The Edinburgh cognitive and behavioral amyotrophic lateral sclerosis screen (ECAS): sensitivity in differentiating between ALS and Alzheimer's disease in a Greek population

What is the extent of reliability and validity evidence for screening tools for cognitive and behavioral change in people with ALS? A systematic review

Objective: This systematic review provides an updated summary of the existing literature on the validity of screening tools for cognitive and behavioral impairment in people with Amyotrophic Lateral Sclerosis (pwALS), and also focuses on their reliability. Method: The following cognitive and behavioral screening tools were assessed in this review: the Edinburgh Cognitive and Behavioral ALS Screen (ECAS); the ALS Cognitive Behavioral Screen (ALS-CBS), the Mini Addenbrooke's Cognitive Examination (Mini-ACE), the Beaumont Behavioral Interview (BBI); the MND Behavior Scale (MiND-B); and the ALS-FTD Questionnaire (ALS-FTD-Q). A search, using Medline, PsychINFO and Embase (21/09/2023), generated 37 results after exclusion criteria were applied. Evidence of internal consistency, item-total correlations, inter-rater reliability, clinical validity, convergent validity, and structural validity were extracted and assessed and risk of bias was evaluated. Results: The cognitive component of the ECAS was the tool with most evidence of reliability and validity for the assessment of cognitive impairment in ALS. It is well-suited to accommodate physical symptoms of ALS. For behavioral assessment, the BBI or ALS-FTD-Q had the most evidence of reliability and validity. The BBI is more thorough, but the ALS-FTD-Q is briefer. Conclusions: There is good but limited evidence for the reliability and validity of cognitive and behavioral screens. Further evidence of clinical and convergent validity would increase confidence in their clinical and research use.

Neuropsychological impairment in amyotrophic lateral sclerosis-frontotemporal spectrum disorder

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a rapid course, characterized by motor neuron dysfunction, leading to progressive disability and death. This Review, which is aimed at neurologists, psychologists and other health professionals who follow evidence-based practice relating to ALS and frontotemporal dementia (FTD), examines the neuropsychological evidence that has driven the reconceptualization of ALS as a spectrum disorder ranging from a pure motor phenotype to ALS-FTD. It focuses on changes in cognition and behaviour, which vary in severity across the spectrum: around 50% individuals with ALS are within the normal range, 15% meet the criteria for ALS-FTD, and the remaining 35% are in the mid-spectrum range with milder and more focal impairments. The cognitive impairments include deficits in verbal fluency, executive functions, social cognition and language, and apathy is the most prevalent behavioural change. The pattern and severity of cognitive and behavioural change predicts underlying regional cerebral dysfunction from brain imaging and post-mortem pathology. Our increased recognition of cognition and behaviour as part of the ALS phenotype has led to the development and standardization of assessment tools, which have been incorporated into research and clinical care. Measuring change over the course of the disease is vital for clinical trials, and neuropsychology is proving to be a biomarker for the earliest preclinical changes.

Determining impairment in the Swedish, Polish and German ECAS: the importance of adjusting for age and education

Objective: Age and years of education are strong predictors of cognitive performance in several versions of the Edinburgh Cognitive and Behavioral ALS Screen (ECAS) and cutoffs for the Swedish and Polish versions are not established yet. Here we evaluated the performance of healthy subjects on the national versions of the Swedish and Polish ECAS and compared cognitive performance on three European translations of the ECAS. Methods: The ECAS performances of healthy subjects from Sweden (n = 111), Poland (n = 124) and Germany (n = 86) were compared. Based on the test results on the national versions of ECAS, age- and education-adjusted cutoffs were compared for the German, Swedish and Polish versions, respectively. Results: Age and years of education correlated with performance in the ECAS. Swedish subjects under the age of 60 years and Swedish subjects with low education level scored significantly higher in memory than the respective German and Polish subgroups. German and Polish subjects over 60 years of age performed significantly better in language than the respective Swedish subgroup. The Polish cohort in total had lower executive scores compared to the Swedish cohort, and lower than the German subjects in the higher education subgroup. Conclusions: The results highlight the importance of establishing age- and education-adjusted ECAS cutoffs not only in general, but also for seemingly similar populations of different origins. The results should be taken into account when comparing cognition data across patient populations including in drug trials where an ECAS test result is being used as an inclusion criterium or outcome measure.

