The Digital Tree Drawing Test for Screening of Early Dementia: An Explorative Study Comparing Healthy Controls, Patients with Mild Cognitive Impairment, and Patients with Early Dementia of the Alzheimer Type

Detection of Mild Cognitive Impairment Through Hand Motor Function Under Digital Cognitive Test: Mixed Methods Study

BACKGROUND

Early detection of cognitive impairment or dementia is essential to reduce the incidence of severe neurodegenerative diseases. However, currently available diagnostic tools for detecting mild cognitive impairment (MCI) or dementia are time-consuming, expensive, or not widely accessible. Hence, exploring more effective methods to assist clinicians in detecting MCI is necessary.

OBJECTIVE

In this study, we aimed to explore the feasibility and efficiency of assessing MCI through movement kinetics under tablet-based "drawing and dragging" tasks.

METHODS

We iteratively designed "drawing and dragging" tasks by conducting symposiums, programming, and interviews with stakeholders (neurologists, nurses, engineers, patients with MCI, healthy older adults, and caregivers). Subsequently, stroke patterns and movement kinetics were evaluated in healthy control and MCI groups by comparing 5 categories of features related to hand motor function (ie, time, stroke, frequency, score, and sequence). Finally, user experience with the overall cognitive screening system was investigated using structured questionnaires and unstructured interviews, and their suggestions were recorded.

RESULTS

The "drawing and dragging" tasks can detect MCI effectively, with an average accuracy of 85% (SD 2%). Using statistical comparison of movement kinetics, we discovered that the time- and score-based features are the most effective among all the features. Specifically, compared with the healthy control group, the MCI group showed a significant increase in the time they took for the hand to switch from one stroke to the next, with longer drawing times, slow dragging, and lower scores. In addition, patients with MCI had poorer decision-making strategies and visual perception of drawing sequence features, as evidenced by adding auxiliary information and losing more local details in the drawing. Feedback from user experience indicates that our system is user-friendly and facilitates screening for deficits in self-perception.

CONCLUSIONS

The tablet-based MCI detection system quantitatively assesses hand motor function in older adults and further elucidates the cognitive and behavioral decline phenomenon in patients with MCI. This innovative approach serves to identify and measure digital biomarkers associated with MCI or Alzheimer dementia, enabling the monitoring of changes in patients' executive function and visual perceptual abilities as the disease advances.

"Build Your Village"-Conducting the Village Test on Cognitively Impaired Patients: A First Journey into Alzheimerland

BACKGROUND

This work aimed to study the Village Test (VT) in a group of patients with Alzheimer's disease (AD) and compare the results with those of a group of patients with mild cognitive impairment (MCI) and controls.

METHODS

A total of 50 patients with AD, 28 patients with MCI, and 38 controls were evaluated. All participants underwent the VT and an extensive neuropsychological evaluation.

RESULTS

The mean ages of the participants were 74.4 years for those with AD, 74 for those with MCI, and 70.2 for the controls. The AD group built smaller and essential villages with a scarce use of pieces, a poor use of dynamic pieces, and scarce use of human figures. All constructions were often concentrated in the center of the table.

CONCLUSIONS

The villages built by the AD group represent a cognitive and affective coarctation and indicate a sense of existential disorientation and isolation. The VT is a useful aid for getting in touch with the inner emotional and existential states of patients with AD, and it could represent a complementary screening tool for orienting cognitive impairment diagnoses.

