Assessing the criterion validity of four highly abbreviated measures from the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS)

Incremental validity of brief and abbreviated neuropsychological tests toward predicting functional outcomes in multiple sclerosis

OBJECTIVE

This study examined the relationships among functional outcomes and performance on standard-length and abbreviated cognitive screening measures for multiple sclerosis (MS).

METHOD

72 adults with MS underwent neurological examination and cognitive screening. They completed standard-length and abbreviated versions of tests from the Minimal Assessment of Cognitive Function in MS (MACFIMS), the abbreviated aMACFIMS, and the Brief International Cognitive Assessment for MS (BICAMS). Functional outcomes included neurological disability, physical and psychological dysfunction, and employment status.

RESULTS

Concordance of impairment classifications was examined between standard-length and abbreviated tests using logistic regression and ROC curve analyses. Overall, the abbreviated test versions showed a broad range of concordance with impairment classifications made using the full-length tests. Processing speed was the strongest correlate of neurological disability and employment status; immediate recall was the strongest predictor of subjective physical dysfunction. Test performance provided unique value toward predicting neurological disability and employment status, but not physical and psychological dysfunction.

CONCLUSIONS

The findings replicate some support for abbreviated tests in MS assessment, although caveats regarding loss of validity associated with abbreviation remain. The findings extend prior research showing that abbreviated tests of processing speed and immediate recall can provide unique predictive information regarding objective functional outcomes.

Identifying prospective memory deficits in multiple sclerosis: Preliminary evaluation of the criterion and ecological validity of a single item version of the memory for intentions test (MIST)

Objectives: Difficulties with prospective memory (PM) are not routinely assessed in persons with multiple sclerosis (MS) even though they can impact daily functioning. This study aimed to examine the preliminary criterion and ecological validity of a highly abbreviated Memory for Intentions Test (MIST) intended to serve as an initial screening of PM in persons with MS. Methods: Participants (n = 112) were classified as impaired if they performed 1.5 standard deviations below the normative mean on the MIST. Individual MIST trials with adequate difficulty and discriminability were examined using receiver operating characteristic analyses, with their classification accuracies, sensitivities, and specificities compared to each other. Regressions were run to evaluate their ecological validity, with appointment attendance and employment as the outcomes. Results: Two trials had a classification accuracy of ≥80%: Trial 3 (79% sensitivity, 84% specificity) and Trial 4 (57% sensitivity, 91% specificity). These two trials had comparable specificity (p=.127), with Trial 3 having slightly higher sensitivity (p=.083). Only Trial 4 was significantly associated with appointment attendance (b = 1.63, p=.047) and unemployment (aOR = 11.20, p=.027). Discussion:Trial 4 of the MIST, a verbal task with a time-based cue that requires participants to complete a pre-specified response after a 15-minute delay, has the potential to be a screener for PM.

Sensitivity of conventional cognitive tests in multiple sclerosis: Application of item response theory

BACKGROUND

Cognitive impairment (CI) is common in Multiple Sclerosis (MS), and its prevalence rate ranges between 22% and 70%. Because CI significantly impacts vocational status, caregiver burden, and quality of life, an accurate neuropsychological assessment is required. Three widely used and validated batteries for MS-associated CI are the Brief Repeatable Neuropsychological Battery (BRN-B), the Minimal Assessment of Cognitive Function (MACFIMS), and the Brief International Cognitive Assessment (BICAMS). Although similar, these batteries differ in time-consuming and in specific tests employed. This study aims to assess the sensitivity of cognitive tests included in these batteries through an Item Response Theory approach.

METHODS

Ninety-seven patients with MS and 91 demographically matched controls (HC) were consecutively assessed using the three neuropsychological batteries (i.e., BRN-B, MACFIMS, and BICAMS). Continuous Response Model (CRM) was used to identify the cognitive test(s) that best discriminate patients with MS from HC. Receiver Operating Characteristic (ROC) curve analysis was used to determine the accuracy of the CRM results.

