Cognitive dysfunction in SLE: development of a screening tool

Association between cognitive impairment and olfactory deficits in systemic lupus erythematosus without major neuropsychiatric syndromes

OBJECTIVE

The aim of the study was to investigate the utility of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), evaluate cognitive deficits in systemic lupus erythematosus (SLE) patients and examine the relationship between cognitive and olfactory functions.

METHODS

55 SLE patients and 50 healthy controls were administered by RBANS including five indexes: immediate memory (IMME), visuospatial/constructional (Vis/Con), language (LANG), attention (ATT), and delayed memory (DEME). Olfactory functions were evaluated by computerized testing including three stages of smell: threshold (THR), identification (ID), and memory (ME) of different odors. The disease activity and cumulative damage were assessed by the SLE Disease Activity Index 2000 (SLEDAI-2K) and the Systemic Lupus International Collaborating Clinics (SLICC)/American College of Rheumatology (ACR) Damage Index (SDI).

RESULTS

SLE patients exhibited significant lower total RBANS scores, IMME, Vis/Con, ATT, and DEME index scores than healthy controls (p < 0.01 for all and p = 0.027 for attention). Reduced RBANS scores were associated with several organ involvement and autoantibodies. SLE patients with higher SLEDAI-2K scores or with accumulated damage (SDI≥1) showed decreased RBANS scores. All the olfactory scores in SLE patients were significantly decreased than controls (p = 0.001). Patients had higher proportion of anosmia (8.57% vs 0%) and hyposmia (28.58% vs 5.72%) than controls (χ2 = 10.533, p = 0.015). Multivariable regression analysis revealed that olfactory functions had a positive effect on RBANS index scores. Olfactory memory and total scores were significantly correlated with the DEME (r = 0.393, p = 0.021) and total scores (r = 0.429, p = 0.011).

CONCLUSION

This study indicates that significantly cognitive and olfactory functions are impaired in SLE patients. The RBANS is a potentially useful instrument for evaluating neuropsychological status in SLE. Physicians are encouraged to perform routine screening in SLE patients to detect subtle cognitive dysfunction.

Prevalence of cognitive impairment and cognitive improvement in patients with systemic lupus erythematosus during a 6-month follow-up study

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.

Assessing the Utility of the Montreal Cognitive Assessment in Screening for Cognitive Impairment in Patients With Systemic Lupus Erythematosus

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.

Cognitive Performance in Patients with Systemic Lupus Erythematosus Using the Ped-ANAM

Computerized batteries have been widely used to investigate cognitive impairment (CI) in patients with SLE. The aim of this study was to evaluate the cognitive performance of patients with SLE in relation to healthy controls using the Pediatric Automated Neuropsychological Assessment Metrics (Ped-ANAM) battery. In addition, we aimed to examine differences in Ped-ANAM scores according to age of disease onset, presence of disease activity, and disease damage. We included 201 consecutive adult-onset (aSLE) and childhood-onset SLE (cSLE) patients who were being followed at the hospital's rheumatology outpatient clinic and 177 healthy controls. We applied the percentage of correct answers on the Ped-ANAM subtests and the Performance Validity Index (PVI) metric and correlated them with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and Systemic Lupus Erythematosus Damage Index (SDI). Then, we established their relationships with neuropsychiatric systemic lupus erythematosus (NPSLE). We observed CI in a total of 38 (18.9%) SLE patients and 8 (4.5%) healthy controls (p < 0.001). CI was observed in eight (19.5%) cSLE patients and 32 (20%) aSLE patients (p = 0.8175). Individual analysis of the aSLE subtests showed a significant difference in all subtests compared to healthy controls; the greatest differences were in matching to sample (p < 0.001) and memory search ( p < 0.001). In the cSLE group, we observed a difference in the code substitution subtests (p = 0.0065) compared to the healthy controls. In the evaluation of clinical outcomes, disease activity was significantly correlated with CI in cSLE (r = 0.33; p = 0.042) and aSLE (r = 0.40; p = 0.001). We also observed an association between disease activity and neuropsychiatric manifestations (p = 0.0012) in aSLE. In conclusion, we determined that cognitive dysfunction, mainly in memory and attention, was more prevalent in patients with SLE. In both the cSLE and aSLE groups, disease activity was associated with worse cognitive function. This is the first study to use the Ped-ANAM in Brazil. Longitudinal studies are necessary to determine how the Ped-ANAM will perform over time.

Montreal cognitive assessment as a screening instrument for cognitive impairment in systemic lupus erythematosus patients without overt neuropsychiatric manifestations

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.

Absence of association between nailfold capillary findings and mild cognitive dysfunction in systemic lupus erythematosus

OBJECTIVE

The role of vascular damage in cognitive dysfunction (CD) in SLE is not entirely understood. Nailfold capillaroscopy (NFC) is a noninvasive method that may aid the description of further vascular contributions to CD in SLE. Therefore, the aim of our study was to examine and compare finger nailfold capillary morphology in subjects with SLE with and without CD.

METHODS

We conducted a cross-sectional study in patients with SLE. Demographic, clinical, and laboratory characteristics were collected. We evaluated nailfold capillary findings including avascular zones, hemorrhage, dilated and tortuous capillaries, disarrangement, crossing, subpapillary venular plexus, branched loops, and shortened loops by NFC. The Montreal Cognitive Assessment (MoCA) scale was used to screen cognitive function. CD was defined as a score < 26/30.

