An empirically based proposal to identify a short battery to detect neuropsychological impairment in a general adult practice

Objectives: To demonstrate that 1) models based on small numbers of tests can be statistically developed to identify neuropsychological impairment in a general adult neuropsychology clinic and 2) those models show strong predictive validity on replication in a slightly different sample. Method: Latent Class Analyses (LCA) were used to determine neuropsychological classification in 231 patients referred to general adult neuropsychology services. A clinical rating scale was also used to approximate clinical decision-making. Regression models were constructed in a training sample (n = 127) drawn from an adult neuropsychology clinic using test scores from seven different a priori test battery combinations to predict group membership or clinical rating. The utility of the seven models was assessed in a testing sample (n = 104) from another independent adult neuropsychology clinic. Results: The LCA yielded a two class solution characterized by impaired versus non-impaired performance on neuropsychological tests. A seven test battery provided the best balance of accuracy and length in predicting LCA group with a sensitivity of 84.4% and a specificity of 90%. Sensitivity and specificity were slightly attenuated using the clinical rating scale as the criterion, but the seven test battery still provided good accuracy (AUC=.906). Conclusions: Test protocols based on only five to eight test scores can accurately identify most patients with clinical impairment in a diverse adult neuropsychology clinic. Development of short protocols with adequate sensitivity and specificity will become increasingly important to address long waiting lists in light of the COVID pandemic against the general backdrop of increasing demand for neuropsychological services.

A comparative study: visual rating scores and the voxel-based specific regional analysis system for Alzheimer's disease on magnetic resonance imaging among subjects with Alzheimer's disease, mild cognitive impairment, and normal cognition

AIM

Hippocampal atrophy shown on magnetic resonance imaging can differentiate Alzheimer's disease (AD) patients from subjects with normal cognition (NC). Simplified automated methods that use volumetric analysis, such as as the voxel-based specific regional analysis system for AD, have become widely used in Japan. However, the diagnostic value of the voxel-based specific regional analysis system compared with visual rating scores for clinical diagnosis is unclear.

METHODS

Study participants consisted of 37 AD patients, 29 mild cognitive impairment (MCI) patients, and 21 NC subjects. All participants underwent neuropsychological testing and magnetic resonance imaging. The imaging was scored visually for regional brain atrophy by two raters based on a newly developed visual rating score. The voxel-based specific regional analysis system for AD scores were calculated with the analysis system's advanced software. We analyzed whether these scores aid in discriminating among AD, MCI, and NC.

RESULTS

The AD group had significantly different visual rating scores, regional analysis scores, and all neuropsychological test scores than the NC group. The AD group had significantly different visual rating scores than the MCI group, and a significant difference was observed between the MCI and NC groups on regional analysis scores. Both the visual rating and regional analysis scores showed equivalent correlations with the neuropsychological test scores.

CONCLUSIONS

Both the visual rating and regional analysis scores are clinically useful tools for differentiating among AD, MCI, and NC.

Longitudinal Changes in Performance on Cognitive Screening Tests in Patients with Mild Cognitive Impairment and Alzheimer Disease

Background

Neuropsychological tests that can track changes in cognitive functions after diagnosis of Alzheimer disease (AD) and mild cognitive impairment (MCI), including episodic memory, should be further developed.

Methods

The participants of our study consisted of 22 mild AD patients and 11 MCI patients. They were followed up for 2 years. Brief cognitive screening tests were administered to the participants. Longitudinal changes in test performance were evaluated and analyzed.

Results

In this longitudinal study, the Scenery Picture Memory Test (SPMT) showed significant changes over 2 years in both MCI and AD participants. The Mini-Mental State Examination (MMSE) and Word Fluency Test-vegetable showed significant changes only in AD participants. Other tests all showed little or no decline in results.

Conclusions

The SPMT can be a useful tool for effectively observing changes during follow-up of MCI and AD patients.

Memory performance on the story recall test and prediction of cognitive dysfunction progression in mild cognitive impairment and Alzheimer's dementia

AIM

To determine the factors that influence diagnosis and differentiation of patients with mild cognitive impairment (MCI) and Alzheimer's dementia (AD) by comparing memory test results at baseline with those at 1-2-year follow up.

