Examining the validity of the Mini-Mental State Examination (MMSE) and its domains using network analysis

BACKGROUND

The Mini-Mental State Examination (MMSE) is the most widely used standardised screener for impairments across a range of cognitive domains. However, the degree to which its domains (orientation, registration, attention, recall, language, and visuospatial) capture cognitive functioning measured using standardised neuropsychological tests is unclear.

METHOD

A longitudinal research design with four biannual assessments over a 6-year period was used with an initial sample of 1037 older adults (aged above 70 years). Participants completed MMSE and neuropsychological tests at each assessment. Network analysis was utilised to investigate unique associations among the MMSE and its domains and neuropsychological test performance at each time point.

RESULTS

The total MMSE and two of its domains, language and recall, were associated with neuropsychological memory performance. The MMSE orientation, registration and visuospatial domains did not have any unique associations with neuropsychological performance. No stable internal interconnections between MMSE domains were found over time. The association of total MMSE as well as its recall domain with neuropsychological memory performance remained very similar over the 6-year period.

CONCLUSIONS

The present study adds evidence to the validity of the MMSE and supports the clinical usage of the MMSE, whereby the total score is used for screening patients with or without cognitive impairments, with repeated administration to monitor cognitive changes over time, to inform intervention. However, the tool is not able to diagnose the cases for changes in specific cognitive domains and as such, should not replace a complete neuropsychological assessment.

The Effect of Adverse Childhood Experiences on ADHD Symptom Reporting, Psychological Symptoms, and Cognitive Performance Among Adult Neuropsychological Referrals

OBJECTIVE

Adverse childhood experiences (ACEs) are early life experiences that influence mental health outcomes, though there are mixed findings reported in relation to attention deficit hyperactivity disorder (ADHD) symptoms. The current study compared adults who experienced ACEs on measures of ADHD symptom reporting, psychological symptoms, and neurocognitive test performance.

METHOD

The sample (n = 115) had mean age of 28.42 (SD = 6.46); educational attainment of 16.47 years (SD = 1.99); and was 35% male/65% female and racially/ethnically diverse. Participants completed measures of ACEs, ADHD symptoms, psychopathology, and perceived stress, as well as neuropsychological tests.

RESULTS

The high ACEs group endorsed higher levels of childhood/adulthood inattentive, impulsive, and hyperactive symptoms, and overall childhood symptoms when compared to the low ACEs group.

CONCLUSIONS

This study provides a more comprehensive understanding of the association between ACEs and cognitive/mental health outcomes. Greater ACEs resulted in higher ADHD symptom reporting but not significantly greater psychological symptoms or worse neurocognitive performance.

Tohoku Medical Megabank Brain Magnetic Resonance Imaging Study: Rationale, Design, and Background

The Tohoku Medical Megabank Brain Magnetic Resonance Imaging Study (TMM Brain MRI Study) was established to collect multimodal information through neuroimaging and neuropsychological assessments to evaluate the cognitive function and mental health of residents who experienced the Great East Japan Earthquake (GEJE) and associated tsunami. The study also aimed to promote advances in personalized healthcare and medicine related to mental health and cognitive function among the general population. We recruited participants for the first (baseline) survey starting in July 2014, enrolling individuals who were participating in either the TMM Community-Based Cohort Study (TMM CommCohort Study) or the TMM Birth and Three-Generation Cohort Study (TMM BirThree Cohort Study). We collected multiple magnetic resonance imaging (MRI) sequences, including 3D T1-weighted sequences, magnetic resonance angiography (MRA), diffusion tensor imaging (DTI), pseudo-continuous arterial spin labeling (pCASL), and three-dimensional fluid-attenuated inversion recovery (FLAIR) sequences. To assess neuropsychological status, we used both questionnaire- and interview-based rating scales. The former assessments included the Tri-axial Coping Scale, Impact of Event Scale in Japanese, Profile of Mood States, and 15-item Depression, Anxiety, and Stress Scale, whereas the latter assessments included the Mini-Mental State Examination, Japanese version. A total of 12,164 individuals were recruited for the first (baseline) survey, including those unable to complete all assessments. In parallel, we returned the MRI results to the participants and subsequently shared the MRI data through the TMM Biobank. At present, the second (first follow-up) survey of the study started in October 2019 is underway. In this study, we established a large and comprehensive database that included robust neuroimaging data as well as psychological and cognitive assessment data. In combination with genomic and omics data already contained in the TMM Biobank database, these data could provide new insights into the relationships of pathological processes with neuropsychological disorders, including age-related cognitive impairment.

