The clock drawing test: A systematic review and meta‐analysis of diagnostic accuracy

Diagnostic accuracy of the Clock Drawing Test in screening for early post-stroke neurocognitive disorder: the Nor-COAST study

BACKGROUND

Post-stroke neurocognitive disorder, though common, is often overlooked by clinicians. Moreover, although the Montreal Cognitive Assessment (MoCA) has proven to be a valid screening test for neurocognitive disorder, even more time saving tests would be preferred. In our study, we aimed to determine the diagnostic accuracy of the Clock Drawing Test (CDT) for post-stroke neurocognitive disorder and the association between the CDT and MoCA.

METHODS

This study is part of the Norwegian Cognitive Impairment After Stroke study, a multicentre prospective cohort study following patients admitted with acute stroke. At the three-month follow-up, patients were classified with normal cognition, mild neurocognitive disorder, or major neurocognitive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Any neurocognitive disorder compromised both mild- and major neurocognitive disorder. The CDT at the three-month assessment was given scores ranging from 0 to 5. Patients able to complete the CDT and whose cognitive status could be classified were included in analyses. The CDT diagnostic accuracy for post-stroke neurocognitive disorder was identified using receiver operating characteristic curves, sensitivity, specificity, positive predictive value, and negative predictive value. The association between the MoCA and CDT was analysed with Spearman's rho.

RESULTS

Of 554 participants, 238 (43.0%) were women. Mean (SD) age was 71.5 (11.8) years, while mean (SD) National Institutes of Health Stroke Scale score was 2.6 (3.7). The area under the receiver operating characteristic curve of the CDT for major neurocognitive disorder and any neurocognitive disorder was 0.73 (95% CI, 0.68-0.79) and 0.68 (95% CI, 0.63-0.72), respectively. A CDT cutoff of < 5 yielded 68% sensitivity and 60% specificity for any neurocognitive disorder and 78% sensitivity and 53% specificity for major neurocognitive disorder. Spearman's correlation coefficient between scores on the MoCA and CDT was 0.50 (95% CI, 0.44-0.57, p < .001).

CONCLUSIONS

The CDT is not accurate enough to diagnose post-stroke neurocognitive disorder but shows acceptable accuracy in identifying major neurocognitive disorder. Performance on the CDT was associated with performance on MoCA; however, the CDT is inferior to MoCA in identifying post-stroke neurocognitive disorder.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02650531). Retrospectively registered January 8, 2016.

Effectiveness of Early Multimodal Non-pharmacological Interventions in Cognitive Preservation in the Elderly

INTRODUCTION

Multimodal non-pharmacological interventions (MNPI) have been determined as effective in delaying cognitive deterioration. The effectiveness of timing of such interventions in elderly is less discussed. We compared the different effectiveness of MNPI in cognitive preservation in elderly subjects with and without dementia.

METHODS

We enrolled volunteer the elderly subjects. Subjects were classified as dementia group and non-dementia group by instrument of ascertainment of dementia 8. All were assigned to attend 3 hours of MNPI (physical fitness training, Chinese capillary, and Chinese drawings and paintings) twice a week over a 16-week period. Neuropsychiatric tests, including Mini-Mental State Examination (MMSE), Cognitive Assessment Screening Instrument (CASI), clinical dementia rating (CDR), and neuropsychiatric inventory (NPI), were administered before and 1 year after MNPI. We demonstrated the changes of cognition and behavioral and psychological symptoms of dementia (BPSD) before and after MNPI. We compared the different effectiveness of cognition preservation between two groups.

RESULTS

In total, there were 43 participants in our study, including 18 with non-dementia and 25 with dementia. The non-dementia group had a significantly higher proportion of cognitive preservation in remote memory (100.0% vs 68.0%, P = .007), orientation (94.4% vs 48.0%, P = .001), drawing (94.4% vs 64.0%, P = .021) and language (77.8% vs 48.0%, P = .049) than the dementia group. The highest proportion of preserved cognition after MNPI was remote memory (100%), followed by orientation (94.4%) and drawing (94.4%) in the non-dementia group. The highest proportion of preserved cognition after MNPI was attention (72%) followed by remote memory (68%), recent memory (64%) and drawing (64%) in the dementia group. Overall, their improved rate in behavioral and psychological symptoms was 55.6%.

CONCLUSION

Our study concluded the benefits of early MNPI in cognition preservation in the elderly, especially in the field of remote memory, orientation, drawing and language.

The correlation between neuropathology levels and cognitive performance in centenarians

INTRODUCTION

Neuropathological substrates associated with neurodegeneration occur in brains of the oldest old. How does this affect cognitive performance?

METHODS

The 100-plus Study is an ongoing longitudinal cohort study of centenarians who self-report to be cognitively healthy; post mortem brain donation is optional. In 85 centenarian brains, we explored the correlations between the levels of 11 neuropathological substrates with ante mortem performance on 12 neuropsychological tests.

RESULTS

Levels of neuropathological substrates varied: we observed levels up to Thal-amyloid beta phase 5, Braak-neurofibrillary tangle (NFT) stage V, Consortium to Establish a Registry for Alzheimer's Disease (CERAD)-neuritic plaque score 3, Thal-cerebral amyloid angiopathy stage 3, Tar-DNA binding protein 43 (TDP-43) stage 3, hippocampal sclerosis stage 1, Braak-Lewy bodies stage 6, atherosclerosis stage 3, cerebral infarcts stage 1, and cerebral atrophy stage 2. Granulovacuolar degeneration occurred in all centenarians. Some high performers had the highest neuropathology scores.

DISCUSSION

Only Braak-NFT stage and limbic-predominant age-related TDP-43 encephalopathy (LATE) pathology associated significantly with performance across multiple cognitive domains. Of all cognitive tests, the clock-drawing test was particularly sensitive to levels of multiple neuropathologies.

Oncological, cognitive, and employment outcomes in a series of patients with IDH-mutated glioma resected following neoadjuvant chemotherapy

PURPOSE

Maximal safe tumor resection is the first line of treatment for IDH-mutated gliomas. However, when upfront surgical resection is deemed unsatisfactory due to tumor size and location, chemotherapy could represent an interesting alternative for reducing glioma extension and allowing for a safer and more efficient removal.

METHODS

We performed a retrospective study (June 2011 to December 2021) on patients with IDH-mutated gliomas undergoing chemotherapy with a neoadjuvant intent, followed by surgical excision in awake conditions. MRI-imaging follow-up was conducted every 3-6 months. Neuropsychological assessments (NPSA) were performed for all patients before surgery, during post-operative period, and at later follow-up, and patients were periodically interviewed about their clinical and job status.

RESULTS

We included 6 patients who underwent awake surgery after neoadjuvant chemotherapy (temozolomide in 5 cases, PCV in 1 case) for an IDH-mutated glioma (3 oligodendrogliomas and 3 astrocytomas). Median tumor volume reduction was 47%, allowing for complete resection in one patient, subtotal resection in 4 patients, and partial resection in 1 patient. No major adverse effects were observed under chemotherapy. At the 4 months NPSA, a worsening of flexibility was observed in 2 patients (verbal fluencies in one case and trail making test in the other). Three out of the four patients working full time before procedure resumed their job full time, after a 7 to 10 months delay.

CONCLUSION

Neoadjuvant chemotherapy followed by maximal safe resection can be offered to patients affected by IDH-mutated gliomas for whom upfront surgery would be inadequate. More studies are necessary given the limited size of our sample.