Sensitivity and specificity of the ECAS in identifying executive function and social cognition deficits in MND

Objective: Motor neurone disease [MND] encompasses broad cognitive impairments, which are not fully captured by most screening tools. This study evaluated the specificity and sensitivity of the Edinburgh Cognitive and Behavioral ALS Screen [ECAS] in detecting impairments in executive function and social cognition. Methods: Participants (MND = 64; Healthy Controls = 45) completed the ECAS and standard neuropsychology tests of executive function and social cognition. Sensitivity and specificity of the ECAS were assessed at three levels (ALS-Specific score, executive function domain score, individual subtests: social cognition, inhibition, working memory, alternation). Results: MND patients were impaired on standard social cognition, initiation, visuomotor alternation, and verbal learning tests but not on inhibition or working memory tests, relative to controls. ECAS results revealed that the ALS-Specific score was high in specificity but low-to-moderately sensitive in identifying social cognition, inhibition, and working memory deficits, and that both sensitivity and specificity were high for identifying alternation deficits. The ECAS executive function domain score was high in specificity but poor in sensitivity for all four executive function domain subtests. The individual ECAS subtests were highly specific with good sensitivity, but the social cognition subtest lacked sensitivity. Conclusions: Impairments in social cognition may go undetected when using the ECAS as a screening tool. Thus, social cognition may need to be considered as a standalone component, distinct from the other executive functions. In addition, the test itself may need to be adjusted to encompass other aspects of social cognition that are affected in MND.Key messagesCognitive screening tools are key to detect cognitive changes in MND, with the domains most affected being executive functions, language, and social cognition.The ECAS measure, developed for MND, has good specificity but lacks sensitivity to impairments in social cognition.Clinical implications are that cognitive impairments in social cognition may not be identified in MND patients by the ECAS.Adjustment to the ECAS cognitive screening tool widely-used in MND is suggested.

Prevalence and associated factors of apathy in Chinese ALS patients

Objectivve

This study aimed to explore the prevalence and clinical correlates of apathy in amyotrophic lateral sclerosis (ALS) in a cohort of Chinese patients.

Methods

A total of 1,013 ALS patients were enrolled in this study. Apathy was recorded during face-to-face interviews using Frontal Behavioral Inventory, and other patient characteristics, including depression, anxiety, and cognitive function, were collected using Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Chinese version of Addenbrooke’s Cognitive Examination-revised. Health-related quality of life of ALS patients and their caregivers was also evaluated, and the potential factors associated with apathy were explored using forward binary regression analysis. Survival was analyzed using the Cox proportional hazards model.

Results

The prevalence of apathy in all patients was 28.9%. Patients in the late disease stage had a higher prevalence of apathy than those in the early disease stage. Furthermore, patients with apathy had a lower ALS Functional Rating Scale revised (ALSFRS-R) score, higher HDRS score, HARS score and higher proportion of reported problems in the anxiety/depression. Additionally, their caregivers had higher score of depression and higher Zarit-Burden Interview scores. Multivariate regression analysis revealed that apathy in ALS was associated with the onset region (p = 0.027), ALSFRS-R score (p = 0.007), depression (p = 0.001) and anxiety (p < 0.001). Apathy had a significant negative effect on survival in ALS patients (p = 0.032).

Conclusion

Apathy is relatively common (28.9%) in Chinese patients with ALS. Apathy is related to both the severity of the disease, and the presentation of non-motor symptoms in ALS, such as depression and anxiety disorders. Apathy is an independent prognostic factor for survival and requires early intervention and management.

