Using Informant and Performance Screening Methods to Detect Mild Cognitive Impairment and Dementia

Validation and extension of the quick dementia rating system (QDRS)

Informant report dementia severity staging measures, such as the Quick Dementia Rating System (QDRS) offer clinicians useful diagnostic and staging information. These measures also potentially avoid many of the pitfalls inherent in mental status examinations (e.g., cultural bias, educational bias, floor and ceiling effects). We derive cut points for the QDRS and comprehensively examine their classification accuracy in a large, diagnostically heterogeneous, rural, memory disorder clinic sample. Our findings suggest the QDRS may be helpful when used in the context of a comprehensive diagnostic and staging evaluation. When used in isolation, the QDRS is insufficiently accurate for diagnosis and staging of dementia.

Combining the AD8 and MMSE for community-based dementia screening

BACKGROUND

This study aimed to determine whether a cognitive test the Mini-Mental State Examination (MMSE) and the Ascertain Dementia 8 (AD8) instrument applied in combination could improve the accuracy of dementia detection in a community setting.

METHODS

Study participants were recruited from a community-based integrated screening program in Tainan, Taiwan. Participants completed the AD8 and were administered the Chinese version of the MMSE by psychologists. In addition, the presence of dementia was determined by neurologists based on the 2011 National Institute on Aging-Alzheimer's Association guidelines. Logistic regression analysis determined whether the combination of these two tests provided any additional information for dementia detection than either test alone. Receiver operating characteristic (ROC) curve analyses were conducted to explore the performances of different screening modalities in detecting dementia.

RESULT

In total, 282 participants with an average age of 69.31 ± 10.27 years were enrolled. The prevalence of dementia among participants aged ≥65 years was 9.29 %. The sensitivity and specificity of the AD8 applied alone for detecting dementia were 64.71 % and 87.89 %, respectively, and of the MMSE applied alone, after adjusting for education level, were 41.18 % and 84.50 %, respectively. Using a cutoff score of 21 for the MMSE resulted in sensitivity of 77.78 % and specificity of 73.58 %. The AD8 and MMSE when combined in parallel yielded 88.89 % sensitivity and 70.16 % specificity. The serial use of the AD8 followed by the MMSE yielded 50 % sensitivity and 93.02 % specificity. Except for when an MMSE cutoff value of 26 was applied, the sensitivity of all examined modalities was poor and specificity was moderate for detecting mild cognitive impairment. ROC curve analysis revealed that the parallel application of the MMSE and AD8 (area under the ROC curve [AUC]: 82.3 % [75.1 %-89.4 %]) resulted in better dementia detection accuracy than the AD8 alone (AUC: 73.3 % [60.7 %-85.9 %]), the MMSE alone (AUC: 77.4 % [67.6 %-87.3 %]), or serial test administration (AUC: 67.6 % [53.4 %-81.8 %]).

CONCLUSION

This study successfully demonstrated that the MMSE and AD8 combination for dementia screening could improve detection accuracy in a community setting.

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study

BACKGROUND

Cognitive impairment after stroke is common and is present in up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of 2 stroke severity ratings and a caregiver-report of poststroke functioning with longitudinal cognitive outcomes.

METHODS AND RESULTS

One hundred fifty-seven caregivers and stroke survivor dyads participated in the CARES (Caring for Adults Recovering From the Effects of Stroke) project, an ancillary study of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) national cohort study. The Glasgow Outcome Scale and modified Rankin Scale scores collected at hospitalization discharge were included as 2 primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at 9 months following stroke were included as a third predictor. Cognition was measured using a biennial telephone battery and included the domains of learning, memory, and executive functioning. Multiple cognitive assessments were analyzed up to 5 years poststroke, controlling for prestroke cognition and demographic variables of the stroke survivor. Separate mixed models showed significant main effects of the Glasgow Outcome Scale (b=0.3380 [95% CI, 0.14-0.5]; P=0.0009), modified Rankin Scale (b=-0.2119 [95% CI, -0.32 to -0.10]; P=0.0002), and caregiver-reported problems (b=-0.0671 [95% CI, -0.09 to -0.04]; P<0.0001) on longitudinal cognitive scores. In a combined model including all 3 predictors, only caregiver-reported problems significantly predicted cognition (b=-0.0480 [95% CI, -0.08 to -0.03]; P<0.0001).

CONCLUSIONS

These findings emphasize the importance of caregiver feedback in predicting cognitive consequences of stroke.

Sex-based dyad differences on informant reports of participants' daily functioning

Functional assessment in neurocognitive evaluation is often provided via informant reports. These subjective reports can vary based on the characteristics of informants and their relationships with participants, such as informant sex. However, whether informant sex intersects with participant sex to impact subjective ratings of participants' daily functioning, and whether such effects mirror observed patterns in neuropsychological performance, has not been adequately examined with ethnoracially diverse samples. We examined differences among participant-informant sex-based dyads on subjective informant reports of participants' daily functioning (assessed via the Functional Activities Questionnaire [FAQ]), and whether any observed differences on reported functioning corresponded to differences in objective participant performance on neuropsychological performance, among middle-aged and older Hispanic/Latino (n = 543), non-Hispanic Black (NHB; n = 1030), and non-Hispanic White (NHW; n = 5356) adults in the National Alzheimer's Coordinating Center cohort (n = 6929). Analysis of covariance (ANCOVA) tests revealed significant dyad differences on FAQ scores in the NHB (p<.001) and NHW subsamples (p<.05), but not in the Hispanic/Latino subsample (p>.05). For the Hispanic/Latino and NHB subsamples, ANCOVA tests revealed no significant effects of dyad on neuropsychological performance (ps>.01), whereas for the NHW subsample, ANCOVA tests revealed significant dyad differences on performance in multiple cognitive domains (ps<.01). Nevertheless, the pattern of dyad differences on neuropsychological performance did not mirror the pattern of observed differences on FAQ scores in the NHW subsample. Findings and their implications, including potential contributions of other informant characteristics on observed dyad differences on reported functioning, are discussed.

