Addenbrooke's Cognitive Examination

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The Addenbrooke’s Cognitive Examination (ACE)[1] was originally developed as a theoretically motivated extension of the Mini-Mental State Examination (MMSE)[2] which attempted to address the neuropsychological omissions and improve the screening performance of the latter.[3] Though taking longer to administer than the MMSE, and therefore best suited to specialist settings, the ACE and its subsequent iterations, ACE-R[4] and ACE-III,[5] have proved easy to use, acceptable to patients, and have shown excellent diagnostic utility in identifying dementia and cognitive impairment in a variety of clinical situations (Alzheimer’s disease, frontotemporal lobar degenerations, Parkinsonian syndromes, stroke and vascular dementia, and brain injury). The ACE is used worldwide and is available in a number of languages.[6][7][8][9]

The ACE encompassed tests of five cognitive domains: attention/orientation, memory, language, verbal fluency, and visuospatial skills.[1] It is scored out of 100, with a higher score denoting better cognitive function. At the recommended cut-off scores of 88 and 83, the ACE was reported to have good sensitivity and specificity for identifying dementia (0.93 and 0.71; 0.82 and 0.96, respectively). The ACE also incorporated the MMSE, such that this score (out of 30) might also be generated.[1][3]

The ACE-R[4] was a development of the earlier ACE which also incorporated the MMSE, but had clearly defined subdomain scores. Like the ACE, the overall ACE-R score was 100, from which domain scores for attention/orientation, memory, fluency, language and visuospatial abilities could be generated. Test reliability was very good as judged by its internal consistency (Cronbach alpha coefficient = 0.8).[4] This version introduced cut-off scores of 88 and 82, which were reported to have good sensitivity and specificity for identifying dementia (0.94 and 0.79; 0.84 and 1.00, respectively).[4]

The ACE-III[5] was developed to expunge the MMSE items in the ACE and ACE-R. In the ACE-III, these MMSE items were substituted like for like as far as possible, for example, the intersecting pentagons were replaced with interlocking infinity loops. In the index study[5] the cohort examined (n = 86; AD 28, FTD 33, controls 25) found the ACE-III to be acceptable and relatively quick to administer (15 min). The ACE-III and ACE-R were highly correlated (r = 0.99), and at the previously recommended cut-off scores (88 and 82) the ACE-III was both highly sensitive and specific (at 88/100: 1.00 and 0.96 respectively; at 82/100: 0.93 and 1.00 respectively). At the cut-off of 88, Elamin and colleagues[10] found the ACE-III distinguished early-onset dementia from healthy controls with high sensitivity (0.915) and specificity (0.964), and also from subjective memory impairment with high sensitivity (0.915) and specificity (0.867). The ACE-III has been validated against standard neuropsychological tests and has been shown to be a valid cognitive screening tool for dementia syndromes.[5][11]

The ACE-III has also been made available as an iPad based app, which is available cost-free via iTunes and at The automated scoring and the clear instructions are designed to reduce errors in administration and scoring.

In 2014, a shorter version of the ACE-III, the Mini-ACE (M-ACE), was developed and validated.[12] It comprises tests of attention, memory (7-item name and address), letter fluency, clock drawing, and memory recall, and takes under five minutes to administer. The M-ACE is scored out of 30, with a higher score indicating better cognitive function, and has two recommended cut-off scores (25 and 21). The higher cut-off score has both high specificity and sensitivity and is at least five times more likely to have come from a dementia patient than without. A score of 21 or less is almost certainly diagnostic of a dementia syndrome regardless of the clinical setting.[12] It has been found to be superior to the MMSE in diagnostic utility.[13][14]


