Effectiveness and Safety of Acupuncture for Vascular Cognitive Impairment: A Systematic Review and Meta-Analysis

Background: Acupuncture may be a promising complementary therapy for vascular cognitive impairment (VCI) and has been extensively applied in China. However, its potential effects remain uncertain, and the clinical findings are inconsistent. This review aimed to systematically appraise the overall effectiveness and safety of acupuncture in treating VCI. Methods: To investigate the effects of acupuncture on VCI from inception to February 28, 2021 using randomized clinical trials (RCTs), seven electro-databases [Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), VIP, and Wanfang] were searched. Two independent investigators identified the eligible RCTs and extracted data into predesigned forms. The risk of bias (ROB) within each individual trial was evaluated using the Cochrane Collaboration's tool. Meta-analyses were conducted for calculating comparative effects in the RevMan software (version 5.3). The strength of attained evidence was rated using the online GRADEpro approach. Results: A total of 48 RCTs involving 3,778 patients with VCI were included. The pooled data demonstrated that acupuncture was more beneficial for a global cognitive function [mean difference (MD) 1.86, 95% CI 1.19-2.54, p < 0.01] and activities of daily living (MD -3.08, 95% CI -4.81 to -1.35, p < 0.01) compared with western medicine (WM). The favorable results were also observed when acupuncture was combined with WM (MD 2.37, 95% CI 1.6-3.14, p < 0.01) or usual care (UC, MD 4.4, 95% CI 1.61-7.19, p = 0.002) in comparison with the corresponding control conditions. Meanwhile, the subgroup analysis did not indicate a statistical effect difference between manual acupuncture (MA) and electroacupuncture (EA) (inter-group I 2 < 50% and p > 0.1) when comparing acupuncture with WM. There were no significant differences in the occurrence of adverse events (AEs) between the acupuncture group and the control group (p > 0.05). Owing to the poor methodological quality and considerable heterogeneity among studies, the certainty of the evidence was low or very low. Conclusions: This review suggests that acupuncture as a monotherapy or an adjuvant therapy may play a positive role in improving the cognition and daily performance of VCI patients associated with few side effects. The difference in styles may not significantly influence its effectiveness. More rigorously designed and preregistered RCTs are highly desirable to verify the therapeutic benefits and determine an optimal acupuncture paradigm. The methodological and reporting quality of future researches should be enhanced by adhering to authoritative standardized statements. Systematic Review Registration: [PROSPERO], identifier [No. CRD42017071820].

Comprehensive Evaluation of the Functional Activities Questionnaire (FAQ) and Its Reliability and Validity

The Functional Activities Questionnaire (FAQ) is a collateral-report measure of difficulties in activities of daily living. Despite its widespread use, psychometric analyses have been limited in scope, piecemeal across samples, and limited primarily to classical test theory. This article consolidated and expanded psychometric analyses using tools from generalizability and item response theories among 27,916 individuals from the National Alzheimer's Coordinating Center database who completed the FAQ. Reliability was evaluated with internal consistency, test-retest, and generalizability analyses. Validity was assessed via convergence with neurocognitive measures, classification accuracy with impairment stage, and confirmatory factor and item response theory analyses. Demographics did not impact scores and there was strong evidence for reliability (0.52-0.95), though coefficients were attenuated when restricted in range to diagnostic groups (e.g., normal cognition). There were strong correlations with neurocognitive measures (rs: -.30 to -.59), strong classification accuracy (areas under the curve: .81-.99), and a single-factor model had excellent fit. All items evidenced strong item response theory discrimination and provided significant information regarding functional disability, albeit within a relatively restricted range. The FAQ is a reliable and valid measure of activities of daily living concerns for use in clinical/research settings. It best assesses mild levels of functional difficulty, which is helpful in distinguishing normal cognition from mild cognitive impairment and dementia.

The Association Between Functional Assessment and Structural Brain Biomarkers in an Ethnically Diverse Sample With Normal Cognition, Mild Cognitive Impairment, or Dementia

OBJECTIVE

To investigate the association between the functional activities questionnaire (FAQ) and brain biomarkers (bilateral hippocampal volume [HV], bilateral entorhinal volume [ERV], and entorhinal cortical thickness [ERT]) in cognitively normal (CN) individuals, mild cognitive impairment (MCI), or dementia.

METHOD

In total, 226 participants (137 females; mean age = 71.76, SD = 7.93; Hispanic Americans = 137; European Americans = 89) were assessed with a comprehensive clinical examination, a neuropsychological battery, a structural magnetic resonance imaging, and were classified as CN or diagnosed with MCI or dementia. Linear regression analyses examined the association between functional activities as measured by the FAQ on brain biomarkers, including HV, ERV, and ERT, controlling for age, education, global cognition, gender, and ethnicity.