RESULTS

Sixty-five females (97.0%) and 2 males (3%) with SLE were analyzed. Means of age and disease duration were 44.3 ± 12.0 years and 15.5 ± 7.6 years, respectively. Thirty-five (54.7%) patients had CD. The rate of patients with ≥ 1 NFC abnormality was 50% in both patients with and without CD (P = 0.14). Eight (22.8%) patients with CD compared to 1 without (3.5%) displayed dilated capillaries (P = 0.036). Other NFC abnormalities differed between patients with and without CD, but the possible relationships between dilated capillaries and CD disappeared after adjusting by age, diabetes, and hypertension.

CONCLUSIONS

NFC findings were not associated with mild CD in patients with SLE. Our exploratory data do not support systemic microvasculopathy measured by NFC related to CD in patients with SLE.

Neuropsychiatric Systemic Lupus Erythematosus: a remaining challenge

Systemic Lupus Erythematosus (SLE) is an autoimmune disease, which affects a wide range of organs with variable clinical features. Involvement of the nervous system is a challenging and multifaceted manifestation of the disease, presenting with a broad range of symptoms. Neuropsychiatric lupus (NPSLE) encompasses seven syndromes of the peripheral and 12 of the central nervous system, associated with a high disease burden. Despite advances in the management of SLE, NP manifestations still pose a challenge to clinicians. First, diagnosis and attribution to SLE is difficult due to the lack of specific biomarkers or imaging modalities. Second, therapeutic options are limited, and evidence is mainly based on case reports and expert consensus, as clinical trials are sparse. Moreover, no validated outcome measure on disease activity exists. Current recommendations for treatment include supportive as well as immunosuppressive medication, depending on the type and severity of manifestations. As NPSLE manifestations are increasingly recognized, a broader spectrum of therapeutic options can be expected.

Evaluation of the Montreal Cognitive Assessment as a screening tool for cognitive dysfunction in SLE

Objectives

Cognitive dysfunction in SLE is common and associated with significant morbidity but is currently underdetected. Early detection requires the use of screening tests, as formal diagnostic cognitive testing is time-consuming. This study aims to evaluate the Montreal Cognitive Assessment (MoCA) as a screening tool for cognitive dysfunction in SLE.

Methods

Patients with SLE (n=95) and demographically matched healthy control participants (n=48) underwent cognitive testing using the 1-hour neuropsychiatric test battery recommended by the American College of Rheumatology for use in SLE and the MoCA. We used regression analyses to determine associations between MoCA and cognitive test scores. We assessed several MoCA cut-offs for predicting cognitive impairment in terms of sensitivity, specificity, positive predictive value and negative predictive value. Receiver operating curve analyses were used to determine the diagnostic accuracy of the MoCA cut-off thresholds.

Results

We found a significant correlation between MoCA score and 9 of the 10 cognitive endpoints studied (all p<0.001). Receiver operating curve analysis suggested that a MoCA cut-off of <27 had highest diagnostic accuracy across the cognitive impairment definitions (area under the curve 0.76–0.78). Using a screening cut-off of <28, the MoCA had sensitivity of 83%–94% and specificity of 46%–59%, depending on the impairment definition used.

Conclusions

The MoCA correlates strongly with cognitive test results in SLE and has sufficient sensitivity for use as a screening tool with a cut-off of <28 as the optimal threshold. This tool can be incorporated into clinical practice for screening for cognitive dysfunction in SLE.

Screening for cognitive impairment in systemic lupus erythematosus: Application of the Montreal Cognitive Assessment (MoCA) in a Greek patient sample

BACKGROUND

Cognitive impairment (CI) is one of the most frequent neuropsychiatric manifestations of systemic lupus erythematosus (SLE). Given that extensive neuropsychological testing is not always feasible in routine clinical practice, brief cognitive screening tools are desirable. The aim of this study was to evaluate the Montreal Cognitive Assessment (MoCA) as a screening tool for CI in SLE.

METHODS

Consecutive SLE patients followed at a single centre were evaluated using MoCA and an extensive neuropsychological test battery (NPT), including the Digits Forward and Digits Backwards, Rey Auditory Verbal Learning Memory Test, Trail Making Test, Stroop Colour-Word Test, Semantic and Phonetic Verbal Fluency tests and a 25-problem version of the General Adult Mental Ability test. The criterion validity of MoCA was assessed through receiver operating characteristic (ROC) analyses using three different case definitions: i) against normative population data, ii) and iii) against average performance of a comparison group of rheumatoid arthritis (RA) patients, to adjust for possible confounding effects of chronic illness and inflammatory processes on cognitive performance. The effect of patient-related (age, years of education, anxiety, depression, fatigue and pain) and disease-related (activity, damage, age at diagnosis, disease duration, use of glucocorticoid, psychotropic and pain medication) parameters on the MoCA was examined.

