Cognitive assessment tools in Asia: a systematic review

Utility of the Japanese version of the Clinical Dementia Rating® plus National Alzheimer's Coordinating Centre Behaviour and Language Domains for sporadic cases of frontotemporal dementia in Japan

BACKGROUND

We aimed to validate the Clinical Dementia Rating (CDR®) dementia staging instrument plus the National Alzheimer's Coordinating Centre Behaviour and Language Domains (CDR® plus NACC FTLD) for use in clinical settings in Japan and in the Japanese language.

METHODS

This prospective observational study enrolled 29 patients with frontotemporal dementia (FTD) and 21 patients with Alzheimer's disease (AD) dementia from the Departments of Psychiatry at Osaka University Hospital and Asakayama General Hospital and the Brain Function Centre at Nippon Life Hospital. CDR® plus NACC FTLD, CDR®, Mini-Mental State Examination (MMSE), Western Aphasia Battery (WAB), Neuropsychiatric Inventory-plus (NPI-plus), Stereotypy Rating Inventory (SRI), and frontal behavioural symptom scores obtained from items of NPI-plus and SRI, were conducted to assess inter- and intra-rater reliability, validity, and responsiveness. We performed receiver operating characteristic (ROC) curve analysis to evaluate the discriminating power of the Behaviour/Comportment/Personality (BEHAV) and Language (LANG) domains of the CDR® plus NACC FTLD and the MEMORY domain of the CDR® in patients AD dementia and FTD.

RESULTS

The CDR® plus NACC FTLD showed good inter- and intra-rater reliabilities. In patients with FTD, the BEHAV domain of the CDR® plus NACC FTLD was significantly correlated with all clinical measures except for the SRI total score, while the LANG domain of the CDR® plus NACC FTLD was significantly correlated with the MMSE and the WAB-Aphasia quotient. In addition, the CDR® plus NACC FTLD sum of boxes significantly changed after 6 months and after 1 year. ROC curve analysis showed that the BEHAV and LANG domains of the CDR® plus NACC FTLD distinguished between patients with AD dementia and FTD better than the MEMORY domain of the CDR®.

CONCLUSIONS

This study validated the Japanese version of the CDR® plus NACC FTLD with good reliability, validity, and responsiveness.

Comparing four frailty assessment tools against seven-year mortality in the Malaysian elders longitudinal research study

AIM

Several frailty assessment tools are currently used in clinics and research, however, there appears to be a lack of head-to-head comparisons between these tools among older adults in developing countries. This study compared the Cardiovascular Health Study, Study of Osteoporotic Fractures, the Tilburg Frailty Indicator and the Canadian Study of Health and Aging frailty assessment tools and evaluated performance of these individual frailty assessment tools with mortality.

METHODS

This prospective cohort study utilized stratified simple random sampling to recruit 1614 participants from the Malaysian Elders Longitudinal Research aged above 55 years within the Klang Valley region from 2013 to 2015. Individual items for the frailty tools, alongside baseline physical and cognitive measures were extracted from the initial survey. Mortality data up to 31 December 2020 were obtained through data linkage from the death registry data obtained from the Malaysian National Registration Department.

RESULTS

Data were available for over 1609 participants, age (68.92 ± 7.52) years and 57 % women, during recruitment. Mortality data revealed 13.4 % had died as of 31 December 2020. Five to 25 % of our study population fulfilled the criteria for frailty using all four frailty tools. This study found an increased risk of mortality with frailty following adjustments for potential factors of falls, total number of illnesses and cognitive impairment, alongside moderate to strong correlation and agreement between frailty tools.

CONCLUSION

Frailty was associated with increased mortality. All four frailty assessment tools can be used to assess frailty within the Malaysian older adult population. The four available tools, however, may not be interchangeable.

Quantitative electroencephalography (qEEG), apolipoprotein A-I (APOA-I), and apolipoprotein epsilon 4 (APOE ɛ4) alleles for the diagnosis of mild cognitive impairment and Alzheimer's disease

INTRODUCTION

Alzheimer's disease (AD) is the most common type of dementia. Amnestic mild cognitive impairment (aMCI), a pre-dementia stage is an important stage for early diagnosis and intervention. This study aimed to investigate the diagnostic value of qEEG, APOA-I, and APOE ɛ4 allele in aMCI and AD patients and found the correlation between qEEG (Delta + Theta)/(Alpha + Beta) ratio (DTABR) and different cognitive domains.

METHODS

All participants were divided into three groups: normal controls (NCs), aMCI, and AD, and all received quantitative electroencephalography (qEEG), neuropsychological scale assessment, apolipoprotein epsilon 4 (APOE ɛ4) alleles, and various blood lipid indicators. Different statistical methods were used for different data.

RESULTS

The cognitive domains except executive ability were all negatively correlated with DTABR in different brain regions while executive ability was positively correlated with DTABR in several brain regions, although without statistical significance. The consequences confirmed that the DTABR of each brain area were related to MMSE, MoCA, instantaneous memory, and the language ability (p < 0.05), and the DTABR in the occipital area was relevant to all cognitive domains (p < 0.01) except executive function (p = 0.272). Also, occipital DTABR was most correlated with language domain when tested by VFT with a moderate level (r = 0.596, p < 0.001). There were significant differences in T3, T5, and P3 DTABR between both AD and NC and aMCI and NCs. As for aMCI diagnosis, the maximum AUC was achieved when using T3 combined with APOA-I and APOE ε4 (0.855) and the maximum AUC was achieved when using T5 combined with APOA-I and APOE ε4 (0.889) for AD diagnosis.

CONCLUSION

These findings highlight that APOA-I, APOE ɛ4, and qEEG play an important role in aMCI and AD diagnosis. During AD continuum, qEEG DTABR should be taken into consideration for the early detection of AD risk.

Modified Brief Cognitive Screening Battery - Indonesian Version: cross-cultural adaptation and normative data based on demographic factors in North Sumatra, Indonesia

Introduction

Key component of early detection of dementia is a brief and culturally appropriate cognitive screening tool. This study aimed to perform a cultural adaptation of the Brief Cognitive Screening Battery (BCSB) and to obtain normative data from the older adult population.

Methods

Cross-cultural adaptation process to develop BCSB-INA was performed. This was followed by a feasibility study from community dwelling older adults from several urban and rural areas in North Sumatra, Indonesia.

Results

The BCSB-INA was generally well understood and showed not much discrepancy in translation from the original version. There were differences in semantic and phonemic fluency and CDT based on years of education, but no difference was found on other domain, including the delayed recall of the FMT. The battery was more influenced by age than education.

Discussion

The BCSB-INA is culturally appropriate and feasible to be used in population with heterogenous educational background in Indonesia.

A detection model for cognitive dysfunction based on volatile organic compounds from a large Chinese community cohort

INTRODUCTION

We explored whether volatile organic compound (VOC) detection can serve as a screening tool to distinguish cognitive dysfunction (CD) from cognitively normal (CN) individuals.

METHODS

The cognitive function of 1467 participants was assessed and their VOCs were detected. Six machine learning algorithms were conducted and the performance was determined. The plasma neurofilament light chain (NfL) was measured.

RESULTS

Distinguished VOC patterns existed between CD and CN groups. The CD detection model showed good accuracy with an area under the receiver-operating characteristic curve (AUC) of 0.876. In addition, we found that 10 VOC ions showed significant differences between CD and CN individuals (p < 0.05); three VOCs were significantly related to plasma NfL (p < 0.005). Moreover, a combination of VOCs with NfL showed the best discriminating power (AUC = 0.877).

DISCUSSION

Detection of VOCs from exhaled breath samples has the potential to provide a novel solution for the dilemma of CD screening.

