Prospective comparison of two cognitive screening tests: diagnostic accuracy and correlation with community integration and quality of life

Reliability and validity of the Montreal Cognitive Assessment's auditory items (MoCA-22)

Objective: To evaluate the latent structure, internal consistency, convergent and discriminant validity, diagnostic accuracy, and criterion validity of the Montreal Cognitive Assessment's auditory items (MoCA-22), which has previously been evaluated in small samples if at all. Methods: 11,284 participants completed the MoCA over 1-2 visits to an Alzheimer Disease Research Center (Mage = 69.2, Meducation = 15.9, 57.6% women, 92.4% non-Hispanic white). MoCA-22 items were probed with alpha, omega, confirmatory factor analysis, and test-retest correlations. Scores were related to measures of neurocognition, daily functioning, behavioral-psychological symptoms (BPS), and vision performance for convergent-discriminant and criterion validity. Dementia stage was used to calculate area under the receiver operating characteristic (AUC-ROC) curves and cutoffs for mild cognitive impairment (MCI) and dementia. Results: A single-factor had good fit (CFI = .961; TLI = .945; RMSEA = .061; SRMR = .031), with good internal consistency (Omega total = .83) and test-retest consistency (ICC = .92 at 2.7 years). The strongest convergent correlations were with general cognition and executive functioning, while discriminant validity was demonstrated with its weakest and negative correlations being with BPS. There was strong classification accuracy in distinguishing MCI from normal cognition (AUC = .79; optimal cutoff point < 18), and mild-to-moderate dementia from MCI (AUC = .85; optimal cutoff point < 13). Furthermore, the MoCA-22 had negligible-to-small differences among those with and without vision limitations. Conclusions: These findings add to the evidence of the MoCA-22's utility and it serves as a useful cognitive screening tool with sound reliability and validity.

"Non-Eloquent" brain regions predict neuropsychological outcome in tumor patients undergoing awake craniotomy

Supratotal resection of primary brain tumors is being advocated especially when involving "non-eloquent" tissue. However, there is extensive neuropsychological data implicating functions critical to higher cognition in areas considered "non-eloquent" by most surgeons. The goal of the study was to determine pre-surgical brain regions that would be predictive of cognitive outcome at 4-6 months post-surgery. Cortical reconstruction and volumetric segmentation were performed with the FreeSurfer-v6.0 image analysis suite. Linear regression models were used to regress cortical volumes from both hemispheres, against the total cognitive z-score to determine the relationship between brain structure and broad cognitive functioning while controlling for age, sex, and total segmented brain volume. We identified 62 consecutive patients who underwent planned awake resections of primary (n = 55, 88%) and metastatic at the University of New Mexico Hospital between 2015 and 2019. Of those, 42 (23 males, 25 left hemispheric lesions) had complete pre and post-op neuropsychological data available and were included in this study. Overall, total neuropsychological functioning was somewhat worse (p = 0.09) at post-operative neuropsychological outcome (Mean = -.20) than at baseline (Mean = .00). Patients with radiation following resection (n = 32) performed marginally worse (p = .036). We found that several discrete brain volumes obtained pre-surgery predicted neuropsychological outcome post-resection. For the total sample, these volumes included: left fusiform, right lateral orbital frontal, right post central, and right paracentral regions. Regardless of lesion lateralization, volumes within the right frontal lobe, and specifically right orbitofrontal cortex, predicted neuropsychological difference scores. The current study highlights the gaps in our current understanding of brain eloquence. We hypothesize that the volume of tissue within the right lateral orbital frontal lobe represents important cognitive reserve capacity in patients undergoing tumor surgery. Our data also cautions the neurosurgeon when considering supratotal resections of tumors that do not extend into areas considered "non-eloquent" by current standards.

Quality of Life and Cognitive Function Evaluations and Interventions for Patients with Brain Metastases in the Radiation Oncology Clinic

Simple Summary

Brain metastases (BMs) are the most common brain malignancy and are projected to increase in incidence over the coming decades. Historically, brain metastasis studies have focused on improving survival outcomes, but recently, the importance of evaluating health-related quality of life (HRQOL) and cognitive function has gained recognition. Although there is a myriad of validated HRQOL and cognitive assessments available in the radiation oncology clinic, there is an urgent need to identify tools tailored to patients with BMs and to adopt a uniform set of tests that measure HRQOL and cognition. This review presents various assessments for measuring HRQOL and cognitive function, current recommendations to improve standardization, and treatments known to preserve HRQOL and cognitive function.

