The Testamentary Capacity Assessment Tool (TCAT): validation and normative data

BACKGROUND

There is an increasing need for objective and standardized assessment of testamentary capacity (TC) in dementia. A new instrument, the Testamentary Capacity Assessment Tool (TCAT), has been recently developed; however, the lack of validation and normative data regarding this cognitive screening test has limited its adoption in forensic and clinical settings. The present study collects normative data for the TCAT and assesses its convergent validity with standardized cognitive tests and the capacity to define what a 'testament' is.

METHODS

The study involved 323 neurologically healthy adults (123 males, 200 females) of different ages (31-93 years) and different educational levels (4-25 years). The TCAT was administered along with the Beck Depression Inventory-II (BDI-II), the Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE), the Frontal Assessment Battery (FAB) and the Testament Definition Scale (TDS).

RESULTS

Multiple regression analyses revealed a significant effect for gender, age and education on TCAT scores. Correlation analyses showed significant associations between the TCAT and the MMSE, MoCA, FAB and BDI-II. A positive correlation between the TCAT and TDS was also found, proving good convergent validity of the TCAT with respect to TC. Finally, cut-off scores and Equivalent Scores (ES) were computed.

DISCUSSION

The present study provides normative data for using the TCAT as an adjuvant cognitive screening test in the neuropsychological evaluation of TC. Our findings shall be of interest for the adoption of the TCAT also in clinical practice, since it evaluates cognitive functions (e.g., autobiographic memory, Theory of Mind) not measured by traditional screening tests.

Reliability of Addenbrooke's Cognitive Examination III in differentiating between dementia, mild cognitive impairment and older adults who have not reported cognitive problems

Diagnosing dementia can be challenging for clinicians, given the array of factors that contribute to changes in cognitive function. The Addenbrooke’s Cognitive Examination III (ACE-III) is commonly used in dementia assessments, covering the domains of attention, memory, fluency, visuospatial and language. This study aims to (1) assess the reliability of ACE-III to differentiate between dementia, mild cognitive impairment (MCI) and controls and (2) establish whether the ACE-III is useful for diagnosing dementia subtypes. Client records from the Northern Health and Social Care Trust (NHSCT) Memory Service (n = 2,331, 2013–2019) were used in the analysis including people diagnosed with Alzheimer’s disease (n = 637), vascular dementia (n = 252), mixed dementia (n = 490), MCI (n = 920) and controls (n = 32). There were significant differences in total ACE-III and subdomain scores between people with dementia, MCI and controls (p < 0.05 for all), with little overlap between distribution of total ACE-III scores (< 39%) between groups. The distribution of total ACE-III and subdomain scores across all dementias were similar. There were significant differences in scores for attention, memory and fluency between Alzheimer’s disease and mixed dementia, and for visuospatial and language between Alzheimer’s disease–vascular dementia (p < 0.05 for all). However, despite the significant differences across these subdomains, there was a high degree of overlap between these scores (> 73%) and thus the differences are not clinically relevant. The results suggest that ACE-III is a useful tool for discriminating between dementia, MCI and controls, but it is not reliable for discriminating between dementia subtypes. Nonetheless, the ACE-III is still a reliable tool for clinicians that can assist in making a dementia diagnosis in combination with other factors at assessment.

Cognitive screening for adult psychiatric outpatients: Comparison of the Cognivue® to the Montreal Cognitive Assessment

