Rouleau version of the Clock Drawing Test: age- and education-adjusted normative data from a wide Italian sample

Brand new norms for a good old test: Northern Italy normative study of MiniMental State Examination

AIM

Mini-Mental State Examination (MMSE) is one of the most used tests for the screening of global cognition in patients with neurological and medical disorders. Norms for the Italian version of the test were published in the 90 s; more recent norms were published in 2020 for Southern Italy only. In the present study, we computed novel adjustment coefficients, equivalent scores and cut-off value for Northern Italy (Lombardia and Veneto) and Italian speaking Switzerland.

METHODS

We recruited 361 healthy young and old (range: 20-95 years) individuals of both sexes (men: 156, women: 205) and from different educational levels (range: 4-22 years). Neuropsychiatric disorders and severe medical conditions were excluded with a questionnaire and cognitive deficits and were ruled out with standardized neuropsychological tests assessing the main cognitive domains. We used a slightly modified version of MMSE: the word 'fiore' was replaced with 'pane' in verbal recalls to reduce the common interference error 'casa, cane, gatto'. The effect of socio-demographic features on performance at MMSE was assessed via multiple linear regression, with test raw score as dependent variable and sex, logarithm of 101-age and square root of schooling as predictors.

RESULTS

Mean raw MMSE score was 28.8 ± 1.7 (range: 23-30). Multiple linear regression showed a significant effect of all socio-demographic variables and reported a value of R2 = 0.26. The new cut off was ≥ 26 /30.

CONCLUSION

We provide here updated norms for a putatively more accurate version of Italian MMSE, produced in a Northern population but potentially valid all over Italy.

Analysis of the Clock-Reading Ability in Patients with Cognitive Impairment: Comparison of Analog Clocks and Digital Clocks

Background: Time disorientation is one of the main symptoms observed in patients with dementia; however, their clock-reading ability has not been fully reported. Objective: This study aimed to investigate the clock-reading ability of both digital and analog clocks in patients with dementia. We newly devised the clock-reading test (CRT) and the number-reading test (NRT) to assess cognitive factors that may affect clock-reading ability. Furthermore, the discriminating power of the CRT was calculated. Methods: 104 participants were categorized based on their Mini-Mental State Examination (MMSE) scores as follows: subjective cognitive decline ∼ mild cognitive impairment (SCD∼MCI, N = 43), early Alzheimer’s disease (AD) (N = 26), and middle-to-late AD (N = 35). Their cognitive abilities were evaluated using the clock-drawing test (CDT), CRT, and NRT. Results: Cognitive decline leads to impairment of clock-reading ability which is more pronounced in the analog clocks than digital ones. This deficit in clock-reading is attributed to a loss of semantic memory regarding clocks at all stages. Additionally, visuospatial dysfunction and reduced ability of number recognition may lead to deficit in clock-reading in the advanced stage of AD. The discriminating power of the CRT (analog) (AUC = 0.853) was high enough to detect cognitive decline. Conclusion: Digital clocks are more readable by patients with dementia. Since reading clocks is closely associated with daily life, the CRT has proved to be a useful tool. A decline of analog clock-reading may be an early detector for the onset of dementia in elderly patients.

Prevalence and severity of cognitive dysfunction in patients referred for transcatheter aortic valve implantation (TAVI): clinical and cognitive impact at 1 year

AIM

We estimated the proportion and severity of cognitive disorders in an unselected population of patients referred for transcatheter aortic valve implantation (TAVI). Second, we describe clinical and cognitive outcomes at 1 year.

METHODS

Eligible patients were aged ≥ 70 years, with symptomatic aortic stenosis and an indication for TAVI. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive dysfunction (CD), defined as no CD if score ≥ 26, mild CD if 18-25; moderate CD if 10-18, and severe CD if < 10. We assessed survival and in-hospital complications at 6 months and 1 year.

