A Quick Test of cognitive speed is sensitive in detecting early treatment response in Alzheimer's disease

Predictors of response to acetylcholinesterase inhibitors in dementia: A systematic review

Background

The mainstay of therapy for many neurodegenerative dementias still relies on acetylcholinesterase inhibitors (AChEI); however, there is debate on various aspects of such treatment. A huge body of literature exists on possible predictors of response, but a comprehensive review is lacking. Therefore, our aim is to perform a systematic review of the predictors of response to AChEI in neurodegenerative dementias, providing a categorization and interpretation of the results.

Methods

We conducted a systematic review of the literature up to December 31st, 2021, searching five different databases and registers, including studies on rivastigmine, donepezil, and galantamine, with clearly defined criteria for the diagnosis of dementia and the response to AChEI therapy. Records were identified through the string: predict * AND respon * AND (acetylcholinesterase inhibitors OR donepezil OR rivastigmine OR galantamine). The results were presented narratively.

Results

We identified 1,994 records in five different databases; after exclusion of duplicates, title and abstract screening, and full-text retrieval, 122 studies were finally included.

Discussion

The studies show high heterogeneity in duration, response definition, drug dosage, and diagnostic criteria. Response to AChEI seems associated with correlates of cholinergic deficit (hallucinations, fluctuating cognition, substantia innominate atrophy) and preserved cholinergic neurons (faster alpha on REM sleep EEG, increased anterior frontal and parietal lobe perfusion after donepezil); white matter hyperintensities in the cholinergic pathways have shown inconsistent results. The K-variant of butyrylcholinesterase may correlate with better response in late stages of disease, while the role of polymorphisms in other genes involved in the cholinergic system is controversial. Factors related to drug availability may influence response; in particular, low serum albumin (for donepezil), CYP2D6 variants associated with reduced enzymatic activity and higher drug doses are the most consistent predictors, while AChEI concentration influence on clinical outcomes is debatable. Other predictors of response include faster disease progression, lower serum cholesterol, preserved medial temporal lobes, apathy, absence of concomitant diseases, and absence of antipsychotics. Short-term response may predict subsequent cognitive response, while higher education might correlate with short-term good response (months), and long-term poor response (years). Age, gender, baseline cognitive and functional levels, and APOE relationship with treatment outcome is controversial.

Clinically Relevant Changes for Cognitive Outcomes in Preclinical and Prodromal Cognitive Stages: Implications for Clinical Alzheimer Trials

BACKGROUND AND OBJECTIVES

Identifying a clinically meaningful change in cognitive test score is essential when using cognition as an outcome in clinical trials. This is especially relevant because clinical trials increasingly feature novel composites of cognitive tests. Our primary objective was to establish minimal clinically important differences (MCIDs) for commonly used cognitive tests, using anchor-based and distribution-based methods, and our secondary objective was to investigate a composite cognitive measure that best predicts a minimal change in the Clinical Dementia Rating-Sum of Boxes (CDR-SB).

METHODS

From the Swedish BioFINDER cohort study, we consecutively included cognitively unimpaired (CU) individuals with and without subjective or mild cognitive impairment (MCI). We calculated MCIDs associated with a change of ≥0.5 or ≥1.0 on CDR-SB for Mini-Mental State Examination (MMSE), ADAS-Cog delayed recall 10-word list, Stroop, Letter S Fluency, Animal Fluency, Symbol Digit Modalities Test (SDMT) and Trailmaking Test (TMT) A and B, and triangulated MCIDs for clinical use for CU, MCI, and amyloid-positive CU participants. For investigating cognitive measures that best predict a change in CDR-SB of ≥0.5 or ≥1.0 point, we conducted receiver operating characteristic analyses.

RESULTS

Our study included 451 cognitively unimpaired individuals, 90 with subjective cognitive decline and 361 without symptoms of cognitive decline (pooled mean follow-up time 32.4 months, SD 26.8, range 12-96 months), and 292 people with MCI (pooled mean follow-up time 19.2 months, SD 19.0, range 12-72 months). We identified potential triangulated MCIDs (cognitively unimpaired; MCI) on a range of cognitive test outcomes: MMSE -1.5, -1.7; ADAS delayed recall 1.4, 1.1; Stroop 5.5, 9.3; Animal Fluency: -2.8, -2.9; Letter S Fluency -2.9, -1.8; SDMT: -3.5, -3.8; TMT A 11.7, 13.0; and TMT B 24.4, 20.1. For amyloid-positive CU, we found the best predicting composite cognitive measure included gender and changes in ADAS delayed recall, MMSE, SDMT, and TMT B. This produced an AUC of 0.87 (95% CI 0.79-0.94, sensitivity 75%, specificity 88%).

DISCUSSION

Our MCIDs may be applied in clinical practice or clinical trials for identifying whether a clinically relevant change has occurred. The composite measure can be useful as a clinically relevant cognitive test outcome in preclinical AD trials.

