UDSNB 3.0 Neuropsychological Test Norms in Older Adults from a Diverse Community: Results from the Einstein Aging Study (EAS)

Comparing the predictive validity of four MCI definitions for incident dementia in demographically diverse community-dwelling individuals: Results from the Einstein Aging Study (EAS)

OBJECTIVE

Research examining (MCI) criteria in diverse and/or health-disparate populations is limited. There is a critical need to investigate the predictive validity for incident dementia of widely used MCI definitions in diverse populations.

METHOD

Eligible participants were non-Hispanic White or Black Bronx community residents, free of dementia at enrollment, with at least one annual follow-up visit after baseline. Participants completed annual neurological and neuropsychological evaluations to determine cognitive status. Dementia was defined based on DSM-IV criteria using case conferences. Cox proportional hazard models assessed predictive validity for incident dementia of four specific MCI definitions (Petersen, Jak/Bondi, number of impaired tests, Global Clinical Ratings) at baseline, controlling for age, sex, education, and race/ethnicity. Time-dependent sensitivity and specificity at 2-7 years for each definition, and Youden's index were calculated as accuracy measures.

RESULTS

Participants (N = 1073) ranged in age from 70 to 100 (mean = 78.4 ± 5.3) years at baseline. The sample was 62.5% female, and educational achievement averaged 13.9 ± 3.5 years. Most participants identified as White (70.0%), though Black participants were well-represented (30.0%). In general, MCI definitions differed in sensitivity and specificity for incident dementia. However, there were no significant differences in Youden's index for any definition, across all years of follow-up.

CONCLUSIONS

This work provides an important step toward improving the generalizability of the MCI diagnosis to underrepresented/health-disparate populations. While our findings suggest the studied MCI classifications are comparable, researchers and clinicians may choose to consider one method over another depending on the rationale for evaluation or question of interest.

Examining the Measurement Equivalence of Alzheimer Disease Research Centers' Neuropsychological Test Battery (Version 3) Between Singapore and US Samples

PURPOSE

Standardization of neuropsychological tests is crucial for consistency in cognitive assessment, as well as for validity and comparability of results across different populations. We examined the applicability and measurement equivalence of the Alzheimer Disease Research Centers' Neuropsychological Test Battery (version 3) (ADRC-NTB3) in Singapore.

METHODS

The ADRC-NTB3 was administered to 978 older persons with normal cognition in Singapore. To provide comparison between Singapore and US samples, a US sample with similar profile was retrieved from the National Alzheimer Coordinating Center (NACC) database.

PATIENTS

Scores were compared with 1853 participants with similar profile from the United States. Score-difference between the populations was computed using multiple linear regression (adjusted for covariates), with equivalent score considered present when 90% CI of the score-difference fell within the predefined margin of equivalence.

RESULTS

Tasks assessing for memory, processing speed, and executive functioning showed equivalence in scores between US and Singapore samples (adjusted-score difference=-0.94 to 0.09). Singapore sample performed marginally better on the visuospatial task (adjusted-score difference=0.50), but poorer on the language task (adjusted-score difference=-3.22).

DISCUSSION

Nonequivalence of visuospatial and language tasks, which may increase potential misinterpretation of cognitive profiles and misdiagnosis, are related to educational and cultural differences. This highlights the need for different normative data for more accurate diagnostic accuracy as well as research priorities.

Development and Validity of Norms for Cognitive Dispersion on the Uniform Data Set 3.0 Neuropsychological Battery

OBJECTIVE

Cognitive dispersion indexes intraindividual variability in performance across a battery of neuropsychological tests. Measures of dispersion show promise as markers of cognitive dyscontrol and everyday functioning difficulties; however, they have limited practical applicability due to a lack of normative data. This study aimed to develop and evaluate normed scores for cognitive dispersion among older adults.

METHOD

We analyzed data from 4,283 cognitively normal participants aged ≥50 years from the Uniform Data Set (UDS) 3.0. We describe methods for calculating intraindividual standard deviation (ISD) and coefficient of variation (CoV), as well as associated unadjusted scaled scores and demographically adjusted z-scores. We also examined the ability of ISD and CoV scores to differentiate between cognitively normal individuals (n = 4,283) and those with cognitive impairment due to Lewy body disease (n = 282).

