A novel speech analysis algorithm to detect cognitive impairment in a Spanish population

Objective

Early detection of cognitive impairment in the elderly is crucial for diagnosis and appropriate care. Brief, cost-effective cognitive screening instruments are needed to help identify individuals who require further evaluation. This study presents preliminary data on a new screening technology using automated voice recording analysis software in a Spanish population.

Method

Data were collected from 174 Spanish-speaking individuals clinically diagnosed as cognitively normal (CN, n = 87) or impaired (mild cognitive impairment [MCI], n = 63; all-cause dementia, n = 24). Participants were recorded performing four common language tasks (Animal fluency, alternating fluency [sports and fruits], phonemic "F" fluency, and Cookie Theft Description). Recordings were processed via text-transcription and digital-signal processing techniques to capture neuropsychological variables and audio characteristics. A training sample of 122 subjects with similar demographics across groups was used to develop an algorithm to detect cognitive impairment. Speech and task features were used to develop five independent machine learning (ML) models to compute scores between 0 and 1, and a final algorithm was constructed using repeated cross-validation. A socio-demographically balanced subset of 52 participants was used to test the algorithm. Analysis of covariance (ANCOVA), covarying for demographic characteristics, was used to predict logistically-transformed algorithm scores.

Results

Mean logit algorithm scores were significantly different across groups in the testing sample (p < 0.01). Comparisons of CN with impaired (MCI + dementia) and MCI groups using the final algorithm resulted in an AUC of 0.93/0.90, with overall accuracy of 88.4%/87.5%, sensitivity of 87.5/83.3, and specificity of 89.2/89.2, respectively.

Conclusion

Findings provide initial support for the utility of this automated speech analysis algorithm as a screening tool for cognitive impairment in Spanish speakers. Additional study is needed to validate this technology in larger and more diverse clinical populations.

Utility of a Short-Form Phonemic Fluency Task

OBJECTIVE

to establish a proof-of-concept and ascertain the reliability of an abbreviated 30-second (30s) phonemic fluency measure as a cognitive screening tool in older adults.

METHODS

in all, 201 English-speaking individuals with normal cognition (NC; n = 119) or cognitive impairment (CI; mild CI or dementia; n = 82) were administered a standard 60s phonemic fluency task (FAS/CFL) with discrete 30s intervals denoted.

RESULTS

for all letters, 30s trial scores significantly predicted 60s scores for the same letter, R2 = .7-.9, F(1, 200) = 850-915, p < .001. As with 60s total scores, 30s cumulative scores (for all three trials) were significantly different between NC and CI groups (p < .001). Receiver operating characteristic analyses showed that 30s total scores distinguished NC and CI groups as effectively (AUC = .675) as 60s total scores (AUC = .658).

CONCLUSIONS

these findings support the utility and reliability of a short-form phonemic fluency paradigm, as 30s performance reliably predicted 60s/trial totals and was equally accurate in distinguishing impaired/non-impaired groups.

Tele-Neuropsychology: From Science to Policy to Practice

OBJECTIVE

The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t).

METHOD

We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access.

RESULTS

The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology.

CONCLUSIONS

More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

Integrating Lifestyle Factor Science into Neuropsychological Practice: A National Academy of Neuropsychology Education Paper

OBJECTIVE

The primary aim of this paper is to review evidence and clinical implications related to lifestyle activities associated with promoting brain and cognitive health. Our review targets four key lifestyle factors: physical activity and exercise, social engagement, cognitively stimulating activity, and consuming Mediterranean-style diets.

METHOD

We conducted a critical review of the lifestyle factor literature in the four domains listed earlier. We contextualize this literature review by translating findings, when possible, into evidence-based recommendations to consider when providing neuropsychological services.

RESULTS

There is significant current evidence supporting the role of physical activity and exercise, social engagement, cognitively stimulating activity, and consuming Mediterranean-style diets on positive brain and cognitive health outcomes. While some null findings are present in all four areas reviewed, the weight of the evidence supports the notion that engaging in these activities may promote brain and cognitive functioning.

CONCLUSIONS

Clinical neuropsychologists can have confidence in recommending engagement in physical activity, social activity, and cognitively stimulating activity, and adhering to a Mediterranean-style diet to promote brain and cognitive health. We discuss limitations in existing lifestyle factor research and future directions to enhance the existing evidence base, including additional research with historically underrepresented groups and individuals with neurological conditions.

B - 33 Characterization of Subjective Cognitive Complaints in a Population-Based Sample

OBJECTIVE

Subjective cognitive complaints (SCCs) represent one's perception of cognitive change that may relate to cognitive decline. This study characterized SCC endorsement and objective cognitive performance in minority populations.

METHOD

Participants from a population-based, multiethnic cardiovascular risk study (N = 2653; Age = (18-85); Female = 58%; Black = 51%; Hispanic = 14%) responded to questions about their subjective cognitive functioning prior to completing the Montreal Cognitive Assessment (MoCA). Participants endorsed "Yes" or "No" to the following items: 1) Do you have consistent memory problems, 2) If YES, do they interfere with everyday activities, and 3) do you have trouble figuring things out/solving problems. Descriptive and chi-squared analyses characterized endorsement among ethnoracial groups. One-way ANCOVA controlling for age, race/ethnicity, and education compared MoCA scores by endorsement pattern.

RESULTS

Nineteen percent (N = 520) of participants endorsed SCCs, in which blacks endorsed SCCs at a higher rate (22.4%; p < 0.008) than other ethnoracial groups (White = 16.3%; Hispanic = 17.8%). ANCOVA revealed significantly higher mean MoCA scores in those without cognitive complaints (MoCA = 23.4, N = 2122) than those who endorsed Item 3 (MoCA = 21.7, N = 42, p = 0.002, η2 = 0.001), Items 1&3 (MoCA = 21.8, N = 42, p = 0.004, η2 = 0.002), and Items 1,2, &3 (MoCA = 19.6, N = 100, p = <0.001, η2 = 0.024), respectively.

CONCLUSIONS

Black individuals were more likely to endorse SCC's than other ethnoracial groups. Interestingly, memory complaints alone were not associated with cognitive performance, while those with problem solving concerns (with or without memory concerns) showed poorer cognitive performance. While a self-appraisal of executive functioning produced the strongest effect, future investigations are needed to characterize and distinguish the most sensitive SCCs to enhance clinical utility of brief screeners.