The indirect effect of cognitive reserve on the relationship between age and cognition in pathological ageing: A cross-sectional retrospective study in an unselected and consecutively enrolled sample

Cognitive reserve (CR) allows individuals to maintain cognitive functionality even in the presence of pathologies. The compensation hypothesis suggests that CR plays an indirect role between age and cognitive decline, contrasting the negative effect of ageing on cognition. We test this hypothesis in an unselected and consecutively enrolled sample of memory clinic attendees (n = 134) who completed the CR Index questionnaire and three neuropsychological tests assessing global cognition (MMSE, FAB, CDT). Participants were divided into two groups based on standard diagnostic criteria (DSM-5): those who were cognitively impaired (n = 92) and those who were preserved (n = 42). A principal component analysis was used to extract a composite measure of global cognitive functioning from the three neuropsychological tests, and mediation analysis was used to examine the relationship between CR, age and global cognitive functioning in the two groups. Results revealed that: (i) age had a significant direct negative effect on the global cognitive score in both groups; (ii) the three socio-behavioural proxies of CR together suppress the direct negative relationship between age and global cognitive score in cognitively impaired patients but not in cognitively preserved participants. This study confirms the association between CR, age and cognition and allows us to validate its role in a population with cognitive impairment and extend findings to a low-to-middle educated population. These results hold important implications for public health and wellness promotion, emphasising the beneficial role of maintaining healthy and active physical, cognitive and social lifestyles.

The Relationship Between Cognitive Impairments and Sleep Quality Measures in Persistent Insomnia Disorder

Study Objectives

Persistent insomnia disorder (pID) is linked to neurocognitive decline and increased risk of Alzheimer's Disease (AD) in later life. However, research in this field often utilizes self-reported sleep quality data - which may be biased by sleep misperception - or uses extensive neurocognitive test batteries - which are often not feasible in clinical settings. This study therefore aims to assess whether a simple screening tool could uncover a specific pattern of cognitive changes in pID patients, and whether these relate to objective aspect(s) of sleep quality.

Methods

Neurocognitive performance (Montreal Cognitive Assessment; MoCA), anxiety/depression severity, and subjective sleep quality (Pittsburgh Sleep Quality Index: PSQI; Insomnia Severity Index: ISI) data were collected from 22 middle-aged pID patients and 22 good-sleepers. Patients underwent overnight polysomnography.

Results

Compared to good-sleepers, patients had lower overall cognitive performance (average: 24.6 versus 26.3 points, Mann-Whitney U = 136.5, p = <0.006), with deficits in clock drawing and verbal abstraction. In patients, poorer overall cognitive performance correlated with reduced subjective sleep quality (PSQI: r(42) = -0.47, p = 0.001; and ISI: r(42) = -0.43, p = 0.004), reduced objective sleep quality (lower sleep efficiency: r(20) = 0.59, p = 0.004 and less REM-sleep: r(20) = 0.52, p = 0.013; and increased sleep latency: r(20) = -0.57, p = 0.005 and time awake: r(20) = -0.59, p = 0.004). Cognitive performance was not related to anxiety/depression scores.

Conclusion

Using a simple neurocognitive screening tool, we found that pID patients showed cognitive deficiencies that related to both subjective/self-reported and objective/polysomnographic measures of sleep quality. Furthermore, these cognitive changes resembled those seen in preclinical non-amnestic AD, and thus could indicate incumbent neurodegenerative processes in pID. Interestingly, increased REM-sleep was correlated with better cognitive performance. However, whether REM-sleep is protective against neurodegeneration requires further investigation.

Treatment of hypertension and obstructive sleep apnea counteracts cognitive decline in common neurocognitive disorders in diagnosis-related patterns

The aim of this study was to investigate the effect of arterial hypertension (AH) and of obstructive sleep apnea (OSA) on cognitive course in the neurocognitive disorder (NCD) cohort RIFADE which enrolled patients with NCD due to Alzheimer's disease (AD), vascular NCD (vNCD), and mixed NCD (AD + vNCD = mNCD). Multiple risk factors (RF), including AH and OSA, that contribute to the development of various kinds of dementia have been identified in previous studies. Studies that observed AH lacked investigation of long-term effects and did not isolate it from other RF. Studies involving OSA as a risk factor did not include participants with all stages of NCD. 126 subjects were screened for AH and OSA. Repeated cognitive measurements were performed with the DemTect as primary outcome and the clock drawing test as secondary outcome measure. 90 patients had AH (71.4%) and 40 patients had OSA (31.7%). RF-status had a significant effect on cognitive outcome in models with RF as single factors (AH p = 0.027, OSA p < 0.001), a 2-factor analysis with AH × OSA (AH as main factor p = 0.027) as well as a model including the 3 factors AH × OSA × diagnosis (p = 0.038). Similarly, a 3-factor model was significant for the clock-drawing test, whereas single factor-models remained insignificant. AH and OSA appear to be risk factors in common NCD and cognitive decline can be mitigated by treatment of these RF.

Evaluating the feasibility of cognitive impairment detection in Alzheimer's disease screening using a computerized visual dynamic test

BACKGROUND

Alzheimer's disease (AD) is a neurodegenerative disease without known cure. However, early medical treatment can help control its progression and postpone intellectual decay. Since AD is preceded by a period of cognitive deterioration, the effective assessment of cognitive capabilities is crucial to develop reliable screening procedures. For this purpose, cognitive tests are extensively used to evaluate cognitive areas such as language, attention, or memory.

METHODS

In this work, we analyzed the potential of a visual dynamics evaluation, the rapid serial visual presentation task (RSVP), for the detection of cognitive impairment in AD. We compared this evaluation with two of the most extended brief cognitive tests applied in Spain: the Clock-drawing test (CDT) and the Phototest. For this purpose, we assessed a group of patients (mild AD and mild cognitive impairment) and controls, and we evaluated the ability of the three tests for the discrimination of the two groups.

RESULTS

The preliminary results obtained suggest the RSVP performance is statistically higher for the controls than for the patients (p-value = 0.013). Furthermore, we obtained promising classification results for this test (mean accuracy of 0.91 with 95% confidence interval 0.72, 0.97).

CONCLUSIONS

Since the RSVP is a computerized, auto-scored, and potentially self-administered brief test, it could contribute to speeding-up cognitive impairment screening and to reducing the associated costs. Furthermore, this evaluation could be combined with other tests to augment the efficiency of cognitive impairment screening protocols and to potentially monitor patients under medical treatment.

The clock drawing test is an important contribution to the Mini Mental State Examination in screening for cognitive impairment

BACKGROUND

The clock drawing test (CDT) and the Mini Mental State Examination (MMSE) are frequently used screening instruments for cognitive impairment, however, the precise contribution of the CDT to the MMSE is largely unknown.

METHODS

We studied patients with subjective cognitive impairment (SCI, n = 481), mild cognitive impairment (MCI, n = 628) and Alzheimer's disease (AD, n = 1099). Discrimination between patients was examined with multiple logistic regression, adjusted for age, sex, and education. Four groups were constructed based on a normal/abnormal MMSE (cut-off <24/30) versus normal/abnormal CDT (cut-off ≤2/3). Visually rated medial temporal lobe atrophy (MTA) on CT was used as parameter of neurodegeneration.

RESULTS

The CDT significantly contributed to the MMSE in discriminating SCI from both MCI and AD patients. Our four group analyses showed that of those patients with a normal MMSE and incorrectly classified as SCI, an abnormal CDT could significantly identify 10.0% as MCI and 13.2% as AD. Among those with an abnormal MMSE, the percentage AD patients shifted from 53.1% to 82.1% due to an abnormal CDT. Presence of an abnormal CDT was significantly related to MTA increase, regardless of the MMSE score.

CONCLUSION

The CDT is an important additional screening tool to the MMSE. An abnormal CDT with a normal MMSE is an indicator for cognitive impairment. An abnormal CDT in combination with an abnormal MMSE can be considered as an indicator of disease progression.

