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.

The measurement of participant-reported memory across diverse populations and settings: a systematic review and meta-analysis of the Multifactorial Memory Questionnaire.

The Multifactorial Memory Questionnaire (MMQ) is a participant-reported measure of memory satisfaction, ability, and strategy use. Initially validated with healthy older adults, it has since been used in many different populations and settings for a variety of purposes. We conducted a systematic review and meta-analysis of the measurement properties of the MMQ across multiple, diverse studies. METHODS: The study was designed using the Consensus-Based Standards for the Selection of Health Measurement Instruments and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We calculated aggregate statistics and evaluated the methodological quality of 29 studies retrieved from PsycINFO, MEDLINE, EMBASE, and Web of Science. RESULTS: Analyses revealed high-quality evidence for internal consistency, stability, measurement error, convergent validity, and known-groups validity of the three MMQ scales. There was moderate-quality evidence for responsiveness and structural validity, with some studies identifying separate factors for internal and external memory strategy use. Measurement properties were similar across languages, participant samples, and study designs. CONCLUSIONS: The MMQ is a valid, reliable, and responsive measure across diverse settings and populations. Future research is needed to determine whether more detailed information can be obtained from the scales, specifically, internal versus external strategy use.

Correction to: The Toronto cognitive assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment.

Upon publication of this article [1], it was brought to our attention that one of the 303 participants in the normative study should have been deleted from the database.

The Toronto Cognitive Assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment.

BACKGROUND: A need exists for easily administered assessment tools to detect mild cognitive changes that are more comprehensive than screening tests but shorter than a neuropsychological battery and that can be administered by physicians, as well as any health care professional or trained assistant in any medical setting. The Toronto Cognitive Assessment (TorCA) was developed to achieve these goals. METHODS: We obtained normative data on the TorCA (n = 303), determined test reliability, developed an iPad version, and validated the TorCA against neuropsychological assessment for detecting amnestic mild cognitive impairment (aMCI) (n = 50/57, aMCI/normal cognition). For the normative study, healthy volunteers were recruited from the Rotman Research Institute registry. For the validation study, the sample was comprised of participants with aMCI or normal cognition based on neuropsychological assessment. Cognitively normal participants were recruited from both healthy volunteers in the normative study sample and the community. RESULTS: The TorCA provides a stable assessment of multiple cognitive domains. The total score correctly classified 79% of participants (sensitivity 80%; specificity 79%). In an exploratory logistic regression analysis, indices of Immediate Verbal Recall, Delayed Verbal and Visual Recall, Visuospatial Function, and Working Memory/Attention/Executive Control, a subset of the domains assessed by the TorCA, correctly classified 92% of participants (sensitivity 92%; specificity 91%). Paper and iPad version scores were equivalent. CONCLUSIONS: The TorCA can improve resource utilization by identifying patients with aMCI who may not require more resource-intensive neuropsychological assessment. Future studies will focus on cross-validating the TorCA for aMCI, and validation for disorders other than aMCI.

A re-examination of Montreal Cognitive Assessment (MoCA) cutoff scores.

OBJECTIVE: The Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) is a cognitive screening tool that aims to differentiate healthy cognitive aging from Mild Cognitive Impairment (MCI). Several validation studies have been conducted on the MoCA, in a variety of clinical populations. Some studies have indicated that the originally suggested cutoff score of 26/30 leads to an inflated rate of false positives, particularly for those of older age and/or lower education. We conducted a systematic review and meta-analysis of the literature to determine the diagnostic accuracy of the MoCA for differentiating healthy cognitive aging from possible MCI. METHODS: Of the 304 studies identified, nine met inclusion criteria for the meta-analysis. These studies were assessed across a range of cutoff scores to determine the respective sensitivities, specificities, positive and negative predictive accuracies, likelihood ratios for positive and negative results, classification accuracies, and Youden indices. RESULTS: Meta-analysis revealed a cutoff score of 23/30 yielded the best diagnostic accuracy across a range of parameters. CONCLUSIONS: A MoCA cutoff score of 23, rather than the initially recommended score of 26, lowers the false positive rate and shows overall better diagnostic accuracy. We recommend the use of this cutoff score going forward. Copyright © 2017 John Wiley & Sons, Ltd.

Long-term maintenance of smartphone and PDA use in individuals with moderate to severe memory impairment.

