Audit of the Addenbrooke's Cognitive Examination (ACE) in clinical practice: 2. longitudinal change

Cognitive deficits in vasculitis of the nervous system: a cross-sectional study

Objectives: To identify the cognitive and functional deficits in a well-characterized group of patients with vasculitis of the nervous system. Methods: Sixty-seven patients diagnosed with Central Nervous System (CNS) or Peripheral nervous System (PNS) vasculitis over a 14-year period were retrospectively identified. Data on clinical presentation, laboratory, radiographic and tissue biopsy investigations, and treatment were collated. Cognitive, functional and quality of life evaluation assessments were performed in 31 patients who agreed to participate and included Addenbrooke's Cognitive Examination-revised (ACE-R), Nottingham Extended Activities of Daily Living (NEADL) and EQ-5D-3L quality of life questionnaires. Results: CNS vasculitis patients exhibited cognitive impairment, with a mean ACE-R score of 74/100 (standard deviation (SD) 16). NEADL and EQ-5D-3L scores were in the impaired range at 41/66 (SD 21) and 57/81 (SD 22), respectively. Patients with just PNS vasculitis exhibited fewer cognitive deficits with ACE-R and NEADL scores of 87 (SD 8) and 46 (SD 16) respectively. EQ-5D-3L score was in the impaired range of 65 (SD 22). Conclusions: Vasculitis of the nervous system and, in particular, CNS vasculitis causes cognitive impairment and deficits in functional ability. Such patients should be targeted for cognitive rehabilitation.

Differential diagnosis of depression and Alzheimer's disease with the Addenbrooke's Cognitive Examination-Revised (ACE-R)

Background

One of the usual problems psychologists and clinicians face in clinical practice is differential diagnostics of Alzheimer’s disease and depression. It has been reported that the ACE and ACE-R could discriminate the cognitive dysfunctions due to depression from that due to dementia, although this is not uniform in all studies. The current study aimed to evaluate the utility of the ACE-R to differentiate late-life onset depression (with severe episode) from mild-moderate Alzheimer’s Disease (AD).

Methods

This study received approval from the Lithuanian Bioethics Committee. All participants were older than 50 years (mean age = 66.52 (±8.76) years). The study sample consisted of 295 individuals: 117 with severe depression, 85 with mild-moderate Alzheimer’s disease (AD), and 94 age, gender and education matched participants of control group.

Results

The ACE-R had high sensitivity (100%) and specificity (81%) at detecting cognitive impairments related to AD. Patients with late-life onset depression (ACE-R mean 76.82, SD = 7.36) performed worse than controls (ACE-R mean 85.08, SD = 7.2), but better than the AD group (ACE-R mean 54.74, SD = 12.19). Participants with late-life onset depression were differentiated by mild impairment in the ACE-R total score with mild memory (13.79, SD = 6.29) and greater deficits in letter fluency (3.65, SD = 1.21) than in semantic fluency (4.68, SD = 1.23). Participants with AD were differentiated by severely impaired performance on attention and orientation (11.80, SD = 2.93), memory (8.25, SD = 3.47) and language subtests (17.21, SD = 4.04), and moderately impaired performance on verbal fluency (6.07, SD = 2.74).

Conclusions

ACE-R has diagnostic accuracy in detecting people with AD and can be used in differential diagnostics of late-life onset depression (severe episode) and AD. Diagnostic accuracy may be improved by analyzing the neuropsychological profiles and using lower cutoffs for different age groups.

Test Your Memory test: diagnostic utility in a memory clinic population

BACKGROUND

Test Your Memory (TYM) test is a recently described cognitive test instrument designed to be self-administered under medical supervision. The pragmatic role of such self-administered tests in cognitive clinics has not previously been examined. We investigated the diagnostic utility of the TYM as an independent test to differentiate patients with and without dementia at initial clinical diagnostic interview in dedicated memory clinics.

METHODS

TYM was administered to consecutive new patient referrals to two memory clinics independent of other tests [Mini-Mental State Examination (MMSE) and the Addenbrooke's Cognitive Examination-Revised] which were used to establish diagnoses according to standard diagnostic criteria (DSM-IV), and results were compared.

RESULTS

In a cohort of 224 patients, 35% fulfilling clinical diagnostic criteria for dementia, TYM proved easy to use and acceptable to patients. Downward adjustment of the TYM test cutoff to ≤30/50, compared to ≤42/50 used in the index study, proved necessary to maximise test accuracy and specificity. Using this revised cutoff, TYM showed comparable diagnostic utility (sensitivity 0.73, specificity 0.88, positive predictive value 0.77, negative predictive value 0.86 and area under receiver operating characteristic curve 0.89) to the MMSE and the Addenbrooke's Cognitive Examination-Revised for the differentiation of cases of dementia from non-dementia.

CONCLUSIONS

TYM is a useful screening test in the cognitive function clinic setting, with patients who fall below the designated cutoff requiring further investigation to ascertain a cause for their cognitive impairment. Self-administered tests such as TYM may be of particular value in situations where clinician time is limited.

The diagnostic accuracy of dementia-screening instruments with an administration time of 10 to 45 minutes for use in secondary care: a systematic review

Early screening for dementia is crucial for identifying reversible causes as well as managing, counseling, and other therapeutic interventions. Many reviews have compared the suitability of very brief screening instruments for use in primary care, but reviews on more extensive instruments in secondary care are scarce. In addition, results on diagnostic accuracy are often biased due to methodological shortcomings, differences in the spectrum of patients or reporting. This systematic review reports the diagnostic accuracy of dementia-screening instruments with an administration time of 10 to 45 minutes, validated in secondary care, restricted to mild dementia and validation studies of ''high quality.'' Characteristics such as cognitive domains and reliability figures are also highlighted.