1.

Dalam file excel tersedia DATA Abnormalitas terdiri dari variabel SGOT/SGPT laki-laki, hemoglobin,
trigliserid, total kolesterol, HDL dan LDL. Hitunglah Nilai Abnormalitas dari data yang tersedia :
1.1. Hitung Harga Rerata
1.2. Hitung Standard Deviasi
1.3. Nilai Abnormalitas adalah
>rerata + 2x Standard Deviasi

Parameter Rerata SD Rerata ±2SD Nilai Abnormalitas

SGOT/SGPT 26,29 13,923 26,29 + 2 (13,923) 54,13 + 0,05 = 54,18

= 54,13
>54,18 dikatakan abnormal

Hemoglobin 12,472 0,3238 12,472 - 2 (0,3238) 11,83 – 0,05 = 11,78

= 11,83
<11,78 dikatakan abnormal

Trigliserid 115,30 20,047 115,30 + 2 (20,027) 155,39 + 0,05 = 155,44

= 155,39
>155,44 dikatakan abnormal

Total 137,23 32,405 137,23 + 2 (32,405) 202,04 + 0,05 = 202,09

Kolesterol = 202,04
>202,09 dikatakan abnormal

HDL 89,44 17,119 89,44 – 2 (17,119) = 55,22 – 0,05 = 55,17

55,22
<55,17 dikatakan abnormal

LDL 76,64 13,634 76,64 + 2 (13,634) 101,91 + 0,05 = 101,96

= 101,91
>101,96 dikatakan abnormal

Buka file DATA Abnormal.sav  Di SPSS , pilih menu Analyze  Descriptive Statistics  Frequencies 
pindahkan semua variabel  statistic pilih Mean , dan Std. Deviation  klik continue  OK  Copy
special tabel nya.
2. Tersedia Clinical Scenario sebagai berikut :
You are a general practioner working in a primary health care team who frequently sees older patients
reporting memory loss and concerned about the onset of dementia. You routinely use the Mini-
Mental State Examination (MMSE) screening tool with these patients to evaluate their cognitive
function as you know this tool to be sensitive, valid and reliable. Recently you have heard of a tool
called the Mini-Cog which is considered quicker to administer and better for patients who or older,
less educated or from culturally and linguistically diverse (CALD) communities. You wish to find out if
the Mini-Cog test is as accurate as the MMSE in detecting Alzheimer’s disease or dementia.
2.1. Tabel P.I.C.O

P Older adult with early sign sympthom of cognitive impairment

I Mini-Cog Screening Test

C Mini-Mental State Examination (MMSE)

O Accurate diagnosis of Dementia or Alzheimer’s disease

2.2. Buatlah Clinical Question

In older adults with early sign-sympthom cognitive impairment, is the Mini-Cog Test
accurate as MMSE in diagnosis of Dementia or Alzheimer’s disease?

2.3. Buatlah Search Term/Search/Keyword

(Mini-Cog OR minicog) AND (mini-mental state exam OR MMSE) AND (Alzheimer
OR Dementia)

