Performance of the NINDS-CSN 5-minute protocol in a national population-based sample

Association of Adherence to a MIND-Style Diet With the Risk of Cognitive Impairment and Decline in the REGARDS Cohort

BACKGROUND AND OBJECTIVES

Diet may influence the development of cognitive impairment and affect cognitive decline, but whether this relationship varies between Black American and White American people is unclear. This study examined the association of Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) and incident cognitive impairment and cognitive trajectories in a biracial prospective cohort study.

METHODS

Using data derived from the Food Frequency Questionnaire in the REasons for Geographic and Racial Differences in Stroke study, we compared MIND diet adherence with incident cognitive impairment and cognitive trajectory in Black participants and White participants. Logistic regression was used to model MIND diet score (continuous variable and using tertiles) and incident cognitive impairment after adjusting for age, sex, race, region, education, income, total energy, hypertension history, dyslipidemia, diabetes, estimated glomerular filtration rate, ischemic heart conditions, atrial fibrillation, and lifestyle factors including sedentary, obesity, and smoking. Mixed-effects models were used to examine the association between cognitive trajectory and MIND diet adherence.

RESULTS

Dietary data to calculate the MIND diet score and cognitive data were available on 14,145 participants with a mean age of 64 years (SD 9.0 years) that was 56.7% female. Greater MIND diet adherence was associated with a decreased incidence of cognitive impairment (odds ratio [OR] 0.96, 95% CI 0.93-0.99, p = 0.02) after adjusting for all covariates. In the fully adjusted model, greater MIND diet adherence was associated with decreased risk of cognitive impairment in female participants (OR 0.92, 95% CI 0.89-0.96, p < 0.001) but not in male participants (OR 1.01, 95% CI 0.97-1.06, p = 0.64). In all models, greater MIND diet adherence was associated with decreased risk of cognitive decline. MIND diet adherence was a better predictor of cognitive decline in Black participants (β = 0.04, SE = 0.007, p < 0.001) than in White participants (β = 0.03, SE = 0.004, p < 0.001).

DISCUSSION

Greater MIND diet adherence was associated with decreased risk of cognitive impairment in female participants but not male participants, with no difference between Black participants and White participants. However, MIND diet adherence was a better predictor of cognitive trajectory in Black participants than in White participants.

Neuropsychiatric and cognitive symptoms in people with hypertension: An examination with the NINDS-CSN consensus protocol

Hypertension has been associated with risk of cognitive impairments. The American Heart Association recommended the use of the harmonized neuropsychological protocol suggested by the National Institute of Neurologic Disorders and Stroke and the Canadian Stroke Network (NINDS-CSN) for studying related cognitive impairments. Initially designed for vascular cognitive impairment, empirical data of results from NINDS-CSN protocol has not been well-established in hypertension. The present study recruited 58 adults diagnosed with hypertension and 44 normotensive controls. Tests from the NINDS-CSN protocol were given in three lengths, including neuropsychological tests and neuropsychiatric inventories. The results showed higher proportions of hypertensive adults with impairments on tests of memory and executive functions and that they performed worse as a group on several tests from the 30-minute protocol, but not on the other additional tests in the full-length version, nor on cognitive screening test in the 5-minute protocol such as the Mini-Mental State Examination or the Montreal Cognitive Assessment. There was no significant group difference on neuropsychiatric symptoms. These findings suggested that the 30-minute version of the NINDS-CSN protocol with the two supplemental tests was able to reveal selective cognitive deficits in hypertensive adults and provide a practical solution for related studies, balancing between the requirement of sensitivity, domain variety, and brevity.

Teleneuropsychology for vascular cognitive impairment: Which tools do we have?

