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Kammeyer R, Ogbu EA, Cooper JC, Stolz E, Piquet AL, Fuhlbrigge RC, Bennett JL, Hutaff-Lee C. [Formula: see text] Cognitive dysfunction in pediatric systemic lupus erythematosus: current knowledge and future directions. Child Neuropsychol 2024; 30:818-846. [PMID: 37902575 PMCID: PMC11058121 DOI: 10.1080/09297049.2023.2273573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/16/2023] [Indexed: 10/31/2023]
Abstract
Cognitive dysfunction (CD) is a neurologic complication of pediatric systemic lupus erythematosus (SLE) that remains poorly understood and understudied, despite the potential negative effects of CD on long-term socioeconomic status and quality of life. Data regarding the prevalence and risk factors for CD in pediatric SLE as well as the optimal screening, treatment, and long-term outcomes for CD are lacking. In this review, we present current knowledge on CD in pediatric SLE with a focus on the application to clinical practice. We discuss the challenges in diagnosis, clinical screening methods, potential impacts, and interventions for this complication. Finally, we discuss the remaining gaps in our knowledge of CD in pediatric SLE, and avenues for future research efforts.
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Affiliation(s)
- Ryan Kammeyer
- Departments of Pediatrics and Neurology, Sections of Child Neurology and Neuroimmunology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ekemini A. Ogbu
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer C. Cooper
- Department of Pediatrics, Section of Pediatric Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Erin Stolz
- Department of Child and Adolescent Psychiatry, Section of Pediatric Medical Psychology, John Hopkins Medicine, Baltimore, MA, USA
| | - Amanda L. Piquet
- Department of Neurology, Section of Neuroimmunology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert C. Fuhlbrigge
- Department of Pediatrics, Section of Pediatric Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jeffrey L. Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christa Hutaff-Lee
- Department of Pediatrics, Section of Neurology-Neuropsychology, University of Colorado School of Medicine, Aurora, CO, USA
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Koolvisoot A, Chumjang S. Prevalence of cognitive impairment and cognitive improvement in patients with systemic lupus erythematosus during a 6-month follow-up study. Lupus 2023; 32:1199-1210. [PMID: 37592859 DOI: 10.1177/09612033231196215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVES The Montreal Cognitive Assessment (MoCA) is a simple and reliable screening tool for early detection for cognitive impairment in systemic lupus erythematosus (SLE). Most previous studies were cross-sectional with small samples. Research on long-term cognitive changes and reversibility is limited. This study aimed to establish the prevalence of cognitive impairment and changes in SLE patients after 6 months and the associated factors. METHODS A prospective study was conducted in 200 patients with SLE between April 2021 and March 2022. Demographic data, disease activity, and medications were recorded. MoCA was administered at baseline and 6 months; for Thais, scores 17-24 indicate mild cognitive impairment, while ≤16 signifies severe impairment. Multivariate analysis identified factors associated with cognitive impairment and improvement. RESULTS The patients' median age was 44 years (range: 19-73), 96% were female, and 55% had < 12 years of education. The median disease duration was 11 years (range: 0-51.8), and 79% of patients had inactive disease. Cognitive impairment was found in 70% of patients (mild, 63%; severe, 7%). The most often affected domains were delayed recall (82%), abstraction (80.5%), language (76%) and visuospatial/executive function (70.5%), whereas orientation and naming were the least involved. Factors significantly associated with cognitive impairment were age > 40 years (OR, 3.71; 95% CI, 1.72-8.00), formal education < 12 years (OR, 3.11; 95% CI, 1.45-6.63), and prednisolone use (OR, 2.21; 95% CI, 1.08-4.51). Sixty-six (38.2%) of 173 patients completing the 6-month re-evaluation exhibited cognitive changes (52 [30.1%] improved; 14 [8.1%] deteriorated). Except for delayed recall, all commonly affected domains showed significant improvement. Disease activity, prednisolone, antimalarials, or immunosuppressant use did not predict cognitive improvement. CONCLUSIONS Mild cognitive impairment is prevalent among patients with SLE. Due to the possibility of reversibility, early recognition and additional research to identify relevant factors are required.