Abstract

Brain metastases (BMs) account for a disproportionately high percentage of cancer morbidity and mortality. Historically, studies have focused on improving survival outcomes, and recent radiation oncology clinical trials have incorporated HRQOL and cognitive assessments. We are now equipped with a battery of assessments in the radiation oncology clinic, but there is a lack of consensus regarding how to incorporate them in modern clinical practice. Herein, we present validated assessments for BM patients, current recommendations for future clinical studies, and treatment advances that have improved HRQOL and cognitive outcomes for BM patients.

Re-examining popular screening measures in neuro-oncology: MMSE and RBANS

BACKGROUND

The Mini-Mental Status Examination (MMSE) is routinely used in neuro-oncology clinics to rule out cognitive impairment. However, the MMSE is known to have poor sensitivity to mild cognitive impairment, raising concern regarding its continued use. More comprehensive cognitive screeners are available, such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and may be better able to assess for cognitive dysfunction.

METHODS

This retrospective cross-sectional study compared the relative rates of impairment using the MMSE-2 and RBANS in a sample of neuro-oncology patients (N = 81). A preliminary analysis of the sensitivity and specificity of the MMSE-2 to the level of cognitive impairment identified on the RBANS was conducted; in addition, we examined whether an adjustment of the MMSE-2 cut-off score improved consensus with a positive screening on the RBANS.

RESULTS

The MMSE-2 failed to identify over half of the patients with cognitive dysfunction that were identified on the RBANS. Further analysis showed limited sensitivity of the MMSE-2 to the level of impairment detected on the RBANS, and an adjustment of the cut-off score did not improve the sensitivity or specificity of the MMSE-2.

CONCLUSIONS

These results provide caution for neuro-oncology clinics using the MMSE. If providers continue to rely on the MMSE to screen for cognitive impairment alone, they may fail to identify individuals with mild cognitive impairments.

Reducing the Cognitive Footprint of Brain Tumor Surgery

The surgical management of brain tumors is based on the principle that the extent of resection improves patient outcomes. Traditionally, neurosurgeons have considered that lesions in “non-eloquent” cerebrum can be more aggressively surgically managed compared to lesions in “eloquent” regions with more known functional relevance. Furthermore, advancements in multimodal imaging technologies have improved our ability to extend the rate of resection while minimizing the risk of inducing new neurologic deficits, together referred to as the “onco-functional balance.” However, despite the common utilization of invasive techniques such as cortical mapping to identify eloquent tissue responsible for language and motor functions, glioma patients continue to present post-operatively with poor cognitive morbidity in higher-order functions. Such observations are likely related to the difficulty in interpreting the highly-dimensional information these technologies present to us regarding cognition in addition to our classically poor understanding of the functional and structural neuroanatomy underlying complex higher-order cognitive functions. Furthermore, reduction of the brain into isolated cortical regions without consideration of the complex, interacting brain networks which these regions function within to subserve higher-order cognition inherently prevents our successful navigation of true eloquent and non-eloquent cerebrum. Fortunately, recent large-scale movements in the neuroscience community, such as the Human Connectome Project (HCP), have provided updated neural data detailing the many intricate macroscopic connections between cortical regions which integrate and process the information underlying complex human behavior within a brain “connectome.” Connectomic data can provide us better maps on how to understand convoluted cortical and subcortical relationships between tumor and human cerebrum such that neurosurgeons can begin to make more informed decisions during surgery to maximize the onco-functional balance. However, connectome-based neurosurgery and related applications for neurorehabilitation are relatively nascent and require further work moving forward to optimize our ability to add highly valuable connectomic data to our surgical armamentarium. In this manuscript, we review four concepts with detailed examples which will help us better understand post-operative cognitive outcomes and provide a guide for how to utilize connectomics to reduce cognitive morbidity following cerebral surgery.

The Association of Insomnia with Depression and Anxiety Symptoms in Patients Undergoing Noncardiac Surgery

OBJECTIVE

Insomnia is common in patients undergoing surgery. It can increase the rate of postoperative complications, interfere with patient recovery, and decrease hospital satisfaction. However, there are few studies on perioperative insomnia. This study was conducted to investigate the differences in the demographic, health status, and clinical characteristics of patients with and without insomnia postoperatively, and to identify the potential risk factors of insomnia.

METHODS

There were 299 non-cardiac surgery patients, 165 females, and 134 males, with a mean age of 55 years, enrolled in the study. The Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and Montreal Cognitive Assessment (MoCA) were administered to all the patients preoperatively. The Visual Analogue Scale (VAS) was used preoperatively, and at the end of the surgery, and then one day, two days, and three days after surgery. The PHQ-9, the GAD-7, and the ISI were repeated three days after surgery. Insomnia was diagnosed by the ISI as being a score of 8-28 (mild: 8-14; moderate-severe: 15-21; severe: 22-28). The patients were divided into group A (with insomnia, N=78) and group B (without insomnia, N=221) according to their ISI score three days after surgery. The general clinical data of the two groups were analyzed first, and then binary logistic regression analysis was conducted to assess the risk factors of insomnia.

