The Clock Drawing Test as a predictor of cognitive decline in non-demented stroke patients

Prognostic value of cognitive impairment, assessed by the Clock Drawing Test, in emergency department patients presenting with non-specific complaints

BACKGROUND

Cognitive impairment (CI) is common among older patients presenting to the emergency department (ED). The failure to recognize CI at ED presentation constitutes a high risk of additional morbidity, mortality, and functional decline. The Clock Drawing Test (CDT) is a well-established cognitive screening test.

AIM

In patients presenting to the ED with non-specific complaints (NSCs), we aimed to investigate the usability of the CDT and its prognostic value regarding length of hospital stay (LOS) and mortality.

METHOD

Secondary analysis of the Basel Non-specific Complaints (BANC) trial, a prospective delayed type cross-sectional study with a 30-day follow-up. In three EDs, patients presenting with NSCs were enrolled. The CDT was administered at enrollment.

RESULTS

In the 1,278 patients enrolled, median age was 81 [74, 87] years and 782 were female (61.19%). A valid CDT was obtained in 737 (57.7%) patients. In patients without a valid CDT median LOS was higher (29 [9, 49] days vs. 22 [9, 45] days), and 30-day mortality was significantly higher than in patients with a valid CDT (n = 45 (8.32%) vs. n = 39 (5.29%)). Of all valid CDTs, 154 clocks (20.9%) were classified as normal, 55 (7.5%) as mildly deficient, 297 (40.3%) as moderately deficient, and 231 (31.3%) as severely deficient. Mortality and LOS increased along with the CDT deficits (p = 0.012 for 30-day mortality; p < 0.001 for LOS).

CONCLUSION

The early identification of patients with CI may lead to improved patient management and resource allocation. The CDT could be used as a risk stratification tool for older ED patients presenting with NSCs, as it is a predictor for 30-day mortality and LOS.

Multiple Early Biomarkers to Predict Cognitive Decline in Dementia-Free Older Adults

INTRODUCTION

Baseline olfactory impairment, poor performance on cognitive test, and medial temporal lobe atrophy are considered biomarkers for predicting future cognitive decline in dementia-free older adults. However, the combined effect of these predictors has not been fully investigated.

METHODS

A group of 110 participants without dementia were continuously recruited into this study, and underwent olfactory, cognitive tests and MRI scanning at baseline and 5-year follow-up. Olfactory function was assessed using the University of Pennsylvania Smell Identification Test (UPSIT). Participants were divided into the cognitive decliners and non-decliners.

RESULTS

Among 87 participants who completed the 5-year follow-up, cognitive decline was present in 32 cases and 55 remained stable. Compared with non-decliners, cognitive decliners presented lower scores on both the UPSIT and the Montreal Cognitive Assessment (MoCA), and smaller hippocampal volume at baseline (all P < .001). The logistic regression analysis revealed that lower scores on UPSIT and MoCA, and smaller hippocampal volume were strongly associated with subsequent cognitive decline, respectively (all P < .001). For the prediction of cognitive decline, lower score on UPSIT performed the sensitivity of 63.6% and specificity of 81.2%, lower score on MoCA with the sensitivity of 74.5% and specificity of 65.6%, smaller hippocampal volume with the sensitivity of 70.9% and specificity of 78.1%, respectively. Combining three predictors resulted in the sensitivity of 83.6% and specificity of 93.7%.

CONCLUSIONS

The combination of olfactory test, cognitive test with structural MRI may enhance the predictive ability for future cognitive decline for dementia-free older adults.

The Luigi Sacco Hospital VAS-COG stroke care pathway: A five-year experience

Background

Psycho-cognitive consequences are a frequent cause of disability in stroke survivors but are often underdiagnosed also because of lack of services dedicated to these aspects. We started assessing systematically cognitive and behavioral functions in acute stroke patients and to follow them up. Here, we report a retrospective analysis of the organization of the Sacco VAS-COG stroke care pathway and the refinements implemented during 5 years of activity.