The halt of clinical activities imposed during the COVID-19 pandemic forced clinicians to find alternative strategies to provide continuity of care and services, and led to a renewed interest in use of teleneuropsychology (TNP) to remotely assess patients. Recent TNP guidelines recommend maximizing the reproduction of standard in-person assessment, particularly through videoconferences. However, consistency of the adaptations of usual cognitive tests to videoconference needs further elucidation. This review aims at critical reviewing which cognitive tests could be recommended for a remote evaluation of patients with vascular cognitive impairment (VCI) among those widely recognized as reference standards. Current evidence supports the use of global cognitive efficiency (MMSE and MoCA), verbal memory (Revised Hopkins Verbal Learning Test), and language tests (phonemic and semantic verbal fluencies, Boston Naming Test), while there is a lack of strong validity support for measures of visuospatial functions (Rey-Osterreith Complex Figure), and executive functioning and processing speed (Trail making Test, and Digit symbol or Symbol digit tests). This represents a major limitation in the evaluation of VCI because its cognitive profile in often characterized by attention and executive deficits. At present, a videoconference TNP visit appears useful for a brief evaluation of global cognitive efficiency, and to 'triage' patients towards a second level in person evaluation. In future, hybrid models of TNP based on data collected across multiple modalities, incorporating both adaptation of usual cognitive tools and new computerized tools in the supervised videoconference setting, are likely to become the best option for a comprehensive remote cognitive assessment.

Post-Stroke Cognitive Impairment and Dementia

Poststroke cognitive impairment and dementia (PSCID) is a major source of morbidity and mortality after stroke worldwide. PSCID occurs as a consequence of ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Cognitive impairment and dementia manifesting after a clinical stroke is categorized as vascular even in people with comorbid neurodegenerative pathology, which is common in elderly individuals and can contribute to the clinical expression of PSCID. Manifestations of cerebral small vessel disease, such as covert brain infarcts, white matter lesions, microbleeds, and cortical microinfarcts, are also common in patients with stroke and likewise contribute to cognitive outcomes. Although studies of PSCID historically varied in the approach to timing and methods of diagnosis, most of them demonstrate that older age, lower educational status, socioeconomic disparities, premorbid cognitive or functional decline, life-course exposure to vascular risk factors, and a history of prior stroke increase risk of PSCID. Stroke characteristics, in particular stroke severity, lesion volume, lesion location, multiplicity and recurrence, also influence PSCID risk. Understanding the complex interaction between an acute stroke event and preexisting brain pathology remains a priority and will be critical for developing strategies for personalized prediction, prevention, targeted interventions, and rehabilitation. Current challenges in the field relate to a lack of harmonization of definition and classification of PSCID, timing of diagnosis, approaches to neurocognitive assessment, and duration of follow-up after stroke. However, evolving knowledge on pathophysiology, neuroimaging, and biomarkers offers potential for clinical applications and may inform clinical trials. Preventing stroke and PSCID remains a cornerstone of any strategy to achieve optimal brain health. We summarize recent developments in the field and discuss future directions closing with a call for action to systematically include cognitive outcome assessment into any clinical studies of poststroke outcome.

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan

Background:

Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society.

Objective:

We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan.

Methods:

A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management.

Results:

Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%).

Conclusion:

Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.

Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 Trial

BACKGROUND AND PURPOSE

Studies of carotid artery disease have suggested that high-grade stenosis can affect cognition, even without stroke. The presence and degree of cognitive impairment in such patients have not been reported and compared with a demographically matched population-based cohort.

METHODS

We studied cognition in 1000 consecutive CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) patients, a treatment trial for asymptomatic carotid disease. Cognitive assessment was after randomization but before assigned treatment. The cognitive battery was developed in the general population REGARDS Study (Reasons for Geographic and Racial Differences in Stroke), involving Word List Learning Sum, Word List Recall, and Word List fluency for animal names and the letter F. The carotid stenosis patients were >45 years old with ≥70% asymptomatic carotid stenosis and no history of prevalent stroke. The distribution of cognitive performance for the patients was standardized, accounting for age, race, and education using performance from REGARDS, and after further adjustment for hypertension, diabetes, dyslipidemia, and smoking. Using the Wald Test, we tabulated the proportion of Z scores less than the anticipated deviate for the population-based cohort for representative percentiles.

RESULTS

There were 786 baseline assessments. Mean age was 70 years, 58% men, and 52% right-sided stenosis. The overall Z score for patients was significantly below expected for higher percentiles (P<0.0001 for 50th, 75th, and 95th percentiles) and marginally below expected for the 25th percentile (P=0.015). Lower performance was attributed largely to Word List Recall (P<0.0001 for all percentiles) and for Word List Learning (50th, 75th, and 95th percentiles below expected, P≤0.01). The scores for left versus right carotid disease were similar.