Hippocampal Metabolic Alterations in Amyotrophic Lateral Sclerosis: A Magnetic Resonance Spectroscopy Study

BACKGROUND

Magnetic resonance spectroscopy (MRS) in amyotrophic lateral sclerosis (ALS) has been overwhelmingly applied to motor regions to date and our understanding of frontotemporal metabolic signatures is relatively limited. The association between metabolic alterations and cognitive performance in also poorly characterised.

MATERIAL AND METHODS

In a multimodal, prospective pilot study, the structural, metabolic, and diffusivity profile of the hippocampus was systematically evaluated in patients with ALS. Patients underwent careful clinical and neurocognitive assessments. All patients were non-demented and exhibited normal memory performance. 1H-MRS spectra of the right and left hippocampi were acquired at 3.0T to determine the concentration of a panel of metabolites. The imaging protocol also included high-resolution T1-weighted structural imaging for subsequent hippocampal grey matter (GM) analyses and diffusion tensor imaging (DTI) for the tractographic evaluation of the integrity of the hippocampal perforant pathway zone (PPZ).

RESULTS

ALS patients exhibited higher hippocampal tNAA, tNAA/tCr and tCho bilaterally, despite the absence of volumetric and PPZ diffusivity differences between the two groups. Furthermore, superior memory performance was associated with higher hippocampal tNAA/tCr bilaterally. Both longer symptom duration and greater functional disability correlated with higher tCho levels.

CONCLUSION

Hippocampal 1H-MRS may not only contribute to a better academic understanding of extra-motor disease burden in ALS, but given its sensitive correlations with validated clinical metrics, it may serve as practical biomarker for future clinical and clinical trial applications. Neuroimaging protocols in ALS should incorporate MRS in addition to standard structural, functional, and diffusion sequences.

Apathy in amyotrophic lateral sclerosis: systematic review and meta-analysis of frequency, correlates, and outcomes

Objectives: To determine the frequency and correlates of apathy in amyotrophic lateral sclerosis (ALS) and its influence on the prognosis of the disease.Methods: Three databases were searched: MEDLINE, PubMed, and Google Scholar. Quantitative synthesis of the frequency of apathy in ALS was conducted using random effects in Stata (College Station, TX). Meta-regression and subgroup analyses were conducted to investigate the association between frequency of apathy in ALS and different covariates.Results: Fifty-two studies (51 cohorts) were included in the analysis. The pooled frequency of apathy in ALS was 25% (95% confidence interval (CI) 14-35%) according to the studies that used self-rated tools and 34% (95% CI 27-41%) according to studies that used informant-rated tools. The emergence of apathy was associated with cognitive decline and bulbar onset of the disease. There was no consistent relationship between apathy and disease stage or the severity of depression. Structural brain imaging studies established that ALS patients with apathy exhibited more prominent changes with structural and functional brain imaging particularly involving fronto-subcortical regions of the brain. Overall, apathy worsened the long-term prognosis of ALS.Discussion: Apathy affects up to a third of ALS patients аnd develops in the context of progressive neurodegeneration. Increased awareness and understanding of non-motor symptoms in ALS highlights the potential utility of apathy as an outcome measure in future clinical trial design.

Executive Dysfunction, Social Cognition Impairment, and Gray Matter Pathology in Myotonic Dystrophy Type 2: A Pilot Study

BACKGROUND

In contrast to myotonic dystrophy type 1, the cognitive and radiologic profile of myotonic dystrophy type 2 (DM2) is relatively poorly characterized.

OBJECTIVE

To conduct a pilot study to systematically evaluate cognitive and radiologic features in a cohort of Greek individuals with DM2.