Interaction of Systemic Morbidity and Oral Health in Ambulatory Patients in Need of Home Care (InSEMaP): an observational study at the sector boundary between dental and general practice care in Germany

INTRODUCTION

Older people in need of home care are at risk of declining oral health as their visits to dentists are becoming less frequent due to restricted mobility. There is increasing evidence that poor oral health and systemic diseases are closely associated, for example, in cardiological, metabolic or neurodegenerative conditions. Thus, Interaction of Systemic Morbidity and Oral Health in Ambulatory Patients in Need of Home Care (InSEMaP) is investigating the need, provision and utilisation of oral healthcare, systemic morbidity and clinical status of the oral cavity in older people.

METHODS AND ANALYSIS

InSEMaP consists of four subprojects (SP), all involving the target population of older people in need of home care. In SP1 part a, a sample is surveyed using a self-report questionnaire. In SP1 part b, stakeholders (general practitioners, dentists, medical assistants, family and professional caregivers) are interviewed regarding barriers and facilitators using focus groups and personal interviews. In SP2, a retrospective cohort study, health insurance claims data are examined to investigate the utilisation of oral healthcare, its association with systemic morbidity and healthcare costs. In SP3, a clinical observational study will assess the oral health of participants by a dentist's visit at home. SP4 synthesises the results of SP1, SP2 and SP3 to develop integrated clinical pathways, identifying strategies to uphold oral healthcare in older people. In assessing and evaluating the process of oral healthcare, and its associated systemic morbidity, InSEMaP aims to improve general healthcare across the sector boundary of dental and general practitioner care.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Institutional Review Board of the Hamburg Medical Chamber (approval number: 2021-100715-BO-ff). The results of this study will be disseminated through conference presentations and publications in peer-reviewed journals. An expert advisory board to support the InSEMaP study group will be established.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register: DRKS00027020.

The Value of Clock Drawing Process Assessment in Screening for Mild Cognitive Impairment and Alzheimer's Dementia

Many clock drawing test (CDT) scoring systems focus on drawing results and lack drawing process assessments. This study created a CDT scoring procedure with drawing process assessment and explored its diagnostic value in screening for mild cognitive impairment (MCI) and early Alzheimer's disease (AD) from normal control (NC). We used logistic regression and receiver operating characteristic (ROC) curves to determine a new, sensitive scoring system for AD and MCI patients in a derivation cohort. The new scoring method was then compared to two common scoring systems and externally validated in a second cohort. We developed a new scoring system named CDT5, which contained one process assessment item: remember setting time without asking. Compared with two published scoring systems, CDT5 had better discriminatory power in distinguishing AD patients from NCs in derivation (area under the ROC curve [area under the curve, AUC] = .890) and validation (AUC = .867) cohorts. Three scoring systems had poor diagnostic accuracy at discriminating MCI patients from controls, with CDT5 being the most sensitive (78.57%). Adding the drawing process in CDT helps accurately detect patients with early AD, but its role in identifying patients with MCI needs to be further explored.

Outcome of visuospatial dysfunction assessment in patients with Parkinson's disease using mobile application software

Background

Visuospatial dysfunction and cognitive impairment are common in Parkinson's disease (PD), which draw increasing attention in the current literature. But clinicians still lack rapid, effective and unified cognitive battery for visuospatial assessment.

Objective

A new approach was studied to explore the feasibility of using mobile application software (APP) to evaluate visuospatial dysfunction in patients with PD and compared with traditional assessment tools. We aimed to verify the threshold score of the APP for early diagnosis.

Materials and methods

A total of 41 patients with PD underwent assessments using several test modules including Digit Symbol Test (DST), Visual Organization Test (VOT), Facial Recognition Test (FRT), Vocabulary Memory Test (VMT) of this APP, as well as Clock Drawing Test (CDT), Cube Copying Test (CCT) and the Mini-Mental State Examination (MMSE) for comparison. Among the 41 PD patients, 30 individuals were found to have visuospatial dysfunction based on CDT score < 5 and CCT score of<18 while the remaining 11 patients served as control.

Results

There were statistically significant differences in DST, VOT, and FRT scores (all p ≤ 0.001 for group comparisons). DST, VOT, and FRT-1 were significantly correlated with MMSE, CDT and CCT and the correlations were moderate or fairly strong. For visuospatial dysfunction diagnosis, all the areas under curves (AUC) of DST, VOT, and FRT-1 were statistically significant (p < 0.0001, p = 0.0002, and p = 0.0002, respectively). The estimates and 95% confidence intervals of AUC were 0.8303 (0.6868, 0.9739), 0.8045 (0.6423, 0.9668), and 0.7833 (0.6344, 0.9322), respectively. Their cut-off points for visuospatial dysfunction were 26, 17, and 19, respectively. After dichotomization by the cut-off points, DST had high sensitivity of 96.67% while VOT and FRT-1 had high specificity of 81.82 and 90.91%.

Conclusion

This study demonstrated that visuospatial disorders was highly prevalent in PD patients, and the APP used in study could be a practical clinical screening tool for visuospatial ability assessment with high sensitivity and specificity.

Limits on using the clock drawing test as a measure to evaluate patients with neurological disorders

BACKGROUND

The Clock Drawing Test (CDT) is used as a quick-to-conduct test for the diagnosis of dementia and a screening tool for cognitive impairments in neurological disorders. However, the association between the pattern of CDT impairments and the location of brain lesions has been controversial. We examined whether there is an association between the CDT scores and the location of brain lesions using the two available scoring systems.

METHOD

One hundred five patients with brain lesions identified by CT scanning were recruited for this study. The Montreal Cognitive Assessment (MoCA) battery including the CDT were administered to all partcipants. To score the CDT, we used a qualitative scoring system devised by Rouleau et al. (1992). For the quantitative scoring system, we adapted the algorithm method used by Mendes-Santos et al. (2015) based on an earlier study by Sunderland et al. (1989). For analyses, a machine learning algorithm was used.

RESULTS

Remarkably, 30% of the patients were not detected by the CDT. Quantitative and qualitative errors were categorized into different clusters. The classification algorithm did not differentiate the patients with traumatic brain injury 'TBI' from non-TBI, or the laterality of the lesion. In addition, the classification accuracy for identifying patients with specific lobe lesions was low, except for the parietal lobe with an accuracy of 63%.

CONCLUSION

The CDT is not an accurate tool for detecting focal brain lesions. While the CDT still is beneficial for use with patients suspected of having a neurodegenerative disorder, it should be cautiously used with patients with focal neurological disorders.

Education bias in typical brief cognitive tests used for the detection of dementia in elderly population with low educational level: a critical review

Dementia is a significant decline in cognition that interfere with independent, daily functioning. Dementia is a syndrome caused by a myriad and include primary neurologic, neuropsychiatric, and medical conditions. It has been projected that the prevalence of dementia will triple in the elderly population by the year 2050. Despite the benefits of early diagnosis, there is an effective under-detection of around 62% of people with mild cognitive impairment (MCI) or dementia. One of the factors associated with this problem is that diagnostic techniques are affected by the educational level of those evaluated. This is an important aspect to consider in the use of brief cognitive tests for the detection of dementia. This review presents and critically analyzes the available evidence regarding the effect of educational level on the diagnostic utility of three of the most widely used tools in the clinical setting: the Mini-mental Test Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Addenbrooke's Cognitive Examination (ACE). Previous evidence shows that the tasks that require reading, writing, calculation, phonological fluency, and visuoconstruction are affected by educational level. These results lead to discourage the use of these tests in older people with less than 6 years of schooling. The development of brief cognitive tests appropriate for people with a low educational level is recommended. We posit that adequate cognitive tests should not consider tasks or items that resemble characteristics of academic contexts and should be more analogous to daily activities situations.

