Physician recognition of cognitive impairment: evaluating the need for improvement

Attention as the primary cognitive domain affected in post-myocardial infarction cognitive impairment: a prospective multicenter study

We analysed cognitive impairment (CI) during the peri-myocardial infarction (MI) period and after 6 months. The study included 326 patients. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) and the Clock Drawing Test (CDT). Routine laboratory and echocardiography data were collected. We distinguished 4 groups of patients: 1 - CI present peri-infarction and after 6 months; 2 - CI present only peri-infarction; 3 - CI present only after 6 months; 4 - without CI. Groups constituted 8.9%, 16.3%, 7.7% and 67.1% of participants (as assessed by MMSE), respectively. In those who improved (group 2) or with worsened cognitive function (group 3), analogous changes in attention function occurred. There was a group of patients with CI on the MMSE who performed the CDT correctly, 12% peri-infarct and 11% at 6-month follow-up, respectively. Patients with a normal CDT score but CI found in the MMSE had impaired attention function. Cognitive function improves in some patients, and deteriorates in others after MI. The uniform type of impaired cognitive function allows us to assume a uniform etiology of CI. Performing the CDT and using the MMSE component assessing attention could prove sufficient for the initial assessment of cognitive functions in patients after MI.

The Diabetic Cognitive Impairment Score for Early Screening of Cognitive Impairment in Type 2 Diabetes Patients

Purpose: Diabetes has been associated with an excess risk of cognitive impairment. The hyperphosphorylation of tau protein leads to neurodegeneration and is closely related to Type 2 diabetes (T2D). This study aimed to characterize the association between P-tau181 and diabetic cognitive impairment and to develop a nomogram-based score to screen cognitive impairment in T2D patients. Methods: We used a cohort of 379 patients diagnosed with T2D as a training dataset to develop a predictive model. Risk factors associated with cognitive impairment were identified using stepwise multivariate logistic regressive analysis. A nomogram was established by incorporating these risk factors, and the diabetic cognitive impairment score (DCIS) was built and externally validated in another cohort. Results: In the training cohort, patients with cognitive impairment had higher levels of P-tau181 (13.3 [10.5-18.7] vs. 10.0 [8.0-13.0], p < 0.001). P-tau181 was negatively correlated with MOCA (r = -0.308, p < 0.001) and MMSE (r = -0.289, p < 0.001), and it was independently associated with cognitive impairment in T2D patients (OR, 1.137 [95% CI, 1.080-1.198]; p < 0.001). Other independent risk factors of diabetic cognitive impairment included age, education level, and diabetic retinopathy. The DCIS was built by nomogram based on the four risk factors, which had an area under the receiver operating characteristic curve (AUC) of 0.795 (95% CI, 0.751-0.840). The optimal cut-off of DCIS for the diagnosis of cognitive impairment in T2D patients was 139.5, with a sensitivity of 72.9% and a specificity of 75.3%. In the validation cohort, the AUC of DCIS for screening diabetic cognitive impairment was 0.770 (95% CI, 0.716-0.824). Conclusions: P-tau181 was independently associated with diabetic cognitive impairment. The DCIS, based on P-tau181, age, education level, and diabetic retinopathy, is effective to identify cognitive impairment in T2D patients.

Cognitive impairment and self-reported health outcomes among older adults: Longitudinal evidence from Australia

BACKGROUND

Australia's population is ageing, with forecasts indicating that individuals aged 65 years and over will account for >20 % of the total population by 2066. Ageing is strongly linked with a significant decrease in cognitive capabilities. This study aimed to explore the association between cognitive impairment and four types of health outcomes among older Australians.

METHODS

Data used for this study was collected from the Household, Income and Labour Dynamics in Australia (HILDA) Survey. The final analysis consisted of 11,146 person-year observations from 7035 unique individuals from Wave 2012 and Wave 2016, respectively. A longitudinal random-effects generalised least squares, and ordered logistic regression were used to analyse the association between cognitive impairment and health outcomes.

RESULTS

The study results suggest that cognitive impairment was negatively associated with general health, mental health, self-assessed health and health satisfaction. Older Australians with cognitive impairment scored lower on general health (β = -2.82, SE = 0.56), mental health (β = -2.93, SE = 0.53), self-assessed health (β = - 0.75, SE = 0.10), and health satisfaction (β = -0.19, SE = 0.09) compared to the counterparts without cognitive impairment. The heterogeneous results also showed cognitive impairment was associated with poor health outcomes across age groups.

CONCLUSION

This study found evidence that cognitive impairment is associated with poor health outcomes. To enhance the physical and mental health and well-being of older adults, the community, government and non-government organizations, and other stakeholders should prioritize routine healthcare prevention, targeted interventions, and treatment practices, particularly for individuals with or at risk of cognitive impairment.

Effectiveness and utilization of a cognitive screening program for primary geriatric care

BACKGROUND

Effective detection of cognitive impairment in the primary care setting is limited by lack of time and specialized expertise to conduct detailed objective cognitive testing and few well-validated cognitive screening instruments that can be administered and evaluated quickly without expert supervision. We therefore developed a model cognitive screening program to provide relatively brief, objective assessment of a geriatric patient's memory and other cognitive abilities in cases where the primary care physician suspects but is unsure of the presence of a deficit.

METHODS

Referred patients were tested during a 40-min session by a psychometrist or trained nurse in the clinic on a brief battery of neuropsychological tests that assessed multiple cognitive domains. Short questionnaires covering subjective cognitive complaints, symptoms of depression, and medical history were also administered. Results were conveyed to a dementia specialist who reviewed them and returned their judgement of the validity of the cognitive complaint to the primary care provider. Retrospective medical records review was carried out for a random (stratified) half of the sample to determine how screening results were utilized. Screening tests were repeated after two years in a subset of 69 patients.

RESULTS

The 638 patients screened (mean age = 75.9 years; mean education = 14.9 years; 58% women) were classified by screening as having normal cognition (n = 177), depression (with possible cognitive changes; n = 115), mild cognitive impairment (MCI; n = 107), or dementia (n = 239). Classification accuracy was shown by high agreement with the eventual clinical diagnosis in the medical record (69%; Cohen's Kappa = .38; p < .001; 77% if MCI and dementia were collapsed; Cohen's Kappa = .58; p < .001) and longitudinal decline in cognitive test scores only in those initially classified as having MCI or dementia. Medical records documented discussion of screening results with the patient in 69% of cases (80% if MCI or dementia was detected) and often referral to a specialist (62%), new brain imaging (54%), or change in medication (58%) when screening indicated potential cognitive impairment.

CONCLUSION

The cognitive screening program was well accepted by primary care providers as an efficient and effective way to evaluate concerns about cognitive decline in older adults.

Developing a prediction model for cognitive impairment in older adults following critical illness

BACKGROUND

New or worsening cognitive impairment or dementia is common in older adults following an episode of critical illness, and screening post-discharge is recommended for those at increased risk. There is a need for prediction models of post-ICU cognitive impairment to guide delivery of screening and support resources to those in greatest need. We sought to develop and internally validate a machine learning model for new cognitive impairment or dementia in older adults after critical illness using electronic health record (EHR) data.

METHODS

Our cohort included patients > 60 years of age admitted to a large academic health system ICU in North Carolina between 2015 and 2021. Patients were included in the cohort if they were admitted to the ICU for ≥ 48 h with ≥ 2 ambulatory visits prior to hospitalization and at least one visit in the post-discharge year. We used a machine learning model, oblique random survival forests (ORSF), to examine the multivariable association of 54 structured data elements available by 3 months after discharge with incident diagnoses of cognitive impairment or dementia over 1-year.

RESULTS

In this cohort of 8,299 adults, 22% died and 4.9% were diagnosed with dementia or cognitive impairment within one year. The ORSF model showed reasonable discrimination (c-statistic = 0.83) and stability with little difference in the model's c-statistic across time.

CONCLUSION

Machine learning using readily available EHR data can predict new cognitive impairment or dementia at 1-year post-ICU discharge in older adults with acceptable accuracy. Further studies are needed to understand how this tool may impact screening for cognitive impairment in the post-discharge period.

Adaptation and Validation of the Psychological Consequences of Screening Questionnaire (PCQ) for Cognitive Screening in Primary Care

BACKGROUND

Context-specific measures with adequate external validity are needed to appropriately determine psychosocial effects related to screening for cognitive impairment.

METHODS

Two-hundred adults aged ≥65 y recently completing routine, standardized cognitive screening as part of their Medicare annual wellness visit were administered an adapted version of the Psychological Consequences of Screening Questionnaire (PCQ), composed of negative (PCQ-Neg) and positive (PCQ-Pos) scales. Measure distribution, acceptability, internal consistency, factor structure, and external validity (construct, discriminative, criterion) were analyzed.