METHOD

Eleven genetically confirmed individuals with DM2 and 26 age- and education-matched healthy controls were administered the Edinburgh Cognitive and Behavioural Amyotrophic Lateral Sclerosis Screen (ECAS) to screen for impairment in multiple cognitive domains. MRI data were evaluated by morphometric analyses to identify disease-specific gray and white matter alterations. The following statistical thresholds were used for cognitive comparisons: PFDR < 0.05 and Bayes factor (BF 10 ) >10.

RESULTS

The DM2 group exhibited cognitive impairment (ECAS Total score; PFDR = 0.001; BF 10 = 108.887), which was dominated by executive impairment ( PFDR = 0.003; BF 10 = 25.330). A trend toward verbal fluency impairment was also identified. No significant impairments in memory, language, or visuospatial function were captured. The analysis of subscores revealed severe impairments in social cognition and alternation. Voxel-based morphometry identified widespread frontal, occipital, and subcortical gray matter atrophy, including the left superior medial frontal gyrus, right medial orbitofrontal gyrus, right operculum, right precuneus, bilateral fusiform gyri, and bilateral thalami.

CONCLUSION

DM2 may be associated with multifocal cortical and thalamic atrophy, which is likely to underpin the range of cognitive manifestations mostly characterized by executive impairment and specifically by impaired social cognition.

Adaptation and norming of the Edinburgh Cognitive and behavioural amyotrophic lateral sclerosis screen (ECAS) for three language groups in South Africa

Objectives: To adapt and translate the Edinburgh Cognitive and behavioural amyotrophic lateral sclerosis screen (ECAS); to generate preliminary normative data for three language groups in South Africa (SA); to assess the convergent validity of the ECAS in SA samples. Methods: The ECAS was linguistically and culturally adapted for Afrikaans-, isiXhosa-, and English-speaking SA adults (n = 108, 100, and 53, respectively). Each language group was stratified by age and educational level. Cutoff scores for cognitive impairment were set at the group mean minus two standard deviations (SDs). A pilot sample of ALS patients and controls (n = 21 each) were administered the ECAS and an extensive neuropsychological evaluation (NPE) and the Montreal Cognitive Assessment (MoCA) to assess convergent validity. Results: Across the three language groups, the total ECAS cutoff scores ranged from 68 to 97. The ECAS score correlated significantly positively with educational level (p < 0.001) and negatively with age (p < 0.005). The restricted letter fluency task demonstrated a floor effect, particularly in Afrikaans-speakers. The mean total ECAS score (±SD) was similar in ALS patients (103.52 ± 11.90) and controls (100.67 ± 20.49; p = 0.58). Three (14.3%) ALS patients scored below the cutoff for cognitive impairment. Correlations between individual ECAS subtests and analogous NPE tests ranged from weak to moderate. The MoCA score was significantly positively correlated with the ECAS total score (r = 0.59; p = < 0.001). Conclusions: The adapted ECAS and associated normative data will aid cognitive screening of African ALS patients. Larger participant numbers are needed to assess the validity of the adapted instrument.

The association of theory of mind with language and visuospatial abilities in amyotrophic lateral sclerosis: a pilot study

Objective: Dysfunction of social cognition is well-recognized as one of amyotrophic lateral sclerosis (ALS) cognitive impairments. Previous studies have mostly associated social cognition subcomponents, including Theory of Mind (ToM), with executive dysfunction using highly-demanding tasks. In the present study, we investigate dysfunction of affective ToM in a sample of ALS patients without dementia and evaluate any possible associations both with executive and non-executive dysfunction.Methods: We included 42 ALS patients and 30 healthy controls (HC) and administered the Edinburgh Cognitive and Behavioral Amyotrophic Lateral Sclerosis Screen (ECAS). Affective ToM was examined based on the ECAS judgment of preference task; total score and type of errors ("favourite", "unclassified") were recorded for all participants.Results: A significant proportion of ALS patients (31%) were impaired on ToM task, scoring significantly lower compared to HC. Impairments in ToM task were more frequent (45%) in patients with cognitive impairment compared to those with intact cognition (15%). ALS patients showed significantly more errors on ToM task compared to HC. A significant association was found between ToM score and ECAS language and visuospatial abilities but not fluency, executive or memory function.Conclusion: Dysfunction of affective ToM appears prevalent in ALS patients without dementia, and associates with language and visuospatial abilities. These associations align with motor and extra-motor symptoms due to the degeneration across corresponding networks. Impaired ToM should be considered in clinical settings, since it might contribute to patients' social life, as well as the burden of their caregivers and relatives.

