Are We There Yet? Exploring the Impact of Translating Cognitive Tests for Dementia Using Mobile Technology in an Aging Population

Self-Testing for Dementia: A Phenomenological Analysis of Fear

Following the growing economic relevance of mobile health (mHealth) and the increasing global prevalence of dementia, self-testing apps for dementia and mild neurocognitive disorder (MCD) have been developed and advertised. The apps' promise of a quick and easy tool has been criticized in the literature from a variety of angles, but as we argue in this article, the celebratory characterization of self-testing also stands in disbalance to the various kinds of fears that may be connected to taking the test. By drawing on Sara Ahmed's phenomenological theory on emotions and by referring to illustrative experiences from two users with a particular dementia self-testing app, we explore four dimensions of fear derived from phenomenology: performative, ontological, embodied, and temporal dimensions. We argue that fear (1) motivates one to take the self-test and to try to take control over one's health; (2) is shaped by and shapes the ways in which we make sense of ourselves and others as cognitively deficient; (3) constructs and is constructed by our differently embodied presence in the world; and that (4) testing makes a fearful future self as cognitively deficient more tangible. In outlining these different dimensions of fear, this article expands the understanding of the meaning of experiencing self-testing in comparison to the mostly quantitative literature on this topic.

Reliability and Validity of a Tablet-Based Neuropsychological Test (the Hellocog) for Screening Dementia

OBJECTIVE

To address the gap in timely diagnosis of dementia due to limited screening tools, we investigated the validity and reliability of the Hellocog, computerized neuropsychological test based on tablets for screening dementia. The higher the probability score on the Hellocog, the higher the likelihood of dementia.

METHODS

This study included 100 patients with dementia and 100 individuals with normal cognition who were aged 60 years or older and free of other major psychiatric, neurological, or medical conditions. They administered the Hellocog on a tablet under the supervision of a neuropsychologist. To determine test-retest reliability, 20 took the Hellocog again after 4 weeks. Diagnostic performance was assessed using the receiver operator characteristics (ROC) analysis.

RESULTS

The Hellocog showed adequate internal consistency (Cronbach's alpha=0.69) and good test-retest reliability (intraclass correlation coefficient=0.86, p<0.001). Participants with dementia scored higher on the Hellocog than those with normal cognition (p<0.001), confirming its high criterion validity. Strong correlations with the Mini-Mental Status Examination (MMSE) score and the total score of the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Assessment Battery (CERAD-TS) highlight the concurrent validity of the Hellocog. The area under the ROC curve for dementia of the Hellocog was excellent (0.971) and comparable to that of the MMSE and CERAD-TS. The sensitivity and specificity for dementia were 0.945 and 0.872%, respectively, which were slightly better than those of the MMSE and CERAD-TS.

CONCLUSION

Hellocog stands out as a valid and reliable tool for self-administered dementia screening, with promise for improving early detection of dementia.

cCOG Web-Based Cognitive Assessment Tool

Cognitive testing is an essential part of clinical diagnostics and clinical trials in Alzheimer's disease. Digital cognitive tests hold a great opportunity to provide more versatile and cost-efficient patient pathways through flexible testing including at home. In this work, we describe a web-based cognitive test, cCOG, that can be used in screening, differential diagnosis, and monitoring the progression of neurodegenerative diseases.

The RODI mHealth app Insight: Machine-Learning-Driven Identification of Digital Indicators for Neurodegenerative Disorder Detection

Neurocognitive Disorders (NCDs) pose a significant global health concern, and early detection is crucial for optimizing therapeutic outcomes. In parallel, mobile health apps (mHealth apps) have emerged as a promising avenue for assisting individuals with cognitive deficits. Under this perspective, we pioneered the development of the RODI mHealth app, a unique method for detecting aligned with the criteria for NCDs using a series of brief tasks. Utilizing the RODI app, we conducted a study from July to October 2022 involving 182 individuals with NCDs and healthy participants. The study aimed to assess performance differences between healthy older adults and NCD patients, identify significant performance disparities during the initial administration of the RODI app, and determine critical features for outcome prediction. Subsequently, the results underwent machine learning processes to unveil underlying patterns associated with NCDs. We prioritize the tasks within RODI based on their alignment with the criteria for NCDs, thus acting as key digital indicators for the disorder. We achieve this by employing an ensemble strategy that leverages the feature importance mechanism from three contemporary classification algorithms. Our analysis revealed that tasks related to visual working memory were the most significant in distinguishing between healthy individuals and those with an NCD. On the other hand, processes involving mental calculations, executive working memory, and recall were less influential in the detection process. Our study serves as a blueprint for future mHealth apps, offering a guide for enhancing the detection of digital indicators for disorders and related conditions.

