Clock drawing: analysis in a retirement community

Developing a fair and interpretable representation of the clock drawing test for mitigating low education and racial bias

The clock drawing test (CDT) is a neuropsychological assessment tool to screen an individual's cognitive ability. In this study, we developed a Fair and Interpretable Representation of Clock drawing test (FaIRClocks) to evaluate and mitigate classification bias against people with less than 8 years of education, while screening their cognitive function using an array of neuropsychological measures. In this study, we represented clock drawings by a priorly published 10-dimensional deep learning feature set trained on publicly available data from the National Health and Aging Trends Study (NHATS). These embeddings were further fine-tuned with clocks from a preoperative cognitive screening program at the University of Florida to predict three cognitive scores: the Mini-Mental State Examination (MMSE) total score, an attention composite z-score (ATT-C), and a memory composite z-score (MEM-C). ATT-C and MEM-C scores were developed by averaging z-scores based on normative references. The cognitive screening classifiers were initially tested to see their relative performance in patients with low years of education (< = 8 years) versus patients with higher education (> 8 years) and race. Results indicated that the initial unweighted classifiers confounded lower education with cognitive compromise resulting in a 100% type I error rate for this group. Thereby, the samples were re-weighted using multiple fairness metrics to achieve sensitivity/specificity and positive/negative predictive value (PPV/NPV) balance across groups. In summary, we report the FaIRClocks model, with promise to help identify and mitigate bias against people with less than 8 years of education during preoperative cognitive screening.

Potential association between obstructive lung diseases and cognitive decline

Introduction

Chronic obstructive lung diseases, such as asthma and COPD, appear to have a more extensive impact on overall functioning than previously believed. The latest data from clinical trials suggests a potential link between cognitive deterioration and chronic obstructive inflammatory lung disease. This raises the question of whether these diseases affect cognitive functions and whether any relevant biomarker may be identified.

Methods

This prospective observational study included 78 patients divided equally into asthma, COPD, and control groups (n=26, 27 and 25 respectively). The participants underwent identical examinations at the beginning of the study and after at least 12 months. The test battery comprised 16 questionnaires (11 self-rated, 5 observer-rated, assessing cognition and mental state), spirometry, and blood samples taken for PKA and CREB mRNA evaluation.

Results

A 2.3-fold increase in CREB mRNA was observed between examinations (p=0.014) for all participants; no distinctions were observed between the asthma, COPD, and control groups. Pooled, adjusted data revealed a borderline interaction between diagnosis and CREB expression in predicting MMSE (p=0.055) in COPD, CREB expression is also associated with MMSE (β=0.273, p=0.034) like with the other conducted tests (β=0.327, p=0.024) from COPD patients. No correlations were generally found for PKA, although one significant negative correlation was found between the first and second time points in the COPD group (β=-0.4157, p=0.049),.

Discussion

Chronic obstructive lung diseases, such as asthma and COPD, may have some linkage to impairment of cognitive functions. However, the noted rise in CREB mRNA expression might suggest a potential avenue for assessing possible changes in cognition, especially in COPD; such findings may reveal additional transcription factors linked to cognitive decline.

FaIRClocks: Fair and Interpretable Representation of the Clock Drawing Test for mitigating classifier bias against lower educational groups

The clock drawing test (CDT) is a neuropsychological assessment tool to evaluate a patient's cognitive ability. In this study, we developed a Fair and Interpretable Representation of Clock drawing tests (FaIRClocks) to evaluate and mitigate bias against people with lower education while predicting their cognitive status. We represented clock drawings with a 10-dimensional latent embedding using Relevance Factor Variational Autoencoder (RF-VAE) network pretrained on publicly available clock drawings from the National Health and Aging Trends Study (NHATS) dataset. These embeddings were later fine-tuned for predicting three cognitive scores: the Mini-Mental State Examination (MMSE) total score, attention composite z-score (ATT-C), and memory composite z-score (MEM-C). The classifiers were initially tested to see their relative performance in patients with low education (<= 8 years) versus patients with higher education (> 8 years). Results indicated that the initial unweighted classifiers confounded lower education with cognitive impairment, resulting in a 100% type I error rate for this group. Thereby, the samples were re-weighted using multiple fairness metrics to achieve balanced performance. In summary, we report the FaIRClocks model, which a) can identify attention and memory deficits using clock drawings and b) exhibits identical performance between people with higher and lower education levels.

Construction and validation of cognitive frailty risk prediction model for elderly patients with multimorbidity in Chinese community based on non-traditional factors

BACKGROUND AND OBJECTIVES

Early identification of risk factors and timely intervention can reduce the occurrence of cognitive frailty in elderly patients with multimorbidity and improve their quality of life. To explore the risk factors, a risk prediction model is established to provide a reference for early screening and intervention of cognitive frailty in elderly patients with multimorbidity.

METHODS

Nine communities were selected based on multi-stage stratified random sampling from May-June 2022. A self-designed questionnaire and three cognitive frailty rating tools [Frailty Phenotype (FP), Montreal Cognitive Assessment (MoCA), and Clinical Qualitative Rating (CDR)] were used to collect data for elderly patients with multimorbidity in the community. The nomogram prediction model for the risk of cognitive frailty was established using Stata15.0.

RESULTS

A total of 1200 questionnaires were distributed in this survey, and 1182 valid questionnaires were collected, 26 non-traditional risk factors were included. According to the characteristics of community health services and patient access and the logistic regression results, 9 non-traditional risk factors were screened out. Among them, age OR = 4.499 (95%CI:3.26-6.208), marital status OR = 3.709 (95%CI:2.748-5.005), living alone OR = 4.008 (95%CI:2.873-5.005), and sleep quality OR = 3.71(95%CI:2.730-5.042). The AUC values for the modeling and validation sets in the model were 0. 9908 and 0.9897. Hosmer and Lemeshow test values for the modeling set were χ2 = 3.857, p = 0.870 and for the validation set were χ2 = 2.875, p = 0.942.

CONCLUSION

The prediction model could help the community health service personnel and elderly patients with multimorbidity and their families in making early judgments and interventions on the risk of cognitive frailty.

Cognitive Frailty as a Predictor of Mortality in Older Adults: A Longitudinal Study in Peru

Objective

To evaluate the role of cognitive frailty and its components as risk factors of mortality in older adults of the Centro Médico Naval (CEMENA) in Callao, Peru during 2010-2015.

Methods

We performed a secondary analysis of data from a prospective cohort that included older adults (60 years and older) treated at the CEMENA Geriatrics service between 2010–2015. Frailty was defined as the presence of three or more criteria of the modified Fried Phenotype. Cognitive impairment was assessed using the Peruvian version of the Mini Mental State Examination (MMSE), considering a score <21 as cognitive impairment. Cognitive frailty was defined as the coexistence of both. In addition, we included sociodemographic characteristics, medical and personal history, as well as the functional evaluation of each participant.