Reliability and validity of a quick test of cognitive speed (AQT) in screening for mild cognitive impairment and dementia

BACKGROUND

Cognitive disorders are one of the important issues in old age. There are many cognitive tests, but some variables affect their results (e.g., age and education). This study aimed to evaluate the reliability and validity of A Quick Test of Cognitive Speed (AQT) in screening for mild cognitive impairment (MCI) and dementia.

METHODS

This is a psychometric properties study. 115 older adults participated in the study and were divided into three groups (46 with MCI, 24 with dementia, and 45 control) based on the diagnosis of two geriatric psychiatrists. Participants were assessed by AQT and Mini-Mental State Examination (MMSE). Data were analyzed using Pearson correlation, independent t-test, and ROC curve by SPSS v.23.

RESULTS

There was no significant correlation between AQT subscales and age and no significant difference between the AQT subscales in sex, educational levels. The test-retest correlations ranges were 0.84 from 097. Concurrent validity was significant between MMSE and AQT. Its correlation was with Color - 0.78, Form - 0.71, and Color-Form - 0.72. The cut-off point for Color was 43.50 s, Form 52 s, and Color-Form 89 s were based on sensitivity and specificity for differentiating older patients with MCI with controls. The cut-off point for Color was 62.50 s, for Form 111 s, and Color-Form 197.50 s based on sensitivity and specificity measures for differentiating older patients with dementia and MCI.

CONCLUSION

The findings showed that AQT is a suitable tool for screening cognitive function in older adults.

A quick test of cognitive speed (AQT): regression-based norms for cognitively healthy 80 to 94-year olds

Slowed processing speed is part of normal aging but also a symptom of many diseases, including dementia. A Quick Test of Cognitive Speed (AQT) consists of three conditions: color naming (AQT1), form naming (AQT2) and dual color-form naming (AQT3) and offers a user-friendly assessment of processing speed that is used internationally to identify cognitive impairment in elderly patients. Appropriate age-norms have however been lacking. This study provides regression-based norms derived from a Swedish sample of 158 cognitively healthy 80 to 94-year olds. The results show age effects in all three conditions, a non-linear education effect in AQT1, and age by gender interactions in AQT2 and AQT3: men performed worse with increasing age, but women remained on a par. However, irrespective of age and gender, AQT2 and AQT3 mean raw and predicted scores were slower than the hitherto recommended cutoff criteria for suspected cognitive impairment.

Association of Enlarged Perivascular Spaces and Measures of Small Vessel and Alzheimer Disease

OBJECTIVE

To investigate the relationship between enlarged perivascular spaces (EPVS) and measures of Alzheimer disease (AD), small vessel disease (SVD), cognition, vascular risk factors, and neuroinflammation, we tested associations between EPVS and different relevant neuroimaging, biochemical, and cognitive variables in 778 study participants.

METHODS

Four hundred ninety-nine cognitively unimpaired (CU) individuals, 240 patients with mild cognitive impairment, and 39 patients with AD from the Swedish Biomarkers for Identifying Neurodegenerative Disorders Early and Reliably (BioFINDER) study were included. EPVS with diameter >1 mm in centrum semiovale (CSO), basal ganglia (BG), and hippocampus (HP); hippocampal volume; white matter lesions (WML); and other SVD markers were determined from MRI. CSF levels of β-amyloid₄₂ (Aβ₄₂), phosphorylated tau, total tau, and neuroinflammatory markers; amyloid accumulation determined with [¹⁸F]-flutemetamol PET; and vascular risk factors and results from cognitive tests were determined and collected.

RESULTS

EPVS in CSO, BG, and HP were associated with WML volume and Fazekas score in individuals without dementia. No associations were found between EPVS and CSF Aβ₄₂, total tau and phosphorylated tau, neuroinflammatory markers, vascular risk factors, and cognitive tests. EPVS in HP were associated with hippocampal atrophy. In a matched group of individuals with AD and CU, EPVS in HP were associated with AD diagnosis.

CONCLUSIONS

EPVS are related to SVD, also in early disease stages, but the lack of correlation with cognition suggests that their importance is limited. Our data do not support a role for EPVS in early AD pathogenesis.

Differentiating depression and ADHD without depression in adults with processing-speed measures

OBJECTIVE

We evaluated processing-speed and shift-cost measures in adults with depression or attention-deficit hyperactivity disorder (ADHD) and monitored the effects of treatment. We hypothesised that cognitive-speed and shift-cost measures might differentiate diagnostic groups.

METHODS

Colour, form, and colour-form stimuli were used to measure naming times. The shift costs were calculated as colour-form-naming time minus the sum of colour- and form-naming times. Measurements were done at baseline and end point for 42 adults with depression and 42 with ADHD without depression. Patients with depression were treated with transcranial pulsed electromagnetic fields and patients with ADHD with methylphenidate immediate release.

RESULTS

During depression treatment, reductions in naming times were recorded weekly. One-way analysis of variance indicated statistical between-group differences, with effect sizes in the medium range for form and colour-form. In both groups, naming times were longer before than after treatment. For the ADHD group, shift costs exceeded the average-normal range at baseline but were in the average-normal range after stabilisation with stimulant medication. For the depression group, shift costs were in the average-normal range at baseline and after treatment. Baseline colour-form-naming times predicted reductions in naming times for both groups, with the largest effect size and index of forecasting efficiency for the ADHD group.