In this editorial we comment on the article by Cahn-Hidalgo D published in a recent issue of the World Journal of Psychiatry 2020; 10(1); 1-11. We focus on the importance of utilizing psychometrically valid cognitive screening tools when assessing for cognitive decline in older adults in a psychiatric outpatient setting. We compared the use of Cognivue^® to use of the montreal cognitive assessment (MoCA) as a cognitive screening tool. A total of 58 patients aged 55 and over participated in this comparison study. Patients completed cognitive screening on Cognivue^®, a new Food and Drug Administration-cleared computer screening device, and the MoCA. The results of patient performance using these two instruments were analyzed. Sixteen (28%) patients screened negative for cognitive impairment on both assessments. Forty-two (72%) patients screened positive on one or both of the assessments. There was 43% agreement between Cognivue^® and the MoCA in identifying patients with cognitive impairment, and individual subtests were weakly correlated. The MoCA was determined to be the preferred instrument due to its high sensitivity and specificity (100% and 87%, respectively) when screening for cognitive impairment. We propose that the use of Cognivue^® cognitive screening tool be closely reviewed until more research proves that the test meets the standards for reliability and validity. It is important for clinicians to remember that screeners should not be used to diagnosis patients with neurocognitive disorders; instead, they should be used to determine whether further evaluation is warranted. Additionally, misdiagnosing of neurocognitive disorders can pose unnecessary psychological and emotional harm to patients and their families and also lead to incorrect treatment and undue healthcare costs.

Cognitive Profile of the Logopenic Variant of Primary Progressive Aphasia Using the Dépistage Cognitif de Québec

BACKGROUND/AIMS

The logopenic variant of primary progressive aphasia (lvPPA) is characterized by impaired word-finding and sentence repetition with phonologic errors but spared motor speech and grammar and semantic knowledge. Although its language deficits have been well studied, the full spectrum of cognitive changes in the lvPPA remains to be defined. We aimed to explore the neurocognitive profile of the lvPPA using a newly developed cognitive screening tool for atypical dementias, the Dépistage Cognitif de Québec (DCQ).

METHODS

We compared 29 patients with lvPPA to 72 amnestic variant Alzheimer disease (aAD) to 438 healthy control (HC) participants. Performance on the 5 indexes of the DCQ (Memory, Visuospatial, Executive, Language and Behavioral) was compared between the 3 groups.

RESULTS

Results showed a significantly lower performance for lvPPA participants in all neurocognitive domains, when compared to HC. When compared to aAD, lvPPA participants had significantly lower scores for language, executive, and visuospatial abilities, but not for memory and behavior.

CONCLUSION

Altogether, these findings better define the neurocognitive changes of lvPPA.

Montreal Cognitive Assessment as Screening Measure for Mild and Major Neurocognitive Disorder in a Chilean Population

Background

The Montreal Cognitive Assessment (MoCA) is a sensitive screening instrument for mild neurocognitive disorder (mild NCD). However, cut-off scores and accuracy indices should be established using representative samples of the population. In this context, the aim of this study was to update the normative values, and diagnostic efficiency statistics of the MoCA to detect mild NCD in the Chilean population.

Methods

This study included 226 participants from the north, center, and south of the country, classified into 3 groups: healthy elderly (HE; n = 113), mild NCD (n = 65), and major neurocognitive disorder (major NCD; n = 48).

Results

The optimal cut-off score to discriminate mild NCD from HE participants was 20 points with a sensitivity of 82.8% and a specificity of 84.1%. The observed balance between sensitivity and specificity shows a good test performance either to confirm or discard a diagnosis. The cut-off between mild NCD and major NCD from HE participants was 19 points with 85.6% of sensitivity and 90.3% of specificity.

Conclusion

Overall diagnostic accuracy can be considered as outstanding (AUC ≥0.904) when discriminating HE from both mild NCD and major NCD. These results showed that the MoCA is a suitable tool to identify mild NCD and major NCD.

Diagnostic accuracy of the repeatable battery of the assessment of neuropsychological status update, Spanish version, in predicting Alzheimer's disease among Hispanic older adults in the United States reporting memory problems

Objectives: There are few standardized, Spanish-language diagnostic tools to help identify Hispanic persons at early stages of Alzheimer's disease (AD). This study evaluated the accuracy of the Spanish version of the Repeatable Battery for the Assessment of Neuropsychological Status-Update (RBANS) in predicting AD in older Hispanic adults in the United States reporting memory problems.Methods: We analyzed data from age, sex, and education level propensity score-matched Hispanic memory clinic patients with (n = 38) and without (n = 38) a clinical diagnosis of AD. Estimates of diagnostic accuracy included sensitivity, specificity, predictive value, and receiver operating characteristic analysis.Results: After controlling for sex and matched pairs, the Total Scale score [area under curve (AUC) = 0.7417] and the Immediate (AUC = 0.7258) and Delayed (AUC = 0.7735) Memory index scores provided better estimates of diagnostic accuracy than Language, Attention, and Visuospatial/Constructional index scores. A minus 2-standard deviation (SD) cut point enhanced the predictive probability of the Delayed Memory index score. A cut point of -1.5 SD optimized the predictive probability of the Total Scale score.Conclusions: These results suggest that optimal cutoff values for the RBANS Delayed Memory index and Total Scale scores that may help identify Hispanic patients with AD as part of a comprehensive diagnostic AD assessment.