Forward and Backward Recalling Sequences in Spatial and Verbal Memory Tasks: What Do We Measure?

There are different views in the literature about the number and inter-relationships of cognitive domains (such as memory and executive function) and a lack of understanding of the cognitive processes underlying these domains. In previous publications, we demonstrated a methodology for formulating and testing cognitive constructs for visuo-spatial and verbal recall tasks, particularly for working memory task difficulty where entropy is found to play a major role. In the present paper, we applied those insights to a new set of such memory tasks, namely, backward recalling block tapping and digit sequences. Once again, we saw clear and strong entropy-based construct specification equations (CSEs) for task difficulty. In fact, the entropy contributions in the CSEs for the different tasks were of similar magnitudes (within the measurement uncertainties), which may indicate a shared factor in what is being measured with both forward and backward sequences, as well as visuo-spatial and verbal memory recalling tasks more generally. On the other hand, the analyses of dimensionality and the larger measurement uncertainties in the CSEs for the backward sequences suggest that caution is needed when attempting to unify a single unidimensional construct based on forward and backward sequences with visuo-spatial and verbal memory tasks.

COGNITO (Computerized assessment of adult information processing): Normative scores for a rural Indian population from the SANSCOG study

INTRODUCTION

Neuropsychological assessments are inexpensive and efficient methods to understand the cognitive abilities of individuals in research studies and clinical settings. Normative scores for such measures are crucial in serving as a reference standard for identifying cognitively healthy and impaired individuals belonging to similar sociodemographic characteristics.

METHODS

Study subjects in rural India recruited into the Srinivaspura Aging, Neuro Senescence and Cognition (SANSCOG) study were administered the COGNITO battery of tests, which traverse cognitive domains of attention, memory, language, and visuospatial abilities. Percentile norms based on age and education stratification were derived for the above cohort.

RESULTS

Percentile norms are commensurate with literacy levels in this population. The percentile scores for the cognitive tests show a decline for the individuals aged 75 years and above indicating lower cognitive functioning in this age group.

DISCUSSION

This is the first-ever study reporting norms for diverse cognitive domains for illiterate, literate, low-literate individuals enrolled in a large-scale community-based cohort study in rural India.

Examining Cognitive Factors for Alzheimer's Disease Progression Using Computational Intelligence

Prognosis of Alzheimer's disease (AD) progression has been recognized as a challenging problem due to the massive numbers of cognitive, and pathological features recorded for patients and controls. While there have been many studies investigated the diagnosis of dementia using pathological characteristics, predicting the advancement of the disease using cognitive elements has not been heavily studied particularly using technologies like artificial intelligence and machine learning. This research aims at evaluating items of the Alzheimer's Disease Assessment Scale-Cognitive 13 (ADAS-Cog-13) test to determine key cognitive items that influence the progression of AD. A methodology that consists of machine learning and feature selection (FS) techniques was designed, implemented, and then tested against real data observations (cases and controls) of the Alzheimer's Disease Neuroimaging Initiative (ADNI) repository with a narrow scope on cognitive items of the ADAS-Cog-13 test. Results obtained by ten-fold cross validation and using dissimilar classification and FS techniques revealed that the decision tree algorithm produced classification models with the best performing results from the cognitive items. For ADAS-Cog-13 test, memory and learning features including word recall, delayed word recall and word recognition were the key items pinpointing to AD advancement. When these three cognitive items are processed excluding demographics by C4.5 algorithm the models derived showed 82.90% accuracy, 87.60% sensitivity and 78.20% specificity.