Results

We included 1,390 older adults (mean follow-up: 2.2 years), with a mean age of 78.5 ± 8.6 years and 59.6% (n = 828) were male. Cognitive frailty was identified in 11.3% (n = 157) and 9.9% (n = 138) died during follow-up. We found that cognitive frailty in older adults (aHR = 3.57; 95%CI: 2.33–5.49), as well as its components, such as sedentary behavior and cognitive impairment (aHR = 7.05; 95%CI: 4.46–11.13), weakness and cognitive impairment (aHR = 6.99; 95%CI: 4.41–11.06), and exhaustion and cognitive impairment (aHR = 4.51; 95%CI: 3.11–6.54) were associated with a higher risk of mortality.

Conclusion

Cognitive frailty and its components were associated with a higher risk of mortality in older adults. It is necessary to develop longitudinal studies with a longer follow-up and that allow evaluating the effect of interventions in this vulnerable group of patients to limit adverse health outcomes, including increased mortality.

Demographic Characteristics, Motivation and Perception of Change as Determinants of Memory Compensation Self-Reports After Acquired Brain Injury

INTRODUCTION

Individuals with brain injuries experience cognitive and emotional changes that have long-lasting impacts on everyday life. In the context of rehabilitation, surveys have stressed the importance of compensating for memory disturbances to ease the impact of disorders on day-to-day autonomy. Despite extensive research on the nature of neurocognitive impairments following brain injury, few studies have looked at patients' perceptions of these day-to-day compensations. This study examines these perceptions; in particular, what brain-injured people believe they do to compensate for memory deficiencies in everyday life. It also investigates the determinants of reported compensation strategies (age, gender, perceived stress, change awareness and motivation to succeed).

METHODS

Eighty patients and 80 controls completed the French Memory Compensation Questionnaire, a self-report measure of everyday memory compensation. Five forms of compensation were investigated: External and Internal strategies, Reliance on social help, and investments in Time and Effort, along with two general factors: the degree of importance attached to Success (motivation) and perceptions of Change. Participants also completed measures of demographic and emotional aspects that may affect everyday compensation perceptions.

RESULTS

The brain-injured group reported significantly more frequent use of memory compensation strategies than controls, with the exception of External aids. Large effects were observed for Reliance and Effort. Demographic, motivation and perception of change determinants were found to have different effects depending on the compensation strategy, and mediated the direct effect of brain injury on reported compensation.

CONCLUSION

Clinical and rehabilitation neuropsychologists often seek to have a better sense of how their patients perceive their compensatory behaviors. In practice, such an understanding is needed to help select appropriate methods and improve the long-term impact of rehabilitation programs: memory rehabilitation will fail if neuropsychologists do not deal, first and foremost, with the emotional and metacognitive issues surrounding traumatic brain injury (TBI), rather than focusing on cognitive efficiency.

Mesenchymal Stem Cell Transplantation for the Treatment of Cognitive Frailty

As life expectancy increases, frailty and cognitive impairment have become major factors influencing healthy aging in elderly individuals. Frailty is a complicated clinical condition characterized by decreased physiological reserve and multisystem abnormalities. Cognitive frailty is a subtype of frailty that has aroused widespread concern among the scientific community and public health organizations. We herein review the pathogenesis of cognitive frailty, such as chronic inflammatory response, immunological hypofunction, imbalanced oxidative stress, reduced regenerative function, endocrine dysfunction, and energy metabolism disorder. Although existing interventions show some therapeutic effects, they do not meet the current clinical needs. To date, studies using stem cell technology for treating age-related diseases have achieved remarkable success. This suggests the possibility of applying stem cell treatment to cognitive frailty. We analyzed stem cell-based strategies for targeting anti-inflammation, antioxidation, regeneration, and immunoregulation using mesenchymal stem cells, as well as potential therapeutic targets for cognitive frailty. Based on this investigation, we propose a highly effective and low-cost stem cell-based replacement strategy. However, there is a lack of comprehensive research on the prospect of stem cell transplantation for improving cognitive frailty. In this review, we aim to provide the scientific background and a theoretical basis for testing cell therapy in future research.

Shared mechanisms for cognitive impairment and physical frailty: A model for complex systems

INTRODUCTION

We describe findings from a large study that provide empirical support for the emerging construct of cognitive frailty and put forth a theoretical framework that may advance the future study of complex aging conditions. While cognitive impairment and physical frailty have long been studied as separate constructs, recent studies suggest they share common etiologies. We aimed to create a population predictive model to gain an understanding of the underlying biological mechanisms for the relationship between physical frailty and cognitive impairment.

METHODS

Data were obtained from the longitudinal "Invecchaiare in Chianti" (Aging in Chianti, InCHIANTI Study) with a representative sample (n = 1453) of older adults from two small towns in Tuscany, Italy. Our previous work informed the candidate 132 single nucleotide polymorphisms (SNPs) and 155 protein biomarkers we tested in association with clinical outcomes using a tree boosting, machine learning (ML) technique for supervised learning analysis.

RESULTS

We developed two highly accurate predictive models, with a Model I area under the curve (AUC) of 0.88 (95% confidence interval [CI] 0.83-0.90) and a Model II AUC of 0.86 (95% CI 0.80-0.90). These models indicate cognitive frailty is driven by dysregulation across multiple cellular processes including genetic alterations, nutrient and lipid metabolism, and elevated levels of circulating pro-inflammatory proteins.

DISCUSSION

While our results establish a foundation for understanding the underlying biological mechanisms for the relationship between cognitive decline and physical frailty, further examination of the molecular pathways associated with our predictive biomarkers is warranted. Our framework is in alignment with other proposed biological underpinnings of Alzheimer's disease such as genetic alterations, immune system dysfunction, and neuroinflammation.

Molecular mechanisms in cognitive frailty: potential therapeutic targets for oxygen-ozone treatment

In the last decade, cognitive frailty has gained great attention from the scientific community. It is characterized by high inflammation and oxidant state, endocrine and metabolic alterations, mitochondria dysfunctions and slowdown in regenerative processes and immune system, with a complex and multifactorial aetiology. Although several treatments are available, challenges regarding the efficacy and the costs persist. Here, we proposed an alternative non-pharmacological, non-side-effect, low cost therapy based on anti-inflammation, antioxidant, regenerative and anti-pathogens properties of ozone, through the activation of several molecular mechanisms (Nrf2-ARE, NF-κB, NFAT, AP-1, HIFα). We highlighted how these specific processes could be implicated in cognitive frailty to identify putative therapeutic targets for its treatment. The oxigen-ozone (O₂-O₃) therapy has never been tested for cognitive frailty. This work provides thus wide scientific background to build a consistent rationale for testing for the first time this therapy, that could modulate the immune, inflammatory, oxidant, metabolic, endocrine, microbiota and regenerative processes impaired in cognitive frailty. Although insights are needed, the O₂-O₃ therapy could represent a faster, easier, inexpensive monodomain intervention working in absence of side effects for cognitive frailty.