Visuospatial memory in apraxia: Exploring quantitative drawing metrics to assess the representation of local and global information

Neuropsychological evidence suggests that visuospatial memory is subserved by two separable processing systems, with dorsal underpinnings for global form and ventral underpinnings for the integration of part elements. Previous drawing studies have explored the effects of Gestalt organisation upon memory for hierarchical stimuli, and we here present an exploratory study of an apraxic dorsal stream patient's (MH) performance. We presented MH with a stimulus set (previously reported by Riddoch et al., Cognitive Neuropsychology, 20(7), 641-671, 2003) and devised a novel quantitative scoring system to obtain a finer grain of insight into performance. Stimuli possessed either good or poor Gestalt qualities and were reproduced in a copy condition and two visual memory conditions (with unlimited viewing before the model was removed, or with 3 s viewing). MH's copying performance was impaired in comparison to younger adult and age-matched older adult controls, with a variety of errors at the local level but relatively few at the global level. However, his performance in the visual memory conditions revealed impairments at the global level. For all participants, drawing errors were modulated by the Gestalt qualities of the stimuli, with accuracy at the global and local levels being lesser for poor global stimuli in all conditions. These data extend previous observations of this patient, and support theories that posit interaction between dorsal and ventral streams in the representation of hierarchical stimuli. We discuss the implications of these findings for our understanding of visuospatial memory in neurological patients, and also evaluate the application of quantitative metrics to the interpretation of drawings.

The "Little Circles Test" (LCT): a dusted-off tool for assessing fine visuomotor function

BACKGROUND

The fine visuomotor function is commonly impaired in several neurological conditions. However, there is a scarcity of reliable neuropsychological tools to assess such a critical domain.

AIMS

The aim of this study is to explore the psychometric properties and provide normative data for the Visual-Motor Speed and Precision Test (VMSPT).

RESULTS

Our normative sample included 220 participants (130 females) aged 18-86 years (mean education = 15.24 years, SD = 3.98). Results showed that raw VMSPT scores were affected by higher age and lower education. No effect of sex or handedness was shown. Age- and education-based norms were provided. VMSPT exhibited weak-to-strong correlations with well-known neuropsychological tests, encompassing a wide range of cognitive domains of clinical relevance. By gradually intensifying the cognitive demands, the test becomes an indirect, performance-oriented measure of executive functioning. Finally, VMSPT seems proficient in capturing the speed-accuracy trade-off typically observed in the aging population.

CONCLUSIONS

This study proposes the initial standardization of a versatile, time-efficient, and cost-effective neuropsychological tool for assessing fine visuomotor coordination. We propose renaming the VMSPT as the more approachable "Little Circles Test" (LCT).

Traces of health-A landscape design task as a diagnostic aid for detecting mental burden? A qualitative focus group study

Background

Mental disorders are most common causes of illness worldwide. Studies on art and drawing tasks, such as the tree-drawing test have already proven their prognostic quality for the diagnosis of Alzheimer's disease, depression or trauma. In the depiction of art in public space, gardens and landscapes are one of the oldest human forms of artistic expression. This study thus aims at exploring the impact of a landscape design task as a prognostic tool to detect mental burden.

Materials and methods

A total of 15 individuals (eight female) aged between 19 and 60 years completed the Brief Symptom Inventory BSI-18 and the State Trait Anxiety Inventory (STAI-S) before being asked to design a landscape in a 3 × 3 m squared area. Material to be used included plants, flowers, branches, and stones. The complete process of landscape design was videotaped and the tapes were analyzed in a two-step focus group analysis from a group of gardening trainees, psychology students and students of arts therapies. Results were condensed in a second step into major categories.

Results

Scores of the BSI-18 showed a range of 2-21 points and STAI-S scores ranged between 29 and 54 points indicating a light to moderate mental burden. Focus group participants identified three mutually perpendicular major components associated with mental health: "Movement and Activity," "Material Selection and Design," and "Connectedness to the task." In a subsample of the three least and three most mentally stressed subjects (based on their GSI and STAI-S scorings), clear differences were found in body posture, action planning and the choice of material and aspects of design.

Discussion

In addition to the well-known therapeutic potential of gardening, this study for the first time showed that gardening and landscape design contains diagnostic elements. Our preliminary findings are in coherence with similar research indicating a high association of movement and design patterns with mental burden. However, due to the pilot nature of the study, the results should be interpreted cautiously. Based on the findings further studies are currently planned.