Methods

The protocol includes baseline collection of clinical history, general and neurologic examinations, functional, neuropsychological, and neuroimaging assessment. At follow-up, a diagnosis of cognitive decline was made based on best clinical judgment in the first period (January 2018 to May 2019, namely VAS-COG protocol 1.0) and then based on an extensive neuropsychological battery (May 2019 to January 2023, namely VASCOG protocol 2.0); psychiatric and behavioral disturbances are investigated through suitable scales.

Results

From January 2018 to December 2022, 834 patients (mean age 76±13.6 years; 46.6 % females) with acute cerebrovascular events were admitted to the stroke unit, mostly (80 %) for ischemic strokes. Pre-event cognitive impairment was not assessable in 78 patients (9.3 %) because no reliable informant was present and was reported in 327/756 (43 %) patients. During follow-up, post-stroke cognitive impairment was detected in 124/217 (57.1 %) patients in VAS-COG protocol 1.0 and in 137/201(68.2 %) patients in VAS-COG protocol 2.0, while 95/218 (43.2 %) patients were found to be depressed and patients presented on average 2.5 neuropsychiatric symptoms on Neuropsychiatric Inventory-questionnaire.

Conclusions

The VAS-COG stroke care pathway represents a model for patients and for their families.

[Dynamics of cognitive functions using the rehabilitation program of cognitive training]

OBJECTIVE

To study the efficiency of the neuropsychological rehabilitation of patients with mild cognitive impairments.

MATERIAL AND METHODS

The study included 103 elderly people, aged 59 to 88 years, including 90 women and 13 men with subjective complaints of memory loss (ICD-10: F06.70; F06.71; F06.78; F06.79). Participants were divided into experimental group (n=43) and comparison group (n=42). The estimated impact was the rehabilitation program «The psychosocial therapy and neurocognitive rehabilitation of elderly patients with cognitive impairments», within which the principle of complex stimulation of various parameters of the cognitive sphere was used in rehabilitation work with patients in the experimental group in accordance with the «Memory Clinic» program. The study was conducted using randomized, equalized comparison groups, and the principle of «triple-blind» research. Non-parametric statistics (SPSS) methods were used to assess differences.

RESULTS

A significant difference between the comparison and experimental groups has been identified, primarily in relation to high-level mental processes associated with the function of the third structural-functional block according to A.R. Luria. After the training, the number of correct answers significantly increased (t(42)=-2.67, p<0.001) in the experimental group, while in the comparison group the indicator did not change (t(41)=0.50, p=0.617). The number of false alarms in the experimental group decreased significantly (t(42)=2.13, p=0.039).

CONCLUSION

The results confirm the leading role of these processes in the hierarchy of mental functions, which suggests that they should primarily be targets of rehabilitation interventions.

Comparison of Rapid Cognitive Screen against Montreal Cognitive Assessment in screening for cognitive impairment in the old and old-old

BACKGROUND

The Montreal Cognitive Assessment (MoCA) was developed as a screening tool for mild cognitive impairment (MCI). Given the need for a rapid screening test in settings such as primary care, we compare the validity of the Rapid Cognitive Screen (RCS) against the MoCA, and determine cut-off scores in the old and old-old.

METHODS

Cross-sectional study involving community-dwelling 'old' (65 to 79 years old) and 'old-old' (≥ 80 years old) without dementia. Cognitive impairment was defined by MoCA score 17 to 22. Validation was done using the receiver operating characteristic (ROC) curve analysis: area under the curve (AUC), sensitivity (Sn), and specificity (Sp).