PASTEC - a prospective, single-center, randomized, cross-over trial of pure physical versus physical plus attentional training in children with cancer

Despite recent improvements in survival rates in children with cancer, long-term toxicities remain a major concern. Physical activity could reduce the impact of long-term sequelae, notably in neuropsychological and physical areas. We report of a randomized trial of pure physical versus physical/attentional training in pediatric oncology patients. Twenty-two patients aged 6-18 y.o. were included, irrespective of their clinical diagnosis or treatment status, stratified by age and randomized 1:1 into pure physical vs. physical/attentional activity arms, with a cross-over at study midpoint. Neurological, motor and neuropsychological assessments were performed at inclusion, start, crossover and end of the program. Feasibility, defined as > 80% patients attending > 80% of sessions, was the primary endpoint. Secondary outcomes were improvements in neuropsychological and motor performance tests. While 68% of patients attended more than 80% of sessions during the pre-crossover phase of the study, this dropped to 36% post-crossover. Our study therefore failed to meet our primary endpoint. Nonetheless, significant improvements in anxiety (p<0.001), emotional control (p = 0.04), organization skills (p = 0.03), as well as motor deficit scores (p = 0.04) were observed. We noted no significant difference between the pure physical and the physical/attentional training arms, or when analyzing subgroups by age or sequence of intervention. We conclude that physical activity has a positive impact on anxiety, emotional and organizational aspects as well as motor deficits. Attendance dropped during the course of the study and motivational interventions should be included in future studies or equivalent programs.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2021.1994677 .

Frequencies and Neuropsychological Characteristics of Errors in the Clock Drawing Test

BACKGROUND

Few studies have investigated associations between types of clock drawing test (CDT) errors and cognitive impairment.

OBJECTIVE

To explore associations of qualitative errors in the CDT with comprehensive neurocognitive assessment scores and clinical diagnosis.

METHODS

Outpatients at a memory clinic were enrolled. Frequencies of errors determined by Cahn's method were explored according to cognitive status (cognitively normal [CN] (n = 279), mild cognitive impairment [MCI] (n = 321), and Alzheimer's disease [AD]) (n = 575). Neuropsychological assessment scores were compared between participants with and without errors.

RESULTS

Stimulus-bound response (SB) was relatively rare (6.8%) in the CN group but was markedly more common in the MCI (23.4%) and AD (33.2%) groups. Conceptual deficit (CD) was found in more than 20%of CN individuals, as well as about 50%of AD patients. Planning deficit (PD) frequencies were relatively similar among the groups. SB in both of CN and MCI individuals, and CD in both of CN and MCI individuals were associated with lower scores in several neuropsychological assessments. Meanwhile, PD was not associated with lower assessment scores in any of CN, MCI, or AD individuals.

CONCLUSION

The frequencies of SB and CD increased from CN, MCI, to AD but showed somewhat different patterns. Both SB and CD were associated with lower cognition in all three cognitive stages.

The Effects of a 5-Year Physical Exercise Intervention with Music in Community- Dwelling Normal Elderly People: The Mihama-Kiho Follow-Up Project

BACKGROUND

We previously reported the enhanced effects of physical exercise when combined with music (ExM) on cognitive function in community-dwelling normal elderly people compared to exercise alone. Following that study, participants voluntarily continued the ExM classes for 5 years.

OBJECTIVE

To identify the effects of a 5-year ExM intervention on cognitive function in normal elderly people.

METHODS

Fifty-four subjects continued the ExM classes once a week for 5 years (ExM group). Thirty-three subjects retired from the ExM class during the 5 years (Retired group). Twenty-one subjects never participated in any intervention over the 5 years (No-exercise group). Cognitive function and ADLs were assessed using neuropsychological batteries and the functional independence measure (FIM), respectively. The voxel-based specific regional analysis system for Alzheimer's disease (VSRAD) was used to investigate medial temporal lobe atrophy.

RESULTS

Analyses of the raw scores after the 5-year intervention showed significant differences between the ExM and No-exercise groups in their MMSE scores, Raven's colored progressive matrices (RCPM) time, logical memory (LM)-I, as well as the total and physical exercise sub-scores of the FIM. Analysis of subjects aged 70- 79 years at the beginning of this project showed significantly quicker performance on the RCPM in the ExM compared to No-exercise groups. The correlation coefficients between the total number of ExM sessions attended and the degree of changes in physical, neuropsychological, and VSRAD scores were significant for RCPM performance time and LM-I scores.