Effects of Intermittent Hypoxia-Hyperoxia Exposure Prior to Aerobic Cycling Exercise on Physical and Cognitive Performance in Geriatric Patients—A Randomized Controlled Trial

Background: It was recently shown that intermittent hypoxic-hyperoxic exposure (IHHE) applied prior to a multimodal training program promoted additional improvements in cognitive and physical performance in geriatric patients compared to physical training only. However, there is a gap in the literature to which extent the addition of IHHE can enhance the effects of an aerobic training. Therefore, the aim of this study was to investigate the efficacy of IHHE applied prior to aerobic cycling exercise on cognitive and physical performance in geriatric patients.

Methods: In a randomized, two-armed, controlled, and single-blinded trial, 25 geriatric patients (77–94 years) were assigned to two groups: intervention group (IG) and sham control group (CG). Both groups completed 6 weeks of aerobic training using a motorized cycle ergometer, three times a week for 20 min per day. The IG was additionally exposed to intermittent hypoxic and hyperoxic periods for 30 min prior to exercise. The CG followed the similar procedure breathing sham hypoxia and hyperoxia (i.e., normoxia). Within 1 week before and after the interventions, cognitive performance was assessed with the Dementia-Detection Test (DemTect) and the Clock Drawing Test (CDT), while physical performance was measured using the Timed “Up and Go” Test (TUG) and the Short-Physical-Performance-Battery (SPPB).

Results: No interaction effect was found with respect to the DemTect (η_p² = 0.02). An interaction effect with medium effect size (η_p² = 0.08) was found for CDT performance with a higher change over time for IG (d = 0.57) compared to CG (d = 0.05). The ANCOVA with baseline-adjustment indicated between-group differences with a large and medium effect size at post-test for the TUG (η_p² = 0.29) and SPPB (η_p² = 0.06) performance, respectively, in favour of the IG. Within-group post-hoc analysis showed that the TUG performance was worsened in the CG (d = 0.65) and remained unchanged in the IG (d = 0.19). Furthermore, SPPB performance was increased (d = 0.58) in IG, but no relevant change over time was found for CG (d = 0.00).

Conclusion: The current study suggests that an additional IHHE prior to aerobic cycling exercise seems to be more effective to increase global cognitive functions as well as physical performance and to preserve functional mobility in geriatric patients in comparison to aerobic exercise alone after a 6-week intervention period.

Comparing drawing under instructions with image copying for mild cognitive impairment (MCI) or dementia screening: a meta-analysis of 92 diagnostic studies

OBJECTIVES

Drawing is a major component of cognitive screening for dementia. It can be performed without language restriction. Drawing pictures under instructions and copying images are different screening approaches. The objective of this study was to compare the diagnostic performance between drawing under instructions and image copying for MCI and dementia screening.

METHOD

A literature search was carried out in the OVID databases with keywords related to drawing for cognitive screening. Study quality and risk of bias were assessed by QUADAS-2. The level of diagnostic accuracy across different drawing tests was pooled by bivariate analysis in a random effects model. The area under the hierarchical summary receiver-operating characteristic curve (AUC) was constructed to summarize the diagnostic performance.

RESULTS

Ninety-two studies with sample size of 22,085 were included. The pooled results for drawing under instructions showed a sensitivity of 79% (95% CI: 76 - 83%) and a specificity of 80% (95% CI: 77 - 83%) with AUC of 0.87 (95% CI: 0.83 - 0.89). The pooled results for image copying showed a sensitivity of 71% (95% CI: 62 - 79%) and a specificity of 83% (95% CI: 72 - 90%) with AUC of 0.83 (95% CI: 0.80 - 0.86). Clock-drawing test was the screening test used in the majority of studies.

CONCLUSION

Drawing under instructions showed a similar diagnostic performance when compared with image copying for cognitive screening and the administration of image copying is relatively simpler. Self-screening for dementia is feasible to be done at home in the near future.

Diagnostic performance and neural basis of the combination of free- and pre-drawn Clock Drawing Test

OBJECTIVES

This study aimed to clarify the diagnostic performance and neural basis of the Clock Drawing Test (CDT) combining free- and pre-drawn methods.

METHODS

This retrospective study included 165 participants (91 with Alzheimer disease [AD], 52 with amnestic mild cognitive impairment [aMCI], and 22 healthy controls [HC]), who were divided into four groups according to their free- and pre-drawn CDT scores: group 1, could do both; group 2, impaired in both; group 3, impaired in pre-drawn CDT; and group 4, impaired in free-drawn CDT. The diagnostic performances of the free-drawn, pre-drawn, and combination methods were compared using receiver operating characteristics analysis; in voxel-based morphometry analysis, the gray matter (GM) volume of groups 2-4 were compared with that of group 1.

RESULTS

The area under the curve of the combination method was greater than that of the free- or pre-drawn method alone when comparing AD with HC or aMCI. Group 2 had a significantly smaller GM volume in the bilateral temporal lobes than group 1. Group 3 had a trend toward smaller GM volumes in the right temporal lobe when a liberal threshold was applied. Group 4 had significantly smaller GM volumes in the left temporal lobe than group 1.

CONCLUSIONS

This study suggests that the combination method may be able to screen for a wider range of brain dysfunction. Combined use of free- and pre-drawn CDT may be useful for screening for AD and its early detection and treatment.

Assessment of the diagnostic accuracy and discriminative validity of the Clock Drawing and Mini-Cog tests in detecting cognitive impairment

INTRODUCTION AND OBJECTIVES

The Mini-Cog is a very brief, widely used cognitive test that includes a memory task and a simplified assessment of the Clock Drawing Test (CDT). There is not a formal evaluation of the Mini-Cog test in Spanish. This study aims to analyse the diagnostic usefulness of the Mini-Cog and CDT for detecting cognitive impairment (CI).

METHODS

We performed a cross-sectional study, systematically including all patients who consulted at our neurology clinic over a 6-month period. We assessed diagnostic usefulness for detecting CI (defined according to the National Institute on Aging-Alzheimer's Association criteria for mild cognitive impairment and dementia) according to the area under the receiver operating characteristic curve (AUC). Sensitivity, specificity, and positive and negative likelihood ratios were calculated for each cut-off point.

RESULTS

The study included 581 individuals (315 with CI); 55.1% were women and 27.7% had not completed primary studies. The Mini-Cog showed greater diagnostic usefulness than the CDT (AUC±sensitivity: 0.88±0.01 vs 0.84±0.01; P<.01). Both instruments were less useful for screening in individuals with a low education level (0.74±0.05 vs 0.75±0.05, respectively). A cut-off point of 2/3 in the Mini-Cog achieved a sensitivity of 0.90 (95%CI, 0.87-0.93) and a specificity of 0.71 (95%CI, 0.65-0.76); a cut-off point of 5/6 in the CDT achieved a sensitivity of 0.77 (95%CI, 0.72-0.81) and a specificity of 0.80 (95%CI, 0.75-0.85).

CONCLUSION

In our neurology clinic, the Mini-Cog showed acceptable diagnostic usefulness for detecting CI, greater than that of the CDT; neither test is an appropriate instrument for individuals with a low level of education.