B - 31 Association of Hippocampal Volume with Subjective and Objective Cognitive Functioning in a Diverse Sample

OBJECTIVE

Individuals with subjective cognitive complaints (SCCs) and reduced hippocampal volumes (HV) may be at increased risk of future cognitive decline, though findings regarding the relationship between SCCs and HV have been mixed. The current study explores the association of HV with SCCs and objective cognitive performance in a diverse sample.

METHOD

Participants in a population-based cardiovascular risk study (N = 1754; MAge = 58.8, 59% Female, 50% Black, 10% Hispanic) responded to three subjective cognitive functioning questions prior to completing the Montreal Cognitive Assessment (MoCA): 1) Do you have consistent memory problems, 2) If YES, do they interfere with everyday activities, and 3) do you have trouble figuring things out/solving problems. HV were derived from a 3-tesla MRI and normalized using total intracranial volume. Partial correlations examined associations between HV, MoCA scores, and SCCs, while one-way ANCOVA compared HV by SCC endorsement pattern, controlling for demographics.

RESULTS

Findings revealed smaller HV in those who endorsed all SCC questions (n = 27; MHV =0.34) compared to those without any SCC (n = 631, MHV = 0.36, p = 0.001), though effect size was small (η2 = 0.015). HV were not correlated with SCCs (r = -0.06, p = 0.10) or cognitive performance (r = 0.01, p = 0.75), and SCCs had a small correlation with MoCA scores (r = -0.18, p < 0.001).

CONCLUSIONS

Subjective cognitive functioning was minimally associated with HV and cognitive performance in this sample, and as a result the clinical significance of these findings is unclear. Further research is needed to understand the possible neuroanatomical correlates of SCC, along with the predictive utility of SCCs in the early identification of cognitive decline.

Impact of word properties on list learning: An explanatory item analysis

OBJECTIVE

A variety of factors affect list learning performance and relatively few studies have examined the impact of word selection on these tests. This study examines the effect of both language and memory processing of individual words on list learning.

METHOD

Item-response data from 1,219 participants, Mage = 74.41 (SD = 7.13), Medu = 13.30 (SD = 2.72), in the Harmonized Cognitive Assessment Protocol were used. A Bayesian generalized (non)linear multilevel modeling framework was used to specify the measurement and explanatory item-response theory models. Explanatory effects on items due to learning over trials, serial position of words, and six word properties obtained through the English Lexicon Project were modeled.

RESULTS

A two parameter logistic (2PL) model with trial-specific learning effects produced the best measurement fit. Evidence of the serial position effect on word learning was observed. Robust positive effects on word learning were observed for body-object integration while robust negative effects were observed for word frequency, concreteness, and semantic diversity. A weak negative effect of average age of acquisition and a weak positive effect for the number of phonemes in the word were also observed.

CONCLUSIONS

Results demonstrate that list learning performance depends on factors beyond the repetition of words. Identification of item factors that predict learning could extend to a range of test development problems including translation, form equating, item revision, and item bias. In data harmonization efforts, these methods can also be used to help link tests via shared item features and testing of whether these features are equally explanatory across samples. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Southwestern Assessment of Processing Speed (SWAPS): A new brief test with demographically-corrected norms in an ethnically and educationally diverse population

Objective. Neuropsychological measures of processing speed have long been used as sensitive indices of cognitive functioning. Most of these commonly used tests are proprietary, and there is a need for brief, freely available tools that can be used in diverse clinical and research settings. The Southwestern Assessment of Processing Speed (SWAPS) is a 60-second digit-symbol transcription task developed as a brief alternative to commercially available coding tests. Demographically-corrected normative data are presented along with reliability and sensitivity/specificity values in older adults with and without cognitive impairment.Method. SWAPS data from 915 healthy aging individuals (NC) and 858 subjects with clinical diagnoses of mild cognitive impairment (MCI; n = 430) and Alzheimer's disease clinical syndrome (ADCS; n = 428) were obtained from the Texas Alzheimer's Research and Care Consortium (TARCC). TARCC participants represent ethnically and educationally diverse community-dwelling individuals age 50+.Results. SWAPS scores showed the expected associations with age, sex, and education, and the interaction between age and education were significant predictors of SWAPS scores. Test-retest reliability in NC was good, and the SWAPS distinguished impaired and non-impaired groups with adequate to excellent sensitivity and specificity for the primary analyses, with optimal cut-off points provided. Raw score- to uncorrected normalized T-scores and demographically-corrected SWAPS T-scores using regression-based norms are presented along with scoring programs for the calculation of each.Conclusions. The SWAPS is a brief, free, easily administered test with demographically-corrected regression-based norms and promising utility for detection of cognitive impairment and efficient assessment of processing speed.

A-148 The Association of Neighborhood Trust and Violence with White Matter Integrity in a Diverse Sample

Objective: Hispanic and non-Hispanic Black older adults are at increased risk of dementia compared with non-Hispanic Whites. Cerebral white matter disease may contribute to this disparity, though little is known about how factors such as neighborhood disadvantage and perceived economic status may relate to white matter integrity in diverse groups.

Method: Participants from a population-based, multiethnic cohort (N=2766; Female=58%; Black=48%; Hispanic=14%) completed a measure of neighborhood perceptions (“resources,” “trust,” “violence”) and perceived SES (“access to food,” “access to healthcare”) and underwent 3T brain MRI with 2D FLAIR and 3D T1-weighted sequences to assess white matter hyperintensity (WMH) burden and white matter volume (WMV), respectively. Linear regression models examined associations among these variables controlling for demographic and traditional SES variables (income, education), followed by post-hoc analyses by race/ethnicity and sex.

Results: Reported income, education, ethnoracial group, and sex were associated with WMH in the overall sample (ps&lt;.05), and “trust,” “access to healthcare,” income, education, race/ethnicity, and sex were significantly associated with cerebral WMV. Post-hoc analyses revealed “violence” was associated with more WMH in Black women (p&lt;.05,β=-0.12), lower “trust” was associated with lower WMV in Hispanic men (p&lt;.05,β=0.22), and lower “access to medical care” was associated with lower WMV in White women (p&lt;.05,β=-0.18).

