Lightning Fast Mini-Cog: Video Featuring Drs. Paul Thisayakorn and Alex Gamble

Here’s a lightning-fast version of the Mini-Cog that two of my talented residents, Paul Thisayakorn and Alex Gamble,  put together using a Flip Video camera. This video demonstrates how to conduct the Mini-Cog in less than three and a half minutes. Watch carefully because Paul, in the role of patient makes a mistake on the Clock Drawing Task (CDT) though Alex, the role of the physician, doesn’t remark on it. Later in the video the CDT is clearly identified as being abnormal.

And Dr. Gamble has some comments as well:

We would at times on the consult service see our colleagues outside of psychiatry struggle to assess changes in mental status, which makes detecting delirium more difficult and in many cases led to our being called in to assist. We hoped that demonstrating the Mini-Cog with a straightforward video demonstration the same way things like central line placement have been done might make the task a bit more approachable and help build confidence in the primary teams’ own assessments.

Remember, we conduct the Mini-Cog as a cognitive test that informs the use of the original Confusion Assessment Method (CAM) as designed by Dr. Sharon Inouye [1]. The Mini-Cog is not a test for delirium; it’s actually a screen for dementia. And the issue of trying to screen for delirium with the CAM is that, unless you do something to test for inattention and cognitive disorganization, the CAM is less useful as a delirium detection tool [2].

If you want the long version, go to the Geriatric Nursing 30 minute presentation sponsored by the Hartford Institute in the menu above labelled “Mini Cog Video.” Both have their merits. The Hartford Institute gives you a comprehensive overview and detail about assessment and management of the cognitively impaired older adult and it’s very well done. I confess I’m partial to the shorter video done by my residents because it’s quick, gets to the point about how to do the actual Mini-Cog test…and because I’m proud of them.

1. Inouye, S. K., C. H. van Dyck, et al. (1990). “Clarifying confusion: the confusion assessment method. A new method for detection of delirium.” Ann Intern Med 113(12): 941-948.
OBJECTIVE: To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. DESIGN: Prospective validation study. SETTING: Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). PATIENTS: The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. MEASUREMENTS AND MAIN RESULTS: An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 – 1.0). CONCLUSIONS: The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

2. Wei, L. A., M. A. Fearing, et al. (2008). “The Confusion Assessment Method: a systematic review of current usage.” Journal of the American Geriatrics Society 56(5): 823-830.
OBJECTIVES: To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium. DESIGN: Systematic literature review. SETTING: Not applicable. MEASUREMENTS: Electronic searches of PubMED, EMBASE, PsychINFO, CINAHL, Ageline, and Google Scholar, augmented by reviews of reference listings, were conducted to identify original English-language articles using the CAM from January 1, 1991, to December 31, 2006. Two reviewers independently abstracted key information from each article. PARTICIPANTS: Not applicable. RESULTS: Of 239 original articles, 10 (4%) were categorized as validation studies, 16 (7%) as adaptations, 12 (5%) as translations, and 222 (93%) as applications. Validation studies evaluated performance of the CAM against a reference standard. Results were combined across seven high-quality studies (N=1,071), demonstrating an overall sensitivity of 94% (95% confidence interval (CI)=91-97%) and specificity of 89% (95% CI=85-94%). The CAM has been adapted for use in the intensive care unit, emergency, and institutional settings and for scoring severity and subsyndromal delirium. The CAM has been translated into 10 languages where published articles are available. In application studies, CAM-rated delirium is most commonly used as a risk factor or outcome but also as an intervention or reference standard. CONCLUSION: The CAM has helped to improve identification of delirium in clinical and research settings. To optimize performance, the CAM should be scored based on observations made during formal cognitive testing, and training is recommended. Future action is needed to optimize use of the CAM and to improve the recognition and management of delirium.


Author: Jim Amos

Dr. James J. Amos is Clinical Professor of Psychiatry in the UI Carver College of Medicine at The University of Iowa in Iowa City, Iowa. Dr. Amos received a B. S. degree in Distributed Studies (Zoology, Chemistry, and Microbiology) in 1985 from Iowa State University and an M.D. from The University of Iowa in Iowa City, Iowa in 1992. He completed his psychiatry residency, including a year as Chief Resident, in 1996 at the Department of Psychiatry at The University of Iowa. He has co-edited a practical book about consultation psychiatry with Dr. Robert G. Robinson entitled Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. As a clinician educator, among Dr. Amos’s most treasured achievements is the Leonard Tow Humanism in Medicine Award.

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