RESULTS

A total of 71 SLE patients were evaluated. MoCA significantly correlated with all NPT scores and was affected by education level (p < 0.001), but not by other demographic or clinical variables. The optimal cutoff for detecting CI, as defined on the basis of normative population data, was 23/30 points, demonstrating 73% sensitivity and 75% specificity. A cutoff of 22/30 points, using neuropsychological profiles of the RA group as inflammatory disease controls, exhibited higher sensitivity (100%, based on both definitions) and specificity (87% and 90%, depending on the definition). The standard cutoff of 26/30 points displayed excellent sensitivity (91-100%) with significant expenses in specificity (43-45%).

CONCLUSION

The MoCA is an easily applied tool, which appears to be reliable for identifying CI in SLE patients. The standard cutoff score (26/30) ensures excellent sensitivity while lower cutoff scores (22-23/30) may, also, provide higher specificity.

Metrics and definitions used in the assessment of cognitive impairment in systemic lupus erythematosus: A systematic review

OBJECTIVE

To review: 1) degree of conformity to the American College of Rheumatology neuropsychological battery (ACR-NB) among studies that used a NB, 2) review definitions of cognitive impairment (CI) from studies that used a NB, and 3) characterize measurement tools used to assess CI in systemic lupus erythematosus (SLE).

METHODS

The literature search was conducted in Ovid Medline, Embase, and PsycINFO for articles on CI in adult SLE patients. We reviewed studies that used a NB and compared their tests to the ACR-NB to assess the degree of conformity. Definitions of CI from studies that used a NB were reviewed when sufficient information was available. We reviewed and categorized CI measurement tools into four broad categories: NB, screening, incomplete/mixed batteries, and computerized batteries.

RESULTS

Of 8727 references, 118 were selected for detailed review and 97 were included in the final analysis. Of 43 studies that used a NB, none of the studies used the ACR-NB exactly as published. Many studies supplemented with other tests. Overall, there was inconsistent use of ACR-NB tests. Definitions for CI varied, with cut-offs ranging from 1 to 3 standard deviations below normative values on domains/tests varying in type and number. The most frequently used measurement tool for assessing CI in SLE was a NB. Use of screening tests and computerized batteries have also increased over the last decade.

CONCLUSION

The assessment and definition of CI in SLE remains heterogeneous. A consensus meeting to address existing inconsistencies should be considered to harmonize the field of CI in SLE.

Cognitive Dysfunction in Systemic Lupus Erythematosus: Immunopathology, Clinical Manifestations, Neuroimaging and Management

Cognitive dysfunction (CD) is a common yet often clinically subtle manifestation that considerably impacts the health-related quality of life in patients with systemic lupus erythaematosus (SLE). Given the inconsistencies in CD assessment and challenges in its attribution to SLE, the reported prevalence of CD differs widely, ranging from 3 to 88%. The clinical presentation of CD in SLE is non-specific and may manifest concurrently with overt neuropsychiatric illness such as psychosis or mood disorders or as isolated impairment of attention, working memory, executive dysfunction or processing speed. Despite the lack of standardized and sensitive neuropsychological tests and validated diagnostic biomarkers of CD in SLE, significant progress has been made in identifying pathogenic neural pathways and neuroimaging. Furthermore, several autoantibodies, cytokines, pro-inflammatory mediators and metabolic factors have been implicated in the pathogenesis of CD in SLE. Abrogation of the integrity of the blood-brain barrier (BBB) and ensuing autoantibody-mediated neurotoxicity, complement and microglial activation remains the widely accepted mechanism of SLE-related CD. Although several functional neuroimaging modalities have consistently demonstrated abnormalities that correlate with CD in SLE patients, a consensus remains to be reached as to their clinical utility in diagnosing CD. Given the multifactorial aetiology of CD, a multi-domain interventional approach that addresses the risk factors and disease mechanisms of CD in a concurrent fashion is the favourable therapeutic direction. While cognitive rehabilitation and exercise training remain important, specific pharmacological agents that target microglial activation and maintain the BBB integrity are potential candidates for the treatment of SLE-related CD.

Validation of the Attention, Memory, and Frontal Abilities Screening Test (AMFAST)

The aim of this study is to validate the Attention, Memory, and Frontal Abilities Screening Test (AMFAST), a novel, 10-minute, paper-and-pencil measure developed to identify attention, processing speed, memory, and executive functioning deficits in children and adults with various conditions characterized by frontal-subcortical dysfunction. We administered the AMFAST to 186 English-speaking healthy control participants (aged 8-88 years) without reported cognitive impairment. The AMFAST was also administered to a mixed clinical sample that included 114 English-speaking individuals (aged 8-84 years) who also received comprehensive neuropsychological testing. Results indicated that total AMFAST scores in the healthy control sample were not significantly affected by education or gender. There was, however, a significant effect of age, as the 8- to 10-year-old group scored significantly lower than other age groups. Thus, only participants 11+ years were included in further analyses. The AMFAST demonstrated high test–retest and interrater reliabilities, good construct validity, and the identified optimal cutoff score of 70 had excellent sensitivity and specificity for differentiating between cognitively intact and cognitively impaired individuals. These findings demonstrate that the AMFAST is a highly effective screening test that can be used to identify attention, memory, processing speed, and executive functioning deficits in individuals from middle childhood through older adulthood.