Conclusions: Neighborhood disadvantage and perceived SES were significantly associated with indicators of white matter pathology, with differential relationships across race and sex. Findings may reflect disproportionate environmental and social stressors encountered by some groups. Future analyses will examine whether these sociocultural factors relate to white matter burden and cognitive function later in life.

Patient Satisfaction with Telephone Neuropsychological Assessment

OBJECTIVE

Telephone-based neuropsychological assessment (TeleNP) has been shown to be a valid alternative to in-person or video-based assessment. However, there is limited information regarding patients' satisfaction with TeleNP. This report presents satisfaction survey data from a diverse, clinical sample who received TeleNP during the coronavirus disease pandemic.

METHOD

A total of 43 adult patients (30.2% Hispanic/Latinx, 32.6% Black), aged 24-75, who received TeleNP as part of routine clinical care participated in a postassessment satisfaction survey. Responses were analyzed qualitatively and via nonparametric comparisons based on demographic factors.

RESULTS

Given options of "Not Satisfied," "Somewhat Satisfied," "Satisfied," or "Very Satisfied," 97.7% of patients reported satisfaction with their visit as well as the visit length, and 80% felt the visit met their needs ("Good" + "Very Good"). There were no significant differences in responses based on age, race/ethnicity, sex, or education. Endorsed advantages of TeleNP included "Avoid potential exposure to illness" and "Flexibility/Convenience," and 20% reported difficulty communicating, concentrating, and/or connecting with their provider as potential disadvantages. Although 67.7% reported a preference for in-person visits, 83.7% expressed interest in another "virtual visit" (telephone or video conference) with their provider.

CONCLUSIONS

TeleNP was well received by the sample and demonstrated good patient satisfaction. These results in conjunction with other research supporting the validity of TeleNP support consideration of this assessment modality for patients who might not otherwise have access to in-person or video conference-based neuropsychological services. Based on these findings, a greater focus on rapport building may be warranted when utilizing TeleNP to enhance patients' sense of connection to their provider.

Detection of Mild Cognitive Impairment Among Community-Dwelling African Americans Using the Montreal Cognitive Assessment

OBJECTIVE

To establish a cut score for the Montreal Cognitive Assessment (MoCA) that distinguishes mild cognitive impairment (MCI) from normal cognition (NC) in a community-based African American (AA) sample.

METHODS

A total of 135 AA participants, from a larger aging study, diagnosed MCI (n = 90) or NC (n = 45) via consensus diagnosis using clinical history, Clinical Dementia Rating score, and comprehensive neuropsychological testing. Logistic regression models utilized sex, education, age, and MoCA score to predict MCI versus NC. Receiver operating characteristic (ROC) curve analysis determined a cut score to distinguish MCI from NC based on optimal sensitivity, specificity, diagnostic accuracy, and greatest perpendicular distance above the identity line. ROC results were compared with previously published MoCA cut scores.

RESULTS

The MCI group was slightly older (MMCI = 64.76[5.87], MNC = 62.33[6.76]; p = .033) and less educated (MMCI = 13.07[2.37], MNC = 14.36[2.51]; p = .004) and had lower MoCA scores (MMCI=21.26[3.85], MNC = 25.47[2.13]; p < .001) than the NC group. Demographics were non-significant in regression models. The area under the curve (AUC) was significant (MoCA = .83, p < .01) and an optimal cut score of <24 maximized sensitivity (72%), specificity (84%), and provided 76% diagnostic accuracy. In comparison, the traditional cut score of <26 had higher sensitivity (84%), similar accuracy (76%), but much lower specificity (58%).

CONCLUSIONS

This study provides a MoCA cut score to help differentiate persons with MCI from NC in a community-dwelling AA sample. A cut score of <24 reduces the likelihood of misclassifying normal AA individuals as impaired than the traditional cut score. This study underscores the importance of culturally appropriate norms to optimize the utility of commonly used cognitive screening measures.

Montreal Cognitive Assessment Performance among Community-Dwelling African Americans

Objective

To report descriptive and normative data for the Montreal Cognitive Assessment (MoCA) in a population-based African American sample.

Method

The MoCA was administered to 1,419 African American participants (mean age 49.89 years, range 18-75, 64% female). After excluding those with subjective cognitive complaints (n = 301), normative data were generated by education and overlapping age ranges (n = 1,118). Pearson correlations and analysis of variance were used to examine the relationship to demographic variables, and frequency of missed items was reviewed.

Results

Total MoCA scores (mean 22.3, SD 3.9) were lower than previously published normative data derived from an elderly Caucasian Canadian population with 80% falling below the suggested cutoff (<26) for impairment. Several MoCA items were missed by a large portion of the sample, including cube drawing (72%), delayed free recall (66% <4/5 words), sentence repetition (63%), and abstraction items (45%).

Conclusion

This is the first study to examine normative performance on the MoCA specific to community-dwelling African Americans. Findings suggest that certain aspects of this measure and previously established cutoff scores may not be well-suited for some populations.

Predictors of Reversion from Mild Cognitive Impairment to Normal Cognition

BACKGROUND/AIMS

Few studies have examined predictors of reversion from mild cognitive impairment (MCI) to normal cognition. We sought to identify baseline predictors of reversion, using the National Alzheimer's Coordinating Center Uniform Data Set, by comparing MCI individuals who reverted to normal cognition to those who progressed to dementia.

METHODS

Participants (n = 1,208) meeting MCI criteria were evaluated at the baseline visit and 3 subsequent annual visits. Clusters of baseline predictors of MCI reversion included demographic/genetic data, global functioning, neuropsychological functioning, medical health/dementia risk score, and neuropsychiatric symptoms. Stepwise logistic regression models identified predictors of MCI reversion per cluster, which were then entered into a final comprehensive model to find overall predictor(s).

RESULTS

At 2 years, 175 (14%) reverted to normal cognition, 612 (51%) remained MCI, and 421 (35%) progressed to dementia, with sustained diagnoses at 3 years. Significant variables associated with MCI reversion were younger age, being unmarried, absence of APOE ε4 allele, lower CDR-SOB score, and higher memory/language test scores.