Digital Cognitive Biomarker for Mild Cognitive Impairments and Dementia: A Systematic Review

The dementia population is increasing as the world's population is growing older. The current systematic review aims to identify digital cognitive biomarkers from computerized tests for detecting dementia and its risk state of mild cognitive impairment (MCI), and to evaluate the diagnostic performance of digital cognitive biomarkers. A literature search was performed in three databases, and supplemented by a Google search for names of previously identified computerized tests. Computerized tests were categorized into five types, including memory tests, test batteries, other single/multiple cognitive tests, handwriting/drawing tests, and daily living tasks and serious games. Results showed that 78 studies were eligible. Around 90% of the included studies were rated as high quality based on the Newcastle-Ottawa Scale (NOS). Most of the digital cognitive biomarkers achieved comparable or even better diagnostic performance than traditional paper-and-pencil tests. Moderate to large group differences were consistently observed in cognitive outcomes related to memory and executive functions, as well as some novel outcomes measured by handwriting/drawing tests, daily living tasks, and serious games. These outcomes have the potential to be sensitive digital cognitive biomarkers for MCI and dementia. Therefore, digital cognitive biomarkers can be a sensitive and promising clinical tool for detecting MCI and dementia.

Comparing drawing under instructions with image copying for mild cognitive impairment (MCI) or dementia screening: a meta-analysis of 92 diagnostic studies

OBJECTIVES

Drawing is a major component of cognitive screening for dementia. It can be performed without language restriction. Drawing pictures under instructions and copying images are different screening approaches. The objective of this study was to compare the diagnostic performance between drawing under instructions and image copying for MCI and dementia screening.

METHOD

A literature search was carried out in the OVID databases with keywords related to drawing for cognitive screening. Study quality and risk of bias were assessed by QUADAS-2. The level of diagnostic accuracy across different drawing tests was pooled by bivariate analysis in a random effects model. The area under the hierarchical summary receiver-operating characteristic curve (AUC) was constructed to summarize the diagnostic performance.

RESULTS

Ninety-two studies with sample size of 22,085 were included. The pooled results for drawing under instructions showed a sensitivity of 79% (95% CI: 76 - 83%) and a specificity of 80% (95% CI: 77 - 83%) with AUC of 0.87 (95% CI: 0.83 - 0.89). The pooled results for image copying showed a sensitivity of 71% (95% CI: 62 - 79%) and a specificity of 83% (95% CI: 72 - 90%) with AUC of 0.83 (95% CI: 0.80 - 0.86). Clock-drawing test was the screening test used in the majority of studies.

CONCLUSION

Drawing under instructions showed a similar diagnostic performance when compared with image copying for cognitive screening and the administration of image copying is relatively simpler. Self-screening for dementia is feasible to be done at home in the near future.

Neuropsychology of posteromedial parietal cortex and conversion factors from Mild Cognitive Impairment to Alzheimer's disease: systematic search and state-of-the-art review

In the present review, we discuss the rationale and the clinical implications of assessing visuospatial working memory (VSWM), awareness of memory deficits, and visuomotor control in patients with mild cognitive impairment (MCI). These three domains are related to neural activity in the posteromedial parietal cortex (PMC) whose hypoactivation seems to be a significant predictor of conversion from MCI to Alzheimer’s disease (AD) as indicated by recent neuroimaging evidence. A systematic literature search was performed up to May 2021. Forty-eight studies were included: 42 studies provided analytical cross-sectional data and 6 studies longitudinal data on conversion rates. Overall, these studies showed that patients with MCI performed worse than healthy controls in tasks assessing VSWM, awareness of memory deficits, and visuomotor control; in some cases, MCI patients’ performance was comparable to that of patients with overt dementia. Deficits in VSWM and metamemory appear to be significant predictors of conversion. No study explored the relationship between visuomotor control and conversion. Nevertheless, it has been speculated that the assessment of visuomotor abilities in subjects at high AD risk might be useful to discriminate patients who are likely to convert from those who are not. Being able to indirectly estimate PMC functioning through quick and easy neuropsychological tasks in outpatient settings may improve diagnostic and prognostic accuracy, and therefore, the quality of the MCI patient’s management.

