Assessment of cognitive function in older hospital inpatients: is the Telephone Interview for Cognitive Status (TICS-M) a useful alternative to the Mini Mental State Examination?

Predicting daily functioning with the modified Telephone Interview for Cognitive Status

Background

The modified Telephone Interview for Cognitive Status (mTICS) is a frequently used telephone-based cognitive screening measure that can distinguish between normal aging, mild cognitive impairment (MCI), and dementia. Although it has been used to predict current and future cognitive function in older adults, no studies have examined if the mTICS can predict daily functioning.

Aims

The current study sought to examine the relationship between the mTICS and a performance-based measure of daily functioning.

Methods

The mTICS and demographic information (age, sex, education) were collected during a telephone screening visit for 149 older adults (65–91 years in age) with amnestic MCI. Three subscales of the Independent Living Scales (ILS; Managing Money, Managing Home and Transportation, Health and Safety) were collected during a baseline visit and during a 16 month follow-up visit in a subsample of 93 individuals.

Results

Using simple hierarchical regression, baseline mTICS total score combined with demographic variables significantly predicted 19–22% of baseline ILS subscale scores. Similarly, in a subsample of 93 participants with 16 month follow-up data, baseline mTICS and demographic information predicted 9–31% of ILS subscale scores at follow-up.

Conclusions

The mTICS appears able to predict daily functioning in older individuals with MCI. Remote tracking of cognition and daily functioning in this at-risk group seems particularly beneficial to geriatricians and other providers, especially during COVID-19.

Sex Differences in Symptom Phenotypes Among Older Patients with Acute Myocardial Infarction

BACKGROUND

Clinicians make a medical diagnosis by recognizing diagnostic possibilities, often using memories of prior examples. These memories, called "exemplars," reflect specific symptom combinations in individual patients, yet most clinical studies report how symptoms aggregate in populations. We studied how symptoms of acute myocardial infarction combine in individuals as symptom phenotypes and how symptom phenotypes are distributed in women and men.

METHODS

In this analysis of the SILVER-AMI Study, we studied 3041 patients (1346 women and 1645 men) 75 years of age or older with acute myocardial infarction. Each patient had a standardized in-person interview during the acute myocardial infarction admission to document the presenting symptoms, which enabled a thorough examination of symptom combinations in individuals. Specific symptom combinations defined symptom phenotypes and distributions of symptom phenotypes were compared in women and men using Monte Carlo permutation testing and repeated subsampling.

RESULTS

There were 1469 unique symptom phenotypes in the entire SILVER-AMI cohort of patients with acute myocardial infarction. There were 831 unique symptom phenotypes in women, as compared with 819 in men, which was highly significant, given the larger number of men than women in the study (P < .0001). Women had significantly more symptom phenotypes than men in almost all acute myocardial infarction subgroups.

CONCLUSIONS

Older patients with acute myocardial infarction have enormous variation in symptom phenotypes. Women reported more symptoms and had significantly more symptom phenotypes than men. Appreciation of the diversity of symptom phenotypes may help clinicians recognize the less common phenotypes that occur more often in women.

Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction According to Cognitive Status: The SILVER-AMI Study

BACKGROUND

While survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors' risk for these outcomes is limited.

METHODS

3041 patients aged ≥75 years hospitalized with acute myocardial infarction (mean age 82 ± 5 years, 56% male) recruited from 94 US hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment, respectively. Readmissions and death at 6 months post-discharge were ascertained via participant report and medical record review. Associations between cognition and outcomes were evaluated with multivariable-adjusted logistic regression.

RESULTS

Mild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort, respectively. Readmission and death at 6 months occurred in 41% and 9% of participants, respectively. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (odds ratio [OR] 1.36; 95% confidence interval [CI], 1.08-1.72 and OR 1.58; 95% CI, 1.18-2.12, respectively) and death (OR 2.19; 95% CI, 1.54-3.11 and OR 3.82; 95% CI, 2.63-5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death (OR 1.69; 95% CI, 1.10-2.59) persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression, but not for readmissions.

CONCLUSIONS

Moderate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes who may benefit from closer oversight and support in the post-discharge period.

Prevalence and patterns of cognitive impairment in acute coronary syndrome patients: A systematic review

BACKGROUND

Minimising risk factors through secondary prevention behaviour is challenging for patients following an acute coronary syndrome. Cognitive impairment can potentially make these changes more difficult. However, cognitive impairment prevalence in acute coronary syndrome patients is poorly understood.