CONCLUSION

A relatively sizable proportion of MCI individuals reverted to normal cognition, which is associated with multiple factors previously noted. Findings may enhance MCI prognostic accuracy and increase precision of early intervention studies of dementia.

Self-Reported Traumatic Brain Injury and Mild Cognitive Impairment: Increased Risk and Earlier Age of Diagnosis

This study examined whether history of traumatic brain injury (TBI) is associated with increased risk and earlier onset of mild cognitive impairment (MCI). Subjects with MCI (n = 3,187) and normal cognition (n = 3,244) were obtained from the National Alzheimer's Coordinating Center database. TBI was categorized based on lifetime reported TBI with loss of consciousness (LOC) without chronic deficit. Logistic regression was used to examine TBI history as a predictor of MCI, adjusted for demographics, apolipoprotein E-ɛ4 (ApoE4), a composite vascular risk score, and history of psychiatric factors. ANCOVA was used to examine whether age at MCI diagnosis and estimated age of onset differed between those with (TBI+) and without (TBI-) a history of TBI. TBI history was a significant predictor (p <  0.01) and associated with increased odds of MCI diagnosis in unadjusted (OR = 1.25; 95% CI = 1.05-1.49) and adjusted models, accounting for age, education, ApoE4, and a composite vascular score (OR = 1.32; 95% CI = 1.10-1.58). This association, however, was largely attenuated (OR = 1.14; 95% CI = 0.94-1.37; p = 0.18) after adjustment for reported history of depression. MCI was diagnosed a mean of 2.3 years earlier (p <  0.001) in the TBI+ group, and although TBI+ subjects had an estimated mean of decline 1.7 years earlier, clinician-estimated age of onset failed to differ (p = 0.13) when gender and psychiatric factors were controlled. This is the first report of a possible role for TBI as a risk factor in MCI, but its association may be related to other factors such as gender and depression and requires further investigation.

Traumatic brain injury history is associated with earlier age of onset of Alzheimer disease

OBJECTIVE

This study examined whether a history of traumatic brain injury (TBI) is associated with earlier onset of Alzheimer disease (AD), independent of apolipoprotein ε4 status (Apoe4) and gender.

METHOD

Participants with a clinical diagnosis of AD (n = 7625) were obtained from the National Alzheimer's Coordinating Center Uniform Data Set, and categorized based on self-reported lifetime TBI with loss of consciousness (LOC) (TBI+ vs. TBI-) and presence of Apoe4. ANCOVAs, controlling for gender, race, and education were used to examine the association between history of TBI, presence of Apoe4, and an interaction of both risk factors on estimated age of AD onset.

RESULTS

Estimated AD onset differed by TBI history and Apoe4 independently (p's < .001). The TBI+ group had a mean age of onset 2.5 years earlier than the TBI- group. Likewise, Apoe4 carriers had a mean age of onset 2.3 years earlier than non-carriers. While the interaction was non-significant (p = .34), participants having both a history of TBI and Apoe4 had the earliest mean age of onset compared to those with a TBI history or Apoe4 alone (M_Difference = 2.8 and 2.7 years, respectively). These results remained unchanged when stratified by gender.

CONCLUSIONS

History of self-reported TBI can be associated with an earlier onset of AD-related cognitive decline, regardless of Apoe4 status and gender. TBI may be related to an underlying neurodegenerative process in AD, but the implications of age at time of injury, severity, and repetitive injuries remain unclear.

Traumatic brain injury history is associated with earlier age of onset of frontotemporal dementia

OBJECTIVE

We retrospectively examined whether a history of traumatic brain injury (TBI) is associated with an earlier age of symptom onset and diagnosis in a large sample of patients with behavioural variant frontotemporal dementia (bvFTD).

METHODS

Data on patients with bvFTD (n=678) were obtained from the National Alzheimer's Coordinating Center Uniform Data Set. TBI was categorised based on reported lifetime history of TBI with loss of consciousness (LOC) but no chronic deficits occurring more than 1 year prior to diagnosis of bvFTD. Analysis of covariance (ANCOVA) was used to determine if clinician-estimated age of symptom onset and age at diagnosis of bvFTD differed between those who reported a history of TBI with LOC (TBI+) and those who did not (TBI-).

RESULTS

Controlling for sex, the TBI+ bvFTD group had an age of symptom onset and age of diagnosis that was on average 2.8 and 3.2 years earlier (p<0.01) than the TBI- bvFTD group.

CONCLUSIONS

TBI history with LOC occurring more than 1 year prior to diagnosis is associated with an earlier age of symptom onset and diagnosis in patients with bvFTD. TBI may be related to the underlying neurodegenerative processes in bvFTD, but the implications of age at time of injury, severity and repetitive injuries remain unclear.

Use of the Montreal Cognitive Assessment and Alzheimer's Disease-8 as cognitive screening measures in Parkinson's disease

OBJECTIVE

To examine the sensitivity and specificity of the Montreal Cognitive Assessment (MoCA), a brief cognitive screening measure previously validated for use in Parkinson's disease (PD), and Alzheimer's Disease-8 (AD8), an eight-item informant report used to screen for dementia, but not yet validated for use in PD, to identify cognitive impairment in a sample of 111 patients with PD.

METHODS

Cognitive impairment was determined based on a battery of neuropsychological measures, excluding the MoCA and AD8. Classification rates of both the MoCA and AD8 in identifying cognitive impairment were examined using logistic regression and receiver operator characteristic (ROC) analysis. Optimal cutoff scores were determined to maximize sensitivity and specificity.

RESULTS

The MoCA correctly classified 78.4% of participants (p < 0.001), and ROC analysis yielded an area under the curve (AUC) of 0.82. A MoCA cutoff score of <25 yielded optimal sensitivity (0.77) and specificity (0.79) for identifying PD patients with cognitive impairment. Similar analyses for the AD8 were statistically nonsignificant, although the classification rate was 70.5%, with an AUC of 0.50.

CONCLUSIONS

These results provide additional support for the MoCA, but not the AD8, in identifying cognitive impairment in patients with PD.