METHODS

We consecutively recruited 23 healthy participants, 44 MCI patients and 27 patients with very mild AD according to the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorder Association criteria for probable Alzheimer's disease and Petersen's clinical diagnostic criteria. We carried out detailed neuropsychological tests, including the Story Recall Test (SRT) and the Seoul Verbal Learning Test, for all participants. We defined study participants as the "progression group" as follows: (i) participants who showed conversion to dementia from the MCI state; and (ii) those with dementia who showed more than a three-point decrement in their Mini-Mental State Examination scores with accompanying functional decline from baseline status, which were ascertained by physician's clinical judgment.

RESULTS

The SRT delayed recall scores were significantly lower in the patients with mild AD than in those with MCI and after progression. Lower (relative risk 1.1, 95% confidence interval 0.1-1.6) and higher SRT delayed recall scores (relative risk 2.1, confidence interval 1.0-2.8), and two-test combined immediate and delayed recall scores (relative risk 2.0, confidence interval 0.9-2.3; and relative risk 2.8, confidence interval 1.1-4.2, respectively) were independent predictors of progression in a stepwise multiple adjusted Cox proportional hazards model, with age, sex, depression and educational level forced into the model.

CONCLUSIONS

The present study suggests that the SRT delayed recall score independently predicts progression to dementia in patients with MCI. Geriatr Gerontol Int 2017; 17: 1603-1609.

Global brain atrophy is associated with physical performance and the risk of falls in older adults with cognitive impairment

AIM

Falls are common in patients with cognitive disorder. The purpose of this study was to determine whether global brain atrophy is associated with cognitive function, physical performance and fall incidents in older adults with mild cognitive disorder.

METHODS

A total of 31 older adults with mild cognitive disorders (mean age 78.9 ± 7.3 years) were studied, and 10 of them had experienced falls and the others had not in the past 1 year. Cognitive function and physical performance were measured in these patients. Global brain atrophy was determined by the Voxel-Based Specific Regional Analysis System for Alzheimer's Disease software.

RESULTS

Fallers showed significantly worse scores than the non-fallers in the Global Brain Atrophy Index, Clock Drawing Test (CDT), Verbal Fluency Test (animal), maximum walking time and Timed Up & Go (TUG) Test. The Global Brain Atrophy Index was correlated with the Verbal Fluency Test (animal; r = -0.522), the Verbal Fluency Test with letter (ka; r = -0.337), CDT (r = -0.547), TUG (r = 0.276) and Five Chair Stands Test (r = 0.303) by age-adjusted correlation analyses. Stepwise regression analysis showed that the Global Brain Atrophy Index (β = 1.265, 95% CI 1.022-1.567) was a significant and independent determinant of falls (R(2) = 0.356, P = 0.003).

CONCLUSION

Global brain atrophy might be indicated as one of the risk factors for falls in older adults with mild cognitive disorders.

Clinical course of patients with familial early-onset Alzheimer's disease potentially lacking senile plaques bearing the E693Δ mutation in amyloid precursor protein

BACKGROUND/AIMS

Oligomeric amyloid β (Aβ) is currently considered to induce Alzheimer's disease (AD). We examined 2 patients with familial AD who possessed the Osaka (E693Δ) mutation in amyloid precursor protein. To the best of our knowledge, these patients are the first AD cases presumably affected with Aβ oligomers in the absence of senile plaques, and they support the Aβ oligomer hypothesis.

METHODS

We evaluated the clinical course, neuropsychological data, cerebrospinal fluid biomarker levels, magnetic resonance imaging (MRI) scans, fluorodeoxyglucose-positron emission tomography (PET) scans, and Pittsburgh compound B (PiB)-PET images of these patients.

RESULTS

In the early stages, these patients developed memory disturbances in a similar rate to patients with sporadic AD. Despite their memory disturbances, both patients showed only limited brain atrophy on MRI and little amyloid accumulation on PiB-PET. Subsequent to the development of memory disturbances, both patients suffered from motor dysfunction, probably due to cerebellar ataxia, and, within a few years, the patients fell into an apallic state.