Prevalence, involved domains, and predictor of cognitive dysfunction in systemic lupus erythematosus

BACKGROUND

Cognitive Dysfunction (CD) can occur in Systemic Lupus Erythematosus (SLE) before the occurrence of Neuropsychiatric Lupus Erythematosus (NPSLE). Given the reversibility and fluctuation of SLE-related CD, the research for possible predictors is of great significance for early detection and intervention.

OBJECTIVE

We sought to determine the prevalence, involved domains, and possible predictors of CD in SLE patients.

METHODS

We conducted a retrospective cross-sectional study at Nanfang Hospital from 2018 to 2019. A total of 78 SLE patients were recruited. The Montreal Cognitive Assessment (MoCA) scale was used to screen cognitive function. Demographic, clinical, and laboratory characteristics were collected. The serum anti-methyl-d-aspartate receptor (anti-NMDAR) antibody and S100β were measured by enzyme-linked immunosorbent assay (ELISA). Multivariate logistic regression analysis and ROC curve were used to assess the predictor of SLE-related CD.

RESULTS

Of 78 recruited patients,53 (67.9%) had CD. It mainly involved delayed recall, abstract generalization, verbal repetition, and fluency. The disease activity index (SLEDAI) was not associated with SLE-related CD (p > 0.05). Multivariate logistic regression showed that an increase in each year of education there was a decrease in the likelihood of CD (OR 0.261, CI 0.080-0.857, p = 0.027) whereas with each unit increase in serum anti-NMDAR antibody there was an increased likelihood of SLE-related CD (OR 1.568, CI 1.073-2.292, p = 0.020).

CONCLUSION

The prevalence of SLE-related CD was 67.9% in our study and SLE-related CD was not associated with disease activity. Serum anti-NMDAR antibody can be used as a predictor for SLE-related CD.

Cognitive dysfunction in Sjögren's syndrome using the Montreal Cognitive Assessment Questionnaire and the Automated Neuropsychological Assessment Metrics: A cross-sectional study

AIM

To describe the prevalence of cognitive impairment and the most affected cognitive domains, employing the Montreal Cognitive Assessment (MoCA) and the Automated Neuropsychological Assessment Metrics (ANAM) of a Latin American primary Sjögren's syndrome (pSS) cohort, and compare these patients to secondary Sjögren's syndrome (sSS) subjects and controls.

METHODS

This was a comparative cross-sectional study of patients with a diagnosis of pSS who fulfilled the American-European Consensus Group 2002 criteria and/or American College of Rheumatology/European League Against Rheumatism 2016 criteria; clinical information was evaluated prior to cognitive evaluation, which consisted of a single session in which the MoCA and ANAM were applied.

RESULTS

A total of 122 subjects were included in the analysis (51 pSS, 20 sSS and 51 controls); mean age of pSS was 56 years (SD 10.4), of which 47 (92.15%) were women. Moderate-severe cognitive impairment by MoCA was 17% in pSS, 5% in sSS, and 15% in controls, and by ANAM were 29% in pSS and 10% in sSS (P > .05). Visuospatial/executive subdomain in the MoCA was different between the pSS and the control group (P = .005). We encountered a statistically significant difference between pSS patients and control scores from the program in 6 of the 7 domains tested by the ANAM.

CONCLUSION

No difference was found in the prevalence of cognitive impairment between pSS subjects and controls by MoCA. Several subdomain scores differed between groups in both scales. Evaluation of cognitive disorders in patients with SS, even in early stages of the disease, seems advisable but the best strategy is yet to be elucidated.

Cognitive dysfunction in autoimmune rheumatic diseases

For people with chronic autoimmune rheumatic diseases (AIRD), such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or systemic sclerosis (SSc), normal cognitive functions are essential for performing daily activities. These diseases may be associated with cognitive dysfunction (CD). In RA, CD has been associated with age, lower education and disease duration and activity. Great advances have been achieved in neuropsychiatric SLE in the identification of pathogenic pathways, assessment and possible treatment strategies. SSc rarely exerts direct effects on the brain and cognitive function. However, the psychological burden that includes depression, anxiety and social impact may be high. AIRD patients with sustained disease activity, organ damage or lower education should be evaluated for CD. The control of systemic inflammation together with tailored behavioural cognitive therapies may benefit these patients.

The Montreal Cognitive Assessment Test: A Useful Tool in Screening of Cognitive Impairment in Patients With Systemic Lupus Erythematosus

BACKGROUND/OBJECTIVE

Systemic lupus erythematosus (SLE) is an inflammatory, chronic, and multisystemic disease, which may be associated with a wide range of neuropsychiatric manifestations, including cognitive impairment. Cognitive evaluations based on screening tests might identify early SLE-related cognitive alterations. The aim of this study was to evaluate and to compare the efficacy of three screening tests (Montreal Cognitive Assessment [MoCA], Mini Mental State Examination [MMSE], Cognitive Symptom Inventory [CSI]) against the gold standard (neuropsychological battery), in order to identify the most efficient screening test for cognitive impairment in patients with SLE.

METHODS

This observational cross-sectional study recruited 44 patients, from August to December 2017, who were diagnosed with SLE according to the Systemic Lupus International Collaborating Clinics (SLICC) Criteria 2012, and had no medical or psychiatric comorbidities. The patients were evaluated using the MoCA, MMSE, CSI, and the gold standard. Spearman's correlation and area under the curve analysis were performed; p < 0.05 was considered significant.

