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Libon DJ, Swenson R, Price CC, Lamar M, Cosentino S, Bezdicek O, Kling MA, Tobyne S, Jannati A, Banks R, Pascual-Leone A. Digital assessment of cognition in neurodegenerative disease: a data driven approach leveraging artificial intelligence. Front Psychol 2024; 15:1415629. [PMID: 39035083 PMCID: PMC11258860 DOI: 10.3389/fpsyg.2024.1415629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/12/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction A rapid and reliable neuropsychological protocol is essential for the efficient assessment of neurocognitive constructs related to emergent neurodegenerative diseases. We developed an AI-assisted, digitally administered/scored neuropsychological protocol that can be remotely administered in ~10 min. This protocol assesses the requisite neurocognitive constructs associated with emergent neurodegenerative illnesses. Methods The protocol was administered to 77 ambulatory care/memory clinic patients (56.40% women; 88.50% Caucasian). The protocol includes a 6-word version of the Philadelphia (repeatable) Verbal Learning Test [P(r)VLT], three trials of 5 digits backward from the Backwards Digit Span Test (BDST), and the "animal" fluency test. The protocol provides a comprehensive set of traditional "core" measures that are typically obtained through paper-and-pencil tests (i.e., serial list learning, immediate and delayed free recall, recognition hits, percent correct serial order backward digit span, and "animal" fluency output). Additionally, the protocol includes variables that quantify errors and detail the processes used in administering the tests. It also features two separate, norm-referenced summary scores specifically designed to measure executive control and memory. Results Using four core measures, we used cluster analysis to classify participants into four groups: cognitively unimpaired (CU; n = 23), amnestic mild cognitive impairment (MCI; n = 17), dysexecutive MCI (n = 23), and dementia (n = 14). Subsequent analyses of error and process variables operationally defined key features of amnesia (i.e., rapid forgetting, extra-list intrusions, profligate responding to recognition foils); key features underlying reduced executive abilities (i.e., BDST items and dysexecutive errors); and the strength of the semantic association between successive responses on the "animal" fluency test. Executive and memory index scores effectively distinguished between all four groups. There was over 90% agreement between how cluster analysis of digitally obtained measures classified patients compared to classification using a traditional comprehensive neuropsychological protocol. The correlations between digitally obtained outcome variables and analogous paper/pencil measures were robust. Discussion The digitally administered protocol demonstrated a capacity to identify patterns of impaired performance and classification similar to those observed with standard paper/pencil neuropsychological tests. The inclusion of both core measures and detailed error/process variables suggests that this protocol can detect subtle, nuanced signs of early emergent neurodegenerative illness efficiently and comprehensively.
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Affiliation(s)
- David J. Libon
- Department of Geriatrics and Gerontology, New Jersey Institute for Successful Aging, Rowan-Virtua School of Osteopathic Medicine, Glassboro, NJ, United States
- Department of Psychology, Rowan University, Glassboro, NJ, United States
| | - Rod Swenson
- Department of Psychiatry and Behavioral Health, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, United States
| | - Catherine C. Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, United States
| | - Melissa Lamar
- Rush Alzheimer's Disease Center and the Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Stephanie Cosentino
- Columbia University Medical Center, Department of Neurology, Cognitive Neuroscience Division, Taub Institute and Sergievsky Center, New York, NY, United States
| | - Ondrej Bezdicek
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University, Prague, Czechia
| | - Mitchel A. Kling
- Department of Geriatrics and Gerontology, New Jersey Institute for Successful Aging, Rowan-Virtua School of Osteopathic Medicine, Glassboro, NJ, United States
| | | | - Ali Jannati
- Linus Health, Boston, MA, United States
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | | | - Alvaro Pascual-Leone
- Linus Health, Boston, MA, United States
- Hinda and Arthur Marcus Institute for Aging Research and Deanna, Sidney Wolk Center for Memory Health, Hebrew Senior Life, Boston, MA, United States
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Akkoyun M, Koçoğlu K, Eraslan Boz H, Tüfekci IY, Ekin M, Akdal G. Visual search for real-world scenes in patients with Alzheimer's disease and amnestic mild cognitive impairment. Brain Behav 2024; 14:e3567. [PMID: 38841742 PMCID: PMC11154822 DOI: 10.1002/brb3.3567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Visual attention-related processes that underlie visual search behavior are impaired in both the early stages of Alzheimer's disease (AD) and amnestic mild cognitive impairment (aMCI), which is considered a risk factor for AD. Although traditional computer-based array tasks have been used to investigate visual search, information on the visual search patterns of AD and MCI patients in real-world environments is limited. AIM The objective of this study was to evaluate the differences in visual search behaviors among individuals with AD, aMCI, and healthy controls (HCs) in real-world scenes. MATERIALS AND METHODS A total of 92 participants were enrolled, including 28 with AD, 32 with aMCI, and 32 HCs. During the visual search task, participants were instructed to look at a single target object amid distractors, and their eye movements were recorded. RESULTS The results indicate that patients with AD made more fixations on distractors and fewer fixations on the target, compared to patients with aMCI and HC groups. Additionally, AD patients had longer fixation durations on distractors and spent less time looking at the target than both patients with aMCI and HCs. DISCUSSION These findings suggest that visual search behavior is impaired in patients with AD and can be distinguished from aMCI and healthy individuals. For future studies, it is important to longitudinally monitor visual search behavior in the progression from aMCI to AD. CONCLUSION Our study holds significance in elucidating the interplay between impairments in attention, visual processes, and other underlying cognitive processes, which contribute to the functional decline observed in individuals with AD and aMCI.