An Abbreviated Montreal Cognitive Assessment (MoCA) for Dementia Screening

OBJECTIVE

The Montreal Cognitive Assessment (MoCA) is a cognitive screening instrument growing in popularity, but few studies have conducted psychometric item analyses or attempted to develop abbreviated forms. We sought to derive and validate a short-form MoCA (SF-MoCA) and compare its classification accuracy to the standard MoCA and Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI), Alzheimer disease (AD), and normal aging.

METHODS

408 subjects (MCI n = 169, AD n = 87, and normal n = 152) were randomly divided into derivation and validation samples. Item analysis in the derivation sample identified most sensitive MoCA items. Receiver Operating Characteristic (ROC) analyses were used to develop cut-off scores and evaluate the classification accuracy of the SF-MoCA, standard MoCA, and MMSE. Net Reclassification Improvement (NRI) analyses and comparison of ROC curves were used to compare classification accuracy of the three measures.

RESULTS

Serial subtraction (Cramer's V = .408), delayed recall (Cramer's V = .702), and orientation items (Cramer's V = .832) were included in the SF-MoCA based on largest effect sizes in item analyses. Results revealed 72.6% classification accuracy of the SF-MoCA, compared with 71.9% for the standard MoCA and 67.4% for the MMSE. Results of NRI analyses and ROC curve comparisons revealed that classification accuracy of the SF-MoCA was comparable to the standard version and generally superior to the MMSE.

CONCLUSIONS

Findings suggest the SF-MoCA could be an effective brief tool in detecting cognitive impairment.

Subclinical atherosclerosis and subsequent cognitive function

OBJECTIVE

To examine the relationship between measures of subclinical atherosclerosis and subsequent cognitive function.

METHOD

Participants from the Dallas Heart Study (DHS), a population-based multiethnic study of cardiovascular disease pathogenesis, were re-examined 8 years later (DHS-2) with the Montreal Cognitive Assessment (MoCA); N = 1904, mean age = 42.9, range 8-65. Associations of baseline measures of subclinical atherosclerosis (coronary artery calcium, abdominal aortic plaque, and abdominal aortic wall thickness) with MoCA scores measured at follow-up were examined in the group as a whole and in relation to age and ApoE4 status.

RESULTS

A significant linear trend of successively lower MoCA scores with increasing numbers of atherosclerotic indicators was observed (F(3, 1150) = 5.918, p = .001). CAC was weakly correlated with MoCA scores (p = .047) and MoCA scores were significantly different between participants with and without CAC (M = 22.35 vs 23.69, p = 0.038). With the exception of a small association between abdominal AWT and MoCA in subjects over age 50, abdominal AWT and abdominal aortic plaque did not correlate with MoCA total score (p ≥ .052). Cognitive scores and atherosclerosis measures were not impacted by ApoE4 status (p ≥ .455).

CONCLUSION

In this ethnically diverse population-based sample, subclinical atherosclerosis was minimally associated with later cognitive function in middle-aged adults.

Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample

OBJECTIVE

To provide normative and descriptive data for the Montreal Cognitive Assessment (MoCA) in a large, ethnically diverse sample.

METHODS

The MoCA was administered to 2,653 ethnically diverse subjects as part of a population-based study of cardiovascular disease (mean age 50.30 years, range 18-85; Caucasian 34%, African American 52%, Hispanic 11%, other 2%). Normative data were generated by age and education. Pearson correlations and analysis of variance were used to examine relationship to demographic variables. Frequency of missed items was also reviewed.

RESULTS

Total scores were lower than previously published normative data (mean 23.4, SD 4.0), with 66% falling below the suggested cutoff (<26) for impairment. Most frequently missed items included the cube drawing (59%), delayed free recall (56%; <4/5 words), sentence repetition (55%), placement of clock hands (43%), abstraction items (40%), and verbal fluency (38%; <11 words in 1 minute). Normative data stratified by age and education were derived.

CONCLUSION

These findings highlight the need for population-based norms for the MoCA and use of caution when applying established cut scores, particularly given the high failure rate on certain items. Demographic factors must be considered when interpreting this measure.

Association Between Dementia Rating Scale Performance and Neurocognitive Domains in Alzheimer’s Disease

The Dementia Rating Scale (DRS; Mattis, 1976, 1988) is commonly used in the assessment of dementia, although little is known about the relationship of performance on this test to specific cognitive deficits in Alzheimer's disease (AD). Additionally, cognitive profiles have not been investigated across different levels of dementia as determined by the DRS. A sample of 133 individuals diagnosed with possible or probable AD was administered the DRS as part of a comprehensive neuropsychological evaluation. Composite scores for the cognitive domains of attention, executive functioning, visuospatial skills, language abilities, immediate recall, and delayed memory were derived by averaging demographically corrected T scores of key measures. Individual domain scores were also averaged to develop a global index score. Pearson correlations between composite and total DRS scores were highly significant (p<.001) for all domains and the global index score, with the exception of delayed memory, which showed a floor effect. When the sample was divided into mild and moderate-to-severe groups to examine the effects of disease severity on the relationship between the DRS and standard neurocognitive domain scores, the resulting mean neuropsychological profile scores were significantly different while maintaining a parallel pattern of impairment across domains. Results demonstrate the relationship between the DRS and standard cognitive domain functions, which appears to underscore the validity and robustness of the DRS in characterizing patterns of cognitive impairment across the AD spectrum.

Validation of the new interpretive guidelines for the clinical dementia rating scale sum of boxes score in the national Alzheimer's coordinating center database

BACKGROUND

It was recently demonstrated that the Clinical Dementia Rating scale Sum of Boxes (CDR-SB) score can be used to accurately stage severity of Alzheimer dementia and mild cognitive impairment (MCI). However, to our knowledge, the utility of those interpretive guidelines has not been cross-validated or applied to a heterogeneous sample of dementia cases.

OBJECTIVE

To cross-validate the staging guidelines proposed in a previous study using the National Alzheimer's Coordinating Center (NACC) database.

DESIGN

The previously published cut scores were applied to the NACC sample and diagnostic accuracy estimates obtained. Next, analyses were restricted to NACC participants with a CDR global score (CDR-GS) of 0.5 and receiver operating characteristic curves generated to determine optimal CDR-SB cut scores for distinguishing MCI from very early dementia.