Assessing the Prevalence of Undetected Possible Dementia in Faroese Nursing Homes

INTRODUCTION

To assess the prevalence of possible dementia among nursing home residents in the Faroe Islands.

METHOD

This cross-sectional study, undertaken in 2017, included all nursing homes in the Faroe Islands (n = 30), housing 591 residents. All residents were invited to participate, except those with an existing clinical diagnosis of dementia or living in dementia units (n = 207). A total of 232 residents participated, while 39 declined and 113 were unable to give consent, had died, or were not permanent residents at the time of examination. Cognitive screening was carried out using the Mini-Mental State Examination (MMSE) and the Informant Questionnaire on Cognitive Decline (IQCODE).

RESULTS

Possible dementia was found in 49% to 78% of the participants depending on the method used. According to both MMSE and IQCODE (AND rule), possible dementia was present in 105 participants (49%). According only to IQCODE, 119 participants (55%) scored above the cut-off (≥3.6), according to MMSE alone, 162 participants (72%) scored below the cut-off (≤24 on MMSE), while 175 participants (78%) screened positive according to either MMSE or IQCODE (OR rule). A rough estimate of the prevalence of possible dementia in the entire nursing home population (n = 591) including residents with known dementia and those with possible dementia from this study was between 61% and 73%.

CONCLUSION

A high percentage (49-78%) of the participating nursing home residents without a pre-dementia diagnosis were assessed to have possible dementia based on screening with standardized tools, indicating a high degree of dementia underdiagnoses in Faroese nursing homes. This high prevalence of dementia is of significance for the clinical practice, running, and planning of nursing homes and pinpoints a need to act upon this, not only in the Faroes but also worldwide.

Validation of the Sinhala Version of the Addenbrooke's Cognitive Examination-Revised for the Detection of Dementia in Sri Lanka: Comparison with the Mini-Mental Status Examination and the Montreal Cognitive Assessment

BACKGROUND

Sri Lanka is a rapidly aging country, where dementia prevalence will increase significantly in the future. Thus, inexpensive and sensitive cognitive screening tools are crucial.

OBJECTIVES

To assess the reliability, validity, and diagnostic accuracy of the Sinhalese version of the Addenbrooke's Cognitive Examination-Revised (ACE-R s).

METHOD

The ACE-R was translated into Sinhala with cultural and linguistic adaptations and administered, together with the Sinhala version of the Montreal Cognitive Assessment (MoCA), to 99 patients with dementia and 93 gender-matched controls.

RESULTS

The ACE-R s cutoff score for dementia was 80 (sensitivity 91.9%, specificity 76.3%). The areas under the curve for the ACE-R s, Mini-Mental State Examination (MMSE) and MoCA were 0.90, 0.86, and 0.86, respectively. The -ACE-R s had good interrater reliability (intraclass correlation = 0.94), test-retest reliability (intraclass correlation = 0.99), and internal consistency (Cronbach's α = 0.8442).

CONCLUSIONS

The ACE-R s is sensitive, specific and reliable to detect dementia in persons aged ≥50 years in a Sinhala-speaking population and its diagnostic accuracy is superior to previously validated tools (MMSE and MoCA).

Validity, reliability, and psychometric properties of a computerized, cognitive assessment test (Cognivue®)

BACKGROUND

Cognitive issues such as Alzheimer’s disease and other dementias confer a substantial negative impact. Problems relating to sensitivity, subjectivity, and inherent bias can limit the usefulness of many traditional methods of assessing cognitive impairment.