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Affiliation(s)
- Müge Akkoyun
- Department of Neuroscience, Institute of Health SciencesDokuz Eylul UniversityIzmirTürkiye
| | - Koray Koçoğlu
- Department of Neuroscience, Institute of Health SciencesDokuz Eylul UniversityIzmirTürkiye
| | - Hatice Eraslan Boz
- Department of Neuroscience, Institute of Health SciencesDokuz Eylul UniversityIzmirTürkiye
- Department of Neurology, Unit of NeuropsychologyDokuz Eylul UniversityIzmirTürkiye
| | - Işıl Yağmur Tüfekci
- Department of Neuroscience, Institute of Health SciencesDokuz Eylul UniversityIzmirTürkiye
| | - Merve Ekin
- Department of Neuroscience, Institute of Health SciencesDokuz Eylul UniversityIzmirTürkiye
| | - Gülden Akdal
- Department of Neuroscience, Institute of Health SciencesDokuz Eylul UniversityIzmirTürkiye
- Department of Neurology, Faculty of MedicineDokuz Eylul UniversityIzmirTürkiye
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Frank B, Bandyopadhyay S, Dion C, Formanski E, Matusz E, Penney D, Davis R, O'Connor MK, Au R, Amini S, Rashidi P, Tighe P, Libon DJ, Price CC. A Network Analysis of Digital Clock Drawing for Command and Copy Conditions. Assessment 2024:10731911241236336. [PMID: 38494894 DOI: 10.1177/10731911241236336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Graphomotor and time-based variables from the digital Clock Drawing Test (dCDT) characterize cognitive functions. However, no prior publications have quantified the strength of the associations between digital clock variables as they are produced. We hypothesized that analysis of the production of clock features and their interrelationships, as suggested, will differ between the command and copy test conditions. Older adults aged 65+ completed a digital clock drawing to command and copy conditions. Using a Bayesian hill-climbing algorithm and bootstrapping (10,000 samples), we derived directed acyclic graphs (DAGs) to examine network structure for command and copy dCDT variables. Although the command condition showed moderate associations between variables (μ | β z | = 0.34) relative to the copy condition (μ | β z | = 0.25), the copy condition network had more connections (18/18 versus 15/18 command). Network connectivity across command and copy was most influenced by five of the 18 variables. The direction of dependencies followed the order of instructions better in the command condition network. Digitally acquired clock variables relate to one another but differ in network structure when derived from command or copy conditions. Continued analyses of clock drawing production should improve understanding of quintessential normal features to aid in early neurodegenerative disease detection.
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Affiliation(s)
- Brandon Frank
- University of Florida, Gainesville, USA
- Boston University, MA, USA
| | | | | | | | | | - Dana Penney
- Lahey Clinic Medical Center, Burlington, MA, USA
| | - Randall Davis
- Massachusetts Institute of Technology, Cambridge, USA
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Libon DJ, Matusz EF, Cosentino S, Price CC, Swenson R, Vermeulen M, Ginsberg TB, Okoli-Umeweni AO, Powell L, Nagele R, Tobyne S, Gomes-Osman JR, Pascual-Leone A. Using digital assessment technology to detect neuropsychological problems in primary care settings. Front Psychol 2023; 14:1280593. [PMID: 38046126 PMCID: PMC10693332 DOI: 10.3389/fpsyg.2023.1280593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/23/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Screening for neurocognitive impairment and psychological distress in ambulatory primary and specialty care medical settings is an increasing necessity. The Core Cognitive Evaluation™ (CCE) is administered/scored using an iPad, requires approximately 8 min, assesses 3- word free recall and clock drawing to command and copy, asks questions about lifestyle and health, and queries for psychological distress. This information is linked with patients' self- reported concerns about memory and their cardiovascular risks. Methods A total of 199 ambulatory patients were screened with the CCE as part of their routine medical care. The CCE provides several summary indices, and scores on 44 individual digital clock variables across command and copy tests conditions. Results Subjective memory concerns were endorsed by 41% of participants. Approximately 31% of participants reported psychological distress involving loneliness, anxiety, or depression. Patients with self-reported memory concerns scored lower on a combined delay 3- word/ clock drawing index (p < 0.016), the total summary clock drawing command/ copy score (p < 0.050), and clock drawing to command Drawing Efficiency (p < 0.036) and Simple and Complex Motor (p < 0.029) indices. Patients treated for diabetes and atherosclerotic cardiovascular disease (ASCVD) scored lower on selected CCE outcome measures (p < 0.035). Factor analyses suggest that approximately 10 underlying variables can explain digital clock drawing performance. Discussion The CCE is a powerful neurocognitive assessment tool that is sensitive to patient's subjective concerns about possible decline in memory, mood symptoms, possible cognitive impairment, and cardiovascular risk. iPad administration ensures total reliability for test administration and scoring. The CCE is easily deployable in outpatient ambulatory primary care settings.