Informant sex/gender moderates associations between reported functioning and memory performance in Mexican American adults

Objective: In neuropsychological evaluations, assessing cognitive functioning is often achieved using objective neuropsychological measures, whereas subjective informant reports are typically obtained to determine manifest daily functioning. Informant reports of participant functioning and their associations with objective participant performance on neuropsychological testing have been shown to vary based on informant characteristics. However, associations among informant characteristics, reported functioning, and neuropsychological performance have not been adequately examined with Mexican American or other Hispanic/Latino samples, despite these populations' disproportionately higher rates of dementia due to Alzheimer's disease and related disorders. Method: We examined associations of informant characteristics with informant reports of participant functioning (assessed via the Functional Activities Questionnaire [FAQ]), and potential moderating effects of these characteristics on associations between reported functioning and participant performance on neuropsychological testing, for Mexican American adult participants in the National Alzheimer's Coordinating Center cohort (n = 294). Results: Female informants reported significantly worse participant functioning compared to male informants (p = .035, r = .126). Moreover, significant associations between reported functioning and memory performance were observed for participants with female informants, but not for those with male informants (p = .024, r = .138). Higher levels of informant education were associated with significantly worse participant functioning (p = .011, r = .151). However, informant education did not moderate associations between reported functioning and neuropsychological performance (ps > .05). Conclusions: Compared to male informants, female informants may provide subjective reports of Mexican American participant functioning that more closely corroborate objective participant performance in memory.

Cognitive Assessment with Cognivue Clarity®: Psychometric Properties and Normative Ranges in a Diverse Population

Background

Detecting cognitive impairment in clinical practice is challenging as most instruments do not perform well in diverse samples of older adults. These same instruments are often used for eligibility into clinical trials making it difficult to recruit minoritized adults into Alzheimer's disease (AD) studies. Cognivue Clarity® is an FDA-cleared computerized 10-minute cognitive screening platform using adaptive psychophysics to detect cognitive impairment.

Objective

Test the ability of Cognivue Clarity to measure cognitive performance in a diverse community sample compared with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

Methods

This study enrolled 452 participants across 6 US study sites and completed both Cognivue Clarity device and RBANS. Psychometric properties and exploratory factor analysis of Cognivue Clarity were explored and comparisons against RBANS across different age, sex, education, and ethnoracial groups were conducted.

Results

Participants had a mean age of 47.9±16.1 years (range: 18-85), 63.6% were female, 45.9% had ≤12 years of education, 31.2% were African American and 9.2% were Hispanic. Cognivue Clarity had strong internal consistency, test-retest reliability and minimal practice effects. A 4-factor structure (Memory, Attention, Visuomotor, and Discrimination) had excellent goodness-of-fit. Normalizing age effects improved performance. Race and education effects were similar to those seen with RBANS. Cognivue Clarity had strong correlations with RBANS.

Conclusions

Our study supports the use of Cognivue Clarity as an easy-to-use, brief, and valid cognitive assessment that measures cognitive performance. In the correct clinical setting, Cognivue Clarity may identify individuals with likely cognitive impairment who could be candidates for AD research studies.

Evaluating Cognitive Impairment in a Large Health Care System: The Cognition in Primary Care Program

Background

The prevalence of Alzheimer's disease and related disorders (ADRD) is rising. Primary care providers (PCPs) will increasingly be required to play a role in its detection but lack the training to do so.

Objective

To develop a model for cognitive evaluation which is feasible in primary care and evaluate its implementation in a large health system.

Methods

The Cognition in Primary Care Program consists of web-based training together with integrated tools built into the electronic record. We implemented the program among PCPs at 14 clinics in a large health system. We (1) surveyed PCPs to assess the impact of training on their confidence to evaluate cognition, (2) measured the number of cognitive assessments they performed, and (3) tracked the number of patients diagnosed with mild cognitive impairment (MCI).

Results

Thirty-nine PCPs completed the training which covered how to evaluate cognition. Survey response rate from those PCPs was 74%. Six months after the end of the training, they reported confidence in assessing cognition (mean 4.6 on 5-point scale). Cognitive assessments documented in the health record increased from 0.8 per month before the training to 2.5 in the six months after the training. Patients who were newly diagnosed with MCI increased from 4.2 per month before the training to 6.0 per month in the six months after the training.

Conclusions

This model for cognitive evaluation in a large health system was shown to increase cognitive testing and increase diagnoses of MCI. Such improvements are essential for the timely detection of ADRD.

Multimodal magnetic resonance scans of patients with mild cognitive impairment

The advancement of neuroimaging technology offers a pivotal reference for the early detection of mild cognitive impairment (MCI), a significant area of focus in contemporary cognitive function research. Structural MRI scans present visual and quantitative manifestations of alterations in brain tissue, whereas functional MRI scans depict the metabolic and functional state of brain tissues from diverse perspectives. As various magnetic resonance techniques possess both strengths and constraints, this review examines the methodologies and outcomes of multimodal magnetic resonance technology in MCI diagnosis, laying the groundwork for subsequent diagnostic and therapeutic interventions for MCI.