AIM

To determine cut-off scores for classification of cognitive impairment, and assess Cognivue^® safety and efficacy in a large validation study.

METHODS

Adults (age 55-95 years) at risk for age-related cognitive decline or dementia were invited via posters and email to participate in two cohort studies conducted at various outpatient clinics and assisted- and independent-living facilities. In the cut-off score determination study (n = 92), optimization analyses by positive percent agreement (PPA) and negative percent agreement (NPA), and by accuracy and error bias were conducted. In the clinical validation study (n = 401), regression, rank linear regression, and factor analyses were conducted. Participants in the clinical validation study also completed other neuropsychological tests.

RESULTS

For the cut-off score determination study, 92 participants completed St. Louis University Mental Status (SLUMS, reference standard) and Cognivue^® tests. Analyses showed that SLUMS cut-off scores of < 21 (impairment) and > 26 (no impairment) corresponded to Cognivue^® scores of 54.5 (NPA = 0.92; PPA = 0.64) and 78.5 (NPA = 0.5; PPA = 0.79), respectively. Therefore, conservatively, Cognivue^® scores of 55-64 corresponded to impairment, and 74-79 to no impairment. For the clinical validation study, 401 participants completed ≥ 1 testing session, and 358 completed 2 sessions 1-2 wk apart. Cognivue^® classification scores were validated, demonstrating good agreement with SLUMS scores (weighted κ 0.57; 95%CI: 0.50-0.63). Reliability analyses showed similar scores across repeated testing for Cognivue^® (R² = 0.81; r = 0.90) and SLUMS (R² = 0.67; r = 0.82). Psychometric validity of Cognivue^® was demonstrated vs. traditional neuropsychological tests. Scores were most closely correlated with measures of verbal processing, manual dexterity/speed, visual contrast sensitivity, visuospatial/executive function, and speed/sequencing.

CONCLUSION

Cognivue^® scores ≤ 50 avoid misclassification of impairment, and scores ≥ 75 avoid misclassification of unimpairment. The validation study demonstrates good agreement between Cognivue^® and SLUMS; superior reliability; and good psychometric validity.

Short test of mental status in the detection of mild cognitive impairment in India

CONTEXT

Mild cognitive impairment (MCI) is an under-diagnosed health problem in the community. Cognitive screening tools are widely used for MCI detection, but many of them lack sensitivity and specificity in MCI detection. On the basis of literature review, Short test of mental status (STMS) was selected for the present purpose.

AIMS

The present study purports to standardize STMS for using as a cognitive screening tool in MCI detection in the community-living elderly people in Kolkata.

MATERIALS AND METHODS

Data were collected from 102 community-living elderly people from the city of Kolkata using the purposive method of sampling. MCI was diagnosed using the Peterson's criteria of MCI as the gold standard. A semi-structured demographic proforma, clock-drawing test (CDT), and the Groningen Activity Restriction Scale (GARS) were used for the purpose. Finally, STMS was administered.

STATISTICAL ANALYSIS

Statistical computation was done using the SPSS 21. Descriptive statistics, receiver operating curve analysis, and binary logistic regression were used for statistical analysis of the data.

RESULTS AND CONCLUSION

STMS emerged as a sensitive and specific cognitive screening tool in the detection of MCI in the current cultural setting. It was also found to be more suited for the purpose than CDT. A score of 34.5 with a sensitivity of 97.5 and a specificity of 90.3% were selected for the optimum cutoff score for the detection of MCI in the present population. With a unit increase in STMS score, the odds of getting diagnosed with MCI were found to be reduced by 48.5%.

Influence of Age and Education on the Performance of Elderly in the Brazilian Version of the Montreal Cognitive Assessment Battery

AIMS

To provide normative data for the Brazilian version of the Montreal Cognitive Assessment (MoCA-BR) and to measure the effect of sociodemographic variables on the cognitive performance of cognitively healthy elderly people.

METHODS

A sample of 110 cognitively healthy individuals, aged over 65 years, with at least 4 years of schooling were recruited from 3 health care centers for the elderly in Recife, Brazil. The cognitive performance was assessed using MoCA-BR.