RESULTS

Participants had a mean age of 73.3 y and were primarily female and socioeconomically advantaged. Most had a normal cognitive screening result (99.5%, n = 199). Overall PCQ scores were low (PCQ-Neg: x ¯ = 1.27, possible range 0-36; PCQ-Pos: x ¯ = 7.63, possible range 0-30). Both scales demonstrated floor effects. Acceptability was satisfactory, although the PCQ-Pos had slightly more item missingness. Both scales had Cronbach alphas >0.80 and a single-factor structure. Spearman correlations between the PCQ-Neg with general measures of psychological distress (Impacts of Events Scale-Revised, Perceived Stress Scale, Kessler Distress Scale) ranged from 0.26 to 0.37 (P's < 0.001); the correlation with the World Health Organization-Five Well-Being Index was -0.19 (P < 0.01). The PCQ-Neg discriminated between those with and without a self-reported subjective cognitive complaint (x ¯ = 2.73 v. 0.89, P < 0.001) and was associated with medical visit satisfaction (r = -0.24, P < 0.001) on the Patient Satisfaction Questionnaire. The PCQ-Pos predicted self-reported willingness to engage in future screening (x ¯ = 8.00 v. 3.00, P = 0.03).

CONCLUSIONS

The adapted PCQ-Neg is an overall valid measure of negative psychological consequences of cognitive screening; findings for the PCQ-Pos were more variable. Future studies should address measure performance among diverse samples and those with abnormal screening results.

HIGHLIGHTS

The PCQ scale is an overall valid measure of psychological dysfunction related to cognitive screening in older adults receiving normal screen results.PCQ scale performance should be further validated in diverse populations and those with abnormal cognitive screening results.The adapted PCQ may be useful to both health research and policy stakeholders seeking improved assessment of psychological impacts of cognitive screening.

Cognitive correlates of psychopathology in functional/dissociative seizures and non-lesional epilepsy: An exploratory study

OBJECTIVE

To explore the relationship between cognitive functioning and psychopathological features in Functional/Dissociative Seizures (FDS), and test whether this differs from that observed in epilepsy.

METHODS

We recruited a cross-sectional sample of adults (age > 18) with a diagnosis of non-lesional epilepsy or FDS between January 2021 and July 2022 (n = 73). Participants completed a series of psychiatric questionnaires and neuropsychological measures. Spearman's Correlation Coefficient was computed between each of the psychiatric and cognitive measures in each group. Fisher's Z test of significance for independent correlation coefficients then tested the significance of the difference between correlation coefficients for the two groups.

RESULTS

There were no group differences in neuropsychological test scores. However, people with FDS reported higher seizure severity, depression levels, number of medically unexplained somatic symptoms, and exposure to traumatic events compared to epilepsy. Results of the Fisher's Z-test revealed significant differences in correlation coefficients between groups in two instances. First, in the association between the number of traumatic experiences and cognitive switching (z = 2.77, p = 0.006); the number of traumatic experiences were positively associated with cognitive switching in epilepsy but showed a non-significant negative trend in FDS. Secondly, in the association between vocabulary abilities and the number of medically unexplained symptoms (z = -2.71; p = 0.007); higher vocabulary ability was associated with fewer somatic symptoms in epilepsy, while no such correlation was observed in FDS.

SIGNIFICANCE

This study provides preliminary evidence for the complex interplay between cognitive functioning and psychopathology in FDS and epilepsy. Neurocognitive functioning such as vocabulary abilities or attentional switching may play a role in the expression or maintenance of pathological features of FDS.

Comparing psychometric characteristics of a computerized cognitive test (BrainCheck Assess) against the Montreal cognitive assessment

Introduction

Previous validation studies demonstrated that BrainCheck Assess (BC-Assess), a computerized cognitive test battery, can reliably and sensitively distinguish individuals with different levels of cognitive impairment (i.e., normal cognition (NC), mild cognitive impairment (MCI), and dementia). Compared with other traditional paper-based cognitive screening instruments commonly used in clinical practice, the Montreal Cognitive Assessment (MoCA) is generally accepted to be among the most comprehensive and robust screening tools, with high sensitivity/specificity in distinguishing MCI from NC and dementia. In this study, we examined: (1) the linear relationship between BC-Assess and MoCA and their equivalent cut-off scores, and (2) the extent to which they agree on their impressions of an individual's cognitive status.

Methods

A subset of participants (N = 55; age range 54-94, mean/SD = 80/9.5) from two previous studies who took both the MoCA and BC-Assess were included in this analysis. Linear regression was used to calculate equivalent cut-off scores for BC-Assess based on those originally recommended for the MoCA to differentiate MCI from NC (cut-off = 26), and dementia from MCI (cut-off = 19). Impression agreement between the two instruments were measured through overall agreement (OA), positive percent agreement (PPA), and negative percent agreement (NPA).

Results

A high Pearson correlation coefficient of 0.77 (CI = 0.63-0.86) was observed between the two scores. According to this relationship, MoCA cutoffs of 26 and 19 correspond to BC-Assess scores of 89.6 and 68.5, respectively. These scores are highly consistent with the currently recommended BC-Assess cutoffs (i.e., 85 and 70). The two instruments also show a high degree of agreement in their impressions based on their recommended cut-offs: (i) OA = 70.9%, PPA = 70.4%, NPA = 71.4% for differentiating dementia from MCI/NC; (ii) OA = 83.6%, PPA = 84.1%, NPA = 81.8% for differentiating dementia/MCI from NC.

Discussion

This study provides further validation of BC-Assess in a sample of older adults by showing its high correlation and agreement in impression with the widely used MoCA.

Identifying a group of factors predicting cognitive impairment among older adults

BACKGROUND

Cognitive impairment has multiple risk factors spanning several domains, but few studies have evaluated risk factor clusters. We aimed to identify naturally occurring clusters of risk factors of poor cognition among middle-aged and older adults and evaluate associations between measures of cognition and these risk factor clusters.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) III (training dataset, n = 4074) and the NHANES 2011-2014 (validation dataset, n = 2510). Risk factors were selected based on the literature. We used both traditional logistic models and support vector machine methods to construct a composite score of risk factor clusters. We evaluated associations between the risk score and cognitive performance using the logistic model by estimating odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Using the training dataset, we developed a composite risk score that predicted undiagnosed cognitive decline based on ten selected predictive risk factors including age, waist circumference, healthy eating index, race, education, income, physical activity, diabetes, hypercholesterolemia, and annual visit to dentist. The risk score was significantly associated with poor cognitive performance both in the training dataset (OR Tertile 3 verse tertile 1 = 8.15, 95% CI: 5.36-12.4) and validation dataset (OR Tertile 3 verse tertile 1 = 4.31, 95% CI: 2.62-7.08). The area under the receiver operating characteristics curve for the predictive model was 0.74 and 0.77 for crude model and model adjusted for age, sex, and race.

CONCLUSION

The model based on selected risk factors may be used to identify high risk individuals with cognitive impairment.

Exploring foundation doctors' self-reported confidence in the assessment and management of mental health conditions

AIMS AND METHOD

This study assesses newly qualified doctors' confidence in practising clinical skills related to the assessment and management of mental health conditions and how this correlates with other areas of medicine. We conducted a national survey of 1311 Foundation Year 1 doctors in the UK. Survey items assessed confidence recognising mentally unwell patients, conducting a mental state examination, assessing cognition and mental capacity, formulating a psychiatric diagnosis and prescribing psychotropic medications.

RESULTS

A substantial proportion of surveyed doctors lacked confidence in their clinical skills related to mental health and prescribing psychotropic medications. Network analysis revealed that items corresponding to mental health were highly correlated, suggesting a potential generalised lack of confidence in mental healthcare.

CLINICAL IMPLICATIONS

We identify areas of lack of confidence in some newly qualified doctors' ability to assess and manage mental health conditions. Future research might explore how greater exposure to psychiatry, integrated teaching and clinical simulation might better support medical students for future clinical work.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review

Objectives

Recognition of the cognitive status of patients is important so that care can be tailored accordingly. The objective of this integrative review was to report on the current practices that acute care hospitals use to identify people with cognitive impairment and how information about cognition is managed within the healthcare record as well as the approaches required and recommended by policies.

Methods

Following Whittemore & Knafl's five-step method, we systematically searched Medline, CINAHL, and Scopus databases and various grey literature sources. Articles relevant to the programs that have been implemented in acute care hospitals regarding the identification of cognitive impairment and management of cognition information were included. The Mixed Methods Appraisal Tool and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) Checklist were used to evaluate the quality of the studies. Thematic analysis was used to present and synthesise results. This review was pre-registered on PROSPERO ( CRD42022343577).