CONCLUSIONS

Baseline cognition of patients with severe carotid stenosis showed below normal cognition compared to the population-based cohort, controlling for demographic and cardiovascular risk factors. This cohort represents the largest group to date to demonstrate that poorer cognition, especially memory, in this disease.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02089217.

Current Update on the Clinical Utility of MMSE and MoCA for Stroke Patients in Asia: A Systematic Review

Objective: Primary care clinicians in Asia employed the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) to aid dementia diagnosis post-stroke. Recent studies questioned their clinical utility in stroke settings for relying on verbal abilities and education level, as well as lack of consideration for aphasia and neglect. We aimed to review the clinical utility of the MMSE and MoCA for stroke patients in Asia and provide recommendations for clinical practice. Methods: PubMed, Scopus, Web of Science, and Science Direct were searched for relevant articles. Included studies were assessed for risk of bias. RevMan 5.4 was used for data synthesis (sensitivity and specificity) and covariates were identified. Results: Among the 48 full-text articles reviewed, 11 studies were included with 3735 total subjects; of these studies, 7 (77%) were conducted in China, 3 (27%) in Singapore, and 1 (9%) in South Korea. Both the MMSE and MoCA generally showed adequate sensitivity and specificity. Education was identified as a covariate that significantly affected detection accuracy. Due to heterogeneity in cutoff scores, methodologies, and languages, it was not feasible to suggest a single cutoff score. One additional point is recommended for MoCA for patients with <6 years of education. Conclusion: Clinicians in Asia are strongly recommended to consider the education level of stroke patients when interpreting the results of the MMSE and MoCA. Further studies in other Asian countries are needed to understand their clinical value in stroke settings.

Relation of Atrial Fibrillation to Cognitive Decline (from the REasons for Geographic and Racial Differences in Stroke [REGARDS] Study)

The association of atrial fibrillation (AF) with cognitive function remains unclear, especially among racially/geographically diverse populations. This analysis included 25,980 black and white adults, aged 48+, from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, free from cognitive impairment and stroke at baseline. Baseline AF was identified by self-reported medical history or electrocardiogram (ECG). Cognitive testing was conducted yearly with the Six Item Screener (SIS) to define impairment and at 2-year intervals to assess decline on: animal naming and letter fluency, Montreal Cognitive Assessment (MoCA), Word List Learning (WLL) and Delayed Recall tasks (WLD). Multivariable regression models estimated the relationships between AF and baseline impairment and time to cognitive impairment. Models were adjusted sequentially for age, sex, race, geographic region, and education, then cardiovascular risk factors and finally incident stroke. AF was present in 2,168 (8.3%) participants at baseline. AF was associated with poorer baseline performance on measures of: semantic fluency (p<0.01); global cognitive performance (MoCA, p<0.01); and WLD (p<0.01). During a mean follow-up of 8.06 years, steeper declines in list learning were observed among participants with AF (p<0.03) which remained significant after adjusting for cardiovascular risk factors (p<0.04) and incident stroke (p<0.03). Effect modification by race, sex and incident stroke on AF and cognitive decline were also detected. In conclusion, AF was associated with poorer baseline cognitive performance across multiple domains and incident cognitive impairment in this bi-racial cohort. Additional adjustment for cardiovascular risk factors attenuated these relations with the exception of learning.

Trajectory of Cognitive Decline After Sepsis

OBJECTIVES

Cognitive impairment is an important consequence of sepsis. We sought to determine long-term trajectories of cognitive function after sepsis.

DESIGN

Prospective study of the Reasons for Geographic and Racial Differences in Stroke cohort.

SETTING

United States.

PATIENTS

Twenty-one thousand eight-hundred twenty-three participants greater than or equal to 45 years, mean (sd) age 64.3 (9.2) years at first cognitive assessment, 30.9% men, and 27.1% Black.