Clock drawing test: comparison between the Pfizer and the Shulman systems

ABSTRACT Cognitive decline can be screened by the clock drawing test (CDT), which has several versions. Objective: This survey aimed to analyze the correlation between two simple methods for scoring the CDT. Methods: This cross-sectional study was nested in the Elo-Creati cohort from Passo Fundo, Brazil and comprised 404 subjects. Two raters underwent previous training and scored the subjects’ CDT according to both the Pfizer and Shulman systems. The inter-observer and intra-observer concordance within each method was analyzed with the Spearman’s rank correlation coefficient, as well as the concordance of the scores between the two methods. Age and scholarity were also correlated with the scores. Results: Most of the participants were women (93.8%) and Caucasian (84.6%), with a mean age of 66.9 (±7.8) years and a scholarity of 10.9 years (±5.6). There was significant inter-observer (Pfizer: r=0.739, p£0.001; Shulman: r=0.727, p£0.001) and intra-observer correlation (Pfizer: rater 1, r=0.628, p≤0.001; rater 2, r=0.821, p≤0.001; Shulman: rater 1, r=0.843, p≤0.001; rater 2: r=0.819; p≤0.001). Intra-observer correlation was also observed comparing Pfizer and Shulman methods (rater 1: r=0.744; p≤0.001; rater 2: r=0.702; p≤0.001). There was weak correlation of the scores with scholarity (Pfizer: r=0.283, p£0.001; Shulman: r=0.244, p£0.001) and age (Pfizer: r=-0.174, p£0.001; Shulman: r=-0.170, p£0.001). More participants were classified with decreased cognition through the Pfizer system (rater 1: 44.3 vs. 26.5%; rater 2: 42.1 vs. 16.3%; p≤0.001). Conclusions: For this population, our results suggest that the Pfizer system of scoring CDT is more suitable for screening cognitive decline.

Evaluation of Digital Drawing Tests and Paper-and-Pencil Drawing Tests for the Screening of Mild Cognitive Impairment and Dementia: A Systematic Review and Meta-analysis of Diagnostic Studies

Digital drawing tests have been proposed for cognitive screening over the past decade. However, the diagnostic performance is still to clarify. The objective of this study was to evaluate the diagnostic performance among different types of digital and paper-and-pencil drawing tests in the screening of mild cognitive impairment (MCI) and dementia. Diagnostic studies evaluating digital or paper-and-pencil drawing tests for the screening of MCI or dementia were identified from OVID databases, included Embase, MEDLINE, CINAHL, and PsycINFO. Studies evaluated any type of drawing tests for the screening of MCI or dementia and compared with healthy controls. This study was performed according to PRISMA and the guidelines proposed by the Cochrane Diagnostic Test Accuracy Working Group. A bivariate random-effects model was used to compare the diagnostic performance of these drawing tests and presented with a summary receiver-operating characteristic curve. The primary outcome was the diagnostic performance of clock drawing test (CDT). Other types of drawing tests were the secondary outcomes. A total of 90 studies with 22,567 participants were included. In the screening of MCI, the pooled sensitivity and specificity of the digital CDT was 0.86 (95% CI = 0.75 to 0.92) and 0.92 (95% CI = 0.69 to 0.98), respectively. For the paper-and-pencil CDT, the pooled sensitivity and specificity of brief scoring method was 0.63 (95% CI = 0.49 to 0.75) and 0.77 (95% CI = 0.68 to 0.84), and detailed scoring method was 0.63 (95% CI = 0.56 to 0.71) and 0.72 (95% CI = 0.65 to 0.78). In the screening of dementia, the pooled sensitivity and specificity of the digital CDT was 0.83 (95% CI = 0.72 to 0.90) and 0.87 (95% CI = 0.79 to 0.92). The performances of the digital and paper-and-pencil pentagon drawing tests were comparable in the screening of dementia. The digital CDT demonstrated better diagnostic performance than paper-and-pencil CDT for MCI. Other types of digital drawing tests showed comparable performance with paper-and-pencil formats. Therefore, digital drawing tests can be used as an alternative tool for the screening of MCI and dementia.

Assessment of the diagnostic accuracy and discriminative validity of the Clock Drawing and Mini-Cog tests in detecting cognitive impairment

INTRODUCTION AND OBJECTIVES

The Mini-Cog is a very brief, widely used cognitive test that includes a memory task and a simplified assessment of the Clock Drawing Test (CDT). There is not a formal evaluation of the Mini-Cog test in Spanish. This study aims to analyse the diagnostic usefulness of the Mini-Cog and CDT for detecting cognitive impairment (CI).

METHODS

We performed a cross-sectional study, systematically including all patients who consulted at our neurology clinic over a 6-month period. We assessed diagnostic usefulness for detecting CI (defined according to the National Institute on Aging-Alzheimer's Association criteria for mild cognitive impairment and dementia) according to the area under the receiver operating characteristic curve (AUC). Sensitivity, specificity, and positive and negative likelihood ratios were calculated for each cut-off point.

RESULTS

The study included 581 individuals (315 with CI); 55.1% were women and 27.7% had not completed primary studies. The Mini-Cog showed greater diagnostic usefulness than the CDT (AUC ± sensitivity: 0.88 ± 0.01 vs 0.84 ± 0.01; P < .01). Both instruments were less useful for screening in individuals with a low education level (0.74 ± 0.05 vs 0.75 ± 0.05, respectively). A cut-off point of 2/3 in the Mini-Cog achieved a sensitivity of 0.90 (95% CI, 0.87-0.93) and a specificity of 0.71 (95% CI, 0.65-0.76); a cut-off point of 5/6 in the CDT achieved a sensitivity of 0.77 (95% CI, 0.72-0.81) and a specificity of 0.80 (95% CI, 0.75-0.85).

CONCLUSION

In our neurology clinic, the Mini-Cog showed acceptable diagnostic usefulness for detecting CI, greater than that of the CDT; neither test is an appropriate instrument for individuals with a low level of education.

Domain-Specific Cognitive Trajectories Among Patients with Minor Stroke or Transient Ischemic Attack in a 6-Year Prospective Asian Cohort: Serial Patterns and Indicators

BACKGROUND

Long-term post-stroke cognitive impairment (PSCI) has often been overlooked, especially among patients with minor stroke or transient ischemic attack (TIA).

OBJECTIVE

To assess 6-year domain-specific cognitive trajectories among survivors of minor stroke or TIA and to identify possible indicators associated with cognitive trajectories, as well as long-term and incident PSCI.

METHODS

Eligible participants completed cognitive and clinical assessments at baseline (2 weeks after stroke) and up to 5 follow-up visits in 6 years. Mixed linear models and generalized estimating equations were adopted to analyze longitudinal data and survival analysis to explore incident PSCI, controlling for demographic, clinical, and vascular indicators.

RESULTS

The prevalence of PSCI and mortality rate ranged from 34.6% to 53.7%, and 0 to 7.7% respectively, among 244 patients. Incidence of PSCI was 21.9%. While visual memory demonstrated a significant improvement (p <  0.05), other cognitive domains showed a fluctuating yet stable pattern across visits (all ps >  0.05). Besides age, baseline IQCODE (attention: -0.218 SD/y, executive function: -0.238 SD/y, visual memory: -0.266 SD/y), and MoCA improvement within 1 year (visuoconstruction: 0.007 SD/y, verbal memory: 0.012 SD/y) were associated with longitudinal cognitive changes. Baseline MoCA (OR = 0.66, 95% CI = [0.59-0.74]), MoCA improvement within 3-6 months (OR = 0.79, 95% CI = [0.71-0.89], and within 1 year (OR = 0.86, 95% CI = [0.76-0.96]) were associated with long-term PSCI, while baseline MoCA (OR = 0.76, 95% CI = [0.61-0.96]) was also associated with incident PSCI.

CONCLUSION

While most domains remained stable across-time, visual memory demonstrated an overall improvement. Short-term cognitive improvement could be an early indicator of long-term cognitive trajectory to identify individuals who may be resilient to PSCI.

Timed "Up & Go" Dual-Task Tests: Age- and Sex-Specific Reference Values and Test-Retest Reliability in Cognitively Healthy Controls

OBJECTIVE

The purpose of the study was to establish reference values for the Uppsala-Dalarna Dementia and Gait (UDDGait) Timed "Up & Go" dual-task (TUGdt) test variables in cognitively healthy adults and to assess these variables' test-retest reliability.

