Screening for cognitive impairment in adults with sickle cell disease: A systematic review and meta-analysis

Neurovascular disease such as symptomatic stroke, silent brain infarcts and vascular cognitive impairment are common complications of sickle cell disease (SCD) that can have devastating consequences on quality of life, employment, and social functioning.  Early recognition of neurovascular disease is a prerequisite for the timely optimization of medical care and to connect patients to adaptive resources. While cognitive impairment has been well described in children, currently available data are limited in adults. As a result, guidance on the optimal cognitive screening strategies in adults is scarce. We conducted a systematic review to identify the different screening tools that have been evaluated in SCD. A meta-analysis was performed to estimate the prevalence of suspected cognitive impairment in this population. In this qualitative synthesis, we present 8 studies that evaluated 6 different screening tools. Patient characteristics that impacted on cognitive screening performance included age, education level, and a prior history of stroke. We report a pooled prevalence of 38% [14-62%] of suspected cognitive impairment. We discuss the relative benefits and limitations of the different screening tools to help clinicians select an adapted approach tailored to their specific patients' needs. Further studies are needed to establish and validate cognitive screening strategies in patients with diverse cultural and educational backgrounds.

The effect of repetitive transcranial magnetic stimulation on cognitive impairment in Parkinson's disease with dementia: Pilot study

BACKGROUND

The exact mechanism of cognitive impairment in PD is not known. Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a possible treatment for cognitive impairment and to treat the motor symptoms in Parkinson's disease (PD) where its effects seem additive to those of dopaminergic medications.

OBJECTIVE

In this pilot study we investigated whether repeated sessions of rTMS have an effect on measures of cognitive impairment in patients with PD dementia.

METHODS

33 patients with PD dementia were randomly assigned sham or real rTMS (2000 pulses; 20 Hz; 90% RMT; 10 trains of 10 s with 25 s between each train) over the hand area of each motor cortex (5 min between hemispheres) for 10 days (5 days/week) followed by 5 booster sessions every month for 3 months. Assessments included the Unified Parkinson's Disease Rating Scale part III (UPDRS), Montreal Cognitive Assessment (MoCA); Mini Mental State Examination (MMSE), Clinical Dementia Rating Scale (CDR); Memory and Executive Screening (MES) and Instrumental activity of Daily Living (IADL). Event related potentials (P300) and cortical excitability were measured before treatment and after the last session.

RESULTS

There were no significant differences in the effects of rTMS between groups. Although rTMS improved motor function in the active group it had only a minor effect on two of the dementia rating scores (the MMSE and MoCA) but not the others (CDR and MES). There was also a reduction in the latency of the P300 in the active group.

CONCLUSIONS

rTMS over M1 is useful for motor function and may have a small positive effect on cognition. However, better approaches for the latter are necessary, may be require multisite rTMS to target both motor and frontal cortical region.

The effect of cognitive dysfunction on mid- and long-term mortality after vascular surgery

Background

In recent decades, previous studies have noted the importance of frailty, which is a frequently used term in perioperative risk evaluations. Psychological and socioeconomical domains were investigated as part of frailty syndrome. The aim of this study was to assess the importance of these factors in mortality after vascular surgery.

Methods

In our prospective, observational study (ClinicalTrials.gov Identifier: NCT02224222), we examined 164 patients who underwent elective vascular surgery between 2014 and 2017. At the outpatient anaesthesiology clinic, patients completed a questionnaire about cognitive functions, depression and anxiety, social support and self-reported quality of life were assessed using a comprehensive frailty index, in addition to medical variables. Propensity score matching was performed to analyse the difference between patients and controls in a nationwide population cohort. The primary outcome was 4 year mortality. The Kaplan-Meier method and Cox regression analysis were used for statistical analyses.

Results

The patients’ mean age was 67.05 years (SD: 9.49 years). Mini-Mental State Examination scores of less than 27 points were recorded for 41 patients. Overall mortality rates were 22.4 and 47.6% in the control and cognitive impairment groups, respectively (p = 0.013). In the univariate Cox regression analysis, cognitive impairment measured using age- and education-adjusted MMSE scores increased the risk of mortality (AHR: 2.842, 95% CI: 1.389-5.815, p = 0.004).

Conclusion

Even mild cognitive dysfunction measured preoperatively using the MMSE represents a potentially important risk factor for mortality after vascular surgery.