MEASUREMENTS AND MAIN RESULTS

The main exposure was time-dependent sepsis hospitalization. The primary outcome was global cognitive function (Six-Item Screener range, 0-6). Secondary outcomes were incident cognitive impairment (Six-Item Screener score ≤ 4 [impaired] vs ≥5 [unimpaired]), new learning (Consortium to Establish a Registry for Alzheimer Disease Word List Learning range, 0-30), verbal memory (word list delayed recall range, 0-10), and executive function/semantic fluency (animal fluency test range, ≥ 30). Over a median follow-up of 10 years (interquartile range, 6-12 yr), 840 (3.8%) experienced sepsis (incidence 282 per 1,000 person-years). Sepsis was associated with faster long-term declines in Six-Item Screener (-0.02 points per year faster [95% CI, -0.01 to -0.03]; p < 0.001) and faster long-term rates of incident cognitive impairment (odds ratio 1.08 per year [95% CI, 1.02-1.15]; p = 0.008) compared with presepsis slopes. Although cognitive function acutely changed after sepsis (0.05 points [95% CI, 0.01-0.09]; p = 0.01), the odds of acute cognitive impairment (Six-Item Screener ≤ 4) immediately after sepsis was not significant (odds ratio, 0.81 [95% CI, 0.63-1.06]; p = 0.12). Sepsis hospitalization was not associated with acute changes or faster declines in word list learning, word list delayed recall, or animal fluency test.

CONCLUSIONS

Sepsis is associated with accelerated long-term decline in global cognitive function.

Psychometric Properties of the National Institute of Neurological Disorders and Stroke and Canadian Stroke Network Neuropsychological Battery in an Asian Older Adult Sample

OBJECTIVE

Despite the wide usage of the National Institute of Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) neuropsychological battery for the detection of vascular cognitive impairment, its reliability and validity have not been established. Therefore, the present study established the psychometric properties of the battery in cognitively normal older adults in a clinical setting in Singapore.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

A total of 105 cognitively normal older adults age 50 years and older were assessed in a memory clinic setting.

METHODS

The 60-minute NINDS-CSN and 5-minute protocol were administered to participants at baseline and 3-month follow-up. Raw scores were transformed into standardized z scores. Test-retest reliability, concurrent validity and construct (convergent and discriminant) validity were reported.

RESULTS

Moderate-to-excellent test-retest reliability (r = 0.36-0.87), concurrent validity, and construct validity (r = 0.41-0.83) were found in both protocols over 3 months (all Ps < 0.01). Although the 5-minute protocol showed moderate validity (r = 0.41), the 60-minute protocol had excellent concurrent validity against a locally validated neuropsychological battery (r = 0.83).

CONCLUSION AND IMPLICATIONS

The NINDS-CSN is reliable and valid in assessing cognitive function. The 60-minute protocol demonstrates great utility beyond its current usage in vascular cognitive impairment populations to the general older adult population. The 5-minute protocol can be used as a brief cognitive screening tool in primary healthcare and the community, due to its brevity and accuracy. Future research should further examine the generalizability of the NINDS-CSN battery in other dementias and cognitive disorders.

The relationship of longitudinal cognitive change to self-reported IADL in a general population

This study examined the relationship between cognitive change and instrumental activities of daily living (IADL) in a large, national, population-based sample. Cognitive change was assessed via verbal fluency, word list learning (WLL), and word list delayed recall (WLD). Incident cognitive impairment was defined by change in Six-Item Screener (SIS) status over a period of 10 years. Impaired IADL was defined as self-reported difficulty or needing assistance performing any IADL at Year 10. A one-word decrease in WLL over a 10-year span increased the odds of impaired IADL by 16% (95% CI 1.08-1.24) and incident cognitive impairment increased the odds of impaired IADL by 59% (95% CI 1.36-1.85) when adjusting for demographic factors, health-related behaviors, vascular risk factors and disease, and depressive symptoms. Cognitive change most strongly predicted impairment in managing finances (OR 2.47, 95% CI 2.04-3.00) and driving (OR 2.06, 95% CI 1.73-2.44).

PCSK9 Variants, Low-Density Lipoprotein Cholesterol, and Neurocognitive Impairment: Reasons for Geographic and Racial Differences in Stroke Study (REGARDS)

BACKGROUND

Despite concerns about adverse neurocognitive events raised by prior trials, pharmacological PCSK9 (proprotein convertase subtilisin/kexin type-9) inhibition was not associated with neurocognitive effects in a recent phase 3 randomized trial. PCSK9 loss-of-function (LOF) variants that result in lifelong exposure to lower levels of low-density lipoprotein cholesterol can provide information on the potential long-term effects of lower low-density lipoprotein cholesterol on neurocognitive impairment and decline.

