Utility of the Abbreviated Fuld Object Memory Evaluation and MMSE for Detection of Dementia and Cognitive Impairment Not Dementia in Diverse Ethnic Groups

Intersectionality in Alzheimer's Disease: The Role of Female Sex and Black American Race in the Development and Prevalence of Alzheimer's Disease

It is well known that vascular factors and specific social determinants of health contribute to dementia risk and that the prevalence of these risk factors differs according to race and sex. In this review, we discuss the intersection of sex and race, particularly female sex and Black American race. Women, particularly Black women, have been underrepresented in Alzheimer's disease clinical trials and research. However, in recent years, the number of women participating in clinical research has steadily increased. A greater prevalence of vascular risk factors such as hypertension and type 2 diabetes, coupled with unique social and environmental pressures, puts Black American women particularly at risk for the development of Alzheimer's disease and related dementias. Female sex hormones and the use of hormonal birth control may offer some protective benefits, but results are mixed, and studies do not consistently report the demographics of their samples. We argue that as a research community, greater efforts should be made to not only recruit this vulnerable population, but also report the demographic makeup of samples in research to better target those at greatest risk for the disease.

Association Between Body Mass Index and Incident Dementia Among Community-Dwelling Older Adults: The Shanghai Aging Study

BACKGROUND

The relationship between body mass index (BMI) and dementia is inconclusive. Undesirable loss of fat-free mass is a risk factor for cognitive decline while obesity is also a risk factor for cardio-metabolic disorders among the older adults.

OBJECTIVE

This study aimed to examine the association between BMI and incident all-cause dementia among Chinese older adults using a prospective study.

METHODS

Participants were 1,627 community residents aged 60 or older without dementia from the Shanghai Aging Study. Cox regression models, incorporated with restricted cubic splines, were used to explore a nonlinear association between baseline BMI and risk of all-cause dementia as measured by hazard ratio (HR) using both frequentist and Bayesian approach.

RESULTS

We diagnosed 136 incident dementia cases during the mean follow-up of 5.3 years. Compared with moderate BMI (18.5-24.0 kg/m2), low BMI (<  18.5 kg/m2) were related to an increased risk of dementia with the HR as 3.38 (95% CI 1.50-7.63), while high BMI (≥24.0 kg/m2) showed a decreased risk of dementia without statistical significance (HR = 0.91, 95% CI 0.60 to 1.39). Sensitivity analysis in participants without central obesity indicated that the association was still significant with even higher HR. Bayesian approach presented the similar results.

CONCLUSION

Our result indicates that low BMI may contribute to high risk of incident dementia, even in individuals without central obesity.

Spousal bereavement and the cognitive health of older adults in the US: New insights on channels, single items, and subjective evidence

This study provides novel insights into older adults' cognitive functioning before and after widowhood onset and possible effect channels. It further examines gender heterogeneity in the adaptation to (anticipated or actual) spousal bereavement, comparing objective evidence with subjective evidence of cognitive abilities. We used longitudinal data of up to 26,584 participants of the Health and Retirement Study, aged over 50 at recruitment, assessed biennially between 1998 and 2016. Two-way fixed effects with dynamic treatment effects were estimated for various cognitive measures, including six aggregated indices and six single item scales. After adjusting for effect channels including depression, social vulnerability, and stress, there remained significant widowhood effects on older adults' cognitive health. Using single item scales, we established the adverse contemporaneous and adaptation effects on bereaved older females' short-term memory, semantic memory, and numeracy. For bereaved older males, working memory and focus-of-attention deteriorated after widowhood onset. Meanwhile, subjective memory rating remained intact, contrary to objective evidence. We conclude that cognitive transitions to and from widowhood can exhibit distinctive patterns across objective and subjective cognitive domains. With the effect channels in mind, cognitive intervention for widowed older adults should be tailored to the temporal distance to spousal loss, gender, and task.

The Utility of Cognitive Screeners in the Detection of Dementia Spectrum Disorders in Spanish-Speaking Populations

Increasing rates of dementia spectrum disorders among Spanish-speaking geriatric populations necessitate the development of culturally appropriate cognitive screening tests that can identify neurodegenerative disorders in their earliest stages when emerging disease-modifying treatments are most likely to be effective. This scoping review identified 26 brief Spanish language cognitive screening tools (<20 minutes) by searching academic databases using a combination of search terms. Results suggest that the Mini-Mental Status Examination and Montreal Cognitive Assessment appear to be less valid than other screeners. Instruments such as the 7-Minute Screen and Mini-Cog evidence higher classification rates of dementia, while Phototest detected mild cognitive impairment at higher rates more consistently than other screeners. Different sensitivity and specificity outcomes and cutoffs were observed when the same cognitive screener was evaluated in different countries. Results indicate that it is imperative to increase nation-specific validation and normative data for these instruments to best serve diverse populations.