A Correlative Relationship Between Heart Failure and Cognitive Impairment: A Narrative Review

Heart failure (HF) is a chronic condition affecting millions of people worldwide. While the cardinal manifestations of HF are related to the cardiovascular system, it has become progressively evident that mild cognitive impairment (MCI) is also a significant complication of the disease. In fact, a significant number of patients with HF may experience MCI, which can manifest as deficits in attention, memory, executive function, and processing speed. The mechanisms responsible for cognitive dysfunction in HF are intricate and multifactorial. Possible factors contributing to this condition include decreased cerebral blood flow, thrombogenicity associated with HF, systemic inflammatory conditions, and proteotoxicity. MCI in HF has significant clinical implications, as it is linked to poorer quality of life, increased morbidity and mortality, and higher healthcare costs. Additionally, MCI can disrupt self-care behaviors, adherence to medication, and decision-making abilities, all of which are crucial for effectively managing HF. However, there is currently no gold standard diagnostic tool and follow-up strategy for MCI in HF patients. There is limited knowledge on the prevention and treatment of MCI. In conclusion, MCI is a common and clinically important complication of HF. Considering the substantial influence of MCI on patient outcomes, it is imperative for healthcare providers to be cognizant of this issue and integrate cognitive screening and management strategies into the care of HF patients.

Cognitive decline assessment in speakers of understudied languages

Projected trends in population aging have forecasted a massive increase in the number of people with dementia, in particular in sub-Saharan Africa and the Middle East and North Africa (MENA) region. Cognitive decline is a significant marker for dementia, typically assessed with standardized neuropsychological tools that have been validated in some well-researched languages such as English. However, with the existing language diversity, current tools cannot cater to speakers of understudied languages, putting these populations at a disadvantage when it comes to access to early and accurate diagnosis of dementia. Here, we shed light on the detrimental impact of this language gap in the context of the MENA region, highlighting inadequate tools and an unacceptable lack of expertise for a MENA population of a half billion people. Our perspective calls for more research to unravel the exact impact of the language gap on the quality of cognitive decline assessment in speakers of understudied languages.

Highlights

Cognitive decline is a marker for dementia, assessed with neuropsychological tests.There is a lack of culturally valid tests for speakers of understudied languages.For example, suboptimal cognitive tests are used in the Middle East and North Africa region.Linguistic diversity should be considered in the development of cognitive tests.

Normative Scores on the Norwegian Version of the Mini-Mental State Examination

BACKGROUND

The Mini-Mental State Examination (MMSE), a simple test for measuring global cognitive function, is frequently used to evaluate cognition in older adults. To decide whether a score on the test indicates a significant deviation from the mean score, normative scores should be defined. Moreover, because the test may vary depending on its translation and cultural differences, normative scores should be established for national versions of the MMSE.

OBJECTIVE

We aimed to examine normative scores for the third Norwegian version of the MMSE.

METHODS

We used data from two sources: the Norwegian Registry of Persons Assessed for Cognitive Symptoms (NorCog) and the Trøndelag Health Study (HUNT). After persons with dementia, mild cognitive impairment, and disorders that may cause cognitive impairment were excluded, the sample contained 1,050 cognitively healthy persons, 860 from NorCog, and 190 from HUNT, whose data we subjected to regression analyses.

RESULTS

The normative MMSE score varied from 25 to 29, depending on years of education and age. More years of education and younger age were associated with higher MMSE scores, and years of education was the strongest predictor.

CONCLUSION

Mean normative MMSE scores depend on test takers' years of education and age, with level of education being the strongest predictor.

Informant-based screening tools for dementia: an overview of systematic reviews

BACKGROUND

Informant-based questionnaires may have utility for cognitive impairment or dementia screening. Reviews describing the accuracy of respective questionnaires are available, but their focus on individual questionnaires precludes comparisons across tools. We conducted an overview of systematic reviews to assess the comparative accuracy of informant questionnaires and identify areas where evidence is lacking.

METHODS

We searched six databases to identify systematic reviews describing diagnostic test accuracy of informant questionnaires for cognitive impairment or dementia. We pooled sensitivity and specificity data for each questionnaire and used network approaches to compare accuracy estimates across the differing tests. We used grading of recommendations, assessment, development and evaluation (GRADE) to evaluate the overall certainty of evidence. Finally, we created an evidence 'heat-map', describing the availability of accurate data for individual tests in different populations and settings.

RESULTS

We identified 25 reviews, consisting of 93 studies and 13 informant questionnaires. Pooled analysis (37 studies; 11 052 participants) ranked the eight-item interview to ascertain dementia (AD8) highest for sensitivity [90%; 95% credible intervals (CrI) = 82-95; 'best-test' probability = 36]; while the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) was most specific (81%; 95% CrI = 66-90; 'best-test' probability = 29%). GRADE-based evaluation of evidence suggested certainty was 'low' overall. Our heat-map indicated that only AD8 and IQCODE have been extensively evaluated and most studies have been in the secondary care settings.

CONCLUSIONS

AD8 and IQCODE appear to be valid questionnaires for cognitive impairment or dementia assessment. Other available informant-based cognitive screening questionnaires lack evidence to justify their use at present. Evidence on the accuracy of available tools in primary care settings and with specific populations is required.

Is vitamin D supplementation of potential benefit for community-living people with Alzheimer's disease?

BACKGROUND

Vitamin D is associated not only with effects on calcium and bone metabolisms but also with many chronic diseases. Low vitamin D levels in patients with Alzheimer's disease have been widely reported in the literature.

AIM

The purpose of this study was to critically review the potential benefit of vitamin D supplementation in individuals with Alzheimer's disease living in the community.

METHODS

A systematic literature search was conducted in PubMed, CINAHL, EMBASE and the Cochrane Library for papers published 2011-2018.

RESULTS

Seven papers were selected, consisting of one clinical trial, five cohort studies and one systematic review. Studies showed an association only between vitamin D deficiency and lower attention in older people. None of the reviewed studies provided evidence of a positive impact of vitamin D supplementation on cognitive function in older people with Alzheimer's disease.

CONCLUSION

There was no evidence that vitamin D supplementation has a direct benefit for Alzheimer's disease. The review synthesised the existing body of knowledge and concluded that optimum levels of vitamin D (neither too low nor too high) do appear to have positive effects on patient outcomes and quality of life. It is still unclear why vitamin D intake is inadequate as people age. Further research is needed to clarify vitamin-D-related aspects of Alzheimer's disease.

MoCA in five Indian languages: A brief screening tool to diagnose dementia and MCI in a linguistically diverse setting

INTRODUCTION AND OBJECTIVES

Early dementia diagnosis in low and middle-income countries (LMIC) is challenging due to limited availability of brief, culturally appropriate, and psychometrically validated tests. Montreal Cognitive Assessment (MoCA) is one of the most widely used cognitive screening tests in primary and secondary care globally. In the current study, we adapted and validated MoCA in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam) and determined the optimal cut-off points that correspond to screening for clinical diagnosis of dementia and MCI.

METHODS

A systematic process of adaptation and modifications of MoCA was fulfilled. A total of 446 participants: 214 controls, 102 dementia, and 130 MCI were recruited across six centers.

RESULTS

Across five languages, the area under the curve for diagnosis of dementia varied from 0.89 to 0.98 and MCI varied from 0.73 to 0.96. The sensitivity, specificity and optimum cut-off scores were established separately for five Indian languages.

CONCLUSIONS

The Indian adapted MoCA is standardized and validated in five Indian languages for early diagnosis of dementia and MCI in a linguistically and culturally diverse population.