2.4. Lakukan Searching

 Sumber: www.tripdatabase.com

2.5. Pastekan Abstract Artikel yang didapat pada lembar Jawaban

Cognitive tests for dementia: MMSE, Mini-Cog and ACE-R

The way we diagnose and detect dementia, therefore, is by systematically assessing the
function of various brain regions by using cognitive tests.‘Cognitive’ here means the ‘higher
brain functions’ I alluded to earlier; things like memory, numeracy, visual
perception, personality change and planning, to name a few.
The commonest cognitive test used is called the Mini-Mental State Examination
(MMSE). In this test you can score up to 30 points by answering a range of questions that
test your orientation to time and place, your memory, attention and so on. The test itself takes
about 10 minutes to complete. As the authors of this paper state, the performance of the
MMSE in detecting dementia as compared to other tests has not been systematically assessed
and so, that is what they set out to do. One of the reasons to assess the relative merits of the
MMSE is that it is a proprietary instrument, owned by ‘Psychological Assessment
Resources’ meaning that it is not actually free for organisations to use.
Methods
The reviewers included studies that:
 Looked for patients with either Alzheimer’s, vascular dementia or Parkinson’s disease in
any clinical setting
 Assessed patients or carers face-to-face
 Used a standardised diagnostic criteria to diagnose dementia
 Published the outcome measures they were interested in.
Results
The initial search yielded 26,380 papers! After applying the inclusion/exclusion criteria they
were left with 149 studies, which covered 11 different diagnostic tests and over 40,000
people from around the world.
MMSE
 The vast majority of the studies looked at MMSE (108 of 149)
 Sample size was 36,080 of whom 10,263 had dementia
 From these studies the:
 o Mean sensitivity was 81% (CI was 78% to 84%)
o Mean specificity was 89% (CI was 87% to 91%)
o All other markers also showed good diagnostic accuracy (LR+ = 7.45, LR- = 0.21,
diagnostic OR was 35.4 and AUC was 92%)
Mini-Cog and ACE-R (the best of the rest)
 Of the 11 remaining tests, two stood out as being ‘better’ than the MMSE
o Mini-Cog (brief test <5 min): sensitivity of 91% and specificity of 86%
o ACE-R (20 min test): sensitivity of 92% and specificity of 89%
 However where the MMSE data was drawn from hundreds of studies:
o Mini-Cog data was drawn from just 9 studies
o ACE-R was drawn from just 13 studies
For all three of the above tests, there was found to be a high degree of heterogeneity. In
essence this is a statistical test telling us that between studies included in the analyses, the
results were quite different from one study to another. Heterogeneity is not a good thing in
systematic reviews.
Further analyses
The reviewers showed that the accuracy of the MMSE was not affected by geographical
location or clinical site (i.e. it was as effective for hospital patients as community patients).
Finally they looked at the accuracy of diagnosing mild cognitive impairment (MCI); a risk
state that precedes dementia. They didn’t really go into much detail in the methods of how
they found the studies or how they defined MCI.
 Only 21 studies using MMSE were used to assess diagnostic accuracy for MCI giving:
o a sensitivity of only 62%
o and a specificity of 87%.
 An alternative test, the MoCA, was found to perform better (in 9 studies) with:
o a sensitivity of 89%
o and a specificity of 75%
 No data was provided on the other tests presumably because there weren’t enough studies.
Conclusions
In short, the MMSE is not a bad screening tool for dementia but it is not miles better than
the rest; it’s just really commonly used, probably for historical reasons. The ACE-R and the
Mini-Cog are both free to use and may be viable alternatives.
The MMSE is less good in mild cognitive impairment.
Final thoughts
It’s important to add that whilst this paper focussed on cognitive screening tests, which play
an important part in diagnosis, a full clinical assessment of someone with suspected dementia
requires a much more detailed approach. Combining information from the history,
examination, investigations and cognitive tests greatly improve the diagnostic accuracy.
Also where the screening tests are not clear, patients can be referred for much more detailed
assessments of cognition performed by neuropsychologists.
Also it is important to remember that the diagnosis of dementia requires evidence of a
progressive illness. This means that repeating cognitive tests and looking for change is often
more helpful than just a snapshot. This aspect was not covered in this systematic review.

2.6. Lakukan Critical Appraisal dari Artikel dengan critical appraisal worksheet (Home Work)
1. Validity Pada penelitian ini, variable yang diukur yaitu
berdasarkan skrinning untuk mendapatkan kriteria
diagnostik dementia dengan menggunakan beberapa
instrumen.
Pengumpulan data dilakukan dengan melakukan
wawancara tatapmuka secara langsung.
Kesimpulan: Penelitian ini dapat dikatakan
valid dan baik.
2. Importance Penelitian ini penting karena hasil uji diagnostik ini
menunjukkan hasil bahwa sensitivitas Mini-Cog
dan ACE-R lebih tinggi daripada MMSE.
Sedangkan, spesifisitas Mini-Cog lebih rendah
dibandingkan MMSE dan sama dengan ACE-R.
Kesimpulan: Melihat tujuan penelitian maka
dapat disimpulkan bahwa penelitian ini penting
dilakukan.
 3. Applicability Penelitian ini dapat diterapkan dalam praktik klinis
untuk skrinning dementia karena berdasarkan hasil
penelitian, Mini-Cog dan ACE-R lebih sensitive dan
bisa dijadikan alternatif MMSE.
Kesimpulan: Hasil penelitian dapat diterapkan.

3. Dalam file excel tersedia DATA Diagnostik. Data terdiri dari variabel LDL dan kreatinin kinase.
3.1. Buatlah Grafik Titik Potong Diagnostik pastekan pada lembar jawaban.
Buka Medcalc  File  Open  ganti format file jadi SPSS data .sav  pilih data diagnostik
 open  klik All  ok
Statistics  ROC Curves  Plot Versus criterion values  di kotak pertama (Variable)
masukan kreatinin_kinase  dikotak kedua (Classification Variable) masukan variable MCI
 pilih connected lines  klik OK , …
Copy graph nya LAKUKAN lagi untuk LDL
Classification: MCI
100
90
80
70
60
Sensitivity (%)
50
Specificity (%)
40
30
20
10
0
40 50 60 70 80
Kreatinin Kinase