SETTING

The 2008 NACC uniform data set.

PARTICIPANTS

There were 12 462 participants (5115 controls; 2551 patients with MCI; 4796 patients with dementia, all etiologies) in the NACC data set used for the current analysis. Main Outcome Measure Accurate prediction of diagnoses (MCI or dementia) using the CDR-SB score.

RESULTS

The previously proposed CDR-SB ranges successfully classified the vast majority of patients across all impairment ranges with a kappa of 0.91 and 94% overall correct classification rate. Additionally, the CDR-SB score discriminated between patients diagnosed with MCI and dementia when CDR-GS was restricted to 0.5 (overall area under the curve = 0.83).

CONCLUSIONS

These findings cross-validate the previously published CDR-SB interpretative guidelines for staging dementia severity and extend those findings to a large heterogeneous sample of patients with dementia. Additionally, the CDR-SB scores distinguished MCI from dementia in patients with reasonable accuracy when CDR-GS was restricted to 0.5.

Qualitative Analysis of WMS-III Logical Memory and Visual Reproduction in Temporal Lobe Epilepsy

Clinical observation of performance on the Logical Memory (LM) and Visual Reproduction (VR) subtests from the WMS-III has revealed some variability in retention rates across stories and figures. This paper examined the degree to which this variability occurs in lateralized temporal lobe epilepsy (TLE) in comparison to a matched group from the WMS-III standardization sample, and explored whether analysis of qualitative aspects of LM and VR performance yield additional lateralizing information in TLE. Analysis of LM and VR scaled scores revealed differences between the TLE groups for LM, but not VR scores. All subjects benefited from repetition of LM Story B, with greater improvement in story retention in the Left versus Right TLE group. Variability in VR recall across figures was seen in all groups, with a bimodal distribution of retention rates for each figure and a sizable percentage of each group completely forgetting two or more figures. These results suggest that more careful analysis of individual LM story performance may be useful in some patients with TLE, whereas variability in VR retention across figures is common and should not be over interpreted.

Can a direct IADL measure detect deficits in persons with MCI?

OBJECTIVE

To determine if a direct measure of instrumental activities of daily living (IADL) scale designed for use with dementia patients can detect differences between persons with mild cognitive impairment (MCI) and normal elderly control subjects (NC).

METHODS

This study used cross-sectional and longitudinal IADL scale data from MCI and NC subjects followed at an Alzheimer's Disease Center.

RESULTS

On a 52-point scale, MCI subjects (n = 30) scored significantly lower than NC subjects (n = 30) on the IADL scale (total score 47.17 vs. 48.77 points; t (58) = 2.34, p = .011) and its Memory subscale (5.27 vs. 6.6 points; t (58) = 3.29, p = .002).Examination of annualized IADL scale change scores revealed that 50% of MCI subjects had declined by one point, compared with 29% of NC.

CONCLUSION

A direct IADL measure for dementia patients is able to detect small differences between MCI and NC and cross-sectionally and longitudinally, but does not distinguish between groups.

Detecting differential memory performance among Spanish-speaking patients with temporal lobe epilepsy

There is relatively little research pertaining to neuropsychological assessment of Spanish-speaking individuals with intractable temporal lobe epilepsy (TLE). The current study examined verbal and visual memory performances in 38 primarily Spanish-speaking patients with TLE (Right = 15, Left = 23) of similar epilepsy duration to determine if lateralizing differences can be found using verbal and nonverbal memory tests. On a test specifically designed to assess auditory learning and memory among Spanish-speaking individuals, the Spanish Verbal Learning Test (SVLT), patients with left TLE performed significantly worse than patients with right TLE. In contrast, no significant differences in story or visual memory were seen using common memory tests translated into Spanish. Similar to what has been found in English speakers, these results show that verbal memory differences can be seen between left and right sided TLE patients who are Spanish-speaking to aid in providing lateralizing information; however, these differences may be best detected using tests developed for and standardized on Spanish-speaking patients.

Patterns of verbal memory performance in mild cognitive impairment, Alzheimer disease, and normal aging

OBJECTIVE

Individuals with mild cognitive impairment (MCI) typically demonstrate memory loss that falls between normal aging (NA) and Alzheimer disease (AD), but little is known about the pattern of memory dysfunction in MCI.

METHOD

To explore this issue, California Verbal Learning Test (CVLT) performance was examined across groups of MCI, AD, and NA.

RESULTS

MCI subjects displayed a pattern of deficits closely resembling that of AD, characterized by reduced learning, rapid forgetting, increased recency recall, elevated intrusion errors, and poor recognition discriminability with increased false-positives. MCI performance was significantly worse than that of controls and better than that of AD patients across memory indices. Although qualitative analysis of CVLT profiles may be useful in individual cases, discriminant function analysis revealed that delayed recall and total learning were the best aspects of learning/memory on the CVLT in differentiating MCI, AD, and NA.

CONCLUSIONS

These findings support the position that amnestic MCI represents an early point of decline on the continuum of AD that is different from normal aging.

Performance of elderly Native Americans and Caucasians on the CERAD Neuropsychological Battery

The performance of 40 elderly Native Americans and 40 demographically similar Caucasians clinically diagnosed with Alzheimer disease were compared on the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Battery (CERAD-NB). The purpose was to determine whether performance on the CERAD-NB, a cognitive screening battery used to evaluate dementia in the elderly, is affected by cultural differences between these two groups, after controlling for age, education, and gender. All subjects were administered the CERAD-NB as part of a standard diagnostic evaluation. Statistical analyses revealed no significant differences between the two groups on any measures from the CERAD-NB. Thus, the CERAD-NB appears to be an efficient cognitive screening assessment in English-speaking Native Americans with known or suspected dementing illness and it appears that special norms may not be necessary in this population. However, additional studies of larger samples are needed for confirmation and to explore factors such as education, acculturation, and degree of Native American heritage, which may influence cognitive test performance.

Subscores of the FAB differentiate frontotemporal lobar degeneration from AD

OBJECTIVE

To determine the clinical utility of the Frontal Assessment Battery (FAB), a short test of frontal lobe functions, in differentiating frontotemporal lobar degeneration (FTLD) from Alzheimer disease (AD).