Different Cognitive Frailty Models and Health- and Cognitive-related Outcomes in Older Age: From Epidemiology to Prevention

Frailty, a critical intermediate status of the aging process that is at increased risk for negative health-related events, includes physical, cognitive, and psychosocial domains or phenotypes. Cognitive frailty is a condition recently defined by operationalized criteria describing coexisting physical frailty and mild cognitive impairment (MCI), with two proposed subtypes: potentially reversible cognitive frailty (physical frailty/MCI) and reversible cognitive frailty (physical frailty/pre-MCI subjective cognitive decline). In the present article, we reviewed the framework for the definition, different models, and the current epidemiology of cognitive frailty, also describing neurobiological mechanisms, and exploring the possible prevention of the cognitive frailty progression. Several studies suggested a relevant heterogeneity with prevalence estimates ranging 1.0–22.0% (10.7–22.0% in clinical-based settings and 1.0–4.4% in population-based settings). Cross-sectional and longitudinal population-based studies showed that different cognitive frailty models may be associated with increased risk of functional disability, worsened quality of life, hospitalization, mortality, incidence of dementia, vascular dementia, and neurocognitive disorders. The operationalization of clinical constructs based on cognitive impairment related to physical causes (physical frailty, motor function decline, or other physical factors) appears to be interesting for dementia secondary prevention given the increased risk for progression to dementia of these clinical entities. Multidomain interventions have the potential to be effective in preventing cognitive frailty. In the near future, we need to establish more reliable clinical and research criteria, using different operational definitions for frailty and cognitive impairment, and useful clinical, biological, and imaging markers to implement intervention programs targeted to improve frailty, so preventing also late-life cognitive disorders.

Neuropsychological Assessment in Elderly Men with Benign Prostatic Hyperplasia Treated with Dutasteride

BACKGROUND AND OBJECTIVE

Benign prostatic hyperplasia (BPH) is a common disease found in elderly men and 5α-reductase (5α-R) inhibitors are a commonly used treatment option. 5α-reduced steroids are compounds that play a role in several functions across different organs and systems. In the adult brain, 5α-R accounts for neuroactive steroid production. Whether neuropsychological impairment could be due to dutasteride treatment, a 5α-R inhibitor affecting the production of dihydrotestosterone (DHT), is still unknown. The aim of our study was to investigate neuropsychological features in men receiving dutasteride.

METHODS

The Mini Mental State Examination (MMSE), the Clock Drawing Test (CDT), the Frontal Assessment Battery (FAB), the Hamilton Anxiety Rating Scale (HAM-A), the Beck Depression Inventory second edition (BDI-II) and the Short Form-12 (SF-12) questionnaire were administered in order to explore both cognitive impairment and psychological features.

RESULTS

In a sample of BPH patients (n = 40; mean age 71.4 ± 7.4 years), men receiving dutasteride showed no significant differences during the neuropsychological assessment in comparison with an age-matched control group, consisting of BPH men not receiving dutasteride (p < 0.05). No significant associations were recorded between treatment duration and any of the administered tests.

CONCLUSIONS

This is the first study investigating the neuropsychological features in dutasteride users. Our preliminary data are consistent with the safety of dutasteride under a mental profile.

The Neural Correlates of the Clock-Drawing Test in Healthy Aging

Importance: The clock-drawing test (CDT) is an important neurocognitive assessment tool, widely used as a screening test for dementia. Behavioral performance on the test has been studied extensively, but there is scant literature on the underlying neural correlates.

Purpose: To administer the CDT naturalistically to a healthy older aging population in an MRI environment, and characterize the brain activity associated with test completion.

Main Outcome and Measure: Blood-oxygen-level dependent (BOLD) functional MRI was conducted as participants completed the CDT using novel tablet technology. Brain activity during CDT performance was contrasted to rest periods of visual fixation. Performance on the CDT was evaluated using a standardized scoring system (Rouleau score) and time to test completion. To assess convergent validity, performance during fMRI was compared to performance on a standard paper version of the task, administered in a psychometric testing room.

Results: Study findings are reported for 33 cognitively healthy older participants aged 52–85. Activation was observed in the bilateral frontal, occipital and parietal lobes as well as the supplementary motor area and precentral gyri. Increased age was significantly correlated with Rouleau scores on the clock number drawing (R2) component (rho = -0.55, p < 0.001); the clock hand drawing (R3) component (rho = -0.50, p < 0.005); and the total clock (rho = -0.62, p < 0.001). Increased age was also associated with decreased activity in the bilateral parietal and occipital lobes as well as the right temporal lobe and right motor areas.

Conclusion and Relevance: This imaging study characterizes the brain activity underlying performance of the CDT in a healthy older aging population using the most naturalistic version of the task to date. The results suggest that the functions of the occipital and parietal lobe are significantly altered by the normal aging process, which may lead to performance decrements.

Towards frailty biomarkers: Candidates from genes and pathways regulated in aging and age-related diseases

OBJECTIVE

Use of the frailty index to measure an accumulation of deficits has been proven a valuable method for identifying elderly people at risk for increased vulnerability, disease, injury, and mortality. However, complementary molecular frailty biomarkers or ideally biomarker panels have not yet been identified. We conducted a systematic search to identify biomarker candidates for a frailty biomarker panel.

METHODS

Gene expression databases were searched (http://genomics.senescence.info/genes including GenAge, AnAge, LongevityMap, CellAge, DrugAge, Digital Aging Atlas) to identify genes regulated in aging, longevity, and age-related diseases with a focus on secreted factors or molecules detectable in body fluids as potential frailty biomarkers. Factors broadly expressed, related to several "hallmark of aging" pathways as well as used or predicted as biomarkers in other disease settings, particularly age-related pathologies, were identified. This set of biomarkers was further expanded according to the expertise and experience of the authors. In the next step, biomarkers were assigned to six "hallmark of aging" pathways, namely (1) inflammation, (2) mitochondria and apoptosis, (3) calcium homeostasis, (4) fibrosis, (5) NMJ (neuromuscular junction) and neurons, (6) cytoskeleton and hormones, or (7) other principles and an extensive literature search was performed for each candidate to explore their potential and priority as frailty biomarkers.

RESULTS

A total of 44 markers were evaluated in the seven categories listed above, and 19 were awarded a high priority score, 22 identified as medium priority and three were low priority. In each category high and medium priority markers were identified.

CONCLUSION

Biomarker panels for frailty would be of high value and better than single markers. Based on our search we would propose a core panel of frailty biomarkers consisting of (1) CXCL10 (C-X-C motif chemokine ligand 10), IL-6 (interleukin 6), CX3CL1 (C-X3-C motif chemokine ligand 1), (2) GDF15 (growth differentiation factor 15), FNDC5 (fibronectin type III domain containing 5), vimentin (VIM), (3) regucalcin (RGN/SMP30), calreticulin, (4) PLAU (plasminogen activator, urokinase), AGT (angiotensinogen), (5) BDNF (brain derived neurotrophic factor), progranulin (PGRN), (6) α-klotho (KL), FGF23 (fibroblast growth factor 23), FGF21, leptin (LEP), (7) miRNA (micro Ribonucleic acid) panel (to be further defined), AHCY (adenosylhomocysteinase) and KRT18 (keratin 18). An expanded panel would also include (1) pentraxin (PTX3), sVCAM/ICAM (soluble vascular cell adhesion molecule 1/Intercellular adhesion molecule 1), defensin α, (2) APP (amyloid beta precursor protein), LDH (lactate dehydrogenase), (3) S100B (S100 calcium binding protein B), (4) TGFβ (transforming growth factor beta), PAI-1 (plasminogen activator inhibitor 1), TGM2 (transglutaminase 2), (5) sRAGE (soluble receptor for advanced glycosylation end products), HMGB1 (high mobility group box 1), C3/C1Q (complement factor 3/1Q), ST2 (Interleukin 1 receptor like 1), agrin (AGRN), (6) IGF-1 (insulin-like growth factor 1), resistin (RETN), adiponectin (ADIPOQ), ghrelin (GHRL), growth hormone (GH), (7) microparticle panel (to be further defined), GpnmB (glycoprotein nonmetastatic melanoma protein B) and lactoferrin (LTF). We believe that these predicted panels need to be experimentally explored in animal models and frail cohorts in order to ascertain their diagnostic, prognostic and therapeutic potential.

