Comparing Approaches to Optimize Cut-off Scores for Short Cognitive Screening Instruments in Mild Cognitive Impairment and Dementia

Background: Although required to improve the usability of cognitive screening instruments (CSIs), the use of cut-off scores is controversial yet poorly researched. Objective: To explore cut-off scores for two short CSIs: the Standardized Mini-Mental State Examination (SMMSE) and Quick Mild Cognitive Impairment (Qmci) screen, describing adjustments in scores for diagnosis (MCI or dementia), age (≤, >75 years), and education (<, ≥12 years), comparing two methods: the maximal accuracy approach, derived from receiver operating characteristic curves, and Youden's Index. Methods: Pooled analysis of assessments from patients attending memory clinics in Canada between 1999-2010 : 766 with mild cognitive impairment (MCI) and 1,746 with dementia, and 875 normal controls. Results: The Qmci was more accurate than the SMMSE in differentiating controls from MCI or cognitive impairment (MCI and dementia). Employing the maximal accuracy approach, the optimal SMMSE cut-off for cognitive impairment was <28/30 (AUC 0.86, sensitivity 74, specificity 88) versus <63/100 for the Qmci (AUC 0.93, sensitivity 85, specificity 85). Using Youden's Index, the optimal SMMSE cut-off remained <28/30 but fell slightly to <62/100 for the Qmci (sensitivity 83, specificity 87). The optimal cut-off for MCI was <29/30 for the SMMSE and <67/100 for the Qmci, irrespective of technique. The maximal accuracy approach generally produced higher Qmci cut-offs than Youden's Index, both requiring adjustment for age and education. There were no clinically meaningful differences in SMMSE cut-off scores by age and education or method employed. Conclusion: Caution should be exercised selecting cut-offs as these differ by age, education, and method of derivation, with the extent of adjustment varying between CSIs.