CONCLUSIONS

The cognitive-processing-speed (colour-form) and shift-cost measures before treatment proved most sensitive in differentiating patients with depression and ADHD. Reductions in naming times for the depression group were suggested to reflect improved psychomotor skills rather than improved cognitive control.

Brief Cognitive Tests Used in Primary Care Cannot Accurately Differentiate Mild Cognitive Impairment from Subjective Cognitive Decline

BACKGROUND

Differentiating mild cognitive impairment (MCI) from subjective cognitive decline (SCD) is important because of the higher progression rate to dementia for MCI and when considering future disease-modifying drugs that will have treatment indications at the MCI stage.

OBJECTIVE

We examined if the two most widely-used cognitive tests, the Mini-Mental State Examination (MMSE) and clock-drawing test (CDT), and a test of attention/executive function (AQT) accurately can differentiate MCI from SCD.

METHODS

We included 466 consecutively recruited non-demented patients with cognitive complaints from the BioFINDER study who had been referred to memory clinics, predominantly from primary care. They were classified as MCI (n = 258) or SCD (n = 208) after thorough neuropsychological assessments. The accuracy of MMSE, CDT, and AQT for identifying MCI was examined both in training and validation samples and in the whole population.

RESULTS

As a single test, MMSE had the highest accuracy (sensitivity 73%, specificity 60%). The best combination of two tests was MMSE < 27 points or AQT > 91 seconds (sensitivity 56%, specificity 78%), but in logistic regression models, their AUC (0.76) was not significantly better than MMSE alone (AUC 0.75). CDT and AQT performed significantly worse (AUC 0.71; p < 0.001-0.05); otherwise no differences were seen between any combination of two or three tests.

CONCLUSION

Neither single nor combinations of tests could differentiate MCI from SCD with adequately high accuracy. There is a great need to further develop, validate, and implement accurate screening-tests for primary care to improve accurate identification of MCI among individuals that seek medical care due to cognitive symptoms.

Pathways of Prevention: A Scoping Review of Dietary and Exercise Interventions for Neurocognition

Alzheimer's disease and related dementias (ADRD) represent an increasingly urgent public health concern, with an increasing number of baby boomers now at risk. Due to a lack of efficacious therapies among symptomatic older adults, an increasing emphasis has been placed on preventive measures that can curb or even prevent ADRD development among middle-aged adults. Lifestyle modification using aerobic exercise and dietary modification represents one of the primary treatment modalities used to mitigate ADRD risk, with an increasing number of trials demonstrating that exercise and dietary change, individually and together, improve neurocognitive performance among middle-aged and older adults. Despite several optimistic findings, examination of treatment changes across lifestyle interventions reveals a variable pattern of improvements, with large individual differences across trials. The present review attempts to synthesize available literature linking lifestyle modification to neurocognitive changes, outline putative mechanisms of treatment improvement, and discuss discrepant trial findings. In addition, previous mechanistic assumptions linking lifestyle to neurocognition are discussed, with a focus on potential solutions to improve our understanding of individual neurocognitive differences in response to lifestyle modification. Specific recommendations include integration of contemporary causal inference approaches for analyzing parallel mechanistic pathways and treatment-exposure interactions. Methodological recommendations include trial multiphase optimization strategy (MOST) design approaches that leverage individual differences for improved treatment outcomes.

Increased functional connectivity of thalamic subdivisions in patients with Parkinson's disease

Parkinson’s disease (PD) affects 2–3% of the population over the age of 65 with loss of dopaminergic neurons in the substantia nigra impacting the functioning of basal ganglia-thalamocortical circuits. The precise role played by the thalamus is unknown, despite its critical role in the functioning of the cerebral cortex, and the abnormal neuronal activity of the structure in PD. Our objective was to more clearly elucidate how functional connectivity and morphology of the thalamus are impacted in PD (n = 32) compared to Controls (n = 20). To investigate functional connectivity of the thalamus we subdivided the structure into two important regions-of-interest, the first with putative connections to the motor cortices and the second with putative connections to prefrontal cortices. We then investigated potential differences in the size and shape of the thalamus in PD, and how morphology and functional connectivity relate to clinical variables. Our data demonstrate that PD is associated with increases in functional connectivity between motor subdivisions of the thalamus and the supplementary motor area, and between prefrontal thalamic subdivisions and nuclei of the basal ganglia, anterior and dorsolateral prefrontal cortices, as well as the anterior and paracingulate gyri. These results suggest that PD is associated with increased functional connectivity of subdivisions of the thalamus which may be indicative alterations to basal ganglia-thalamocortical circuitry.

