Monitoring cognitive change in multiple sclerosis using a computerized cognitive battery

The Real-World Usability, Feasibility, and Performance Distributions of Deploying a Digital Toolbox of Computerized Assessments to Remotely Evaluate Brain Health: Development and Usability Study

BACKGROUND

An ongoing global challenge is managing brain health and understanding how performance changes across the lifespan.

OBJECTIVE

We developed and deployed a set of self-administrable, computerized assessments designed to measure key indexes of brain health across the visual and auditory sensory modalities. In this pilot study, we evaluated the usability, feasibility, and performance distributions of the assessments in a home-based, real-world setting without supervision.

METHODS

Potential participants were untrained users who self-registered on an existing brain training app called BrainHQ. Participants were contacted via a recruitment email and registered remotely to complete a demographics questionnaire and 29 unique assessments on their personal devices. We examined participant engagement, descriptive and psychometric properties of the assessments, associations between performance and self-reported demographic variables, cognitive profiles, and factor loadings.

RESULTS

Of the 365,782 potential participants contacted via a recruitment email, 414 (0.11%) registered, of whom 367 (88.6%) completed at least one assessment and 104 (25.1%) completed all 29 assessments. Registered participants were, on average, aged 63.6 (SD 14.8; range 13-107) years, mostly female (265/414, 64%), educated (329/414, 79.5% with a degree), and White (349/414, 84.3% White and 48/414, 11.6% people of color). A total of 72% (21/29) of the assessments showed no ceiling or floor effects or had easily modifiable score bounds to eliminate these effects. When correlating performance with self-reported demographic variables, 72% (21/29) of the assessments were sensitive to age, 72% (21/29) of the assessments were insensitive to gender, 93% (27/29) of the assessments were insensitive to race and ethnicity, and 93% (27/29) of the assessments were insensitive to education-based differences. Assessments were brief, with a mean duration of 3 (SD 1.0) minutes per task. The pattern of performance across the assessments revealed distinctive cognitive profiles and loaded onto 4 independent factors.

CONCLUSIONS

The assessments were both usable and feasible and warrant a full normative study. A digital toolbox of scalable and self-administrable assessments that can evaluate brain health at a glance (and longitudinally) may lead to novel future applications across clinical trials, diagnostics, and performance optimization.

Instruments measuring change in cognitive function in multiple sclerosis: A systematic review

BACKGROUND

Multiple sclerosis (MS) is a chronic demyelinating/neurodegenerative disease associated with change in cognitive function (CF) over time. This systematic review aims to describe the instruments used to measure change in CF over time in people with MS (PwMS).

METHODS

PubMed, OVID, Web of Science, and Scopus databases were searched in English until May 2021. Articles were included if they had at least 100 participants and at least a 1-year interval between baseline and last follow-up measurement of CF. Results were quantitatively synthesized, presented in tables and risk of bias was assessed with the Newcastle-Ottawa Scale.

RESULTS

Fifty-seven articles met the inclusion criteria (41,623 PwMS and 1105 controls). An intervention (drug/rehabilitation) was assessed in 22 articles. In the studies that used a test battery, Visual and verbal learning and memory were the most frequently measured domains, but when studies that used test battery or a single test are combined, Information processing speed was the most measured. The Symbol Digit Modalities Test (SDMT) was the most frequently used test as a single test and in a test battery combined. Most studied assessed "change in CF" as cognitive decline defined as 1 or more tests measured as ≥ 1.5 SD from the study control or normative mean in a test battery at baseline and follow-up. Meta-analysis of change in SDMT scores with seven articles indicated a nonstatistically significant -0.03 (95% CI -0.14, 0.09) decrease in mean SDMT score per year.

CONCLUSION

This study highlights the slow rate of measured change in cognition in PwMS and emphasizes the lack of a gold standard test and consistency in measuring cognitive change at the population level. More sensitive testing utilizing multiple domains and longer follow-up may define subgroups where CF change follows different trajectories thus allowing targeted interventions to directly support those where CF is at greatest risk of becoming a clinically meaningful issue.

Mobile health (mHealth) usage, barriers, and technological considerations in persons with multiple sclerosis: a literature review

OBJECTIVES

Persons with multiple sclerosis (MS) can face a number of potential healthcare-related barriers, for which mobile health (mHealth) technology can be potentially beneficial. This review aimed to understand the frequency, current uses, and potential barriers with mHealth usage among persons with MS.

METHODS

A query string was used to identify articles on PubMed, MEDLINE, CINAHL, and IEEE Xplore that were published in English between January 2010 and December 2019. Abstracts were reviewed and selected based on a priori inclusion and exclusion criteria. Fifty-nine peer-reviewed research studies related to the study questions are summarized.

RESULTS

The majority of persons with MS were reported as using smartphones, although rates of mHealth utilization varied widely. mHealth usage was grouped into 3 broad categories: (1) disability and symptom measurement; (2) interventions and symptom management; and (3) tracking and promoting adherence. While there have been an increasing number of mHealth options, certain limitations associated with MS (eg, poor dexterity, memory problems) may affect usage, although including persons with MS in the design process can address some of these issues.

DISCUSSION

Given the increased attention to mHealth in this population and the current need for telehealth and at home devices, it is important that persons with MS and healthcare providers are involved in the development of new mHealth tools to ensure that the end product meets their needs. Considerations for addressing the potential mHealth use barriers in persons with MS are discussed.