CONCLUSION

Long-term ExM intervention reinforces multifaceted cognitive function in normal elderly people, and is especially beneficial for psychomotor speed.

The Effects of High-Intensity Aerobic Exercise on Cognitive Performance After Stroke: A Pilot Randomised Controlled Trial

Background:

Aerobic exercise is an effective treatment to improve aerobic capacity following stroke and might also improve cognitive impairments in sub-acute stroke survivors. The aim of the study was to assess the effect of high-intensity aerobic exercise on cognitive impairments in sub-acute stroke survivors.

Methods:

A pilot, randomised controlled trial on the effects of aerobic exercise on cognitive impairments of stroke patients in the sub-acute (1-3 months) phase was conducted. Thirty patients with moderate cognitive impairments (maximum score of 5 on at least two items on the cognitive subscales of the Functional Independence Measure [FIM]) were included in the study and randomly assigned to either the intervention group – performing high-intensity aerobic exercise (above 70% of maximum heart rate), or the control group – performing low-intensity aerobic exercise (below 60%). Patients in both groups exercised for 50 min twice a week for 4 weeks. Primary neuropsychological outcome: Trail Making Test B.

Results:

Thirty stroke patients completed the interventions. The results showed that the high-intensity group, compared with the low-intensity group, achieved significant improvements on Trail Making Test B, which assesses processing speed and divided attention (P = .04 after training and P = .01 at follow-up). However, the significant improvements on Trail Making Test B might relate to a ceiling effect in the control group.

Conclusions:

This study does not provide evidence to support that aerobic exercise can improve cognition in stroke survivors, even though significant improvement was revealed on the primary outcome in sub-acute stroke survivors following high-intensity aerobic exercise compared with low-intensity general exercise.

Clinical Findings in a Multicenter MRI Study of Mild TBI

Background: Uncertainty continues to surround mild traumatic brain injury (mTBI) diagnosis, symptoms, prognosis, and outcome due in part to a lack of objective biomarkers of injury and recovery. As mTBI gains recognition as a serious public health epidemic, there is need to identify risk factors, diagnostic tools, and imaging biomarkers to help guide diagnosis and management. Methods: One hundred and eleven patients (15-50 years old) were enrolled acutely after mTBI and followed with up to four standardized serial assessments over 3 months. Each encounter included a clinical exam, neuropsychological assessment, and magnetic resonance imaging (MRI). Chi-square and linear mixed models were used to assess changes over time and determine potential biomarkers of mTBI severity and outcome. Results: The symptoms most frequently endorsed after mTBI were headache (91%), not feeling right (89%), fatigue (86%), and feeling slowed down (84%). Of the 104 mTBI patients with a processed MRI scan, 28 (27%) subjects had white matter changes which were deemed unrelated to age, and 26 of these findings were deemed unrelated to acute trauma. Of the neuropsychological assessments tested, 5- and 6-Digit Backward Recall, the modified Balance Error Scoring System (BESS), and Immediate 5-Word Recall significantly improved longitudinally in mTBI subjects and differentiated between mTBI subjects and controls. Female sex was found to increase symptom severity scores (SSS) at every time point. Age ≥ 25 years was correlated with increased SSS. Subjects aged ≥ 25 also did not improve longitudinally on 5-Digit Backward Recall, Immediate 5-Word Recall, or Single-Leg Stance of the BESS, whereas subjects < 25 years improved significantly. Patients who reported personal history of depression, anxiety, or other psychiatric disorder had higher SSS at each time point. Conclusions: The results of this study show that 5- and 6-Digit Backward Recall, the modified BESS, and Immediate 5-Word Recall should be considered useful in demonstrating cognitive and vestibular improvement during the mTBI recovery process. Clinicians should take female sex, older age, and history of psychiatric disorder into account when managing mTBI patients. Further study is necessary to determine the true prevalence of white matter changes in people with mTBI.