RESULTS

A total of 299 non-cardiac surgery patients with a mean age of 55 years were enrolled in the study. Of the included patients, the number of females was 165 and the number of the male was 134. The incidence of insomnia at 3 days postoperatively was 26.1% (78/299). The average points that group A patients scored in the ISI, PHQ-9, and the GAD-7 were significantly higher than those in group B. The VAS score three days after surgery was significantly higher in group A. The PHQ-9 and the GAD-7 three days after surgery showed significantly higher depression and anxiety scores in group A. Logistic regression showed that the ISI (p<0.001, 95% CI=1.218-1.500) and the GAD-7 (p=0.003, 95% CI=1.041-1.218) preoperatively, and the PHQ-9 postoperatively (p<0.001, 95% CI=1.226-1.555), were risk factors of insomnia.

CONCLUSION

Insomnia is common and can worsen after surgery. The present study suggests that depression and anxiety are risk factors for insomnia after surgery. There is a need for further research and the development of strategies for depression and anxiety management to ensure better sleep quality for patients, which will be of significant benefit to their health.

CLINICAL TRIAL REGISTRATION

The study was registered at clinical trial (NCT04027751); Trial registration: clinical trial, NCT04027751. Registered 22 July 2019; https://clinicaltrials.gov/ct2/show/NCT04027751?cond=NCT04027751&cntry=CN&draw=2&rank=1.

Sensitivity of the Montreal Cognitive Assessment in screening for cognitive impairment in patients with newly diagnosed high-grade glioma

INTRODUCTION

Cognitive impairment is frequent in patients with high-grade glioma and requires cognitive follow-up. Cognitive screening tools such as the Montreal Cognitive Assessment (MoCA) have been used to assess cognition in these patients. Here we assessed the sensitivity of the MoCA in screening for cognitive impairment in a cohort of 156 patients with newly-diagnosed high-grade glioma, after surgery and before radiochemotherapy.

METHODS

We assessed cognitive performance with the MoCA and a neuropsychological battery. Cognitive scores were analyzed in terms of a previously validated framework designed to control false positives and data for 1003 control participants from the GRECOGVASC study. After comparison of performance on the tests, we used stepwise logistic regression to produce a cognitive summary score from the neuropsychological battery. Then we analyzed sensitivity and specificity of the MoCA with receiver operator characteristic (ROC) curve analysis.

RESULTS

Both raw and adjusted MoCA scores showed only moderate sensitivity. The area under the ROC curve was 0.759 (95% CI 0.703-0.815) for the raw score and 0.788 (95% CI 0.734-0.842) for the adjusted score. Optimal discrimination was obtained with a raw score ≤ 25 (sensitivity: 0.526; specificity: 0.832; positive predictive value: 0.2; negative predictive value: 0.96) and an adjusted score - 0.603 (sensitivity: 0.716; specificity: 0.768; positive predictive value: 0.24; negative predictive value: 0.96).

CONCLUSION

The moderate sensitivity of MoCA indicates that it is not a suitable screening tool for detecting cognitive impairment in patients with newly-diagnosed high-grade glioma.

Embracing the complexity: Older adults with cancer-related cognitive decline-A Young International Society of Geriatric Oncology position paper

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population.

Effect of early palliative care for patients with glioblastoma (EPCOG): a randomised phase III clinical trial protocol

​INTRODUCTION: Randomised controlled trials (RCTs) have shown a positive effect of early integration of palliative care (EIPC) in various advanced cancer entities regarding patients' quality of life (QoL), survival, mood, caregiver burden and reduction of aggressiveness of treatment near the end of life. However, RCTs investigating the positive effect of EIPC for patients suffering from glioblastoma multiforme (GBM) are lacking. After modelling work identifying the specific needs of GBM patients and their caregivers, the aim of this study is to investigate the impact of EIPC in this particular patient group. ​METHODS AND ANALYSIS: The recruitment period of this multicenter RCT started in May 2019. GBM patients (n=214) and their caregivers will be randomly assigned to either the intervention group (receiving proactive EIPC on a monthly basis) or the control group (receiving treatment according to international standards and additional, regular assessment of QoL ('optimised' standard care)).The primary outcome is QoL assessed by subscales of the Functional Assessment of Cancer Therapy for brain tumour (FACT-Br) from baseline to 6 months of treatment. Secondary outcomes are changes in QoL after 12 (end of intervention), 18 and 24 months (end of follow-up), the full FACT-Br scale, patients' palliative care needs, depression/anxiety, cognitive impairment, caregiver burden, healthcare use, cost-effectiveness and overall survival. ​ETHICS AND DISSEMINATION: The study will be conducted in accordance with the Declaration of Helsinki and has been approved by the local ethics committees of the University Clinics of Cologne, Aachen, Bonn, Freiburg and Munich (LMU). Results of the trial will be submitted for publication in a peer-reviewed, open access journal and disseminated through presentations at conferences. TRIAL REGISTRATION NUMBER: German Register for Clinical Studies (DRKS) (DRKS00016066); Pre-results.