Classification: MCI
100
90
80
70
60
Sensitivity (%)
50
Specificity (%)
40
30
20
10
0
80 100 120 140 160 180 200
LDL
 3.2. Perkirakan secara visual nilai titik potong diagnostik dan interpretasikan.
Statistics  ROC Curves  ROC Curves Analysis  di kotak pertama (Variable) masukan
kreatinin_kinase  dikotak kedua (Classification Variable) masukan variable MCI  pilih List of
criterion values with test characteristics, Include all observed criterion values, Sensitivity/specificity ,
Likelihood ratios, Display ROC Curve Window  klik OK , …
Copy graph nya , LAKUKAN lagi untuk LDL

Kreatinin Kinase
100
Sensitivity: 100.0
Specificity: 92.0
80 Criterion: >69.1098
Sensitivity

60

40

20

0
0 20 40 60 80 100
100-Specificity

LDL
100

80 Sensitivity: 84.6
Specificity: 47.1
Criterion: ≤143.002
Sensitivity

60

40

20

0
0 20 40 60 80 100
100-Specificity
 3.3. Hitunglah Seluruh Nilai Diagnostik memakai MedCalc dan Epicalc buatlah kesimpulan

9 Nilai Diagnostik

1. Sensitivity
2. Specificity
3. Accuracy
4. Nilai prediksi Positif
5. Nilai prediksi Negatif
6. Likelihood Ratio (+)
7. Likelihood Ratio (-)
8. Likelihood Ratio test
9. Area Under Curve (AUC)

Area under the ROC curve (AUC)

Area under the ROC curve (AUC) 0.973

Standard Error a 0.0140
95% Confidence interval b 0.919 to 0.995
z statistic 33.901
Significance level P (Area=0.5) <0.0001
a DeLong et al., 1988
b Binomial exact

Youden index

Youden index J 0.9195

Associated criterion >69.1098
Sensitivity 100.00
Specificity 91.95

Screening [95% CI]

Prevalence : 0.20 [0.13, 0.29]
Sensitivity : 1.00 [0.80, 1.00]
Specificity : 1.00 [0.94, 1.00]
Accuracy : 1.00 [0.95, 1.00]
Predictive value of +ve result : 1.00 [0.80, 1.00]
Predictive value of -ve result : 1.00 [0.94, 1.00]

Kesimpulan : Kreatinin kinase dapat mendeteksi MCI pada sensitivitas 100 dan spesifisitas 92
pada titik potong >69, 1098 (artinya : MCI Positif bila Kreatinin Kinase >69,1098 , MCI Negatif
bila <=69,1098)
 Area under the ROC curve (AUC)

Area under the ROC curve (AUC) 0.598

Standard Error a 0.0855

95% Confidence interval b 0.495 to 0.695

z statistic 1.143

Significance level P (Area=0.5) 0.2531

a DeLong et al., 1988
b Binomial exact

Youden index

Youden index J 0.3174

Associated criterion ≤143.002

Sensitivity 84.62

Specificity 47.13

Screening [95% CI]

Prevalence : 0.20 [0.13, 0.29]
Sensitivity : 0.75 [0.51, 0.90]
Specificity : 0.53 [0.41, 0.64]
Accuracy : 0.57 [0.47, 0.67]
Predictive value of +ve result : 0.28 [0.17, 0.43]
Predictive value of -ve result : 0.89 [0.76, 0.96]

Kesimpulan : LDL mendeteksi MCI pada sensitivitas 84,62 dan spesifisitas 47.13 pada titik
potong <=143.002 (artinya : MCI Positif bila LDL <=143.002 , MCI Negatif bila LDL
>143.002)

4. Dalam File Excel tersedia DATA Therapy Bad Outcome.

4.1. Hitunglah Nilai Nilai Importance
Buka File Data Bad Outcome di SPSS  Analyze  Descriptive Statistics  Crosstabs 
masukan Kelompok di Row dan Outcome di Coloumn
Nilai importance untuk Bad Outcome :
ERR
CER
RR
 ARR
RRR
NNT
Gunakan Epicalc dan Statcalc

4.2. Buatlah Kesimpulan

 Kesimpulan :Ace inhibitor dalam mencegah kematian MCI = 58%
NNT = 7.14, setiap 7 pasien yg diobati dgn ace inhibitor untuk mencegah 1
kejadian meninggal

5. Dalam File Excel tersedia DATA Therapy Effectiveness.

5.1. Hitunglah Nilai Importance
Nilai importance untuk Therapy Effectiveness
ERR
CER
RR
ARI
RRI
NNH
Gunakan Epicalc dan Statcalc
5.2. Buatlah Kesimpulan

NNH = 3.083, ini berarti dari 3 pasien yang diterapi, satu diantaranya akan mengalami efek
samping