Results

Twenty-two primary studies and ten government/industry publications were included in the analysis. Findings included gaps between practice and policy. Although identification of cognitive impairment, transparency of cognition information, and interaction with patients, families, and carers (if appropriate) about this condition were highly valued at a policy level, sometimes in practice, cognitive assessments were informal, patient cognition information was not recorded, and interactions with patients, families, and carers were lacking.

Discussion

By incorporating cognitive assessment, developing an integrated information management system using information technology, establishing relevant laws and regulations, providing education and training, and adopting a national approach, significant improvements can be made in the care provided to individuals with cognitive impairment.

Cognitive status is associated with performance of manual wheelchair skills in hospitalized older adults

PURPOSE

To examine the relationship between manual wheelchair skills and cognitive function in hospitalized older adults.

METHODS

The observational study included older adults who used a manual wheelchair following hip/knee surgery. Participants underwent a series of tests to evaluate manual wheelchair skills and cognitive performance. Four items appearing on the Wheelchair Skills Test: brake handling (locking/unlocking), a 10-metre forward roll, a 2-metre backward roll and rotating in place, were used to evaluate manual wheelchair skills. Cognitive function was evaluated by the Montreal Cognitive Assessment (MoCA), Trail Making Test (TMT), the Clock Drawing Test, and the Loewenstein Occupational Therapy Cognitive Assessment. The relationship between wheelchair skills and cognitive scores was assessed by a series of univariate linear regression analyses.

RESULTS

Fifty older adults, aged 65-85, participated in the study. The MoCA-7 (orientation) explained 19.3% of the variance related to the turn in place wheelchair skill, 18.8% of the variance related to the two-metre backwards roll and 31.9% of the variance related to the 10-metre forward roll. The addition of gender (to the MoCA-7) increased the explained variance related to the 10-metre forward roll and turn in place skills to 38.5% and 28.5%, respectively. As for the brakes handling skill test, gender explained 18.3% of the variance. The addition of the CDT (to gender) increased the explained variance for the brakes handling skill to 31.4%.

CONCLUSIONS

Because cognitive impairments negatively affect the performance of wheelchair skills, rehabilitation therapists may need to adjust wheelchair mobility training methods for cognitively impaired older adults.Implication for rehabilitationGiven the prevalence of older adults with cognitive impairments who use manual wheelchairs, it is critical to better understand the relationship between cognition and wheelchair skills.Poor results reported on the cognitive tests, specifically, visual attention and orientation, were found to be associated with poor performance of four manual wheelchair skills.Rehabilitation therapists should consider the cognitive status of older adults when teaching manual wheelchair skills, specifically in new users. Future studies should examine whether a customized preparation program, enhancing visuospatial orientation, can benefit manual wheelchair control in older adults.

Relationship Between Cognitive Impairment and Depression Among Middle Aged and Older Adults in Primary Care

Objectives: To determine rates of previously undetected cognitive impairment among patients with depression in primary care. Methods: Patients ages 55 and older with no documented history of dementia or mild cognitive impairment were recruited from primary care practices in New York City, NY and Chicago, IL (n = 855). Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA) and depression with the Patient Health Questionnaire-8. Results: The mean age was 66.8 (8.0) years, 45.3% were male, 32.7% Black, and 29.2% Latinx. Cognitive impairment increased with severity of depression: 22.9% in persons with mild depression, 27.4% in moderate depression and 41.8% in severe depression (p = .0002). Severe depression was significantly associated with cognitive impairment in multivariable analysis (standardized β = -.11, SE = 0.33, p < .0001). Discussion: Depression was strongly associated with previously undetected cognitive impairment. Primary care clinicians should consider screening, or expand their screening, for both conditions.

Association of time-varying sleep duration and cognitive function with mortality in the elderly: a 12-year community-based cohort study

BACKGROUND

Sleeping problems and cognitive impairment are common in elders. Baseline sleep duration and cognitive status are predictors of mortality. But few studies have explored whether longitudinal changes in sleep duration and cognitive function are related to mortality in older adults. The present study investigated the time-varying relationships of sleep duration and cognitive function with subsequent mortality among community-dwelling elders by using 12 years of repeated-measure data.

METHODS

Taichung Community Health Study for Elders (TCHS-E) is a retrospective, population-based cohort that started in 2009 (wave 1) with a total of 912 elders aged 65 years or above. Follow up was conducted in 2010 (wave 2), 2018 (wave 3), and 2020 (wave 4). Sleep duration and Mini-Mental State Examination (MMSE) forms were executed at baseline and three visits during follow-up. Time-varying Cox proportional hazards regression estimated adjusted hazard ratios (HRs) of mortality with 95% confidence intervals (CIs).

RESULTS

During about 12 years (9,396 person-years) follow-up, 329 deaths from all causes were documented, including 102 deaths due to expanded cardiovascular disease (CVD). In the multivariable-adjusted, time-varying Cox proportional hazard model, the adjusted HR values of all-cause mortality were 1.47 (1.02-2.12) for sleep duration > 9 h/day (vs. 7 h/day) and 1.81 (1.26-2.59) for MMSE < 27 (vs. 30). The adjusted HR values of the expanded CVD mortality were 2.91 (1.24-6.83) for MMSE of 29; 2.69 (1.20-6.05) for MMSE of 27-28; and 4.32 (95% CI: 1.92-9.74) for MMSE < 27. The dose-dependent relationship was significant (p < 0.001). The combinations of sleep duration longer than 9 h/day and MMSE < 27 were linked with the highest risks for expanded CVD and all-cause mortality.

CONCLUSIONS

Long sleep duration and low cognitive function were jointly and independently linked with higher risk of mortality in elders residing in community.

Health System Change for Alzheimer's Disease-Modifying Therapies in Canada: Beginning the Discussion

Alzheimer's disease (AD) is a neurodegenerative disorder that accounts for 60%-70% of patients with dementia, and it is estimated that over one million Canadians will be living with dementia by 2030. Disease-modifying therapies (DMTs) targeting the underlying pathophysiology of AD are currently in development. Several models have demonstrated that the potential arrival of Alzheimer's DMTs will most likely overwhelm the already-constrained Canadian healthcare system. Canada does not have a strategy to address the extensive requirements of using DMTs, including providing an early diagnosis of AD, confirming DMT eligibility via amyloid biomarkers, and conducting ongoing treatment monitoring. Thus, a multidisciplinary group of experts involved in AD care in Canada gathered to review (1) the current barriers to diagnosis and management of AD; (2) how existing clinic models, including those used in multiple sclerosis (MS), could be applied to address key barriers in AD; and (3) how to design and implement optimal care pathways in the future. The actions outlined in this review will help clinicians and healthcare systems improve readiness to integrate the use of disease-modifying therapies in Alzheimer's disease, if such therapies are approved in Canada.

The electronic health record Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) Brain Health Trial: Protocol for an embedded, pragmatic clinical trial of a low-cost dementia detection algorithm

BACKGROUND

About half of people living with dementia have not received a diagnosis, delaying access to treatment, education, and support. We previously developed a tool, eRADAR, which uses information in the electronic health record (EHR) to identify patients who may have undiagnosed dementia. This paper provides the protocol for an embedded, pragmatic clinical trial (ePCT) implementing eRADAR in two healthcare systems to determine whether an intervention using eRADAR increases dementia diagnosis rates and to examine the benefits and harms experienced by patients and other stakeholders.

METHODS

We will conduct an ePCT within an integrated healthcare system and replicate it in an urban academic medical center. At primary care clinics serving about 27,000 patients age 65 and above, we will randomize primary care providers (PCPs) to have their patients with high eRADAR scores receive targeted outreach (intervention) or usual care. Intervention patients will be offered a "brain health" assessment visit with a clinical research interventionist mirroring existing roles within the healthcare systems. The interventionist will make follow-up recommendations to PCPs and offer support to newly-diagnosed patients. Patients with high eRADAR scores in both study arms will be followed to identify new diagnoses of dementia in the EHR (primary outcome). Secondary outcomes include healthcare utilization from the EHR and patient, family member and clinician satisfaction assessed through surveys and interviews.

CONCLUSION

If this pragmatic trial is successful, the eRADAR tool and intervention could be adopted by other healthcare systems, potentially improving dementia detection, patient care and quality of life.

Association of neurocognitive disorders with morbidity and mortality in older adults undergoing major surgery in the USA: a retrospective, population-based, cohort study

BACKGROUND

Neurocognitive disorders become increasingly common as patients age, and increasing numbers of surgical interventions are done on older patients. The aim of this study was to understand the clinical characteristics and outcomes of surgical patients with neurocognitive disorders in the USA in order to guide future targeted interventions for better care.

METHODS

This retrospective cohort study used claims data for US Medicare beneficiaries aged 65 years and older with a record of inpatient admission for a major diagnostic or therapeutic surgical procedure between Jan 1, 2017, and Dec 31, 2018. Data were retrieved through a data use agreement between Dartmouth Hitchcock Medical Center and US Centers for Medicare and Medicaid Services via the Research Data Assistance Center. The exposure of interest was the presence of a pre-existing neurocognitive disorder as defined by diagnostic code within 3 years of index hospital admission. The primary outcome was mortality at 30 days, 90 days, and 365 days from date of surgery among all patients with available data.