RESULTS

The average score of these elderly people in the MoCA-BR was 23.2 ± 2.7. Their schooling correlated positively with the cognitive performance, with a Spearman's coefficient of 0.33 (p < 0.001). There was a statistically significant negative correlation between age and the cognitive performance (Spearman's rho = -0.19). The multiple linear regression model with the highest adjusted coefficient of determination was the one that included schooling and age (adjusted R2 = 0.127).

CONCLUSIONS

The cognitive performance of healthy elderly was evaluated and was strongly influenced by schooling and, to a lower degree, by age.

A Brief Informant Screening Instrument for Dementia in the ICU: The Diagnostic Accuracy of the AD8 in Critically Ill Adults Suspected of Having Pre-Existing Dementia

BACKGROUND/AIM

The diagnostic accuracy of brief informant screening instruments to detect dementia in critically ill adults is unknown. We sought to determine the diagnostic accuracy of the 2- to 3-min Ascertain Dementia 8 (AD8) completed by surrogates in detecting dementia among critically ill adults suspected of having pre-existing dementia by comparing it to the Clinical Dementia Rating Scale (CDR).

METHODS

This substudy of BRAIN-ICU included a subgroup of 75 critically ill medical/surgical patients determined to be at medium risk of having pre-existing dementia (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE] score ≥3.3). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and AUC for the standard AD8 cutoff of ≥2 versus the reference standard CDR score of ≥1 for mild dementia.

RESULTS

By the CDR, 38 patients had very mild or no dementia and 37 had mild dementia or greater. For diagnosing mild dementia, the AD8 had a sensitivity of 97% (95% CI 86-100), a specificity of 16% (6-31), a PPV of 53% (40-65), an NPV of 86% (42-100), and an AUC of 0.738 (0.626-0.850).

CONCLUSIONS

Among critically ill patients judged at risk for pre-existing dementia, the 2- to 3-min AD8 is highly sensitive and has a high NPV. These data indicate that the brief tool can serve to rule out dementia in a specific patient population.

One Size Does Not Fit All: Comparative Diagnostic Accuracy of the Rowland Universal Dementia Assessment Scale and the Mini Mental State Examination in a Memory Clinic Population with Very Low Education

Background

Diagnosing dementia in elderly immigrants is often difficult due to language and cultural barriers, low education, and illiteracy. We compared the diagnostic accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) to that of the Mini Mental State Examination (MMSE).

Methods

A total of 144 patients (42 with intact cognition, 44 with mild cognitive impairment [MCI], and 58 with dementia) were administered both instruments and were diagnosed by specialists blinded for MMSE and RUDAS results.

Results

Areas under the curve for discriminating intact cognition from MCI and dementia were comparable for RUDAS (0.81; 95% confidence interval 0.74–0.88) and MMSE (0.75; 95% confidence interval 0.69–0.85). Education and literacy were not correlated with the RUDAS but had a medium-large correlation with the MMSE (rho = 0.39).

Conclusions

The study provides additional evidence for the usefulness of the RUDAS in a highly illiterate, culturally diverse geriatric outpatient population.

Montreal Cognitive Assessment in a 63- to 65-year-old Norwegian Cohort from the General Population: Data from the Akershus Cardiac Examination 1950 Study

Aims

To investigate Montreal Cognitive Assessment (MoCA) test scores in a cohort aged 63–65 years from a general population in relation to the proposed cut-off score of 26 for mild cognitive impairment (MCI) and to explore the impact of education.

Methods

MoCA scores were assessed in the Akershus Cardiac Examination 1950 Study, a cross-sectional cohort study of all men and women born in 1950 living in Akershus County, Norway. The participants were aged 63–65 at the time of data collection.

Results

MoCA scores were available in 3,413 participants, of which 47% had higher education (>12 years). The mean MoCA score was 25.3 (95% confidence interval [CI] 25.2–25.4), and 49% had a score below the suggested cut-off of 26 points. Those with higher education had significantly higher scores (mean 26.2, 95% CI 26.1–26.3 vs. 24.4, 95% CI 24.3–24.6, p < 0.001).