DESIGN

This study was based on a systematic review.

METHODS

A systematic review was conducted of PubMed, Medline, PsycINFO and Cochrane databases up to March 2019, to identify studies reporting the prevalence of cognitive impairment in acute coronary syndrome patients. Predefined inclusion criteria were specified, including use of a validated cognitive impairment screening tool. Studies were excluded if patients had diagnosed dementia or coronary artery bypass graft surgery. Strengthening The Reporting of Observational Studies in Epidemiology and Cochrane Risk of Bias tools were used to assess quality.

RESULTS

From 747 potential studies, nine were included. The total sample size was 6457 (range 53-2174), mean age range was 51.3-77.4 years, and range of proportions of males was 57-100%. Reported cognitive impairment prevalence rates varied substantially (9-85%) with no clear pattern over time. From the two studies which examined domains, verbal fluency, memory and language were affected the most. Meta-analysis could not be undertaken due to diverse screening tools (n = 9), cut-off scores and screening timepoints.

CONCLUSIONS

Cognitive impairment in acute coronary syndrome patients is currently poorly described, and likely affects a substantial number of acute coronary syndrome patients who remain undetected and have the potential to develop to dementia in the future. As domains are most affected, this could impact understanding and retention of health education. Research is needed to accurately determine the prevalence of cognitive impairment in acute coronary syndrome patients and create suitable standardised measures and thresholds.

An analysis of a digital variant of the Trail Making Test using machine learning techniques

BACKGROUND

The goal of this work is to develop a digital version of a standard cognitive assessment, the Trail Making Test (TMT), and assess its utility.

OBJECTIVE

This paper introduces a novel digital version of the TMT and introduces a machine learning based approach to assess its capabilities.

METHODS

Using digital Trail Making Test (dTMT) data collected from (N = 54) older adult participants as feature sets, we use machine learning techniques to analyze the utility of the dTMT and evaluate the insights provided by the digital features.

RESULTS

Predicted TMT scores correlate well with clinical digital test scores (r = 0.98) and paper time to completion scores (r = 0.65). Predicted TICS exhibited a small correlation with clinically derived TICS scores (r = 0.12 Part A, r = 0.10 Part B). Predicted FAB scores exhibited a small correlation with clinically derived FAB scores (r = 0.13 Part A, r = 0.29 for Part B). Digitally derived features were also used to predict diagnosis (AUC of 0.65).

CONCLUSION

Our findings indicate that the dTMT is capable of measuring the same aspects of cognition as the paper-based TMT. Furthermore, the dTMT's additional data may be able to help monitor other cognitive processes not captured by the paper-based TMT alone.

Guided Imagery for Total Knee Replacement: A Randomized, Placebo-Controlled Pilot Study

OBJECTIVES

To determine the effect of guided imagery (GI) on functional outcomes of total knee replacement (TKR), explore psychological and neuroimmune mediators, and assess feasibility of study implementation.

DESIGN

Investigator-blinded, randomized, placebo-controlled pilot study.

SETTINGS

Hospital, surgeon's office, participant's home.

PARTICIPANTS

82 persons undergoing TKR.

INTERVENTIONS

Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments.

OUTCOME MEASURES

Gait velocity and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Function scale.

RESULTS

Outcomes for 58 participants (29 receiving GI and 29 controls) were analyzed at 6 months after surgery. The most frequent reason for noncompletion was protocol-driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint (n = 15). With imaging ability as a moderator, gait velocity, but not WOMAC Function score, was significantly improved at 6 months in the GI group. Participants in the GI group, but not the control group, had lower WOMAC Pain scores at 3 weeks after surgery than at baseline. Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group. GI group participants had lower treatment adherence but greater treatment credibility than the control group.

CONCLUSION

Randomized controlled trials of GI in the TKR population are feasible, but inclusion/exclusion criteria influence attrition. Further studies are needed to elaborate this study's findings, which suggest that guided imagery improves objective, but not patient-reported, outcomes of TKR. Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated. Further investigation into optimal content and dosing of GI is needed.

Applicability of the Telephone Interview for Cognitive Status (Modified) in a community sample with low education level: association with an extensive neuropsychological battery

OBJECTIVE

To explore the applicability of a Portuguese (PT) version of the Telephone Interview for Cognitive Status (TICS), with a delayed recall item [modified (M)], here termed TICSM-PT, against an extensive (in-person) battery of neuropsychological instruments, in a sample of older individuals with low educational level and without clinically manifest/diagnosed cognitive impairment.