3D-Deep Learning Based Automatic Diagnosis of Alzheimer's Disease with Joint MMSE Prediction Using Resting-State fMRI

We performed this research to 1) evaluate a novel deep learning method for the diagnosis of Alzheimer's disease (AD) and 2) jointly predict the Mini Mental State Examination (MMSE) scores of South Korean patients with AD. Using resting-state functional Magnetic Resonance Imaging (rs-fMRI) scans of 331 participants, we obtained functional 3-dimensional (3-D) independent component spatial maps for use as features in classification and regression tasks. A 3-D convolutional neural network (CNN) architecture was developed for the classification task. MMSE scores were predicted using: linear least square regression (LLSR), support vector regression, bagging-based ensemble regression, and tree regression with group independent component analysis (gICA) features. To improve MMSE regression performance, we applied feature optimization methods including least absolute shrinkage and selection operator and support vector machine-based recursive feature elimination (SVM-RFE). The mean balanced test accuracy was 85.27% for the classification of AD versus healthy controls. The medial visual, default mode, dorsal attention, executive, and auditory related networks were mainly associated with AD. The maximum clinical MMSE score prediction accuracy with the LLSR method applied on gICA combined with SVM-RFE features had the lowest root mean square error (3.27 ± 0.58) and the highest R² value (0.63 ± 0.02). Classification of AD and healthy controls can be successfully achieved using only rs-fMRI and MMSE scores can be accurately predicted using functional independent component features. In the absence of trained clinicians, AD disease status and clinical MMSE scores can be jointly predicted using 3-D deep learning and regression learning approaches with rs-fMRI data.

[Prevalence of cognitive impairments in acute nursing care-Analysis and comparison of routine data]

Hintergrund

Aufgrund des demografischen Wandels ist von einer zunehmenden Prävalenz stationärer Patienten mit kognitiven Beeinträchtigungen auszugehen. Für eine bestmögliche Versorgung gilt es, diese Patientengruppe mit einem routinemäßigen Verfahren frühzeitig zu erkennen.

Methode

Die aktuelle Studie untersuchte die Prävalenzrate von kognitiven Beeinträchtigungen bei stationären Patienten >65 Jahre, die mit dem Mini-Mental-Status-Test (MMST) während der pflegerischen Aufnahme untersucht wurden. Anhand der Screeningquote wurde die Bereitschaft von Pflegekräften, den MMST als Routineinstrument zu verwenden, überprüft. Die Quote wurde zudem mit der Anzahl der kodierten F‑Diagnosen der ICD-10-GM verglichen. Diese retrospektive Studie wurde vom Oktober 2018 bis März 2019 an einer Universitätsklinik durchgeführt.

Ergebnisse

Von 7311 stationären Patienten >65 Jahre wurden 11,7 % gescreent. Die Prävalenz kognitiver Beeinträchtigungen betrug 20,7 % und war höher als die Prävalenzrate von Demenz und Delir aufgrund medizinischer Diagnosen (p < 0,001). Mit 11,7 % ist die Bereitschaft des Pflegepersonals, den MMST zur Einschätzung kognitiver Beeinträchtigungen während der Patientenaufnahmen einzusetzen, gering.

Diskussion

Die höhere Prävalenz bestätigt die Notwendigkeit, Patienten mit kognitiven Störungen zu erkennen. Die geringe Bereitschaft, den MMST anzuwenden, legt jedoch nahe, dass zum einen ein kürzeres Instrument verwendet und zum anderen Pflegenden mehr Informationen zu kognitiv beeinträchtigten Patienten vermittelt werden sollten.

[Preoperative cognitive function in very old patients : Influence on the complication rate and length of hospitalization]

BACKGROUND

Gastrointestinal cancer is a frequent diagnosis in older patients. A curative resection, possibly in combination with radiotherapy and/or chemotherapy, is the standard therapy. The advanced age of the patients with an increasing number of comorbidities and often the presence of cognitive impairment represents a high risk for perioperative complications and a longer stay in hospital. The challenge in the clinical routine is to recognize a cognitive impairment in older patients and to prepare these patients for the operative intervention in the best possible way.

OBJECTIVE

This retrospective analysis was carried out to find out whether preoperative cognitive impairment is a prognostic factor for the postoperative outcome.

METHODS

In patients over the age of 75 years who were prepared for abdominal surgery of gastrointestinal cancer in the preoperative consultation, the mini mental state examination (MMSE) and the clock test were carried out. The results of the tests were retrospectively compared with the complication rate and the duration of hospital stay.

RESULTS

Low MMSE values were significantly associated with the complication rate and the development of a severe complication (Clavien-Dindo grade ≥ 3a). A cut-off value of 24 points in the MMSE was predictive for the development of complications and a longer hospital stay. The age of the patients was not associated with the MMSE.

CONCLUSION

Cognitive impairment is an important prognostic factor for the development of perioperative complications and the duration of the hospital stay in patients undergoing extensive abdominal surgery for gastrointestinal cancer. Therefore, a preoperative assessment, for example with the MMSE, is recommended in order to identify high-risk patients.