Can MoCA and MMSE Be Interchangeable Cognitive Screening Tools? A Systematic Review

BACKGROUND AND OBJECTIVES

Cognitive disorders may be an early sign of neuropsychiatric disorders; however, it remains unclear whether the screening measures are interchangeable. The aim of this study was to contrast the most commonly used screening tools-Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)-for early detection of neurocognitive disorder (NCD).

RESEARCH DESIGN AND METHODS

This study presents a descriptive systematic review and informative literature according to the Cochrane Foundation's guidelines. The keywords "Mini-Mental State Examination" and "Montreal Cognitive Assessment" were searched in the Web of Science, SciELO, and LILACS databases.

RESULTS

Fifty-one studies were selected including a total sample of 11,870 participants (8,360 clinical patients and 3,510 healthy controls). Most studies were published in the past 5 years using a cross-sectional design, carried out across the world. They were organized by age ranges (18-69 years and 20-89 years), years of schooling, and mental status (with and without mental and behavior disorders). Sixteen of 18 studies had participants aged 18-69 years, and 21 out of 33 studies within the older set suggested that the MoCA is a more sensitive tool for detecting NCD.

DISCUSSION AND IMPLICATIONS

Thirty-seven studies suggested that the MoCA is a more sensitive tool for NCD detection because it assesses executive function and visuospatial abilities. Some individuals who demonstrated normal cognitive function on the MMSE had lower performance on the MoCA. However, it seems necessary to establish different cutoffs based on years of schooling to avoid false positives. Future studies should contrast MoCA with other screening tools designed for NCD assessment.

Cancer-related cognitive impairment and associated factors in a sample of older male oral-digestive cancer survivors

OBJECTIVE

This study examines the demographic and clinical variables associated with cancer-related cognitive impairment (CRCI) in a sample of older, male, oral-digestive cancer survivors at VA Medical Centers in Boston and Houston.

METHODS

A two-time point, longitudinal design was used, with cognitive assessment conducted at 6 and 18 months post-diagnosis. Using ANCOVA, the cognitive functioning of 88 older adults with head and neck, esophageal, gastric, or colorectal cancers was compared with that of 88 healthy controls. Paired t-tests examined cognitive change over time in the cancer group. Hierarchical linear regression examined variables potentially associated with cognitive impairment at 18 months.

RESULTS

Forty-eight percent of cancer patients exhibited cognitive impairment 6 months post-cancer diagnosis, and 40% at 18 months. Cancer survivors were impaired relative to controls on measures of sustained attention, memory, and verbal fluency at 18 months, controlling for age. Older age, low hemoglobin, and cancer-related PTSD were associated with worse cognition at 18 months.

CONCLUSIONS

CRCI is more frequent in older adults than reported in studies of younger adults and may be more frequent in men. Potential areas of intervention for CRCI include psychotherapy for cancer-related PTSD, treatment of anemia, and awareness of particularly vulnerable cognitive domains such as sustained attention, memory, and verbal fluency.

Health Related Quality of Life in Adult Low and High-Grade Glioma Patients Using the National Institutes of Health Patient Reported Outcomes Measurement Information System (PROMIS) and Neuro-QOL Assessments

Health related quality of life (HRQOL) measures have become increasingly important in the management of glioma patients in both research and clinical practice settings. Functional impairment is common in low-grade and high-grade glioma patients as the disease has both oncological and neurological manifestations. Natural disease history as well as medical or surgical treatment can negatively influence HRQOL. There are no universal standards for HRQOL assessment in glioma patients. In this study, we examine patient perspectives on functional outcome domains and report the prevalence of impairments rates using the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS) and Neuro-QOL item banks as measures of HRQOL. Retrospective analysis of a prospectively collected dataset involving 79 glioma patients reveals that quality of life concerns are the most important consideration behind making decisions about treatment in 80.7% of patients. The prevalence of functional impairment by PROMIS and NEURO-QOL assessment is high, ranging from 28.6% in the physical function domain to 43.9% in the cognitive function domain. Pain and anxiety related to physical decline is higher in LGG patients compared to HGG patients. Aphasia severity also impacts HRQOL. The results of this study suggest that the PROMIS and NEURO-QOL assessments may be important HRQOL metrics for future use in larger clinical research and clinical trial settings.