RESULTS

The MoCA test showed the highest correspondence with the gold standard (AUC = 99.4%, p < 0.001), sensitivity (84%), and specificity (100%). This was followed by the MMSE (AUC = 92.6%, p < 0.001; sensitivity, 54.8%; specificity, 100%) and the CSI (AUC = 30.6%, p < 0.05; sensitivity, 54.8%; specificity, 30.76%).

CONCLUSION

The MoCA is a brief, easily applied screening test that is highly effective for detecting cognitive impairment in SLE patients. It could be useful in clinical follow-up as a tool for early detection of cognitive alterations.

Two Novel Technologies for the Detection of Anti-cardiolipin and Anti β2-Glycoprotein Antibodies in the Real Life: Chemiluminescent in Comparison to the Addressable Laser Bead Immunoassays

In the present study, we evaluated two novel technologies, the chemiluminescent immunoassay (CIA) QUANTA Flash on BIO-FLASH (Inova Diagnostics, San Diego, CA, USA) and the addressable laser bead immunoassay (ALBIA) on BioPlex™ 2200 (Bio-Rad, Hercules, CA, USA) for the detection of anti-cardiolipin IgG/IgM (aCL) and anti-β2-glycoprotein IgG/IgM (aβ2GPI) antibodies. The study was performed on 134 samples from consecutive patients (59 males and 75 females, mean age 54 ± 10 years) who consulted a rheumatologist because thrombosis and/or pregnancy complications were present or another immunological disease (Sjogren's syndrome, inflammatory arthritis). Fourteen patients of the total fulfilled 25the Sydney criteria for APS and for these patients previous results of aPLs were available. Sera were tested for aCL and aβ2GPI of IgG and IgM isotypes using CIA (BIO-FLASH) and ALBIA (BioPlex™ 2200). Overall agreement between CIA and ALBIA ranged from 88.1% (aCL IgG) to 97.8% (aβ2GPI IgG). Cohen's kappa coefficient ranged from 0.53 to 0.91, implying moderate to almost perfect agreement. Almost perfect agreement was found between BioPlex™ 2200 and BIO-FLASH aβ2GPI IgG and aCL IgM with Cohen's kappa of 0.91 and 0.88, respectively. On the other hand, moderate agreement was found between BioPlex™ 2200 and BIO-FLASH aCL IgG and β2GPI IgM assays with Cohen's kappa of 0.57 and 0.53, respectively. The two novel technologies look promising and comparable but further studies with larger cohorts are needed to contribute to the better understanding of the new aPLs antibodies assays performance.

Montreal cognitive assessment in primary sjogrens syndrome. A brief screening tool

OBJECTIVE

To use the Montreal Cognitive Assessment (MoCA) test to assess the subclinical cognitive impairment in patients with Primary Sjogren`s Syndrome (PSS) and assess the correlation of MoCA results with magnetic resonance imaging (MRI) findings in these patients.

METHODS

The MoCA test was prospectively administered to 32 consecutive patients (31 females, 1 male) diagnosed with PSS and 30 healthy controls (29 females, 1 male) at Antalya Education and Research Hospital between June 2014 and October 2015. Twenty PSS patients underwent a brain MRI (T1, T2, and T2- FLAIR-weighted sequences).

RESULTS

The mean age was 45.84 (range 24-63) in the PSS group, and the mean duration of disease was 3.5 years (4 months - 18 years). There were 22 patients (68.80%) with 5-8 years of education and 10 patients (31.30%) with more than 8 years of education. The mean age was 42.8 (28-64) in the control group. There were 20 controls (66.70%) with 5-8 years of education and 10 controls (33.3%) with more than 8 years of education. The delayed recall rate of the patient group with 5-8 years of education was significantly lower than that of the control group, and the recall rate with multiple choice cues for the same patient group was significantly higher than that of the control group (p less than 0.05). There was no correlation between the number of lesions and total MoCA score or subgroups.

CONCLUSION

We suggest that the MoCA test is a single-page, easy-to-administer test, can be used to assess cognition in patients with PSS especially in large groups.

No Difference in Cognitive Dysfunction Among Patients with ANCA-Associated Vasculitis, Rheumatoid Arthritis or Chronic Kidney Disease

OBJECTIVE

To characterize cognitive function in patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) in comparison with other chronic conditions, and to investigate its association with disease activity, and other psychological factors.

METHODS

Cross-sectional study including patients with AAV, rheumatoid arthritis (RA) (n = 30), and chronic kidney disease (CKD) (n = 29). Patients underwent a standardized neuropsychological battery (NEUROPSI). Sleep quality, fatigue, depression, and anxiety levels were assessed.