RESULTS

Between June 2019 and October 2020, 105 patients were included; 21 (20%) did not undergo TAVI, and thus, 84 were analyzed; median age 85 years, 53.6% females, median EuroScore 11.5%. Median MoCA score was 22 (19-25); CD was excluded in 18 (21%), mild in 50 (59.5%), moderate in 15 (19%) and severe in 1. Mean MoCA score at follow-up was 21.9(± 4.69) and did not differ significantly from baseline (21.79 (± 4.61), p = 0.73). There was no difference in success rate, in-hospital complications, or death across CD categories.

CONCLUSION

The clinical course of patients with mild or moderate CD is not different at 1 year after TAVI compared to those without cognitive dysfunction.

Mild Cognitive Impairment Subtypes Are Associated With Peculiar Gait Patterns in Parkinson's Disease

Background

Mild cognitive impairment (MCI) is frequent in Parkinson's disease (PD) and represents a risk factor for the development of dementia associated with PD (PDD). Since PDD has been associated with disability, caregiver burden, and an increase in health-related costs, early detection of MCI associated with PD (PD-MCI) and its biomarkers is crucial.

Objective

Given that gait is considered a surrogate marker for cognitive decline in PD, the aim of this study was to compare gait patterns in PD-MCI subtypes in order to verify the existence of an association between specific gait features and particular MCI subtypes.

Methods

A total of 67 patients with PD were consecutively enrolled and assessed by an extensive clinical and cognitive examination. Based on the neuropsychological examination, patients were diagnosed as patients with MCI (PD-MCI) and without MCI (no-PD-MCI) and categorized in MCI subtypes. All patients were evaluated using a motion capture system of a BTS Bioengineering equipped with six IR digital cameras. Gait of the patients was assessed in the ON-state under three different tasks (a single task and two dual tasks). Statistical analysis included the t-test, the Kruskal-Wallis test with post hoc analysis, and the exploratory correlation analysis.

Results

Gait pattern was poorer in PD-MCI vs. no-PD-MCI in all tasks. Among PD-MCI subtypes, multiple-domain PD-MCI and amnestic PD-MCI were coupled with worse gait patterns, notably in the dual task.

Conclusion

Both the magnitude of cognitive impairment and the presence of memory dysfunction are associated with increased measures of dynamic unbalance, especially in dual-task conditions, likely mirroring the progressive involvement of posterior cortical networks.

Psychometrics and diagnostics of Italian cognitive screening tests: a systematic review

BACKGROUND

Cognitive screening tests (CSTs) are crucial to neuropsychological diagnostics, and thus need to be featured by robust psychometric and diagnostic properties. However, CSTs happen not to meet desirable statistical standards, negatively affecting their level of recommendations and applicability. This study aimed at (a) providing an up-to-date compendium of available CSTs in Italy, (b) report their psychometric and diagnostic properties, and (c) address related limitations.

METHODS

This review was implemented by consulting Preferred Reporting Items for Systematic Reviews and Meta-Analyses and pre-registered on the International Prospective Register of Systematic Reviews. Standardization and usability studies focusing on norms, validity, reliability, or sensitivity/specificity (and derived metrics) in adults were considered for eligibility. Quality assessment was performed by means of an ad hoc checklist collecting information on sampling, psychometrics/diagnostics, norming, and feasibility.

RESULTS

Sixty studies were included out of an initial N = 683. Identified CSTs (N = 40) were classified into general, domain-, and disease-specific (N = 17, 7, and 16, respectively), the latter being less statistically robust than remaining categories. Validity and reliability evidence was provided for 29 and 26 CSTs, respectively, sensitivity/specificity for 20 and norms for 33. Prevalence- and post-test-based diagnostic metrics were seldomly represented; factorial structures, ceiling/floor effects, and acceptability rarely investigated; content, face, and ecological validity never assessed.

DISCUSSION

Although available Italian CSTs overall met basic psychometric/diagnostic requirements, their statistical profile often proved to be poor on several properties that are desirable for clinical applications, with a few exceptions among general and domain-specific ones.