The Early Diagnosis of Alzheimer's Disease: A Patient-Centred Conversation with the Care Team

Alzheimer's disease (AD) is a neurodegenerative disorder which accounts for 60-80% of dementia cases, affecting approximately 10 million people in Europe. Neuroimaging techniques and cerebrospinal fluid biomarkers used in combination with cognitive assessment tools open the door to early diagnosis of AD. However, these tools present some challenges that need to be overcome, such as low sensitivity or specificity, high cost, limited availability or invasiveness. Thus, low-cost and non-invasive alternatives, such as plasma biomarkers, have the potential to drive changes in AD screening and diagnosis. In addition to the technical aspects, organisational challenges as well as ethical concerns need to be addressed. In many countries, there is an insufficient number of specialists to recognise, evaluate and diagnose dementia and the waiting times to see a specialist are long. Given that there is currently no cure for AD, it is important to consider the potential psychological impact of an early diagnosis. In addition, counselling before biomarker sampling and during diagnosis disclosure is vital to guarantee that the patients have all the information necessary and their queries are addressed in a sensitive manner. Here, we illustrate (using a clinical vignette) current challenges of diagnosis and discuss some of the benefits and challenges of early diagnosis in AD including the value of biomarkers in combination with clinical evaluation. Lastly, some guidelines for disclosing early diagnosis of AD are provided based on our experiences.

Hierarchical Two-Stage Cost-Sensitive Clinical Decision Support System for Screening Prodromal Alzheimer's Disease and Related Dementias

BACKGROUND

The detection of subtle cognitive impairment in a clinical setting is difficult. Because time is a key factor in small clinics and research sites, the brief cognitive assessments that are relied upon often misclassify patients with very mild impairment as normal.

OBJECTIVE

In this study, we seek to identify a parsimonious screening tool in one stage, followed by additional assessments in an optional second stage if additional specificity is desired, tested using a machine learning algorithm capable of being integrated into a clinical decision support system.

METHODS

The best primary stage incorporated measures of short-term memory, executive and visuospatial functioning, and self-reported memory and daily living questions, with a total time of 5 minutes. The best secondary stage incorporated a measure of neurobiology as well as additional cognitive assessment and brief informant report questionnaires, totaling 30 minutes including delayed recall. Combined performance was evaluated using 25 sets of models, trained on 1,181 ADNI participants and tested on 127 patients from a memory clinic.

RESULTS

The 5-minute primary stage was highly sensitive (96.5%) but lacked specificity (34.1%), with an AUC of 87.5% and diagnostic odds ratio of 14.3. The optional secondary stage increased specificity to 58.6%, resulting in an overall AUC of 89.7% using the best model combination of logistic regression and gradient-boosted machine.

CONCLUSION

The primary stage is brief and effective at screening, with the optional two-stage technique further increasing specificity. The hierarchical two-stage technique exhibited similar accuracy but with reduced costs compared to the more common single-stage paradigm.

Digital detection of dementia (D3): a study protocol for a pragmatic cluster-randomized trial examining the application of patient-reported outcomes and passive clinical decision support systems

BACKGROUND

Early detection of Alzheimer's disease and related dementias (ADRD) in a primary care setting is challenging due to time constraints and stigma. The implementation of scalable, sustainable, and patient-driven processes may improve early detection of ADRD; however, there are competing approaches; information may be obtained either directly from a patient (e.g., through a questionnaire) or passively using electronic health record (EHR) data. In this study, we aim to identify the benefit of a combined approach using a pragmatic cluster-randomized clinical trial.

METHODS

We have developed a Passive Digital Marker (PDM), based on machine learning algorithms applied to EHR data, and paired it with a patient-reported outcome (the Quick Dementia Rating Scale or QDRS) to rapidly share an identified risk of impairment to a patient's physician. Clinics in both south Florida and Indiana will be randomly assigned to one of three study arms: 1200 patients in each of the two populations will be administered either the PDM, the PDM with the QDRS, or neither, for a total of 7200 patients across all clinics and populations. Both incidence of ADRD diagnosis and acceptance into ADRD diagnostic work-up regimens is hypothesized to increase when patients are administered both the PDM and QDRS. Physicians performing the work-up regimens will be blind to the study arm of the patient.

DISCUSSION

This study aims to test the accuracy and effectiveness of the two scalable approaches (PDM and QDRS) for the early detection of ADRD among older adults attending primary care practices. The data obtained in this study may lead to national early detection and management program for ADRD as an efficient and beneficial method of reducing the current and future burden of ADRD, as well as improving the annual rate of newly documented ADRD in primary care practices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05231954 . Registered February 9, 2022.

Identification of Major Cognitive Disorders in Self-Reported versus Administrative Health Data: A Cohort Study in Quebec

BACKGROUND

The first imperative in producing the relevant and needed knowledge about major neurocognitive disorder (MNCD) is to identify people presenting with the condition adequately. To document potential disparities between administrative health databases and population-based surveys could help identify specific challenges in this population and methodological shortfalls.

OBJECTIVE

To describe and compare the characteristics of community-dwelling older adults according to four groups: 1) No MNCD; 2) Self-reported MNCD only; 3) MNCD in administrative health data only; 4) MNCD in both self-reported and administrative health data.

METHODS

This retrospective cohort study used the Care Trajectories-Enriched Data (TorSaDE) cohort, a linkage between five waves of the Canadian Community Health Survey (CCHS) and health administrative health data. We included older adults living in the community who participated in at least one cycle of the CCHS. We reported on positive and negative MNCD in self-reported versus administrative health data. We then compared groups' characteristics using chi-square tests and ANOVA.