METHODS

FAB total scores and subscores for 23 subjects with FTLD and 31 subjects with AD were compared for sensitivity, specificity, and positive predictive value. Concurrent validity of the FAB with the Mini-Mental State Examination (MMSE) and other scales was also assessed.

RESULTS

The FAB did not have positive predictive value for FTLD. Total FAB scores did not differ between the FTLD and AD groups. However, three subtests of the FAB (mental flexibility, motor programming, and environmental autonomy) demonstrated significant differences between the two groups. Total FAB scores correlated with scores on the MMSE, a more general test of cognition.

CONCLUSION

The Frontal Assessment Battery did not discriminate subjects with frontotemporal lobar degeneration from those with Alzheimer disease, though certain subtests may be helpful in differential diagnosis.

A total score for the CERAD neuropsychological battery

OBJECTIVE

To develop a total or composite score for the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery.

METHOD

CERAD total scores were obtained by summing scores from the individual CERAD subtests (excluding the Mini-Mental State Examination [MMSE]) into a total composite (maximum score = 100). The method of tabulating the total score was constructed using normal controls (NCs; n = 424) and patients with AD (n = 835) from the CERAD registry database. The utility of the total score was further tested in independent samples of mild AD (n = 95), mild cognitive impairment (MCI; n = 60), and NC (n = 95) subjects.

RESULTS

The CERAD total score was highly accurate in differentiating NC and AD subjects in the CERAD registry. Age, gender, and education effects were observed, and demographic correction scores were derived through multiple regression analysis. Demographically corrected CERAD total scores showed excellent test-retest reliability across samples (r = 0.95) and were highly correlated with the MMSE (r = 0.89) and Clinical Dementia Rating Scale (r = -0.83) in mixed AD and NC samples and with the Blessed Dementia Rating Scale in an AD sample (r = -0.40). The CERAD total score was highly accurate in differentiating independent samples of NC, MCI, and AD subjects.

CONCLUSION

Results provide support for the validity of a Consortium to Establish a Registry for Alzheimer's Disease (CERAD) total score that can be used along with the normative data to provide an index of overall level of cognitive functioning from the CERAD neuropsychological battery.

Three-word recall in normal aging

Three-word recall tasks are widely used as brief measures of verbal memory function, although interpretation of performance is complicated by variations in test instructions and procedures. The purpose of this study was to examine 3-word recall performance in samples of healthy subjects aged 5275 (M age = 70) and age 7692 (M age = 82) compared to patients with Alzheimer's Disease (AD) when explicit prompts to remember the words were given. Those in the younger aging group remembered significantly more words than those in the older sample after a brief delay (M= 2.8 and 2.3, respectively). However, the majority of control subjects recalled 2 or 3 words after the delay, with only 3% of the 5075 year old group and 17% of the 76+ year old group recalling 0 or 1 word on delayed recall. This is in stark contrast to the 87% of individuals with AD who recalled 0 or 1 word. Even though 3-word recall performance decreases with age, good recall (2 or 3 words) can be expected in most cases of normal aging.

Category fluency in mild cognitive impairment: reduced effect of practice in test-retest conditions

Verbal fluency tests are commonly used in neurocognitive and mental status examinations in patients with suspected dementia. Inflation of test scores as a result of practice effects may yield false-negative results in test-retest and multidisciplinary settings, particularly among patients with mild cognitive deficits. To address this issue, animal naming was administered twice within a 1-week period to a group of individuals referred for suspected dementia who were ultimately diagnosed with mild cognitive impairment (MCI; amnestic form), probable Alzheimer disease (AD), or no dementia. A 2 x 3 repeated-measures analysis of variance revealed a statistically significant interaction between administration time and group. Post hoc analyses indicated that nondemented controls were the only group to demonstrate a significant practice effect, producing an average of approximately three more animal names at time two. Like patients with a diagnosis of AD, subjects with amnestic MCI failed to benefit from repeated exposure to the animal naming test, and only controls showed an average improvement upon retest. This underscores the cognitive similarity between individuals diagnosed with amnestic MCI and AD and suggests that improvement upon retest may be a diagnostically useful finding.

Dyadic short forms of the Wechsler Adult Intelligence Scale-III

Various short forms of the Wechsler Adult Intelligence Scale (WAIS)/WAIS-R have been developed to obtain estimates of overall intellectual level, although little research of WAIS-III short forms has been published to date. Full Scale IQ (FSIQ) estimatesfromfour WAIS-III dyadic short forms were obtained by entering selected subtest scores from a mixed neurologic/ psychiatric sample (n = 196) into regression equations. Results were cross validated on a second sample (n = 57). Within both samples, WAIS-III FSIQ scores were highly correlated (r = .90-.92, p < .001) with estimated FSIQ scores. Estimated FSIQ fell within 5 points of actual FSIQ in 49% to 74% of cross-validation cases and within 10 points of actual FSIQ in 81% to 93% of the sample. Comparable to findings from previous short-form investigations, actual and estimated FSIQ classification levels agreed in 46% to 67% of cases in the cross-validation sample. These dyadic WAIS-III forms appear appropriate for obtaining gross estimates of FSIQ in similar populations, although caution is recommended in interpreting estimated IQ scores.

Comparison of the hopkins verbal learning test-revised to the California verbal learning test in Alzheimer's disease

We examined the validity of the revised Hopkins Verbal Learning Test (HVLT-R) by comparing performances on the HVLT-R and the California Verbal Learning Test (CVLT) in participants with Alzheimer's disease (AD). Total learning, delayed recall, intrusion errors, and recognition performance were significantly related across tests, but the number of perseverative responses showed no linear association. Despite similar results across measures, some of the variables were only modestly correlated, which may reflect differences in test procedures and the limited range of scores for some variables. Furthermore, the HVLT-R may not be challenging enough to elicit some of the types of recall errors commonly seen in AD to the same extent as the CVLT Nonetheless, the HVLT-R shows promise for providing a multidimensional assessment of verbal learning and memory and may be ideal in cases where brief assessment ofmemory and/or serial evaluations are needed.