Effects of surgery on neurocognitive function in patients with glioma: a meta-analysis of immediate post-operative and long-term follow-up neurocognitive outcomes

PURPOSE

This study aims to identify the neuropsychological tests commonly used for assessment in each neurocognitive domain, and quantify the post-operative changes in neurocognitive function in the immediate post-operation and follow-up.

METHODS

With the use of the PubMed, a comprehensive search of the English literature was performed following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. There were 1021 publications identified for screening. Standardized mean differences (SMD) in neuropsychological task performance were calculated both for immediate post-operation (up to 1 week) and follow-up (up to 6 months).

RESULTS

Out of 12 studies which met the inclusion criteria, 11 studies were analyzed in this meta-analysis, with a total of 313 patients (age range 18-82, 50% males) with intracranial gliomas (45% high-grade, 55% low-grade). Complex attention, language and executive function were the most frequently tested neurocognitive domains. Surgery had a positive impact in the domains of complex attention, language, learning and memory tasks in the immediate post-operative period and sustained improvement at follow-up. In contrast, surgery was found to negatively impact performance for executive function in the immediate post-operative period with sustained decline in performance in the long term.

CONCLUSIONS

This meta-analysis suggests that surgery for glioma confers a benefit for the domains of complex attention, language, learning and memory, while negatively affecting executive function, in the periods immediately after surgery and at 6 months follow-up. In addition, awake surgery seemed to confer a beneficial effect on neurocognitive functions. Future research should attempt to standardize a battery of neuropsychological tests for patients undergoing surgical resection for glioma, perhaps with a particular focus on executive function.

Sensitivity and specificity of a briefer version of the Cambridge Cognitive Examination (CAMCog-Short) in the detection of cognitive decline in the elderly: An exploratory study

OBJECTIVE

To create a reduced and briefer version of the widely used Cambridge Cognitive Examination (CAMCog) battery as a concise cognitive test to be used in primary and secondary levels of health care to detect cognitive decline. Our aim was to reduce the administration time of the original test while maintaining its diagnostic accuracy.

METHODS

On the basis of the analysis of 835 CAMCog tests performed by 429 subjects (107 controls, 192 mild cognitive impairment [MCI], and 130 dementia patients), we extracted items that most contributed to intergroup differentiation, according to 2 educational levels (≤8 and >8 y of formal schooling).

RESULTS

The final 33-item "low education" and 24-item"high education" CAMCog-Short correspond to 48.5% and 35% of the original version and yielded similar rates of accuracy: area under ROC curves (AUC) > 0.9 in the differentiation between controls × dementia and MCI × dementia (sensitivities > 75%; specificities > 90%); AUC > 0.7 for the differentiation between controls and MCI (sensitivities > 65%; specificities > 75%).

CONCLUSIONS

The CAMCog-Short emerges as a promising tool for a brief, yet sufficiently accurate, screening tool for use in clinical settings. Further prospective studies designed to validate its diagnostic accuracy are needed.

Profiling Cognitive Deficits in Intra-Axial and Extra-Axial Tumors Using Addenbrooke's Cognitive Examination as a Screening Tool: An Indian Experience

BACKGROUND

Tumors of the brain, whether intra- or extra-axial, results in cognitive deficits. The aim of the present study was to profile cognitive deficits using Addenbrooke's Cognitive Examination-Malayalam (ACE-M) as a screen and to determine the sensitivity and specificity of the same.

METHODS

Seventy-four drug naïve patients diagnosed to have brain tumors were assessed for cognitive functioning using ACE-M before surgery.

RESULTS

Patients with high-grade intra-axial tumors showed a significant association on the cognitive domains of registration (0.04), recall (0.01), and visuospatial functioning (0.02). Gender showed an association between registration (0.02) and verbal fluency (0.02) with females performing better while education was significantly associated with retrograde or remote memory (0.00) with college-educated sample performing better. Significance was assumed at P < 0.05. In extra-axial tumors, laterality had a single association with recall (0.02). Males showed a significant cognitive decline on the cognitive domains of attention (0.02), recall (0.05), naming (0.02), and language functions (0.01). College educated group performed better on registration (0.01), recall (0.09), naming (0.00), and visuospatial functioning (0.00). The area under the receiver operating characteristic curve was estimated as 0.75, which indicates fairly good discriminative ability with a cut off of 71/100; sensitivity at 77.3 and specificity fixed at 67.