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Affiliation(s)
- David J. Libon
- School of Osteopathic Medicine, New Jersey Institute for Successful Aging, Rowan University, Stratford, NJ, United States
- Department of Psychology, Rowan University, Glassboro, NJ, United States
| | - Emily Frances Matusz
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, United States
| | - Stephanie Cosentino
- Cognitive Neuroscience Division, Department of Neurology, Taub Institute and Sergievsky Center, Columbia University Medical Center, New York, NY, United States
| | - Catherine C. Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, United States
| | - Rod Swenson
- School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Meagan Vermeulen
- Department of Family Practice, School of Osteopathic Medicine, Rowan University, Stratford, NJ, United States
| | - Terrie Beth Ginsberg
- School of Osteopathic Medicine, New Jersey Institute for Successful Aging, Rowan University, Stratford, NJ, United States
| | - Adaora Obiageli Okoli-Umeweni
- School of Osteopathic Medicine, New Jersey Institute for Successful Aging, Rowan University, Stratford, NJ, United States
| | - Leonard Powell
- School of Osteopathic Medicine, New Jersey Institute for Successful Aging, Rowan University, Stratford, NJ, United States
| | - Robert Nagele
- School of Osteopathic Medicine, New Jersey Institute for Successful Aging, Rowan University, Stratford, NJ, United States
| | | | | | - Alvaro Pascual-Leone
- Linus Health, Boston, MA, United States
- Sidney Wolk Center for Memory Health, and Eleanor and Herbert Bearak Memory Wellness for Life Program, Hinda and Arthur Marcus Institute for Aging Research and Deanna, Hebrew SeniorLife, Boston, MA, United States
- Department of Neurology and Harvard Medical School, Boston, MA, United States
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Kehl-Floberg KE, Marks TS, Edwards DF, Giles GM. Conventional clock drawing tests have low to moderate reliability and validity for detecting subtle cognitive impairments in community-dwelling older adults. Front Aging Neurosci 2023; 15:1210585. [PMID: 37705561 PMCID: PMC10495769 DOI: 10.3389/fnagi.2023.1210585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023] Open
Abstract
Background Early identification of subtle cognitive decline in community-dwelling older adults is critical, as mild cognitive impairment contributes to disability and can be a precursor to dementia. The clock drawing test (CDT) is a widely adopted cognitive screening measure for dementia, however, the reliability and validity of paper-and-pencil CDT scoring scales for mild cognitive impairment in community samples of older adults is less well established. We examined the reliability, sensitivity and specificity, and construct validity of two free-drawn clock drawing test scales-the Rouleau System and the Clock Drawing Interpretation Scale (CDIS)-for subtle cognitive decline in community-dwelling older adults. Methods We analyzed Rouleau and CDIS scores of 310 community-dwelling older adults who had MoCA scores of 20 or above. For each scale we computed Cronbach's alpha, receiver operating characteristic curves (ROC) for sensitivity and specificity using the MoCA as the index measure, and item response theory models for difficulty level. Results Our sample was 75% female and 85% Caucasian with a mean education of 16 years. The Rouleau scale had excellent interrater reliability (94%), poor internal consistency [0.37 (0.48)], low sensitivity (0.59) and moderate specificity (0.71) at a score of 9. The CDIS scale had good interrater reliability (88%), moderate internal consistency [0.66 (0.09)], moderate sensitivity (0.78) and low specificity (0.45) at a score of 19. In the item response models, both scales' total scores gave the most information at lower cognitive levels. Conclusion In our community-dwelling sample, the CDIS's psychometric properties were better in most respects than the Rouleau for use as a screening instrument. Both scales provide valuable information to clinicians screening older adults for cognitive change, but should be interpreted in the setting of a global cognitive battery and not as stand-alone instruments.