METHODS

We investigated the association between PCSK9 LOF variants and neurocognitive impairment and decline among black REGARDS study (Reasons for Geographic and Racial Differences in Stroke) participants with (n=241) and without (n=10 454) C697X or Y142X LOF variants. Neurocognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery (Word List Learning, World List Delayed Recall, Semantic Animal Fluency) and Six-Item Screener (SIS) assessments, administered longitudinally during follow-up. Neurocognitive impairment was defined as a score ≥1.5 SD below age, sex, and education-based stratum-specific means on 2 or 3 CERAD assessments or, separately, a score <5 on any SIS assessment at baseline or during follow-up. Neurocognitive decline was assessed using standardized continuous scores on individual neurocognitive tests.

RESULTS

The mean sample age was 64 years (SD, 9), 62% were women, and the prevalence of neurocognitive impairment at any assessment was 6.3% by CERAD and 15.4% by SIS definitions. Adjusted odds ratios for neurocognitive impairment for participants with versus without PCSK9 LOF variants were 1.11 (95% confidence interval [CI], 0.58-2.13) using the CERAD battery and 0.89 (95% CI, 0.61-1.30) using the SIS assessment. Standardized average differences in individual neurocognitive assessment scores over the 5.6-year (range, 0.1-9.1) study period ranged between 0.07 (95% CI, -0.06 to 0.20) and -0.07 (95% CI, -0.18 to 0.05) among participants with versus without PCSK9 LOF variants. Patterns of neurocognitive decline were similar between participants with and without PCSK9 LOF variants (all P>0.10). Odds ratios for neurocognitive impairment per 20 mg/dL low-density lipoprotein cholesterol decrements were 1.02 (95% CI, 0.96-1.08) and 0.99 (95% CI, 0.95-1.02) for the CERAD and SIS definitions of impairment, respectively.

CONCLUSIONS

These results suggest that lifelong exposure to low PCSK9 levels and cumulative exposure to lower levels of low-density lipoprotein cholesterol are not associated with neurocognitive effects in blacks.

Prediction of post-stroke dementia using NINDS-CSN 5-minute neuropsychology protocol in acute stroke

BACKGROUND

The National Institute of Neurological Disease and Stroke-Canadian Stroke Network (NINDS-CSN) 5-minute neuropsychology protocol consists of only verbal tasks, and is proposed as a brief screening method for vascular cognitive impairment. We evaluated its feasibility within two weeks after stroke and ability to predict the development of post-stroke dementia (PSD) at 3 months after stroke.

METHOD

We prospectively enrolled subjects with ischemic stroke within seven days of symptom onset who were consecutively admitted to 12 university hospitals. Neuropsychological assessments using the NINDS-CSN 5-minute and 60-minute neuropsychology protocols were administered within two weeks and at 3 months after stroke onset, respectively. PSD was diagnosed with reference to the American Heart Association/American Stroke Association statement, requiring deficits in at least two cognitive domains.

RESULTS

Of 620 patients, 512 (82.6%) were feasible for the NINDS-CSN 5-minute protocol within two weeks after stroke. The incidence of PSD was 16.2% in 308 subjects who had completed follow-up at 3 months after stroke onset. The total score of the NINDS-CSN 5-minute protocol differed significantly between those with and without PSD (4.0 ± 2.7, 7.4 ± 2.7, respectively; p < 0.01). A cut-off value of 6/7 showed reasonable discriminative power (sensitivity 0.82, specificity 0.67, AUC 0.74). The NINDS-CSN 5-minute protocol score was a significant predictor for PSD (adjusted odds ratio 6.32, 95% CI 2.65-15.05).

DISCUSSION

The NINDS-CSN 5-minute protocol is feasible to evaluate cognitive functions in patients with acute ischemic stroke. It might be a useful screening method for early identification of high-risk groups for PSD.

The Utility of Brief Cognitive Tests for Patients With Type 2 Diabetes Mellitus: A Systematic Review

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with an increased risk for mild cognitive impairment and dementia in both middle-aged and older individuals. Brief cognitive tests can potentially serve as a reliable and cost effective approach to detect for cognitive decrements in clinical practice.

OBJECTIVE

This systematic review examined the utility of brief cognitive tests in studies with patients with T2DM.