Examination of the reliability and feasibility of two smartphone applications to assess executive functioning in racially diverse older adults

Inclusion of Black participants in clinical research is a national priority. Mobile applications and remote data collection may increase study access for diverse populations. This study examined the reliability and feasibility of two mobile smartphone application-based cognitive measures in a diverse middle aged and older adult sample. Black (n = 44; Mage = 59.93) and non-Hispanic white (NHW; n = 50; Mage = 61.06) participants completed traditional paper-based neuropsychological testing and two app-based measures, Arrows and Number Match. Intraclass correlations demonstrated poor to moderate reliability (range: .417-.569) between performance on the app-based versions and performance on the traditional versions. Performance score differences by racial group were not statistically significant. Both Black and NHW participants rated the app-based measures as feasible and acceptable, though Black participants endorsed a stronger likelihood of future use. These findings add to the growing literature on remote cognitive testing .

Validity and Reliability of the Digital Functioning Assessment Short Test (D-FAST) in the Brazilian Sample

Background

The COVID-19 pandemic has caused major disruptions in all aspects of daily functioning, from school and work to interactions with friends and family. The Functioning Assessment Short Test (FAST) is an interviewer-administered scale validated in the psychiatric sample with no previous study assessing its validity and reliability in a digital format. Thus, we aimed to analyse the psychometric properties of the digital version of the FAST and understand the implications of COVID-19 and restrictive measures on functioning.

Methods

Data were collected using an online survey. The psychometric properties of the digital FAST were assessed by confirmatory factor analysis, Cronbach's alpha, and discriminant functional by cluster analysis in a community sample.

Results

Out of the total sample, 2,543 (84.1%) were female, and the mean (SD) age was 34.28 (12.46) years. The digital FAST retained the six factors structure observed in the original version, with Cronbach's alpha above 0.9. In addition, we showed evidence of discriminant validity by differentiating three clusters of psychosocial functioning. Clinical and demographic differences between groups explained, in part, the heterogeneity of functioning, thus providing support for the construct validity of the instrument.

Conclusion

The digital FAST is a simple and easy-to-understand instrument that provides a multidimensional assessment of functioning without the need for an interviewer. Furthermore, our findings may help to better understand the psychosocial implications of the pandemic and the importance of planning specific interventions to rehabilitee the affected group.

Web-Based Assessment of the Phenomenology of Autobiographical Memories in Young and Older Adults

Autobiographical memories (ABMs) produce rich phenomenological experiences. Although few standardized and comprehensive measures of the phenomenology of ABMs have been developed, a web-based assessment of the full range of phenomenological properties is still missing. In the present study, we aimed to fill this gap and tested the psychometric properties of a web-based version of the Assessment of the Phenomenology of Autobiographical Memory (APAM) in a group of young and older adults. Specifically, taking advantage of the flexibility of web-based assessment methodology, we tested the rating consistency of APAM items, asking participants to rate the phenomenology of their ABMs with respect to seven cues, administered in one per day in seven different days. In each session, we also collected ratings of mood and arousal. Using linear mixed modeling (LMM), we could examine whether the phenomenology ratings differed with respect to age group while controlling for sex, age of the memory, arousal, mood, and specificity of the memory. Results revealed an adequate level of consistency of ratings in both young and older adults. Moreover, LMMs revealed a more intense experience of recollection and reliving (i.e., sensory and emotional) and a higher confidence in memory accuracy in older compared to younger adults. The theoretical and practical usefulness of a web-based assessment of the phenomenology of ABMs are discussed.

The trail-making-test: Comparison between paper-and-pencil and computerized versions in young and healthy older adults