Frailty Phenotype and Neuropsychological Test Performance: A Preliminary Analysis

Context

Frailty is a common problem that affects adults older than 65 years. Correlations between the frailty phenotype and neuropsychological impairment have not been thoroughly researched.

Objective

To examine the association between frailty phenotype, neuropsychological screening test results, and neuropsychological domains known to characterize patients with mild cognitive impairment and dementia.

Methods

This retrospective medical record analysis consisted of ambulatory patients aged 65 years or older seen in an outpatient geriatric practice. All patients were assessed with the Montreal Cognitive Assessment (MoCA). A portion of those patients also underwent a comprehensive neuropsychological evaluation that assessed executive control, naming/lexical access, and declarative memory expressed as 3 neuropsychological index scores. Frailty phenotype was determined using criteria by Fried et al.

Results

Simple correlation found that lower MoCA test scores were associated with a higher level of frailty (r=-0.34, P<.032). Regression analyses found that greater frailty was associated with worse performance on tests that assessed executive control and working memory (backward digit span; r2=0.267; β=-0.517; P<.011) and delayed recognition memory (r2=0.207; β=-0.455; P<.025).

Conclusion

A correlation was found between frailty and neuropsychological impairment, which suggests that frailty may be a potential indicator for the emergence of mild cognitive impairment and dementia.

Progesterone and human cognition

Progesterone is a neurosteroid and a neuroactive steroid, produced primarily by the corpus luteum and the placenta. In some animal models, progesterone affects cognitive performance, and its potential role in human cognition is especially germane to women. This role can be investigated through associations between peripheral concentrations of progesterone in blood or saliva and neuropsychological test results, through differences in cognitive profiles between women using menopausal hormone therapy with and without a progestogen, and through clinical trials. In naturally cycling reproductive-age women and pregnant women, there is no consistent relation between progesterone levels and cognition. In postmenopausal women within 6 years of menopause and not using hormone therapy, progesterone levels are positively associated with verbal memory and global cognition, but reported associations in older postmenopausal women are null. Some observational studies of postmenopausal women using hormone therapy raise concern of a small deleterious cognitive effect of progestogen (medroxyprogesterone acetate was most often reported in these studies), but this association may due to confounding factors. Small, short-term clinical trials of progesterone show no meaningful effect on cognition. The quality of evidence is low, but overall findings do not reveal consistent, clinically important effects of progesterone on cognitive function in women.

Early Detection of Alzheimer's Disease Based on the Patient's Creative Drawing Process: First Results with a Novel Neuropsychological Testing Method

Based on the knowledge of art therapy, we developed a new neuropsychological drawing test in order to identify individuals with mild cognitive impairment (MCI) as well as dementia patients and healthy controls (HC). By observing a variety of drawing characteristics of 92 participants with a mean age of 67.7, art therapy and dementia experts discriminate HC from MCI, early dementia of the Alzheimer-type (eDAT), and moderate dementia of the Alzheimer-type (mDAT) by the process analysis of tree drawings on a digitizing tablet. The art therapist's average categorical rating of healthy and MCI or demented individuals matched the clinical diagnosis by 88%. In a first small study, we analyzed interrater reliability, sensitivity, specificity, negative and positive predicted values of our tree drawing test (TDT) in comparison with the clock drawing test (CDT). Similar values of moderate interrater reliability were found for the TDT (0.56) as well as for the CDT (0.54). A significant high sensitivity of 0.9 within this binary impairment scale (HC versus impaired or demented) can be demonstrated. Substantial values for the specificity (0.67) could be obtained that however remain under a perfect value of the CDT (1.0). Considering 31 individuals that received the clinical diagnosis "impaired or demented" the TDT shows a higher recognition rate for the MCI group than the CDT. Furthermore in 8 of 12 borderline cases of clinical diagnosis, the outcome of the TDT diagnosis was consistent with the final clinical result.

The Clock Drawing Test versus Mini-mental Status Examination as a Screening Tool for Dementia: A Clinical Comparison

There is a growing incidence of dementia patients in the community, and with this growth, there is need for rapid, valid, and easily administrable tests for the screening of dementia and mild cognitive impairment in the community. This review looks at the two most commonly used tests in dementia screening, namely, the clock drawing test (CDT) and the mini-mental status examination (MMSE). Both these tests have been used in dementia screening over the past three decades and have been the subject of scrutiny of various studies, reviews, and meta-analysis. Both these tests are analyzed on their ability to assess dementia and screen for it in the community, general practice and general hospital settings. The methods of administration and scoring of each test are discussed, and their advantages and disadvantages are explained. There is also a direct comparison made between the MMSE and CDT in dementia screening. Future research needs with these tests are also elucidated.

Cognitive Frailty: Mechanisms, Tools to Measure, Prevention and Controversy

Physical frailty is often associated with cognitive impairment, possibly because of common underlying pathophysiologic mechanisms. To stimulate research in this field, the concept cognitive frailty was proposed, emphasizing the important role of brain aging. Cognitive frailty was defined as the presence of cognitive deficits in physically frail older persons without dementia. This subtype of frailty is deemed important, as it may represent a prodromal phase for neurodegenerative diseases and is potentially a suitable target for early intervention. The aim of this report is to refine the framework for the definition and mechanisms of cognitive frailty and relevant screening tools.

Targeting Cognitive Frailty: Clinical and Neurobiological Roadmap for a Single Complex Phenotype

Late-life cognitive disorders may be prevented by influencing age-related conditions such as frailty, characterized by decreased resistance to stressors and increased risk for adverse health outcomes. In the present review article, we examined clinical and epidemiological studies investigating the possible role of different frailty models in modulating the risk of Alzheimer's disease (AD), dementia, vascular dementia (VaD), mild cognitive impairment (MCI), and late-life cognitive impairment/decline that have been published over the past 3 years. Both deficit accumulation and physical frailty models were associated with late-life cognitive impairment/decline, incident dementia, AD, MCI, VaD, non-AD dementias, and AD pathology, proposing cognitive frailty as a new clinical construct with coexisting physical frailty and cognitive impairment in nondemented older subjects. Two subtypes of this new clinical condition have been recently proposed: "potentially reversible" cognitive frailty and "reversible" cognitive frailty. The physical factors should be physical prefrailty and frailty, while the cognitive impairment of potentially reversible cognitive frailty should be MCI (Clinical Dementia rating Scale = 0.5), while the cognitive impairment of reversible cognitive frailty should be pre-MCI Subjective Cognitive Decline (SCD), as recently proposed by the SCD Initiative Working Group. The mechanisms underlying the cognitive-frailty link are multifactorial and vascular, inflammatory, nutritional, and metabolic influences may be of major relevance. Considering both physical frailty and cognition as a single complex phenotype may be crucial in the prevention of dementia and its subtypes with secondary preventive trials on cognitive frail older subjects.

