The Portuguese version of Addenbrooke’s Cognitive Examination–Revised (ACE-R) in the diagnosis of subcortical vascular dementia and Alzheimer’s disease

Shorter Reperfusion Time in Stroke is Associated with Better Cognition

BACKGROUND

Cognitive changes that result from cerebrovascular disease contribute to a poor functional outcome with reduced quality of life. Among patients undergoing endovascular therapy (EVT), we aim to assess cognitive function and evaluate the impact of reperfusion time in cognitive performance.

METHODS

Patients with acute right anterior circulation strokes that underwent EVT between January 2018 and August 2020 at Centro Hospitalar de Vila Nova de Gaia/Espinho, participated in the study. Modified treatment in cerebral infarction (mTICI) assessed the level of recanalization. Cognitive evaluation was assessed with Addenbrooke's Cognitive Examination revised (ACE-R). Multiple linear regression analyses were used to determine the association between time for recanalization and ACE-R. The level of significance adopted was 0.05.

RESULTS

The mean age of participants was 71.5 (interquartile range [IQR] 62.0-78.2) years, and 50% (22) were women. The median time after stroke was 28.6 months (IQR 18.94-31.55). All patients in our sample had a successful level of recanalization with EVT (mTICI ≥ 2b). Time for recanalization showed an inverse association with the ACE-R (b = -0.0207, P = 0.0203). Also the mRS at 3 months had an inverse association with cognition (b = -5.2803, p = 0.0095). Level of education had a strong and direct relationship with ACE-R results (b = 3.0869, p < 0.0001).

CONCLUSIONS

Longer time between stroke symptoms and recanalization with EVT in patients with right hemisphere ischemic stroke lead to lower ACE-R scores. Measures to improve door-to-recanalization time are also important for cognitive performance after ischemic stroke.

HLA-A23/HLA-A24 serotypes and dementia interaction in the elderly: Association with increased soluble HLA class I molecules in plasma

MHC class I molecules regulate brain development and plasticity in mice and HLA class I molecules are associated with brain disorders in humans. We investigated the relationship between plasma-derived soluble human HLA class I molecules (sHLA class I), HLA class I serotypes and dementia. A cohort of HLA class I serotyped elderly subjects with no dementia/pre-dementia (NpD, n = 28), or with dementia (D, n = 28) was studied. Multivariate analysis was used to examine the influence of dementia and HLA class I serotype on sHLA class I levels, and to compare sHLA class I within four groups according to the presence or absence of HLA-A23/A24 and dementia. HLA-A23/A24 and dementia, but not age, significantly influenced the level of sHLA class I. Importantly, the concurrent presence of HLA-A23/A24 and dementia was associated with higher levels of sHLA class I (p < 0.001). This study has shown that the simultaneous presence of HLA-A23/HLA-A24 and dementia is associated with high levels of serum sHLA class I molecules. Thus, sHLA class I could be considered a biomarker of neurodegeneration in certain HLA class I carriers.

The clinical profile of cerebral small vessel disease: Toward an evidence-based identification of cognitive markers

There is no consensus on which test is more suited to outline the cognitive deficits of cerebral small vessel disease (cSVD) patients. We explored the ability of eight cognitive tests, selected in a previous systematic review as the most commonly used in this population, to differentiate among cSVD patients, controls, and other dementing conditions performing a meta-analysis of 86 studies. We found that cSVD patients performed worse than healthy controls in all tests while data on the comparison to neurodegenerative diseases were limited. We outlined a lack of data on these tests' accuracy on the diagnosis. Cognitive tests measuring processing speed were those mostly associated with neuroimaging cSVD markers. There is currently incomplete evidence that a single test could differentiate cSVD patients with cognitive decline from other dementing diseases. We make preliminary proposals on possible strategies to gain information about the clinical definition of cSVD that currently remains a neuroimaging-based one.

Applications of artificial intelligence to aid early detection of dementia: A scoping review on current capabilities and future directions

BACKGROUND & OBJECTIVE

With populations aging, the number of people with dementia worldwide is expected to triple to 152 million by 2050. Seventy percent of cases are due to Alzheimer's disease (AD) pathology and there is a 10-20 year 'pre-clinical' period before significant cognitive decline occurs. We urgently need, cost effective, objective biomarkers to detect AD, and other dementias, at an early stage. Risk factor modification could prevent 40% of cases and drug trials would have greater chances of success if participants are recruited at an earlier stage. Currently, detection of dementia is largely by pen and paper cognitive tests but these are time consuming and insensitive to the pre-clinical phase. Specialist brain scans and body fluid biomarkers can detect the earliest stages of dementia but are too invasive or expensive for widespread use. With the advancement of technology, Artificial Intelligence (AI) shows promising results in assisting with detection of early-stage dementia. This scoping review aims to summarise the current capabilities of AI-aided digital biomarkers to aid in early detection of dementia, and also discusses potential future research directions.