Elevated heavy metals levels in cognitively impaired patients from Pakistan

The deficit in the visuospatial skills, thinking, learning and memory is termed as cognitive impairment. Human exposure to heavy metals is a potential risk factor for developing cognitive impairment. This study aimed to investigate the possible association between the concentration of heavy metals and the extent of cognitive impairment. Blood samples were subjected to microwave assisted acid digestion and evaluated for metals levels using atomic absorption spectrophotometry. We measured the levels of Cu, Pb, Al, Zn, Cd and Mn in 183 patients diagnosed with cognitive impairment; mild (n = 72), moderate (n = 86) and severe (n = 25) and compared them to age-matched healthy controls (n = 90). Results showed that all the aforementioned elements were significantly higher in cognitively impaired patients and increasing concentration was strongly correlated with increase in severity of the disease. The correlation study has shown that among the studied metals, Al and Cu are strongly associated with the cognitive impairment. This suggests the need for decrease in metal exposure to humans from environment, food and industries.

Predictors of cognitive impairment assessed by Mini Mental State Examination in community-dwelling older adults: relevance of the step test

BACKGROUND

Several predictors of cognitive impairment assessed by Mini Mental State Examination (MMSE) have previously been identified. However, which predictors are the most relevant and what is their effect on MMSE categories remains unclear.

METHODS

Cross-sectional and longitudinal study using data from 1116 older adults (72.6 ± 5.6 years, 579 female), 350 of whom were followed for 7 years. At baseline, the following variables were collected: personal data, marital status, occupation, anthropometric measures, risk factors, previous cardiovascular events, self-rated health and physical activity during the last week. Furthermore, routine laboratory tests, abdominal echography and a step test (with measurement of the time needed to ascend and descend two steps 20 times) were performed. The associations of these variables with cross-sectional cognitive deficit (MMSE < 24) and longitudinal cognitive decline (decrease of MMSE score over 7 years of follow-up) were investigated using logistic regression models.

RESULTS

Cross-sectional cognitive deficit was independently associated with school education ≤ 5 years, prolonged step test duration, having been blue collar or housewife (P ≤ 0.0001 for all) and, with lower significance, with advanced age, previous stroke and poor recent physical activity (P < 0.05). Longitudinal cognitive decline was mainly associated with step test duration (P = 0.0001) and diastolic blood pressure (P = 0.0002). The MMSE categories mostly associated with step test duration were orientation, attention, calculation and language, while memory appeared to be poorly or not affected.

CONCLUSIONS

In our cohort of older adults, step test duration was the most relevant predictor of cognitive impairment.

Agreement and conversion formula between mini-mental state examination and montreal cognitive assessment in an outpatient sample

AIM

To explore the agreement between the mini-mental state examination (MMSE) and montreal cognitive assessment (MoCA) within community dwelling older patients attending an old age psychiatry service and to derive and test a conversion formula between the two scales.

METHODS

Prospective study of consecutive patients attending outpatient services. Both tests were administered by the same researcher on the same day in random order.

RESULTS

The total sample (n = 135) was randomly divided into two groups. One to derive a conversion rule (n = 70), and a second (n = 65) in which this rule was tested. The agreement (Pearson’s r) of MMSE and MoCA was 0.86 (P < 0.001), and Lin’s concordance correlation coefficient (CCC) was 0.57 (95%CI: 0.45-0.66). In the second sample MoCA scores were converted to MMSE scores according to a conversion rule from the first sample which achieved agreement with the original MMSE scores of 0.89 (Pearson’s r, P < 0.001) and CCC of 0.88 (95%CI: 0.82-0.92).

CONCLUSION

Although the two scales overlap considerably, the agreement is modest. The conversion rule derived herein demonstrated promising accuracy and warrants further testing in other populations.

Relationship between glycated hemoglobin A1c and cognitive function in nondemented elderly patients with type 2 diabetes

Elderly patients with type 2 diabetes are at a greater risk for cognitive decline. The purpose of this study was to assess the relationship between the degree of hyperglycemia and cognitive status in nondemented, elderly diabetics. Between Jan 2013 and Dec 2014, 1174 geriatric patients with type 2 diabetes were enrolled in the study (579 males; age ≥ 60 years; from Fuzhou, Fujian, China). Cognitive function was measured with the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). A statistically significant, age-adjusted association was observed between the A1C levels and the scores on two cognitive tests (MMSE and MoCA). Specifically, a 1% higher A1C value was associated with a 0.21-point lower MMSE score (95% CI; compare -0.11 to -0.28; P < 0.0001), as well as a 0.11-point lower MoCA score (95% CI; compare -0.10 to -0.38; P < 0.0001). Higher A1C levels were not significantly associated with lower MMSE and MoCA test scores after adjusting for all variables. No significant correlation was found between the two variables in patients older than 80 years of age (n = 215; OR = 1.019; 95% CI = 0.968 - 1.099; p = 0.251). Evidence strongly suggests that chronic hyperglycemia is associated with a decline in cognitive function in nondemented elderly patients with type 2 diabetes. When cognitive assessments are made, comprehensive factors such as advanced age, education level, duration of diabetes, hypertension and other vascular risks should be taken into account. For older geriatric patients (age ≥ 80 years), there is no significant correlation between A1c levels and cognitive function.