Total Cerebral Small Vessel Disease Burden Is Related to Worse Performance on the Mini-Mental State Examination and Incident Dementia: A Prospective 5-Year Follow-Up

Individual cerebral small vessel disease (CSVD) may cause cognitive decline. However, the association between total burden of CSVD and cognitive deterioration in the general population remains unclear. We aimed to determine whether total CSVD score is associated with cognitive performance change and incident dementia in the general population. In the longitudinal population-based Taizhou Imaging Study, 556 participants free of neurological disorders underwent brain MRI and neuropsychological testing at baseline. A total of 456 participants were followed up for cognitive performance for a mean (standard deviation) of 4.6 (0.6) years. Total CSVD score (range 0-4) was calculated by assigning 1 point for the presence of each of the following markers: lacune, white matter hyperintensity, cerebral microbleed, and perivascular space. Beta regression was used to evaluate the association between total CSVD burden and MMSE score change. The association of prevalent CSVD with incident dementia was studied using Fisher's exact test. CSVDs were present in 262 individuals (47.1%). The total CSVD score was significantly associated with MMSE score decline (p = 0.001). Compared to those with no CSVD, participants with 4 CSVD markers had a steeper decline in MMSE score (β: -0.53, 95% CI: -0.86 to -0.21; p = 0.001). A total of 15 participants developed dementia during follow-up. The presence of more than three CSVD markers at baseline was associated with a significantly higher risk of dementia (p = 0.020). Total CSVD burden appears to be associated with MMSE score decline and incident dementia in a general population in China.

A Systematic Review of Neuropsychological Tests for the Assessment of Dementia in Non-Western, Low-Educated or Illiterate Populations

OBJECTIVE

Neuropsychological tests are important instruments to determine a cognitive profile, giving insight into the etiology of dementia; however, these tests cannot readily be used in culturally diverse, low-educated populations, due to their dependence upon (Western) culture, education, and literacy. In this review we aim to give an overview of studies investigating domain-specific cognitive tests used to assess dementia in non-Western, low-educated populations. The second aim was to examine the quality of these studies and of the adaptations for culturally, linguistically, and educationally diverse populations.

METHOD

A systematic review was performed using six databases, without restrictions on the year or language of publication.

RESULTS

Forty-four studies were included, stemming mainly from Brazil, Hong Kong, Korea, and considering Hispanics/Latinos residing in the USA. Most studies focused on Alzheimer's disease (n = 17) or unspecified dementia (n = 16). Memory (n = 18) was studied most often, using 14 different tests. The traditional Western tests in the domains of attention (n = 8) and construction (n = 15), were unsuitable for low-educated patients. There was little variety in instruments measuring executive functioning (two tests, n = 13), and language (n = 12, of which 10 were naming tests). Many studies did not report a thorough adaptation procedure (n = 39) or blinding procedures (n = 29).

CONCLUSIONS

Various formats of memory tests seem suitable for low-educated, non-Western populations. Promising tasks in other cognitive domains are the Stick Design Test, Five Digit Test, and verbal fluency test. Further research is needed regarding cross-cultural instruments measuring executive functioning and language in low-educated people.

Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Early identification of cognitive impairment may improve patient and caregiver health outcomes.

OBJECTIVE

To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019.

STUDY SELECTION

Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being.

RESULTS

The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance.

CONCLUSIONS AND RELEVANCE

Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers.

Screening for Alzheimer's disease in low-educated or illiterate older adults in Brazil: a systematic review

INTRODUCTION

Cognitive screening instruments are influenced by education and/or culture. In Brazil, as illiteracy and low education rates are high, it is necessary to identify the screening tools with the highest diagnostic accuracy for Alzheimer's disease (AD).

OBJECTIVE

To identify the cognitive screening instruments applied in the Brazilian population with greater accuracy, to detect AD in individuals with a low educational level or who are illiterate.

METHODS

Systematic search in SciELO, PubMed and LILACS databases of studies that used cognitive screening tests to detect AD in older Brazilian adults with low or no education.

RESULTS

We found 328 articles and nine met the inclusion criteria. The identified instruments showed adequate or high diagnostic accuracy.

CONCLUSION

For valid cognitive screening it is important to consider sociocultural and educational factors in the interpretation of results. The construction of specific instruments for the low educated or illiterate elderly should better reflect the difficulties of the Brazilian elderly in different regions of the country.