RESULTS

Cognitive tests loaded on two different latent variables: the 'higher-order executive functioning,' consisting of tests assessing concept formation, problem-solving, and inhibitory control, and the 'memory and information processing speed,' comprising tests assessing long-term, working memory, and information processing speed. The Delis Kaplan Executive Functioning System-Sorting Test and the Stroop Test were the most sensitive tests in differentiating cognitive functioning between MS and HC.

CONCLUSIONS

This study confirms the importance of including a more extensive executive assessment in MS clinical practice since higher-order executive functions (e.g., abstraction and inhibitory control) significantly impact patients' quality of life and functional autonomy. Clinical implications of careful dissection of executive functioning in MS neuropsychological assessment are discussed.

The Role of Cognitive Impairment on Physical Therapy Attendance and Outcomes in Multiple Sclerosis

BACKGROUND AND PURPOSE

Many persons with multiple sclerosis (PwMS) experience cognitive impairments, which may affect their ability to engage in physical therapy. There is limited information on how cognitive impairments are associated with PwMS' ability to participate and improve their functional outcomes. This study aimed to assess the relationship between cognitive functioning and PwMS' attendance, total goal attainment, and functional improvement following physical therapy intervention.

METHODS

Participants (n = 45) were PwMS who participated in a larger self-management study and enrolled in physical therapy within the past 2 years. Objective cognitive functioning was examined using tests of prospective memory, retrospective memory, working memory, and processing speed, along with a self-report measure. Bivariate analyses were conducted to examine the relationship between cognitive functioning and each physical therapy outcome (session attendance, attaining goals, and changes in functional outcome measures), followed by logistic regressions with age, education, gender, and disability level as covariates.

RESULTS

Difficulty learning new verbal information was associated with a greater likelihood of "no showing" one or more of their physical therapy sessions. Reductions in working memory and processing speed were associated with PwMS not meeting all their rehabilitation goals. Despite deficits in new learning, memory, and processing speed, 85.2% of those with pre-/postscores showed improvements in at least one functional outcome measure following physical therapy intervention.

DISCUSSION AND CONCLUSIONS

These findings demonstrate the ability for PwMS to make functional motor gains despite the presence of cognitive impairments and highlight the potential contributions of cognitive functioning on attendance and goal attainment of physical therapy intervention.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A362, which includes background, methods, results, and discussion in the authors' own voices).

Managing Cognitive Dysfunction in Multiple Sclerosis: A Snapshot of Changes in Screening, Assessment, and Treatment Practices

Background: Cognitive dysfunction is prevalent in multiple sclerosis (MS) and can have a negative effect on several aspects of the daily lives of persons with MS. In 2010, members of the Consortium of Multiple Sclerosis Centers (CMSC) were surveyed to understand MS clinicians’ screening, assessment, and treatment practices for cognitive problems. Given the advancements made in the field in the past decade, it was deemed time to reevaluate how cognitive dysfunction is managed in the clinical setting.

Methods: An online questionnaire was completed by 56 CMSC members in which they were asked to describe their clinical practices, procedures for screening and further evaluation, and treatment recommendations for cognitive dysfunction. Participants were also asked whether their practice had changed in terms of the number of cognitive screenings, prescriptions for cognitive problems, and referrals for neuropsychological assessment and cognitive remediation in the past 5 years to allow for clinicians who had not been in practice for 10 years.

Results: Participants reported an increase in the number of cognitive screenings and referrals for neuropsychological assessments and cognitive remediation during the past 5 years. Compared with 2010, participants endorsed greater use of person-administered screening measures, such as the Symbol Digit Modalities Test, and fewer prescriptions for medications to improve cognitive functioning.

Conclusions: Clinical practices are becoming more in line with the literature, with increased use of cognitive screening and remediation. Continued attention to cognitive problems will be an ongoing important component of MS-related care.