RESULTS

The study cohort was composed of 25,125 older adults, of which 784 (3.12%) had MNCD. About 70% of people with an MNCD identified in administrative health data did not report it in the CCHS. The four groups present specific challenges related to the importance of perception, timely diagnosis, and the caregivers' roles in reporting health information.

CONCLUSION

To a certain degree, both data sources fail to consider subgroups experiencing issues related to MNCD; studies like ours provide insight to understand their characteristics and needs better.

The Brain Health Platform: Combining Resilience, Vulnerability, and Performance to Assess Brain Health and Risk of Alzheimer's Disease and Related Disorders

BACKGROUND

It is difficult to assess brain health status and risk of cognitive impairment, particularly at the initial evaluation. To address this, we developed the Brain Health Platform to quantify brain health and identify Alzheimer's disease and related disorders (ADRD) risk factors by combining a measure of brain health: the Resilience Index (RI), a measure of risk of ADRD; the Vulnerability Index (VI); and the Number-Symbol Coding Task (NSCT), a measure of brain performance.

OBJECTIVE

The Brain Health Platform is intended to be easily and quickly administered, providing an overview of a patient's risk of developing future impairment based on modifiable and non-modifiable factors as well as current cognitive performance.

METHODS

This cross-sectional study comprehensively evaluated 230 participants (71 controls, 71 mild cognitive impairment, 88 ADRD). VI and RI scores were derived from physical assessments, lifestyle questionnaires, demographics, medical history, and neuropsychological examination including the NSCT.

RESULTS

Individuals with abnormal scores were 95.7% likely to be impaired, with a misclassification rate of 9.7%. The combined model had excellent discrimination (AUC:0.923±0.053; p < 0.001), performing better than the Montreal Cognitive Assessment.

CONCLUSION

The Brain Health Platform combines measures of resilience, vulnerability, and performance to provide a cross-sectional snapshot of overall brain health. The Brain Health Platform can effectively and accurately identify even the very mildest impairments due to ADRD, leveraging brief yet powerful and actionable indices of brain health and risk that could be used to develop personalized, precision medicine-like interventions.

Informant report of practical judgment ability in a clinical sample of older adults with subjective cognitive decline, mild cognitive impairment, and dementia

Despite the importance of capturing problems with judgment and decision-making during neuropsychological evaluations of older adults, there are a limited number of validated measures and no informant rating scales. We developed an informant measure that captures compromised judgment related to safety, medical, financial, and social-ethical issues After item refinement and piloting in a memory disorders clinic, we utilized the Test of Practical Judgment-Informant (TOP-J-Informant) at two clinics in the Midwestern U.S., including 189 patient/informant dyads (mean age = 79.0, median years of education = 13, % female = 67.7) with various preclinical and clinical dementia conditions. We found psychometric support, including evidence for convergent, divergent, and criterion-related validity, and internal consistency. Importantly, we were able to discriminate between diagnostic groups in the expected direction. The TOP-J-Informant is brief (<5 minutes), easy to administer, and can reveal areas of concern related to poor judgment when administered in the context of a neuropsychological evaluation or clinic visit.

Validation of AD8-Philippines (AD8-P): A Brief Informant-Based Questionnaire for Dementia Screening in the Philippines

AIM

This study was aimed at validating the Filipino version of AD8 (AD8-P).

METHODS

Community-dwelling Filipino older persons aged ≥60 years, together with their informants, participated in this study. Psychologists independently interviewed the informants with AD8-P and administered the Filipino-validated Mini-Mental State Examination (MMSE-P) and Montreal Cognitive Assessment (MoCA-P) to the older persons. Neurologists and geriatrician conducted physical and neurological examination and Clinical Dementia Rating™ (CDR™) to determine cognitive diagnosis and were blinded with the results of AD8-P. Dementia was diagnosed based on DSM-IV-TR criteria. AD8-P discriminatory ability to screen for dementia was evaluated according to DSM-IV-TR diagnostic criteria for dementia.

RESULTS

A total of 366 community-dwelling Filipino older persons aged ≥60 years, 213 with normal cognition and 153 with dementia, and their informants were included in this study. Majority (90%) were at the mildest stage of dementia. Area under the receiver-operating-characteristic curve (AUROC) for AD8-P was 0.94 (95% CI 0.92 to 0.96), demonstrating excellent overall predictive power to screen for dementia. The optimal AD8-P cut-off score with best balance sensitivity (91.5%) and specificity (77.9%) was ≥3.

CONCLUSION

AD8-P demonstrated good psychometric properties to screen for dementia, even at the earliest stage of cognitive decline.

Self-Reported Cognitive Decline Based on the Ascertain Dementia 8 Questionnaire May Be Effective for Detecting Mild Cognitive Impairment and Dementia in the Community: The Wakuya Project

Introduction

To assess cognitive impairment, self-awareness is an important issue. The Ascertain Dementia 8 questionnaire (AD8) is a brief observation checklist for detecting mild cognitive impairment (MCI) and dementia. After analyzing the reliability and validity of a self-reported Japanese version of the AD8 (AD8-J), we compared self- and informant-reported versions of the AD8-J.

Methods

A total of 93 community residents aged 75 years or older living in Wakuya, Northern Japan, agreed to participate in this study; 35 were rated as Clinical Dementia Rating (CDR) 0 (healthy), 46 as CDR 0.5 (defined herein as MCI), and 12 as CDR 1 or above (dementia, confirmed by the DSM-IV). We examined the reliability and validity using a receiver operating characteristic (ROC) curve. We analyzed the differences between self-reported and informant-reported AD8-J using a repeated measures ANOVA.