RESULTS

A total of 60 patients with AAV were included, median age of 54 years, and disease duration of 5.6 years. Prevalence of cognitive dysfunction (CD) in AAV patients was similar to RA and CKD (35%, 40%, and 39.3%, respectively, p = .88). When AAV patients with (n = 21) and without (n = 39) CD were compared, significantly more patients with CD had high disease activity (67% vs. 31%, p = .009). Abnormal performance was more frequent in the executive functions in the three groups (45% AAV, 51.7% RA, and 50% CKD), followed by language (25%, 13.8%, and 25%, respectively). Verbal and visual attentional tests were more frequently impaired in patients from the CKD group (p = .021), and psychomotor functions were more frequently affected in AAV patients (p &lt; .05). Hospital Anxiety and Depression Scale (HADS) total score (especially anxiety) was higher in patients with memory impairment than in those with normal memory function (M = 6.79, SD = 4.53 vs. M = 4.5, SD = 3.6, p &lt; .01). Neither Sleep Quality Index nor fatigue scale scores differed between those cognitively impaired and not impaired.

CONCLUSIONS

No statistically significant differences were found in the frequency of CD among the three clinical populations. (JINS, 2019, 25, 595-602).

Prevalence of cognitive impairment using the Montreal Cognitive Assessment questionnaire among patients with systemic lupus erythematosus: a cross-sectional study at two tertiary centres in Malaysia

Introduction

Cognitive impairment is a common neuropsychiatric manifestation of systemic lupus erythematosus (SLE). However, it is not routinely assessed for despite its high prevalence and significant disease burden.

Aims

This study aimed to determine the prevalence of mild cognitive impairment (MCI) using the Montreal Cognitive Assessment (MoCA) and its associated factors among patients diagnosed with SLE in Malaysia.

Methods

A total of 200 SLE patients were recruited prospectively from the outpatient clinics of two tertiary hospitals in Malaysia. Standardized clinical interview was utilized to obtain information on socio-demographic characteristics. All patients were then assessed using the MoCA questionnaire for presence of cognitive impairment; the Patient Health Questionnaire 9 (PHQ-9) for presence of depressive symptoms; and the Wong–Baker Faces Pain Scale (WBFPS) for severity of pain. The evaluation of disease activity and severity were performed by the treating rheumatologists and nephrologists using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and Systemic Lupus International Collaborating Clinics Damage Index (SLICC DI).

Results

The prevalence of MCI was 35%. The significant associated factors from the bivariate analysis were male gender ( p = 0.04), educational level ( p = 0.00), WBFPS score ( p = 0.035) and anticardiolipin IgM ( p = 0.01). Further analysis using logistic regression model found that male gender (OR = 7.43, 95% confidence interval 1.06–52.06, p = 0.04), lower educational level (OR = 4.4, 95% confidence interval 1.47–13.21, p = 0.01) and presence of anticardiolipin IgM (OR = 6.81, 95% confidence interval 1.45–32.01, p = 0.031) were associated with impaired MoCA scores. Also, increasing pain scores increased the risk of patients being affected by cognitive impairment.

Conclusion

Over one-third of patients with SLE in our cohort were found to have MCI. Risk factors included male gender, lower educational level, higher pain score and presence of anticardiolipin IgM. Physicians are encouraged to perform routine screening to detect cognitive dysfunction in patients with SLE in their clinical practice as part of a more comprehensive management.

Screening for cognitive dysfunction in systemic lupus erythematosus: the Montreal Cognitive Assessment Questionnaire and the Informant Questionnaire on Cognitive Decline in the Elderly

BACKGROUND

Cognitive dysfunction (CD) is among the most common neuropsychiatric manifestations of systemic lupus erythematosus (SLE). Traditional neuropsychological testing and the Automated Neuropsychologic Assessment Metrics (ANAM) have been used to assess CD but neither is an ideal screening test. The Montreal Cognitive Assessment Questionnaire (MoCA) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) are brief and inexpensive tests. This study evaluated the MoCA and IQCODE as screening tools.

METHODS

SLE patients fulfilling American College of Rheumatology (ACR) classification criteria were evaluated using the ANAM as the reference standard. The performance characteristics of the MoCA and IQCODE were assessed in comparison with normal controls (NCs) and rheumatoid arthritis (RA) patients. Four different definitions of CD were utilized.

RESULTS

In total, 78 patients were evaluated. MoCA and ANAM scores were significantly correlated ( r = 0.51, p < 0.001). At the optimal cutoff, the sensitivity of the MoCA was ≥ 90% (depending on definition of CD) vs RA patients and ≥83% vs NCs. ANAM and IQCODE scores did not correlate ( p = 0.8152). IQCODE sensitivities were low for both RA patients and NCs regardless of definition and cutoff used.

CONCLUSION

The MoCA appears to be a promising and practical screening tool for identification of patients with SLE at risk for CD.

Review: Nervous System Disease in Systemic Lupus Erythematosus: Current Status and Future Directions

The American College of Rheumatology's case definitions for 19 neuropsychiatric syndromes in systemic lupus erythematosus (SLE) constitute a comprehensive classification of nervous system events in this disease. However, additional strategies are needed to determine whether a neuropsychiatric syndrome is attributable to SLE versus a competing comorbidity. Cognitive function is a clinical surrogate of overall brain health, with applications in both diagnosis and determination of clinical outcomes. Ischemic and inflammatory mechanisms are both key components of the immunopathogenesis of neuropsychiatric SLE (NPSLE), including abnormalities of the blood-brain barrier and autoantibody-mediated production of proinflammatory cytokines. Advances in neuroimaging provide a platform to assess novel disease mechanisms in a noninvasive way. The convergence of more rigorous clinical characterization, validation of biomarkers, and brain neuroimaging provides opportunities to determine the efficacy of novel targeted therapies in the treatment of NPSLE.