  1. ^ a b c Mathuranath, P. S., Nestor, P. J., Berrios, G. E., Rakowicz, W., & Hodges, J. R. (2000). A brief cognitive test battery to differentiate Alzheimer's disease and frontotemporal dementia. Neurology, 55(11), 1613-1620
  2. ^ Hodges, J. R., & Larner, A. J. (2017). Addenbrooke’s Cognitive Examinations: ACE, ACE-R, ACE-III, ACEapp, and M-ACE. Cognitive Screening Instruments (pp. 109-137): Springer.
  3. ^ a b Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. Journal of psychiatric research, 12(3), 189-198.
  4. ^ a b c d Mioshi, E., Dawson, K., Mitchell, J., Arnold, R., & Hodges, J. R. (2006). The Addenbrooke's Cognitive Examination Revised (ACE‐R): a brief cognitive test battery for dementia screening. International journal of geriatric psychiatry, 21(11), 1078-1085.
  5. ^ a b c d Hsieh, S., Schubert, S., Hoon, C., Mioshi, E., & Hodges, J. R. (2013). Validation of the Addenbrooke's Cognitive Examination III in frontotemporal dementia and Alzheimer's disease. Dementia and geriatric cognitive disorders, 36(3-4), 242-250.
  6. ^ Matías-Guiu, J. A., Fernández-Bobadilla, R., Fernández-Oliveira, A., Valles-Salgado, M., Rognoni, T., Cortés-Martínez, A., . . . Matías-Guiu, J. (2016). Normative data for the Spanish version of the Addenbrooke's Cognitive Examination III. Dementia and geriatric cognitive disorders, 41(5-6), 243-250.
  7. ^ Pigliautile, M., Ricci, M., Mioshi, E., Ercolani, S., Mangialasche, F., Monastero, R., . . . Mecocci, P. (2011). Validation study of the Italian Addenbrooke’s Cognitive Examination Revised in a young-old and old-old population. Dementia and geriatric cognitive disorders, 32(5), 301-307.
  8. ^ Raimondi, C., Gleichgerrcht, E., Richly, P., Torralva, T., Roca, M., Camino, J., & Manes, F. (2012). The Spanish version of the Addenbrooke's Cognitive Examination—Revised (ACE-R) in subcortical ischemic vascular dementia. Journal of the neurological sciences, 322(1), 228-231.
  9. ^ Yoshida, H., Terada, S., Honda, H., Kishimoto, Y., Takeda, N., Oshima, E., . . . Uchitomi, Y. (2012). Validation of the revised Addenbrooke's Cognitive Examination (ACE-R) for detecting mild cognitive impairment and dementia in a Japanese population. International Psychogeriatrics, 24(1), 28-37.
  10. ^ Elamin, M., Holloway, G., Bak, T. H., & Pal, S. (2016). The utility of the Addenbrooke's Cognitive Examination version three in early-onset dementia. Dementia and geriatric cognitive disorders, 41(1-2), 9-15.
  11. ^ Matias-Guiu, J. A., Cortés-Martínez, A., Valles-Salgado, M., Rognoni, T., Fernández-Matarrubia, M., Moreno-Ramos, T., & Matías-Guiu, J. (2017). Addenbrooke's Cognitive Examination III: diagnostic utility for mild cognitive impairment and dementia and correlation with standardized neuropsychological tests. International Psychogeriatrics, 29(1), 105-113.
  12. ^ a b Hsieh, S., McGrory, S., Leslie, F., Dawson, K., Ahmed, S., Butler, C. R., . . . Hodges, J. R. (2015). The Mini-Addenbrooke's Cognitive Examination: a new assessment tool for dementia. Dementia and geriatric cognitive disorders, 39(1-2), 1-11.
  13. ^ Larner, A. J. (2015). Mini‐Addenbrooke's Cognitive Examination: a pragmatic diagnostic accuracy study. International journal of geriatric psychiatry, 30(5), 547-548.
  14. ^ Larner, A. J. (2015). Mini‐Addenbrooke's cognitive examination diagnostic accuracy for dementia: reproducibility study. International journal of geriatric psychiatry, 30(10), 1103-1104.

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