Early predictors of brain injury in patients with acute carbon monoxide poisoning and the neuroprotection of mild hypothermia

INTRODUCTION

Carbon monoxide (CO) poisoning can cause serious neurological sequelae. However, there is neither effective treatment strategy nor reliable indicators to determine the prognosis of patients with CO poisoning. The present study aimed to observe the changes of neurological function score, disease severity score, cerebral oxygen utilization (O₂UCc), bispectral (BIS) index and neuron-specific enolase (NSE) concentration, and to elucidate the clinical significance of these potential indicators and the neuroprotective effect of mild hypothermia on brain injury in patients with severe acute CO poisoning.

MATERIALS AND METHODS

A total of 277 patients with acute severe CO poisoning from 2013 to 2018 were enrolled in our hospital. Patients were divided into three groups according to their body temperature on the day of admission and their willingness to treat: a fever group (n = 78), a normal temperature group (NT group, n = 113), and a mild hypothermia group (MH group, n = 86). All patients were given hyperbaric oxygen therapy, while those in the MH group received additional mild hypothermia treatment. The severity of the disease, the neurobehavioral status, the incidence of delayed encephalopathy after acute carbon monoxide poisoning (DEACMP), and other indicators including BIS, O₂UCc, NSE were further evaluated in all patients at given time-points.

RESULTS

Mild hypothermia therapy improved the prognosis of patients with CO poisoning, significantly decreased the value of O₂UCc and NSE, and up-regulated BIS. The incidence of DEACMP at 6 months was 27% in the fever group, 23% in the NT group, and 8% in the MH group. The values of Glasgow-Pittsburgh coma scale (G-P score), BIS index and NSE were closely related to the occurrence of DEACMP, the cutoff values were 12.41, 52.17 and 35.20 ng/mL, and the sensitivity and specificity were 79.3%, 77.6%, 79.3% and 67.6%, 89.5%, 88.6% in the receiver operating characteristic curve (ROC), respectively.

CONCLUSIONS

Early mild hypothermia treatment could significantly reduce the severity of brain injury after CO poisoning, and might be further popularized in clinic. G-P scores, NSE and BIS index can be regarded as the prediction indicators in the occurrence and development of DEACMP.

CLINICAL TRIAL REGISTRATION

The study protocol was granted from Qingdao University Research Ethics Committee (Clinical trial registry and ethical approval number: QD81571283).

Trajectories of Mini-Mental State Examination Scores over the Lifespan in General Populations: A Systematic Review and Meta-Regression Analysis

Objectives: Over the lifespan cumulative changes to the brain lead to cognitive decline and eventually to dementia in 20-25% of adults 85 years and older. A commonly used screening tool for cognitive function is the Standard 30 point Mini-Mental State Examination (MMSE). Though the MMSE is used to screen for dementia, little is known about the changes in scores over the lifespan in general populations.Method: A systematic search was conducted using Cochrane, EMBASE, MEDLINE and PsycINFO for articles published from January 1, 2007 to May 25, 2017. Articles were included if they had a longitudinal design reporting at least two MMSE scores. A mixed-effect meta-regression analysis was conducted to examine the influence of age on MMSE score followed by a change-point regression analysis determining the age at which MMSE declines.Results: 45 articles including 58,939 individuals (age range 18-108 years, 61.2% female) summarized 222 MMSE point estimates from 35 cohorts. The meta-regression demonstrated a significant decrease in MMSE scores with higher age (regression coefficient of age: -0.10 (Confidence Interval (CI) -0.15, -0.05)). The average annual decline in MMSE scores identified by the change-point analysis at the age of 41 years and 84 years were -0.04 (95% CI: -0.05, -0.03) and -0.53 (95% CI: -0.55, -0.50), respectively.Conclusions: Between the age of 29 and 105 years MMSE scores decline, with the highest decline between age 84 and 105 years.Clinical Implementations: The use of MMSE should be restricted to higher age categories in aging general populations.

Cognitive Impairment in Heart Failure: Landscape, Challenges, and Future Directions

Heart failure (HF) is a major global healthcare problem accounting for substantial deterioration of prognosis. As a complex clinical syndrome, HF often coexists with multi-comorbidities of which cognitive impairment (CI) is particularly important. CI is increasing in prevalence among patients with HF and is present in around 40%, even up to 60%, of elderly patients with HF. As a potent and independent prognostic factor, CI significantly increases the hospitalization and mortality and decreases quality of life in patients with HF. There has been a growing awareness of the complex bidirectional interaction between HF and CI as it shares a number of common pathophysiological pathways including reduced cerebral blood flow, inflammation, and neurohumoral activations. Research that focus on the precise mechanism for CI in HF is still ever insufficient. As the tremendous adverse consequences of CI in HF, effective early diagnosis of CI in HF and interventions for these patients may halt disease progression and improve prognosis. The current clinical guidelines in HF have begun to emphasize the importance of CI. However, nearly half of CI in HF is underdiagnosed, and few recommendations are available to guide clinicians about how to approach CI in patients with HF. This review aims to synthesize knowledge about the link between HF and cognitive dysfunction, issues pertaining to screening, diagnosis and management of CI in patients with HF, and emerging therapies for prevention. Based on data from current studies, critical gaps in knowledge of CI in HF are identified, and future research directions to guide the field forward are proposed.

Cultural adaptation of Alzheimer's disease assessment scale-cognitive subscale for use in India and validation of the Tamil version for South Indian population

OBJECTIVE

Currently no standardized tools are available in the Indian languages to assess changes in cognition. Our objectives are to culturally adapt the Alzheimer's disease Assessment Scale-Cognitive Subscale (ADAS-Cog) for use in India and to validate the Tamil version in an urban Tamil-speaking older adult population.

METHODS

Two panels of key stakeholders and a series of qualitative interviews informed the cultural and linguistic adaptation of the ADAS-Cog-Tamil. Issues related to levels of literacy were considered during the adaptation. Validation of the ADAS-Cog-Tamil was completed with 107 participants - 54 cases with a confirmed diagnosis of mild-moderate dementia, and 53 age, gender and education matched controls. Concurrent validity was examined with the Vellore Screening Instrument for Dementia (VSID) in Tamil. Internal consistency using Cronbach's alpha, sensitivity and specificity data using the Area under the Receiver Operating Characteristics (AUROC) curve values were computed. Inter-rater reliability was established in a subsample.

RESULTS

The ADAS-Cog-Tamil shows good internal consistency (α = 0.91), inter-rater reliability and concurrent validity (with VSID-Patient version: r = -0.84 and with VSID-Caregiver version: r = -0.79). A cut-off score of 13, has a specificity of 89% and sensitivity of 90% for the diagnosis of dementia.

CONCLUSION

ADAS-Cog-Tamil, derived from a rigorous, replicable linguistic and cultural adaptation process involving service users and experts, shows good psychometric properties despite the limitations of the study. It shows potential for use in clinical settings with urban Tamil speaking populations. The English version of the tool derived from the cultural adaptation process could be used for further linguistic adaptation across South Asia.

Prevalence and Associated Risk Factors of Cognitive Frailty: A Systematic Review and Meta-Analysis

Objective

Currently, the prevalence of CF (Cognitive Frailty) is not very clear, and the relationship between CF and its associated risk factors has not been accurately evaluated. Therefore, it is necessary to conduct a systematic review and meta-analysis further to understand CF's prevalence and associated factors.

Methods

Embase, PubMed, Web of Science, Ovid, and Cochrane were systematically searched for articles exploring the prevalence of CF, the deadline of searching date was up to March 2021. For the prevalence of CF, the events of CF and the total number of patients in every included study were extracted to estimate the prevalence of CF. For associated factors of CF, Odds Ratios (ORs) with (corresponding) 95% confidence intervals (CIs) were used for estimations.