Body symmetry and reproductive hormone levels in women

Fluctuating asymmetry (FA), a morphological marker of developmental stability, may be related to an individual's biological condition, e.g., health or fertility. The aim of this study was to test if the level of a woman's FA was related to her fertility and reproductive potential as measured by reproductive hormone levels. Fifty-three healthy, non-pregnant, naturally cycling women (mean age = 23.42, SD = 1.85 years), participated in the study, conducted in Wrocław (Poland) in May 2015. Early-follicular phase serum levels of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were measured. FA was calculated based on anthropometric measures of six bilateral body traits, and the composite FA index was used in statistical analyses. No relationship was observed between FA and the levels of FSH, LH, and AMH (p > .05), controlled for potential confounders. However, the level of E2 was positively correlated with FA (p < .05). Thus, in young women, FA was not related to hormones levels related to ovarian reserve, but more symmetrical women had lower E2 levels. As FA is an index of developmental stability, environmental, and genetic stress, the results of the study confirm previous research suggesting that developmental conditions may be related to women's endogenous estrogen levels.

Performance of Screening Tests for Cognitive Impairment in Systemic Lupus Erythematosus

Objective.

There is a need for a cognitive function screening test that can be administered to patients with systemic lupus erythematosus (SLE) in clinic. The objectives of this study were to determine (1) prevalence of cognitive impairment (CI) in SLE by the Montreal Cognitive Assessment (MoCA), Mini Mental State Examination (MMSE), in relation to the Hopkins Verbal Learning Test–Revised (HVLT-R), and Perceived Deficits Questionnaire 5-Item (PDQ-5); and (2) associated factors with CI.

Methods.

Consecutive patients followed at a single center were recruited. HVLT-R, MoCA, and MMSE were administered. Sensitivity/specificity, positive (PPV)/negative (NPV) predictive values, and positive likelihood ratio (LR+) of MoCA/MMSE were determined (compared to HVLT-R). A test on intellectual ability and questionnaires on anxiety, depression, and perceived cognitive deficits were completed. Regression analyses determined associations with CI.

Results.

Of 98 patients, 48% had CI using MoCA and 31% using HVLT-R. Sensitivity was higher for MoCA (73%) compared to MMSE (27%), though MMSE was more specific (90%) than MoCA (63%). PPV and LR+ were similar in MoCA and MMSE (PPV: 47%, 53%; LR+: 2.0, 2.6, respectively), but NPV was higher in MoCA (84%) than MMSE (74%). PDQ-5 predicted objective CI (HVLT-R: sensitivity 100%, specificity 89%). Although CI was associated with depression in univariate analyses, it did not hold in the multivariate analysis, while longer SLE disease duration and more years of education remained significant.

Conclusion.

CI is highly prevalent and MoCA may be a useful tool to screen for CI in SLE. Patients with more years of education were less likely to have CI.

Neuropsychiatric Lupus in clinical practice

ABSTRACT Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple organs, characterized by the production of autoantibodies and the development of tissue injury. The etiology of SLE is partially known, involving multiple genetic and environmental factors. As many as 50% of patients with SLE have neurological involvement during the course of their disease. Neurological manifestations are associated with impaired quality of life, and high morbidity and mortality rates. Nineteen neuropsychiatric syndromes have been identified associated with SLE, and can be divided into central and peripheral manifestations. This article reviews major neuropsychiatric manifestations in patients with SLE and discusses their clinical features, radiological findings and treatment options.

Biomarkers for CNS involvement in pediatric lupus

CNS disease, or central neuropsychiatric lupus erythematosus (cNPSLE), occurs frequently in pediatric lupus, leading to significant morbidity and poor long-term outcomes. Diagnosing cNPSLE is especially difficult in pediatrics; many current diagnostic tools are invasive and/or costly, and there are no current accepted screening mechanisms. The most complicated aspect of diagnosis is differentiating primary disease from other etiologies; research to discover new biomarkers is attempting to address this dilemma. With many mechanisms involved in the pathogenesis of cNPSLE, biomarker profiles across several modalities (molecular, psychometric and neuroimaging) will need to be used. For the care of children with lupus, the challenge will be to develop biomarkers that are accessible by noninvasive measures and reliable in a pediatric population.

Executive dysfunction, obsessive-compulsive symptoms, and attention deficit and hyperactivity disorder in Systemic Lupus Erythematosus: Evidence for basal ganglia dysfunction?

INTRODUCTION

Chorea is well described in a group of patients with Systemic Lupus Erythematosus (SLE). There is less information, however, on other movement disorders as well as non-motor neuropsychiatric features such as obsessive-compulsive symptoms (OCS), executive dysfunction and attention deficit and hyperactivity disorder (ADHD) in subjects with SLE.

METHODS

Fifty-four subjects with SLE underwent a battery of neuropsychiatric tests that included the Mini Mental State Examination, the Montreal Cognitive Assessment, the Frontal Assessment Battery (FAB), the FAS verbal and the categorical (animals) semantic fluency tests, the Obsessive and Compulsive Inventory - Revised, the Yale-Brown Obsessive and Compulsive Scale and Beck's Anxiety and Depression Scales. ADHD was diagnosed according to DSM-IV criteria. SLE disease activity and cumulative damage were evaluated according to the modified SLE Disease Activity Index 2000 (mSLEDAI-2K) and the SLICC/ACR, respectively.