Results

The self-reported AD8-J showed a satisfactory reliability (i.e., Cronbach coefficient, α = 0.71; Guttman split half method coefficient = 0.60). For CDR 0 vs. CDR 0.5 or above, the area under the ROC curve was 0.74 and the cutoff score was 1/2, with a sensitivity of 70.7% and a specificity of 65.7%. Analysis of the subscores of AD8 suggested that, from the early stage of dementia, the subjects showed a subjective decline in memory and interest in hobbies/activities, as well as problems with judgment.

Conclusion

It is suggested that the self-reported AD8-J was effective in detecting MCI and dementia. We could use it for detecting MCI and dementia, including in those living alone, in the primary health checkup.

Screening for Early-Stage Alzheimer's Disease Using Optimized Feature Sets and Machine Learning

BACKGROUND

Detecting early-stage Alzheimer's disease in clinical practice is difficult due to a lack of efficient and easily administered cognitive assessments that are sensitive to very mild impairment, a likely contributor to the high rate of undetected dementia.

OBJECTIVE

We aim to identify groups of cognitive assessment features optimized for detecting mild impairment that may be used to improve routine screening. We also compare the efficacy of classifying impairment using either a two-class (impaired versus non-impaired) or three-class using the Clinical Dementia Rating (CDR 0 versus CDR 0.5 versus CDR 1) approach.

METHODS

Supervised feature selection methods generated groups of cognitive measurements targeting impairment defined at CDR 0.5 and above. Random forest classifiers then generated predictions of impairment for each group using highly stochastic cross-validation, with group outputs examined using general linear models.

RESULTS

The strategy of combining impairment levels for two-class classification resulted in significantly higher sensitivities and negative predictive values, two metrics useful in clinical screening, compared to the three-class approach. Four features (delayed WAIS Logical Memory, trail-making, patient and informant memory questions), totaling about 15 minutes of testing time (∼30 minutes with delay), enabled classification sensitivity of 94.53% (88.43% positive predictive value, PPV). The addition of four more features significantly increased sensitivity to 95.18% (88.77% PPV) when added to the model as a second classifier.

CONCLUSION

The high detection rate paired with the minimal assessment time of the four identified features may act as an effective starting point for developing screening protocols targeting cognitive impairment defined at CDR 0.5 and above.

A Modified CAIDE Risk Score as a Screening Tool for Cognitive Impairment in Older Adults

BACKGROUND

Although an efficacious dementia-risk score system, Cardiovascular Risk Factors, Aging, and Dementia (CAIDE) was derived using midlife risk factors in a population with low educational attainment that does not reflect today's US population, and requires laboratory biomarkers, which are not always available.

OBJECTIVE

Develop and validate a modified CAIDE (mCAIDE) system and test its ability to predict presence, severity, and etiology of cognitive impairment in older adults.

METHODS

Population consisted of 449 participants in dementia research (N = 230; community sample; 67.9±10.0 years old, 29.6%male, 13.7±4.1 years education) or receiving dementia clinical services (N = 219; clinical sample; 74.3±9.8 years old, 50.2%male, 15.5±2.6 years education). The mCAIDE, which includes self-reported and performance-based rather than blood-derived measures, was developed in the community sample and tested in the independent clinical sample. Validity against Framingham, Hachinski, and CAIDE risk scores was assessed.

RESULTS

Higher mCAIDE quartiles were associated with lower performance on global and domain-specific cognitive tests. Each one-point increase in mCAIDE increased the odds of mild cognitive impairment (MCI) by up to 65%, those of AD by 69%, and those for non-AD dementia by > 85%, with highest scores in cases with vascular etiologies. Being in the highest mCAIDE risk group improved ability to discriminate dementia from MCI and controls and MCI from controls, with a cut-off of ≥7 points offering the highest sensitivity, specificity, and positive and negative predictive values.

CONCLUSION

mCAIDE is a robust indicator of cognitive impairment in community-dwelling seniors, which can discriminate well between dementia severity including MCI versus controls. The mCAIDE may be a valuable tool for case ascertainment in research studies, helping flag primary care patients for cognitive testing, and identify those in need of lifestyle interventions for symptomatic control.

The Resilience Index: A Quantifiable Measure of Brain Health and Risk of Cognitive Impairment and Dementia

BACKGROUND

There is increasing interest in lifestyle modification and integrative medicine approaches to treat and/or prevent mild cognitive impairment (MCI) and Alzheimer's disease and related dementias (ADRD).

OBJECTIVE

To address the need for a quantifiable measure of brain health, we created the Resilience Index (RI).

METHODS

This cross-sectional study analyzed 241 participants undergoing a comprehensive evaluation including the Clinical Dementia Rating and neuropsychological testing. Six lifestyle factors including physical activity, cognitive activity, social engagements, dietary patterns, mindfulness, and cognitive reserve were combined to derive the RI (possible range of scores: 1-378). Psychometric properties were determined.

RESULTS

The participants (39 controls, 75 MCI, 127 ADRD) had a mean age of 74.6±9.5 years and a mean education of 15.8±2.6 years. The mean RI score was 138.2±35.6. The RI provided estimates of resilience across participant characteristics, cognitive staging, and ADRD etiologies. The RI showed moderate-to-strong correlations with clinical and cognitive measures and very good discrimination (AUC: 0.836; 95% CI: 0.774-0.897) between individuals with and without cognitive impairment (diagnostic odds ratio = 8.9). Individuals with high RI scores (> 143) had better cognitive, functional, and behavioral ratings than individuals with low RI scores. Within group analyses supported that controls, MCI, and mild ADRD cases with high RI had better cognitive, functional, and global outcomes than those with low RI.