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Affiliation(s)
- Ajchara Koolvisoot
- Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sasamon Chumjang
- Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Tayer-Shifman OE, Yuen K, Green R, Kakvan M, Katz P, Bingham KS, Diaz-Martinez JP, Ruttan L, Wither JE, Tartaglia MC, Su J, Bonilla D, Choi MY, Appenzeller S, Barraclough M, Beaton DE, Touma Z. Assessing the Utility of the Montreal Cognitive Assessment in Screening for Cognitive Impairment in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2023; 75:569-577. [PMID: 35724303 DOI: 10.1002/acr.24971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/24/2022] [Accepted: 06/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Screening for cognitive impairment (CI) in systemic lupus erythematosus (SLE) relies on the American College of Rheumatology (ACR) neuropsychological battery (NB). By studying the concurrent criterion validity, our goal was to assess the Montreal Cognitive Assessment (MoCA) as a screening tool for CI compared to the ACR-NB and to evaluate the added value of the MoCA to the Automated Neuropsychological Assessment Metrics (ANAM). METHODS A total of 285 adult SLE patients were administered the ACR-NB, MoCA, and ANAM. For the ACR-NB, patients were classified as having CI if there was a Z score of ≤-1.5 in ≥2 domains. The area under the curve (AUC) and sensitivities/specificities were determined. A discriminant function analysis was applied to assess the ability of the MoCA to differentiate between CI, undetermined CI, and non-CI patients. RESULTS CI was not accurately identified by the MoCA compared to the ACR-NB (AUC of 0.66). Sensitivity and specificity were poor at 50% and 69%, respectively, for the cutoff of 26, and 80% and 45%, respectively, for the cutoff of 28. The MoCA had a low ability to identify CI status. The addition of the MoCA to the ANAM led to improvement on the AUC by only 2.5%. CONCLUSION The MoCA does not have adequate concurrent criterion validity to accurately identify CI in patients with SLE. The low specificity of the MoCA may lead to overdiagnosis and concern among patients. Adding the MoCA to the ANAM does not substantially improve the accuracy of the ANAM. These results do not support using the MoCA as a screening tool for CI in patients with SLE.
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Affiliation(s)
- Oshrat E Tayer-Shifman
- Meir Medical Center, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kimberley Yuen
- Toronto Western Hospital and University Health Network, Toronto, and Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Robin Green
- University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Mahta Kakvan
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Kathleen S Bingham
- University Health Network Centre for Mental Health, Toronto, Ontario, Canada
| | - Juan Pablo Diaz-Martinez
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Lesley Ruttan
- University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Joan E Wither
- Schroeder Arthritis Institute and University Health Network, Toronto, Ontario, Canada
| | | | - Jiandong Su
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Dennisse Bonilla
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Michelle Barraclough
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Zahi Touma
- Toronto Western Hospital, Schroeder Arthritis Institute, University Health Network, and University of Toronto, Toronto, Ontario, Canada
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Raghunath S, Glikmann-Johnston Y, Golder V, Kandane-Rathnayake R, Morand EF, Stout JC, Hoi A. Clinical associations of cognitive dysfunction in systemic lupus erythematosus. Lupus Sci Med 2023; 10:10/1/e000835. [PMID: 36854540 PMCID: PMC9980376 DOI: 10.1136/lupus-2022-000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/10/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE Cognitive dysfunction in SLE is common, but clinical risk factors are poorly understood. This study aims to explore the associations of cognitive dysfunction in SLE with disease activity, organ damage, biomarkers and medications. METHODS We performed cross-sectional cognitive assessment using a conventional neuropsychological test battery, with normative values derived from demographically matched healthy subjects. Endpoints included two binary definitions of cognitive dysfunction and seven individual cognitive domain scores. Clinical parameters included disease activity (SLEDAI-2K) and organ damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index). We performed regression analyses to determine associations between clinical parameters and cognitive endpoints. RESULTS 89 patients with SLE were studied, with median age of 45 and disease duration of 15 years. Organ damage was significantly associated with severe cognitive dysfunction (OR 1.49, CI 1.01-2.22) and worse cognitive test performance in three of the seven individual cognitive domains. In contrast, no significant associations were found between SLEDAI-2K at the time of cognitive assessment and any cognitive endpoints on multivariate analysis. Higher time-adjusted mean SLEDAI-2K was associated with better verbal memory scores but had no significant associations with other cognitive endpoints. The presence of anti-dsDNA antibodies and high IFN gene signature were negatively associated with severe cognitive dysfunction; there were no significant associations with the other autoantibodies studied or any medications. Substance use was significantly associated with lower psychomotor speed. Only 8% of patients who had cognitive dysfunction on testing had been recognised by clinicians on their SDI score. CONCLUSIONS In SLE, cognitive dysfunction was positively associated with organ damage, but not associated with disease activity, and serological activity and high IFN signature were negatively associated. Cognitive dysfunction was poorly captured by clinicians. These findings have implications for preventative strategies addressing cognitive dysfunction in SLE.