A normative study of the Czech Edinburgh Cognitive and Behavioural ALS Screen (ECAS): a brief report

Edinburgh Cognitive and Behavioural ALS Screen (ECAS) is a brief, standardized assessment of cognitiveimpairment inamyotrophic lateral sclerosis.

OBJECTIVE

We aimed to createa normative dataset for the ECAS Czech version (ECAS-CZ) in order to make the assessment applicable for clinical settings.

METHOD

Included were 102 healthy participants (mean age: 54.92 ± 14.55; education: 14.52 ± 2.44; 54:48 females/males) that fulfilled rigorous exclusion criteria and controlled for depressive symptoms.

RESULTS

The internal consistency of ECAS-CZ was acceptable (Cronbach's α = .69). We found medium correlations (rho ≈ .5) of age and education with ECAS-CZ Total score but not with gender. Cut-offs with -2 SD's threshold are presented for the differentiation of cognitive impairment. We report percentile values for ECAS-CZ Total including all subscales.

CONCLUSION

We provide normative values for ECAS-CZ that are well suited for the detection of cognitive impairment in clinical settings especially for patients with ALS.Supplemental data for this article is available online at https://doi.org/10.1080/13854046.2021.1978553 .

Compensating for verbal-motor deficits in neuropsychological assessment in movement disorders: sensitivity and specificity of the ECAS in Parkinson's and Huntington's diseases

INTRODUCTION

The study aims at investigating psychometric properties of the Edinburgh cognitive and behavioural ALS screen (ECAS) in Parkinson's (PD) and Huntington's (HD) diseases. The sensitivity and specificity of the ECAS in highlighting HD and PD cognitive-behavioural features and in differentiating between these two populations and from healthy controls (HC) were evaluated. Moreover, correlations between the ECAS and traditional cognitive measures, together with core clinical features, were analysed.

METHODS

Seventy-three PD patients, 38 HD patients, and 49 education-matched healthy participants were enrolled. Participants were administered the ECAS, together with other cognitive screening tools and psychological questionnaires. Patients' behavioural assessment was also carried out with carers.

RESULTS

The ECAS distinguished between HD patients and HC and between the two clinical syndromes with high sensitivity and specificity. Even if the diagnostic accuracy of the ECAS in distinguishing between PD and HC was low, the PD cognitive phenotype was very well described by the ECAS performances. Convergent validity of the ECAS against other traditional cognitive screening was observed, as well as correlations with psychological aspects and typical clinical features, especially for the HD group.

CONCLUSIONS

The ECAS represents a rapid and feasible tool, useful also in other neurodegenerative disorders affecting verbal-motor abilities than the amyotrophic lateral sclerosis such as PD and HD. Clinical applications in these neurodegenerative conditions require further investigations and, probably, some adaptations of the original test.

Persian adaptation of Edinburgh Cognitive and Behavioural Screen (ECAS)

Objectives: To adapt the Edinburgh Cognitive and Behavioral screen (ECAS) English version into Persian. Methods: The ECAS test was adapted and implemented to 30 ALS patients and 31 healthy volunteers in Tehran, Iran. The ECAS results were compared to MoCA and ALS-FRS-r, the other standard tools to determine whether the translated version is reliable and valid in the new language. In addition, the patients' caregivers were interviewed for behavioral and psychiatric changes. Results: The Persian version of ECAS revealed high internal consistency (α = 0.791), alongside the strong correlation of ECAS and its subscales with MoCA and ALS-FRS. Moreover, Persian ECAS discriminated against the patients and the healthy population well. Sensitivity analysis revealed promising results of Persian ECAS with an area under the curve of 0.871 in ROC curve analysis. Cognitive impairment was observed in 43.33% of patients. Conclusion: The Persian version of the ECAS, exclusively designed for the Iranian population, is the first screening tool to assess multiple neuropsychological functions, which provides a rapid and inclusive screen of cognitive and behavioral impairments specifically in ALS patients.