Psychometric validation of Fuld Object Memory Evaluation in older adults with cognitive impairments

OBJECTIVES

Mild cognitive impairment (MCI) refers to an early but abnormal state of cognitive impairment with minimal functional impairment. The present study aimed to evaluate the validity of Fuld Object Memory Evaluation (FOME) as a measure of episodic memory function.

METHOD

The study sample included 204 Chinese older adults with cognitive impairments. The participants completed five recall trials and a delayed trial in FOME, neurocognitive measures on digit spans and trail making, and daily functioning. Discriminative power of FOME to differentiate between MCI and dementia was inspected via receiver operating characteristic curve analysis.

RESULTS

FOME showed good test-retest reliability and convergent validity with digit spans and trail making. Controlling for gender, age, and education, lower levels of FOME total retrieval, verbal fluency, and daily functioning significantly predicted a higher likelihood of dementia compared to MCI. The optimal cut-off scores for total retrieval, verbal fluency, and daily functioning to differentiate dementia were 37/38 (77% sensitivity and 83% specificity), 28/29 (85% sensitivity and 72% specificity), and 14/15 (92% sensitivity and 78% specificity), respectively, in the younger subgroup. The corresponding figures were 34/35 (69% sensitivity and 76% specificity) and 27/28 (92% sensitivity and 62% specificity), and 11/12 (74% sensitivity and 80% specificity), respectively, in the older subgroup.

CONCLUSION

The findings support the FOME as a valid assessment tool of episodic memory function in older Chinese adults. The combined use of FOME and daily functioning is recommended to distinguish persons with dementia from MCI.

Relationship between Cognitive Performance and Measures of Neurodegeneration among Hispanic and White Non-Hispanic Individuals with Normal Cognition, Mild Cognitive Impairment, and Dementia

OBJECTIVES

The aim of this study was to determine the presence and severity of potential cultural and language bias in widely used cognitive and other assessment instruments, using structural MRI measures of neurodegeneration as biomarkers of disease stage and severity.

METHODS

Hispanic (n=75) and White non-Hispanic (WNH) (n=90) subjects were classified as cognitively normal (CN), amnestic mild cognitive impairment (aMCI) and mild dementia. Performance on the culture-fair and educationally fair Fuld Object Memory Evaluation (FOME) and Clinical Dementia Rating Scale (CDR) between Hispanics and WNHs was equivalent, in each diagnostic group. Volumetric and visually rated measures of the hippocampus entorhinal cortex, and inferior lateral ventricles (ILV) were measured on structural MRI scans for all subjects. A series of analyses of covariance, controlling for age, depression, and education, were conducted to compare the level of neurodegeneration on these MRI measures between Hispanics and WNHs in each diagnostic group.

RESULTS

Among both Hispanics and WNH groups there was a progressive decrease in volume of the hippocampus and entorhinal cortex, and an increase in volume of the ILV (indicating increasing atrophy in the regions surrounding the ILV) from CN to aMCI to mild dementia. For equivalent levels of performance on the FOME and CDR, WNHs had greater levels of neurodegeneration than did Hispanic subjects.

CONCLUSIONS

Atrophy in medial temporal regions was found to be greater among WNH than Hispanic diagnostic groups, despite the lack of statistical differences in cognitive performance between these two ethnic groups. Presumably, unmeasured factors result in better cognitive performance among WNH than Hispanics for a given level of neurodegeneration. (JINS, 2018, 24, 176-187).

Handling clinical comorbidity in randomized clinical trials in psychiatry

The purpose of this paper is to a) outline the importance of including patients with clinical comorbidities in Randomized Clinical Trials (RCTs) of psychiatric treatments; and b) to propose a specific approach for best handling, analyzing and interpreting the data on clinical comorbidities in terms of their impact on treatment outcomes. To do this we first define and describe clinical comorbidity and differentiate it from other forms of comorbidity. We then describe the methodological and analytical problems associated with excluding patients with clinically comorbid conditions from RCTs, including the impact on the outcomes of RCTs in psychiatry and the impact on evidence-based clinical decision-making. We then address the challenges inherent to including patients with clinical comorbidities in RCTs. Finally, we propose a methodological and analytic approach to deal with these issues in RCTs which aims to significantly improve the information yielded from RCTs in psychiatry, and thus improve clinical decision-making.

Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations

BACKGROUND

The Mini Mental State Examination (MMSE) is a cognitive test that is commonly used as part of the evaluation for possible dementia.

OBJECTIVES

To determine the diagnostic accuracy of the Mini-Mental State Examination (MMSE) at various cut points for dementia in people aged 65 years and over in community and primary care settings who had not undergone prior testing for dementia.