RESULTS

The FAQ significantly predicted HV, ERV, and ERT for the entire sample. However, this association was not significant for ERV and ERT when excluding the dementia group. The FAQ score remained a significant predictor of HV for the non-dementia group. Age, education, gender, ethnicity, Montreal Cognitive Assessment score, and FAQ were also significant predictors of HV for the overall sample, suggesting that younger Hispanic females with fewer years of education, higher global mental status, and better functioning, were more likely to have larger HV.

CONCLUSION

FAQ scores were related to HV in older adults across clinical groups (CN, MCI, and dementia), but its association with the entorhinal cortex was driven by individuals with dementia. Demographic variables, including ethnicity, additionally influenced these associations.

Active case finding of dementia in ambulatory care settings: a comparison of three strategies

BACKGROUND AND PURPOSE

To reduce the diagnostic gap of dementia, three strategies can be employed for case finding of cognitive impairment in ambulatory care settings, namely using informant report, brief cognitive test or a combination of informant report and brief cognitive test. The right strategy to adopt across different healthcare settings remains unclear. This diagnostic study compared the performance of the three strategies for detecting dementia (primary aim), as well as for detecting both mild cognitive impairment (MCI) and dementia (secondary aim).

METHODS

Participants aged ≥65 years (n = 11 057) were recruited from Alzheimer's Disease Centers across the USA. Participants provided data on an informant report (Functional Activities Questionnaire), brief cognitive test (four-item short variant of Montreal Cognitive Assessment) and a combined measure with informant report and brief cognitive test (sum of Functional Activities Questionnaire and Montreal Cognitive Assessment short variant). They also received standardized assessments (clinical history, physical examination and neuropsychological testing) to diagnose MCI and dementia. Areas under the receiver operating characteristic curve (AUCs) of the three strategies were compared using the DeLong method, with AUC > 90% indicating excellent performance.

RESULTS

All three strategies had excellent performance in detecting dementia, although informant report [AUC, 95.9%; 95% confidence intervals (CI), 95.4-96.3%] was significantly better than brief cognitive test (AUC, 93.0%; 95% CI, 92.4-93.6%) and the combined measure had the best performance (AUC, 97.0%; 95% CI, 96.7-97.4%). However, to detect both MCI and dementia, only the combined measure had excellent performance (AUC, 93.0%; 95% CI, 92.5-93.4%), whereas stand-alone informant report or brief cognitive test performed suboptimally (AUC < 90%). Performance of the three strategies was not affected by participants' age, educational attainment or underlying prevalence of MCI and dementia.

CONCLUSIONS

For case finding of dementia in ambulatory care settings, informant reports would suffice as first-line measures and brief cognitive tests may optionally be added on, in services with available resources, to further improve the accuracy of detection. For case finding of both MCI and dementia, a combination of informant reports and brief cognitive tests remains the most appropriate strategy.

Assessment of cognitive-driven activity of daily living impairment in non-demented Parkinson's patients

The core criterion for Parkinson's disease dementia (PDD) is the impairment in activities of daily living (ADL) function primarily caused by cognitive, not motor symptoms. There is evidence to assume that mild ADL impairments in mild cognitive impairment (PD-MCI) characterize those patients at high risk for dementia. Data of 216 Parkinson's disease (PD) patients assessed with comprehensive motor and neuropsychological assessments were analysed. Based on linear regression models, subscores of the Functional Activities Questionnaire (FAQ) primarily reflecting patients' global cognitive status (FAQ_C ) or PD-related motor severity (FAQ_M ) were developed. A quotient (FAQ_Q ) of both scores was calculated, with values >1 indicating more cognitive- compared to motor-driven ADL impairment. Both FAQ_C and FAQ_M scores were higher in PD-MCI than cognitively normal (PD-CN) patients, indicating more severe cognitive- and motor-driven ADL impairments in this group. One third (31.6%) of the PD-MCI group had a FAQ_Q score >1, which was significantly different from patients with PD-CN (p = .02). PD-MCI patients with an FAQ_Q score >1 were more impaired on tests assessing attention (p = .019) and language (p = .033) compared to PD-MCI patients with lower FAQ_Q values. The differentiation between cognitive- and motor-driven ADL is important, as the loss of functional capacity is the defining factor for a diagnosis of PDD. We were able to differentiate the cognitive-driven from the motor-driven ADL impairments for the FAQ. PD-MCI patients with more cognitive- compared to motor-driven ADL impairments may pose a risk group for conversion to PDD and can be targeted for early treatments.