Visual-Attentional Load Unveils Slowed Processing Speed in Multiple Sclerosis Patients: A Pilot Study with a Tablet-Based Videogame

Slowing in information processing speed (IPS) is the key cognitive deficit in multiple sclerosis (MS). Testing IPS in different cognitive load conditions by using computerized tools might reveal initial IPS slowness underestimated by classic paper-and-pencil tests. To investigate the extent to which IPS can be affected by increased task demands, we developed three tasks based on the manipulation of the visual-attentional load, delivered with a home-made, tablet-based videogame. Fifty-one patients with MS (pwMS), classified as having no cognitive impairment in classic paper-and-pencil tests, and 20 healthy controls (HC) underwent the videogame tasks; reaction times (RTs) and accuracy were recorded. A significant reduced performance of pwMS as compared with HC was found on the videogame tasks, with pwMS being on average slower and less accurate than HC. Furthermore, pwMS showed a significantly more pronounced decrement in accuracy as a function of the visual-attentional load, suggesting a higher susceptibility to increased task demands. Significant correlations among the Symbol Digit Modalities Test (SDMT) and the videogame mean RTs and accuracy were found, providing evidence for the concurrent validity of the videogame as a valid tool to test IPS in pwMS. The high potential that might derive from the adoption of computerized assessment tools in clinical practice should be taken into consideration and investigated further.

Lost in Classification: Lower Cognitive Functioning in Apparently Cognitive Normal Newly Diagnosed RRMS Patients

Cognitive functioning in multiple sclerosis (MS) patients is usually related to the classic, dichotomic classification of impaired vs. unimpaired cognition. However, this approach is far from mirroring the real efficiency of cognitive functioning. Applying a different approach in which cognitive functioning is considered as a continuous variable, we aimed at showing that even newly diagnosed relapsing–remitting MS (RRMS) patients might suffer from reduced cognitive functioning with respect to a matched group of neurologically healthy controls (HCs), even if they were classified as having no cognitive impairment (CI). Fifty newly diagnosed RRMS patients and 36 HCs were tested with an extensive battery of neuropsychological tests. By using Z-scores applied to the whole group of RRMS and HCs together, a measure of cognitive functioning (Z-score index) was calculated. Among the 50 RRMS patients tested, 36 were classified as cognitively normal (CN). Even though classified as CN, RRMS patients performed worse than HCs at a global level (p = 0.004) and, more specifically, in the domains of memory (p = 0.005) and executive functioning (p = 0.006). These results highlight that reduced cognitive functioning can be present early in the disease course, even in patients without an evident CI. The current classification criteria of CI in MS should be considered with caution.

Computerized neuropsychological assessment devices in multiple sclerosis: A systematic review

Background:

The proliferation of computerized neuropsychological assessment devices (CNADs) for screening and monitoring cognitive impairment is increasing exponentially. Previous reviews of computerized tests for multiple sclerosis (MS) were primarily qualitative and did not rigorously compare CNADs on psychometric properties.

Objective:

We aimed to systematically review the literature on the use of CNADs in MS and identify test batteries and single tests with good evidence for reliability and validity.

Method:

A search of four major online databases was conducted for publications related to computerized testing and MS. Test–retest reliability and validity coefficients and effect sizes were recorded for each CNAD test, along with administration characteristics.

Results:

We identified 11 batteries and 33 individual tests from 120 peer-reviewed articles meeting the inclusion criteria. CNADs with the strongest psychometric support include the CogState Brief Battery, Cognitive Drug Research Battery, NeuroTrax, CNS-Vital Signs, and computer-based administrations of the Symbol Digit Modalities Test.

Conclusion:

We identified several CNADs that are valid to screen for MS-related cognitive impairment, or to supplement full, conventional neuropsychological assessment. The necessity of testing with a technician, and in a controlled clinic/laboratory environment, remains uncertain.

The feasibility, reliability and concurrent validity of the MSReactor computerized cognitive screening tool in multiple sclerosis

Background:

Multiple sclerosis (MS) cognitive tests are resource intensive and limited by practice effects that prevent frequent retesting. Brief, reliable and valid monitoring tools are urgently needed to detect subtle, subclinical cognitive changes in people with MS. Cognitive monitoring over time could contribute to a new definition of disease progression, supplementing routine clinical monitoring.

Methods:

MSReactor is a web-based battery that measures psychomotor (processing) speed, visual attention and working memory, using simple reaction time tasks. Clinic-based tasks were completed at baseline and 6 monthly with home testing 1–3 monthly. Acceptability, quality of life, depression and anxiety surveys were completed. We studied its correlation with the Symbol Digit Modalities Test, practice effects, test–retest reliability and the discriminative ability of MSReactor.

Results:

A total of 450 people with MS were recruited over 18 months, with 81% opting to complete home-based testing. Most participants (96%) would be happy (or neutral) to repeat the tasks again and just four reported the tasks made them ‘very anxious’. Persistence of home testing was high and practice effects stabilized within three tests. MSReactor tasks correlated with Symbol Digit Modalities Test scores and participants with MS performed slower than healthy controls.

Conclusion:

MSReactor is a scalable and reliable cognitive screening tool that can be used in the clinic and remotely. MSReactor task performance correlated with another highly validated cognitive test, was sensitive to MS and baseline predictors of cognitive performance were identified.