Results

Firstly, the estimated prevalence of CF I (Cognitive Frailty in the model I) was 16%, 95% CI (0.13–0.19), and the estimated prevalence of CF II (Cognitive Frailty in model II) was 6%, 95% CI (0.05–0.07). Secondly, both lower engagement in activities and age were calculated to be independent risk factors of CF, and the OR (95% CI) was 3.31 (2.28–4.81) and 1.10 (1.04–1.16), respectively. Finally, depression was also a prominent risk factor of CF, with the overall OR (95% CI) as 1.57 (1.32–1.87).

Conclusion

CF was a high prevalence in community older. The various assessment scales and the different cutoff values of diagnostic criteria would affect the prevalence of CF. Lower engagement in activities, age, and depression was the risky factor of CF.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42019121369.

Evaluation of Available Cognitive Tools Used to Measure Mild Cognitive Decline: A Scoping Review

Cognitive decline is a broad syndrome ranging from non-pathological/age-associated cognitive decline to pathological dementia. Mild cognitive impairment MCI) is defined as the stage of cognition that falls between normal ageing and dementia. Studies have found that early lifestyle interventions for MCI may delay its pathological progression. Hence, this review aims to determine the most efficient cognitive tools to discriminate mild cognitive decline in its early stages. After a systematic search of five online databases, a total of 52 different cognitive tools were identified. The performance of each tool was assessed by its psychometric properties, administration time and delivery method. The Montreal Cognitive Assessment (MoCA, n = 15), the Mini-Mental State Examination (MMSE, n = 14) and the Clock Drawing Test (CDT, n = 4) were most frequently cited in the literature. The preferable tools with all-round performance are the Six-item Cognitive Impairment Test (6CIT), MoCA (with the cut-offs of ≤24/22/19/15.5), MMSE (with the cut-off of ≤26) and the Hong Kong Brief Cognitive Test (HKBC). In addition, SAGE is recommended for a self-completed survey setting whilst a 4-point CDT is quick and easy to be added into other cognitive assessments. However, most tools were affected by age and education levels. Furthermore, optimal cut-off points need to be cautiously chosen while screening for MCI among different populations.

Short daytime napping reduces the risk of cognitive decline in community-dwelling older adults: a 5-year longitudinal study

BACKGROUND

Beneficial effects of napping on cognition have been suggested in cross-sectional studies. This study aimed to clarify longitudinal associations between cognitive decline and sleep characteristics, particularly daytime napping, over a 5-year period in older adults.

METHODS

Study participants were 389 community-dwelling individuals aged ≥65 years living in Ojiya City, Niigata, Japan. Baseline and follow-up examinations were conducted in 2011-2013 and 2016-2018, respectively. Trained nurses visited and interviewed participants to collect the following information at baseline and follow-up: demographic characteristics, disease history, lifestyle habits including bedtime, sleeping hours, and daytime nap duration, and cognitive function. The assessment of cognitive function was performed using the revised Hasegawa's dementia scale (HDS-R), with cognitive decline defined as a change in the HDS-R of ≤ - 3 over 5 years. Odds ratios (ORs) for cognitive decline were calculated using multiple logistic regression analysis.

RESULTS

Mean age of participants was 74.6 years (SD 6.4), and the cumulative incidence of cognitive decline was 106/389 (27.3%). The adjusted OR for 1-29 min daytime napping was significantly lower compared to that for no napping (OR = 0.47, 95%CI: 0.23-0.96). Earlier bedtime was associated with cognitive decline (adjusted P for trend = 0.0480).

CONCLUSION

Short daytime napping (< 30 min) reduces the risk of cognitive decline over 5 years for community-dwelling older people. A future study will be necessary to confirm the effect of short napping on the reduction of risk for clinically diagnosed dementia.

Current Update on the Clinical Utility of MMSE and MoCA for Stroke Patients in Asia: A Systematic Review

Objective: Primary care clinicians in Asia employed the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) to aid dementia diagnosis post-stroke. Recent studies questioned their clinical utility in stroke settings for relying on verbal abilities and education level, as well as lack of consideration for aphasia and neglect. We aimed to review the clinical utility of the MMSE and MoCA for stroke patients in Asia and provide recommendations for clinical practice. Methods: PubMed, Scopus, Web of Science, and Science Direct were searched for relevant articles. Included studies were assessed for risk of bias. RevMan 5.4 was used for data synthesis (sensitivity and specificity) and covariates were identified. Results: Among the 48 full-text articles reviewed, 11 studies were included with 3735 total subjects; of these studies, 7 (77%) were conducted in China, 3 (27%) in Singapore, and 1 (9%) in South Korea. Both the MMSE and MoCA generally showed adequate sensitivity and specificity. Education was identified as a covariate that significantly affected detection accuracy. Due to heterogeneity in cutoff scores, methodologies, and languages, it was not feasible to suggest a single cutoff score. One additional point is recommended for MoCA for patients with <6 years of education. Conclusion: Clinicians in Asia are strongly recommended to consider the education level of stroke patients when interpreting the results of the MMSE and MoCA. Further studies in other Asian countries are needed to understand their clinical value in stroke settings.

Diagnostic accuracy of dementia screening tools in the Chinese population: a systematic review and meta-analysis of 167 diagnostic studies

BACKGROUND

The rate of undetected dementia is high in China. However, the performance of dementia screening tools may differ in the Chinese population due to the lower education level and cultural diversity. This study aimed to evaluate the diagnostic accuracy of dementia screening tools in the Chinese population.

METHODS

Eleven electronic databases were searched for studies evaluating the diagnostic accuracy of dementia screening tools in older Chinese adults. The overall diagnostic accuracy was estimated using bivariate random-effects models, and the area under the summary receiver operating characteristic curve was presented.

RESULTS

One hundred sixty-seven studies including 81 screening tools were identified. Only 134 studies qualified for the meta-analysis. The Mini-Mental State Examination (MMSE) was the most commonly studied tool, with a combined sensitivity (SENS) and specificity (SPEC) of 0.87 (95%CI 0.85-0.90) and 0.89 (95%CI 0.86-0.91), respectively. The Addenbrooke's Cognitive Examination-Revised (ACE-R) (SENS: 0.96, 95%CI 0.89-0.99; SPEC: 0.96, 95%CI 0.89-0.98) and Montreal Cognitive Assessment (MoCA) (SENS: 0.93, 95%CI 0.88-0.96; SPEC: 0.90, 95%CI 0.86-0.93) showed the highest performance. The General Practitioner Assessment of Cognition (GPCOG), Hasegawa's Dementia Scale and Cognitive Abilities Screening Instrument had performances comparable to that of the MMSE. The cut-off scores ranged widely across studies, especially for the MMSE (range: 15-27) and MoCA (range: 14-26).

CONCLUSIONS

A number of dementia screening tools were validated in the Chinese population after cultural and linguistical adaptations. The ACE-R and MoCA had the best diagnostic accuracy, whereas the GPCOG, with an administration time < 5 minutes, could be considered as a rapid screening tool.

Prevalence and Factors Associated with Falls among Older Outpatients

Falls in older people are a major public health issue, as they are associated with increased risks of morbidity and mortality. This study aims to investigate the prevalence and factors associated with falls among older outpatients. A cross-sectional study was conducted in 539 outpatients aged 60 and over at the National Geriatric Hospital, Hanoi, Vietnam. Falls and their associated factors were analyzed by multivariable logistic regression. The prevalence of falls was 23.7% (single fall 17.9%, recurrent falls 5.8%). The majority of falls occurred at home (69.6%) and were caused by a slippery floor (51.6%). After falling, most patients sustained physical injuries (65.6%); notably, women suffered more severe injuries than men. Alcohol consumption, using psychotropic medications, having three or more comorbidities, hypertension, COPD, urinary incontinence, frailty, fear of falling, ADL/IADL limitation, slow walking speed and mobility impairment were significantly associated with falls. Overall, the data indicated that falls were prevalent among older outpatients. Behavior factors, comorbidities, geriatric syndromes and physical function were substantially associated with falls, suggesting that most falls are preventable. Further longitudinal studies of longer periods are needed to comprehensively investigate the risk factors for falls.