Cross-modal connectivity effects in age-related hearing loss

Age-related sensorineural hearing loss (HL) leads to localized brain changes in the primary auditory cortex, long-range functional alterations, and is considered a risk factor for dementia. Nonhuman studies have repeatedly highlighted cross-modal brain plasticity in sensorial brain networks other than those primarily involved in the peripheral damage, thus in this study, the possible cortical alterations associated with HL have been analyzed using a whole-brain multimodal connectomic approach. Fifty-two HL and 30 normal hearing participants were examined in a 3T MRI study along with audiological and neurological assessments. Between-regions functional connectivity and whole-brain probabilistic tractography were calculated in a connectome-based manner and graph theory was used to obtain low-dimensional features for the analysis of brain connectivity at global and local levels. The HL condition was associated with a different functional organization of the visual subnetwork as revealed by a significant increase in global efficiency, density, and clustering coefficient. These functional effects were mirrored by similar (but more subtle) structural effects suggesting that a functional repurposing of visual cortical centers occurs to compensate for age-related loss of hearing abilities.

Psychometric properties of the Beck Depression Inventory-II in progressive supranuclear palsy

OBJECTIVES

Depression is one of the most common neuropsychiatric symptoms in progressive supranuclear palsy (PSP). Yet, few studies have examined the ability of available instruments to detect depressive symptoms in PSP. Aims of the present study were to (I) report psychometric properties of the Beck Depression Inventory Second Edition (BDI-II) in PSP, (II) establish the BDI-II cut-off indicating the presence of depression in PSP and (III) describe clinical correlates as well as correlation with quality of life of depressive symptoms in PSP.

DESIGN, SETTING AND PARTICIPANTS

At the Center for Neurodegenerative Diseases of the University of Salerno, Italy, the BDI-II was validated in 62 PSP patients diagnosed according to the Movement Disorder Society criteria. Patients underwent a clinical interview, a motor evaluation, extensive cognitive and behavioral testing.

RESULTS

The mean BDI-II total score was 15.92 ± 10.31. The internal consistency was high (Cronbach's alpha = 0.868); corrected item-total correlation was >0.40 for the majority of items. The significant and moderate correlation of the BDI-II with other tools evaluating depressive symptoms indicated adequate convergent validity of the scale. The satisfactory cut-off to identify patients with clinically significant depression was >14.5. We also showed a correlation between higher scores on BDI-II and lower quality of life, irrespective of motor and cognitive burden.

CONCLUSION

In conclusion, the BDI-II is a reliable and valid tool for the assessment of depression symptoms in PSP. Such data are useful to standardize studies of depression in PSP and to quantify the effectiveness of any interventions on this disabling symptom.

Short-Term Effects of a Multidisciplinary Residential Rehabilitation Program on Perceived Risks, Confidence Toward Continuous Positive Airway Pressure Treatment, and Self-Efficacy in a Sample of Individuals Affected by Obstructive Sleep Apnea Syndrome

Continuous positive airway pressure (CPAP) therapy is the standard treatment for obstructive sleep apnea (OSA) syndrome. However, optimizing adherence to CPAP therapy of individuals remains very challenging for clinicians because of the role played by the psychological components. In this study, we verified the changes in cognitions and beliefs of individuals after a four-week multidisciplinary residential rehabilitation program targeting the adaptation to CPAP therapy for OSA syndrome. We assessed the components of perceived risks, confidence toward the treatment, and self-efficacy through the self-report questionnaire, namely the Self-Efficacy Measure for Sleep Apnea (SEMSA) questionnaire. We also explored the role played by the temperamental traits on the changes registered in these components after the treatment. Forty-five participants completed the rehabilitation program, showing a higher level of adherence to the treatment. Significant changes were observed in terms of confidence toward the treatment, although no change was reported in terms of perceived risks and self-efficacy. Moreover, those individuals with a higher persistent temperamental trait reported a significant improvement in perceived risks, in the absence of other significant results. After the rehabilitation treatment, our participants were more prone to consider the effect of CPAP treatment on health outcomes. This was in line with the educational aim of the rehabilitation treatment. The temperament seemed to play only a marginal role in the global changes reported by our participants. We discussed the need for behavioral interventions, in addition to education, in improving self-efficacy.