CONCLUSION

The RI is a brief, easy to administer, score and interpret assessment of brain health that incorporates six modifiable protective factors. Results from the RI could provide clinicians and researchers with a guide to develop personalized prevention plans to support brain health.

Overcoming the COVID-19 Pandemic for Dementia Research: Engaging Rural, Older, Racially and Ethnically Diverse Church Attendees in Remote Recruitment, Intervention and Assessment

BACKGROUND

Access to cognitive screening in rural underserved communities is limited and was further diminished during the COVID-19 pandemic. We examined whether a telephone-based cognitive screening intervention would be effective in increasing ADRD knowledge, detecting the need for further cognitive evaluation, and making and tracking the results of referrals.

METHOD

Using a dependent t-test design, older, largely African American and Afro-Caribbean participants completed a brief educational intervention, pre/post AD knowledge measure, and cognitive screening.

RESULTS

Sixty of 85 eligible individuals consented. Seventy-percent of the sample self-reported as African American, Haitian Creole, or Hispanic, and 75% were female, with an average age of 70. AD knowledge pre-post scores improved significantly (t (49) = -3.4, p < .001). Of the 11 referred after positive cognitive screening, 72% completed follow-up with their provider. Five were newly diagnosed with dementia. Three reported no change in diagnosis or treatment. Ninety-percent consented to enrolling in a registry for future research.

CONCLUSION

Remote engagement is feasible for recruiting, educating, and conducting cognitive screening with rural older adults during a pandemic.

Using Optical Coherence Tomography to Screen for Cognitive Impairment and Dementia

BACKGROUND

Screening for Alzheimer's disease and related disorders (ADRD) and mild cognitive impairment (MCI) could increase case identification, enhance clinical trial enrollment, and enable early intervention. MCI and ADRD screening would be most beneficial if detection measures reflect neurodegenerative changes. Optical coherence tomography (OCT) could be a marker of neurodegeneration (part of the amyloid-tau-neurodegeneration (ATN) framework).

OBJECTIVE

To determine whether OCT measurements can be used as a screening measure to detect individuals with MCI and ADRD.

METHODS

A retrospective cross-sectional study was performed on 136 participants with comprehensive clinical, cognitive, functional, and behavioral evaluations including OCT with a subset (n = 76) completing volumetric MRI. Pearson correlation coefficients tested strength of association between OCT and outcome measures. Receiver operator characteristic curves assessed the ability of OCT, patient-reported outcomes, and cognitive performance measures to discriminate between individuals with and without cognitive impairment.

RESULTS

After controlling for age, of the 6 OCT measurements collected, granular cell layer-inner plexiform layer (GCL + IPL) thickness best correlated with memory, global cognitive performance, Clinical Dementia Rating, and hippocampal atrophy. GCL + IPL thickness provided good discrimination in cognitive status with a cut-off score of 75μm. Combining GCL + IPL thickness as a proxy marker for hippocampal atrophy with a brief patient-reported outcome and performance measure correctly classified 87%of MCI and ADRD participants.

CONCLUSION

Multimodal approaches may improve recognition of MCI and ADRD. OCT has the potential to be a practical, non-invasive biomarker for ADRD providing a screening platform to quickly identify at-risk individuals for further clinical evaluation or research enrollment.

The Number Symbol Coding Task: A brief measure of executive function to detect dementia and cognitive impairment

INTRODUCTION

Alzheimer's disease and related dementias (ADRD) affect over 5.7 million Americans and over 35 million people worldwide. Detection of mild cognitive impairment (MCI) and early ADRD is a challenge to clinicians and researchers. Brief assessment tools frequently emphasize memory impairment, however executive dysfunction may be one of the earliest signs of impairment. To address the need for a brief, easy-to-score, open-access test of executive function for use in clinical practice and research, we created the Number Symbol Coding Task (NSCT).

METHODS

This study analyzed 320 consecutive patient-caregiver dyads who underwent a comprehensive evaluation including the Clinical Dementia Rating (CDR), patient and caregiver versions of the Quick Dementia Rating System (QDRS), caregiver ratings of behavior and function, and neuropsychological testing, with a subset undergoing volumetric magnetic resonance imaging (MRI). Estimates of cognitive reserve were calculated using education, combined indices of education and occupation, and verbal IQ. Psychometric properties of the NSCT including data quality, data distribution, floor and ceiling effects, construct and known-groups validity, discriminability, and clinical profiles were determined.

RESULTS

The patients had a mean age of 75.3±9.2 years (range 38-98y) with a mean education of 15.7±2.8 years (range 6-26y) of education. The patients had a mean CDR-SB of 4.8±4.7 (range 0-18) and a mean MoCA score of 18.6±7.1 (range 1-30). The mean NSCT score was 30.1±13.8 and followed a normal distribution. All healthy controls and MCI cases were able to complete the NSCT. The NSCT showed moderate-to-strong correlations with clinical and neuropsychological measures with the strongest association (all p's < .001) for measures with executive components (e.g., Judgement and Problem Solving box of the CDR, Decision Making and Problem Solving domain of the QDRS, Trailmaking B, and Cognigram Attention and Executive Composite Scores). Women slightly outperformed men, and individuals with lower educational attainment and lower education-occupation indices had lower NSCT scores. Decreasing NSCT scores corresponded to older age, worse cognitive scores, higher CDR sum of boxes scores, worse caregiver ratings of function and behavior, worse patient and informant QDRS ratings, and smaller hippocampal volumes and hippocampal occupancy scores. The NSCT provided excellent discrimination (AUC: .866; 95% CI: .82-.91) with a cut-off score of 36 providing the best combination of sensitivity (0.880) and specificity (0.759). Combining the NSCT with patient QDRS and caregiver QDRS ratings improved discrimination (AUC: .908; 95% CI: .87-.94).