Bilateral Memory Dysfunction in Epilepsy Surgery Candidates Detected by the Intracarotid Amobarbital Procedure (Wada Memory Test)

The intracarotid amobarbital procedure (IAP) is widely used in the evaluation of candidates for resective epilepsy surgery, in part to identify patients at risk for postoperative amnesia. Yet there is no widely accepted standardized protocol, and there is a paucity of quantitative data to assess the factors associated with poor IAP performance. This report summarizes our findings on 110 patients with intractable focal epilepsy who underwent IAP testing at our center. Ipsilateral IAP scores for patients with left-sided seizure foci were significantly lower than those for patients with right-sided seizure foci. Falsely and poorly lateralizing scores were also significantly more common in subjects with left-sided seizure onsets. Twenty-four percent of subjects failed the IAP bilaterally, and patients who failed the IAP bilaterally had significantly lower scores on neuropsychologic measures. There was no difference between patients who passed and failed in the location, etiology, duration, or age of onset of epilepsy. We conclude that bilateral memory dysfunction is common in patients with intractable partial epilepsy. Whether memory dysfunction detected by IAP testing as performed at our center is predictive of functionally limiting postoperative amnesia remains to be determined.

Cognitive functioning in individuals with "benign" essential tremor

Essential tremor (ET) is the most common type of movement disorder, although its etiology and neurophysiological substrates remain unclear. While thought to be a benign condition, it has yet to be studied from a neuropsychological perspective. We examined the neurocognitive functioning of 13 nondemented subjects with severe ET, including aspects of memory, cognitive flexibility, and attention. Results revealed that 12/13 subjects demonstrated impairment on 1 or more cognitive measures in comparison with published normative data. The pattern of findings was suggestive of relative dysfunction of frontal-mediated processes not unlike that seen in Parkinson's disease. These deficits were found in subjects irrespective of the presence of cognitive complaints, depression, or the existence of other potential neurocognitive risk factors. These findings suggest that mild cognitive deficits are not uncommon in association with severe ET and may be related to subcortical systems.

Comparison of the CERAD and CVLT list-learning tasks in Alzheimer's disease

This investigation examined the relationship of the word list from the CERAD neuropsychological battery to the California Verbal Learning Test (CVLT) in a sample of 138 subjects with Probable Alzheimer's disease (AD). Results revealed modest but statistically significant associations between the two measures on many key variables. Total words learned showed the strongest association, with lower correlations for delayed recall, intrusion errors, and recognition variables. As expected, the CERAD and CVLT assess similar aspects of verbal learning in patients with AD. However, the modest level of many of the correlations suggests that caution should be exercised in applying the same interpretive strategies derived on more comprehensive measures to shorter ones.

Neuropsychological outcome following unilateral stereotactic pallidotomy in intractable Parkinson's disease

Neuropsychological functioning was examined at baseline and 2- to 3-month follow-up in 40 subjects with advanced Parkinson's disease (PD) who underwent unilateral posteroventral pallidotomy. Most subjects demonstrated improved verbal learning, visual memory, confrontation naming, and figural fluency at follow-up. Right pallidotomy was associated with decreased cognitive flexibility and increased verbal fluency, whereas Left pallidotomy uniquely resulted in a decline in verbal fluency. Significant motor improvement was demonstrated in both groups. Pallidotomy appears to be an effective treatment for advanced PD, providing a significant improvement in motor functioning, while resulting in few deleterious neurocognitive changes in most cases.

Brief recall tasks and memory assessment in Alzheimer's disease

Memory measures that permit pattern and error analysis are useful in the differential diagnosis of dementia. However, little is known about the relative utility or relations among verbal memory tests of different lengths. A 6-item verbal learning test (6-VLT) that assesses qualitative performance features was developed and compared to 3-word recall and the California Verbal Learning Test (CVLT) in patients with Alzheimer's disease. Stronger correlations were observed between the 6-VLT and the CVLT. Significant relations were found between 6-VLT and CVLT indexes of learning, recall, and recognition (hits and false positive errors), although free recall errors were unrelated. Brief tasks such as the 6-VLT may provide more useful information regarding gross memory capacity than 3-word recall, although more challenging tasks may be required to elicit characteristic error patterns in Alzheimer's disease.

Comparative analysis of qualitative verbal fluency performance in normal elderly and demented populations

Verbal fluency tasks are commonly used in the assessment of patients with known or suspected dementia. Whereas total word production is often analyzed, less attention has been paid to qualitative aspects of verbal fluency performance. The purpose of this study was to examine the diagnostic utility of a qualitative scoring technique for semantic and phonemic fluency tasks in individuals with Alzheimer's disease (AD), Parkinson's disease (PD) with and without dementia, and in a group of older normal controls (ONC). In addition to total words produced, the groups were compared on their use of clustering (i.e., ratio of words generated within subcategories) and switching (i.e., frequency of shifts between clusters) strategies as originally defined by Troyer et al. (1997a). In terms of total number of words produced, controls were superior to the AD and demented PD subjects, who performed similarly. A similar trend was found in relation to switching and clustering scores. PD patients without dementia performed similar to the ONC group on semantic fluency, but were impaired relative to controls on all phonemic fluency variables (i.e., total words produced, clustering, switching). Discriminant function analyses using the three fluency variables revealed that total words was equal to or surpassed the other variables in distinguishing the groups, suggesting that these qualitative verbal fluency features may not provide significant additional information in terms of diagnostic utility.

The Hopkins Verbal Learning Test and CVLT: a preliminary comparison

A preliminary examination of the relationship between two clinical measures of verbal memory was conducted among healthy older subjects. Correlations between selected scores from the Hopkins Verbal Learning Test (HVLT) and the California Verbal Learning Test (CVLT) revealed that the total number of words learned across trials for both tests were significantly related (r =.74, p <.001), while there was no association between error rates (i.e., perseverations and intrusions). Recognition hits alone were not related, but recognition discriminability indices (accounting for false-positive errors) on the two measures were significantly correlated (r =.46, p =.02). While the HVLT appears to adequately assess basic verbal learning capacity, its utility in assessing some of the more complex and qualitative aspects of verbal learning and memory function may be limited, and interpretations of HVLT performances based on the CVLT literature must be made with caution. A clinical case example is presented to illustrate some of the issues in comparing performance on the HVLT and CVLT.