Bloodstream infections in the elderly: what is the real goal?

Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.

Consistency and applicability of different brief screen instrument of cognitive function in elderly population

BACKGROUND

Screening for cognitive impairment (CI) is often hampered by lack of consensus as to which screening instrument to use. The aim is to assess the consistence and applicability of different CI screening tools.

METHOD

In a cross-sectional study from October 2017 to September 2018 in 7 communities in Shanghai, China, elder (≧60) residential volunteers with no history of major cardiovascular diseases, cancers and other comorbidities known to affect cognitive functions were recruited. The participants underwent tests with 7 cognitive function screening instruments. Multivariate linear regressions were performed to test correlations between demographic characteristics, including gender, age, education, and marital status, with cognitive test scores. Mini-Mental State Examination (MMSE) score adjusted according to the correlation coefficients was used to detect CI with a cutoff of 24. Other cognitive function scores were compared between participants with and without CI. In addition, Pearson's correlation test was used to detect association between different test scores.

RESULTS

172 participants with relatively low education levels were included. Age and education showed significant association with cognitive test scores. Using adjusted MMSE, 39.6% of participants were identified with CI, while the percentage was 87.2% when adjusted Montreal Cognitive Assessment (MoCA) with cutoff of 26 was used. Analysis of "abnormal" test scores showed that MMSE had the highest percentage of valid data (98.8%). MoCA and Isaacs test of Verbal Fluency (VF) score had correlation with most the other scores, while MMSE only significantly associated with VF and MoCA.

CONCLUSIONS

MMSE may still present the most applicable tools for quick screen of cognitive functions, especially when environmental conditions may interfere with participants' attention.

Instrumental Activities of Daily Living Scales to Detect Cognitive Impairment and Dementia in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The largest proportion of people with dementia worldwide live in low- and middle- income countries (LMICs), with dementia prevalence continuing to rise. Assessment and diagnosis of dementia involves identifying the impact of cognitive decline on function, usually measured by instrumental activities of daily living (IADLs).

OBJECTIVE

This review aimed to identify IADL measures which are specifically developed, validated, or adapted for use in LMICs to guide selection of such tools.

METHODS

A systematic search was conducted (fourteen databases) up to April 2020. Only studies reporting on development, validation, or adaptation of IADL measures for dementia or cognitive impairment among older adults (aged over 50) in LMICs were included. The QUADAS 2 was used to assess quality of diagnostic accuracy studies.

RESULTS

22 papers met inclusion criteria; identifying 19 discrete IADL tools across 11 LMICs. These were either translated from IADL measures used in high-income countries (n = 6), translated and adapted for cultural differences (n = 6), or newly developed for target LMIC populations (n = 7). Seven measures were investigated in multiple studies; overall quality of diagnostic accuracy was moderate to good.

CONCLUSION

Reliability, validity, and accuracy of IADL measures for supporting dementia diagnosis within LMICs was reported. Key components to consider when selecting an IADL tool for such settings were highlighted, including choosing culturally appropriate, time-efficient tools that account for gender- and literacy-bias, and can be conducted by any volunteer with appropriate training. There is a need for greater technical and external validation of IADL tools across different regions, countries, populations, and cultures.

Conversion between Mini-Mental State Examination and Montreal Cognitive Assessment scores in older adults undergoing selective surgery using Rasch analysis

AIMS

To develop and validate a conversion table between the MMSE and the MoCA using Rasch analysis in older adults undergoing selective surgery and examine its diagnostic accuracy in detecting cognitive impairment.

DESIGN

Cross-sectional study.

METHODS

Older patients [N = 129; age 66.0 (4.6) years, education 7.7 (3.5) years] undergoing elective surgery were recruited from December 2017 to June 2018. All participants completed the MMSE and MoCA and 113 of them completed a battery of neuropsychological tests. Common person linking based on Rasch analysis was performed to develop the conversion table. The conversions were validated by calculating the intraclass correlation coefficient (ICC), score differences between actual and converted scores, and root mean squared error of the difference (RMSE). The diagnostic accuracy of the conversions for detecting cognitive impairment was also tested.

RESULTS

The MoCA [person measure: 1.3 (1.1) logits] was better targeted to the patients than the MMSE [person measure: 3.2 (1.3) logits]. Conversion from MoCA to MMSE scores (ICC 0.84, 95% CI 0.77-0.88; RMSE 1.36) was more precise than conversion from MMSE to MoCA (ICC 0.82, 95% CI 0.75-0.87; RMSE 2.56). Conversion from MoCA to MMSE demonstrated better diagnostic accuracy in detecting cognitive impairment than the actual MMSE, whereas conversion from MMSE to MoCA exhibited the opposite pattern.

CONCLUSION

Conversion from MoCA to MMSE was more precise and had better diagnostic accuracy in detecting pre-operative cognitive impairment in older patients undergoing selective surgery than conversion from MMSE into MoCA.

IMPACT

The finding is useful for interpreting, comparing, and integrating cognitive measurements in surgical settings and clinical research. Statistically sound conversion between MoCA and MMSE based on Rasch analysis is now possible for surgical setting and clinical research.

Mild cognitive impairment, dementia, and cognitive dysfunction screening using machine learning

Objective

To develop a machine learning algorithm to identify cognitive dysfunction based on neuropsychological screening test results.

Methods

This retrospective study included 955 participants: 341 participants with dementia (dementia), 333 participants with mild cognitive impairment (MCI), and 341 participants who were cognitively healthy. All participants underwent evaluations including the Mini-Mental State Examination and the Montreal Cognitive Assessment. Each participant’s caregiver or informant was surveyed using the Korean Dementia Screening Questionnaire at the same visit. Different machine learning algorithms were applied, and their overall accuracies, Cohen’s kappa, receiver operating characteristic curves, and areas under the curve (AUCs) were calculated.

Results

The overall screening accuracies for MCI, dementia, and cognitive dysfunction (MCI or dementia) using a machine learning algorithm were approximately 67.8% to 93.5%, 96.8% to 99.9%, and 75.8% to 99.9%, respectively. Their kappa statistics ranged from 0.351 to 1.000. The AUCs of the machine learning models were statistically superior to those of the competing screening model.

Conclusion

This study suggests that a machine learning algorithm can be used as a supportive tool in the screening of MCI, dementia, and cognitive dysfunction.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Dementia Diagnosis in Seven Languages: The Addenbrooke’s Cognitive Examination-III in India

Objective

With the rising burden of dementia globally, there is a need to harmonize dementia research across diverse populations. The Addenbrooke’s Cognitive Examination-III (ACE-III) is a well-established cognitive screening tool to diagnose dementia. But there have been few efforts to standardize the use of ACE-III across cohorts speaking different languages. The present study aimed to standardize and validate ACE-III across seven Indian languages and to assess the diagnostic accuracy of the test to detect dementia and mild cognitive impairment (MCI) in the context of language heterogeneity.

Methods

The original ACE-III was adapted to Indian languages: Hindi, Telugu, Kannada, Malayalam, Urdu, Tamil, and Indian English by a multidisciplinary expert group. The ACE-III was standardized for use across all seven languages. In total, 757 controls, 242 dementia, and 204 MCI patients were recruited across five cities in India for the validation study. Psychometric properties of adapted versions were examined and their sensitivity and specificity were established.

Results

The sensitivity and specificity of ACE-III in identifying dementia ranged from 0.90 to 1, sensitivity for MCI ranged from 0.86 to 1, and specificity from 0.83 to 0.93. Education but not language was found to have an independent effect on ACE-III scores. Optimum cut-off scores were established separately for low education (≤10 years of education) and high education (&gt;10 years of education) groups.