METHODS & MATERIALS

In this scoping review, we used PubMed and IEEE Xplore to identify relevant papers. The resulting records were further filtered to retrieve articles published within five years and written in English. Duplicates were removed, titles and abstracts were screened and full texts were reviewed.

RESULTS

After an initial yield of 1,463 records, 1,444 records were screened after removal of duplication. A further 771 records were excluded after screening titles and abstracts, and 496 were excluded after full text review. The final yield was 177 studies. Records were grouped into different artificial intelligence based tests: (a) computerized cognitive tests (b) movement tests (c) speech, conversion, and language tests and (d) computer-assisted interpretation of brain scans.

CONCLUSIONS

In general, AI techniques enhance the performance of dementia screening tests because more features can be retrieved from a single test, there are less errors due to subjective judgements and AI shifts the automation of dementia screening to a higher level. Compared with traditional cognitive tests, AI-based computerized cognitive tests improve the discrimination sensitivity by around 4% and specificity by around 3%. In terms of speech, conversation and language tests, combining both acoustic features and linguistic features achieve the best result with accuracy around 94%. Deep learning techniques applied in brain scan analysis achieves around 92% accuracy. Movement tests and setting smart environments to capture daily life behaviours are two potential future directions that may help discriminate dementia from normal aging. AI-based smart environments and multi-modal tests are promising future directions to improve detection of dementia in the earliest stages.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

BACKGROUND AND PURPOSE

The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis.

METHODS

Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations.

RESULTS

There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes.

CONCLUSIONS

These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.

Personalized Cognitive Stimulation through Personhood: A Case Report on Dementia Diagnosis Acceptance and Therapeutic Engagement

Objectives: Dementia related cognitive impairment, as forgetting recent memories, brings several emotional challenges to patients and their families. This paper reports a case of a non-collaborative high-education level patient. who recurrently refused a set of conventional cognitive stimulation exercises, as he also was in refusal of his cognitive impairment. The aim of this report is to show the benefits of a personalized cognitive stimulation (PCS) program.Methods: A24-sessions PCS program was conceived within a person-centered care approach and in active co-creation between the therapist and the patient.Results: The results evidence the patient's increasing therapeutic engagement in the proposed activities, along with mild cognitive improvement. This procedure also promoted a diagnosis acceptance and the patient's mood stabilization. Two illustrative materials used in this tailored intervention are available as supplemental material.Conclusions: Cognitive stimulating programs benefit from tailoring and personalization. Personalization indeed helped the patient feeling engaged and increased his participation in the activities. Furthermore, his mood stabilized, and the patient accepted his cognitive impairments. Thus, PCS is a way of reaching person-centered care.Clinical implications: PCS may be used to improve patient's engagement in the stimulating activities. Also, PCS promoted the dementia diagnosis acceptance..

Cognitive screening instruments to identify vascular cognitive impairment: A systematic review

INTRODUCTION

Vascular cognitive impairment (VCI) is common and important to detect as controlling risk factors, particularly hypertension, may slow onset and progression. There is no consensus as to which cognitive screening instrument (CSI) is most suitable for VCI. We systematically reviewed the psychometric properties of brief CSIs for vascular mild cognitive impairment (VMCI) and vascular dementia (VaD).

METHODS

Literature searches were performed using scholarly databases from inception until 31 May 2018. Studies were eligible if participants were aged 18 or older, interviewed face-to-face, and standard diagnostic criteria for VCI were applied, excluding those specifically identifying post-stroke dementia. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

RESULTS

Fifteen studies were identified including eight types of CSIs (27 subtests/variants) and 4575 participants (1015 with VCI), mean age range: 51.6 to 75.5 years. Most studies compared more than one instrument. Five papers examined clock-drawing; four, the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE); and three used the Brief Memory and Executive Test (BMET). The MoCA (AUC > 0.90) and MMSE (AUC: 0.86-0.99) had excellent accuracy in differentiating VaD from controls; the MoCA had good internal consistency (Cronbach's α: .83-.88). The MoCA (AUC: 0.87-0.93) and BMET (AUC: 0.94) had the greatest accuracy in separating VMCI from controls. Most studies had low to moderate risk of bias in all domains of the QUIPS. Data were heterogeneous, precluding a meta-analysis.