FINDINGS

Among 5 263 264 Medicare patients who underwent a major surgical procedure, 767 830 (14·59%) had a pre-existing neurocognitive disorder and 4 495 434 (85·41%) had no pre-existing neurocognitive disorder. Adjusting for demographic factors and comorbidities, patients with a neurocognitive disorder had higher 30-day (hazard ratio 1·24 [95% CI 1·23-1·25]; p<0·0001), 90-day (1·25 [1·24-1·26]; p<0·0001), and 365-day mortality (1·25 [1·25-1·26]; p<0·0001) compared with patients without a neurocognitive disorder.

INTERPRETATION

Our findings suggest that the presence of a neurocognitive disorder is independently associated with an increased risk of mortality. Identification of a neurocognitive disorder before surgery can help clinicians to better disclose risks and plan for patient care after hospital discharge.

FUNDING

Department of Anesthesiology and Perioperative Medicine at Dartmouth Hitchcock Medical Center.

Screening of cognitive performance in kidney transplant recipients: a mini review

Why should we screen?

The prevalence of cognitive impairment in kidney transplant recipients (KTRs) is up to 58%. The 10-year graft loss and mortality rates are above 30% and 50%, respectively, and executive malfunctioning increases disadvantageous outcomes.

What causes cognitive impairment in KTRs?

Strong risk factors are older age and chronic kidney disease. However, causes are multifactorial and include cardiovascular, cerebrovascular, neurodegenerative, inflammatory, uremic, psychiatric, and lifestyle-related susceptibilities.

How should we screen?

KTR-specific validated instruments or strategies do not exist. The central element should be a multidomain cognitive screening test that is sensitive to mild cognitive impairment, corrects for age and education, and includes executive functions testing. Cognitive trajectories, effects on everyday life and psychiatric comorbidities should be assessed by integrating the perspectives of both patients and knowledgeable informants.

When should we screen?

Screening should not be postponed if there is suspicion of impaired cognition. Different time points after transplantation tend to have their own characteristics.

Who should conduct the screening?

Screening should not be limited to specialists. It can be carried out by any healthcare professional who has received a limited amount of training.

What are the benefits of screening?

Screening does not provide a diagnosis. However, suggestive results change care in multiple ways. Goals are: Initiation of professional dementia work-up, securing of adherence, anticipation of potential complications (delirium, falls, frailty, functional impairment, malnutrition, etc.), mitigation of behavioral disorders, adjustment of diagnostic and therapeutic "load", reduction of caregiver burden and meeting of changing needs. We summarize data on the prevalence, risk factors and sequelae of cognitive impairment in KTRs. We also discuss the requirements for appropriate screening strategies and provide guiding principles regarding appropriate and safe care.

Acute Myocardial Infarction and Risk of Cognitive Impairment and Dementia: A Review

Cognitive impairment (CI) shares common cardiovascular risk factors with acute myocardial infarction (AMI), and is increasingly prevalent in our ageing population. Whilst AMI is associated with increased rates of CI, CI remains underreported and infrequently identified in patients with AMI. In this review, we discuss the evidence surrounding AMI and its links to dementia and CI, including pathophysiology, risk factors, management and interventions. Vascular dysregulation plays a major role in CI, with atherosclerosis, platelet activation, microinfarcts and perivascular inflammation resulting in neurovascular unit dysfunction, disordered homeostasis and a dysfunctional neurohormonal response. This subsequently affects perfusion pressure, resulting in enlarged periventricular spaces and hippocampal sclerosis. The increased platelet activation seen in coronary artery disease (CAD) can also result in inflammation and amyloid-β protein deposition which is associated with Alzheimer's Dementia. Post-AMI, reduced blood pressure and reduced left ventricular ejection fraction can cause chronic cerebral hypoperfusion, cerebral infarction and failure of normal circulatory autoregulatory mechanisms. Patients who undergo coronary revascularization (percutaneous coronary intervention or bypass surgery) are at increased risk for post-procedure cognitive impairment, though whether this is related to the intervention itself or underlying cardiovascular risk factors is debated. Mortality rates are higher in dementia patients with AMI, and post-AMI CI is more prevalent in the elderly and in patients with post-AMI heart failure. Medical management (antiplatelet, statin, renin-angiotensin system inhibitors, cardiac rehabilitation) can reduce the risk of post-AMI CI; however, beta-blockers may be associated with functional decline in patients with existing CI. The early identification of those with dementia or CI who present with AMI is important, as subsequent tailoring of management strategies can potentially improve outcomes as well as guide prognosis.

Study Quality and Patient Inclusion in Geriatric Orthopaedic Trauma Research: A Scoping Review

OBJECTIVES

To evaluate the quality of evidence published in geriatric traumatology, to investigate how many studies include patients with cognitive impairment, and to investigate which methods are used to determine cognitive impairment.

DATA SOURCES

A search was conducted in PubMed for all publications in English in 154 selected journals between 01/01/2017 and 01/01/2020.

STUDY SELECTION

Clinical studies investigating patients 65 years of age and older with fractures in the appendicular skeleton or pelvis were included.

DATA EXTRACTION

Two independent reviewers performed full-text screening and data extraction for all articles.

DATA SYNTHESIS

A comparative analysis was performed for prospective cohort studies and RCTs. The results are discussed in a narrative review.

CONCLUSIONS

A total of 2711 publications were screened for eligibility, and after exclusion, a total of 723 articles were included. There is a focus on retrospective studies investigating mortality and complications. Studies are often small in sample size, and there are relatively few prospective studies, RCT studies, patient-reported outcomes, and quality of life. Patients with cognitive impairment are selectively excluded from clinical studies, and no consensus exists on how cognitive impairment is diagnosed. This review identified pitfalls and provides recommendations to navigate these issues for future studies. Many studies exclude cognitively impaired patients, which may result in selection bias and inability to extrapolate results. The lack of use of objective measures to define cognitive impairment and lack appropriate outcome measures for the cognitively impaired is an important issue that needs to be addressed in future research.

Rates of Undiagnosed Cognitive Impairment and Performance on the Montreal Cognitive Assessment Among Older Adults in Primary Care

BACKGROUND

The number of adults in the USA with cognitive impairment is increasing; however, few studies report prevalence rates of undiagnosed cognitive impairment among older adults in primary care.

OBJECTIVE

To determine the prevalence of undiagnosed cognitive impairment among adults ages 55 years and older in primary care settings and provide normative data for the Montreal Cognitive Assessment in this context.

DESIGN

Single interview, observational study.

PARTICIPANTS

English-speaking adults ages 55 years and older without diagnoses of cognitive impairment recruited from primary care practices in New York City, NY, and Chicago, IL (n = 872).

MAIN MEASURES

Montreal Cognitive Assessment (MoCA). Undiagnosed cognitive impairment was defined by age and education adjusted z-scores more than 1.0 and 1.5 standard deviations below published norms, corresponding to mild or moderate to severe cognitive impairment, respectively.

KEY RESULTS

The mean age was 66.8 (8.0) years, 44.7% were male, 32.9% were Black or African-American, and 29.1% were Latinx. Undiagnosed cognitive impairment was identified in 20.8% of subjects (mild impairment, 10.5%; moderate-severe impairment, 10.3%). Impairment at any level of severity was associated in bivariate analyses with several patient characteristics, most notably for race and ethnicity (White, non-Latinx, 6.9% vs. Black, non-Latinx, 26.8%, Latinx, 28.2%, other race, 21.9%; p < 0.0001), place of birth (US 17.5% vs. non-US 30.7%, p < 0.0001), depression (33.1% vs. no depression, 18.1%; p < 0.0001), and impairment in activities of daily living (≥ 1 ADL impairment, 34.0% vs. no ADL impairment, 18.2%; p < 0.0001).

CONCLUSIONS

Undiagnosed cognitive impairment is common among urban dwelling older adults attending primary care practices, and was associated with several patient characteristics, including non-White race and ethnicity and depression. Normative data for the MoCA from this study may serve as a useful resource for studies of similar patient populations.