Maximum gait speed is associated with a wide range of cognitive functions in Japanese older adults with a Clinical Dementia Rating of 0.5

AIM

Physical and cognitive functions are mutually associated. However, it is unknown which markers of physical functions or body composition are most strongly associated with cognition. Here, we explored the association between body composition/physical performance and comprehensive neuropsychological assessments in an effort to identify reliable markers of cognition among factors in body composition/physical performance, including both usual and maximum gait speeds.

METHODS

We examined a total of 161 Japanese individuals (71 men, 90 women; aged 76.3 ± 7.2 years) with a Clinical Dementia Rating of 0.5 and a Mini-Mental State Examination score >24. A battery of neuropsychological assessments, physical functional assessments and measurements of body composition was carried out. We conducted a multiple regression analysis to investigate the associations between cognitive performance and the factors in body composition and physical performance with adjustments for age, sex, and number of school years.

RESULTS

Maximum gait speed was the factor most widely associated with cognitive performance among the factors of body composition and physical performance.

CONCLUSION

Maximum gait speed might be the best marker for cognition in this population of older individuals. Geriatr Gerontol Int 2018; 18: 1323-1329.

Physical Exercise with Music Maintains Activities of Daily Living in Patients with Dementia: Mihama-Kiho Project Part 21

BACKGROUND

Recent studies suggest that combined non-pharmacological interventions are more beneficial than single interventions for primary and secondary prevention of dementia. We previously reported enhanced effects of physical exercise with music (ExM) on cognitive function in normal elderly people compared to exercise alone.

OBJECTIVE

To identify if ExM improves cognitive function and activities of daily livings (ADLs) in dementia patients over cognitive stimulation (CS).

METHODS

We enrolled 85 patients with mild to moderate dementia. Forty-three subjects performed ExM developed by the Yamaha Music Foundation, and 42 subjects performed cognitive stimulation using portable game consoles and drills involving easy calculations, mazes, and mistake-searching in pictures. Interventions were performed once a week for 40 minutes. Before and after the six-month intervention, patients were assessed using neuropsychological batteries, and ADLs were assessed by patients' caregivers using the functional independence measure (FIM). Voxel-based specific regional analysis system for Alzheimer's disease (VSRAD) was used to assess medial temporal lobe atrophy.

RESULTS

Twenty-three subjects dropped out during the intervention. Thirty-one patients from each group were analyzed. Post-intervention, both groups showed significantly improved visuospatial function. Significant benefits were observed in psychomotor speed or memory in the ExM or CS groups, respectively. FIM scores, reflecting ADLs, and VSRAD scores were significantly preserved in the ExM group, but significantly worsened in the CS group.

CONCLUSIONS

ExM produced greater positive effects on cognitive function and ADLs in patients with mild to moderate dementia than CS, excluding memory. Optimal interventions for dementia will likely be achieved by combining ExMand CS.

Cognitive assessments for the early diagnosis of dementia after stroke

The early detection of poststroke dementia (PSD) is important for medical practitioners to customize patient treatment programs based on cognitive consequences and disease severity progression. The aim is to diagnose and detect brain degenerative disorders as early as possible to help stroke survivors obtain early treatment benefits before significant mental impairment occurs. Neuropsychological assessments are widely used to assess cognitive decline following a stroke diagnosis. This study reviews the function of the available neuropsychological assessments in the early detection of PSD, particularly vascular dementia (VaD). The review starts from cognitive impairment and dementia prevalence, followed by PSD types and the cognitive spectrum. Finally, the most usable neuropsychological assessments to detect VaD were identified. This study was performed through a PubMed and ScienceDirect database search spanning the last 10 years with the following keywords: "post-stroke"; "dementia"; "neuro-psychological"; and "assessments". This study focuses on assessing VaD patients on the basis of their stroke risk factors and cognitive function within the first 3 months after stroke onset. The search strategy yielded 535 articles. After application of inclusion and exclusion criteria, only five articles were considered. A manual search was performed and yielded 14 articles. Twelve articles were included in the study design and seven articles were associated with early dementia detection. This review may provide a means to identify the role of neuropsychological assessments as early PSD detection tests.