Screening Tools for Various Health Conditions

This article discusses various screening tools used for different health conditions such as depression, alcohol abuse, and dementia. It provides information on the purpose, administration, and validity of screeners like SLUMS, CLOCK-DRAWING, CAGE, PHQ-9, MMSE, T-ACE, and AUDIT Tests.

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SCREENING TOOLS
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Screening Tools
In the context of medicine, screening refers to a strategy which is used in a given
population in order to identify or detect the presence of undiagnosed diseases which have no
symptoms in individuals. This makes screening tests anomalous in nature since they are
performed on individuals who are in good health status. Screening is usually done to identify a
certain disease in a community early enough for necessary intervention measures to be
undertaken. Various screening tools are used based on the disease being investigated. Some of
them include SLUMS, CAGE, PHQ-9, CAGE-AID, CLOCK-DRAW AND MMSE among
others. The above screening tools have been discussed and their various comparisons made based
on their usage as well as a recommendation for their improvement.
The SLUMS (“Saint Louis University Mental Status Examination”) was established by a
Director at Saint Louis University who was working at the Division of Geriatric Medicine. It is a
screening method which detects Alzheimer’s and Dementia. The people who are suspected to
have the disease are given a brief oral or written exam. SLUMS is superior to MMSE in that it is
capable of identifying very early symptoms of dementia in individuals and hence early
interventions are taken (Buckingham et al, 2013). It is also free to use and already includes
CLOCK-DRAWING in it. SLUMS generally has 11 items and involves measurement of various
cognition aspects which include geometric figures recognition, short-term memory, the test of
clock drawing, orientation, animals’ naming, and calculations. It can be administered at the
approximated time of seven minutes and its scores range from 0 to 30. If the screener is given to
two people, then judgment is made based on their scores. Scores of 27-30 indicate that a person
who has high school education is normal, 21-26 indicate that a person has a mild neurocognitive
disorder while 0-20 indicate dementia. SLUMS screener is highly reliable and valid especially

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for older adults and geriatric care, non-specific patient population, and population with
progressive Dementia and Alzheimer’s disease. For instance, Feliciano et al 2013, found out that
excellent validity for community-dwelling elders was r=0.75 for their research while Stewart et
al, 2012 found out that validity for long-term care facility was r=0.83 for their research. SLUMS
may be improved by structuring it to sound more of medically related exercise rather than an
examination as many of those who take it feel intimidated as they have a feeling that they are
taking an exam rather than a medical exercise intended to help them.
CLOCK-DRAWING TEST was developed in the early 1900s to investigate the mental
capability of soldiers who had head injuries. It is used to identify people who may have
neurological problems (for example Dementia and Alzheimer among others) (Ehreke et al,
2010). For more accurate results, it is used with other screening tools such as SLUMS but it can
also be used independently. A person under clock drawing test is issued with a paper with a
circle drawn in it; he or she is asked to draw clock numbers in the circle and draw clock hands to
indicate the time of interest by the clinician. Different times may be used but 10 minutes after 11
is commonly used. If the screener is given to two people of 60 years and above, the results
obtained are used to draw a conclusion. Many ways may be used to grade the test but the
commonly used one is a score of one point for a correct process which indicates that Dementia is
absent while an abnormal clock completion is grade zero which indicates that a person should be
evaluated further. This screener is faster to use as it can be administered within one minute
compared to other screeners such as SLUMS and MMSE. The screener can also be used to
identify executive functioning problems and this is not possible with other screeners such as
MMSE and SLUMS. The test is reliable and valid for identifying cognitive ability among
individuals especially with Dementia. It covers various cognitive areas including concentration,

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execution function, motor programming and visuospatial abilities among others. The screener
can be improved by clinicians agreeing on one method of interpreting the results as numerous
methods used may lead to inaccurate conclusions.
MMSE (“Mini-Mental State Exam”) was established by Marshall Folstein in 1975 in
order to assist in assessing memory problems and cognitive ability especially Alzheimer’s
disease. It involves the issuance of questionnaires which are of 30 points for measurement of
cognitive impairment (Hawkins et al, 2014). MMSE has an advantage over other screeners such
as SLUMS and CLOCK-DRAWING in that it involves the use of diverse languages and can be
used for people who are visually impaired. However, it has a disadvantage of its scores being
adjusted for various ages, ethnicity and education level. It is also has a demerit in that it is
charged as it has a copyright as compared to other screeners such as SLUMS which are offered
free. If the screener is issued to two aged people above 60 years of age, then results are
interpreted based on their scores as follows. Scores of 25-30 indicate that the person is normal,
19-24 indicate early Alzheimer’s stage, 10-19 shows moderate dementia while below 10 scores
indicate shows that an individual is severely impaired. MMSE screener is highly reliable and
valid for screening Alzheimer’s disease. Researches, especially by Kim et al 2014, have shown
that the MMSE screening performance can be improved by supplementing it with Verbal
Fluency.
The PHQ-9 was developed by Robert Spitzer, Janet Williams, and Kurt Kroenke at
Columbia University together with their colleagues during the year 2001 for measuring
depression signs and symptoms among adolescents, middle-aged adults and older adults
especially women. The screener is simple to administer as it is short and takes only a few
minutes. It is also offered free and can be used across various languages, nations, and cultures. It