β-amyloid pathology and hippocampal atrophy are independently associated with memory function in cognitively healthy elderly

The independent effects of different brain pathologies on age-dependent cognitive decline are unclear. We examined this in 300 cognitively unimpaired elderly individuals from the BioFINDER study. Using cognition as outcome we studied the effects of cerebrospinal fluid biomarkers for amyloid-β (Aβ42/40), neuroinflammation (YKL-40), and neurodegeneration and tau pathology (T-tau and P-tau) as well as MRI measures of white-matter lesions, hippocampal volume (HV), and regional cortical thickness. We found that Aβ positivity and HV were independently associated with memory. Results differed depending on age, with memory being associated with HV (but not Aβ) in older participants (73.3–88.4 years), and with Aβ (but not HV) in relatively younger participants (65.2–73.2 years). This indicates that Aβ and atrophy are independent contributors to memory variability in cognitively healthy elderly and that Aβ mainly affects memory in younger elderly individuals. With advancing age, the effect of brain atrophy overshadows the effect of Aβ on memory function.

Attention Measures of Accuracy, Variability, and Fatigue Detect Early Response to Donepezil in Alzheimer's Disease: A Randomized, Double-blind, Placebo-Controlled Pilot Trial

OBJECTIVE

Donepezil is widely used to treat Alzheimer's disease (AD), but detecting early response remains challenging for clinicians. Acetylcholine is known to directly modulate attention, particularly under high cognitive conditions, but no studies to date test whether measures of attention under high load can detect early effects of donepezil. We hypothesized that load-dependent attention tasks are sensitive to short-term treatment effects of donepezil, while global and other domain-specific cognitive measures are not.

METHOD

This longitudinal, randomized, double-blind, placebo-controlled pilot trial (ClinicalTrials.gov Identifier: NCT03073876) evaluated 23 participants newly diagnosed with AD initiating de novo donepezil treatment (5 mg). After baseline assessment, participants were randomized into Drug (n = 12) or Placebo (n = 11) groups, and retested after approximately 6 weeks. Cognitive assessment included: (a) attention tasks (Foreperiod Effect, Attentional Blink, and Covert Orienting tasks) measuring processing speed, top-down accuracy, orienting, intra-individual variability, and fatigue; (b) global measures (Alzheimer's Disease Assessment Scale-Cognitive Subscale, Mini-Mental Status Examination, Dementia Rating Scale); and (c) domain-specific measures (memory, language, visuospatial, and executive function).

RESULTS

The Drug but not the Placebo group showed benefits of treatment at high-load measures by preserving top-down accuracy, improving intra-individual variability, and averting fatigue. In contrast, other global or cognitive domain-specific measures could not detect treatment effects over the same treatment interval.

CONCLUSIONS

The pilot-study suggests that attention measures targeting accuracy, variability, and fatigue under high-load conditions could be sensitive to short-term cholinergic treatment. Given the central role of acetylcholine in attentional function, load-dependent attentional measures may be valuable cognitive markers of early treatment response.

Pre-diabetes and diabetes are independently associated with adverse cognitive test results: a cross-sectional, population-based study

BACKGROUND

Diabetes is a risk factor for cognitive impairment, but whether there is also a link between pre-diabetes and cognitive dysfunction is not yet fully established. The aim of this observational study was to investigate associations between pre-diabetes/diabetes and cognitive test results, and also between glucose levels measured during the Oral Glucose Tolerance Test (OGTT) and cognitive outcomes.

METHODS

During 2007-2012, in all 2994 people (mean age 72 years), residing in Malmö, Sweden, underwent a clinical examination including the OGTT, cardiovascular measurements including carotid-femoral pulse wave velocity (c-f PWV) and two cognitive tests, the Mini Mental State Examination (MMSE), measuring global cognitive function, and A Quick Test of Cognitive Speed (AQT), measuring processing speed and executive functioning. Regression analyses were performed to investigate associations between: (a) categories of normal or impaired glucose metabolism, and (b) OGTT measurements, respectively, as exposure variables and cognitive test results as outcomes. Adjustments were made for demographics, lifestyle factors and cardiovascular risk factors.

RESULTS

Participants with pre-diabetes and diabetes scored slightly worse cognitive test results compared to the control group. Results of participants with a long disease duration of diabetes since the baseline examination 13 years earlier were poorer (mean AQT test time 17.8 s slower than controls, p < 0.001). Linear associations were found between fasting and 2-h glucose and cognitive outcomes in the whole population, but also in a sub-analysis including only individuals without diabetes (for 2-h glucose and MMSE results: B = - 2.961, p = 0.005). Associations were stronger for older or less physically active individuals. When adjusting for cardiovascular risk factors, most correlations were non-significant.

CONCLUSIONS

Pre-diabetes and diabetes are associated with minor deficits in global cognitive function, processing speed and executive functioning. Long-standing diabetes is associated with bigger deficits. There appears to be a continuous inverse correlation between glucose levels and cognitive test results, also for people without diabetes. Associations are stronger in older and less physically active individuals. Cardiovascular factors are important mediating factors in the pathway between diabetes and cognitive dysfunction.