CONCLUSIONS

ACE-M is capable of bringing out cognitive deficits along with a number of cognitive domains in patients with intra- and extra-axial tumors in the capacity of a screen, with fairly good levels of sensitivity and specificity.

Changes in Cognition and Decision Making Capacity Following Brain Tumour Resection: Illustrated with Two Cases

Changes in cognition, behaviour and emotion frequently occur in patients with primary and secondary brain tumours. This impacts the ability to make considered decisions, especially following surgical resection, which is often overlooked in the management of patients. Moreover, the impact of cognitive deficits on decision making ability affects activities of daily living and functional independence. The assessment process to ascertain decision making capacity remains a matter of debate. One avenue for evaluating a patient’s ability to make informed decisions in the context of brain tumour resection is neuropsychological assessment. This involves the assessment of a wide range of cognitive abilities on standard measurement tools, providing a robust approach to ascertaining capacity. Evidence has shown that a comprehensive and tailored neuropsychological assessment has greater sensitivity than brief cognitive screening tools to detect subtle and/or specific cognitive deficits in brain tumours. It is the precise nature and severity of any cognitive deficits that determines any implications for decision making capacity. This paper focuses on cognitive deficits and decision making capacity following surgical resection of both benign and malignant, and primary and secondary brain tumours in adult patients, and the implications for patients’ ability to consent to future medical treatment and make decisions related to everyday activities.

Screening for Mild Cognitive Impairment: Comparison of "MCI Specific" Screening Instruments

Background:

Sensitive and specific instruments are required to screen for cognitive impairment (CI) in busy clinical practice. The Montreal Cognitive Assessment (MoCA) is widely validated but few studies compare it to tests designed specifically to detect mild cognitive impairment (MCI).

Objective:

Comparison of two “MCI specific” screens: the Quick Mild Cognitive Impairment screen (Qmci) and MoCA.

Methods:

Patients with subjective memory complaints (SMC; n = 73), MCI (n = 103), or dementia (n = 274), were referred to a university hospital memory clinic and underwent comprehensive assessment. Caregivers, without cognitive symptoms, were recruited as normal controls (n = 101).

Results:

The Qmci was more accurate than the MoCA in differentiating MCI from controls, area under the curve (AUC) of 0.90 versus 0.80, p = 0.009. The Qmci had greater (AUC 0.81), albeit non-significant, accuracy than the MoCA (AUC 0.73) in separating MCI from SMC, p = 0.09. At its recommended cut-off (<62/100), the Qmci had a sensitivity of 90% and specificity of 87% for CI (MCI/dementia). Raising the cut-off to <65 optimized sensitivity (94%), reducing specificity (80%). At <26/30 the MoCA had better sensitivity (96%) but poor specificity (58%). A MoCA cut-off of <24 provided the optimal balance. Median Qmci administration time was 4.5 (±1.3) minutes compared with 9.5 (±2.8) for the MoCA.

Conclusions:

Although both tests distinguish MCI from dementia, the Qmci is particularly accurate in separating MCI from normal cognition and has shorter administration times, suggesting it is more useful in busy hospital clinics. This study reaffirms the high sensitivity of the MoCA but suggests a lower cut-off (<24) in this setting.

A Cross-Sectional Cohort Study of Cerebrovascular Disease and Late Effects After Radiation Therapy for Craniopharyngioma

BACKGROUND

The study objective was to describe radiation-induced vascular abnormalities, stroke prevalence, and stroke risk factors in survivors of childhood craniopharyngioma.

PROCEDURE

Twenty survivors of childhood craniopharyngioma who received radiotherapy (RT) were included in the study. A clinical history, quality of life assessment, cognitive functioning assessment, magnetic resonance angiogram or computed tomography angiogram, fasting lipid profile, and fasting glucose or hemoglobin A1c test were obtained.

RESULTS

Median age at diagnosis was 10.3 years and median age at time of study was 29.0 years. Vascular abnormalities were detected in six (32%) of 19 patients' angiograms (vascular stenosis, decreased artery size, aneurysm, cavernoma, and small vessel disease). Five (25%) of 20 patients experienced a stroke after RT. Median time since RT was 27.8 versus 9.1 years in patients with versus without vascular abnormalities (P = 0.02). A low level of high-density lipoproteiin (HDL) was present in 100% (5/5) of patients who had a post-RT stroke as compared with 13% (2/15) of patients who did not have any post-RT stroke (P = 0.02). Previous stroke had occurred in 0% (0/5) of patients receiving growth hormone (GH) replacement at the time of study, compared to 40% (6/15) of patients who were not receiving GH replacement (P = 0.09).

CONCLUSIONS

Patients with craniopharyngioma treated with RT have a high prevalence of stroke and vascular abnormalities, particularly those with low HDL and longer duration of time since RT. There is a trend to suggest that continual GH replacement may reduce the risk of stroke. These patients should undergo careful monitoring and aggressive modification of stroke risk factors.