METHODS

For reference values, 166 participants were recruited with approximately equal numbers and proportions of women and men in the age groups 50 to 59, 60 to 69, 70 to 79, and 80+ years (mean age = 70 years, age range = 50-91 years, 51% women). For reliability testing, 43 individuals (mean age = 69 years, age range = 50-89 years, 51% women) were recruited. Two dt tests were carried out: TUGdt naming animals and TUGdt months backward, representing 8 test variables: time scores, costs (the relative difference between single-task and dt time scores), "number of animals," "number of months," "animals/10 seconds ," and "months/10 seconds ." Reference ranges for the variables were established by quantile regression in age- and sex-specific groups. For reliability, intraclass correlation coefficients (ICCs), standard error of measurement, minimal detectable change, and Bland-Altman plots were used.

RESULTS

Reference values for the TUGdt test variables are presented for the 2.5th and 97.5th percentiles. The reliability of TUGdt time scores was excellent (ICCs between 0.85 and 0.86). "Number of animals" and "animals/10 seconds" as well as "months/10 seconds" showed fair to good levels of reliability (ICCs between 0.45 and 0.58), whereas the reliability for both cost measures and "number of months" was poor (ICCs between 0.34 and 0.39).

CONCLUSION

Normative reference values, potentially useful for clinical and research purposes, were presented in 4 age- and sex-specific groups from 50 years and older. Reliability for the test variables varied between poor and excellent, the lower estimates partly explained by some variables being the ratio of 2 other variables. In UDDGait, TUGdt tests are intended for diagnostic and predictive purposes, for which these tests are promising and require further investigations.

IMPACT

Normative reference values and test-retest reliability results for the UDDGait TUGdt test variables were presented. These results should be useful for both clinical and research purposes.

A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients

Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the "Mada" and "Metatron" packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58-0.87) with specificity of 0.70 (0.51-0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.

Demographic characteristics and neuropsychological assessments of subjective cognitive decline (SCD) (plus)

BACKGROUND

Since SCD (plus) was standardized, little is known about its demographic characteristics and its outcomes of neuropsychological assessments, including the SCD questionnaire 9 (SCD-Q9).

OBJECTIVE

To characterize SCD (plus) by comparing the neuropsychological features among its subgroups and with normal controls (NC). Also, to explore its demographics and to understand the relation of the chief complaints and the scores of SCD-Q9.

METHODS

Multistage stratified cluster random sampling was conducted to select participants. As a result, 84 NC and 517 SCD (plus) were included. SCD (plus) was further classified into several subgroups (SCD-C: concerned cognitive decline; SCD-F: complaints about SCD within the past five years; SCD-P: feeling performance being not as good as their peers; SCD+: presented> 3 of SCD (plus) features; SCD-: presented ≤ 3 of SCD (plus) features (see the diagnostic criteria for the details)) and between-group comparisons of neuropsychological scores were conducted. Point-biserial correlation and binary logistic regression analyses were performed to investigate the demographic characteristics of its subgroups. Finally, Spearman correlation was used to better understand the relation of SCD (plus) to SCD-Q9.

RESULTS

(1) Scores of AVLT-LR (AVLT-LR: Auditory Verbal Learning Test-Long Delayed Recall) and MoCA-B (MoCA: Montreal Cognitive Assessment-Basic) were lower in the SCD-P group than those in the NC group, and the SCD+ group scored lower in the MoCA-B and CDT(CDT: Clock Drawing Test) than the SCD- group. (2) Females were more concerned than male participants. Individuals with lower education level felt that their cognitive performance were worse than their peers. Also, younger people might express concerns more than the more elderly. People who had complaints of SCD-P might be more likely to report SCD-C, but less likely to report SCD-F. (3) Positive correlations were found between the chief complaints of SCD (plus) and some items of SCD-Q9.

CONCLUSIONS

SCD (plus) may be related to demographic factors. Individuals with SCD (plus) already exhibited cognitive impairment, which can be detected by SCD-Q9.

Dual-Task Tests Predict Conversion to Dementia-A Prospective Memory-Clinic-Based Cohort Study

The aim of this study was to investigate whether Timed Up-and-Go (TUG) dual-task (TUGdt) tests predict dementia incidence among patients with subjective or mild cognitive impairment (SCI; MCI). Other study objectives were to determine whether TUGdt improves dementia prediction compared to a) demographic characteristics and standard cognitive tests alone; and b) TUG and Verbal Fluency performed separately. Patients (n = 172, age range 39–91 years, 78 women) with SCI or MCI performed TUGdt tests, including 1) naming animals and 2) reciting months backwards, and clinical cognitive tests at baseline. Diagnoses were identified at follow-up after 2.5 years. Logistic regression was used to predict dementia incidence, receiver operating characteristic (ROC) curves and c-statistics for predictive capacity. Analyses were stratified by age and gender. At follow-up, 51 patients had developed dementia. The TUGdt result “animals/10 s” was associated with dementia incidence (standardized odds ratio (OR) = 4.06, 95% confidence interval (CI) 2.28–7.23, p < 0.001), more so among patients under the median age of 72 years (standardized OR = 19.4, 95% CI 3.53–106.17, p < 0.001). TUGdt “animals/10 s” improved dementia prediction compared to demographic characteristics and standard tests alone (c-statistics 0.88 to 0.94) and single-task tests (c-statistics 0.86 to 0.89), but only in the younger patient group. TUGdt has the potential to become a useful tool for dementia prediction.

Clock-drawing test: Normative data of three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City and clinical utility in patients with acute ischemic stroke

OBJECTIVE

The clock-drawing test (CDT) is a widely used screening tool for detecting cognitive decline. However, normative data for Chinese individuals are scarce. Our study aimed to provide standardized values for the three quantitative CDT scoring methods that were tailored for Chinese-speaking adults in Shijiazhuang City and explore the discriminant validity of the CDT scores in patients with acute ischemic stroke.

METHODS

We conducted the CDT among 418 healthy individuals aged between 35 and 84 years. The CDT was administered and scored by five raters using the method derived from the Montreal Cognitive Assessment (MoCA), Rouleau's, and Babins' scoring systems. The influence of age, education, and sex on the performance in the CDT was analyzed. Furthermore, 336 patients with acute ischemic stroke were enrolled to explore the discriminant validity of CDT scores.

RESULTS

In all three scoring systems, CDT scores were significantly correlated with age and years of education but not with sex. Normative data stratified for age and years of education were established. Interrater and intersystem reliability were high in our study. CDT total scores and subscores showed significant differences between stroke patients and healthy individuals.

CONCLUSIONS

Our study provides CDT normative data using three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City. Age and education level were the key factors that affected the CDT scores. CDT total scores and subscores provided good discriminant validity for patients with acute ischemic stroke.

Current Cognition Tests, Potential Virtual Reality Applications, and Serious Games in Cognitive Assessment and Non-Pharmacological Therapy for Neurocognitive Disorders

As the global population ages, the incidence of major neurocognitive disorders (major NCDs), such as the most common geriatric major NCD, Alzheimer's disease (AD), has grown. Thus, the need for more definitive cognitive assessment or even effective non-pharmacological intervention for age-related NCDs is becoming more and more pressing given that no definitive diagnostics or efficacious therapeutics are currently unavailable for them. We evaluate the current state of the art of cognitive assessment for major NCDs, and then briefly glance ahead at potential application of virtual reality (VR) technologies in major NCD assessment and in cognition training of visuospatial reasoning in a 3D environment, as well as in the alleviation of depression and other symptoms of cognitive disorders. We believe that VR-based technologies have tremendous potentials in cognitive assessment and non-pharmacological therapy for major NCDs.