CONCLUSIONS

Although few studies were available and further research is required, data suggests that the MoCA is accurate and reliable for differentiating VaD and VMCI from controls.

Systematic review of the diagnostic accuracy of the non-English versions of Addenbrooke's cognitive examination - revised and III

OBJECTIVE

This systematic review aims to review the evidence for the diagnostic accuracy of the non-English updated versions of Addenbrooke's Cognitive Examination (ACE) - the ACE-Revised (ACE-R) and the ACE-III - in the diagnosis of dementia.

METHODS

A systematic search resulted in 16 eligible studies evaluating the diagnostic accuracy of ACE-R and ACE-III in ten different languages. Most studies were assessed as of medium to low quality using Standards for Reporting of Diagnostic Accuracy (STARD) guidance.

RESULTS

The findings of excellent diagnostic accuracy are compromised by the methodological limitations of studies. While studies generally reported excellent diagnostic accuracy across and within different languages, optimal cut-offs even within particular language versions, varied.

CONCLUSION

There is a need for future research to address these limitations through adherence to STARD guidelines. The ACE-III is particularly under-evaluated and should be a focus of future research. The variance in obtained optimal cut-offs within language versions is an issue compromising clinical utility and could be addressed in future work through use of a-priori defined thresholds.

Comparing Sensitivity and Specificity of Addenbrooke's Cognitive Examination-I, III and Mini-Addenbrooke's Cognitive Examination in Parkinson's Disease

Background

Parkinson's disease (PD) is the second most common neurodegenerative disorder characterized by numerous motor and nonmotor symptoms. Neurocognitive disorders (NCD) are one of the most troublesome problems and their diagnosis is often challenging.

Methods

We compared the sensitivity and specificity of several versions of Addenbrooke Cognitive Examination (ACE, ACE-III, and Mini-ACE) on 552 subjects with PD. Normal cognition, mild and major NCD were judged in accordance with the respective criteria of the Diagnostic and Statistical Manual of Mental Disorders 5^th edition. Subsequently, we applied the receiver operation characteristic (ROC) analysis in comparison of different education levels.

Results

For subjects with education level 0–8 and 9–12 years, the ACE-III had the best discriminating capabilities for mild NCD (cut-off scores: 83.5 and 85.5 points, respectively), while Mini-ACE was the best for subjects having education > 12 years (cut-off score: 25.5 points). For detecting major NCD, ACE-III had the best diagnostic accuracy in all levels of education (cut-off scores: 70.5, 77.5, and 78.5 points for subjects having education level 0–8, 9–12, and >12 years, respectively).

Conclusion

ACE-III and its nested version, the Mini-ACE, had the best screening abilities for detecting mild and major NCD in PD.

Addenbrooke's cognitive examination-revised: normative and accuracy data for seniors with heterogeneous educational level in Brazil

BACKGROUND

Several cognitive tools have been developed aiming to diagnose dementia. The cognitive battery Addenbrooke's Cognitive Examination - Revised (ACE-R) has been used to detect cognitive impairment; however, there are few studies including samples with low education. The aim of the study was to provide ACE-R norms for seniors within a lower education, including illiterates. An additional aim was to examine the accuracy of the ACE-R to detect dementia and cognitive impairment no dementia (CIND).

METHODS

Data originated from an epidemiological study conducted in the municipality of Tremembé, Brazil. The Brazilian version of ACE-R was applied as part of the cognitive assessment in all participants. Of the 630 participants, 385 were classified as cognitively normal (CN) and were included in the normative data set, 110 individuals were diagnosed with dementia, and 135 were classified as having CIND.

RESULTS

ACE-R norms were provided with the sample stratified into age and education bands. ACE-R total scores varied significantly according to age, education, and sex. To distinguish CN from dementia, a cut-off of 64 points was established (sensitivity 91%, specificity 76%) and to differentiate CN from CIND the best cut-off was 69 points (sensitivity 73%, specificity 65%). Cut-off scores varied according to the educational level.

CONCLUSIONS

This study offers normative and accuracy parameters for seniors with lower education and it should expand the use of the ACE-R for this population segment.