.
The TYM test is not a diagnostic test. The diagnosis of Alzheimer’s
disease needs a proper clinical assessment from a trained professional.
The TYM test is an aid in this process but not a replacement for it. Human
beings and brain diseases are inherently variable and it is unlikely that
there will ever be a quick memory test which would allow an untrained
person to safely diagnose Alzheimer’s disease or distinguish Alzheimer’s
disease from other forms of degenerative or vascular dementia. An
experienced clinician may recognize a pattern of scoring on the TYM which
suggests Alzheimer’s disease or semantic dementia in many patients.
The TYM test can be completed quickly by most patients and be
supervised by an individual who has received minimal training. This is not
the same as saying that it should be done in a busy room or casually. The
patient should give verbal consent, be sat in a quiet area away from other
patients, clocks and newspapers and the supervisor will need to help if
necessary. In many of the clinics where we have used the TYM, certain
nurses or receptionists have proven very competent at supervising the test
and there has been a suitable area. If this is not possible or there is
more time then we supervise the test ourselves. We would agree that there
are clear advantages in the clinician supervising the test. Whilst this
will take up 5 minutes of the clinician’s time watching the patient often
yields more information and we usually find it possible to do some other
tasks such as reading notes or filling forms at the same time.
The TYM test as published is culturally biased. A major advantage of
the TYM test is that it can be translated and adapted for many other
cultures and languages without changing the basic structure. Over a dozen
different language/cultural versions are under preparation; these
different versions of the TYM test will also need to be validated. We hope
to place these on the website tymtest.com. We are also working on versions
of the TYM suitable for patients with visual impairment and physical
disabilities.
In answer to more specific points, we include a wide age range of
controls because many younger patients have cognitive complaints as a
result of epilepsy, multiple sclerosis and other conditions and we believe
the TYM test may be useful in these patients. The average TYM scores of
controls are remarkably stable but do fall off after the age of 70 years
as do most similar tests. There were no significant differences between
older and younger patients with Alzheimer’s disease.
The use of occasional prompts is to try to make as clear as possible
to patients the answer required – so that failure to complete a space
properly is because the task couldn’t be done not that the patient was
unsure of what was required.
We are well aware of the ethical debate around early diagnosis of
Alzheimer’s disease and share many of the concerns of your correspondents.
It is vital, in our opinion, that progress is made towards early diagnosis
for several reasons; one important reason is that if a treatment which
halts Alzheimer’s disease becomes available, we need a test to identify
those likely to benefit.
Competing interests:
None declared
Competing interests: No competing interests
Dear sir,
I read the interesting article of Brown et al. and other rapid responses.
I want to ask about the effect of educational level of patients on the
test. In my country illiteracy is common especially in the elderly
group and I think this is a problem of many countries. Authors mentioned
about disabled people or patients with hearing loss or eye problems but if a
patient is illiterate which category of help should be assigned? With my
respects,
Competing interests:
None declared
Competing interests: No competing interests
The Brown et al (1) study has generated intense discussion, not only
by clinicians, but very appropriately, by lay people as well. The study
was designed well in most repsects; some of the shortcomings have already
been highlighted in the rapid responses so far.
I would like to highlight another fallacy which has not yet been
commented upon. This study was conducted in a memory clinic environment in
Cambridge on patients suffering from dementia, mostly of Alzheimer’s type
as per NINCDS-ARDRA criteria. The authors mention that patients with
depression were excluded, presumably based on a diagnostic assessment by
the psychiatrist. I would like to comment on the validity of the screening
test, as an important subgroup of patients has been excluded. Most memory
clinics would have a substantial number of patients who present with
cognitive impairment due to depression rather than dementia. It is vitally
important to know how these patients fared on the TYM test as the
specificity of the test to delineate dementia from depression would be
crucial. The authors sadly have not furnished this data/have not attempted
to explore this in the paper.
Professor Black has already commented on the high number of possible false
positives in patients who underwent the TYM. If there is a high false
positive rate in patients with depression as well, it will further reduce
the validity of the TYM test.