Strengths and Limitations of the MoCA for Assessing Cognitive Functioning: Findings From a Large Representative Sample of Irish Older Adults

BACKGROUND

The Montreal Cognitive Assessment (MoCA) is a very widely used test for mild cognitive impairment. Differing recommendations have been made regarding its utility in providing a profile of performance across several cognitive domains.

OBJECTIVES

To examine the factor structure of the MoCA in a nationally representative population study of older Irish adults and evaluate its utility in providing domain-specific information.

METHODS

A cross-sectional analysis of wave 1 data from the Irish Longitudinal Study on Ageing was undertaken. Data from a subset of 2342 participants assessed using the MoCA were analyzed using both confirmatory factor analytic (CFA) and exploratory factor analytic (EFA) methods.

RESULTS

Mean age was 72.64 (range 65 to 98), 53% female. The CFA provided evidence of adequate overall model fit for a previously proposed 6-factor model. In contrast, EFA yielded a 3-factor solution and test items cross-loaded onto a number of factors with no clear pattern of underlying cognitive domains. Using EFA to explore the 6-factor model yielded good fit, but again test items cross-loaded onto a number of factors with no clear pattern evident.

CONCLUSION

Lack of concordance between the CFA and EFA findings demonstrates that the correspondence between individual tests and their assumed cognitive domains is not robust, reflecting at least in part a current lack of consensus on how core cognitive constructs are defined and on what subcomponents can be subsumed under different cognitive domains. The MoCA should not be viewed as a substitute for more in-depth neuropsychological assessment when domain-specific information is required.

Cognitive screening in brain tumors: short but sensitive enough?

Cognitive deficits in brain tumors are generally thought to be relatively mild and non-specific, although recent evidence challenges this notion. One possibility is that cognitive screening tools are being used to assess cognitive functions but their sensitivity to detect cognitive impairment may be limited. For improved sensitivity to recognize mild and/or focal cognitive deficits in brain tumors, neuropsychological evaluation tailored to detect specific impairments has been thought crucial. This study investigates the sensitivity of a cognitive screening tool, the Montreal Cognitive Assessment (MoCA), compared to a brief but tailored cognitive assessment (CA) for identifying cognitive deficits in an unselected primary brain tumor sample (i.e., low/high-grade gliomas, meningiomas). Performance is compared on broad measures of impairment: (a) number of patients impaired on the global screening measure or in any cognitive domain; and (b) number of cognitive domains impaired and specific analyses of MoCA-Intact and MoCA-Impaired patients on specific cognitive tests. The MoCA-Impaired group obtained lower naming and word fluency scores than the MoCA-Intact group, but otherwise performed comparably on cognitive tests. Overall, based on our results from patients with brain tumor, the MoCA has extremely poor sensitivity for detecting cognitive impairments and a brief but tailored CA is necessary. These findings will be discussed in relation to broader issues for clinical management and planning, as well as specific considerations for neuropsychological assessment of brain tumor patients.

Cognitive changes associated with central nervous system malignancies and treatment

OBJECTIVES

To review the cognitive changes associated with infiltrative, malignant brain tumors and treatments for brain tumors.

DATA SOURCE

Review of journal articles and textbooks.

CONCLUSION

Improvements in surgical, radiation, and medical therapies for central nervous system malignancies have resulted in increased patient survival. However, an increase in cognitive decline also has been associated with the presence of tumor and with tumor treatment modalities. Consequently, a negative impact on quality of life, as well as additional stress on caregivers occurs.

IMPLICATIONS FOR NURSING PRACTICE

The role of the neuro-oncology nurse is to assist in identifying cognitive impairments in patients with central nervous system malignancies, and to aid in promoting strategies for improved quality of life for patients and their caregivers. The long-term goal for the neuro-oncology community is to further improve treatments, to minimize side effects and, ultimately, to reduce the cognitive sequelae of these tumors and their treatments.

Cognitive and neuropsychiatric impairment in cerebral radionecrosis patients after radiotherapy of nasopharyngeal carcinoma

Background

We sought to characterize the cognitive function and neuropsychiatric symptoms in cerebral radionecrosis (CRN) patients who have received conformal radiation for nasopharyngeal carcinoma.

Methods

A total of 40 patients treated with radiotherapy (RT) that developed CRN (RT + CRN), 40 patients treated with radiotherapy that did not have CRN (RT-No-CRN), and 36 newly diagnosed untreated nasopharyngeal carcinoma patients (No-RT) were recruited. The cognitive function and neuropsychiatric symptoms were evaluated with Montreal cognitive assessment (MoCA), the mini-mental state examination (MMSE), activity of daily living scale (ADL), neuropsychiatric inventory (NPI), Hamilton depression scale (HAMD) and Hamilton anxiety scale (HAMA).