Structural and Functional Connectivity Substrates of Cognitive Impairment in Multiple Sclerosis

Cognitive impairment (CI) occurs in 43 to 70% of multiple sclerosis (MS) patients at both early and later disease stages. Cognitive domains typically involved in MS include attention, information processing speed, memory, and executive control. The growing use of advanced magnetic resonance imaging (MRI) techniques is furthering our understanding on the altered structural connectivity (SC) and functional connectivity (FC) substrates of CI in MS. Regarding SC, different diffusion tensor imaging (DTI) measures (e.g., fractional anisotropy, diffusivities) along tractography-derived white matter (WM) tracts showed relevance toward CI. Novel diffusion MRI techniques, including diffusion kurtosis imaging, diffusion spectrum imaging, high angular resolution diffusion imaging, and neurite orientation dispersion and density imaging, showed more pathological specificity compared to the traditional DTI but require longer scan time and mathematical complexities for their interpretation. As for FC, task-based functional MRI (fMRI) has been traditionally used in MS to brain mapping the neural activity during various cognitive tasks. Analysis methods of resting fMRI (seed-based, independent component analysis, graph analysis) have been applied to uncover the functional substrates of CI in MS by revealing adaptive or maladaptive mechanisms of functional reorganization. The relevance for CI in MS of SC–FC relationships, reflecting common pathogenic mechanisms in WM and gray matter, has been recently explored by novel MRI analysis methods. This review summarizes recent advances on MRI techniques of SC and FC and their potential to provide a deeper understanding of the pathological substrates of CI in MS.

Mobile-phone-based e-diary derived patient reported outcomes: Association with clinical disease activity, psychological status and quality of life of patients with multiple sclerosis

BACKGROUND

The applicability of mobile digital technology to promote clinical care of people with multiple sclerosis (pwMS) is gaining increased interest as part of the implementation of patient-centered approaches. We aimed at assessing adherence to a smartphone-based e-diary, which was designed to collect patient-reported outcomes (PROs). Secondary objectives were to evaluate the construct and predictive validity of e-diary derived PROs and to explore the various factors that were associated with changes in PROs over time.

MATERIALS AND METHODS

In this observational cohort study patients downloaded an MS tailored e-diary into their personal smartphones. Report of PROs was enquired once monthly for a period of one year through a smartphone-based application, using previously validated tools. An e-diary derived bodily function summary score (eBF) was defined as the sum of scores depicting vision, limbs function, pain, bowl/ bladder dysfunction, pseudobulbar affect and spasticity. Multiple linear regression and analysis of covariance were used to determine the association between PROs, clinician-reported outcomes (ClinROs) of disease activity and quality of life (QoL). Regression coefficient analysis was used to compare the slope of change in eBF before and after a relapse.

RESULTS

97 pwMS downloaded the e-diary [Female: 64 (66%), EDSS 3.4±2.1]. 76 patients (78%) completed the 12-month study period. 53 patients (55%) submitted ≥75% of requested surveys. Anxiety was negatively associated with adherence to periodic PROs assessments by the e-diary. E-diary derived PROs were significantly correlated with corresponding functional system scores (0.38< r <0.8, P<0.001). eBF score significantly predicted QoL (β = -0.36, P = 0.001) while EDSS did not. Change in eBF score over time was independently associated with the occurrence of an MS relapse (F = 4.4, P = 0.04), anxiety (F = 6.4, P = 0.01) and depression (F = 5.1, P = 0.03). Individual regression slopes of eBF scores were significantly higher pre-relapse than post-relapse (3.0±3.3 vs. -0.8±2.0, P = 0.007).

CONCLUSION

Adherence of pwMS to recording in an e-diary collecting PROs was high. Changes in e-diary derived PROs over time predict clinical MS relapses on the group level and thus carry the potential of usage in clinical research as well as for improved MS care in real world setting.

Identifying Early Neuropsychological Indicators of Cognitive Involvement in Multiple Sclerosis

Multiple sclerosis (MS) is a debilitating disease of the central nervous system that is most commonly seen in early to middle adulthood, although it can be diagnosed during childhood or later in life. While cognitive impairment can become more prevalent and severe as the disease progresses, signs of cognitive involvement can be apparent in the early stages of the disease. In this review, we discuss the prevalence and types of cognitive impairment seen in early MS, including the specific measures used to identify them, as well as the challenges in characterizing their frequency and progression. In addition to examining the progression of early cognitive involvement over time, we explore the clinical factors associated with early cognitive involvement, including demographics, level of physical disability, disease modifying therapy use, vocational status, and psychological and physical symptoms. Given the prevalence and functional impact these impairments can have for persons with MS, considerations for clinicians are provided, such as the role of early cognitive screenings and the importance of comprehensive neuropsychological assessments.