METHODS

Following translation/back-translation and pilot testing in 33 community dwellers, 142 community dwellers aged 52 to 84 years (mean = 67.45, SD = 7.91) were selected from local health care centres for the study (convenience sampling; stratified age and gender). Cronbach's alpha was used to assess internal consistency, and convergent validity was evaluated through the correlation between TICSM-PT and the Mini Mental State Examination (MMSE), as well as with a comprehensive battery of cognitive instruments. Divergent/discriminant validity was assessed through a battery of psychological instruments. The receiver operating curve was determined for TICSM-PT to classify participants with and without possible indication of cognitive impairment.

RESULTS

TICSM-PT showed a satisfactory internal consistency (Cronbach's alpha = 0.705), convergent validity and discriminant validity. TICSM-PT presented a positive association with the global cognitive measures Mini Mental State Examination and the Montreal Cognitive Assessment, and also with most neuropsychological parameters. Receiver operating curve curves presented a sensitivity of 90.6% and specificity of 73.7%. The area under the curve statistic yielded a threshold score equal or below 13.5 for cognitive impairment.

CONCLUSION

TICSM-PT is a practical tool for rapid cognitive assessment among older individuals with low educational background.

Calibration and validation of an innovative approach for estimating general cognitive performance

OBJECTIVE

To evaluate a new approach for creating a composite measure of cognitive function, we calibrated a measure of general cognitive performance from existing neuropsychological batteries.

METHODS

We applied our approach in an epidemiological study and scaled the composite to a nationally representative sample of older adults. Criterion validity was evaluated against standard clinical diagnoses. Convergent validity was evaluated against the Mini-Mental State Examination (MMSE).

RESULTS

The general cognitive performance factor was scaled to have a mean of 50 and standard deviation of 10 in a nationally representative sample of older adults. A cutoff point of approximately 45, corresponding to an MMSE of 23/24, optimally discriminated participants with and without dementia (sensitivity = 0.94, specificity = 0.90, area under the curve = 0.97). The general cognitive performance factor was internally consistent (Cronbach's α = 0.91) and provided reliable measures of functional ability across a wide range of cognitive functioning. It demonstrated minimal floor and ceiling effects, which is an improvement over most individual cognitive tests.

CONCLUSIONS

The cognitive composite is a highly reliable measure, with minimal floor and ceiling effects. We calibrated it using a nationally representative sample of adults over the age of 70 in the USA and established diagnostically relevant cutoff points. Our methods can be used to harmonize neuropsychological test results across diverse settings and studies.

The daily living self-efficacy scale: a new measure for assessing self-efficacy in stroke survivors

PURPOSE

To develop and examine the psychometric properties of the Daily Living Self-Efficacy Scale (DLSES) designed to assess stroke survivors' self-efficacy in daily functioning.

METHOD

Two groups of participants (N = 424) were recruited, a stroke survivor group (n = 259) who were recruited through two stroke associations in Australia and a non-stroke group (n = 165) who were the partners/carers of the stroke survivors (n = 93) and members of the community in Queensland, Australia (n = 72). Principal Component Analyses (PCA) were used to assess the factor structure of the scale and investigations of internal consistency, test-retest reliability, convergent and discriminant validity were conducted.

RESULTS

The final measure is a 12-item scale comprising two subscales: self-efficacy for psychosocial functioning and self-efficacy for activities of daily living. The scale demonstrated high internal consistency, temporal stability and convergent validity, and it discriminated well between the stroke and non-stroke groups.

CONCLUSION

The DLSES is a psychometrically sound measure of self-efficacy in psychosocial functioning and self-efficacy in activities of daily living appropriate for stroke survivors, regardless of level of physical impairment. Implications for Rehabilitation A key factor that may influence outcome following a stroke is the level of self-efficacy that stroke survivors have in their ability to function in their daily life. The DLSES provides a measure of this ability that may be useful in enhancing preparation for the return to the community. The DLSES assesses self-efficacy in two important areas of daily functioning--activities of daily living and psychosocial functioning. This new measure can be administered to stroke individuals regardless of the nature or degree of physical impairment.

Cognitive impairment and outcomes in older adult survivors of acute myocardial infarction: findings from the translational research investigating underlying disparities in acute myocardial infarction patients' health status registry

BACKGROUND

Cognitive impairment without dementia (CIND) and acute myocardial infarction (AMI) are prevalent in older adults; however, the association of CIND with outcomes after AMI is unknown.