CONCLUSIONS

Familial AD patients with Osaka (E693Δ) mutation show severe dementia, cerebellar ataxia, and gait disturbances.

[Use of honorifics in all situations by a patient with semantic dementia]

We report the case of a 72-year-old man who had been given a diagnosis of semantic dementia (SD) at 64 years of age, and who began to use honorifics in all situations during the later clinical course. His initial clinical features were problems in word comprehension and naming, and some behavioural changes, including clockwatching and aberrant eating behaviours. The most prominent feature in this case was the use of honorifics in all situations, while other aspects of his language ability deteriorated. He even used honorifics with members of his family, including young grandchildren. Although it is difficult to explain the reason why the patient used honorifics in all situations, we considered 2 possibilities. The first is that although he remains able to use honorifics, he is unable to distinguish when the use of honorifics is not required. The second is that a change in emotional state, such as the "taming effect" or "placidity" that has been suggested to accompany frontotemporal lobar degeneration, might have affected his use of honorifics. The regular schedule of daycare services provides him with emotional stability because he does not have to constantly be aware of the time. Since no standard treatment has been established for SD, our experience with this case might be beneficial in caring for patients with SD.

Scenery Picture Memory Test: a new type of quick and effective screening test to detect early stage Alzheimer's disease patients

AIM

It is highly desirable to develop a neuropsychological screening test which is sensitive to the early stage of Alzheimer's disease (AD), and is easy to administer at the primary care physician's (PCP's) office.

METHODS

Participants were 128 AD patients and 54 healthy volunteers. Brief cognitive screening tests were administered to the participants including the Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Verbal Fluency Test (VFT), a Verbal Category Cued Memory test (CCMT) and the Scenery Picture Memory Test (SPMT). In the SPMT, a scenery picture of a living room containing 23 familiar objects was used. The administration of the SPMT comprised the first shallow memory session (Pict 1) and the second deep memory session (Pict 2). The area under the receiver-operator curve (AUC) was used to compare the efficacy of SPMT with other cognitive tests.

RESULTS

Pict 1, which requires less than 2 min to complete, had the same AUC as Pict 2, and showed significantly larger AUC than MMSE, CDT and VFT for all (MMSE 19-23) and very mild (MMSE > or = 24) AD patients. When we conducted the similar analysis separately for those younger than 75 years and those aged 75 years or older, we obtained the same results as above among the older age group. Pict 1 showed larger AUC than CCMT in overall sample and also in the older age group, although the difference was not statistically significant.

CONCLUSION

The SPMT could be useful for detection of mild and very mild AD in settings even where time is limited.

Evaluating the uses of the total score and the domain scores in the Cognitive Abilities Screening Instrument, Chinese version (CASI C-2.0): results of confirmatory factor analysis

BACKGROUND

The Cognitive Abilities Screening Instrument (CASI) consists of items which are designed to measure the nine domains of cognitive ability. Its total score is used clinically to represent the overall underlying cognitive ability of the patient. This study aimed to evaluate the justification of the uses of the all-domain-total-score as an overall cognitive measure and the domain scores as measures of designated individual cognitive ability.

METHODS

To justify the use of total score of all the items as an overall measure of cognitive ability, a second-order confirmatory factor analysis was performed to examine whether the items in CASI contributed significantly to a common underlying construct. The uses of domain scores were also examined by inspecting the loadings of the items on their designated domains. The CASI data from 608 patients, 68 normal and 540 with Alzheimer's disease, were analyzed.

RESULTS

The goodness-of-fit indices for the second-order factor model were as follows: CFI was 0.912 for WLSMV and 0.977 for WLSM; TLI and RMSEA values were 0.975 and 0.090 respectively. The loadings of the items on the common underlying construct are all salient (>0.3). The loadings of all but the long-term memory items on their respective subdomains were also salient.

CONCLUSIONS

The items of the CASI C-2.0 were useful not only in profiling the correlated cognitive domain scores, but also in forming an overall measure of the underlying cognitive ability of the patients.