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Affiliation(s)
- Sudha Raghunath
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia .,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
| | - Yifat Glikmann-Johnston
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Vera Golder
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
| | - Rangi Kandane-Rathnayake
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
| | - Julie C Stout
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Alberta Hoi
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
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Lim XR, Chew POK, Lim GH, Low YL, Lim JWP, Ong HN, Law WG, Tan JWL, Thong BY, Chia FLA, Lian TY, Chan GYL, Chan MTL, Koh ET, Kong KO, Howe HS. Montreal cognitive assessment as a screening instrument for cognitive impairment in systemic lupus erythematosus patients without overt neuropsychiatric manifestations. Lupus 2022; 31:1759-1769. [PMID: 36218127 DOI: 10.1177/09612033221132237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The Montreal Cognitive Assessment (MoCA) is an increasingly used screening tool for cognitive impairment. The aim of this study was to examine how MoCA performed in identifying cognitive impairment (CI) domains in SLE patients compared with formal standardized neuropsychological testing (NPT). Factors related to SLE disease, immunologic and psychological state associated with CI were also explored. METHODS This cross-sectional study recruited 50 SLE patients without overt neuropsychiatric manifestations from April 2017 to May 2018. The patients were evaluated with MoCA, formal NPT and the Depression, Anxiety, and Stress Scales (DASS) 42-item self-report questionnaire. Values of sensitivity and specificity were computed for different cut-offs of MoCA within each cognitive domain of NPT and descriptive analysis was used to identify the factors affecting cognitive function. RESULTS The median score for MoCA was 27.5 (range 22-30). Using a MoCA cutoff of <26, 18 (36%) were identified to have CI using NPT compared to 8 (16%) using MoCA. The most frequently affected cognitive domain was executive functioning with 15 affected patients. Sensitivities and specificities of the MoCA range from 50% to 100% and 5.7% to 16.7%, respectively, across cognitive domains. A lower MoCA cutoff of <25 improve sensitivity of identifying impairment in executive functioning from 60% to 80%. In univariate analysis, DASS scores, disease activity, presence of antiphospholipid antibodies, presence of concurrent autoimmune disease, current, and cumulative corticosteroid therapy did not predict cognitive performance. CONCLUSION MoCA may be a useful screening tool to identify the most frequently affected cognitive domain which is executive functioning using a lower cutoff of <25 in SLE patients without overt neuropsychiatric manifestations.
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Affiliation(s)
- Xin Rong Lim
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Gek Hsiang Lim
- Clinical Research and Innovation Office, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Yung Ling Low
- Department of Psychology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - June Wei Ping Lim
- Department of Psychology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Huey Ni Ong
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Weng Giap Law
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Justina Wei Lynn Tan
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Bernard Yh Thong
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Faith Li-Ann Chia
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Tsui Yee Lian
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Grace Yin Lai Chan
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Madelynn Tsu-Li Chan
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Ee Tzun Koh
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Kok Ooi Kong
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
| | - Hwee Siew Howe
- Department of Rheumatology, Allergy and Immunology, 63703Tan Tock Seng Hospital, Singapore, Singapore
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