Cognitive Frailty: A Systematic Review of Epidemiological and Neurobiological Evidence of an Age-Related Clinical Condition

Advancing age is the focus of recent studies on familial and sporadic Alzheimer's disease (AD), suggesting a prolonged pre-clinical phase several decades before the onset of dementia symptoms. Influencing some age-related conditions, such as frailty, may have an impact on the prevention of late-life cognitive disorders. Frailty reflects a nonspecific state of vulnerability and a multi-system physiological change with increased risk for adverse health outcomes in older age. In this systematic review, frailty indexes based on a deficit accumulation model were associated with late life cognitive impairment and decline, incident dementia, and AD. Physical frailty constructs were associated with late-life cognitive impairment and decline, incident AD and mild cognitive impairment, vascular dementia, non-AD dementias, and AD pathology in older persons with and without dementia, thus also proposing cognitive frailty as a new clinical condition with co-existing physical frailty and cognitive impairment in non-demented older subjects. Considering both physical frailty and cognitive impairment as a single complex phenotype may be central in the prevention of dementia and its subtypes with secondary preventive trials on cognitive frail older subjects. The mechanisms underlying the cognitive-frailty link are multi-factorial, and vascular, inflammatory, nutritional, and metabolic influences may be of major relevance. There is a critical need for randomized controlled trials of intervention investigating the role of nutrition and/or physical exercise on cognitive frail subjects with the progression to dementia as primary outcome. These preventive trials and larger longitudinal population-based studies targeting cognitive outcomes could be useful in further understanding the cognitive-frailty interplay in older age.

Compensating for memory losses throughout aging: validation and normalization of the memory compensation questionnaire (MCQ) for non-clinical French populations

AIM

The MCQ is a seven-factor scale that measures individual differences in the tendency to select particular strategies and to overcome perceived or real memory losses. Our aim was to establish a French version of the MCQ and to evaluate its psychometric properties in a lifespan perspective. We first tested the underlying factor structure of the MCQ in a large sample of 749 adults from aged from 18 to 92 years.

RESULTS

The results showed that the factor structure of the French version corresponded well with the one obtained in English-, Dutch- and Spanish-speaking samples, supporting the cross-national robustness of the MCQ. We confirmed a seven-factor order model that supports the construct validity of the questionnaire. The reliabilities of the scales were good (α>.70) to acceptable (α=.66 and .62). Criterion validity was verified by means of significant correlations between health composites and MCQ subscales. Gender and Age affected most of the MCQ subscales but not the Level of Education (LE).

CONCLUSION

The MCQ revealed to be a heuristic tool for assessing daily compensatory behaviors that are developed in order to achieve successful aging. Thus, regression-based normative data and a user-friendly computer program were provided to facilitate scoring and norming by clinicians and researchers who need to assess daily compensatory behaviors.

Prehabilitation improves physical function of individuals with severe disability from hip or knee osteoarthritis

PURPOSE

To evaluate the effects of prehabilitation (enhancing physical capacity before total hip or knee joint arthroplasty) on pain and physical function of adults with severe hip and knee osteoarthritis (OA).

METHODS

Consecutive patients (n=650) from 2006 to 2008 with hip or knee OA awaiting total joint arthroplasty (TJA) attended a hospital outpatient clinic for a prehabilitation assessment. All participants completed self-report (Lower Extremity Functional Scale [LEFS] and visual analogue scale for pain [VAS]) and functional performance measures (self-paced walk [SPW], timed stair, and timed up-and-go [TUG] tests). A subset of 28 participants with severe disability participated in a structured outpatient prehabilitation programme. Between-group differences were assessed via independent t-tests; paired Student's t-tests and Wilcoxon signed rank tests were used to compare changes in pain and function following the prehabilitation programme.

RESULTS

A total of 28 individuals (16 female) with mean age 67 (SD 10) years and BMI 33 (8) kg/m(2) awaiting TJA (10 hips, 18 knees) participated in a prehabilitation programme of 9 (6) weeks' duration. Relative to baseline, there was significant improvement in LEFS score (mean change 7.6; 95% CI, 1.7-13.5; p=0.013), SPW (mean change 0.17 m/s; 95% CI, 0.07-0.26; p=0.001), TUG (mean change 4.2 s; 95% CI, 2.0-6.4; p<0.001), and stair test performance (mean change 3.8 s [SD 14.6]; p=0.005) following prehabilitation.

CONCLUSION

This study presents preliminary evidence that prehabilitation improves physical function even in the most severely compromised patients with OA awaiting TJA.

[Cognitive function screening of community-dwelling elderly people using the clock drawing test -quantitative and qualitative analyses]

AIM

The purpose of this study was to evaluate whether the clock drawing test (CDT) is useful to assess the cognitive function of community-dwelling elderly people. We evaluated the CDT as a tool to measure cognitive function by qualitative and quantitative analyses.

METHODS

A total of 14,949 community-dwelling elderly were invited by mail to undergo cognitive screening by CDT. Of these, 8,815 responded, of which 8,684 were eligible for enrollment. We were also able to determine the educational background of 7,404 of these. There were 3,525 men (age: 73.05±6.20 [mean±standard deviation] years old, duration of education: 11.40±2.81 years) and 3,879 women (73.67±6.66, 10.34±2.19) . The drawn clocks were evaluated using the Freedman method, and those clocks drawn with obvious errors such as no circle, numbers, or hands were recorded and analyzed. In addition, any vertical deviation from the center points was also evaluated.

RESULTS

The recorded percentages of the subjects who correctly completed the individual clock drawing test components varied. The mean total scores were 14.16±1.67 in men and 14.40±1.36 in women. The percentages of subjects with total scores of less than 13 were 16.09% in men and 11.7% in women. The percentage of subjects who made obvious errors was 3.24%, whose total points were significantly lower than those of the subjects who did not. Approximately half of all subjects showed vertical deviation from the center of the clock, and the percentage of upper deviation was greater than that of lower deviation.

CONCLUSION

CDT is useful to assess the cognitive function of community-dwelling elderly people, and it is also helpful to determine subjects with a potential risk of cognitive impairments.

Longitudinal assessment of cognitive function by clock drawing in older adults

AIMS

To test the hypotheses that performance on a clock-drawing task (CDT) diminishes over time and that poor performance is associated with development of dementia and reduced survival.

METHODS

Participants in the population-based Leisure World Cohort Study were asked to complete a CDT in follow-up questionnaires mailed in 1992 and 1998. Dementia status was determined using in-person evaluations, follow-up questionnaires, hospital data, and death certificates.