Gauging innovation and health impact from biomedical research: survey results and interviews with recipients of EU-funding in the fields of Alzheimer's disease, breast cancer and prostate cancer

Biomedical research on Alzheimer's disease (AD), breast cancer (BC) and prostate cancer (PC) has globally improved our understanding of the etiopathological mechanisms underlying the onset of these diseases, often with the goal to identify associated genetic and environmental risk factors and develop new medicines. However, the prevalence of these diseases and failure rate in drug development remain high. Being able to retrospectively monitor the major scientific breakthroughs and impact of such investment endeavors is important to re-address funding strategies if and when needed. The EU has supported research into those diseases via its successive framework programmes for research, technological development and innovation. The European Commission (EC) has already undertaken several activities to monitor research impact. As an additional contribution, the EC Joint Research Centre (JRC) launched in 2020 a survey addressed to former and current participants of EU-funded research projects in the fields of AD, BC and PC, with the aim to understand how EU-funded research has contributed to scientific innovation and societal impact, and how the selection of the experimental models may have underpinned the advances made. Further feedback was also gathered through in-depth interviews with some selected survey participants representative of the diverse pre-clinical models used in the EU-funded projects. A comprehensive analysis of survey replies, complemented with the information derived from the interviews, has recently been published in a Synopsis report. Here we discuss the main findings of this analysis and propose a set of priority actions that could be considered to help improving the translation of scientific innovation of biomedical research into societal impact.

Sharing Health Care Wishes in Primary Care (SHARE) among older adults with possible cognitive impairment in primary care: Study protocol for a randomized controlled trial

OBJECTIVE

Little is known about effective strategies to improve advance care planning (ACP) for persons with cognitive impairment in primary care, the most common setting of care. We describe a randomized controlled trial to test the efficacy of a multicomponent communication intervention, "Sharing Healthcare Wishes in Primary Care" (SHARE).

PARTICIPANTS

Planned enrollment of 248 dyads of adults 80 years and older with possible cognitive impairment and their care partner, from primary care clinics at 2 Mid-Atlantic health systems.

METHODS

The treatment protocol encompasses an introductory letter from the clinic; access to a designated facilitator trained in ACP; person-family agenda-setting to align perspectives about the family's role; and print education. The control protocol encompasses minimally enhanced usual care, which includes print education and a blank advance directive. Randomization occurs at the individual dyad-level. Patient and care partner surveys are fielded at baseline, 6-, 12-, and 24- months. Fidelity of interventionist delivery of the protocol is measured through audio-recordings of ACP conversations and post-meeting reports, and by ongoing monitoring and support of interventionists.

OUTCOMES

The primary outcome is quality of end-of-life care communication at 6 months; secondary outcomes include ACP process measures. An exploratory aim examines end-of-life care quality and bereaved care partner experiences for patients who die by 24 months.

CONCLUSIONS

Caregiver burden, clinician barriers, and impaired decisional capacity amplify the difficulty and importance of ACP discussions in the context of cognitive impairment: this intervention will comprehensively examine communication processes for this special subpopulation in a key setting of primary care.

REGISTRATION

ClinicalTrials.gov: NCT04593472.

Temporal characterization of Alzheimer's Disease with sequences of clinical records

BACKGROUND

Alzheimer's Disease (AD) is a complex clinical phenotype with unprecedented social and economic tolls on an ageing global population. Real-world data (RWD) from electronic health records (EHRs) offer opportunities to accelerate precision drug development and scale epidemiological research on AD. A precise characterization of AD cohorts is needed to address the noise abundant in RWD.

METHODS

We conducted a retrospective cohort study to develop and test computational models for AD cohort identification using clinical data from 8 Massachusetts healthcare systems. We mined temporal representations from EHR data using the transitive sequential pattern mining algorithm (tSPM) to train and validate our models. We then tested our models against a held-out test set from a review of medical records to adjudicate the presence of AD. We trained two classes of Machine Learning models, using Gradient Boosting Machine (GBM), to compare the utility of AD diagnosis records versus the tSPM temporal representations (comprising sequences of diagnosis and medication observations) from electronic medical records for characterizing AD cohorts.

FINDINGS

In a group of 4985 patients, we identified 219 tSPM temporal representations (i.e., transitive sequences) of medical records for constructing the best classification models. The models with sequential features improved AD classification by a magnitude of 3-16 percent over the use of AD diagnosis codes alone. The computed cohort included 663 patients, 35 of whom had no record of AD. Six groups of tSPM sequences were identified for characterizing the AD cohorts.

INTERPRETATION

We present sequential patterns of diagnosis and medication codes from electronic medical records, as digital markers of Alzheimer's Disease. Classification algorithms developed on sequential patterns can replace standard features from EHRs to enrich phenotype modelling.

FUNDING

National Institutes of Health: the National Institute on Aging (RF1AG074372) and the National Institute of Allergy and Infectious Diseases (R01AI165535).

Cognitive Impairment in Older Adults and Oral Health Considerations: Treatment and Management

Current research aims at improving early detection and treatment of cognitive impairment (CI), particularly in patients at high risk for progression to dementia. It is important to treat signs and symptoms as early as possible to normalize quality of life. In older cognitively impaired patients, dentists and physicians should consider polypharmacy, uncontrolled cardiovascular risk factors, depression, metabolic or endocrine derangements, delirium due to intercurrent illness, and dementia, all of which may increase risk for CI and other negative outcomes. An interdisciplinary team approach is a necessity for a responsible and safe treatment sequence.

Office- and Bedside-based Screening for Cognitive Impairment and the Dementias: Which Tools to Use, Interpreting the Results, and What Are the Next Steps?

Elderly patients and their families are concerned about the patients' cognitive abilities, and cognitive screening is an efficient diagnostic tool, as long as clinicians administer the screens in a standardized manner and interpret the screen results accurately. The following brief summary reviews commonly used screening instruments and provides information about how to interpret screening test results. It concludes by showing how cognitive screening fits into a four-step process (Education, Screening, Follow-up, and Referral) of how to respond to patients with cognitive concerns.

Sauver J, Sohn S. Characterizing Performance Gaps of a Code-Based Dementia Algorithm in a Population-Based Cohort of Cognitive Aging

BACKGROUND

Multiple algorithms with variable performance have been developed to identify dementia using combinations of billing codes and medication data that are widely available from electronic health records (EHR). If the characteristics of misclassified patients are clearly identified, modifying existing algorithms to improve performance may be possible.

OBJECTIVE

To examine the performance of a code-based algorithm to identify dementia cases in the population-based Mayo Clinic Study of Aging (MCSA) where dementia diagnosis (i.e., reference standard) is actively assessed through routine follow-up and describe the characteristics of persons incorrectly categorized.

METHODS

There were 5,316 participants (age at baseline (mean (SD)): 73.3 (9.68) years; 50.7% male) without dementia at baseline and available EHR data. ICD-9/10 codes and prescription medications for dementia were extracted between baseline and one year after an MCSA dementia diagnosis or last follow-up. Fisher's exact or Kruskal-Wallis tests were used to compare characteristics between groups.

RESULTS

Algorithm sensitivity and specificity were 0.70 (95% CI: 0.67, 0.74) and 0.95 (95% CI: 0.95, 0.96). False positives (i.e., participants falsely diagnosed with dementia by the algorithm) were older, with higher Charlson comorbidity index, more likely to have mild cognitive impairment (MCI), and longer follow-up (versus true negatives). False negatives (versus true positives) were older, more likely to have MCI, or have more functional limitations.

CONCLUSIONS

We observed a moderate-high performance of the code-based diagnosis method against the population-based MCSA reference standard dementia diagnosis. Older participants and those with MCI at baseline were more likely to be misclassified.

Risks and Benefits of Clinical Diagnosis Around the Time of Dementia Onset

Diagnostic delay in dementia is common in the U.S. Drivers of diagnostic delay are poorly understood, but appear related to misconceptions about dementia, stigma, concerns about autonomy, the nature of the diagnostic process, and provider-related factors. There is little quantitative evidence underlying cited risks and benefits of receiving a diagnosis around the time of dementia onset, including impacts on physical health, impacts on mental health, care partner interactions, costs of care, increased time for care planning, or earlier access to treatment. While various groups continue to push for reductions in diagnostic delay, realization of benefits and mitigation of harms will require new research on potential benefits and harms. Workforce and resource constraints, coupled with the expected growth in the number of persons living with dementia, may be a barrier to realization of potential benefits and mitigation of identified harms, which will require adequate access to providers, services, and supports.

Applications of artificial intelligence in dementia research

More than 50 million older people worldwide are suffering from dementia, and this number is estimated to increase to 150 million by 2050. Greater caregiver burdens and financial impacts on the healthcare system are expected as we wait for an effective treatment for dementia. Researchers are constantly exploring new therapies and screening approaches for the early detection of dementia. Artificial intelligence (AI) is widely applied in dementia research, including machine learning and deep learning methods for dementia diagnosis and progression detection. Computerized apps are also convenient tools for patients and caregivers to monitor cognitive function changes. Furthermore, social robots can potentially provide daily life support or guidance for the elderly who live alone. This review aims to provide an overview of AI applications in dementia research. We divided the applications into three categories according to different stages of cognitive impairment: (1) cognitive screening and training, (2) diagnosis and prognosis for dementia, and (3) dementia care and interventions. There are numerous studies on AI applications for dementia research. However, one challenge that remains is comparing the effectiveness of different AI methods in real clinical settings.