Results

The RT + CRN group had the lowest mean MMSE, MoCA and ADL scores, while highest mean NPI, HAMD and HAMA scores among the three patient groups (P < 0.05). Thirty (75%) of the RT + CRN patients were deemed cognitively impaired by the MoCA compared with 9 (22.5%) by the MMSE (χ² = 22.064; P < 0.001). Eighty-two percents of subject in RT + CRN group experienced neuropsychiatric symptoms within the past 4 weeks. Irritability, anxiety, depression and agitation in the RT + CRN group were of the most significantly frequent among the 3 groups.

Conclusions

The CRN patients generally have manifestations in cognitive and psychological impairment, which have their typical characteristics, and should be considered in CRN treatment and rehabilitation. The MoCA classifies more CRN patients as cognitively impaired than the MMSE, justifying further studies of the MoCA as an appropriate screen for CRN.

Canadian academy of geriatric psychiatry survey of brief cognitive screening instruments

Background

The use of brief cognitive screening instruments is essential in the assessment of dementia. The purpose of this study is to determine the frequency of use and perceived characteristics of cognitive screening instruments among Canadian psychogeriatric clinicians.

Methods

Members of the Canadian Academy of Geriatric Psychiatry (CAGP) and attendees to the 2010 Annual Scientific Meeting were asked to complete a computerized survey. This survey assessed the perceived characteristics and frequency of use of 14 instruments.

Results

The survey had a 55% response rate, with a total of 155 respondents. The most commonly used instruments are the Clock Drawing Test (CDT), Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), and Delayed Word Recall. Effectiveness, ease of administration, and speed of administration were the perceived characteristics of instruments most correlated with frequency of use.

Conclusions

Consistent with previous surveys, a small number of cognitive screening instruments are used by the majority of clinicians. Use of the CDT and the MMSE were comparable. To our knowledge, this is the first survey demonstrating that the MMSE is not the most commonly used tool, and other, newer instruments like the MoCA, are gaining prominence.

Limitations for interpreting failure on individual subtests of the Montreal Cognitive Assessment

BACKGROUND

The Montreal Cognitive Assessment (MoCA) is sensitive to mild forms of cognitive impairment in geriatric populations and asks questions under the subheadings visuospatial/executive, naming, attention, language, abstraction, delayed recall, and orientation. This study examined the extent to which these subsets of MoCA items evaluate their intended cognitive domains.

METHODS

Clinical data from 185 geriatric memory clinic outpatients who underwent cognitive screening and subsequent neuropsychological assessment were analyzed. Factor analysis of their neuropsychological test scores identified 5 cognitive domains memory, language, visuospatial ability, attention/processing speed, and cognitive control. Scores on MoCA subtests were examined for their correlations with individual factor scores and for their sensitivity and specificity in predicting impairment within each domain.

RESULTS

The MoCA subtest scores correlated significantly but modestly with neuropsychological test factor scores in their corresponding domains, for example, the correlation between 5-word recall and the memory factor was 0.46. However, subtest scores were poor predictors of impaired performance on the tests contributing to each cognitive domain. The best predictive accuracy was seen for the visuospatial/executive subtest that showed fair accuracy at predicting impairment on tests in the visuospatial domain. Other subtests showed unacceptably poor levels of accuracy when predicting impaired scores in their respective domains (60%-67%).

CONCLUSIONS

In a sample of geriatric outpatients referred for cognitive assessment, performance on individual items and subtests of the MoCA yields insufficient information to draw conclusions about impairment in specific cognitive domains as determined by neuropsychological testing.

Determining an appropriate cutting score for indication of impairment on the Montreal Cognitive Assessment

OBJECTIVE/METHODS

The Montreal Cognitive Assessment (MoCA) is a brief yet comprehensive cognitive instrument used to assess level of impairment in neurological populations. The purpose of the present study was to assess the ability of the MoCA to detect cognitive impairment in a veteran patient population referred for neuropsychological testing and to determine optimal cutoff scores on the MoCA when compared with widely used neuropsychological measures.

RESULTS

Using receiver operator characteristic (ROC) analyses, the findings indicate that the optimal cutoff score to detect impairment (i.e., ≤ 20) in the present sample was notably lower than that suggested by others.

CONCLUSIONS

Use of the previously suggested cut score of <26 may overpathologize neurologically intact individuals. Further research utilizing ROC curve analysis should be conducted to establish appropriate cutoff scores for various populations which may differ from the present sample.