DISCUSSION

The NSCT is a brief, 90-second executive task that incorporates attention, planning and set-switching that can be completed by individuals into the moderate-to-severe stages of dementia. The NSCT may be a useful tool for dementia screening, case-ascertainment in epidemiological or community-based ADRD studies, and in busy primary care settings where time is limited. Combining the NSCT with a brief structured interview tool such as the QDRS may provide excellent power to detect cognitive impairment. The NSCT performed well in comparison to standardized scales of a comprehensive cognitive neurology evaluation across a wide array of sociodemographic variables in a brief fashion that could facilitate its use in clinical care and research.

The Quick Physical Activity Rating (QPAR) scale: A brief assessment of physical activity in older adults with and without cognitive impairment

INTRODUCTION

Alzheimer's disease and related dementias (ADRD) currently affect over 5.7 million Americans and over 35 million people worldwide. At the same time, over 31 million older adults are physically inactive with impaired physical performance interfering with activities of daily living. Low physical activity is a risk factor for ADRD. We examined the utility of a new measure, the Quick Physical Activities Rating (QPAR) as an informant-rated instrument to quantify the dosage of physical activities in healthy controls, MCI and ADRD compared with Gold Standard assessments of objective measures of physical performance, fitness, and functionality.

METHODS

This study analyzed 390 consecutive patient-caregiver dyads who underwent a comprehensive evaluation including the Clinical Dementia Rating (CDR), mood, neuropsychological testing, caregiver ratings of patient behavior and function, and a comprehensive physical performance and gait assessment. The QPAR was completed prior to the office visit and was not considered in the clinical evaluation, physical performance assessment, staging or diagnosis of the patient. Psychometric properties including item variability and distribution, floor and ceiling effects, strength of association, known-groups performance, and internal consistency were determined.

RESULTS

The patients had a mean age of 75.3±9.2 years, 15.7±2.8 years of education and were 46.9% female. The patients had a mean CDR-SB of 4.8±4.7 and a mean MoCA score of 18.6±7.1 and covered a range of healthy controls (CDR 0 = 54), MCI or very mild dementia (CDR 0.5 = 161), mild dementia (CDR 1 = 92), moderate dementia (CDR 2 = 64), and severe dementia (CDR 3 = 29). The mean QPAR score was 20.2±18.9 (range 0-132) covering a wide range of physical activity. The QPAR internal consistency (Cronbach alpha) was very good at 0.747. The QPAR was correlated with measures of physical performance (dexterity, grip strength, gait, mobility), physical functionality rating scales, measures of activities of daily living and comorbidities, the UPDRS, and frailty ratings (all p < .001). The QPAR report of physical activities was able to discriminate between individuals with impaired physical functionality (32.2±23.9 vs 15.2±13.8, p < .001), falls risk (28.4±21.6 vs. 14.5±13.2, p < .001), and the presence of frailty (28.1±22.7 vs. 11.8±9.4, p < .001). The QPAR showed strong psychometric properties and excellent data quality, and worked equally well across different patient ages, sexes, informant relationships, and in individuals with and without cognitive impairment.

DISCUSSION

The QPAR is a brief detection tool that captures informant reports of physical activities and differentiates individuals with normal physical functionality from those individuals with impaired physical functionality. The QPAR correlated with Gold Standard assessments of strength and sarcopenia, activities of daily living, gait and mobility, fitness, health related quality of life, frailty, global physical performance, and provided good discrimination between states of physical functionality, falls risk, and frailty. The QPAR performed well in comparison to standardized scales of objective physical performance, but in a brief fashion that could facilitate its use in clinical care and research.

Using a patient-reported outcome to improve detection of cognitive impairment and dementia: The patient version of the Quick Dementia Rating System (QDRS)

INTRODUCTION

Community detection of mild cognitive impairment (MCI) and Alzheimer's disease and related disorders (ADRD) is a challenge. While Gold Standard assessments are commonly used in research centers, these methods are time consuming, require extensive training, and are not practical in most clinical settings or in community-based research projects. Many of these methods require an informant (e.g., spouse, adult child) to provide ratings of the patients' cognitive and functional abilities. A patient-reported outcome that captures the presence of cognitive impairment and corresponds to Gold Standard assessments could improve case ascertainment, clinical care, and recruitment into clinical research. We tested the patient version of the Quick Dementia Rating System (QDRS) as a patient-reported outcome to detect MCI and ADRD.

METHODS

The patient QDRS was validated in a sample of 261 consecutive patient-caregiver dyads compared with the informant version of the QDRS, the Clinical Dementia Rating (CDR), neuropsychological tests, and Gold Standard measures of function, behavior, and mood. Psychometric properties including item variability, floor and ceiling effects, construct, concurrent, and known-groups validity, and internal consistency were determined.

RESULTS

The patient QDRS strongly correlated with Gold Standard measures of cognition, function, mood, behavior, and global staging methods (p-values < .001) and had strong psychometric properties with excellent data quality and internal consistency (Cronbach alpha = 0.923, 95%CI:0.91-0.94). The patient QDRS had excellent agreement with the informant QDRS, the CDR and its sum of boxes (Intraclass Correlation Coefficients: 9.781-0.876). Receiver operator characteristic curves showed excellent discrimination between normal controls from CDR 0.5 (AUC:0.820;95% CI: 0.74-0.90) and for normal controls from any cognitive impairment (AUC:0.885;95% CI: 0.83-0.94).