METHODS

We used a multicenter registry to study 772 patients ≥65 years with AMI, enrolled between April 2005 and December 2008, who underwent cognitive function assessment with the Telephone Interview for Cognitive Status-modified (TICS-m) 1 month after AMI. Patients were categorized by cognitive status to describe characteristics and in-hospital treatment, including quality of life and survival 1 year after AMI.

RESULTS

Mean age was 73.2 ± 6.3 years; 58.5% were men, and 78.2% were white. Normal cognitive function (TICS-m >22) was present in 44.4%; mild CIND (TICS-m 19-22) in 29.8%; and moderate/severe CIND (TICS-m <19) in 25.8% of patients. Rates of hypertension (72.6%, 77.4%, and 81.9%), cerebrovascular accidents (3.5%, 7.0%, and 9.0%), and myocardial infarction (20.1%, 22.2%, and 29.6%) were higher in those with lower TICS-m scores (P < .05 for comparisons). AMI medications were similar by cognitive status; however, CIND was associated with lower cardiac catheterization rates (P = .002) and cardiac rehabilitation referrals (P < .001). Patients with moderate/severe CIND had higher risk-adjusted 1-year mortality that was nonstatistically significant (adjusted hazard ratio 1.97, 95% CI 0.99-3.94, P = .054; referent normal, TICS-m >22). Quality of life across cognitive status was similar at 1 year.

CONCLUSIONS

Most older patients surviving AMI have measurable CIND. Cognitive impairment without dementia was associated with less invasive care, less referral and participation in cardiac rehabilitation, and worse risk-adjusted 1-year survival in those with moderate/severe CIND, making it an important condition to consider in optimizing AMI care.

Telephone interview for cognitive status (TICS) screening for clinical trials of physical activity and cognitive training: the seniors health and activity research program pilot (SHARP-P) study

OBJECTIVE

To examine the performance of the Telephone Interview for Cognitive Status (TICS) for identifying participants appropriate for trials of physical activity and cognitive training interventions.

METHODS

Volunteers (N=343), ages 70-85 years, who were being recruited for a pilot clinical trial on approaches to prevent cognitive decline, were administered TICS and required to score ≥ 31 prior to an invitation to attend clinic-based assessments. The frequencies of contraindications for physical activity and cognitive training interventions were tallied for individuals grouped by TICS scores. Relationships between TICS scores and other measures of cognitive function were described by scatterplots and correlation coefficients.

RESULTS

Eligibility criteria to identify candidates who were appropriate candidates for the trial interventions excluded 51.7% of the volunteers with TICS<31. TICS scores above this range were not strongly related to cognition or attendance at screening visits, however overall enrollment yields were approximately half for participants with TICS=31 versus TICS=41, and increased in a graded fashion throughout the range of scores.

CONCLUSIONS

Use of TICS to define eligibility criteria in trials of physical activity and cognitive training interventions may not be worthwhile in that many individuals with low scores would already be eliminated by intervention-specific criteria and the relationship of TICS with clinic-based tests of cognitive function among appropriate candidates for these interventions may be weak. TICS may be most useful in these trials to identify candidates for oversampling in order to obtain a balanced cohort of participants at risk for cognitive decline.

Outcome after emergency surgery without angiography in patients with intracerebral haemorrhage after aneurysm rupture

BACKGROUND

Patients with large intracerebral haematomas (ICH) from aneurysm rupture often present in a poor clinical condition and have a poor prognosis. Time delay for preoperative angiography might in some cases be unappealing. We evaluated the outcome after immediate haematoma removal and aneurysm occlusion without preoperative angiography.

METHODS

We retrospectively identified 13 consecutive patients. We recorded clinical data and evaluated mortality and morbidity with the Glasgow Outcome Score (GOS) and Telephone Interview of Cognitive Status (TICS).

FINDINGS

At follow up seven of thirteen patients had favourable outcome assessed by GOS. Three patients had severe disability and three patients died. None of the survived patients interviewed had impaired cognition.

CONCLUSIONS

In patients presented in a critical state with aneurysmal ICH, emergency haematoma removal and aneurysm clipping without the delay for diagnostic angiography may be life saving and a satisfactory outcome can be accomplished.

Protocol for Fit Bodies, Fine Minds: a randomized controlled trial on the affect of exercise and cognitive training on cognitive functioning in older adults

Background

Declines in cognitive functioning are a normal part of aging that can affect daily functioning and quality of life. This study will examine the impact of an exercise training program, and a combined exercise and cognitive training program, on the cognitive and physical functioning of older adults.