METHOD

This systematic review was conducted according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. "PubMed," "PsychINFO," "ScienceDirect," and "ProQuest" electronic databases were searched to identify articles published from January 1, 2005 to December 31, 2015.

RESULTS

The search yielded 22 studies, with only 8 using brief tests as a cognitive screening tool, whereas the majority using these tests as a measure of global cognitive functions. In regard to cognitive screening studies, most had failed to fulfil the standard reporting of diagnostic test accuracy criteria such as Standards for Reporting of Diagnostic Accuracy for dementia and cognitive impairment. Moreover, few studies reported discriminant indices such as sensitivity, specificity, and positive and negative predictive values of brief cognitive tests in detecting cognitive impairment in patients with T2DM. Among studies which used brief cognitive tests as a measure of global cognitive function, patients with diabetes tended to perform worse than patients without diabetes. Processing speed appeared to be particularly impaired among patients with diabetes, therefore, measures of processing speed such as the Digit Symbol Substitution Test may add value to brief cognitive tests such as the Montreal Cognitive Assessment.

CONCLUSIONS

The Montreal Cognitive Assessment supplemented by the Digit Symbol Substitution Test indicate initial promise in screening for cognitive impairment in T2DM.

Rapid Screening for Cognitive Impairment in Parkinson's Disease: A Pilot Study

Aim. This study sought to establish the discriminant validity of a rapid cognitive screen, that is, the National Institute of Neurological Disease and Stroke-Canadian Stroke Network (NINDS-CSN) 5-minute protocol, and compare its discriminant validity to the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE) in detecting cognitive impairment (CI) in PD patients. Methods. One hundred and one PD patients were recruited from a movement disorders clinic in Singapore and they received the NINDS-CSN 5-minute protocol, MoCA, and MMSE. No cognitive impairment (NCI) was defined as Clinical Dementia Rating (CDR) = 0 and CI was defined as CDR ≥ 0.5. Results. Area under the receiver operating characteristic curve of NINDS-CSN 5-minute protocol was statistically equivalent to MoCA and larger than MMSE (0.86 versus 0.90, P = 0.07; 0.86 versus 0.76, P = 0.03). The sensitivity of NINDS-CSN 5-minute protocol (<9) was statistically equivalent to MoCA (<22) (0.77 versus 0.85, P = 0.13) and superior to MMSE (<24) (0.77 versus 0.52, P < 0.01) in detecting CI, while the specificity of NINDS-CSN 5-minute protocol (<9) was statistically equivalent to MoCA (<22) and MMSE (<24) (0.78 versus 0.88, P = 0.34). Conclusion. The NINDS-CSN 5-minute protocol is time expeditious while remaining statistically equivalent to MoCA and superior to MMSE and therefore is suitable for rapid cognitive screening of CI in PD patients.

Telephone-based cognitive screening for stroke patients in China

BACKGROUND

Valid telephone assessment for cognitive impairment is lacking in stroke settings. We investigated the feasibility and validity of the 5-minute National Institute of Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) protocol and six-item screener (SIS) in stroke patients by telephone administration.

METHODS

Patients were assessed with a comprehensive face-to-face neuropsychological assessment after three months of stroke onset, followed by the 5-minute NINDS-CSN protocol (30 points) and SIS (6 points) at least one month later. Administration time was recorded for the telephone tests. Validity of both tests was determined using the area under the receiver operating characteristics curve (AUC).

RESULTS

Eighty-nine patients (age, 62.9 ± 8.6 years; male, 65.2%) received a face-to-face assessment and 80 completed telephone tests. The time required to administer the 5-minute NINDS-CSN protocol was 4.3 ± 1.0 minutes, and SIS 57.3 ± 17.7 seconds. Validity of detecting cognitive impairment as assessed by AUC was 0.86 (95% CI, 0.78-0.94) for 5-minute NINDS-CSN protocol, and 0.74 (95% CI, 0.63-0.85) for SIS. Sensitivity and specificity were optimal with the cut-off values of 23.5/24 for the 5-minute NINDS-CSN protocol, and 4/5 for SIS.

CONCLUSIONS

Both the telephone-based 5-minute NINDS-CSN protocol and SIS were feasible and valid in screening cognitive impairment after stroke in China.