Comparison of Performance on the Clock Drawing Test Using Three Different Scales in Dialysis Patients

Background

The clock drawing test (CDT) is frequently used to detect changes in cognition. Multiple scales of varying length have been published to assess performance. The aim of this study is to compare the CDT performance measured by three scales among a sample of nondemented patients on renal dialysis and identify the variables that affect performance. Methodology. This is a cross-sectional study performed at the dialysis unit at King Saud University Medical City. Eighty-nine dialysis patients performed the CDT. The CDT was scored by the methods of Rouleau et al. (RCS 10-point), Babins et al. (BCS 18-point), and the MoCA (MCS 3-point). Regression models were used to determine influencing demographic and dialysis variables. Scores were then correlated, and a combined factor analysis of scale components was done.

Results

Females represented 44.6%, the mean (SD) age was 49.99 (15.49) years, and education duration was 10.29 (5.5) years. Dialysis vintage was 55.81 (62.91) months. The scores for the MCS, RCS, and BCS were 2.18 (1.08), 6.67 (3.07), and 11.8 (5.5), respectively, with significant correlation (P < 0.0001). In all scales, increasing age was associated with a lower score (each P < 0.0001). The scores increased with increasing education (each P < 0.0001). Diabetics had a lower score on both the BCS and MCS by 2.56 (SE 1.2) (P = 0.035) and 0.71 (P = 0.003) points, respectively. However, only age and years of education were significant in the multivariable analysis. In factor analysis, two shared factors appeared between the three scales: hand and number placement and the clock face.

Conclusion

Age and education influence the performance on the CDT, and factors diverged into executive and visuospatial components. The MCS is likely to yield useful information but should be interpreted as part of the MoCA.

Predicting non-elective hospital readmission or death using a composite assessment of cognitive and physical frailty in elderly inpatients with cardiovascular disease

Background

We aimed to assess the utility of the combination of the mini-mental state examination (MMSE) + clock drawing test (CDT) and the Fried phenotype for predicting non-elective hospital readmission or death within 6 months in elderly inpatients with cardiovascular disease (CVD).

Methods

A single-center prospective cohort was conducted from September 2018 to February 2019. Inpatients ≥65 years old were recruited. Predictive validity was tested using a Cox proportional hazards regression model analysis, and the discriminative ability was evaluated by the receiver operating characteristic (ROC) curve.

Results

A total of 542 patients were included. Overall, 12% (64/542) screened positive for cognitive impairment, 16% (86/542) were physically frail and 8% (44/542) had cognitive impairment combined with physical frailty, showing an older age (P < 0.001) and a lower education level (P < 0.001) than physically frail patients. A total of 113 patients (20.9%) died or were readmitted at 6 months. Frail participants with a normal (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 1.06–2.82, P = 0.028) or impaired cognition (HR: 2.50, 95% CI: 1.27–4.91, P = 0.008) had a higher risk of non-elective hospital readmission or death than robust patients after adjusting for the age, sex, education level, marital status, the presence of diabetes mellitus, heart failure, and history of stroke. The area under the ROC curve (AUC) showed that the discriminative ability in relation to 6 months readmission and death for the MMSE + CDT + Fried phenotype was 0.65 (95% CI: 0.60–0.71), and the AUC for men was 0.71 (95% CI: 0.63–0.78), while that for women was 0.60 (95% CI: 0.51–0.69).

Conclusions

Accounting for cognitive impairment in the frailty phenotype may allow for the better prediction of non-elective hospital readmission or death in elderly inpatients with CVD in the short term.

Trial registration

ChiCTR1800017204; date of registration: 07/18/2018.

Aluminum-Induced Cognitive Impairment and PI3K/Akt/mTOR Signaling Pathway Involvement in Occupational Aluminum Workers

Epidemiological studies indicate that long-term occupational exposure to aluminum (Al) causes neurotoxicity and cognitive impairment. While the molecular underpinnings associated with workers' cognitive impairment is unclear, one mechanism may involve Al-induced PI3K/Akt/mTOR activation and neuronal cell death, which impairs learning and memory in rats. Here, we sought to determine whether PI3K/Akt/mTOR is also associated with cognitive impairment in Al-exposed occupational workers. Cognitive function was screened by Mini-Mental State Examination (MMSE) and Clock-Drawing Test (CDT), and serum Al and PI3K/Akt/mTOR-associated gene expression was quantified. A negative correlation between serum Al and scores of MMSE and CDT was found, which might relate with downregulation of PI3K/Akt/mTOR. To determine the role of the PI3K/Akt/mTOR pathway cognitive function, we treated zebrafish with Al and observed a profound impairment in learning and memory. Increased brain Al levels was associated with decreased expression of PI3K/Akt/mTOR in Al-exposed zebrafish. Finally, rapamycin, an mTOR inhibitor, was added to isolate the role of mTOR specifically in the Al exposed zebrafish. The results suggested that Al induces learning and memory deficits by downregulating PI3K, Akt, and mTOR1 expression and inducing neuronal cell death like rapamycin group. This study indicates that aluminum exposure can cause cognitive impairment through PI3K/Akt/mTOR pathway, with mTOR activity being a critical player involved in this mechanism. Future studies are necessary to further characterize the role of PI3K/Akt/mTOR1 signaling in Al-induced neurocognitive decline among Al occupational workers. These findings draw attention to Al risk exposure among occupational workers and the need to implement novel safety and protective measures to mitigate neurocognitive health risks in the Al industrial workspace.

Daily exposure to digital displays may affect the clock-drawing test: from psychometrics to serendipity

BACKGROUND

The clock-drawing test (CDT) is a neuropsychological screening tool largely used to explore cognitive functioning. It requires participants to draw an analog clock face. Many studies have reported a good correlation between the CDT and the Mini-Mental State Examination (MMSE). The CDT has also showed a variable specificity. There are, however, some inconsistencies concerning the effect of sociodemographic variables (sex, age, education) on clock-drawing abilities. The present study aimed at examining these issues in a sample of middle-aged/young-old healthy adults.

METHOD

Participants (n = 97) performed the MMSE and CDT. Clock drawings were assessed by five formal scoring systems (Wolf-Klein, Watson, Freedman, Manos, Shulman). In addition, three naïve raters provided a dichotomous judgment (normal vs. abnormal) for each clock.

RESULTS

Sociodemographic variables did not affect CDT performance. Unlike earlier studies, CDT scores did not correlate with MMSE. Moreover, test specificity was appropriate only for Freedman's, Shulman's, and Wolf-Klein's methods. Interestingly, some participants drew clocks with numbers as they appear in digital clocks. By re-running the statistical analyses after removing these atypical clocks, four out of the five formal scores showed a significant correlation with MMSE; furthermore, CDT specificity slightly increased for all scoring systems including naïve ratings.

CONCLUSIONS

CDT is not affected by sociodemographic variables. The finding of some clocks with digitally represented numbers suggests the need to align neuropsychological assessments with demands from an increasing digitalized environment. Moreover, the occurrence of high false-positives and possible digital contaminations suggest great caution in interpreting the clinical significance of CDT.

Field Application of Digital Technologies for Health Assessment in the 10,000 Families Study

BACKGROUND

We field tested new-to-market portable, digital applications to assess hearing, pulmonary, and cognitive function to determine the feasibility of implementing these applications across a range of age groups in the pilot phase of the 10,000 Families Study (10KFS), a new Minnesota family-based prospective cohort study.

METHODS

We followed manufacturer recommended protocols for audiometry (SHOEBOX Inc), spirometry (NuvoAir), and the digital clock drawing test (dCDT; Digital Cognition Technologies Inc).

RESULTS

These digital devices were low cost and readily implemented in a 2.5-hour health fair visit with minimal training (2-3 hours) of study staff. To date, we have performed these measurements on 197 eligible 10KFS participants during an in-person clinic visit. A total of 37 children (age 4-17 years), 107 adults (18-64 years), and 53 seniors (≥65 years) were eligible to undergo hearing and pulmonary assessments. Children were less likely to successfully complete the hearing test (76%) compared with adults (86%) and seniors (89%). However, successful completion of the pulmonary assessment was high across all groups: 100% of children and seniors and 98% of adults. The dCDT was performed among those over the age of 40, and completion rates were 92% for those aged 41-64 and 94% for those ≥65 years.