DISCUSSION

The patient QDRS validly and reliably differentiates individuals with and without cognitive impairment and can be completed by patients through all stages of dementia. The patient QDRS is highly correlated with Gold Standard measures of cognitive, function, behavior, and global staging. The patient QDRS provides a rapid method to screen patients for MCI and ADRD in clinical practice, determine study eligibility, improve case ascertainment in community studies.

What older adults do with the results of dementia screening programs

Introduction

Alzheimer’s disease and related dementias (ADRD) and mild cognitive impairment (MCI) are often under-recognized in the community. MCI/ADRD screening could offer benefits such as early treatment, research participation, lifestyle modification, and advanced care planning. To date, there are no clear guidelines regarding the benefits vs. harms of dementia screening or whether a dementia screening program could be successful.

Methods

A community-based study was conducted to evaluate an MCI/ADRD screening program and determine what older adults would do with the information. Measures of cognition, physical health, functionality, and mood were collected. Participants met with a health professional, were given screening results with recommendations, and then contacted 60 days later to determine what was done with the results. Logistic regression models were used to build predictive models.

Results

Participants (n = 288) had a mean age of 71.5±8.3y, mean education of 13.3±4.8y, and were 70% female, 67% White, 26% African American, and 48% Hispanic. After 60 days, 75% of participants were re-contacted; 54% shared results with family, 33% shared results with health care providers (HCPs), and 52% initiated behavioral change. Among participants sharing results with HCPs, 51% reported HCPs did not follow-up on the results, and 18% that HCPs did not show any interest in the screening visit or its results. Predictors of sharing results with HCPs were elevated hemoglobin A1C (OR = 1.85;95%CI:1.19–2.88), uncontrolled hypertension (OR = 2.73;95%CI:1.09–6.83), and mobility issues (OR = 2.43;95%CI: 1.93–5.54). Participant behavioral changes included lifestyle modification (58%), social engagement (10%), cognitive stimulation (5%), and advanced care planning (4%). The most significant predictors of sharing with family were better overall mental health (OR = 0.19; 95%CI: 0.06–0.59) and better physical function (OR = 0.38; 95%CI: 0.17–0.81).

Discussion

MCI/ADRD screening was well-received by a diverse community sample. Participants showed interest in sharing the results with their family and HCPs and many attempted behavioral change. While HCPs did not always act on screening results, 25% ordered further testing and evaluation. Efforts need to be directed toward (1) increasing self-efficacy of older adults to discuss screening results with their HCPs, and (2) educating HCPs on the value of early detection of MCI/ADRD. Community dementia screening programs can increase MCI/ADRD detection and improve patient-centered outcomes and medical decision-making.

Intention to Be Screened for Alzheimer's Disease in Nondemented Older Adults: Integrated Behavioral Model and Self-Efficacy as Mediation Effect

The study explored factors associated with intention to be screened for Alzheimer's disease (AD). The study also examined whether self-efficacy mediates the relationship between knowledge about screening and the intention to be screened for AD. A population-based, random-digit dialing survey was performed and 1,043 responses were collected from a sample of nondemented persons (50 years or older) living in urban, suburban, and rural areas in a Midwestern state. The findings showed that participants who were younger and who had higher levels of (a) perceived benefits and barriers, (b) social support, and (c) self-efficacy reported higher levels of intention to be screened for AD. Older adults with positive life orientation reported greater intention to be screened for AD, whereas depressed participants were more likely to report a plan to be screened for AD. Self-efficacy mediated the relationship between knowledge about screening and intention to be screened. Older adults were more likely to report intention to be screened when they had positive attitudes about the screen and believed that they could receive the screen. The intention to be screened for AD could serve public awareness by defining effective ways to assist older adults to seek a cognitive screen.

Validity of screening instruments for the detection of dementia and mild cognitive impairment in hospital inpatients: A systematic review of diagnostic accuracy studies

INTRODUCTION

As the population ages, Alzheimer's disease and other subtypes of dementia are becoming increasingly prevalent. However, in recent years, diagnosis has often been delayed or not made at all. Thus, improving the rate of diagnosis has become an integral part of national dementia strategies. Although screening for dementia remains controversial, the case is strong for screening for dementia and other forms of cognitive impairment in hospital inpatients. For this reason, the objective of this systematic review was to provide clinicians, who wish to implement screening, an up-to-date choice of cognitive tests with the most extensive evidence base for the use in elective hospital inpatients.

METHODS

For this systematic review, PubMed, PsycINFO and Cochrane Library were searched by using a multi-concept search strategy. The databases were accessed on April 10, 2019. All cross-sectional studies that utilized brief, multi-domain cognitive tests as index test and a reference standard diagnosis of dementia or mild cognitive impairment as comparator were included. Only studies conducted in the hospital setting, sampling from unselected, elective inpatients older than 64 were considered.

RESULTS

Six studies met the inclusion criteria, with a total of 2112 participants. Diagnostic accuracy data for the Six-Item Cognitive Impairment Test, Cognitive Performance Scale, Clock-Drawing Test, Mini-Mental Status Examination, and Time & Change test were extracted and descriptively analyzed. Clinical and methodological heterogeneity between the studies precluded performing a meta-analysis.

DISCUSSION

This review found only a small number of instruments and was not able to recommend a single best instrument for use in a hospital setting. Although it was not possible to estimate the pooled operating characteristics, the included description of instrument characteristics, the descriptive analysis of performance measures, and the critical evaluation of the reporting studies may contribute to clinician's choice of the screening instrument that fits best their purpose.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients

SUMMIT PARTICIPANTS

ORGANIZATIONS REPRESENTED

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.