RESULTS

Of the 4,842 cohort members (mean age 80 years) who completed the CDT in 1992, 1,521 also completed it in 1998. Although performance in the CDT diminished over time in only a proportion of the cohort, the mean total score and the percentage of subjects with correctly drawn clocks decreased with each successive 5-year age group (p = 0.0001) and over time. Mean scores were lower in non-demented subjects later identified as demented compared with those who remained free of dementia. A low CDT score in 1992 was associated with a 28% increased risk of dementia and 13% reduced survival.

CONCLUSION

A CDT may help predict cognitive decline and future disability in the elderly. Identification of high-risk individuals using a CDT may lead to earlier diagnosis and treatment and improved patient management.

Predictors of clock drawing test (CDT) performance in elderly patients attending an internal medicine outpatient clinic: a pilot study on sun exposure and physical activity

Influence of sun exposure and physical activity on cognition has not been evaluated simultaneously. We aimed to evaluate predictors of clock drawing test (CDT) performance on n=125 patients attending an internal medicine outpatient clinic. Interview data was gathered on sociodemographic, health-related and lifestyle factors referring to the last year. Factors associated with obtaining a score >0 and a full score (10/10) were analyzed by univariate (UVA) and multivariate (MVA) logistic regression analyses. Mean age of the participants was 72 ± 5, 58% were women and 17% were illiterate. Mean CDT score was 4.70 ± 2.27, 61.6% scored >0 and 21.6% scored 10/10. Both duration of walking and summer sun exposure predicted a CDT score >0 in UVA. However only summer sun exposure was an independent predictor (odds ratio=OR=1.73, 95% confidence interval=CI=1.16-2.57). Other factors independently associated with obtaining a score >0 were education level (OR=2.70, 95%CI=1.77-4.12) and cerebrovascular disease (CVD) history (OR=0.08, 95%CI=0.008-0.78). Factors independently associated with obtaining a full score were weight (OR=1.05, 95%CI=1.00-1.10), education level (OR=2.04, 95%CI=1.38-3.00) and visiting the clinic alone (OR=3.92, 95%CI=1.354-11.39). Our study shows that CDT can be utilized to unravel the lifestyle factors associated with cognitive function. To our knowledge, this is the first study to suggest an association between sun exposure and cognition.

The Dutch Memory Compensation Questionnaire: psychometric properties and regression-based norms

The Memory Compensation Questionnaire (MCQ) is a psychometrically sound instrument that assesses the variety and extent to which an individual compensates for actual or perceived memory losses. Until now, only an English version of the MCQ has been psychometrically evaluated. The aim of the present study was to establish a Dutch version of the MCQ and evaluate its psychometric properties. The MCQ data of N = 556 cognitively healthy adults (61.8% females) aged between 50.1 and 95.3 years (M = 73.9 years, SD = 8.0) were analyzed. The results showed that the factor structure of the Dutch version of the MCQ corresponded well with that of the English version of the MCQ. The reliabilities of the scales of the Dutch version of the MCQ were all high (all Cronbach's αs ≥ .77). Demographic variables (especially age and gender) affected most of the MCQ scale scores. Regression-based normative data that take these demographic influences into account were established, and a user-friendly computer program was provided to facilitate the scoring and norming of the MCQ.

Is the Clock Drawing Test a screening tool for the diagnosis of mild cognitive impairment? A systematic review

BACKGROUND

The clock drawing test (CDT) is a common and widely used cognitive screening instrument for the diagnosis of dementia. However, it has remained unclear whether it is a suitable method to identify mild cognitive impairment (MCI). The aim of this paper is to review systematically the studies concerning the utility of the CDT in diagnosing MCI.

METHOD

A systematic literature search was conducted. All studies dealing with utility of CDT in diagnosing MCI regardless of the applied CDT scoring system and MCI concept were selected.

RESULTS

Nine relevant studies were identified. The majority of the studies compared average CDT scores of cognitively healthy and mildly impaired subjects, and four of them identified significant mean differences. If reported, sensitivity and specificity have been mostly unsatisfactory.

CONCLUSION

CDT should not be used for MCI-screening.

Patient clock drawing and accuracy of self-report compared with chart review for colorectal cancer (CRC) screening

The purpose of this study was to test the accuracy of patient colorectal cancer (CRC) screening self-report and CRC screening documented in their medical record for those who are cognitively impaired and those who are not based on the clock drawing task. A cross-sectional study where patient survey and medical record information were linked was conducted in 16 primary care offices. Of the 960 patients mailed questionnaires, there were 493 respondents who completed the questionnaire and clock drawing, had a chart review, and had no help in drawing the clock or completing the questionnaire. Chart review was conducted for CRC screening in physician offices. Clock drawings were scored 0-7 according to the Watson method. Accuracy of ever being screened for CRC or being up-to-date for CRC screening was determined by comparing self-report with medical records and calculating sensitivity, specificity, positive and negative predictive values, false positive rate, and false negative rate. Seventy-five clocks were abnormal, scoring 4 or more. Agreement between self-reported colonoscopy and medical record review was higher in subjects with normal clock drawings than those with abnormal clock drawings. When examining predictors of agreement/disagreement for colonoscopy screening, abnormal clock drawing was the single predictor for higher disagreement.

Can an 18-point clock-drawing scoring system predict dementia in elderly individuals with mild cognitive impairment?

The purpose of this study was to develop a clock-drawing scoring system better suited to detecting possible early markers of dementia in individuals with mild cognitive impairment (MCI). We modified the scoring system of Freedman et al. (1994), in which the major components are integrity of the circle, placement and size of the hands, and placement and sequence of the numbers. We rescored the clock-drawing test using a novel 18-point scoring system, which emphasizes hand elements-number of hands, direction indicated, and size differences. We retrospectively assessed 123 individuals (ages 58-88 years) selected from the Memory Clinic at the Jewish General Hospital in Montreal. These consisted of 21 normal elderly individuals (NORM group), 41 participants with mild cognitive impairment who did not develop dementia on follow-up visits (MCI-NP), 41 participants with mild cognitive impairment who became demented after a 48-month follow-up (MCI-D), and 20 participants diagnosed with Alzheimer's disease (AD). On the 18-point system, the MCI-NP and the MCI-D did not show any difference on overall total score (p = .166), However, using Pearson chi-squares to examine the within-categories effects comparing the mildly cognitively impaired groups (MCI-NP and MCI-D), there were three significant hand items that appear to be possible early markers of progression to dementia. The clock has two hands (p = .043), hour hand is towards correct number (p = .023), and size difference of the hands is respected (p = .004), all showed significant differences between progressors and nonprogressors. The 18-point clock-drawing scoring system may have advantages in better indicating MCI individuals more likely to progress to dementia.

The clock-drawing test: time for a change?

Clock-drawing tests are simple and rapid screening devices for dementia. It was observed that individuals <60 years of age showed similar performance with a digital prompt (" . . .make the clock read 12:45") or an analog prompt (" . . .quarter to 1"), whereas individuals >70 years of age showed improved performance with an analog prompt. The digital prompt has routinely been used to force participants to recode the prompt via conceptualization. Differential scoring across a range of ages has likely derived from the advent and increase of digital clocks with the younger segment of the population. This implies the need for as-yet undetermined alteration in the nature of prompts to force recoding as the current younger population ages.