One of the key challenges in assessing cognitive performance is to detect not only apparent impairment but to also pick up on subtle differences. Computerized tests benefit especially from the acquisition of fine-grained outcome measures. However, the equivalency of paper-based and computerized tests cannot be assumed. The Trail-Making-Test is a paper-pencil cognitive assessment tool (ppTMT) that has been used in many research studies to evaluate visuomotor abilities and mental flexibility. A digital version of the extended TMT (including a condition measuring fine motor speed) called the dTMT has been developed. This study aims to test (1) reliability, (2) equivalence, and (3) agreement of the ppTMT and dTMT. A total of 53 healthy individuals aged 19 to 82 years of age (22 men, 31 women; mean age 42.2, SD = 22.8) completed three trials per ppTMT and dTMT condition. Part M involves following a predefined path, Part A links numbers randomly distributed in space, in ascending order, and Part B alternates between linking numbers and letters. dTMT scores were highly reproducible, correlated strongly with paper-pencil administered durations, and discriminated young from older adults. Measures of reliability, sensitivity, and clinical meaning for dTMT scores were favorable compared with ppTMT-based testing. Our findings support the comparability of TMT-indices in computerized assessments. While many digital biomarker efforts are in progress (e.g., neurodegenerative disorders), the dTMT sets itself apart through its high sensitivity, the alternate forms, and the additional component measures. In this light, it could serve as a starting point for an early diagnostic tool.

Validation of SATURN, a free, electronic, self-administered cognitive screening test

BACKGROUND

Cognitive screening is limited by clinician time and variability in administration and scoring. We therefore developed Self-Administered Tasks Uncovering Risk of Neurodegeneration (SATURN), a free, public-domain, self-administered, and automatically scored cognitive screening test, and validated it on inexpensive (<$100) computer tablets.

METHODS

SATURN is a 30-point test including orientation, word recall, and math items adapted from the Saint Louis University Mental Status test, modified versions of the Stroop and Trails tasks, and other assessments of visuospatial function and memory. English-speaking neurology clinic patients and their partners 50 to 89 years of age were given SATURN, the Montreal Cognitive Assessment (MoCA), and a brief survey about test preferences. For patients recruited from dementia clinics (n = 23), clinical status was quantified with the Clinical Dementia Rating (CDR) scale. Care partners (n = 37) were assigned CDR = 0.

RESULTS

SATURN and MoCA scores were highly correlated (P < .00001; r = 0.90). CDR sum-of-boxes scores were well-correlated with both tests (P < .00001) (r = -0.83 and -0.86, respectively). Statistically, neither test was superior. Most participants (83%) reported that SATURN was easy to use, and most either preferred SATURN over the MoCA (47%) or had no preference (32%).

DISCUSSION

Performance on SATURN-a fully self-administered and freely available (https://doi.org/10.5061/dryad.02v6wwpzr) cognitive screening test-is well-correlated with MoCA and CDR scores.

Establishing reliability and validity for mental health screening instruments in resource-constrained settings: Systematic review of the PHQ-9 and key recommendations

Mental illness is one of the largest contributors to the global disease burden. The importance of valid and reliable mental health measures is crucial in order to accurately measure said burden, to capture symptom improvement, and to ensure that symptoms are appropriately identified and quantified. This is of particular importance in low and middle-income countries (LMICs), where the burden of mental illness is relatively high, and there is heterogeneity in linguistic, racial, and ethnic groups. Using the PHQ-9 as an illustrative example, this systematic review aims to provide an overview of existing work and highlight common validation and reporting practices. A systematic review of published literature validating the use of the PHQ-9 in LMICs as indexed in the PubMed and PsychInfo databases was conducted. The review included n = 49 articles (reduced from n = 2,349). This manuscript summarizes these results in terms of the frequency of reporting on important procedures and in regards to the types of reliability and validity measured. Then, building off of the existing literature, we provide key recommendations for measure validation in LMICs, which can be generalized for any type of measure used in a setting in which it was not initially developed.

cCOG: A web-based cognitive test tool for detecting neurodegenerative disorders

INTRODUCTION

Web-based cognitive tests have potential for standardized screening in neurodegenerative disorders. We examined accuracy and consistency of cCOG, a computerized cognitive tool, in detecting mild cognitive impairment (MCI) and dementia.

METHODS

Clinical data of 306 cognitively normal, 120 mild cognitive impairment (MCI), and 69 dementia subjects from three European cohorts were analyzed. Global cognitive score was defined from standard neuropsychological tests and compared to the corresponding estimated score from the cCOG tool containing seven subtasks. The consistency of cCOG was assessed comparing measurements administered in clinical settings and in the home environment.

RESULTS

cCOG produced accuracies (receiver operating characteristic-area under the curve [ROC-AUC]) between 0.71 and 0.84 in detecting MCI and 0.86 and 0.94 in detecting dementia when administered at the clinic and at home. The accuracy was comparable to the results of standard neuropsychological tests (AUC 0.69-0.77 MCI/0.91-0.92 dementia).