RESULTS

We generated normative tables to map raw ISD and CoV scores onto a normal distribution of scaled scores. Cognitive dispersion indices were associated with age, education, and race/ethnicity but not sex. Regression equations were used to develop a freely accessible Excel calculator for deriving demographically adjusted normed scores for ISD and CoV. All measures of dispersion demonstrated excellent diagnostic utility when evaluated by the area under the curve produced from receiver operating characteristic curves.

CONCLUSIONS

Results of this study provide evidence for the clinical utility of sample-based and demographically adjusted normative standards for cognitive dispersion on the UDS 3.0. These standards can be used to guide interpretation of intraindividual variability among older adults in clinical and research settings.

Mayo normative studies: regression-based normative data for ages 30-91 years with a focus on the Boston Naming Test, Trail Making Test and Category Fluency

OBJECTIVE

Normative neuropsychological data are essential for interpretation of test performance in the context of demographic factors. The Mayo Normative Studies (MNS) aim to provide updated normative data for neuropsychological measures administered in the Mayo Clinic Study of Aging (MCSA), a population-based study of aging that randomly samples residents of Olmsted County, Minnesota, from age- and sex-stratified groups. We examined demographic effects on neuropsychological measures and validated the regression-based norms in comparison to existing normative data developed in a similar sample.

METHOD

The MNS includes cognitively unimpaired adults ≥30 years of age (n = 4,428) participating in the MCSA. Multivariable linear regressions were used to determine demographic effects on test performance. Regression-based normative formulas were developed by first converting raw scores to normalized scaled scores and then regressing on age, age2, sex, and education. Total and sex-stratified base rates of low scores (T < 40) were examined in an older adult validation sample and compared with Mayo's Older Americans Normative Studies (MOANS) norms.

RESULTS

Independent linear regressions revealed variable patterns of linear and/or quadratic effects of age (r2 = 6-27% variance explained), sex (0-13%), and education (2-10%) across measures. MNS norms improved base rates of low performance in the older adult validation sample overall and in sex-specific patterns relative to MOANS.

CONCLUSIONS

Our results demonstrate the need for updated norms that consider complex demographic associations on test performance and that specifically exclude participants with mild cognitive impairment from the normative sample.

Does the Cognitive Change Index Predict Future Cognitive and Clinical Decline? Longitudinal Analysis in a Demographically Diverse Cohort

Background

The Cognitive Change Index (CCI) is a widely-used measure of self-perceived cognitive ability and change. Unfortunately, it is unclear if the CCI predicts future cognitive and clinical decline.

Objective

We evaluated baseline CCI to predict transition from normal cognition to cognitive impairment in nondemented older adults and in predementia groups including, subjective cognitive decline, motoric cognitive risk syndrome, and mild cognitive impairment. Different versions of the CCI were assessed to uncover any differential risk sensitivity. We also examined the effect of ethnicity/race on CCI.

Methods

Einstein Aging Study participants (N = 322, Mage = 77.57±4.96, % female=67.1, Meducation = 15.06±3.54, % non-Hispanic white = 46.3) completed an expanded 40-item CCI version (CCI-40) and neuropsychological evaluation (including Clinical Dementia Rating Scale [CDR], Montreal Cognitive Assessment, and Craft Story) at baseline and annual follow-up (Mfollow - up=3.4 years). CCI-40 includes the original 20 items (CCI-20) and the first 12 memory items (CCI-12). Linear mixed effects models (LME) and generalized LME assessed the association of CCI total scores at baseline with rate of decline in neuropsychological tests and CDR.

Results

In the overall sample and across predementia groups, the CCI was associated with rate of change in log odds on CDR, with higher CCI at baseline predicting faster increase in the odds of being impaired on CDR. The predictive validity of the CCI broadly held across versions (CCI-12, 20, 40) and ethnic/racial groups (non-Hispanic black and white).

Conclusions

Self-perception of cognitive change on the CCI is a useful marker of dementia risk in demographically/clinically diverse nondemented samples. All CCI versions successfully predicted decline.

Concordance Between Logical Memory and Craft Story 21 in Community-Dwelling Older Adults: The Role of Demographic Factors And Cognitive Status

OBJECTIVE

Episodic memory loss, a hallmark symptom of Alzheimer's Disease, is frequently quantified by story memory performance. The National Alzheimer's Coordinating Center Uniform Data Set Neuropsychological Battery (UDSNB) replaced Logical Memory with Craft Story 21 in UDSNB Version 3. The concordance between these story memory tasks is poorly characterized in demographically diverse older adults, possibly jeopardizing the integrity of longitudinal data in aging cohorts.