RESULTS

Of the 183 participants (mean age 72.1 ± 5.2 years),15.8% (n = 29) were classified as cognitively impaired. The overall ROC curve had an AUC of 0.82 (95% CI 0.75-0.90, P < 0.01) with an optimal cut-off of 7/8 on RCS (Sn 0.77, Sp 0.72). The 'old' and 'old-old' group had AUC of 0.82 (95% CI 0.74-0.91, P < 0.01) with 8/9 as optimal cut-off (Sn 0.51, Sp 0.96) and AUC of 0.85 (95% CI 0.66-1.03, P < 0.01) with 7/8 as optimal cut-off (Sn 0.71, Sp 1.00) respectively. In multivariate analysis, age was associated with 0.05 (95% CI -0.10-0.00, P < 0.04) point decrement, while >6 years of education was associated with 0.82 (95% CI 0.32-1.33, P < 0.01) point increment in RCS scores.

CONCLUSION

The three-item RCS is quick and easy to administer. Although RCS met the criterion for good validity against MoCA in predicting cognitive impairment, its utility as a first-line screening tool needs to be further validated in a large-scale population study.

Prediction of post-stroke cognitive impairment by Montreal Cognitive Assessment (MoCA) performances in acute stroke: comparison of three normative datasets

Background

Cognitive assessment in acute stroke is relevant for identifying patients at risk of persistent post-stroke cognitive impairment (PSCI). Despite preliminary evidence on MoCA accuracy, there is no consensus on its optimal score in the acute stroke setting to predict PSCI.

Aims

(1) To explore whether the application of different normative datasets to MoCA scores obtained in the acute stroke setting results in variable frequency of patients defined as cognitively impaired; (2) to assess whether the normality cut-offs provided by three normative datasets predict PSCI at 6–9 months; (3) to calculate alternative MoCA cut-offs able to predict PSCI.

Methods

Consecutive stroke patients were reassessed at 6–9 months with extensive neuropsychological and functional batteries for PSCI determination.

Results

Out of 207 enrolled patients, 118 (57%) were followed-up (mean 7.4 ± 1.7 months), and 77 of them (65%) received a PSCI diagnosis. The application of the normality thresholds provided by the 3 normative datasets yielded to variable (from 28.5% to 41%) rates of patients having an impaired MoCA performance, and to an inadequate accuracy in predicting PSCI, maximizing specificity instead of sensitivity. In ROC analyses, a MoCA score of 22.82, adjusted according to the most recent normative dataset, achieved a good diagnostic accuracy in predicting PSCI.

Conclusions

The classification of acute stroke patients as normal/impaired based on MoCA thresholds proposed by general population normative datasets underestimated patients at risk of persistent PSCI. We calculated a new adjusted MoCA score predictive of PSCI in acute stroke patients to be further tested in larger studies.

[Effectiveness of brain-computer interfaces and cognitive training using computer technologies in restoring cognitive functions in patients after stroke]

OBJECTIVE

To study the effectiveness of brain-computer interfaces (BCI) and cognitive training using computer technologies in restoring cognitive functions in poststroke patients.

MATERIAL AND METHODS

Thirty-four stroke patients (mean age 59.3±10.8 years) with stroke duration of 5.1±4.7 months, were included. To assess the effectiveness of treatment, patients before and after treatment were tested using memorization of words according to the method of Luria A.R. «10 words», the Montreal Cognitive Assessment Scale (MoCA), the Clock Drawing Test (CDT). All patients received standard rehabilitation therapy (exercise therapy, physiotherapy, sessions with a speech therapist-neuropsychologist). Patients of the first group additionally received training on the «Neurochat» complex, patients of the second group - on the «Exokist-2» complex, patients of the third group - cognitive training according to standard programs using computer technology and visual material.

RESULTS

Patients of the three groups showed a significant improvement in the total MoCA score: in the 1^st and 2^nd groups - p<0.01, in the 3^rd group - p<0.05. According to CDT, there was a significant change in the 2^nd group (p=0.018). The Luria method «10 words» revealed an improvement in memory in all groups (p<0.01, p<0.05), being more pronounced in the 1^st and 2^nd groups.

CONCLUSION

The effectiveness of BCI in restoring cognitive functions in patients after a stroke in comparison with cognitive training without BCI has been demonstrated. However, there are reasons to believe that various BCIs have a specific effect on cognitive functions and have their own target group.