In an earlier paper we described a structured, theory-driven training programme which was administered to 10 individuals with moderate-to-severe memory impairment. All individuals received an errorless-fading-of-cues protocol in the use of personal digital assistants (PDAs) or smartphones (Svoboda, Richards, Leach, & Mertens, 2012) and demonstrated generalisation of acquired skills to day-to-day memory challenges. Maintenance of intervention gains over the long-term is another indicator of successful generalisation. Here we present the maintenance of device use in the same group of individuals 12 to 19 months after programme completion. A within-subject, ABABB multi-case experimental design was used to evaluate the impact of PDA or smartphone use on day-to-day memory functioning at baseline, immediately post-intervention, at return to baseline, and at short-term and long-term follow-up. Results presented here focus predominantly on long-term follow-up. All 10 individuals showed maintenance of gains in day-to-day functioning as quantified across several ecologically valid questionnaire and task-based measures. This was corroborated by family members with whom six of the participants resided. This study further demonstrates the programme's clinical effectiveness in enabling individuals with moderate-to-severe memory impairment to function more independently and with greater confidence up to 19 months following programme completion.

Development and evaluation of a self-administered on-line test of memory and attention for middle-aged and older adults.

There is a need for rapid and reliable Internet-based screening tools for cognitive assessment in middle-aged and older adults. We report the psychometric properties of an on-line tool designed to screen for cognitive deficits that require further investigation. The tool is composed of measures of memory and executive attention processes known to be sensitive to brain changes associated with aging and with cognitive disorders that become more prevalent with age. Measures included a Spatial Working Memory task, Stroop Interference task, Face-Name Association task, and Number-Letter Alternation task. Normative data were collected from 361 healthy adults age 50-79 who scored in the normal range on a standardized measure of general cognitive ability. Participants took the 20-minute on-line test on their home computers, and a subset of 288 participants repeated the test 1 week later. Analyses of the individual tasks indicated adequate internal consistency, construct validity, test-retest reliability, and alternate version reliability. As expected, scores were correlated with age. The four tasks loaded on the same principle component. Demographically-corrected z-scores from the individual tasks were combined to create an overall score, which showed good reliability and classification consistency. These results indicate the tool may be useful for identifying middle-aged and older adults with lower than expected scores who may benefit from clinical evaluation of their cognition by a health care professional.

Discrimination of the cognitive profiles of MCI and depression using the KBNA.

OBJECTIVE: The current study sought to determine if the Kaplan-Baycrest Neurocognitive Assessment (KBNA) was capable of discriminating individuals with subjective memory complaints associated with depression from individuals with mild cognitive impairment (MCI). METHODS: Scores on 12 subtests of the KBNA were compared for 27 participants with MCI and 28 participants being treated for depression using Bonferroni correct between-group comparisons for each subtest. KBNA subtest scores were corrected for age and education. RESULTS: Significant between-group differences were obtained on six subtests with large effect sizes (Cohen's d) ranging from 1.19 - 1.58. The six subtests involved encoding and delayed episodic memory for verbal and visual information. Using logistic regression analysis, five subtests of the KBNA were able to correctly classify 96.4% of study participants. CONCLUSION: The results from this preliminary investigation indicate that the KBNA has the potential to serve as a brief and reliable assessment tool capable of distinguishing individuals with subjective memory complaints associated with depression from individuals with MCI in a clinical setting. Limitations of the current study and future research are discussed.

Impact of posttraumatic stress disorder and depression on neuropsychological functioning in electrical injury survivors.

To examine neuropsychological functioning in survivors of electrical injury with posttraumatic stress disorder (PTSD) and depression. This was a prospective research study that was done in an outpatient clinic of a rehabilitation hospital. Thirty participants were recruited for the study between January 2008 and December 2010. All participants completed questionnaires measuring depression, PTSD, and a series of standardized psychometric measures of neuropsychological functioning. Domains tested included verbal and visual memory, attention, and executive functioning. A correlation analysis was performed to explore association between variables. Based on the level of PTSD symptoms, subjects were divided into three groups: no PTSD, subclinical PTSD, and PTSD, and a series of one-way analyses of variance were done to explore this association further. A series of analyses of covariance were done to control for depression. PTSD had a significant (P < .05) negative association with immediate verbal memory and immediate and delayed visual memory. Subjects with PTSD had significantly (P < .05) worse scores on immediate and delayed verbal memory and visual memory than those with subclinical PTSD or no PTSD. Measures of attention, working memory, and executive functioning were not significantly different between PTSD groups. When depression was introduced as a covariate, verbal and visual memory scores were not significantly different between PTSD groups. The findings suggest that there is a negative association between PTSD and cognitive performance that may be related to depression among those with electrical injury. A larger sample size is warranted to explore this further.

PDA and smartphone use by individuals with moderate-to-severe memory impairment: application of a theory-driven training programme.