Cognitive and motor slowing mediate the relationship between depression and falls in multiple sclerosis patients

OBJECTIVE

Given the limited research concerning the relationship between depression and falls in multiple sclerosis (MS), this study aimed to examine the direct and indirect association between fall history and depressive symptoms.

METHODS

One hundred and forty seven MS patients had completed at least one neuropsychological assessment that included detailed information regarding fall history, as well as measures of depression, motor function, and cognitive processing speed.

RESULTS

Fall history was associated with higher depressive symptoms and poorer overall motor function. Higher self-reported depressive symptoms were associated with higher odds of falls in the last year (OR = 1.64, 95% CI 1.16, 2.31) in an age adjusted model. Cognitive and motor slowing serially mediated the relationship between depressive symptoms and fall history (estimate = 0.060, 95% CI = 0.01, 0.15).

CONCLUSIONS

With the extensive research on the cognitive and motor correlates of falls in MS, our findings suggest that depressive symptoms are also associated with falls in people with MS. Moreover, this study provides preliminary support for a pathway by which depressive symptoms are related to falls in part through their relationships with cognitive and motor slowing.

Treatment and management of cognitive dysfunction in patients with multiple sclerosis

Cognitive impairment is a common and devastating manifestation of multiple sclerosis (MS). Although disease-modifying therapies have been efficacious for reducing relapse rates in MS, such treatments are ineffective for treating cognitive dysfunction. Alternative treatment approaches for mitigating cognitive problems are greatly needed in this population. To date, cognitive rehabilitation and exercise training have been identified as possible candidates for treating MS-related cognitive impairment; however, cognitive dysfunction is still often considered to be poorly managed in patients with MS. This Review provides a comprehensive overview of recent developments in the treatment and management of cognitive impairment in people with MS. We describe the theoretical rationales, current states of the science, field-wide challenges and recent advances in cognitive rehabilitation and exercise training for treating MS-related cognitive impairment. We also discuss future directions for research into the treatment of cognitive impairment in MS that should set the stage for the inclusion of cognitive rehabilitation and exercise training into clinical practice within the next decade.

Can semantic fluency be used as an alternative or additional measure in the abbreviated Minimal Assessment of Cognitive Function in Multiple Sclerosis (aMACFIMS)?

BACKGROUND

The abbreviated Minimal Assessment of Cognitive Function in Multiple Sclerosis (aMACFIMS) was designed using four shortened measures from the MACFIMS. Semantic fluency was suggested as an alternative task; however, its equivalency as part of this battery has yet to be examined.

OBJECTIVES

1) To determine the optimal semantic fluency raw score cut-offs; 2) compare the modified aMACFIMS (with semantic fluency) to the standard aMACFIMS (with phonemic fluency); and 3) compare the expanded aMACFIMS (with both verbal fluency measures) to the Brief International Cognitive Assessment in MS (BICAMS).

METHODS

Receiver-operating-characteristic curves were used to identify the optimal cut-off at -1.5 and - 2.0 standard deviation (SD) impairment criteria (n = 335). The diagnostic accuracies were compared between the different versions of the aMACFIMS and BICAMS (n = 146).

RESULTS

The raw score cut-offs for semantic fluency (13 and 11 words) had high sensitivity (100%) and specificity (96.6% - 98.6%). The modified aMACFIMS did not significantly differ from the standard aMACFIMS. The expanded aMACFIMS had stronger specificity (84.8%) and positive predictive value (85.9%) than the BICAMS.

CONCLUSIONS

Semantic fluency can be used as an alternative, though including both measures results in the most effective aMACFIMS version. Using semantic fluency may be especially valuable when evaluating older PwMS.