Methods/Design

Fit Bodies, Fine Minds is a randomized, controlled trial. Community-dwelling adults, aged between 65 and 75 years, are randomly allocated to one of three groups for 16 weeks. The exercise-only group do three 60-minute exercise sessions per week. The exercise and cognitive training group do two 60-minute exercise sessions and one 60-minute cognitive training session per week. A no-training control group is contacted every 4 weeks. Measures of cognitive functioning, physical fitness and psychological well-being are taken at baseline (0 weeks), post-test (16 weeks) and 6-month follop (40 weeks). Qualitative responses to the program are taken at post-test.

Discussion

With an increasingly aged population, interventions to improve the functioning and quality of life of older adults are particularly important. Exercise training, either alone or in combination with cognitive training, may be an effective means of optimizing cognitive functioning in older adults. This study will add to the growing evidence base on the effectiveness of these interventions.

Trial Registration

Australian Clinical Trials Register: ACTRN012607000151437

Cognitive Functioning in Patients with Cerebral Aneurysms Measured with the Mini Mental State Examination and the Telephone Interview for Cognitive Status

BACKGROUND:

Clinicians and researchers use brief instruments, such as the Mini Mental State Examination (MMSE) and the Telephone Interview for Cognitive Status (TICS), to measure cognitive functioning in patients with cerebral aneurysms. MMSE and TICS scores are often dichotomized to classify patients as cognitively impaired or not. Frequently, after an initial MMSE face-to-face evaluation, the TICS is used for follow-up assessments by telephone.

METHODS:

A cross-sectional cohort of patients with cerebral aneurysms completed the MMSE at baseline and the MMSE or TICS at the 12-month follow-up examination. Multivariate logistic regression adjusting for demographics was used to model cognitive impairment. MMSE and TICS results were compared using the MMSE as the “gold standard.”

RESULTS:

Eleven out of 171 (6%) patients had baseline MMSE scores less than 24, indicating cognitive impairment. Multivariate analysis showed that a history of subarachnoid hemorrhage was associated with cognitive impairment measured with the MMSE (odds ratio, 13.9; P = 0.021; C statistic = 0.87); there was no relationship between subarachnoid hemorrhage or treatment and TICS cognitive impairment (i.e., score &lt; 27). In patients without recent or interim invasive interventions that might affect cognition (n = 65), raw baseline MMSE and 12-month TICS scores had fair correlations (r = 0.30, P = 0.015); however, dichotomized scores had poor agreement, and TICS sensitivity and positive predictive value was 0% compared with the MMSE.

CONCLUSION:

The MMSE may be more sensitive than the TICS to the effects of subarachnoid hemorrhage on cognitive functioning. Raw MMSE and TICS scores are well correlated, but dichotomized MMSE and TICS scores are probably not interchangeable in this patient population.

Use of an Italian version of the telephone interview for cognitive status in Alzheimer's disease

OBJECTIVES

Validation of an Italian version of the Telephone Interview for Cognitive Status (I-TICS).

METHODS

Telephone administration of the I-TICS within 6 weeks of face-to-face testing with the Mini Mental State Examination (MMSE), in Probable Alzheimer's disease (AD) patients and healthy controls. Two hundred and seven consecutive outpatients with cognitive impairment were recruited from Dementia Clinic of University Campus BioMedico. Of these, 45 probable AD patients with complete data were analyzed. Other dementias, Mild Cognitive Impairment (MCI), and patients with incomplete data were excluded. The control sample consisted of 64 age- and sex-matched healthy subjects. For diagnosis, an extensive clinical evaluation, laboratory testing, brain imaging, EEG, neuropsychological battery and a depression scale were used. For I-TICS validation, telephone I-TICS and face-to-face MMSE were administered.

RESULTS

The I-TICS correlated highly and linearly with the MMSE (Pearson's r=0.904). Conversion equations are provided. Sensitivity and specificity were similar between tests (area under curve=0.894 for the I-TICS; 0.966 for the MMSE). I-TICS sensitivity was 84% and specificity 86% at a cut-off score of 28. No significant difference in accuracy with the MMSE was present. Total agreement between I-TICS and MMSE was 'substantial' at 86% (Cohen's K=0.717). Repeated testing in a subset of patients showed a disease progression related decrease of 4.2 points/year (t=2.664; p=0.018) in I-TICS scores.

CONCLUSION

The I-TICS is a valid instrument in clinical and research screening and monitoring of AD. Potential applications in other dementias and MCI are worth further studies.