A quick test of cognitive speed in older adults with Alzheimer's disease and mild cognitive impairment: A preliminary behavioral and brain imaging study

The purpose of this study was to assess scores and processing speed distributions of the instrument, A Quick Test of Cognitive Speed (AQT), in Korean older adults through behavioral and brain imaging approaches. Participants were instructed to say the color names, stimuli's form, and both the color and form. Test scores and processing speeds were measured in these three subtests of color, form, and color-form. A total of 67 patients (22 healthy controls (HC), 22 with mild cognitive impairment (MCI), and 23 with Alzheimer's disease (AD)) participated. Only color-form score and processing speed of the three subtests could be used to differentiate AD from MCI and HC. Color-form score showed the largest effects size (partial η² = 0.268) for distinguishing AD, MCI from HC and ROC curve analysis confirmed a high level of sensitivity (0.857) and specificity (0.826) for discrimination between AD and HC. None of the subtests could differentiate HC from MCI. Voxel-based morphometry analysis of brain structure in 27 participants (9 in each group) revealed that gray matter volume of the middle occipital gyrus and inferior parietal cortex were associated with color-form score. This study suggests preliminary evidence in the clinical utility of the AQT for screening AD in older Korean adults. The color-form score could be implemented for clinical utilization in a very brief time. Furthermore, strong positive correlations between color-form scores and the brain areas responsible for visuospatial working memory corroborate the validity of AQT.

Accurate risk estimation of β-amyloid positivity to identify prodromal Alzheimer's disease: Cross-validation study of practical algorithms

INTRODUCTION

The aim was to create readily available algorithms that estimate the individual risk of β-amyloid (Aβ) positivity.

METHODS

The algorithms were tested in BioFINDER (n = 391, subjective cognitive decline or mild cognitive impairment) and validated in Alzheimer's Disease Neuroimaging Initiative (n = 661, subjective cognitive decline or mild cognitive impairment). The examined predictors of Aβ status were demographics; cognitive tests; white matter lesions; apolipoprotein E (APOE); and plasma Aβ₄₂/Aβ₄₀, tau, and neurofilament light.

RESULTS

Aβ status was accurately estimated in BioFINDER using age, 10-word delayed recall or Mini-Mental State Examination, and APOE (area under the receiver operating characteristics curve = 0.81 [0.77-0.85] to 0.83 [0.79-0.87]). When validated, the models performed almost identical in Alzheimer's Disease Neuroimaging Initiative (area under the receiver operating characteristics curve = 0.80-0.82) and within different age, subjective cognitive decline, and mild cognitive impairment populations. Plasma Aβ₄₂/Aβ₄₀ improved the models slightly.

DISCUSSION

The algorithms are implemented on http://amyloidrisk.com where the individual probability of being Aβ positive can be calculated. This is useful in the workup of prodromal Alzheimer's disease and can reduce the number needed to screen in Alzheimer's disease trials.

18F-AV-1451 in Parkinson's Disease with and without dementia and in Dementia with Lewy Bodies

Mixed pathologies of α-synuclein, β-amyloid and tau are relatively common in Parkinson’s disease (PD) and Dementia with Lewy Bodies (DLB). We therefore wanted to study the retention patterns of ¹⁸F-AV-1451 in PD, PD-dementia (PDD), and DLB. To do this 44 healthy controls, 11 non-demented patients with PD, 18 patients with PDD, and six patients with DLB underwent MRI and ¹⁸F-AV-1451 PET scanning and cognitive testing. We found that parietal ¹⁸F-AV-1451 retention was increased in patients with DLB compared to controls and PD patients, while ¹⁸F-AV-1451 uptake was reduced in the substantia nigra in PDD. Increased parietal ¹⁸F-AV-1451 PET uptake was associated with impaired performance on verbal fluency tests, and the decreased uptake in the substantia nigra correlated with worse motor function. We found no effect of the monoamine oxidase B inhibitor rasagiline on ¹⁸F-AV-1451 binding. In conclusion DLB patients have increased parietal ¹⁸F-AV-1451 uptake. Increased parietal tau is associated with executive impairment in patients with synucleinopathies, while decreased uptake in the substantia nigra is associated with parkinsonism. Further, our data indicate that ¹⁸F-AV-1451 does not significantly bind to MAO-B in vivo.

Ineffective initiation contributes to deficient verbal and non-verbal fluency in patients with schizophrenia

AIMS

Patients with schizophrenia (SCH) show impaired verbal and non-verbal fluency. However, these individuals' fluctuations in words or designs generation efficiency over time, a phenomenon that may significantly affect fluency, have never been studied. Thus, the aim of this research was to investigate if individuals with SCH may present with alternations in the dynamics of the information production and its control as well as to test if the potential abnormalities in this regard might affect these patients' overall performance on both verbal and non-verbal fluency tasks.

METHOD

Forty-four patients with SCH and 40 healthy controls (HC) completed both verbal (phonological, semantic) and non-verbal fluency tests. To analyse processing efficiency changes over time, the period in which subjects had to generate words or designs (60 s) has been divided into 15-s sections.