The Tree Drawing Test in Evolution: An Explorative Longitudinal Study in Alzheimer's Disease

OBJECTIVE

To study the evolution of the Tree Drawing Test (TDT) in a group of Alzheimer's disease (AD) patients.

METHODS

A total of 33 AD patients were consecutively evaluated by Mini Mental State Evaluation (MMSE) and TDT. The evolution of the TDT parameters, trunk-to-crown (TC) and space occupation (SO) index, were analyzed.

RESULTS

The median age at first visit was 79 years. Globally, trees drawn by patients showed an evolution characterized by a progressive reduction of the crown compared to the trunk. TC index showed a significant linear growth change (2.52 points per year) while SO index did not significantly increase. No significant associations were found examining the relations between MMSE and TC and SO index.

CONCLUSIONS

TDT could represent a complementary technique to the main neuropsychological screening tests for orienting cognitive impairment diagnosis and an aid in following the evolution of cognitive impairment over time in AD patients.

Diagnostic performance of digital cognitive tests for the identification of MCI and dementia: A systematic review

BACKGROUND

The use of digital cognitive tests is getting common nowadays. Older adults or their family members may use online tests for self-screening of dementia. However, the diagnostic performance across different digital tests is still to clarify. The objective of this study was to evaluate the diagnostic performance of digital cognitive tests for MCI and dementia in older adults.

METHODS

Literature searches were systematically performed in the OVID databases. Validation studies that reported the diagnostic performance of a digital cognitive test for MCI or dementia were included. The main outcome was the diagnostic performance of the digital test for the detection of MCI or dementia.

RESULTS

A total of 56 studies with 46 digital cognitive tests were included in this study. Most of the digital cognitive tests were shown to have comparable diagnostic performances with the paper-and-pencil tests. Twenty-two digital cognitive tests showed a good diagnostic performance for dementia, with a sensitivity and a specificity over 0.80, such as the Computerized Visuo-Spatial Memory test and Self-Administered Tasks Uncovering Risk of Neurodegeneration. Eleven digital cognitive tests showed a good diagnostic performance for MCI such as the Brain Health Assessment. However, all the digital tests only had a few validation studies to verify their performance.

CONCLUSIONS

Digital cognitive tests showed good performances for MCI and dementia. The digital test can collect digital data that is far beyond the traditional ways of cognitive tests. Future research is suggested on these new forms of cognitive data for the early detection of MCI and dementia.

Evaluation of Digital Drawing Tests and Paper-and-Pencil Drawing Tests for the Screening of Mild Cognitive Impairment and Dementia: A Systematic Review and Meta-analysis of Diagnostic Studies

Digital drawing tests have been proposed for cognitive screening over the past decade. However, the diagnostic performance is still to clarify. The objective of this study was to evaluate the diagnostic performance among different types of digital and paper-and-pencil drawing tests in the screening of mild cognitive impairment (MCI) and dementia. Diagnostic studies evaluating digital or paper-and-pencil drawing tests for the screening of MCI or dementia were identified from OVID databases, included Embase, MEDLINE, CINAHL, and PsycINFO. Studies evaluated any type of drawing tests for the screening of MCI or dementia and compared with healthy controls. This study was performed according to PRISMA and the guidelines proposed by the Cochrane Diagnostic Test Accuracy Working Group. A bivariate random-effects model was used to compare the diagnostic performance of these drawing tests and presented with a summary receiver-operating characteristic curve. The primary outcome was the diagnostic performance of clock drawing test (CDT). Other types of drawing tests were the secondary outcomes. A total of 90 studies with 22,567 participants were included. In the screening of MCI, the pooled sensitivity and specificity of the digital CDT was 0.86 (95% CI = 0.75 to 0.92) and 0.92 (95% CI = 0.69 to 0.98), respectively. For the paper-and-pencil CDT, the pooled sensitivity and specificity of brief scoring method was 0.63 (95% CI = 0.49 to 0.75) and 0.77 (95% CI = 0.68 to 0.84), and detailed scoring method was 0.63 (95% CI = 0.56 to 0.71) and 0.72 (95% CI = 0.65 to 0.78). In the screening of dementia, the pooled sensitivity and specificity of the digital CDT was 0.83 (95% CI = 0.72 to 0.90) and 0.87 (95% CI = 0.79 to 0.92). The performances of the digital and paper-and-pencil pentagon drawing tests were comparable in the screening of dementia. The digital CDT demonstrated better diagnostic performance than paper-and-pencil CDT for MCI. Other types of digital drawing tests showed comparable performance with paper-and-pencil formats. Therefore, digital drawing tests can be used as an alternative tool for the screening of MCI and dementia.