The authors also quote that they have been able to demonstrate very
high sensitivity and specificity of the TYM test, 93% and 86%
respectively. However, studies using other cognitive screening tests eg.
the modified Danish version of the ACE have found similar, if not better,
sensitivity and specificity (99% and 94% respectively) (2). The above
paper(2) did though mention that specificity dropped to 64% in patients
with depression. This again highlights the need for a screening test to
differentiate between depression and dementia, which is as yet not readily
available.
1.Brown, J et al. Self administered cognitive screening test (TYM)
for detection of Alzheimer’s Disease: cross sectional study. BMJ
2009;338:b030
2. Validation of the Danish Addenbrooke's Cognitive Examination as a
screening test in a memory clinic. Stokholm J, Vogel A, Johannsen P,
Waldemar G. Dement Geriatr Cogn Disord. 2009;27(4):361-5. Epub 2009 Mar
20.
Competing interests:
None declared
Competing interests: No competing interests
Test your memory (TYM) is a self-administered cognitive screening
test for detection of Alzheimer´s disease (AD). The test takes about 5
minutes for healthy subjects; information on test duration in demented
subjects is missing, but it is considered to be an economic test.
Some important comments should be made: The first one refers to the
relevance of memory impairment for dementia. In the TYM there is only one
sentence which has to be copied and recalled afterwards, making only 6 out
of 50 possible points for the episodic memory domain – next to
orientation, calculation, visuospatial abilities etc.
Secondly, a major
limitation of the TYM is the missing evidence for performing the test
without help in a waiting room. What happens if help is needed? Should the
test be stopped? What happens with the delayed recall of the only real
episodic memory item? Will a severe bias of the individuals eligible for
screening occur? Looking at the items it is evident that healthy subjects
and MCI patients will usually be able to handle the tasks, but will
Alzheimer patients be able to do this? The authors report a sensitivity to
detect AD of 92% and a specificity of 84% when applying a cut-off score of
43 out of 50 points. The diagnosis of the patients included was based on
examinations in three hospitals including a memory clinic. The test then
identified AD patients because they have the most severe impairment.
However, patients with MCI might only have problems with the one item
testing episodic memory and not with semantic memory.
Furthermore,
comparisons of patients with dementia of different aetiology are missing,
especially of patients with vascular dementia. Furthermore, experience of
test administration by general practitioners would be important. Another
important aspect is that the test is language based and can only be
administered when the subject is able to read and write. However, a
considerable number of functional illiterates exist, and another amount of
people may not speak the language due to different reasons. For these
subjects, the test is not valid and perhaps not even applicable.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir, the recent publicity generated by the article on the test
'test your memory (TYM)'(1)highlights intense general interest in early
and accurate recognition of dementia, usually Alzheimer's disease.
Although the TYM is 'self administered' it was given out by clinic staff
to clinic attendees in a setting to which people had been referred with
comparisons provided for defined clinical subgroups; the people filling in
the questionnaires had already been through at least one filter and seen
their gp. They were also seen immediately afterwards by a clinician who
could address any concerns. The danger of calling a test 'self
administered' in the title is that it provides a very different and
potentially misleading message - that of downloading the test from the
internet and doing it in the home setting with no forum for interpretation
or provision of support; the diagnosis of dementia is a process which
requires multidisciplinary assessement and often over a period of time(2).
Many older people are now asking their doctors whether they should get and
do the test. In addition, the TYM was administered to a relatively young
population (median ages under 70) with potentially high educational
levels; memory clinic referrals have not been demonstrated to be
representative of the general older population. It is uncertain exactly
how much advantage it provides over MMSE as the full MMSE ROCurve was not
provided. These factors mean that it would be unwise to assume it would
perform as well in the very different settings such as general practice
waiting rooms or at home. If this is the intention of this test it must be
applied in many different and appropriate settings, with longitudinal
follow up to ensure validity, as well as appropriate support to those
completing it. All this has to be done before any suggestion that this
might be a useful test in any more extended settings for early detection
of Alzheimer's disease or dementia.
1. Brown, J., et al. Self-administered cognitive screening test (TYM)
for detection of Alzheimer’s disease : cross sectional study. BMJ
2009;338:b030
2. Nicholl, C. Diagnosis of dementia. BMJ 2009; 338:b1176
http://www.bmj.com/cgi/content/extract/338/jun08_3/b1176?papetoc
Competing interests:
None declared
Competing interests: No competing interests
The Test Your Memory (TYM) test has been designed as a tool to be
quick to administer by a non specialist, test a range of cognition and be
accurate in diagnosis of Alzheimer’s. It was created as an improvement to
the current “gold standard” test the Mini Mental State Examination (MMSE).