Conclusions

The adapted versions of ACE-III have been standardized and validated for use across seven Indian languages, with high diagnostic accuracy in identifying dementia and MCI in a linguistically diverse context.

Hindi Version of Addenbrooke's Cognitive Examination III: Distinguishing Cognitive Impairment Among Older Indians at the Lower Cut-Offs

Background

Screening and diagnostic tests provide an objective measure of cognitive performance and also aid in distinguishing mild cognitive impairment (MCI) from major neurocognitive disorder (MNCD). Further, when such tests are culturally and educationally unbiased, it strengthens their diagnostic utility. This study aimed to validate the Hindi version of Addenbrooke’s Cognitive Examination III (ACE-III) in Indian older adults and compare its validity with the Hindi Mini-Mental State Examination (HMSE).

Methods

A sample of 412 consenting older adults visiting a memory clinic was recruited into the study. They were categorized into three groups: healthy controls (n=222), MCI (n=70), and MNCD (n=120). The complete clinical protocol was followed. Hindi ACE-III and HMSE were administered and were statistically analyzed.

Results

The optimal cut-off values to detect MCI and MNCD with ACE-III were 71 and 62 (AUC: 0.849 and 0.884), respectively, which were slightly higher than with HMSE (AUC: 0.822, 0.861). Education- and age-stratified cut-offs were also computed.

Conclusion

Hindi ACE-III has good discriminating power at lower cut-offs than the standard scores in differentiating between MCI and MNCD.

A Systematic Review of Neuropsychological Tests for the Assessment of Dementia in Non-Western, Low-Educated or Illiterate Populations

OBJECTIVE

Neuropsychological tests are important instruments to determine a cognitive profile, giving insight into the etiology of dementia; however, these tests cannot readily be used in culturally diverse, low-educated populations, due to their dependence upon (Western) culture, education, and literacy. In this review we aim to give an overview of studies investigating domain-specific cognitive tests used to assess dementia in non-Western, low-educated populations. The second aim was to examine the quality of these studies and of the adaptations for culturally, linguistically, and educationally diverse populations.

METHOD

A systematic review was performed using six databases, without restrictions on the year or language of publication.

RESULTS

Forty-four studies were included, stemming mainly from Brazil, Hong Kong, Korea, and considering Hispanics/Latinos residing in the USA. Most studies focused on Alzheimer's disease (n = 17) or unspecified dementia (n = 16). Memory (n = 18) was studied most often, using 14 different tests. The traditional Western tests in the domains of attention (n = 8) and construction (n = 15), were unsuitable for low-educated patients. There was little variety in instruments measuring executive functioning (two tests, n = 13), and language (n = 12, of which 10 were naming tests). Many studies did not report a thorough adaptation procedure (n = 39) or blinding procedures (n = 29).

CONCLUSIONS

Various formats of memory tests seem suitable for low-educated, non-Western populations. Promising tasks in other cognitive domains are the Stick Design Test, Five Digit Test, and verbal fluency test. Further research is needed regarding cross-cultural instruments measuring executive functioning and language in low-educated people.

Standardising Dementia Diagnosis Across Linguistic and Educational Diversity: Study Design of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB)

OBJECTIVES

While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings.

METHODS

A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India.

RESULTS

Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed.

CONCLUSIONS

A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.

The Efficacy of General Practitioner Assessment of Cognition in Chinese Elders Aged 80 and Older

OBJECTIVES

This study examined the efficacy of the General Practitioner Assessment of Cognition-Chinese version (GPCOG-C) in screening dementia and mild cognitive impairment (MCI) among older Chinese.

METHODS

Survey questionnaires were administered to 293 participants aged 80 or above from a university hospital in mainland China. Alzheimer disease and MCI were diagnosed in light of the National Institute on Aging and the Alzheimer's Association (NIA/AA) criteria. The sensitivity and specificity of GPCOG-C and Mini-Mental State Examination (MMSE) in screening dementia and MCI were compared to the NIA/AA criteria.

RESULTS

The GPCOG-C had the sensitivity of 62.3% and specificity of 84.6% in screening MCI, which had comparable efficacy as the NIA/AA criteria. In screening dementia, GPCOG-C had a lower sensitivity (63.7%) than the MMSE and a higher specificity (82.6%) higher than the MMSE.

CONCLUSIONS

The GPCOG-C is a useful and efficient tool to identify dementia and MCI in older Chinese in outpatient clinical settings.

Cognitive function measured with the Revised Hasegawa's Dementia Scale among elderly individuals in Lao PDR

In Lao PDR, measurement of cognitive function has rarely been conducted among elderly individuals. This study aimed to investigate the cognitive function among elderly individuals who lived at their homes with family in Lao PDR. Participants were elderly individuals aged 60 years or over registered with the local government in urban (Vientiane capital; VC) and rural areas (Khammouane province; KP). Those with serious mental/physical diseases, those who could not walk by themselves, or those who could not speak the Lao language were excluded. The information was collected through interviews with the participants and their family members. A newly developed Lao version of the Revised Hasegawa’s Dementia Scale (HDS-R) was applied to measure cognitive function. The participants were 414 elderly individuals (224 males and 190 females) aged 60 to 98 years. The average HDS-R score was 23.0 among 115 men in VC, 22.7 among 92 women in VC, 20.3 among 109 men in KP, and 17.5 among 98 women in KP. The main caregiver was a daughter (40.6%) followed by a spouse (31.4%). Among 414 elderly individuals, 42 (10.0%) stated the necessity of support. Those with HDS-R < 20 accounted for 38.8% in men and 48.9% in women. The adjusted odds ratio of HDS-R < 20 was significant for those in rural areas (3.83) relative to those in urban areas. Among superficially healthy elderly individuals residing with their families, those with reduced cognitive function were more common among women and in rural areas.

Effects of an abnormal mini-mental state examination score on postoperative outcomes in geriatric surgical patients: a meta-analysis

Background

Perioperative cognitive impairment (CI) following surgeries is prevalent in geriatric surgical population aged 60 and older. This meta-analysis was designed to investigate whether the Mini-Mental State Examination (MMSE) has prognostic value on adverse outcomes in aged surgical patients.

Methods

PubMed, Cochrane, Embase and Medline through the Ovid were searched. Meta-analyses were carried out for CI versus non-cognitive impairment (NCI). Quality of evidence was assessed by the GRADE approach.

Results

One randomized controlled trial, two retrospective cohort trials, and 18 prospective cohort trials were included in the meta-analysis. Perioperative diagnosis of CI by the MMSE had higher rates of patients suffering from postoperative delirium (POD) [odd ratio (OR) 5.02, 95% confidence interval (CI) 3.27, 7.71, P < 0.00001], in-hospital mortality (OR 7.51, 95% CI 2.17, 26.02, P = 0.001), mortality within 1 year (OR 2.53, 95% CI 1.95,3.29, P < 0.00001). Postoperative CI patients had no extended length of stay in orthopedic [standardized mean difference (SMD) -0.10, 95% CI -0.20, 0.17, P = 0.91)] nor rehabilitation wards ((SMD, 0.04; 95% CI, − 0.23 to 0.31; P = 0.78).

Conclusion

Older patients with perioperative CI were more likely to suffer from POD and mortality. The MMSE showed certain value on risk stratification and prognosis evaluation in geriatric surgical population.

Trial registration

PROSPERO CRD42018108739.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0735-5) contains supplementary material, which is available to authorized users.

Validity of screening tools for dementia and mild cognitive impairment among the elderly in primary health care: a systematic review

OBJECTIVES

This systematic review aims to provide updated and comprehensive evidence on the validity and feasibility of screening tools for mild cognitive impairment (MCI) and dementia among the elderly at primary healthcare level.