RESULTS

In comparison to HCs, individuals with SCH obtained significantly lower total scores for all fluency measures. Furthermore, group differences in the dynamics of the test performance also emerged, with SCH patients having a significantly worse production during the initial 15 s of each fluency task. Additionally, the initial production deficiency seen in patients with SCH has accounted for these individuals' total performance. Moreover, comparisons of errors distribution over time during the phonemic and figural fluency performance also revealed differences, suggesting there was a rapid depletion in maintaining of cognitive control in the SCH sample.

CONCLUSIONS

Inefficient fluency in SCH may arise from a more general initiation deficits that may partly account for these patients' cognitive problems.

The Montreal Cognitive Assessment: Normative Data from a Large Swedish Population-Based Cohort

BACKGROUND

The Montreal Cognitive Assessment (MoCA) has a high sensitivity for detecting cognitive dysfunction. Swedish normative data does not exist and international norms are often derived from populations where cognitive impairment has not been screened for and not been thoroughly assessed to exclude subjects with dementia or mild cognitive impairment.

OBJECTIVE

To establish norms for MoCA and develop a regression-based norm calculator based on a large, well-examined cohort.

METHODS

MoCA was administered on 860 randomly selected elderly people from a population-based cohort from the EPIC study. Cognitive dysfunction was screened for and further assessed at a memory clinic. After excluding cognitively impaired participants, normative data was derived from 758 people, aged 65-85.

RESULTS

MoCA cut-offs (-1 to -2 standard deviations) for cognitive impairment ranged from <25 to <21 for the lowest educated and <26 to <24 for the highest educated, depending on age group. Significant predictors for MoCA score were age, sex and level of education.

CONCLUSION

We present detailed normative MoCA data and cut-offs according to the DSM-5 criteria for cognitive impairment based on a large population-based cohort of elderly individuals, screened and thoroughly investigated to rule out cognitive impairment. Level of education, sex, and age should be taken in account when evaluating MoCA score, which is facilitated by our online regression-based calculator that provide percentile and z-score for a subject's MoCA score.

The Cognitive Functions in Adults with Chronic Pain: A Comparative Study

Background. Several studies have reported an association between chronic pain and reduction of cognitive abilities of adults living in Western cultures. No literature could be found on the relationship between chronic pain and cognition among Middle Eastern adults. Objective. To compare four of the most commonly reported cognitive domains [memory, attention, processing speed, and executive functioning] among Middle Eastern adults with and without chronic pain. Methods. This matched group comparative study included 69 community residing and functionally independent Middle Eastern adults. Forty participants had chronic pain and 29 were pain-free. We administered five standardized cognitive assessments that are independent of culture and language to measure variable tasks of memory, attention, processing speed, and executive functioning. The study was conducted in a rehabilitation research setting with a controlled environment. Results. Evidence of decreased cognitive processing was found in patients with chronic pain. The chronic pain participants performed significantly worse than the pain-free participants on the cognitive measures of long-term memory, selective attention, processing speed, and executive functioning. Conclusion. The effect of Middle Eastern culture on the cognitive abilities of patients with chronic pain was negligible. Despite the wide variations between Eastern and Western cultures, the performance of our Middle Eastern participants in this study was consistent with performance of Western adults reported in previous studies.

Hearing impairment, cognition and speech understanding: exploratory factor analyses of a comprehensive test battery for a group of hearing aid users, the n200 study

OBJECTIVE

The aims of the current n200 study were to assess the structural relations between three classes of test variables (i.e. HEARING, COGNITION and aided speech-in-noise OUTCOMES) and to describe the theoretical implications of these relations for the Ease of Language Understanding (ELU) model.

STUDY SAMPLE

Participants were 200 hard-of-hearing hearing-aid users, with a mean age of 60.8 years. Forty-three percent were females and the mean hearing threshold in the better ear was 37.4 dB HL.

DESIGN

LEVEL1 factor analyses extracted one factor per test and/or cognitive function based on a priori conceptualizations. The more abstract LEVEL 2 factor analyses were performed separately for the three classes of test variables.

RESULTS

The HEARING test variables resulted in two LEVEL 2 factors, which we labelled SENSITIVITY and TEMPORAL FINE STRUCTURE; the COGNITIVE variables in one COGNITION factor only, and OUTCOMES in two factors, NO CONTEXT and CONTEXT. COGNITION predicted the NO CONTEXT factor to a stronger extent than the CONTEXT outcome factor. TEMPORAL FINE STRUCTURE and SENSITIVITY were associated with COGNITION and all three contributed significantly and independently to especially the NO CONTEXT outcome scores (R(2) = 0.40).

CONCLUSIONS

All LEVEL 2 factors are important theoretically as well as for clinical assessment.