Differentiation of patients with mild cognitive impairment and healthy controls based on computer assisted hand movement analysis: a proof-of-concept study

Mild cognitive impairment (MCI) is the prodromal phase of dementia, and it is highly underdiagnosed in the community. We aimed to develop an automated, rapid (< 5 min), electronic screening tool for the recognition of MCI based on hand movement analysis. Sixty-eight individuals participated in our study, 46 healthy controls and 22 patients with clinically defined MCI. All participants underwent a detailed medical assessment including neuropsychology and brain MRI. Significant differences were found between controls and MCI groups in mouse movement characteristics. Patients showed higher level of entropy for both the left (F = 5.24; p = 0.001) and the right hand (F = 8.46; p < 0.001). Longer time was required in MCI to perform the fine motor task (p < 0.005). Furthermore, we also found significant correlations between mouse movement parameters and neuropsychological test scores. Correlation was the strongest between motor parameters and Clinical Dementia Rating scale (CDR) score (average r: - 0.36, all p's < 0.001). Importantly, motor parameters were not influenced by age, gender, or anxiety effect (all p's > 0.05). Our study draws attention to the utility of hand movement analysis, especially to the estimation of entropy in the early recognition of MCI. It also suggests that our system might provide a promising tool for the cognitive screening of large populations.

Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients: Protocol for a Multisite Randomized Controlled Trial

BACKGROUND

Older adults with cognitive impairment have more emergency department visits and 30-day readmissions and are more likely to die after visiting the emergency department than people without cognitive impairment. Emergency department providers frequently do not identify cognitive impairment. Use of cognitive screening tools, along with better understanding of root causes for emergency department visits, could equip health care teams with the knowledge needed to develop individually tailored care management strategies for post-emergency department care. By identifying and directly addressing patients' and informal caregivers' (or care partners') psychosocial and health care needs, such strategies could reduce the need for repeat acute care. We have used the terms "caregiver" and "care partner" interchangeably.

OBJECTIVE

We aimed to describe the protocol for a randomized controlled trial of a new care management intervention, the Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED) trial, compared with usual care. We described the research design, intervention, outcome measures, data collection techniques, and analysis plans.

METHODS

Emergency department patients who were aged ≥75 years and screened positive for cognitive impairment via either the Mini-Cog or the proxy-reported Short Informant Questionnaire on Cognitive Decline in the Elderly, with a planned discharge to home, were recruited to participate with their identified informal (family or friend) caregiver in the 2-site POISED randomized controlled trial at New York University Langone Health and Indiana University. The intervention group received 6 months of care management from the POISED Care Team of registered nurses and specialty-trained paraprofessionals, who perform root cause analyses, administer standardized assessments, provide advice, recommend appropriate referrals, and, when applicable, implement dementia-specific comorbid condition protocols. The control group received care as recommended at emergency department discharge (usual care) and were given information about resources for further cognitive assessment. The primary outcome is repeat emergency department use; secondary outcomes include caregiver activation for patient health care management, caregiver depression, anxiety, and experience of social support as important predisposing and time-varying enabling and need characteristics. Data were collected from questionnaires and patients' electronic health records.

RESULTS

Recruitment was conducted between March 2018 and May 2021. Study findings will be published in peer-reviewed journals and presented to peer audiences, decision makers, stakeholders, and other interested persons.

CONCLUSIONS

The POISED intervention is a promising approach to tailoring care management based on root causes for emergency department admission of patients with cognitive impairment with the aim of reducing readmissions. This trial will provide insights for caregivers and emergency department and primary care providers on appropriate, personalized, and proactive treatment plans for older adults with cognitive impairment. The findings will be relevant to audiences concerned with quality of life for individuals with cognitive impairment and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03325608; https://clinicaltrials.gov/ct2/show/NCT03325608.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36607.

Automated assessment of speech production and prediction of MCI in older adults

The population of older adults is growing dramatically and, with it comes increased prevalence of neurological disorders, including Alzheimer's disease (AD). Though existing cognitive screening tests can aid early detection of cognitive decline, these methods are limited in their sensitivity and require trained administrators. The current study sought to determine whether it is possible to identify persons with mild cognitive impairment (MCI) using automated analysis of spontaneous speech. Participants completed a brief neuropsychological test battery and a spontaneous speech task. MCI was classified using established research criteria, and lexical-semantic features were calculated from spontaneous speech. Logistic regression analyses compared the predictive ability of a commonly-used cognitive screening instrument (the Modified Mini Mental Status Exam, 3MS) and speech indices for MCI classification. Testing against constant-only logistic regression models showed that both the 3MS [χ2(1) = 6.18, p = .013; AIC = 41.46] and speech indices [χ2(16) = 32.42, p = .009; AIC = 108.41] were able to predict MCI status. Follow-up testing revealed the full speech model better predicted MCI status than did 3MS (p = .049). In combination, the current findings suggest that spontaneous speech may have value as a potential screening measure for the identification of cognitive deficits, though confirmation is needed in larger, prospective studies.

Observational study of patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment without dementia

BACKGROUND

Timely diagnosis of cognitive impairment is a key goal of the National Plan to Address Alzheimer's Disease, but studies of factors associated with a timely diagnosis are limited.

OBJECTIVE

To identify patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment (MCI).

DESIGN

Retrospective observational study using survey data from the Health and Retirement Study (HRS) from 1995-2016 (interview waves 3-13).

PARTICIPANTS

4,760 respondents with incident dementia and 1,864 with incident MCI identified using longitudinal measures of cognitive functioning.

MAIN MEASURES

Timely or delayed diagnosis based on the timing of a self or proxy report of a healthcare provider diagnosis in relation to respondents first dementia or MCI-qualifying cognitive score, sociodemographic characteristics, health status, health care utilization, insurance provider, and year of first qualifying score.

KEY RESULTS

Only 26.0% of the 4,760 respondents with incident dementia and 11.4% of the 1,864 respondents with incident MCI received a timely diagnosis. Non-Hispanic Black respondents and respondents with less than a college degree were significantly less likely to receive a timely diagnosis of either dementia or MCI than Non-Hispanic White respondents (dementia odds ratio (OR): 0.61, 95% CI: 0.50, 0.75; MCI OR: 0.40, 95% CI: 0.23, 0.70) and those with a college degree (dementia OR for less than high school degree: 0.30, 95% CI: 0.23, 0.38; MCI OR: 0.36, 95% CI: 0.22, 0.60). Respondents that lived alone were also less likely to receive a timely diagnosis of dementia (OR: 0.69, 95% CI: 0.59, 0.81), though not MCI. Timely diagnosis of both conditions increased over time.

CONCLUSIONS

Targeting resources for timely diagnosis of cognitive impairment to individuals from racial and ethnic minorities, lower educational attainment, and living alone may improve detection and reduce disparities around timely diagnosis of dementia and MCI.

Strategies for Maintaining Brain Health: The Role of Stroke Risk Factors Unique to Elderly Women

Stroke risk and prevalence increase with advanced age and women tend to be older than men at the time of their first stroke. Advanced age in women confers unique stroke risks that are beyond reproductive factors. Previous reviews and guidelines have largely focused on risk factors specific to women, with a predominant focus on reproductive factors and, therefore, younger to middle-aged women. This review aims to specifically describe stroke risk factors in elderly women, the population of women where the majority of strokes occur, with a focus on atrial fibrillation, hormone therapy, psychosocial risk factors, and cognitive impairment. Our review suggests that prevention and management of stroke risks that are unique or more prevalent in elderly women needs a coordinated system of care from general physicians, general neurologists, vascular and cognitive neurologists, psychologists, cardiologists, patients, and their caretakers. Early identification and management of the elderly woman-specific and traditional stroke risk factors is key for decreasing stroke burden in elderly women. Increased education among elderly women regarding stroke risk factors and their identification should be considered, and an update to the guidelines for prevention of stroke in women is strongly encouraged.

Cognitive Trajectories in Older Patients with Cancer Undergoing Radiotherapy—A Prospective Observational Study

Cognitive function can be affected by cancer and/or its treatment, and older patients are at a particular risk. In a prospective observational study including patients ≥65 years referred for radiotherapy (RT), we aimed to investigate the association between patient- and cancer-related factors and cognitive function, as evaluated by the Montreal Cognitive Assessment (MoCA), and sought to identify groups with distinct MoCA trajectories. The MoCA was performed at baseline (T0), RT completion (T1), and 8 (T2) and 16 (T3) weeks later, with scores ranging between 0 and 30 and higher scores indicating better function. Linear regression and growth mixture models were estimated to assess associations and to identify groups with distinct MoCA trajectories, respectively. Among 298 patients with a mean age of 73.6 years (SD 6.3), the baseline mean MoCA score was 24.0 (SD 3.7). Compared to Norwegian norm data, 37.9% had cognitive impairment. Compromised cognition was independently associated with older age, lower education, and physical impairments. Four groups with distinct trajectories were identified: the very poor (6.4%), poor (8.1%), fair (37.9%), and good (47.7%) groups. The MoCA trajectories were mainly stable. We conclude that cognitive impairment was frequent but, for most patients, was not affected by RT. For older patients with cancer, and in particular for those with physical impairments, we recommend an assessment of cognitive function.