DISCUSSION

cCOG provides a promising tool for detecting MCI and dementia with potential for a cost-effective approach including home-based cognitive assessments.

Evaluating the Feasibility of Frequent Cognitive Assessment Using the Mezurio Smartphone App: Observational and Interview Study in Adults With Elevated Dementia Risk

Background

By enabling frequent, sensitive, and economic remote assessment, smartphones will facilitate the detection of early cognitive decline at scale. Previous studies have sustained participant engagement with remote cognitive assessment over a week; extending this to a period of 1 month clearly provides a greater opportunity for measurement. However, as study durations are increased, the need to understand how participant burden and scientific value might be optimally balanced also increases.

Objective

This study explored the little but often approach to assessment employed by the Mezurio app when prompting participants to interact every day for over a month. Specifically, this study aimed to understand whether this extended duration of remote study is feasible, and which factors promote sustained participant engagement over such periods.

Methods

A total of 35 adults (aged 40-59 years) with no diagnosis of cognitive impairment were prompted to interact with the Mezurio smartphone app platform for up to 36 days, completing short, daily episodic memory tasks in addition to optional executive function and language tests. A subset (n=20) of participants completed semistructured interviews focused on their experience of using the app.

Results

Participants complied with 80% of the daily learning tasks scheduled for subsequent tests of episodic memory, with 88% of participants still actively engaged by the final task. A thematic analysis of the participants’ experiences highlighted schedule flexibility, a clear user interface, and performance feedback as important considerations for engagement with remote digital assessment.

Conclusions

Despite the extended study duration, participants demonstrated high compliance with the schedule of daily learning tasks and were extremely positive about their experiences. Long durations of remote digital interaction are therefore definitely feasible but only when careful attention is paid to the design of the users’ experience.

Virtual navigation tested on a mobile app is predictive of real-world wayfinding navigation performance

Virtual reality environments presented on tablets and smartphones have potential to aid the early diagnosis of conditions such as Alzheimer’s dementia by quantifying impairments in navigation performance. However, it is unclear whether performance on mobile devices can predict navigation errors in the real world. We compared the performance of 49 participants (25 females, 18-35 years old) at wayfinding and path integration tasks designed in our mobile app ‘Sea Hero Quest’ with their performance at similar tasks in a real-world environment. We first performed this experiment in the streets of London (UK) and replicated it in Paris (France). In both cities, we found a significant correlation between virtual and real-world wayfinding performance and a male advantage in both environments, although smaller in the real world (Cohen’s d in the game = 0.89, in the real world = 0.59). Results in London and Paris were highly similar, and controlling for familiarity with video games did not change the results. The strength of the correlation between real world and virtual environment increased with the difficulty of the virtual wayfinding task, indicating that Sea Hero Quest does not merely capture video gaming skills. The fact that the Sea Hero Quest wayfinding task has real-world ecological validity constitutes a step toward controllable, sensitive, safe, low-cost, and easy to administer digital cognitive assessment of navigation ability.

Mobile Technology for Cognitive Assessment of Older Adults: A Scoping Review

BACKGROUND AND OBJECTIVES

The number of people diagnosed with dementia is rising appreciably as the population ages. In an effort to improve outcomes, many have called for facilitating early detection of cognitive decline. Increased use of mobile technology by older adults provides the opportunity to deliver convenient, cost-effective assessments for earlier detection of cognitive impairment. This article presents a review of the literature on how mobile platforms-smartphones and tablets-are being used for cognitive assessment of older adults along with benefits and opportunities associated with using mobile platforms for cognitive assessment.

RESEARCH DESIGN AND METHODS

We searched MEDLINE, Web of Science, PsycInfo, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials in October 2018. This search returned 7,024 articles. After removing 1,464 duplicates, we screened titles and abstracts then screened full-text for those articles meeting inclusion and exclusion criteria.

RESULTS

Twenty-nine articles met our inclusion criteria and were categorized into 3 groups as follows: (a) mobile versions of existing article or computerized neuropsychological tests; (b) new cognitive tests developed specifically for mobile platforms; and (c) the use of new types of data for cognitive assessment. This scoping review confirms the considerable potential of mobile assessment.

DISCUSSION AND IMPLICATIONS

Mobile technologies facilitate repeated and continuous assessment and support unobtrusive collection of auxiliary behavioral markers of cognitive impairment, thus allowing users to view trends and detect acute changes that have traditionally been difficult to identify. Opportunities include using new mobile sensors and wearable devices, improving reliability and validity of mobile assessments, determining appropriate clinical use of mobile assessment information, and incorporating person-centered assessment principles and digital phenotyping.