CONCLUSIONS

Our field testing indicates these digital applications are easy and cost-effective to implement in epidemiologic studies.

IMPACT

Digital applications provide exciting opportunities to collect data in population studies. Issues related to data privacy, data access, and reproducibility of measurements need to be addressed before deploying digital applications in epidemiologic studies.See all articles in this CEBP Focus section, "Modernizing Population Science."

Screening for cognitive impairment in Arabic-speaking Hajj pilgrims

Background

Although cognitive impairment is common in the elderly population, studies investigating its rate in Hajj pilgrims are lacking.

Objectives

To estimate the rate of cognitive impairment among a sample of Arabic-speaking elderly Hajj pilgrims and examine its association with their activities of daily living (ADL).

Methods

A cross-sectional study was conducted during the Hajj season 1438 Hijri Calendar (August 2017). Hajj pilgrims were recruited using a probability sampling method and were interviewed for demographics, the MINI-Cog and the ADL instrument.

Results

Among the 340 recruited pilgrims, 99 (29.2%) had positive results in the MINI-Cog indicating probable cognitive impairment. In multivariate logistic regression, the educational level (odds ratio (OD) 0.456; 95% CI 0.346 to 0.598) and the need for help during Hajj (OD 0.581; 95% CI 0.342 to 0.984) were found significantly associated with positive MINI-Cog. Although no significant differences in the ADL were found between pilgrims with and without positive MINI-Cog, the scores of the ADL and the MINI-Cog were found to be positively correlated but weak (rs = 0.134, P = 0.013) indicating a possible association between better cognitive functions and better ADL performance.

Conclusion

Probable cognitive impairment among Arabic elderly Hajj pilgrims was found to be very common. Further diagnostic studies and studies on the impact of cognitive impairment on the performance of Hajj pilgrims are warranted.

Tau PET Distributional Pattern in AD Patients with Visuospatial Dysfunction

BACKGROUND

Visuospatial dysfunction is one predominant symptom in many atypical Alzheimer's disease (AD) patients, however, until now its neural correlates still remain unclear. For the accumulation of intracellular hyperphosphorylated tau proteins is a major pathogenic factor in neurodegeneration of AD, the distributional pattern of tau could highlight the affected brain regions associated with specific cognitive deficits.

OBJECTIVE

We investigated the brain regions particularly affected by tau accumulation in patients with visuospatial dysfunction to explore its neural correlates.

METHODS

Using 18F-AV-1451 tau positron emission tomography (PET), voxel-wise two-sample t-tests were performed between AD patients with obvious visuospatial dysfunction (VS-AD) and cognitively normal subjects, AD patients with little-to-no visuospatial dysfunction (non VS-AD) and cognitively normal subjects, respectively.

RESULTS

Results showed increased tau accumulations mainly located in occipitoparietal cortex, posterior cingulate cortex, precuneus, inferior and medial temporal cortex in VS-AD patients, while increased tau accumulations mainly occurred in the inferior and medial temporal cortex in non VS-AD patients.

CONCLUSION

These findings suggested that occipitoparietal cortex, posterior cingulate cortex and precuneus, which were particularly affected by increased tau accumulation in VS-AD patients, may associate with visuospatial dysfunction of AD.

Risk Factors and Neuropsychological Assessments of Subjective Cognitive Decline (plus) in Chinese Memory Clinic

Background

Since subjective cognitive decline (SCD) was standardized in 2014, many studies have investigated its features. However, the risk of SCD (plus) progressing to AD is much higher, and yet there have been few studies reporting the risk factors and neuropsychological assessment characteristics of SCD (plus).

Objective

To characterize SCD (plus) by comparing it with normal control (NC), amnesic mild cognitive impairment (aMCI), and Alzheimer Disease (AD) regarding their demographics, lifestyle, family history of dementia, multimorbidity and the neuropsychological assessments.

Methods

A total of 135 participants were recruited, including 23 NC, 30 SCD (plus), 45 aMCI and 37 AD. Descriptive statistics were provided. A logistic regression model was used to analyze the affecting factors of SCD (plus), and finally the Receiver Operating Characteristic (ROC) analysis was applied to distinguish between SCD (plus) and NC.

Results

(1) SCD (plus) group was younger than both the aMCI group and AD group. It consisted of more participants with mental work and higher body mass index (BMI) than the AD group. (2) Scores of Auditory Verbal Learning Test - Immediate recall (AVLT-IR) and AVLT-Long delayed recall (AVLT-LR) decreased in the following order: NC→SCD (plus)→aMCI→AD. (3) The Area Under Curve (AUC) for discriminating SCD (plus) and NC group was from 0.673 to 0.838.

Conclusion

Aging is an important risk factor of both NC progressing to SCD (plus), and SCD (plus) progressing to aMCI or AD. In addition to aging, lower education level and lower BMI were significantly associated with greater odds of SCD (plus) progressing to aMCI or AD patients, whereas mental work was a protective factor of SCD (plus) progressing to AD. Finally, AVLT is a sensitive indicator of the cognitive decline and impairment in SCD (plus) in relative to normal controls.

Cognitive screening instruments to identify vascular cognitive impairment: A systematic review

INTRODUCTION

Vascular cognitive impairment (VCI) is common and important to detect as controlling risk factors, particularly hypertension, may slow onset and progression. There is no consensus as to which cognitive screening instrument (CSI) is most suitable for VCI. We systematically reviewed the psychometric properties of brief CSIs for vascular mild cognitive impairment (VMCI) and vascular dementia (VaD).

METHODS

Literature searches were performed using scholarly databases from inception until 31 May 2018. Studies were eligible if participants were aged 18 or older, interviewed face-to-face, and standard diagnostic criteria for VCI were applied, excluding those specifically identifying post-stroke dementia. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

RESULTS

Fifteen studies were identified including eight types of CSIs (27 subtests/variants) and 4575 participants (1015 with VCI), mean age range: 51.6 to 75.5 years. Most studies compared more than one instrument. Five papers examined clock-drawing; four, the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE); and three used the Brief Memory and Executive Test (BMET). The MoCA (AUC > 0.90) and MMSE (AUC: 0.86-0.99) had excellent accuracy in differentiating VaD from controls; the MoCA had good internal consistency (Cronbach's α: .83-.88). The MoCA (AUC: 0.87-0.93) and BMET (AUC: 0.94) had the greatest accuracy in separating VMCI from controls. Most studies had low to moderate risk of bias in all domains of the QUIPS. Data were heterogeneous, precluding a meta-analysis.

CONCLUSIONS

Although few studies were available and further research is required, data suggests that the MoCA is accurate and reliable for differentiating VaD and VMCI from controls.

'Likelihood to be diagnosed or misdiagnosed': application to meta-analytic data for cognitive screening instruments

Aim: To extend use of the recently described 'likelihood to be diagnosed or misdiagnosed' (LDM) metric for test accuracy studies through application to recent meta-analytic data of commonly used cognitive screening instruments. Methods: Raw data (true positives and negatives, false positives and negatives) were extracted from meta-analyses (minimum 5 studies or 1000 patients), from which LDM was calculated. LDM values were compared with those previously reported for single test accuracy studies. Results: LDM values for diagnosis of dementia ranged from around two to seven, and for diagnosis of mild cognitive impairment from two to three. LDM values based on meta-analytic data were larger than those reported for individual studies. Conclusion: LDM is an easily calculated and potentially useful unitary, global metric for test accuracy studies.

Delirium Assessment in Older People in Emergency Departments. A Literature Review

Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.