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Affiliation(s)
- Kristen E. Kehl-Floberg
- Institute for Clinical and Translational Science, University of Wisconsin-Madison, Madison, WI, United States
| | - Timothy S. Marks
- Department of Kinesiology-Occupational Therapy, University of Wisconsin-Madison, Madison, WI, United States
| | - Dorothy F. Edwards
- Institute for Clinical and Translational Science, University of Wisconsin-Madison, Madison, WI, United States
- Department of Kinesiology-Occupational Therapy, University of Wisconsin-Madison, Madison, WI, United States
| | - Gordon M. Giles
- Department of Occupational Therapy, Samuel Merritt University, Oakland, CA, United States
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Akkoyun M, Koçoğlu K, Eraslan Boz H, Keskinoğlu P, Akdal G. Saccadic Eye Movements in Patients with Mild Cognitive Impairment: A Longitudinal Study. J Mot Behav 2023; 55:354-372. [PMID: 37080551 DOI: 10.1080/00222895.2023.2202620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/28/2023] [Accepted: 04/09/2023] [Indexed: 04/22/2023]
Abstract
Saccadic eye movements are one of the sensitive and noninvasive methods to help monitor the cognitive course of mild cognitive impairment (MCI). The study aimed to evaluate both pro and anti-saccade longitudinally and the relationship between cognitive functions and eye movements in MCI subgroups and healthy controls (HCs) at a two-year follow-up. This study revealed that the anti-saccade anticipatory responses decreased in amnestic MCI (aMCI). Correct vertical pro-saccades increased in non-amnestic MCI (naMCI), while the express saccades decreased. Our study demonstrated that longer than two years of follow-up is necessary to monitor the course of MCI. Findings of the relationships between longitudinal changes of saccades and cognitive measurements demonstrated the usability of eye movements in evaluating the process of MCI.
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Affiliation(s)
- Müge Akkoyun
- Department of Neurosciences, Institute of Health Sciences, Dokuz Eylül University, İzmir, Türkiye
| | - Koray Koçoğlu
- Department of Neurosciences, Institute of Health Sciences, Dokuz Eylül University, İzmir, Türkiye
| | - Hatice Eraslan Boz
- Department of Neurosciences, Institute of Health Sciences, Dokuz Eylül University, İzmir, Türkiye
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Türkiye
| | - Pembe Keskinoğlu
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylül University, İzmir, Türkiye
| | - Gülden Akdal
- Department of Neurosciences, Institute of Health Sciences, Dokuz Eylül University, İzmir, Türkiye
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Türkiye
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Dion C, Tanner JJ, Libon DJ, Price CC. Contributions of Cardiovascular Burden, Peripheral Inflammation, and Brain Integrity on Digital Clock Drawing Performance in Non-Demented Older Adults. J Alzheimers Dis 2023; 95:453-467. [PMID: 37545230 PMCID: PMC10870342 DOI: 10.3233/jad-221011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Greater cardiovascular burden and peripheral inflammation are associated with dysexecutive neuropsychological profiles and a higher likelihood of conversion to vascular dementia. The digital clock drawing test (dCDT) is useful in identifying neuropsychological dysfunction related to vascular etiology. However, the specific cognitive implications of the combination of cardiovascular risk, peripheral inflammation, and brain integrity remain unknown. OBJECTIVE We aimed to examine the role of cardiovascular burden, inflammation, and MRI-defined brain integrity on dCDT latency and graphomotor metrics in older adults. METHODS 184 non-demented older adults (age 69±6, 16±3 education years, 46% female, 94% white) completed dCDT, vascular assessment, blood draw, and brain MRI. dCDT variables of interest: total completion time (TCT), pre-first hand latency, digit misplacement, hour hand distance from center, and clock face area. Cardiovascular burden was calculated using the Framingham Stroke Risk Profile (FSRP-10). Peripheral inflammation markers included interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor-alpha, and high sensitivity C-reactive protein. Brain integrity included bilateral entorhinal cortex volume, lateral ventricular volume, and whole brain leukoaraiosis. RESULTS FSRP-10, peripheral inflammation, and brain integrity explained an additional 14.6% of the variance in command TCT, where FSRP-10 was the main predictor. FSRP-10, inflammatory markers, and brain integrity explained an additional 17.0% in command digit misplacement variance, with findings largely driven by FSRP-10. CONCLUSION Subtle graphomotor behavior operationalized using dCDT metrics (i.e., TCT and digit misplacement) is partly explained by cardiovascular burden, peripheral inflammation, and brain integrity and may indicate vulnerability to a disease process.
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Affiliation(s)
- Catherine Dion
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Jared J. Tanner
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - David J. Libon
- Department of Geriatrics and Gerontology, New Jersey Institute for Successful Aging, School of Osteopathic Medicine, Rowan University, Glassboro, NJ, USA
- Department of Psychology, Rowan University, Glassboro, NJ, USA
| | - Catherine C. Price
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA
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