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is administered by use of nine questions which are short and simple and are created by use of
depression criteria which was identified by DSM-IV (“Diagnostic and Statistical Manual of
Mental Disorders, 4th edition”). If the screener is issued to two aged people, then conclusions are
drawn based on the results which sum up to 27 points. A score of 20 and above indicates severe
depression, 15-19 shows moderately severe depression, 10-14 shows possibilities range of minor
and major depression and Dysthymia, 5-9 shows mild depression symptoms and 0-4 shows no
depression is present. The screener is highly reliable and valid for measuring depression and its
severity. The PHQ-9 can be improved by subjecting those under examination to counseling on
the importance of the exercise to their health to enable them to give accurate answers and hence
take the necessary intervention.
The CAGE screener was developed at North Carolina during the year 1998 to measure
alcohol abuse. The screener does not focus on a specific population but generally on excessive
alcohol drinkers in need of treatment. The screener is short and simple to use as it involves the
administration of four questions to indented individuals. It is not accurate for the older
population, African and Mexican Americans and white women as compared to other tests such
as T-ACE and AUDIT Tests which give accurate information for all gender and ethnic groups.
The test involves administration of four questions designed from CAGE acronyms and results
are recorded. If two “yes” answers are recorded, then it is concluded that an individual has
alcohol problems. The screener is valid and reliable for alcohol abuse detection although it is not
valid for diagnosing use of other substance disorders (Skogen, Overland, Knudsen & Mykletun,
2011). To improve the test accuracy, the four questions form should be completed online by the
indented individuals since alcohol talks may be stigmatizing and may lead to false information as
people tend to give the socially desirable answers.

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CAGE-AID screener was developed during the year 1995 at the University of Wisconsin
by Richard Brown and Laura Saunders to detect alcohol and other drugs abuse. It is generally
referred to as CAGE Adapted to Include Drugs and is designed to screen alcohol and drug
problems conjointly across the older adults and the aged population. It is efficient as compared to
the CAGE in that it is adapted to screen other substance abuse apart from alcohol. It is
administered through the issuance of four questions just like CAGE but the questions are adapted
to include drug use (Basu et al, 2016). Two “yes” answers show a positive screening test
indicating alcohol and substance abuse and hence further evaluation is needed. The screener is
reliable and valid for detecting alcohol abuse as well as other substance abuse. The accuracy of
responses to the questionnaires can be improved by providing the forms to be completed online
by the indented individual to avoid false answers due to social bias.
In a nutshell, screening is done to identify the presence of various suspected health
hazards. Screeners are chosen based on their purpose some of which include depression, alcohol,
and substance abuse and dementia detection purposes among others. Some of the commonly
used screeners include SLUMS, CLOCK-DRAWING, CAGE, PHQ-9, MMSE, T-ACE and
AUDIT Tests. It is always advised to have a regular screening on various health conditions so as
to seek the necessary interventions at an early stage if diagnosed with a certain disorder before it
becomes critical.

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References
Basu, D., Ghosh, A., Hazari, N., & Parakh, P. (2016). Use of Family CAGE-AID questionnaire
to screen the family members for diagnosis of substance dependence. The Indian journal
of medical research, 143(6), 722.
Buckingham, D. N., Mackor, K. M., Miller, R. M., Pullam, N. N., Molloy, K. N., Grigsby, C. C.,
... & Winningham, R. G. (2013). Comparing the cognitive screening tools: MMSE and
SLUMS. Pure Insights, 2(1), 3.
Ehreke, L., Luppa, M., König, H. H., & Riedel-Heller, S. G. (2010). Is the Clock Drawing Test a
screening tool for the diagnosis of mild cognitive impairment? A systematic
review. International Psychogeriatrics, 22(1), 56-63.
Feliciano, L., Horning, S. M., Klebe, K. J., Anderson, S. L., Cornwell, R. E., & Davis, H. P.
(2013). Utility of the SLUMS as a cognitive screening tool among a nonveteran sample
of older adults. The American Journal of Geriatric Psychiatry, 21(7), 623-630.
Hawkins, M. A., Gathright, E. C., Gunstad, J., Dolansky, M. A., Redle, J. D., Josephson, R., &
Hughes, J. W. (2014). The MoCA and MMSE as screeners for cognitive impairment in a
heart failure population: a study with comprehensive neuropsychological testing. Heart
& Lung: The Journal of Acute and Critical Care, 43(5), 462-468.
Kim, J. W., Lee, D. Y., Seo, E. H., Sohn, B. K., Choe, Y. M., Kim, S. G., . . . Woo, J. I. (2014,
January). Improvement of Screening Accuracy of Mini-Mental State Examination for
Mild Cognitive Impairment and Non-Alzheimer's Disease Dementia by Supplementation

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of Verbal Fluency Performance. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942551/
Skogen, J. C., Øverland, S., Knudsen, A. K., & Mykletun, A. (2011). Concurrent validity of the
CAGE questionnaire. The Nord-Trøndelag Health Study. Addictive behaviors, 36(4),
302-307.
Stewart, S., O'Riley, A., Edelstein, B., & Gould, C. (2012). A preliminary comparison of three
cognitive screening instruments in long term care: The MMSE, SLUMS, and
MoCA. Clinical Gerontologist, 35(1), 57-75.