Time that tells: critical clock-drawing errors for dementia screening

BACKGROUND

Clock-drawing tests are popular components of dementia screens but no single scoring system has been universally accepted. We sought to identify an optimal subset of clock errors for dementia screening and compare them with three other systems representative of the existing wide variations in approach (Shulman, Mendez, Wolf-Klein), as well as with the CDT system used in the Mini-Cog, which combines clock drawing with delayed recall.

METHODS

The clock drawings of an ethnolinguistically and educationally diverse sample (N = 536) were analyzed for the association of 24 different errors with the presence and severity of dementia defined by independent research criteria. The final sample included 364 subjects with > or = 5 years of education, as preliminary examination suggested different error patterns in subjects with 0-4 years of education and inadequate numbers of normal controls for reliable analysis.

RESULTS

Eleven of 24 errors were significantly associated with dementia in subjects with > or = 5 years of education, and six were combined to identify dementia with 88% specificity and 71% sensitivity: inaccurate time setting, no hands, missing numbers, number substitutions or repetitions, or refusal to attempt clock drawing. Time setting was the most prevalent error at all dementia stages, refusal occurred only in moderate and severe dementia; and ethnicity and language of administration had no effect. All critical errors increased in frequency with dementia stage. This simplified scoring system had much better specificity than two other systems (88% vs 39% for Mendez's system - 63% for Shulman's) and much better sensitivity than Wolf-Klein's (71% vs 51%). Stepwise logistic regression found the simplified system to be more strongly predictive of dementia than the three other CDT systems of dementia. Substituting the new CDT algorithm for that used in the original CDT Mini-Cog improved the Mini-Cog's specificity from 89 to 93% with minimal change in sensitivity.

CONCLUSIONS

Only six errors need be assessed to capture most of the power of clock drawing to discriminate between people with dementia and normal subjects, and improves specificity over older systems in subjects with > or = 5 years of education. These errors require minimal conceptual classification and are easily detected and scored by non-specialists.

Clock drawing performance in cognitively normal elderly

The Clock Drawing Test (CDT) is a common neuropsychological measure sensitive to cognitive changes and functional skills (e.g., driving test performance) among older adults. However, normative data have not been adequately developed. We report the distribution of CDT scores using three common scoring systems [Mendez, M. F., Ala, T., & Underwood, K. L. (1992). Development of scoring criteria for the Clock Drawing Task in Alzheimer's Disease. Journal of the American Geriatrics Society, 40, 1095-1099; Cahn, D. A., Salmon, D. P., Monsch, A. U., Butters, N., Wiederholt, W. C., & Corey-Bloom, J. (1996). Screening for dementia of the Alzheimer type in the community: The utility of the Clock Drawing Test. Archives of Clinical Neuropsychology, 11(6), 529-539], among 207 cognitively normal elderly. The systems were well correlated, took little time to use, and had high inter-rater reliability. We found statistically significant differences in CDT scores based on age and WRAT-3 Reading score, a marker of education quality. We present means, standard deviations, and t- and z-scores based on these subgroups. We found that "normal" CDT performance includes a wider distribution of scores than previously reported. Our results may serve as useful comparisons for clinicians wishing to know whether their patients perform in the general range of cognitively normal elderly.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

Correlation of Mini-Mental-State-Examination (MMSE), Syndrom-Kurztest (SKT) and Clock test (CT) scores in patients with cognitive impairment assessed by means of multiple regression and response surface analysis

The objective of our study was to assess the correlation of routine neuropsychological test results in elderly patients referred to a gerontopsychiatric ward. MMSEs, CTs and SKTs were performed in 94 patients (age: median = 74 years, range = 54-89 years; 64 f, 30 m) with mild to moderate dementia and evaluated retrospectively. Pairwise Spearman rank correlation, multiple regression and response surface analysis were used to assess relations between test results. The scores of all three tests used were reciprocally correlated (P < 0.05) yielding the following pairwise R-values: SKT versus MMSE: -0.77, SKT versus CT: 0.69, MMSE versus Clock test: -0.61. Multiple regression analysis showed a maximum correlation of 0.87 and marked standardised beta values, if SKT was chosen as dependent variable. Test scores could be well fitted to both symmetric linear (SKT = a + b x CT + c x MMSE; R(2) = 0.67, P < 0.01) and non-linear (SKT = a + b x CT + c x MMSE + d x CT(2) + e x MMSE(2) + f x CT x MMSE; R(2) = 0.67, P < 0.01) response surfaces. In conclusion, test scores of SKT, CT or MMSE in patients with dementia showed a marked correlation. In clinical practice the may be considered as almost interchangeable test options.

Nonsteroidal anti-inflammatory drugs for the prevention of Alzheimer's disease: a systematic review

OBJECTIVE

Alzheimer's disease, the most prevalent dementia, is a prominent source of chronic illness in the elderly. Laboratory evidence suggests that nonsteroidal anti-inflammatory drugs (NSAIDs) might prevent the onset of Alzheimer's disease. Since the early 1990s numerous observational epidemiological studies have also investigated this possibility. The purpose of this meta-analysis is to summarize and evaluate available evidence regarding exposure to nonaspirin NSAIDs and risk of Alzheimer's disease using meta-analyses of published studies.

METHODS

A systematic search was conducted using Medline, Biological Abstracts, and the Cochrane Library for publications 1960 onwards. All cross-sectional, retrospective, or prospective observational studies of Alzheimer's disease in relation to NSAID exposure were included in the analysis. At least 2 of 4 independent reviewers characterized each study by source of data and design, including method of classifying exposure and outcome, and evaluated the studies for eligibility. Discrepancies were resolved by consensus of all 4 reviewers.

RESULTS

Of 38 publications, 11 met the qualitative criteria for inclusion in the meta-analysis. For the 3 case-control and 4 cross-sectional studies, the combined risk estimate for development of Alzheimer's disease was 0.51 (95% Cl=0.40-0.66) for NSAID exposure. In the prospective studies, the estimate was 0.74 (95% Cl=0.62-0.89) for 4 studies reporting lifetime NSAID exposure and it was 0.42 (95% Cl=0.26-0.66) for the 3 studies reporting a duration of use of 2 or more years.

CONCLUSIONS

Based on analysis of prospective and nonprospective studies, NSAID exposure was associated with decreased risk of Alzheimer's disease. An issue that requires further exploration in future trials or observational studies is the temporal relationship between NSAID exposure and protection against Alzheimer's disease.