Psychological Well-Being in Obstructive Sleep Apnea Syndrome Associated With Obesity: The Relationship With Personality, Cognitive Functioning, and Subjective and Objective Sleep Quality

Obstructive sleep apnea (OSA) syndrome severely affects psychological well-being. This syndrome frequently occurs in obesity; however, no previous study has investigated the level of psychological well-being in the case of OSA syndrome associated with obesity. In this work, we assessed the level of psychological well-being in fifty-two individuals affected by OSA syndrome and obesity through the Psychological General Well-Being Index. Moreover, we investigated the role of personality, cognitive functioning and attentional capabilities, subjective perception and objective measurement about sleeping, on the subjective perception of psychological well-being. Our sample reported a lower level of psychological well-being; the participants' scores were below the normative cut-off in all components, except for depression symptoms. A lower expression of harm avoidance temperament and a lower level of daily sleepiness predicted a higher level of psychological well-being. Psychological well-being seemed to be severely affected in individuals affected by OSA syndrome and obesity. The temperament and subjective perception of daily alertness and sleepiness, rather than the syndrome severity, seemed to play a crucial role in the individual perception of the psychological well-being.

Non-motor impairments affect walking kinematics in Parkinson disease patients: A cross-sectional study

BACKGROUND

In patients with Parkinson disease (PD), severe postural and gait impairments are rarely observed in early stage of disease and non-motor symptoms (NMS) are often overlooked.

OBJECTIVE

This observational study aimed to characterize the impact of non-motor impairments on walking kinematics in early stages PD patients, and to assess the differences of gait parameters and NMS between PD patients with and without mild cognitive impairment (MCI).

METHODS

Twenty-six patients with Modified Hoehn and Yahr Scale score≤2 were evaluated for NMS using Kings Parkinson's Pain Scale, Parkinson Fatigue Severity scale, Parkinson Anxiety Scale, Beck Depression Inventory and Epworth Sleepiness Scale, kinematic parameters through an inertial sensor and cognitive performance by a comprehensive neuropsychological battery.

RESULTS

Fatigue had a moderate negative correlation with step cadence, and a moderate to strong positive correlation with gait duration, Timed Up and Go (TUG) and TUG Dual Task (p < 0.01). Pain showed positive moderate correlation with gait duration (p < 0.01). Twelve patients resulted affected by MCI and reported significantly worse scores in gait duration, pain and fatigue (p < 0.05). According to cognitive z scores, PD-MCI group showed a moderate negative correlation between visuospatial abilities and fatigue (p < 0.05).

CONCLUSIONS

NMS significantly affect walking kinematics whereas a limited role of cognitive status on motor performance occur in the early PD stages.

Clock-drawing test: Normative data of three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City and clinical utility in patients with acute ischemic stroke

OBJECTIVE

The clock-drawing test (CDT) is a widely used screening tool for detecting cognitive decline. However, normative data for Chinese individuals are scarce. Our study aimed to provide standardized values for the three quantitative CDT scoring methods that were tailored for Chinese-speaking adults in Shijiazhuang City and explore the discriminant validity of the CDT scores in patients with acute ischemic stroke.

METHODS

We conducted the CDT among 418 healthy individuals aged between 35 and 84 years. The CDT was administered and scored by five raters using the method derived from the Montreal Cognitive Assessment (MoCA), Rouleau's, and Babins' scoring systems. The influence of age, education, and sex on the performance in the CDT was analyzed. Furthermore, 336 patients with acute ischemic stroke were enrolled to explore the discriminant validity of CDT scores.

RESULTS

In all three scoring systems, CDT scores were significantly correlated with age and years of education but not with sex. Normative data stratified for age and years of education were established. Interrater and intersystem reliability were high in our study. CDT total scores and subscores showed significant differences between stroke patients and healthy individuals.

CONCLUSIONS

Our study provides CDT normative data using three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City. Age and education level were the key factors that affected the CDT scores. CDT total scores and subscores provided good discriminant validity for patients with acute ischemic stroke.

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.