We describe a structured, theory-driven training programme for individuals with moderate-to-severe memory impairment in the use of emerging commercial technology. We demonstrate its application to 10 individuals with memory impairment from a variety of aetiologies. A within-subject, ABAB multi-case experimental design was used to evaluate the impact of personal digital assistant or smartphone use on day-to-day memory functioning at baseline, immediately post-intervention, at return to baseline, and at short-term follow-up (range = 3-8 months). An errorless fading-of-cues protocol enabled all participants to acquire the skill set necessary to operate their PDA or smartphone independently. All 10 individuals showed robust improvement in day-to-day functioning post-intervention as quantified across a number of ecologically valid questionnaire and task-based measures. This was further corroborated by family members with whom six of the participants resided. These findings demonstrate that individuals with moderate-to-severe memory impairment can acquire the skills necessary to independently, flexibly and broadly apply commercial technology to support their everyday memory functioning. Moreover the findings confirm that the gap between individuals with memory impairment and potent emerging technology can be closed by the application of a systematic theory-driven training programme.

The diagnostic prediction of the Kaplan-Baycrest neurocognitive assessment for identification of mild dementia.

The purpose of this study was to: (1) determine the diagnostic prediction of the global score of the Kaplan-Baycrest Neurocognitive Assessment and (2) determine which subtests discriminate individuals with mild dementia from individuals without dementia. A case-control study of 33 individuals, diagnosed with mild dementia, was matched with 33 individuals with no cognitive or memory complaints, on age, education, and gender. A global measure score correctly classified 94% of the total sample with a sensitivity of 0.91 and specificity of 0.97. A measure composed of three subtest scores, representing verbal episodic memory, visual episodic memory, and semantic fluency, correctly classified 98% of the sample with a sensitivity of 1.00 and specificity of 0.97. The results indicate that the Kaplan-Baycrest Neurocognitive Assessment is a valid tool for prediction of cognitive impairment associated with mild dementia.

Recollection and familiarity for public events in neurologically intact older adults and two brain-damaged patients.

Despite extensive investigations of the role of recollection and familiarity on laboratory-acquired memories, there is a dearth of such research on memories formed in real life settings. We used the Remember/Know paradigm to investigate the relative contribution of recollection and familiarity processes to memory of public historical events reported in the media across the life span of two groups of neurologically intact older adults (old-old: 74-85, young-old: 58-69) and on two patients with brain damage. First, in neurologically intact participants, recollection rates decreased as a function of time elapsed since the event occurred, at a significantly higher rate than the corresponding decrease in familiarity or global memory. Second, consistent with the hypothesis that memories become increasingly semantic as they age, and that recollection is selectively impaired in older adults, across decades, old-old participants exhibited lower recollection, but not familiarity, relative to young-old participants. Finally, as a demonstration of how this procedure may be applied to studies of clinical populations, we tested two patients, one with medial temporal lesions and another with relative sparing of the medial temporal lobes, but with anterior temporal damage. We found that recollection was disproportionately impaired relative to familiarity across most of the life span in the patient with medial temporal lesions severely while recollection was relatively intact in the patient with anterior lateral temporal damage. We discuss the present results in the context of neuroanatomical and process-oriented theories of how memories age.

Cognitive functioning under stress: evidence from informal caregivers of palliative patients.

BACKGROUND: Caring for a terminally ill family member can be extremely stressful, and stress is known to have a negative influence on aspects of cognition. In contrast to the well-known physical and mental health risks associated with caregiving, little is known about its impact on cognitive functioning. OBJECTIVE: The primary objective of this study was to explore cognition among caregivers of palliative family members with a battery of neuropsychological tests. A secondary objective was to examine changes in cognition following caregiving by retesting a subset of participants at least 6 months after the death of their care recipient. METHOD: While caregiving, 27 participants completed an assessment battery measuring attention, learning, and memory, as well as intelligence, mood, and general health; 22 participants completed this battery again post-caregiving. We compared caregivers' cognitive performance to healthy normative samples. RESULTS: Participants who were caring for palliative relatives exhibited significant impairments in attention, including difficulty monitoring their performance and regulating their attentional resources. In contrast, participants' episodic and working memory performance was not impaired while caregiving. A mixed pattern of improvement and worsening of cognitive functioning was evident among caregivers retested after their family member's death. CONCLUSIONS: In addition to the well-documented physical and mental health risks associated with caregiving, this study adds to a small body of literature demonstrating impaired cognitive functioning among family members providing end-of-life care. Secondary findings of both improvement and deterioration of cognition post caregiving provide tentative support for the possibility of reversing certain cognitive deficits by reducing caregiver stress.