D-KEFS ST Failure Identifies Multiple Sclerosis Patients With Worse Objective and Self-Perceived Physical and Cognitive Disability

Background and Objectives: The Brief Repeatable Battery of Neuropsychological Test (BRB-NT) does not explore the executive functions. We combined BRB-NT and Delis-Kaplan Executive Function System Sorting Test (D-KEFS ST) to obtain a more comprehensive evaluation of cognitive impairment in Multiple Sclerosis (MS) patients.

Methods: 137 Relapsing Remitting MS (RRMS) patients underwent a detailed neuropsychological assessment including BRB-NT, D-KEFS ST and self-administrated questionnaires, namely the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), the Fatigue Severity Scale (FSS) and the Beck Depression Inventory-Second Edition (BDI-II).

Results: Fifty-four patients (39.4%) had normal scores in each item of both batteries (cognitive normal), while 64 patients (46.7%) failed in at least one test of BRB-NT but not of D-KEFS ST (BRB-NT impaired) and 18 (13.1%) failed in at least one test of both batteries (BRB-NT+D-KEFS ST impaired). Only one patient (0.7%) failed in D-KEFS ST, but not in BRB-NT and was excluded from further analysis. BRB-NT+D-KEFS ST impaired patients had a significant higher mean disease duration and median EDSS score (15.5 ± 13.6 years and 3.5, respectively) compared to those with only BRB-NT impaired (7.9 ± 9.2, p < 0.01 and 2.5, p < 0.05) and with cognitive normal patients (6.7 ± 9.4, p < 0.005 and 2.0, p < 0.01). SDMT was more frequently impaired in BRB-NT+D-KEFS ST impaired patients (77.8%) compared to only BRB-NT impaired ones (20.0%, p < 0.001). The failure in D-KEFS ST was associated with the number of failed BRB-NT items (OR 1.46, IC95% 1.07–1.99, p < 0.05) and with pathological SDMT z-value (OR 10.56, IC95% 2.50–44.66, p < 0.005). Compared to BRB-NT impaired patients and the cognitive normal ones, BRB-NT+D-KEFS ST impaired patients had significant higher MSNQ (p < 0.01) and BDI-II (p < 0.05) values.

Conclusion: D-KEFS ST did not increase the number of cognitively impaired MS patients identified by BRB-NT, but provided a more comprehensive evaluation of cognitive decline. D-KEFS ST identified a subgroup of patients with increased self-perception of cognitive decline, depression and higher physical disability.

Comparison of the abbreviated minimal assessment of cognitive function in multiple sclerosis (aMACFIMS) and the brief international cognitive assessment for multiple sclerosis (BICAMS)

BACKGROUND

Cognitive impairment is a prevalent and often intrusive problem among persons with multiple sclerosis (PwMS). Valid and reliable assessments, including quick screening measures, are crucial. The Brief International Cognitive Assessment for MS (BICAMS) was developed for this reason. While it lends itself to use in locations where formal neuropsychological resources might be limited, it does not include measures of verbal fluency or executive functioning, domains assessed as part of the Minimal Assessment of Cognitive Function in MS (MACFIMS).

OBJECTIVE

Given previous evidence that shortened MACFIMS measures have strong criterion validity, this study aimed to determine which of these should be included in the abbreviated MACFIMS (aMACFIMS), and how the aMACFIMS compares to the BICAMS.

METHODS

One hundred forty-seven PwMS were included in the analyses. A stepwise logistic regression was used to determine the measures in the aMACFIMS. Receiver-operating-characteristic (ROC) curves assessed the classification accuracy, sensitivity, and specificity. The batteries' sensitivity, specificity, and predictive values were then compared.

RESULTS

Compared to the BICAMS, the final aMACFIMS had higher specificity (87% versus 72%) and positive predictive value (86% versus 77%), but lower sensitivity (71% versus 81%).

CONCLUSION

The aMACFIMS has several benefits, including reduced administration time and the addition of a verbal fluency/executive functioning measure.