Psychometric Properties of Cognitive Assessment in Amyotrophic Lateral Sclerosis: A Systematic Review

Purpose

We aimed to list all tests used to assess cognitive change in patients with amyotrophic lateral sclerosis (ALS) and to provide a descriptive synthesis of the psychometric properties of tests that were evaluated in a population of ALS patients.

Materials and Methods

The protocol is registered in PROSPERO (ID: CRD42017055603). We systematically search for literature in 11 databases. Full-text articles, in any language, with original research were included. All included articles were scrutinised by two independent authors. Disagreement was resolved by consensus. The framework of Lezak informed conceptualises of the tests identified. To evaluate methodological quality, we used the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). Data were synthesised using criteria proposed by the Cochrane Back Review Group.

Results

Of 319 included articles, 46 articles reported information on the psychometric properties of cognitive tests used in patients with ALS. We found that the highest level of evidence was supported for the Reading the Mind in the Eye Test (RME), Addenbrooke’s Cognitive Evaluation (ACE) and Frontal Assessment Battery (FAB). Moderate level of evidence was found for the screening tests; Edinburgh Cognitive and Behavioural ALS Screen (ECAS) and the Montreal Cognitive Assessment (MoCA).

Conclusion

The screening test, ECAS and the social cognition test, RME, may have some advantages over other tests that have been used for assessing cognitive change in ALS patients. Recommendations of ALS-specific tests with sound psychometric properties are urgently needed.

A Comparison of the Greek ACE-III, M-ACE, ACE-R, MMSE, and ECAS in the Assessment and Identification of Alzheimer's Disease

OBJECTIVE

This study aimed to adapt the Addenbrooke's Cognitive Examination-III (ACE-III) and Mini-Addenbrooke's Cognitive Examination (M-ACE) into Greek and then to examine the convergent validity against their predecessors Addenbrooke's Cognitive Examination-Revised (ACE-R) and Mini-Mental State Examination (MMSE) in a Greek population. Moreover, a primary aim was to appraise the utility of each screen by conducting a comparison of the psychometric properties of ACE-III, M-ACE, ACE-R, MMSE, and the Edinburgh Cognitive and Behavioural Amyotrophic Lateral Sclerosis (ALS) Screen (ECAS) in detecting Alzheimer's disease (AD).

METHODS

Forty patients with AD were recruited and matched with 38 controls. Bayesian Pearson's correlation analysis was conducted to examine the convergent validity. Receiver operating characteristic curve analysis was implemented to appraise the sensitivity and specificity of the tests in detecting AD.

RESULTS

The ACE-III, M-ACE, and the ECAS scores robustly correlated with ACE-R and MMSE. The ACE-III and the ECAS-ALS Non-Specific score were the most sensitive and specific tools in detecting AD, closely followed by ECAS Total score and M-ACE. Only ECAS Total score correlated with the duration of disease. The ECAS scores were more resilient to ceiling effects than the other screens. M-ACE produced fewer ceiling effects than MMSE.

CONCLUSION

The Greek ACE-III and M-ACE were successfully adapted and showed good convergent validity against their predecessors. They showed very good psychometric properties in detecting AD and may be considered in hectic clinical settings. ECAS Total score and ECAS-ALS Non-Specific showed comparable psychometric properties in the detection of AD and may be considered in polypathological clinics where motor impairments are common.