STUDY DESIGN

A review of articles was performed.

METHODS

A search strategy was used by using electronic bibliographic databases including PubMed, Embase and CENTRAL for published studies and reference list of published studies. The articles were exported to a bibliographic database for further screening process. Two reviewers worked independently to screen results and extract data from the included studies. Any discrepancies were resolved and confirmed by the consensus of all authors.

RESULTS

There were three screening approaches for detecting MCI and dementia - screening by a healthcare provider, screening by a self-administered questionnaire and caretaker informant screening. Montreal Cognitive Assessment (MoCA) was the most common and preferable tool for MCI screening (sensitivity [Sn]: 81-97%; specificity [Sp]: 60-86%), whereas Addenbrooke's Cognitive Examination (ACE) was the preferable tool for dementia screening (Sn: 79-100%; Sp: 86%).

CONCLUSION

This systematic review found that there are three screening approaches for detecting early dementia and MCI at primary health care. ACE and MoCA are recommended tools for screening of dementia and MCI, respectively.

Validation of the Malay Version of Addenbrooke's Cognitive Examination III in Detecting Mild Cognitive Impairment and Dementia

Background/Aims

This study aimed to investigate the validity and reliability of the Malay version of Addenbrooke's Cognitive Examination III (ACE-III) for detecting mild cognitive impairment (MCI) and dementia.

Methods

A total of 152 participants (dementia = 53, MCI = 38, controls = 61) were recruited from two teaching hospitals. The Malay version of ACE-III was translated following the standard guidelines for cross-cultural adaptation of measure. All the participants were assessed with the Malay version of ACE-III and Mini-Mental State Examination (MMSE).

Results

The reliability of the Malay version of ACE-III was good with Cronbach's α coefficient of 0.829 and intraclass correlation coefficient of 0.959. There was a strong positive correlation between the Malay version of ACE-III and MMSE (r = 0.806). Age (r = -0.335) and years of education (r = 0.536) exerted a significant correlation with total score performance. The cutoff score to discriminate dementia from healthy controls was 74/75 (sensitivity = 90.6%, specificity = 82.0%) whereas to discriminate MCI, the cutoff score was 77/78 (sensitivity = 63.2%, specificity = 63.9%). The diagnostic accuracy of ACE-III was higher than that of MMSE in the detection of dementia (area under the curve: ACE-III = 0.929 vs. MMSE = 0.915).

Conclusions

The Malay version of ACE-III demonstrated to be a reliable and valid screening tool for dementia.

Myanmar language version of the Revised Hasegawa's Dementia Scale

Reduced cognitive function among the elderly is an important issue not only in developed countries, but also in developing countries. As a test to measure cognitive function, the Revised Hasegawa’s Dementia Scale (HDS-R) has been used in Asian countries including Japan, Korea, and China. Since there was no HDS-R version in Myanmar language, a questionnaire and manual for the HDS-R were developed. The translation from English to Myanmar language was done by two Myanmar researchers. Back-translation was conducted to confirm the accuracy of the translation by two other Myanmar researchers. Back-translated English was compared to the original by two Japanese researchers, and inconsistencies were discussed by all six researchers to reach consensus. Five Myanmar researchers independently read the questionnaire and manual to verify the expressions are familiar in Myanmar language. The modified points were as follows. 1) The date order in Question 2 is day/month/year. 2) The words to be memorized in Questions 4 and 7 are padauk tree, cat, and bullock cart for the first set, and tamarind tree, dog, and car for the second set. 3) The objects to be memorized in Question 8 are shown with pictures, not actual objects. 4) Like the Lao version, we introduced two new rules; a clear time definition for no reply (10 seconds), and repeating questions twice for those with hearing problems. The revised version of the HDS-R has been prepared to be an applicable standard questionnaire for use on assessment of cognitive function in suspected dementia cases in Myanmar, both in the clinical and public healthcare setting.

Conversion From The Korean Dementia Screening Questionnaire To The Informant Questionnaire On Cognitive Decline In The Elderly

PURPOSE

The ability to convert scores between cognitive measurements would facilitate the longitudinal assessment of cognition in clinical practice and the comparison and synthesis of cognitive data from international, multicenter, or longitudinal studies. The primary aim of this study was to apply a simple and reliable method for converting scores from the Korean Dementia Screening Questionnaire (KDSQ) to those of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

PATIENTS AND METHODS

A total of 627 participants, with and without cognitive dysfunction, received both the KDSQ and the IQCODE at the same visit. The scores of both tools were calculated, and equipercentile equating was used to create a method for converting scores from the KDSQ to the IQCODE.

RESULTS

KDSQ scores were highly correlated with IQCODE scores (Pearson r = 0.905, P < 0.01). We developed scores for converting the KDSQ to the IQCODE using equipercentile equating and log-linear smoothing. We provide an easy-to-use table that enables the conversion of KDSQ scores to IQCODE scores.

CONCLUSION

We delivered a simple and reliable method for converting scores from the KDSQ to the IQCODE. The conversion score table reported here enables direct and easy comparison of these cognitive measurements in older adults.

Current approaches to dementia screening and case finding in low- and middle-income countries: Research update and recommendations

Approximately 47 million people have dementia worldwide, with this figure, it is expected to almost triple by 2050. Most people with dementia (approximately two-thirds) live in low- and middle-income countries (LMICs). This presents a significant challenge for such countries that often have limited financial resources and less well-developed health and social care systems. In the absence of a cure, reducing the future costs of dementia care and burden of disease may be best achieved by a greater emphasis on (1) more timely diagnosis with earlier intervention to maintain functional independence and (2) undertaking "screening" in groups at high risk of developing dementia, case finding, and using brief cognitive assessment instruments. In clinical settings, a wide range of instruments for dementia screening and diagnosis are currently available; however, few cognitive assessment tools have been developed specifically for clinical use within LMIC settings. Screening for dementia and cognitive impairment in LMICs largely relies on tools adapted from high-income countries (HICs); these often lack validation in these settings leading to education, literacy, and cultural biases. Research is urgently needed to develop cognitive assessment tools and dementia diagnostic approaches that are appropriate and feasible for clinical use in LMIC settings.

Lao language version of the Revised Hasegawa's Dementia Scale

With the aging of society, the number of elderly with reduced cognitive function has been increasing worldwide. As a test to measure the cognitive function, the Revised Hasegawa’s Dementia Scale (HDS-R) has been used in Japan, Korea, and China. Since there was no HDS-R version for Laotians, the questionnaire and manual were developed through the cooperation of Lao and Japanese researchers. Back-translation was conducted to confirm the accuracy of the translation. The score on the 9-item HDS-R ranges 0 to 30 points, and reduced cognitive function is usually defined as a score of 20 points or lower. After receiving explanation regarding the use of the tool and practicing its implementation, 3 female doctors interviewed 30 superficially healthy volunteers aged 31 to 84 years (12 males and 18 females) who lived with his/her family in Vientiane Capital, Lao PDR. Their score distributed from 4 to 30 points, with an average of 24.7 (standard deviation 5.4) points. Six (20.0%) participants scored 20 points or lower. The discussion before and after the pilot interviews revealed that the following changes needed to be made in accordance to the culture of Lao people; 1) order of date in Question 2, 2) words to be memorized in Questions 4 and 7, 3) objects to be memorized using pictures, not actual objects, in Question 8. Additionally, we introduced new two rules; a clear time definition for no reply (10 seconds), and repetition of questions twice for those with ear problems. The revised version of the HDS-R was thought to be an appropriate standard questionnaire for use in studies on cognitive function among Laotians.