A computerized, self-administered test of verbal episodic memory in elderly patients with mild cognitive impairment and healthy participants: A randomized, crossover, validation study

Introduction

Performance of “Revere”, a novel iPad-administered word-list recall (WLR) test, in quantifying deficits in verbal episodic memory, was evaluated versus examiner-administered Rey Auditory Verbal Learning Test (RAVLT) in patients with mild cognitive impairment and cognitively normal participants.

Methods

Elderly patients with clinically diagnosed mild cognitive impairment (Montreal Cognitive Assessment score 24–27) and cognitively normal (Montreal Cognitive Assessment score ≥28) were administered RAVLT or Revere in a randomized crossover design.

Results

A total of 153/161 participants (Revere/RAVLT n = 75; RAVLT/Revere n = 78) were randomized; 148 (97%) completed study; 121 patients (mean [standard deviation] age: 70.4 [7.84] years) were included for analysis. Word-list recall scores (8 trials) were comparable between Revere and RAVLT (Pearson's correlation coefficients: 0.12–0.70; least square mean difference [Revere-RAVLT]: −0.84 [90% CI, −1.15; −0.54]). Model factor estimates indicated trial (P < .001), period (P < .001) and evaluation sequence (P = .038) as significant factors. Learning over trials index and serial position effects were comparable.

Discussion

Participants' verbal recall performance on Revere and RAVLT were equivalent.

Digitally translated Self-Administered Gerocognitive Examination (eSAGE): relationship with its validated paper version, neuropsychological evaluations, and clinical assessments

BACKGROUND

The original paper Self-Administered Gerocognitive Examination (SAGE) is a valid and reliable cognitive assessment tool used to identify individuals with mild cognitive impairment (MCI) or early dementia. We evaluated identical test questions in a digital format (eSAGE) made for tablet use with the goals of calibrating it against SAGE and establishing its association with other neuropsychological tests and clinical assessments of cognitive impairment.

METHODS

Subjects aged 50 and over who had taken SAGE were recruited from community and clinic settings. Subjects were randomly selected to participate in a clinical evaluation including neuropsychological evaluations. SAGE and eSAGE were administered using a crossover design. Subjects were identified as dementia, MCI, or normal based on standard clinical criteria. Associations were investigated using Spearman correlations, linear regression, and sensitivity and specificity measures.

RESULTS

Of the 426 subjects screened, 66 completed the evaluation. eSAGE score correlation to a battery of neuropsychological tests was 0.73 (p < 0.0001) with no significant difference between the paper and digital format. Spearman correlation of SAGE versus eSAGE was 0.88 (p < 0.0001), and they are related by the formula: eSAGE score = -1.05 + 0.99 × SAGE score. Since the slope is very close to 1 (p = 0.86) there is strong evidence that the scaling is identical between eSAGE and SAGE, with no scale bias. Overall, eSAGE scores are lower by an average of 1.21 and the decrease is statistically significant (p < 0.0001). For those subjects familiar with smartphones or tablets (one measure of digital proficiency), eSAGE scores are lower by an average of 0.83 points (p = 0.029). With a score 16 and higher being classified as normal, eSAGE had 90% specificity and 71% sensitivity in detecting those with cognitive impairment from normal subjects.

CONCLUSIONS

Tablet-based eSAGE shows a strong association with the validated paper SAGE and a neuropsychological battery. It shows no scale bias compared to SAGE. Both have the advantage of self-administration, brevity, four interchangeable forms, and high sensitivity and specificity in detecting cognitive impairment from normal subjects. Their potential widespread availability will be a major factor in overcoming the many obstacles in identifying early cognitive changes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02544074 . Registered on 18 March 2015.

Alzheimer's Disease: An Overview of Recent Developments and a Look to the Future

Alzheimer's disease is a major public health concern, affecting an estimated 40 million people worldwide. Over the past few years, several new diagnostic tests and new diagnostic nomenclatures have emerged, and more than 70 disease-modifying agents are in clinical trials. Naturalistic studies that include biomarkers-such as genomics, metabolomics, and imaging-have yielded additional insights into disease mechanisms and timelines of preclinical disease onset. This article reviews recent developments in epidemiology, diagnostic criteria, and diagnostic tests; provides updates on symptomatic therapies, ongoing prevention trials, and neuropsychiatric symptom treatment options; and ends with a discussion on prospects for a cure.