Stroop interference and AQT cognitive speed may play complementary roles in differentiating dementias with frontal and posterior lesions

Forty neurotypical adults (ages 65-74) were administered three different assessments, as follows: Montreal Cognitive Assessment (MoCA), A Quick Test of Cognitive Speed (AQT), and Stroop Color and Word Test. Correlation coefficients (Pearson r) indicated a significant but moderate association between MoCA scores and AQT dual-dimension processing speed (p < 0.01). AQT color and color-form combination naming correlated significantly with Stroop Color, Word, and Color-Word t-scores, and the observed statistical power was high. Form naming correlated significantly with Stroop Word and Color-Word measures (p < 0.01). The associations between the AQT color, form, and color-form combination and Stroop interference measures were low and non-significant (p > 0.01). Based on evidence of frontal lobe control of inhibition (Stroop) and bilateral temporal-parietal control of dual-dimension processing speed (AQT), results suggest that the AQT dual-dimension processing-speed and Stroop interference tests may complement each other in differentiating dementias associated with frontal and posterior lesions.

A Quick Test of Cognitive Speed: norm-referenced criteria for 121 Italian adults aged 45 to 90 years

ABSTRACT Background: A Quick Test of Cognitive Speed (AQT) is a brief test that can identify cognitive impairment. AQT has been validated in Arabic, English, Greek, Japanese, Norwegian, Spanish, and Swedish. The aim of this study was to develop Italian criterion-referenced norms for AQT. Methods: AQT consists of three test plates where the patient shall rapidly name (1) the color of 40 blue, red, yellow, or black squares (AQT color), (2) the form of 40 black figures (circles, squares, triangles, or rectangles; AQT form), (3) the color and form of 40 figures (consisting of previous colors and forms; AQT color-form). The AQT test was administered to 121 Italian cognitively healthy primary care patients (age range: 45-90 years). Their mean Mini-Mental State Examination (MMSE) score was 28.8 ± 0.9 points (range 26-30 points). AQT naming times in seconds were used for developing preliminary criterion cut-off times for different age groups. Results: Age was found to have a significant moderate positive correlation with AQT naming times color (r = 0.65, p < 0.001), form (r = 0.53, p < 0.001), color-form (r = 0.63, p < 0.001) and a moderate negative correlation with MMSE score (r = -0.44, p < 0.001) and AQT naming times differed significantly between younger (45-55 years old), older (56-70 years old), and the oldest (71-90 years old) participants. Years of education correlated positively but weakly with MMSE score (r = 0.27, p = 0.003) and negatively but weakly with AQT color (r = -0.16, p = ns), form (r = -0.24, p = 0.007), and color-form (r = -0.19, p = 0.005). We established preliminary cut-off times for the AQT test based on +1 and +2 standard deviations according to the approach in other languages and settings. Conclusions: This is the first Italian normative AQT study. Future studies of AQT - a test useful for dementia screening in primary care - will eventually refine cut-off times for normality balancing sensitivity and specificity in cognitive diagnostics.

Progression of mild Alzheimer's disease: knowledge and prediction models required for future treatment strategies

Introduction

Knowledge of longitudinal progression in mild Alzheimer’s disease (AD) is required for the evaluation of disease-modifying therapies. Our aim was to observe the effects of long-term cholinesterase inhibitor (ChEI) therapy in mild AD patients in a routine clinical setting.

Methods

This was a prospective, open-label, non-randomized, multicenter study of ChEI treatment (donepezil, rivastigmine or galantamine) conducted during clinical practice. The 734 mild AD patients (Mini-Mental State Examination (MMSE) score 20 to 26) were assessed at baseline and then semi-annually over three years. Outcome measures included the MMSE, Alzheimer’s Disease Assessment Scale-cognitive subscale (ADAS-cog), Clinician’s Interview-Based Impression of Change (CIBIC) and Instrumental Activities of Daily Living (IADL) scale.

Results

After three years of ChEI therapy, 31% (MMSE) and 33% (ADAS-cog) of the patients showed improved/unchanged cognitive ability, 33% showed improved/unchanged global performance and 14% showed improved/unchanged IADL capacity. Higher mean dose of ChEI and lower educational level were both predictors of more positive longitudinal cognitive and functional outcomes. Older participants and those with a better IADL score at baseline exhibited a slower rate of cognitive decline, whereas younger participants and those with higher cognitive status showed more preserved IADL ability over time. Gender and apolipoprotein E (APOE) genotype showed inconsistent results. Prediction models using the abovementioned scales are presented.

Conclusions

In naturalistic mild AD patients, a marked deterioration in IADL compared with cognitive and global long-term outcomes was observed, indicating the importance of functional assessments during the early stages of the disease. The participants’ time on ChEI treatment before inclusion in studies of new therapies might affect their rate of decline and thus the comparisons of changes in scores between various studies. An increased understanding of expected disease progression in different domains and potential predictors of disease progression is essential for assessment of future therapies in AD.