However, I have several concerns regarding the TYM test.
Firstly the issue of consent with testing does not appear to have
been thought through. When conducting testing, consent must be given to
carry out the test and the implication of any possible outcomes, good and
bad made explicitly clear. Will consent be discussed with the individual
before they start completing the TYM test in the waiting area? Who will do
this if they are not seeing the medic until the have completed that test?
As well as this, the fact that the test is completed by the
individuals unsupervised or – as the article suggests – with the
receptionist supervising them in the waiting area needs to be considered.
As this test includes the clock drawing test, will all clocks be removed
for waiting areas where the test is being carried out? Will the
supervising receptionist be able to stop them looking at their own watch
or indeed preventing anyone who chooses to cheat from doing so? Or will
the carer have to responsibility to ensure that the individual does not
cheat? If this is the case, this adds more stress to an already stressful
job. It is also worthwhile noting that confidentiality is also a large
issue if cognitive assessments are being suggested to be completed in an
open public area.
Furthermore, in administering the test with the individual, large
amounts of qualitative information can be gathered and noted when scoring
and interpreting the test. Looking for signs of anxiety when completing to
the test to see if this is a factor in the interpretation of the test
score for example. If the tests are completed without an observer to take
in this type of information, I fail to see how the TYM can do as it
claims, offering “thorough testing in minimal time“ by having the
individuals complete the test themselves.
In the TYM test is has some prompts that I feel deny the collection
of interesting data. By offering the individual the prompt in the year of
“20—“ this will automatically help orientate to the year. Some of the most
interesting qualitative data that can be found from testing is in the free
recall of the orientation data. If the year recalled is inaccurate, it can
give an indication of possibly when the cognitive problems started to
occur, or to an important time in that person’s life.
Using the question “when did the first world war start?” to test
recall of remote information is culturally specific and possibly not
relevant for some younger adults that may be experiencing the beginnings
of memory problems. I note that the authors of the TYM test state that
they will change the wording on the question ‘Who is the Prime Minister’
so that is relevant in other cultures. It is worthwhile applying a
modification to the First World War question too?
Finally I would like conclude that brief testing is no substitute for
thorough testing conducted by professional in the appropriate environment.
While I accept that due to time pressure on services, shorter tests such
as the TYM test are very helpful. However, it seems remiss of us to be
losing out on useful information that can be gathered by simply taking
some time to administer tests with the individual ourselves.
Competing interests:
None declared
Competing interests: No competing interests
Regarding Prof. Black's calculation of 11 false positives for every
correct diagnosis of Alzheimer's disease: many screening tests, such as
mammography, have been criticized for producing too many false positives
that generate worry and unnecessary intervention.
One can only imagine the anguish a false diagnosis of Alzheimer's
disease would generate. It is disturbing that this information--which must
surely be considered in implementation of the test, as well as patient
counseling--was not included in the study itself, but owes it reporting to
Prof. Black.
The fact that it takes only 5 minutes and a pencil to produce such
worrisome results is even more disheartening. At least with mammography,
time, cost, availability, and risk are factored into its use.
I would strongly urge that anyone taking the test, or their
caretaker, be required to read and sign a statement indicating they
understand that 11 people are falsely diagnosed with Alzheimer's for every
person correctly identified. In other words, the potential for good news,
even with a "bad" result, vastly outweighs the probability for genuine bad
news.
I would also recommend that there be a clear list of other tests that
will or can be done to more accurately diagnose Alzheimer's, particularly
at an early stage, and that no action be taken in terms of treating,
counselling for care, or anything else until a more accurate diagnosis is
established.
This is particularly important in nursing homes, where such screening
may become widespread and patients with reversible problems may simply be
lumped into the "Alzheimer's group."
Competing interests:
None declared
Competing interests: No competing interests
Obtaining copies of test
this is a very interesting article.
I would like to obtain a copy of the test for use in my office. How may I
obtain one? Thanks you Edward W Beal, MD
Competing interests:
None declared
Competing interests: No competing interests