CCCDTD5 recommendations on early and timely assessment of neurocognitive disorders using cognitive, behavioral, and functional scales

Mild Behavioral Impairment and Quality of Life in Community Dwelling Older Adults

OBJECTIVES

Mild behavioral impairment (MBI) is a dementia risk indicator in older adults characterized by later-life emergent and persistent neuropsychiatric symptoms. Quality of life (QoL) is a multi-dimensional concept encompassing physical, spiritual, and emotional well-being. QoL aims to measure and quantify perceptions of individual health, well-being, standard of living, personal fulfillment, and satisfaction. As MBI symptoms may arise from early-stage neurodegenerative disease, MBI may contribute to declining QoL before dementia onset. In this study, we investigated the relationship between symptoms of MBI and QoL in older adults.

METHODS

The sample comprised 1107 individuals aged ≥ 50 years from the Canadian Platform for Research Online to Investigate Health, Quality of Life, Cognition, Behavior, Function, and Caregiving in Aging (CAN-PROTECT). Multivariable linear regressions were used to model the associations between MBI symptom severity (exposure), measured using the MBI Checklist (MBI-C), and QoL (outcome) assessed by the EuroQol-5D (EQ-5D, higher score = poorer QoL) and the novel Quality of Life and Function Five Domain Scale (QFS-5) (QFS-5, lower score = poorer QoL). Covariates were age, sex, cognition, education, ethnocultural origin, marital status, employment status, high blood pressure, heart disease, and diabetes. Moderation analysis explored potential sex differences. A sensitivity analysis was performed removing anxiety/depression items from the EQ-5D score.

RESULTS

Across the sample (mean age = 64.4 ± 7.2, 79.4% female) every 1-point increase in MBI-C score was associated with a 0.06-point standard deviation (SD) increase in EQ-5D score (95% confidence interval (CI): 0.05-0.06, p < 0.001) and 0.08 SD decrease in QFS-5 score (95% CI: -0.09 to -0.08, p < 0.001). Neither association depended on sex (p = 0.59 and p = 0.41, respectively). The association remained significant after removing anxiety/depression items from the EQ-5D score (β = 0.04, 95% CI: 0.03- 0.04, p < 0.001).

CONCLUSIONS

The study shows that MBI is associated with poorer QoL, independent of sex, on two QoL scales. We addressed depression/anxiety items in the EQ-5D as a potential confounder for the observed MBI-QoL association by conducting a sensitivity analysis that excluded those items from the EQ-5D total score and by employing a novel measure of QoL (QFS-5) that excludes psychiatric symptoms from measurement of QoL. Associations of MBI with the novel QFS-5 were similar to associations between MBI and the EQ-5D. Finding interventions to reduce the burden of MBI symptoms might improve quality of life.

Diagnostic accuracy of cognitive screening tools validated for older adults in Iran: a systematic review and meta-analysis

BACKGROUND

This systematic review aims to comprehensively assess the diagnostic accuracy of cognitive screening tools validated for older adults in Iran, providing evidence-based recommendations for clinicians and researchers.

METHODS

A comprehensive search in March 2023 across Web of Science, PubMed, Scopus, ScienceDirect, SID, IranMedex, and IranDoc, enhanced by hand-searching references and Google Scholar, identified cross-sectional studies on cognitive screening in Iranian seniors. We assessed diagnostic accuracy, cognitive domains, and test strengths and weaknesses. A bivariate random-effects meta-analysis provided summary estimates and 95% confidence intervals, illustrated in forest plots.

RESULTS

Our review, derived from an initial screening of 38 articles, focused on 17 studies involving 14 cognitive screening tools and participant counts from 60 to 350, mostly from specialized clinics. The MMSE was the only tool examined in at least three studies, prompting a meta-analysis revealing its sensitivity at 0.89 and specificity at 0.77 for dementia detection, albeit amidst significant heterogeneity (I^2 > 80%). ACE-III demonstrated the highest diagnostic accuracy for MCI and dementia, while MoCA's performance was deemed adequate for MCI and excellent for dementia. High bias risk in studies limits interpretation.

CONCLUSION

This review identifies key cognitive tools for dementia and MCI in Iranian older adults, tailored to educational levels for use in primary and specialized care. It emphasizes the need for further validation to enhance diagnostic precision across diverse settings, within a concise framework prioritizing brevity and accuracy for clinical applicability.