Digitalization in psychology: A bit of challenge and a byte of success

Digital transformation affects research in almost every scientific discipline. We give a brief overview on how digital technologies have emerged into psychological science in the past and what the challenges and opportunities currently are. Providing two recent examples from our own research, we argue that interdisciplinary collaborations that make use of digital approaches without giving up a strong theoretical foundation will greatly enhance psychological research in the future.

Electronic Cognitive Screen Technology for Screening Older Adults With Dementia and Mild Cognitive Impairment in a Community Setting: Development and Validation Study

BACKGROUND

A digital cognitive test can be a useful and quick tool for the screening of cognitive impairment. Previous studies have shown that the diagnostic performance of digital cognitive tests is comparable with that of conventional paper-and-pencil tests. However, the use of commercially available digital cognitive tests is not common in Hong Kong, which may be due to the high cost of the tests and the language barrier. Thus, we developed a brief and user-friendly digital cognitive test called the Electronic Cognitive Screen (EC-Screen) for the detection of mild cognitive impairment (MCI) and dementia of older adults.

OBJECTIVE

The aim of this study was to evaluate the performance of the EC-Screen for the detection of MCI and dementia in older adults.

METHODS

The EC-Screen is a brief digital cognitive test that has been adapted from the Rapid Cognitive Screen test. The EC-Screen uses a cloud-based platform and runs on a tablet. Participants with MCI, dementia, and cognitively healthy controls were recruited from research clinics and the community. The outcomes were the performance of the EC-Screen in distinguishing participants with MCI and dementia from controls, and in distinguishing participants with dementia from those with MCI and controls. The cohort was randomly split into derivation and validation cohorts based on the participants' disease group. In the derivation cohort, the regression-derived score of the EC-Screen was calculated using binomial logistic regression. Two predictive models were produced. The first model was used to distinguish participants with MCI and dementia from controls, and the second model was used to distinguish participants with dementia from those with MCI and controls. Receiver operating characteristic curves were constructed and the areas under the curves (AUCs) were calculated. The performances of the two predictive models were tested using the validation cohorts. The relationship between the EC-Screen and paper-and-pencil Montreal Cognitive Assessment-Hong Kong version (HK-MoCA) was evaluated by the Pearson correlation coefficient.

RESULTS

A total of 126 controls, 54 participants with MCI, and 63 participants with dementia were included in the study. In differentiating participants with MCI and dementia from controls, the AUC of the EC-Screen in the derivation and validation cohorts was 0.87 and 0.84, respectively. The optimal sensitivity and specificity in the derivation cohorts were 0.81 and 0.80, respectively. In differentiating participants with dementia from those with MCI and controls, the AUC of the derivation and validation cohorts was 0.90 and 0.88, respectively. The optimal sensitivity and specificity in the derivation cohort were 0.83 and 0.83, respectively. There was a significant correlation between the EC-Screen and HK-MoCA (r=-0.67, P<.001).

CONCLUSIONS

The EC-Screen is suggested to be a promising tool for the detection of MCI and dementia. This test can be self-administered or assisted by a nonprofessional staff or family member. Therefore, the EC-Screen can be a useful tool for case finding in primary health care and community settings.