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Table 4. Vision Impairment & Diet Characteristics Eye Diseases (n=100 ) Patients Diet Risk (N) (N) Cataracts 55 38 Glaucoma 12 8 Optic Neuropathy 6 2

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Table 4. Vision Impairment & Diet Characteristics

Eye Diseases (n=100)

Patients Diet Risk

(N) (N)


55 38


12 8

Optic Neuropathy

6 2

Diabetic Retinopathy

6 2


15 13


6 37


100 100

Table 3.

A Comparative Study of Mini-Mental State Exam and the Saint Louis University Mental Status for Detecting Mild Cognitive ImpairmentAmong Eye Care Patients

Patricia C. Heyn, Ph.D.1, Tammie Nakamura, M.S.1, Rosa Tang, M.D., M.P.H.2, Mukaila Raji, M.D.,MSc.2, Young-Fang Kuo, Ph.D.2

1Division of Geriatric Medicine • The University of Colorado Health Sciences Center • Denver, Colorado

2 School of Medicine • The University of Texas Medical Branch • Galveston, Texas


Aging is one of the major factors for cognitive dysfunction. The combination of an aging population and the promise of disease-modifying therapies for Alzheimer’s Disease (AD), inspire the dementia research field to seek screening approaches to identify the early stages of AD. Although screening instruments for cognitive impairment (CI) are frequently used in the elderly, the concept of mild cognitive impairment (MCI) is aimed to capture patients in the transition from normality to dementia. If MCI is identified patients could be informed about options for intervention and treatment that could delay the progression of this syndrome.

The World Health Organization identifies visual impairment (VI) as one of the major reasons for disability in the elderly. VI directly and indirectly affects the health of the elderly. It was reported that 1.668 million British adults were disabled by defective vision in 19881. Cataract was the most common cause of disability and blindness.

Recent studies are supporting a cause-and-effect association between type of severity of visual loss and the major causes of dementia 2-3. A key public health strategy to reduce disease burden and slow down disability processes in the elderly is early screening for potentially treatable health factors at specific target sites, such as the Eye Clinic. Older adults visit the ophthalmology clinic more often than other health-care specialties (Table 1).


To examine the Saint Louis University Mental Status (SLUMS) examination as a screen for MCI; and to test if the SLUMS is more sensitive than the Mini-Mental State Exam (MMSE) in mild cognitive screening. The SLUMS like the MMSE is a11-item scale with scores ranging from 0-30, with lower scores indicating increasing severity of CI in the domains of orientation,memory, attention, language & executive function.


100 patients age 60 and older attending the University of Texas Medical Branch (UTMB) Eye Clinic were consented to participate. Study was approved by the UTMB IRB. After educational adjustments4, 60% of the sample scored in the CI range of the SLUMS but not on the MMSE. African American and Hispanics presented more CI compared to white patients as defined by the SLUMS (OR, 2.80; 95% CI,1.05-7.44), independent of age, years of education and chronic diseases.

  • Mental status screening by the St Louis Mental Status Examination (SLUMS) showed that 65 pts scored for cognitive impairment (CI), 46 for mild CI, and 19 for severe CI (Fig.1).
  • Significant Correlations were found between the SLUMS and MMSE domains (Table 3).
  • Pts w/ diabetes were more likely to have CI (81.6%) diabetics versus 54.8% in non-diabetics, p=0.006.
  • Diabetes was significantly predictive of CI (OR,3.28).
  • No significant association between VI & CI (p=0.06).
  • Cataracts was the most common eye disease.
  • on this sample (Table 4).

Table 2.Sample Characteristics (N= 100) Value

Age, mean +SD 68.4+8.1

Men % 42.0

White % 61.0

African American,% 22.0

Hispanic, % 16.0

Income (>$20,000 )% 33.3

Education (>high school) 36.0

Living Alone % 35.0

Currently Married % 60.0

Currently Taking Medications % 89.0

Chronic Disease History % 92.0

(Diabetes, Hypertension, Stroke, CAD, Cancer, etc)

Eye Disease % 87.0

BMI > 25 % 74.7

Systolic Blood Pressure >135mmHG % 68.4

MMSE, mean +SD 27.5+3.7

SLUMS, mean +SD 21.8+ 5.5

Table 1. The National Ambulatory Medical Survey: ophthalmology ranked as the second most visited specialty by patients 65 yrs and older.

Figure 3. MMSE & SLUMS Domains & Demographic Comparisons

Figure 1. Frequency of cognitive impairment using the

St. Louis University Mental Status Examination Scale (SLUMS), N=100 (adjusted by education levels).

  • Limited associations between vision and cognition function due to the small number of participants.
  • Inferences between ethnicity, chronic disease status, and CI variables are limited due to the cross sectional design.
  • Potential bias from recruiting participants from one site Eye clinic site.
  • Lack of confirmatory diagnostic exam for CI.
  • Despite the small sample and sampling procedures limitations,

these findings do support the need to further determine the association between cognitive function and disease development in visually impaired elders.

  • The results suggest that the SLUMS is more sensitive to detect MCI than the MMSE.
  • 65% of participants 60 yrs and older attending the UTMB Eye Clinic screened positive for CI on the SLUMS.
  • African American & Hispanics adults (non-whites) and participants with diabetes were significantly more likely to present CI.
  • Early screening for CI might slow down the progression of cognitive decline and disability in the ophthalmic elderly patient.
  • The Eye Clinic seems to be a feasible site for health screening and it could be a valuable and low cost strategy to detect elderly at risk for developing dementia.
  • Further research is needed to assess the effects of interventions on the progression of CI and diabetes.
  • Results should be cross-validated on a larger sample.

Figure 2. Canonical Discriminate Function (X2=48.6,18df,p<0.0001; 74% variance explained by scale, 26% with significant loadings for SLUMS domains - Registration & Recall, Attention, Calculation, Executive Function, Language


1. Congdon NG, Friedman DS, Lietman TL. (2003). Important causes of visual impairment in the world today. JAMA(290):2057-60

2. Duffy C.J. (1999). Visual loss in Alzheimer’s disease. Neurology; 52:10-11.

3. Giannakopoulos P. et al (1999). Neuroanatomic correlates of visual agnosia in Alzheimer’s disease: a clinicopathologic study. Neurology; 52:71-77.

4.Crum RM, Anthony JC, Bassett SS, Folstein MF.. Population-based norms for the Mini-Mental State Examination by age and educational level .JAMA. 1993 May 12; 269(18):2386-91.

Acknowledgments: Dr.Heyn is supported by the National Institute on Aging, Trainee Grant in Geriatric Research NIH/NIA# ST 60877. Ms. Nakamura is supported by the NIH R01 AG0193398. This study was also supported by the Galveston Jamail Foundation. The authors thank the developers of the Saint Louis University Mental Status Examination (SLUMS) instrument for allowing the use of their instrument.