RESULTS

Six (11.1%) and 33 (61.1%) patients had cognitive impairment according to the MMSE and MoCA, respectively. Eleven (20.4%) had abnormal FAB scores, and 5 (9.3%) had lower semantic fluency scores than expected. The overall frequency of cognitive dysfunction was 72.2% (39 patients) and of neuropsychiatric SLE was 77.8% (42 patients). Two patients (3.7%) had movement disorders. Fifteen (27.8%) had OCS and 17 (31.5%) met diagnostic criteria for ADHD. ADHD and OCS correlated with higher disease activity, p=0.003 and 0.006, respectively. Higher cumulative damage correlated with lower FAB scores (p 0.026).

CONCLUSIONS

Executive dysfunction, ADHD, OCS, and movement disorders are common in SLE. Our finding suggests that there is frequent basal ganglia dysfunction in SLE.

Anti-NR2A/B Antibodies and Other Major Molecular Mechanisms in the Pathogenesis of Cognitive Dysfunction in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects approximately 1–45.3 per 100,000 people worldwide. Although deaths as a result of active and renal diseases have been substantially declining amongst SLE patients, disease involving the central nervous system (CNS), collectively termed neuropsychiatric systemic lupus erythematosus (NPSLE), remains one of the important causes of death in these patients. Cognitive dysfunction is one of the most common manifestations of NPSLE, which comprises deficits in information-processing speed, attention and executive function, in conjunction with preservation of speech. Albeit a prevalent manifestation of NPSLE, the pathogenetic mechanisms of cognitive dysfunction remain unclear. Recent advances in genetic studies, molecular techniques, neuropathology, neuroimaging and cognitive science have gleaned valuable insights into the pathophysiology of lupus-related cognitive dysfunction. In recent years, a role for autoantibodies, molecular and cellular mechanisms in cognitive dysfunction, has been emerging, challenging our previous concept of the brain as an immune privileged site. This review will focus on the potential pathogenic factors involved in NPSLE, including anti-N-methyl-d-aspartate receptor subunit NR2A/B (anti-NR2A/B) antibodies, matrix metalloproteinase-9, neutrophil extracellular traps and pro-inflammatory mediators. Better understanding of these mechanistic processes will enhance identification of new therapeutic modalities to halt the progression of cognitive decline in SLE patients.

Brain metabolism and autoantibody titres predict functional impairment in systemic lupus erythematosus

Objective

We investigated whether systemic lupus erythematosus (SLE) disease duration or serology associate with abnormal regional glucose metabolism as measured with [¹⁸F]2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) and deficits on neuropsychological testing.

Methods

Subjects with SLE with stable disease activity, without brain damage or clinical symptoms of neuropsychiatric (NP) SLE, stratified by disease duration (short-term (ST)-SLE=disease ≤2 years, long-term (LT)-SLE=disease ≥10 years), underwent clinical assessments, neuropsychological testing, resting FDG-PET scan imaging and measurement of serum titres of antibody to N-methyl-d-aspartate receptor (DNRAb). FDG-PET scans were compared with age-matched and gender-matched healthy controls.

Results

Subjects with LT-SLE demonstrated hypometabolism in the prefrontal and premotor cortices that correlated with accrued SLE-related damage, but not with DNRAb titre or performance on NP testing. Independent of disease duration, subjects with SLE demonstrated hypermetabolism in the hippocampus and orbitofrontal cortex that correlated with impaired memory performance and mood alterations (depression, anxiety, fatigue). Serum DNRAb also correlated independently with impaired memory performance and increased anxiety. Together, serum DNRAb titre and regional hypermetabolism were more powerful predictors of performance than either alone.

Interpretation

The presence of serum DNRAbs can account for some aspects of brain dysfunction in patients with SLE, and the addition of regional measurements of resting brain metabolism improves the assessment and precise attribution of central nervous system manifestations related to SLE.

Neuropsychiatric Lupus: Classification Criteria in Neuroimaging Studies

This systematic review described the criteria and main evaluations methods procedures used to classify neuropsychiatric systemic lupus erythematosus (NPSLE) patients. Also, within the evaluations methods, this review aimed to identify the main contributions of neuropsychological measurements in neuroimaging studies. A search was conducted in PubMed, EMBASE and SCOPUS databases with the terms related to neuropsychiatric syndromes, systemic lupus erythematosus, and neuroimaging techniques. Sixty-six abstracts were found; only 20 were completely analyzed and included. Results indicated that the 1999 American College of Rheumatology (ACR) criteria is the most used to classify NPSLE samples together with laboratorial, cognitive, neurological and psychiatric assessment procedures. However, the recommended ACR assessment procedures to classify NPSLE patients are being used incompletely, especially the neuropsychological batteries. Neuropsychological instruments and neuroimaging techniques have been used mostly to characterize NPSLE samples, instead of contributing to their classifications. The most described syndromes in neuroimaging studies have been seizure/cerebrovascular disease followed by cognitive dysfunctions as well as headache disorder.