Conclusions

Approximately 50% scored below the cut-off score of 26 points, suggesting that the cut-off score may have been set too high to distinguish normal cognitive function from MCI. Educational level had a significant impact on MoCA scores.

Characteristic differences in the mini-mental state examination used in Asian countries

BACKGROUND

The mini-mental state examination (MMSE) was adapted by individual countries according to their languages and cultures, though it has not been systematically compared. The objective of this study was to compare the linguistic and cultural variations of the MMSE used in various Asian countries. With this, we can analyze the strengths and weaknesses of the MMSE and consider using a common version in future international clinical studies in Asia.

METHODS

We collected the MMSEs used in 11 Asian nations. After translating those into English, we compared them to understand the differences in the questionnaires with regard to cultural aspects.

RESULTS

Many items may be applicable or comparable with a little modification, for Asian countries. However, attention and calculation and repetition may be incomparable. There were some differences in the contents and the ways to administer.

CONCLUSIONS

The lack of consideration of the cultural differences and their influences on the interpretation of the same cognitive test makes cross-cultural studies difficult. Some items of MMSE tasks need readjusting for, if any, multi-national studies. This study might serve as a first step in the development of a standardized cross-cultural cognitive instrument, especially in Asia.

Test Your Memory is sensitive to cognitive change but lacks prospective validity

OBJECTIVE

To determine the prospective validity of Test Your Memory (TYM) and its sensitivity to change in cognitive state.

METHODS

This longitudinal prospective study followed 71 patients with subjective cognitive symptoms and 48 with mild cognitive impairment for a mean time period of 35.2 ± 15 months. Subjects did not have dementia or depression at the beginning of follow-up and each participant was given the TYM at least two times. A psychometric threshold was established to determine presence of a cognitive deficit (z-score ≤ 1.5 on at least one cognitive domain) and the Disability Assessment for Dementia scale was used to ensure full functional ability. The criterion for deterioration was a change in the stage on the Global Deterioration Scale.

RESULTS

Sixty-one patients remained cognitively stable and 58 worsened. There were no differences between them with respect to sex, educational attainment, the initial stage on the GDS, or the score on the first TYM. Subjects who worsened were older than those who did not. The TYM increased an average of 0.04 points per month in patients who remained stable or improved (95% CI, -0.01 to 0.08) and decreased an average of 0.14 points per month in those whose condition worsened (95% CI, -0.19 to -0.09). Subjects with mild cognitive impairment who worsened displayed a sharper loss of TYM points than did subjects with subjective cognitive symptoms.

CONCLUSIONS

While the TYM lacks prospective validity, it is sensitive to changes in cognitive state.

[Standardization of the Test Your Memory and evaluation of their concordance with the outcome of the psychometric examination]

OBJECTIVE

To explore the relationship between scores on the Test Your Memory (TYM) battery and findings from a more exhaustive neurocognitive assessment.

METHODS

The TYM and fourteen psychometric tests were administered to 84 subjects aged 50 or older who attended an outpatient neurology clinic due to cognitive symptoms. Each patient's cognitive state was determined independently from his/her score on the TYM (CDR 0, n=25; CDR 0.5, n=45; CDR 1, n=14). We analysed concurrent validity of TYM scores and results from the psychometric tests, as well as the degree of concordance between the two types of measurement, by contrasting normalised data from each instrument.

RESULTS

Although the intraclass correlation coefficient was 0.67 (confidence interval 95%, 0.53-0.77), analysis of the Bland-Altman plot and the curve on the survival-agreement plot (Luiz et al. method) demonstrates that the individual distances between the two methods exhibit excessive dispersion from a clinical viewpoint. TYM-based predictions of the mean z-score on psychometric tests differed substantially from real results in 30% of the subjects. Concordance of 95% can only be achieved by accepting absolute inter-instrument differences of up to 0.87 as identical values. Furthermore, the TYM underestimates cognitive performance for low values and overestimates it for high values.

CONCLUSIONS

The TYM is a cognitive screening test which should not be used to predict results on psychometric tests or to detect cognitive changes in clinical trials.