A Quick Test of Cognitive Speed: Preliminary Screening Criteria for Arabic-Speaking Adults, Ages 40 to 80 Years

A Quick Test of Cognitive Speed (AQT) color, form, and color-form scales were administered to 90 educated (5–22 years of education) and 45 uneducated (0–2 years of education) healthy, Arabic-speaking adults. Lognormal ( ln) transformations of time measures (sec.) were used for statistical analyses. There were statistically significant mean differences for the color-form processing-speed measures between middle-aged (ages 40–50) and older (ages 51–80) educated adults and between educated and uneducated adults (ages 40–78). The study developed preliminary criterion cut-off times for color-form naming for screening educated and uneducated Arabic-speaking adults. The normal, slower-than-normal, and atypical/pathological performance ranges were characterized with frequency distributions and standard deviations. Age and education are factors that must be considered in stratifying samples in future studies to develop valid and reliable criteria for cognitive screening of Arabic speakers with the AQT.

Diabetes mellitus and elevated copeptin levels in middle age predict low cognitive speed after long-term follow-up

BACKGROUND/AIMS

We examined the potential impact of vascular risk factors including copeptin - a robust surrogate marker of arginine vasopressin associated with the metabolic syndrome and diabetes risk - on future cognitive abilities in a population-based cohort.

METHODS

Participants (n = 933) were investigated using baseline data, including copeptin levels, and data collected 16 years later using the Mini-Mental State Examination (MMSE) and A Quick Test of Cognitive Speed (AQT).

RESULTS

Logistic regression showed that diabetes (OR, 1.86; p < 0.05) and higher copeptin levels (OR, 1.19; p < 0.05) were independently associated with an increased risk of low AQT performance.

CONCLUSION

Prevalence of diabetes mellitus and elevated copeptin levels in middle age predict lower cognitive speed after long-term follow-up.

A quick test of cognitive speed for comparing processing speed to differentiate adult psychiatric referrals with and without attention-deficit/hyperactivity disorders

OBJECTIVE

This retrospective study used A Quick Test of Cognitive Speed (AQT) to compare processing speed and efficiency measures by adults with attention-deficit/hyperactivity disorder (ADHD) or non-ADHD psychiatric disorders and healthy controls.

METHOD

Color, form, and color-form combination naming tests were administered to 104 adults, ages 17-55 years, referred for psychiatric evaluation of possible ADHD. Thirty healthy adults were controls. Psychiatric intake procedures identified 64 adults with ADHD (ICD-10 and DSM-IV criteria) and 40 with mild psychiatric disorders without ADHD. The study was conducted from 2008 through 2010.

RESULTS

At intake, color, form, and color-form combination naming times (seconds) were longer and overhead [color-form combination - (color + form)] was larger for patients with ADHD than for non-ADHD patients and controls. In the ADHD group, color and form measures were in the normal range. Color-form combination was in the slower-than-normal speed (60-70 seconds) and overhead, a processing-efficiency measure, in the atypical range (> 10 seconds). In the non-ADHD patient and control groups, all AQT measures were in the normal range. Analysis of variance with post hoc analysis of log-normal values for color, form, and color-form combination and time for overhead indicated significant (Bonferroni P < .01) mean differences between the ADHD and other groups, but not between the non-ADHD and control groups. When using fail criteria for either color-form combination or overhead, the sensitivity for the ADHD group was 89%.

CONCLUSIONS

RESULTS support AQT as a possible complement to psychiatric intake procedures to differentiate adults with ADHD from those with mild psychiatric disorders, and they suggest that a controlled prospective study might be productive.

Donepezil combined with natural hirudin improves the clinical symptoms of patients with mild-to-moderate Alzheimer's disease: a 20-week open-label pilot study

AIM

To evaluate the efficacy and safety of donepezil plus natural hirudin in patients with mild-to-moderate Alzheimer's Disease.

METHODS

In the 20-week, randomized, open-label and controlled study, 84 patients received either donepezil (5 mg/day for the first 4 weeks and 10 mg/day thereafter) or donepezil plus natural hirudin (3 g/day) treatment. Efficacy was reflected by the change of the total scores of Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-Cog), Activities of Daily Life (ADL) and Neuropsychiatric Inventory (NPI).

RESULTS

The patients with the donepezil plus natural hirudin treatment showed more significant improvement in the daily activities and the decline of the cognition than those with donepezil treatment. Significant difference was present in the groups since the 8th week. No group difference was found in the NPI change. However, within the hirudin treatment group, more powerful efficacy including NPI assessment was found in the patients with vascular risk factors (VRF) as comparing to with those without VRF. The combination of donepezil and natural hirudin was well tolerated. The dropout rate was greater in the donepezil and natural hirudin (50%) treatment group than in the donepezil (39%) treatment group. Similar result was found in the incidence of adverse events (23.8% vs 19.0%), but there was no statistical difference between the two groups. Adverse events were the most common reason for the dropout. Although hemorrhage and hypersensitiveness were more common in donepezil plus Maixuekang treatment (11.9% and 7.1%) group than in donepezil treatment (2.4% and 2.4%) group, no significant difference was present between the two groups. Economic problem was another important reason for the patients' withdrawal.

CONCLUSIONS

Compared with the donepezil treatment in the patients with mild-to-moderate AD, our results suggest that donepezil combined with natural hirudin may improve the treatment effects in the ADL, BPSD and cognition of the patients. Furthermore, this joint treatment is safe.