Clock Drawing Test-Modified and Integrated Approach (CDT-MIA): description and preliminary examination of its validity and reliability in dementia patients referred to a specialized psychogeriatric setting

The authors developed a scoring system for clock drawing, based on modification and integration of 3 established scoring methods. The Clock Drawing Test-Modified and Integrated Approach (CDT-MIA) is a 4-step, 20-item instrument, with a maximum score of 33, which emphasizes differential scoring of contour, numbers, hands, and center. It was administered to 139 patients (93 with and 46 without dementia). Dementia patients revealed significantly more impairment on the CDT-MIA total score and hours and hands subscores. Correlations between CDT-MIA and 2 CDTs were high. With receiver operating characteristics (ROC) curves, the area constructed under CDT-MIA curve was large. The best trade-off between sensitivity and specificity for CDT-MIA was the cut-point 23 (91% and 80%, respectively). The internal consistency of CDT-MIA was high, and there was a high degree of interrater reliability. Thus, CDT-MIA was found to be a valid and reliable evaluation instrument for dementia patients in a specialized setting.

The clock-drawing test in elderly Italian community dwellers: associations with sociodemographic status and risk factors for vascular cognitive impairment

To evaluate whether performance in the clock-drawing test (CDT) is associated with sociodemographic status and risk factors for cognitive impairment, we examined 744 Italian community dwellers aged > or =65 (73 +/- 6) years scoring > or =24 on the MMSE. CDT was scored by two different methods, the Sunderland and the Wolf-Klein methods. Sociodemographic, lifestyle, clinical and biochemical variables were also recorded. For both scoring methods, lower CDT scores were associated with age, poor education, increased serum C-reactive protein and history of cancer. Associations of lower CDT scores with increased serum glucose and history of cerebrovascular disease were also found for the method with the highest sensitivity to cognitive impairment. This study shows that in elderly community dwellers, CDT may be not totally free from sociodemographic biases, and that it is associated with risk factors for cognitive impairment and frailty.

A population based study on the intra and inter-rater reliability of the clock drawing test in Brazil: the Bambuí Health and Ageing Study

BACKGROUND

Reliability should be considered when selecting a scoring system since it influences validity. CDT reliability has rarely been assessed in population based studies and in developing countries. The aim of the present study was to determine intra and inter-rater reliabilities of the CDT scored by the Shulman (2000) method, in elderly with very low formal educational level from Brazil.

METHODS

CDTs performed by a random sample of 202 subjects of a population-based cohort of elderly were scored on two occasions by the same rater and by two independent raters. Reliability was measured using the kappa statistic, weighted kappa and the intraclass correlation coefficient. Data were stratified according to gender, age and schooling level.

RESULTS

Intra and inter-rater reliabilities were excellent when CDTs were classified as 'normal' (scores 4 or 5) or 'abnormal' (scores 0 to 3) (kappa = 0.99 and 0.94, respectively) and were in the good to excellent range when scored from 0 to 5 (kappa = 0.88 and 0.74, respectively). Difficulties in distinguishing between scores 4 and 5, and a low proportion of score 1 tests were found.

CONCLUSIONS

The CDT scored by the Shulman (2000) method appears to have good to excellent reliability in an elderly population with very low formal educational level. However, difficulties in distinguishing between scores 4 and 5, and a low proportion of score 1 tests suggest these scores may not be totally adequate for this population. Further studies are necessary to determine the consistency of our results in similar populations.

Neurotoxic effects of aluminium among foundry workers and Alzheimer's disease

BACKGROUND

In a cross-sectional case-control study conducted in northern Italy, 64 former aluminium dust-exposed workers were compared with 32 unexposed controls from other companies matched for age, professional training, economic status, educational and clinical features. The findings lead the authors to suggest a possible role of the inhalation of aluminium dust in pre-clinical mild cognitive disorder which might prelude Alzheimer's disease (AD) or AD-like neurological deterioration.

METHODS

The investigation involved a standardised occupational and medical history with particular attention to exposure and symptoms, assessments of neurotoxic metals in serum: aluminium (Al-s), copper (Cu-s) and zinc (Zn-s), and in blood: manganese (Mn-b), lead (Pb-b) and iron (Fe-b). Cognitive functions were assessed by the Mini Mental State Examination (MMSE), the Clock Drawing Test (CDT) and auditory evoked Event-Related Potential (ERP-P300). To detect early signs of mild cognitive impairment (MCI), the time required to solve the MMSE (MMSE-time) and CDT (CDT-time) was also measured.

RESULTS

Significantly higher internal doses of Al-s and Fe-b were found in the ex-employees compared to the control group. The neuropsychological tests showed a significant difference in the latency of P300, MMSE score, MMSE-time, CDT score and CDT-time between the exposed and the control population. P300 latency was found to correlate positively with Al-s and MMSE-time. Al-s has significant effects on all tests: a negative relationship was observed between internal Al concentrations, MMSE score and CDT score; a positive relationship was found between internal Al concentrations, MMSE-time and CDT-time. All the potential confounders such as age, height, weight, blood pressure, schooling years, alcohol, coffee consumption and smoking habit were taken into account.

CONCLUSIONS

These findings suggest a role of aluminium in early neurotoxic effects that can be detected at a pre-clinical stage by P300, MMSE, MMSE-time, CDT-time and CDT score, considering a 10 micrograms/l cut-off level of serum aluminium, in aluminium foundry workers with concomitant high blood levels of iron. The authors raise the question whether pre-clinical detection of aluminium neurotoxicity and consequent early treatment might help to prevent or retard the onset of AD or AD-like pathologies.

The clock drawing test and questionable dementia: reliability and validity

OBJECTIVES

In order to evaluate the suitability of the clock drawing test (CDT) for the detection of questionable dementia (QD), we assessed the inter-rater reliabilities and intercorrelations of four common scoring methods of the CDT in a sample of non-demented subjects and determined the concurrent validity.

METHODS

The study sample consisted of 253 discharged general hospital patients, aged between 65 and 85 years. Subjects were screened for cognitive impairment during their hospital stay. Four to six weeks after discharge each non-demented patient was visited at home and interviewed by a trained psychologist. The interview procedure included a cognitive test battery incorporating the CDT, the Mini-Mental State Examination (MMSE), the Syndrome Short Test (SKT), and a verbal fluency test (VF). The criteria of the Clinical Dementia Rating (CDR) were used to differentiate between cognitively normal subjects and those with QD. Clock drawings were scored independently and blindly by two raters according to four different methods. The agreement between raters was assessed, as well as the agreement between the different scoring methods. The association of gender, education, age, test performance and CDR-rating with CDT scores was examined. Accuracy of the CDT for the detection of QD was calculated.

RESULTS

Inter-rater reliabilities were high for all four scoring methods. However, substantial differences among the scoring methods were observed, the proportion of abnormal test results varying between 9% and 50%. The CDT correlated significantly with MMSE, SKT and VF, but correlation coefficients were low (r = 0.13 to r = 0.32). Furthermore, CDT scores were influenced by age, gender, and education. Sensitivity of the CDT for QD was 66%, specificity was 65%; the negative predictive value was 73%, the positive predictive value 58%.

CONCLUSION

In a sample of non-demented elderly, the reliability of the CDT was sufficiently high, but the different scoring methods were not equivalent. When established cut-off scores were used, the proportion of abnormal CDTs were significantly different. Concurrent validity with other common cognitive tests was unsatisfactory. The CDT lacks sufficient sensitivity and specificity for the identification of QD and should not be used alone to screen for possible prodromal stages of dementing illnesses. The association of age, gender and level of education with CDT scores should be taken into account by clinicians using the CDT.