Health System Change for Alzheimer's Disease-Modifying Therapies in Canada: Beginning the Discussion

Alzheimer's disease (AD) is a neurodegenerative disorder that accounts for 60%-70% of patients with dementia, and it is estimated that over one million Canadians will be living with dementia by 2030. Disease-modifying therapies (DMTs) targeting the underlying pathophysiology of AD are currently in development. Several models have demonstrated that the potential arrival of Alzheimer's DMTs will most likely overwhelm the already-constrained Canadian healthcare system. Canada does not have a strategy to address the extensive requirements of using DMTs, including providing an early diagnosis of AD, confirming DMT eligibility via amyloid biomarkers, and conducting ongoing treatment monitoring. Thus, a multidisciplinary group of experts involved in AD care in Canada gathered to review (1) the current barriers to diagnosis and management of AD; (2) how existing clinic models, including those used in multiple sclerosis (MS), could be applied to address key barriers in AD; and (3) how to design and implement optimal care pathways in the future. The actions outlined in this review will help clinicians and healthcare systems improve readiness to integrate the use of disease-modifying therapies in Alzheimer's disease, if such therapies are approved in Canada.

It's all about cognitive trajectory: Accuracy of the cognitive charts-MoCA in normal aging, MCI, and dementia

BACKGROUND

The Montreal Cognitive Assessment (MoCA) is an established cognitive screening tool in older adults. It remains unclear, however, how to interpret its scores over time and distinguish age-associated cognitive decline (AACD) from early neurodegeneration. We aimed to create cognitive charts using the MoCA for longitudinal evaluation of AACD in clinical practice.

METHODS

We analyzed data from the National Alzheimer's Coordinating Center (9684 participants aged 60 years or older) who completed the MoCA at baseline. We developed a linear regression model for the MoCA score as a function of age and education. Based on this model, we generated the Cognitive Charts-MoCA designed to optimize accuracy for distinguishing participants with MCI and dementia from healthy controls. We validated our model using two separate data sets.

RESULTS

For longitudinal evaluation of the Cognitive Charts-MoCA, sensitivity (SE) was 89%, 95% confidence interval (CI): [86%, 92%] and specificity (SP) 79%, 95% CI: [77%, 81%], hence showing better performance than fixed cutoffs of MoCA (SE 82%, 95% CI: [79%, 85%], SP 68%, 95% CI: [67%, 70%]). For current cognitive status or baseline measurement, the Cognitive Charts-MoCA had a SE of 81%, 95% CI: [79%, 82%], SP of 84%, 95% CI: [83%, 85%] in distinguishing healthy controls from mild cognitive impairment or dementia. Results in two additional validation samples were comparable.

CONCLUSIONS

The Cognitive Charts-MoCA showed high validity and diagnostic accuracy for determining whether older individuals show abnormal performance on serial MoCAs. This innovative model allows longitudinal cognitive evaluation and enables prompt initiation of investigation and treatment when appropriate.

Decision making under uncertainty in the diagnosis and management of Alzheimer's Disease in primary care: A study protocol applying concepts from neuroeconomics

Background

The current management of patients with Dementia, primarily with Alzheimer's Disease (AD) is rapidly evolving. However, limited information is available about the current gaps and decision-making in primary care.

Objectives

To evaluate factors associated with gaps, risk preferences regarding diagnostic and therapeutic choices in the management of patients with AD by primary care physicians (PCP) from across Canada.

Methods

We propose a non-interventional, cross-sectional pilot study involving 120 primary care physicians referred from the College of Family Physicians of Canada to assess diagnostic and therapeutic decisions in the management of ten simulated AD-related case-scenarios commonly encountered in clinical practice. We initially describe the current landscape and gaps regarding diagnostic and therapeutic challenges in the management of patients with AD in primary care. Then, we provide concepts from behavioral economics and neuroeconomics applied to medical decision-making. Specifically, we include standardized tests to measure risk aversion, physicians' reactions to uncertainty, and questions related to risk preferences in different domains. Finally, we summarize the protocol to be implemented to address our goals. The primary study outcome is the proportion of participants that elect to defer initial investigations to the specialist and the associated factors. Secondary outcomes include the proportion of PCP willing to order cerebral spinal fluid studies, PET scans, or initiate treatment according to the simulated case-scenarios. The study will be conducted in English and French.

Conclusions

The study findings will contribute a better understanding of relevant factors associated with diagnostic and therapeutic decisions of PCP in the management of AD, identifying participant's preferences and evaluating the role of behavioral aspects such tolerance to uncertainty, aversion to ambiguity, and therapeutic inertia.