Examine Race/Ethnicity Disparities in Perception, Intention, and Screening of Dementia in a Community Setting: Scoping Review

BACKGROUND

Delayed detection and diagnosis of Alzheimer's Disease and related dementia (ADRD) can lead to suboptimal care and socioeconomic burdens on individuals, families, and communities. Our objective is to investigate dementia screening behavior focusing on minority older populations and assess whether there are ethnic differences in ADRD screening behavior.

METHODS

The scoping review method was utilized to examine ADRD screening behavior and contributing factors for missed and delayed screening/diagnosis focusing on race/ethnicity.

RESULTS

2288 papers were identified, of which 21 met the inclusion criteria. We identified six dimensions of ADRD screening behavior: Noticing Symptoms, Recognizing a problem, Accepting Screen, Intending Screen, Action, and Integrating with time. Final findings were organized into study race/ethnicity, theoretical background, the methods of quantitative and qualitative studies, description and measures of ADRD screening behavior, and racial/ethnic differences in ADRD screening behavior.

CONCLUSIONS

A trend in ethnic disparities in screening for ADRD was observed. Our findings point to the fact that there is a scarcity of studies focusing on describing ethnic-specific ADRD screening behavior as well as a lack of those examining the impact of ethnicity on ADRD screening behavior, especially studies where Asian Americans are almost invisible.

Survey Results of Speech-Language Pathologists Working With Cognitive-Communication Disorders: Improving Practices for Mild Cognitive Impairment and Early-Stage Dementia From Alzheimer's Disease

PURPOSE

As the incidence of Alzheimer's disease (AD) continues to rise, there is a need for interventions that focus on risk reduction and early disease management. Speech-language pathologists (SLPs) can contribute to risk reduction efforts and deliver cognitive interventions; however, the nature and frequency of current clinical practice in those areas is unclear. Therefore, the purpose of this study was to conduct an exploratory survey of the cognitive-communication practices and needs of SLPs for adults with mild cognitive impairment (MCI) and early-stage dementia from AD, to inform future research and clinical training efforts.

METHOD

SLPs completed an online survey that assessed five areas of practice specific to cognitive-communication and MCI and early-stage dementia: (a) education and training, (b) MCI subtype knowledge and consideration, (c) goals and treatment practices, (d) assessment of everyday living skills, and (e) general clinical practices and needs.

RESULTS

One hundred fifty-seven SLPs completed the survey and represented a range of practice experience. Results revealed a discrepancy between the number of SLPs who provide services to adults with MCI or early-stage dementia and those who have received formal training to do so, suggesting a reliance on clinical practice experience. Participants primarily reported using interview and informal methods to assess daily activities and often described using compensatory-based treatments.

CONCLUSIONS

These findings contribute to the limited knowledge about SLPs' cognitive-communication practices to help improve early-disease management for AD, a rapidly growing population in need of SLPs' services. More research is needed to support SLPs in being maximally effective when working with clients early in the AD continuum.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19787728.

Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people

BACKGROUND

In primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests.

OBJECTIVES

To determine the diagnostic accuracy of GPs' clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies.

SEARCH METHODS

We searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021.

SELECTION CRITERIA

We selected cross-sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS-2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta-analysis using the bivariate method.

MAIN RESULTS

We identified 18,202 potentially relevant articles, of which 12,427 remained after de-duplication. We assessed 57 full-text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta-analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS-2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS-2 domains. Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta-analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61). For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40). It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD-10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test.

AUTHORS' CONCLUSIONS

Clinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some - such as some people with depression - may suffer delayed intervention for an alternative treatable pathology.

Feasibility of Extracting Meaningful Patient Centered Outcomes From the Electronic Health Record Following Critical Illness in the Elderly

Background

Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside the research setting. The Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR.

Methods

Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen's kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively whether a patient's condition was “better,” “unchanged” or “worse.” Days alive and out of hospital/health care facility was a secondary outcome.

Results

Thirty six of the 41 randomly selected patients (88%) survived critical illness. EHR contained sufficient information to determine the difference in health status before and after critical illness in most survivors (86%). Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up.

Conclusion

We demonstrated the feasibility and reliability of assessing the trajectory of changes in functional status, cognition, and selected mental health outcomes from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes could be used alongside survival in quality improvement studies and pragmatic clinical trials.

Detection of Dementia Signals from Longitudinal Clinical Visits Using One-Class Classification

Dementia is one of the major health challenges in aging populations, with 50 million people diagnosed worldwide. However, dementia is often underdiagnosed or delayed resulting in missed opportunities for appropriate care plans. Identifying early signs of dementia is essential for better life quality of aging populations. Monitoring early signs of individual health changes could help clinicians diagnose dementia in its early stages with more effective treatment plans. However, rare data for dementia cases compared to the normal (i.e., imbalance class distribution) make it challenging to develop robust supervised learning models. In order to alleviate this issue, we investigated one-class classification (OCC) techniques, which use only majority class (i.e., normal cases) in model development to detect dementia signals from older adult clinical visits. The OCC models identify abnormality of older adults' longitudinal health conditions to predict incident dementia. The predictive performance of the OCC was compared with a recent streaming clustering-based technique and demonstrated higher predictive power. Our analysis showed that OCC has a promising potential to increase power in predicting dementia.

Comparison of Neuropsychological Assessment by Videoconference and Face to Face

OBJECTIVE

To compare the administration of neuropsychological tests by teleneuropsychology (TeleNP) and face to face (F-F) in order to determine the feasibility and reliability of TeleNP.

METHOD

At the inclusion visit, all participants underwent a traditional F-F neuropsychological assessment as part of their standard care. Four months after inclusion, they were randomized to undergo an additional neuropsychological assessment either by F-F administration or by TeleNP.

RESULTS

A total of 150 adults with cognitive complaints, but with no major cognitive or sensorial impairment were included. At 4 months, 69 participants were randomized in the F-F arm and 71 in TeleNP arm (10 lost in the follow-up). The overall satisfaction was high: 87.1% in the TeleNP arm were "very satisfied", and 82.9% indicated no preference between F-F and TeleNP. In agreement with previous data from the literature, neuropsychological assessments gave similar results across both administration conditions for a large majority of tests [Mini-Mental State Examination (MMSE), Free and Cued Selective Reminding Test (FCSRT) French version, Mahieux gestural praxis battery, Frontal Assessment Battery (FAB), time of completion of the Trail making Test (TMT) A and B, number of errors of the TMT B, Rey complex figure test, categorical et phonological verbal fluency tests] and minor differences for others [80-picture naming test (DO-80), FAB, Digit Span forward and backward and number of errors in the TMT A].

CONCLUSIONS

TeleNP is a promising method to be able to test patients as an alternative to F-F condition. Before this procedure can be generalized, it is now necessary to standardize the adaptation of certain tests and to test them in populations with more significant cognitive disorders.

Derivation and validation of the Rapid Assessment of Dementia Risk (RADaR) for older adults

BACKGROUND

There is no practical dementia risk score in the clinical setting.

OBJECTIVE

To derive and validate a score obtained by a rapid and simple assessment, which guides primary care providers in predicting the risk of dementia among older adults.

DESIGN

A total of 4178 participants from three longitudinal cohorts (mean age at baseline = 76.8 [SD = 7.6] years), without baseline dementia, followed annually for a median of 10 years (IQR: 5 to16 years, Reverse Kaplan-Meier).

PARTICIPANTS

To derive the score, we used data from 1,780 participants from the Rush Memory and Aging Project (93% White). To validate the score, we used data from 1,299 participants from the Religious Order Study (92% White), and to assess generalizability, 679 participants from the Minority Aging Research Study (100% Black).

MEASUREMENTS

Clinician-based dementia diagnosis at any time after baseline and predictive variables associated with dementia risk that can be collected in a primary care setting: demographics, clinical indicators, medical history, memory complaints, cognitive and motor tests, and questions to assess functional disability, depressive symptoms, sleep, social isolation, and genetics (APOE e4 and AD polygenic risk score).

RESULTS

At baseline, age, memory complaint, the ability to handle finances, the recall of the month, recall of the room, and recall of three words, were associated with the cumulative incidence of dementia, in the derivation cohort. The discrimination of the RADaR (Rapid Risk Assessment of Dementia) was good for the derivation and external-validation cohorts (AUC3 years = 0.82-0.86), compared to the overall discrimination of age alone (AUC3 years = 0.73), a major risk factor for dementia. Adding genetic data did not increase discrimination.