Frailty and Cognitive Impairment in Predicting Mortality Among Oldest-Old People

Backgrounds: Frailty and cognitive impairment are critical geriatric syndromes. In previous studies, both conditions have been identified in old-age adults as increased risk factors for mortality. However, the combined effect of these two syndromes in predicting mortality among people with advanced age is not well understood. Thus, we used Chinese community cohort to determine the impact of the combined syndromes on the oldest-old people. Methods: Our present study is part of an ongoing project on Longevity and Aging in Dujiangyan, which is a community study on a 90+ year cohort in Sichuan Province in China. Participants were elderly people who completed baseline health assessment in 2005 followed by a collection of mortality data in 2009. Frailty and cognitive function were assessed with 34-item Rockwood Frailty Index and the Mini-Mental Status Examination, respectively, and the combined effect(s) of these two parameters on death was examined using the Cox proportional hazard regression model. Results: This study consisted of a total of 705 participants (age = 93.6 ± 3.3 years; 67.4% females), of which 53.8% died during a four-year follow-up period. The prevalence of frailty, cognitive impairment, and the overlap of these two syndromes was 63.7, 74.2, and 50.3%, respectively. Our data showed that the subjects with combined frailty and cognitive impairment were associated with increased risk of death (age, gender, education level, and other potential confounders adjusted); the hazard ratio was 2.13 (95% confidence interval 1.39, 3.24), compared with the control group. However, neither frailty alone nor cognitive impairment alone increased the risk of death in these individuals. Conclusion: The combined frailty and cognitive impairment, other than the independently measured syndromes (frailty or cognitive impairment alone), was a significant risk factor for death among the oldest-old Chinese people.

A novel language-neutral Visual Cognitive Assessment Test (VCAT): validation in four Southeast Asian countries

Background

Cognitive screeners are imperative for early diagnosis of dementia. The Visual Cognitive Assessment Test (VCAT) is a language-neutral, visual-based test which has proven useful for a multilingual population in a single-center study. However, its performance utility is unknown in a wider and more diverse Southeast Asian cohort.

Methods

We recruited 164 healthy controls (HC) and 120 cognitively impaired (CI) subjects- 47 mild cognitive impairment (MCI) and 73 mild Alzheimer’s disease (AD) dementia participants, from four countries between January 2015 and August 2016 to determine the usefulness of a single version of the VCAT, without translation or adaptation, in a multinational, multilingual population. The VCAT was administered along with established cognitive evaluation.

Results

The VCAT, without local translation or adaptation, was effective in discriminating between HC and CI subjects (MCI and mild AD dementia). Mean (SD) VCAT scores for HC and CI subjects were 22.48 (3.50) and 14.17 (5.05) respectively. Areas under the curve for Montreal Cognitive Assessment (0.916, 95% CI 0.884–0.948) and the VCAT (0.905, 95% CI 0.870–0.940) in discriminating between HCs and CIs were comparable. The multiple languages used to administer VCAT in four countries did not significantly influence test scores.

Conclusions

The VCAT without the need for language translation or cultural adaptation showed satisfactory discriminative ability and was effective in a multinational, multilingual Southeast Asian population.

Clinical utility and tolerability of transcranial direct current stimulation in mild cognitive impairment

BACKGROUND

Neuromodulatory interventions like transcranial direct current stimulation (tDCS) is emerging as a potential therapeutic strategy to promote cognitive function in healthy and pathological aging. There is need for more studies evaluating the utility and tolerability of tDCS in Mild cognitive impairment (MCI). Since MCI is considered as the prodromal stage of dementia, it has emerged as the most important target for intervention in dementia.

OBJECTIVE AND METHOD

This study investigated the feasibility, tolerability and clinical utility of tDCS in patients with MCI. In this observational study that included 11 patients with MCI, tDCS with an intensity of 2mA and duration of 20minutes per day was administered for 5 consecutive days with anode over left dorsolateral prefrontal cortex (DLPFC) and cathode over right supra orbital region. Treatment outcome was measured using picture memory impairment test (PMIT) immediately and also 1 month after the 5th session of tDCS RESULTS: All the patients tolerated tDCS sessions without any significant adverse effects. Stimulation of left DLPFC with tDCS was noted to significantly improve the immediate and delayed recall performance of the patients in PMIT after five days of stimulation and most of the benefits were persistent at one month follow up.

CONCLUSION

This study findings suggests that tDCS is safe and potentially beneficial in combating cognitive deficits in patients with MCI and provides a framework for further studies with better methodology (randomized and sham controlled trial) to investigate the same.

How Can We Best Screen for Cognitive Impairment in Malaysia? A Pilot of the IDEA Cognitive Screen and Picture-Based Memory Impairment Scale and Comparison of Criterion Validity with the Mini Mental State Examination

OBJECTIVES

To pilot two new cognitive screening tools for use in an urban Malaysian population and to compare their criterion validity against a gold standard, the well-established Mini-Mental State Examination (MMSE).

METHODS

The IDEA cognitive screen, Picture-based Memory Impairment Scale (PMIS), and MMSE were administered to a convenience sample of elderly (≥ 65 years) from the community and outpatient clinics at an urban teaching hospital. Consensus diagnosis was performed by two geriatricians blinded to PMIS and IDEA cognitive screen scores using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) clinical criteria. The MMSE performance was used as a reference.

RESULTS

The study enrolled 66 participants, with a median age of 78.5 years (interquartile range [IQR], 72.5-83.0) years and 11.0 median years of education (IQR, 9.0-13.0). Forty-three (65.2%) were female, and 32 (48.4%) were Chinese. The area under the receiver operating characteristic (AUROC) curve values were .962 (IDEA cognitive screen), .970 (PMIS), and .935 (MMSE). The optimal cutoff values for sensitivity and specificity were: IDEA cognitive screen: ≤ 11, 90.9% and 89.7%; PMIS: ≤ 6, 97.3% and 69.0%; and MMSE: ≤ 23, 84.6% and 76.0%. Although the sample size was small, multivariable logistic regression modelling suggested that all three screen scores did not appear to be educationally biased.

CONCLUSION

The IDEA and PMIS tools are potentially valid screening tools for dementia in urban Malaysia, and perform at least as well as the MMSE. Further work on larger representative, cohorts is needed to further assess the psychometric properties.

CLINICAL IMPLICATIONS

Study provides alternative screening tools for dementia for both non-specialists and specialists.

Rural-urban differences in the prevalence of cognitive impairment in independent community-dwelling elderly residents of Ojiya city, Niigata Prefecture, Japan

BACKGROUND

This study aimed to examine rural-urban differences in the prevalence of cognitive impairment in Japan.

METHODS

We targeted 592 residents aged 65 years and older who did not use long-term care insurance services in one rural and two urban areas in Ojiya City, Japan. Of these, 537 (90.7 %) participated in the study. The revised Hasegawa's dementia scale (HDS-R) was used to assess cognitive function, and cognitive impairment was defined as a HDS-R score ≤20. Lifestyle information was obtained through interviews. The prevalence of cognitive impairment was compared according to the levels of predictor variables by odds ratios (ORs) calculated by a logistic regression analysis.

RESULTS

Mean age of participants was 75.7 years (SD 7.0). The prevalence of cognitive impairment was 20/239 (8.4 %) in the rural area and 6/298 (2.0 %) in the urban areas, for a total of 26/537 (4.8 %) overall. Men tended to have a higher prevalence of cognitive impairment (P = 0.0628), and age was associated with cognitive impairment (P for trend <0.0001). The rural area had a significantly higher prevalence of cognitive impairment (age- and sex-adjusted OR = 4.04, 95 % CI: 1.54-10.62) than urban areas. This difference was significant after adjusting for other lifestyle factors.

CONCLUSIONS

The prevalence of cognitive impairment was higher in the rural area relative to urban areas in Ojiya city. This regional difference suggests the existence of potentially modifiable factors other than lifestyle in relation to cognitive impairment.