Aging and response inhibition: Normative data for the Victoria Stroop Test.

Increased difficulty with response inhibition occurs with age, although there is some controversy as to whether increased interference on Stroop tasks reflects difficulties with response inhibition or simply reflects generalized cognitive slowing. The Victoria Stroop Test (VST) is a brief, easily administered, psychometrically sound version of Stroop's original task. Performance on the VST by adults across a wide age span was examined to determine the association between age and various measures of interference. In addition, normative data for the VST were calculated. Participants were 272 healthy, community-dwelling adults age 18 to 94. Age and speed were negatively correlated on all trials of the VST. Importantly, however, interference scores that were corrected for baseline slowing remained highly correlated with age. Similarly, age and error scores on the interference trial were positively correlated, indicating decreased accuracy with age. These findings suggest that increased interference on Stroop tasks with age is not accounted for by simple cognitive slowing and more likely reflects other cognitive changes, such as decreased response inhibition. The VST has a number of administrative and psychometric strengths, and the provision of normative data should enhance its potential for clinical and research applications.

The utility of the mini-mental status exam in older adults with traumatic brain injury.

PRIMARY OBJECTIVE: To assess the utility of the Mini-Mental Status Examination (MMSE) among the older TBI population. METHODS AND PROCEDURES: The MMSE and a number of other neuropsychological tests were administered to forty-three adults aged 50 and over one year following mild to moderate TBI. The sensitivity, specificity, and predictive value of the MMSE were evaluated in relation to these tests. MAIN OUTCOMES AND RESULTS: The domains of the MMSE generally exhibited low sensitivity while high specificity was demonstrated by Attention and Language. Positive predictive value was high only for Language but negative predictive value was moderate to high for all domains. CONCLUSIONS: These results suggest that one year following mild to moderate TBI among older adults, the MMSE should not be used to identify those with cognitive impairment; if administered, a perfect score on a component of the MMSE suggests that enhanced testing in that given domain may not reveal further impairment. A small sample size and a small number of those impaired limit our results.

Is cerebral microembolism in mechanical prosthetic heart valves clinically relevant?

BACKGROUND AND PURPOSE: High-intensity transient signals (HITS) are frequently detected by transcranial Doppler (TCD) ultrasound in patients with mechanical prosthetic heart valves (PHVs), but published data about their clinical relevance are controversial. This study was undertaken to determine the clinical relevance of HITS in patients with mechanical PHVs. METHODS: The authors prospectively studied patients with mechanical PHVs using TCD monitoring for microemboli detection with and without O2 inhalation. The cognitive testing of patients included the Mini-Mental State Examination, the Dementia Rating Scale, and MicroCog. RESULTS: The authors studied 36 patients (20 women, aged 58 +/- 13 years). HITS were detected in 72% of patients, with a nonsignificant increase of HITS rate in the aortic valve group (P = .07). There was no significant difference in HITS rate between asymptomatic and symptomatic patients. In a multiple linear regression model, HITS rate was predicted only by younger age (P = .024). No correlation was found between HITS rate and the cognitive performance of patients. There was a significant decrease in HITS rate after 100% O2 inhalation compared to baseline levels (32.8 +/- 40.2 vs 6.1 +/- 11.3, P = .011). Subgroup analysis in asymptomatic patients confirmed this finding (P = .017), but in symptomatic patients, decreased HITS rate was not statistically significant (P = .18). CONCLUSION: Only age was a significant predictor of HITS in patients with mechanical PHVs. The lack of association between HITS, clinical symptoms, and cognitive functioning suggests that most of these signals represent harmless epiphenomena, and only HITS detected after O2 inhalation have any clinical relevance.

A shrinking span of temporal continuity in dementia of the Alzheimer's type.

OBJECTIVE: To examine the integrity of memory function in terms of temporal continuity in a way that would engage a patient in everyday behavior, such as informal conversation, but still allow memory function to be quantified. BACKGROUND: This bedside task allowed the measurement of the duration of continuous, conscious experience of the present and was therefore termed "span of temporal continuity." METHOD: We tracked span of temporal continuity in a patient we believed was in the very early stages of Alzheimer's disease longitudinally. RESULTS: We found a progressively smaller span in which this patient experiences continuity in keeping with disease duration. CONCLUSION: In terms of span of temporal continuity in our single subject, we were able to document a progressively smaller span in which VB experiences continuity before any telling neuropsychologic deficits. Hence, our measure might serve to better identify and characterize dementia of the Alzheimer's type in its incipient stages.