SEARCH METHODS

We searched the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), LILACS (BIREME), ALOIS, BIOSIS previews (Thomson Reuters Web of Science), and Web of Science Core Collection, including the Science Citation Index and the Conference Proceedings Citation Index (Thomson Reuters Web of Science). We also searched specialised sources of diagnostic test accuracy studies and reviews: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). We attempted to locate possibly relevant but unpublished data by contacting researchers in this field. We first performed the searches in November 2012 and then fully updated them in May 2014. We did not apply any language or date restrictions to the electronic searches, and we did not use any methodological filters as a method to restrict the search overall.

SELECTION CRITERIA

We included studies that compared the 11-item (maximum score 30) MMSE test (at any cut point) in people who had not undergone prior testing versus a commonly accepted clinical reference standard for all-cause dementia and subtypes (Alzheimer disease dementia, Lewy body dementia, vascular dementia, frontotemporal dementia). Clinical diagnosis included all-cause (unspecified) dementia, as defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); International Classification of Diseases (ICD) and the Clinical Dementia Rating.

DATA COLLECTION AND ANALYSIS

At least three authors screened all citations.Two authors handled data extraction and quality assessment. We performed meta-analysis using the hierarchical summary receiver-operator curves (HSROC) method and the bivariate method.

MAIN RESULTS

We retrieved 24,310 citations after removal of duplicates. We reviewed the full text of 317 full-text articles and finally included 70 records, referring to 48 studies, in our synthesis. We were able to perform meta-analysis on 28 studies in the community setting (44 articles) and on 6 studies in primary care (8 articles), but we could not extract usable 2 x 2 data for the remaining 14 community studies, which we did not include in the meta-analysis. All of the studies in the community were in asymptomatic people, whereas two of the six studies in primary care were conducted in people who had symptoms of possible dementia. We judged two studies to be at high risk of bias in the patient selection domain, three studies to be at high risk of bias in the index test domain and nine studies to be at high risk of bias regarding flow and timing. We assessed most studies as being applicable to the review question though we had concerns about selection of participants in six studies and target condition in one study.The accuracy of the MMSE for diagnosing dementia was reported at 18 cut points in the community (MMSE score 10, 14-30 inclusive) and 10 cut points in primary care (MMSE score 17-26 inclusive). The total number of participants in studies included in the meta-analyses ranged from 37 to 2727, median 314 (interquartile range (IQR) 160 to 647). In the community, the pooled accuracy at a cut point of 24 (15 studies) was sensitivity 0.85 (95% confidence interval (CI) 0.74 to 0.92), specificity 0.90 (95% CI 0.82 to 0.95); at a cut point of 25 (10 studies), sensitivity 0.87 (95% CI 0.78 to 0.93), specificity 0.82 (95% CI 0.65 to 0.92); and in seven studies that adjusted accuracy estimates for level of education, sensitivity 0.97 (95% CI 0.83 to 1.00), specificity 0.70 (95% CI 0.50 to 0.85). There was insufficient data to evaluate the accuracy of the MMSE for diagnosing dementia subtypes.We could not estimate summary diagnostic accuracy in primary care due to insufficient data.

AUTHORS' CONCLUSIONS

The MMSE contributes to a diagnosis of dementia in low prevalence settings, but should not be used in isolation to confirm or exclude disease. We recommend that future work evaluates the diagnostic accuracy of tests in the context of the diagnostic pathway experienced by the patient and that investigators report how undergoing the MMSE changes patient-relevant outcomes.

Prevalence of mild cognitive impairment in an urban community in China: a cross-sectional analysis of the Shanghai Aging Study

BACKGROUND

Substantial variations in the prevalence of mild cognitive impairment (MCI) have been reported, although mostly in Western countries. Less is known about MCI in the Chinese population.

METHODS

We clinically and neuropsychologically evaluated 3141 community residents ≥60 years of age. Diagnoses of MCI and its subtypes were made using standard criteria via consensus diagnosis.

RESULTS

Among 2985 nondemented individuals, 601 were diagnosed with MCI, resulting in a prevalence of 20.1% for total MCI, 13.2% for amnestic MCI (aMCI), and 7.0% for non-amnestic MCI (naMCI). The proportions of MCI subtypes were: aMCI single domain (SD), 38.9%; aMCI multiple domains (MD), 26.5%; naMCI-SD, 25.0%; and naMCI-MD, 9.6%. The prevalence of aMCI-MD increased rapidly with age in women APOE ε4 carriers (from 60 to 69 years to ≥80 years, 3.1%-33.3%, P < .001).

CONCLUSIONS

Our findings suggest that 20% of Chinese elderly are affected by MCI. Prospective studies in China are needed to examine progression to dementia and related risk factors.