LIMITATIONS

Participants were volunteers, may not represent the general population.

CONCLUSIONS

The RADaR, derived from community-dwelling older persons, is a brief and valid tool to predict dementia risk at 3 years in older White and Black persons.

Dementia diagnosis in the hospital and outcomes among patients with advanced dementia documented in the Minimum Data Set

BACKGROUND

Individuals with dementia do not always have a diagnosis of dementia noted on their hospital claims. Whether this lack of documentation is associated with patient outcomes is unknown. We examined the association between a dementia diagnosis listed on a hospital claim and patient outcomes among individuals with a Minimum Data Set (MDS) assessment.

METHODS

A retrospective cohort study was conducted using administrative claims data and nursing home MDS assessments. Hospitalized patients aged 66 and older with advanced dementia noted on an MDS assessment completed within 120 days prior to their first hospitalization in 2017 were included. Advanced dementia was defined based on an MDS diagnosis of dementia, dependency in four or more activities of daily living, and a Cognitive Function Scale score indicative of moderate to severe impairment. Multilevel regression with a random intercept at the hospital level was used to examine the relationship between documentation of dementia in inpatient hospital Medicare claims and the following patient outcomes after adjusting for patient and hospital characteristics: invasive mechanical ventilation (IMV) use, intensive care unit or coronary care unit (ICU/CCU) use, 30-day mortality, and hospital length of stay (LOS).

RESULTS

In 2017, among 120,989 patients with advanced dementia and a nursing home stay, 90.57% had a dementia diagnosis on their hospital claims. In adjusted models, documentation of a dementia diagnosis was associated with lower use of the ICU/CCU (adjusted odds ratio [AOR]: 0.78 [95% confidence interval 0.74, 0.81]), use of IMV (AOR: 0.50 [0.47, 0.54]), and 30-day mortality (AOR: 0.81 [0.77, 0.85]). Patients with a dementia diagnosis had a shorter LOS.

CONCLUSIONS

Among patients with advanced dementia, those whose dementia diagnosis was documented on their inpatient hospital Medicare claim experienced lower use of ICU/CCU, use of IMV, lower 30-day mortality, and shorter LOS than those whose diagnosis was not documented.

Patient, Family Caregiver, and Provider Perceptions on Self-Assessment Screening for Cognitive Impairment in Primary Care: Findings From a Qualitative Study

The purpose of this study was to evaluate patient, family, and provider perspectives on routine cognitive screening of older adults in primary care using a novel self-assessment tool for detection of early cognitive impairment (CI). We conducted four virtual focus groups with patients aged 65 and older with no CI (n = 18) and family caregivers of patients with CI (n = 5) and interviews with primary care providers (n = 11). Patient and family caregiver participants felt that early detection of CI was important in primary care and may facilitate planning for the future including finances, living arrangements, and advance care planning. Providers reported that they do not use a standardized tool to routinely screen patients for CI yet endorsed the use of a self-assessment CI screening tool. These results suggest that routine screening of older adults using a brief, self-assessment screening tool for CI in primary care may be acceptable to patients, family caregivers, and providers. The findings from this study will inform the development of a brief self-assessment CI screening tool for use in primary care.

Early Alert of Elderly Cognitive Impairment using Temporal Streaming Clustering

more than 44 million people have been diagnosed with dementia worldwide, and this number is estimated to triple by next three decades. Given this increasing trend of older adults with cognitive impairment (CI; dementia and mild cognitive impairment) and its significant underdiagnosis, early identification of CI and understanding its progression is a critical step towards a better quality of life for the aging population. Early alert of individual health changes could facilitate better ways for clinicians to diagnose CI in its early stages and come up with more effective treatment plans. However, there is a lack of approaches to characterize patient health conditions accounting for temporal information in an unsupervised manner. Limited CI cases and its costly ascertainment in clinical settings also make unsupervised learning more promising in CI research. In this paper, a streaming clustering model was used to determine distinct patterns of older adults' health changes from their clinical visits in Mayo Clinic Study of Aging. The streaming clustering was also examined to study its ability to generate early alerts for potential incidents of CI. Our analysis demonstrated that temporal characteristics incorporated in a streaming clustering model has a promising potential to increase power in predicting CI.

Screening for subjective cognitive decline in the elderly via subjective cognitive complaints and informant-reported questionnaires: a systematic review

BACKGROUND

Subjective cognitive decline may represent at-risk persons progressing to mild cognitive impairment (MCI), which can be exacerbated by effects of anesthesia and surgery. The objective of this systematic review is to identify the most common questions in subjective cognitive complaint and informant-reported questionnaires used in assessing cognitive impairment of elderly patients that are correlated with standardized tests for cognitive impairment screening.

METHODS

We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database, Emcare Nursing, Web of Science, Scopus, CINAHL, ClinicalTrials.Gov, and ICTRP between September 20, 2005 to August 31, 2020. We included studies that evaluated subjective cognitive complaints and informant-reported questions in elderly patients.

RESULTS AND CONCLUSION

A total of 28,407 patients were included from 22 studies that assessed 21 subjective complaint questionnaires and nine informant-reported questionnaires. The most common subjective cognitive complaints were those assessing anterograde memory, closely followed by perceptual-motor function and executive function. The most common informant-reported questions were those assessing executive function, temporal orientation, and anterograde memory. Questions assessing learning and memory were most associated with results from standardized tests assessing cognitive impairment. Assessing learning and memory plays a key role in evaluating subjective cognitive decline in elderly patients. Delivering subjective cognitive complaints questions to elderly patient preoperatively may aid in screening for those exhibiting cognitive signs, and in turn are at risk of postoperative complications. Thus, the results from this review contribute to knowledge for healthcare professionals regarding the use of subjective cognitive complaints and informant-reported complaints in preoperative settings.

Prominent Cognitive Impairment Sequelae in Adult Survivors of Acute Respiratory Distress Syndrome

PURPOSE

The primary objective of this scoping review was to identify prominent cognitive impairment sequelae in adult survivors of an intensive care unit admission for acute respiratory distress syndrome (ARDS).

DESIGN

A scoping review was performed.

METHODS

Search terms were entered into multiple EBSCOhost databases. Articles pertaining to pediatric survivors, not in English, lacking cognitive impairment sequelae, or focused on a single sequela were excluded; 12 articles remained.

RESULTS

Cognitive impairment developed in 83.5% of patients with ARDS prior to discharge and persisted in 51.3% (n = 300/585) of survivors at the 1 year mark after discharge (range: 16.7%-100% across studies). Prominent sequelae included impairments in executive function, mental processing speed, immediate memory, and attention/concentration.

CONCLUSIONS

Survivors of an intensive care unit stay for ARDS often develop cognitive impairment persisting long after their admission. Clinicians in rehabilitation facilities should screen for these sequelae and connect survivors with treatment to improve cognitive outcomes.

CLINICAL RELEVANCE

Early recognition of prominent cognitive impairment sequelae by rehabilitation clinicians and referrals to neuropsychologists by providers are critical to limiting the severity of impairment.

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review

Cognitive assessment is a cornerstone of geriatric care. Cognitive impairment has the potential to significantly impact multiple phases of a person's cancer care experience. Accurately identifying this vulnerability is a challenge for many cancer care clinicians, thus the use of validated cognitive assessment tools are recommended. As international cancer guidelines for older adults recommend Geriatric Assessment (GA) which includes an evaluation of cognition, clinicians need to be familiar with the overall interpretation of the commonly used cognitive assessment tools. This rapid review investigated the cognitive assessment tools that were most frequently recommended by Geriatric Oncology guidelines: Blessed Orientation-Memory-Concentration test (BOMC), Clock Drawing Test (CDT), Mini-Cog, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Short Portable Mental Status Questionnaire (SPMSQ). A detailed appraisal of the strengths and limitations of each tool was conducted, with a focus on practical aspects of implementing cognitive assessment tools into real-world clinical settings. Finally, recommendations on choosing an assessment tool and the additional considerations beyond screening are discussed.

Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within a secondary care setting

BACKGROUND

The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual's functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable 'informant' who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool for identifying those who may have dementia. In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established.

OBJECTIVES

To determine the accuracy of the informant-based questionnaire IQCODE for detection of dementia in a secondary care setting.

SEARCH METHODS

We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects - via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate.

SELECTION CRITERIA

We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the 'secondary care' setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist 'memory' assessment, typically in psychogeriatric services.

DATA COLLECTION AND ANALYSIS

We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool.

MAIN RESULTS

From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22). There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a 'general' setting. We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration. There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice.

AUTHORS' CONCLUSIONS

The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.