METHOD

Einstein Aging Study participants (n = 298; Mage = 76.6; Meducation = 15; 66.4% women; 43.3% Non-Hispanic White) completed UDSNB measures, including Craft Story and Logical Memory. Classification as normal cognition (n = 206) or mild cognitive impairment (n = 90) was based on Jak/Bondi criteria. Analyses included correlations, linear regression, and equipercentile equating methods to characterize the relationship between Logical Memory and Craft Story. Multivariate linear mixed effects models explored the association of covariates and practice effects over follow-up, stratified by cognitive status and race/ethnicity.

RESULTS

Immediate (r = 0.54) and delayed (r = 0.56) versions of Logical Memory and Craft Story were moderately correlated. Age, education, depression, and female sex were associated with Logical Memory, while age, education, cognitive status, and male sex were associated with Craft Story. Significant differential effects of sex on story memory were observed.

CONCLUSIONS

We demonstrated that Logical Memory and Craft Story may be used largely interchangeably; however, memory may be enhanced for stories with a protagonist of the same sex as the participant. Craft Story was somewhat more associated with mild cognitive impairment in the overall sample, but especially in non-Hispanic Black participants. We discuss how results inform test selection considerations.

Multivariate Base Rates of Low Neuropsychological Test Scores in Cognitively Intact Older Adults with Subjective Cognitive Decline from a Specialist Memory Clinic

OBJECTIVE

To avoid misdiagnosing mild cognitive impairment (MCI), knowledge of the multivariate base rates (MVBRs) of low scores on neuropsychological tests is crucial. Base rates have typically been determined from normative population samples, which may differ from clinically referred samples. The current study addresses this limitation by calculating the MVBR of low or high cognitive scores in older adults who presented to a memory clinic experiencing subjective cognitive decline but were not diagnosed with MCI.

METHOD

We determined the MVBRs on the Kaplan-Baycrest Neurocognitive Assessment for 107 cognitively healthy older adults (M age = 75.81), by calculating the frequency of patients producing n scores below or above different cut-off values (i.e., 1, 1.5, 2.0, 2.5 SD from the mean), stratifying by education and gender.

RESULTS

Performing below or above cut-off was common, with more stringent cut-offs leading to lower base rates (≥1 low scores occurred in 84.1% of older adults at -1 SD, 55.1% at -1.5 SD, and 39.3% at -2 SD below the mean; ≥1 high scores occurred in 80.4% of older adults at +1 SD, 35.5% at +1.5 SD, and 16.8% at +2 SD above the mean). Higher education was associated with varying base rates. Overall, the MVBR of obtaining a low cognitive test score was higher in this clinic sample, compared with prior studies of normative samples.

CONCLUSIONS

MVBRs for clinically referred older adults experiencing memory complaints provide a diagnostic benefit, helping to prevent attributing normal variability to cognitive impairment and limiting false positive diagnoses.

The Influence of Cerebrovascular Pathology on Cluster Analysis of Neuropsychological Scores in Patients With Mild Cognitive Impairment

OBJECTIVES

The diagnostic entity of mild cognitive impairment (MCI) is heterogeneous, highlighting the need for data-driven classification approaches to identify patient subgroups. However, these approaches can be strongly determined by sample characteristics and selected measures. Here, we applied a cluster analysis to an MCI patient database from a neuropsychology clinic to determine whether the inclusion of patients with MCI with vascular pathology would result in a different classification of subgroups.

METHODS

Participants diagnosed with MCI (n = 166), vascular cognitive impairment-no dementia (n = 26), and a group of older adults with subjective cognitive concerns but no objective impairment (n = 144) were assessed using a full neuropsychological battery and other clinical measures. Cognitive measures were analyzed using a hierarchical cluster analysis and then a k-means approach, with resulting clusters compared on a range of demographic and clinical variables.

RESULTS

We found a 4-factor solution: a cognitively intact cluster, a globally impaired cluster, an amnestic/visuospatial impairment cluster, and a mild, mixed-domain cluster. Interestingly, group differences in self-reported multilingualism emerged in the derived clusters that were not observed when comparing diagnostic groups.

CONCLUSIONS

Our results were generally consistent with previous studies using cluster analysis in MCI. Including patients with primarily cerebrovascular disease resulted in subtle differences in the derived clusters and revealed new insights into shared cognitive profiles of patients beyond diagnostic categories. These profiles should be further explored to develop individualized assessment and treatment approaches.