Global Perspectives on Brief Cognitive Assessments for Dementia Diagnosis.

BACKGROUND: Timely diagnosis of dementia is a global healthcare priority, particularly in low to middle income countries where rapid increases in older adult populations are expected. OBJECTIVE: To investigate global perspectives on the role of brief cognitive assessments (BCAs) in dementia diagnosis, strengths and limitations of existing measures, and future directions and needs. METHODS: This is a qualitative study of 18 dementia experts from different areas of the world. Participants were selected using purposeful sampling based on the following criteria: 1) practicing in countries with projected growth of older adult population of over 100%by 2050; 2) expertise in dementia diagnosis and treatment; 3) involvement in clinical practice and training; and 4) recognition as a national dementia expert based on leadership positions within healthcare system, research, and/or policy work. Participants were individually interviewed in their language of choice over secure videoconference sessions. Interviews were analyzed by a multidisciplinary team using theme identification approach. RESULTS: Four domains with subthemes emerged illustrating participants' perspectives: 1) strengths of BCAs; 2) limitations of BCAs; 3) needs related to the use of BCAs; and 4) characteristics of an ideal BCA. While most experts agreed that BCAs were important and useful for dementia diagnosis, the themes emphasized the need for development and validation of novel measures that are sensitive, psychometrically sound, and culturally appropriate. CONCLUSION: BCAs are important for guiding diagnosis and care for dementia patients. Findings provide a roadmap for novel BCA development to assist in diagnostic decision making for clinicians serving a rapidly growing and diverse dementia population.

Development of a Brief Screen to Detect Cognitive Impairment in Older Adults: The QuickSort.

BACKGROUND: Sorting tests detect cognitive decline in older adults who have a neurodegenerative disorder, such as Alzheimer's and Parkinson's disease. Although equally effective at detecting impairment as other cognitive screens (e.g. Mini-Mental State Examination (MMSE)), sorting tests are not commonly used in this context. This study examines the QuickSort, which is a new brief sorting test that is designed to screen older adults for cognitive impairment. DESIGN: Observational cohort study. SETTING: General community and inpatients, Australia. PARTICIPANTS: Older (≥60 years) community-dwelling adults (n = 187) and inpatients referred for neuropsychological assessment (n = 78). A normative subsample (n = 115), screened for cognitive and psychological disorders, was formed from the community sample. MEASUREMENTS: Participants were administered the QuickSort, MMSE, Frontal Assessment Battery (FAB), and Depression Anxiety and Stress Scale-21. The QuickSort requires people to sort nine stimuli by color, shape, and number, and to explain the basis for their correct sorts. Sorting (range = 0-12), Explanation (range = 0-6), and Total (range = 0-18) scores were calculated for the QuickSort. RESULTS: The Cognitively Healthy subsample completed the QuickSort within 2 minutes, 50% had errorless performance, and 95% had Total scores of 10 or greater. The likelihood of community-dwelling older adults and inpatients (n = 260) being impaired on either the MMSE or FAB, or both, increased by a factor of 3.75 for QuickSort Total scores of less than 10 and reduced by a factor of 0.23 for scores of 10 or greater. CONCLUSION: The QuickSort provides a quick, reliable, and valid alternative to lengthier cognitive screens (e.g., MMSE and FAB) when screening older adults for cognitive impairment. The QuickSort performance of an older adult can be compared with a cognitively healthy normative sample and used to estimate the likelihood they will be impaired on either the MMSE or FAB, or both. Clinicians can also use evidence-based modeling to customize the QuickSort for their setting.

Validation of a Brief Multi-Dimensional Assessment of Dementia Severity.

BACKGROUND/OBJECTIVES: Briefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD). DESIGN: Prospective follow-up study. SETTING: University-based dementia care management program. PARTICIPANTS: 1,091 PWD. MEASUREMENTS: We assessed cognition (Mini Mental State Examination (MMSE)-11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S)-12 items), and functional ability (Activities of Daily Living (ADL)-6 items; Functional Activities Questionnaire (FAQ)-10 items). Item response theory was used to select subsets of items by identifying low item discrimination (<1.50), poor item fit (χ2 ), local dependence (LD), and with difficulty similar to other items. We estimated correlations between original and shorter scales and compared their associations with mortality. We added two symptoms (trouble swallowing, coughing when eating) reflecting late-stage dementia complications, created a multi-dimensional dementia assessment composite, and examined its association with mortality. RESULTS: Five MMSE tasks were eliminated: two with low discrimination, two with difficulty similar to other items, and one with poor fit. The remaining tasks were correlated with the full MMSE at r = 0.82. We retained three ADLs that were correlated with the total ADL set at r = 0.95 and kept five FAQ items that were not LD (correlation with full FAQ, r = 0.97). Associations with mortality were similar between the longer and shorter scales. A higher score on the composite (range 0-100) indicates worse dementia impact and was associated with mortality (hazard ratio (HR) per scale point: 1.03 (1.02-1.04)). CONCLUSION: These brief assessments and dementia composite may reduce administration time while preserving validity.

Cognitive Assessment of Alzheimer's Disease and Dementias in Clinical Practice: Pragmatics of Brief Instruments and Neuropsychological Evaluation.

Detection of cognitive impairment and dementia (CID) through the use of brief cognitive assessment tools (BCATs) is the first step to establishing an accurate diagnosis and care plan for individuals seen in primary practices. While the cognitive-behavioral syndrome and underlying etiology may not be readily apparent through brief assessment, clinicians can refer patients for a more comprehensive neuropsychological evaluation. A timely diagnosis maximizes the potential for patients to be involved in decision-making and planning for their future, and allows for expedited intervention and harm reduction. This activity provides a practical review of validated and standardized BCATs that can aid in the detection of CID; reviews cognitive and neuropsychological domains and their clinical relevance; and delineates circumstances for referral to neuropsychology and the utility of neuropsychological evaluation to practicing clinicians.

The relationship between the Wechsler Memory Scale-Revised scores and whole-brain structure in patients with schizophrenia and healthy individuals.

INTRODUCTION: The Wechsler Memory Scale (WMS) is a standardised battery for assessing memory functions. We aimed to investigate the relationship between all WMS scores, including subtests, and whole-brain structure in a relatively large sample. METHODS: Participants were 93 patients with schizophrenia and 117 healthy individuals, all right-handed and of Japanese ethnicity, and matched for age and sex. Their memory functions were assessed using the WMS-Revised (WMS-R). Their grey and white matter structure was analyzed using voxel-based morphometry and diffusion tensor imaging. RESULTS: Verbal memory score correlated positively with volumes of the left parahippocampal gyrus and hippocampus, while general memory score correlated positively with volumes of the left parahippocampal and fusiform gyri and hippocampus (p < 0.05, corrected), while there was no correlation with white matter fractional anisotropy values in healthy individuals. No correlation was observed between any WMS-R score and grey or white matter structure in patients. CONCLUSIONS: Using whole-brain structural magnetic resonance imaging, we found several significant correlations between WMS-R scores and grey matter volume in the brains of healthy individuals, while no correlation was found in those of patients with schizophrenia.

Evaluating the accuracy of the Wechsler Memory Scale-Fourth Edition (WMS-IV) logical memory embedded validity index for detecting invalid test performance.

Embedded performance validity tests (PVTs) allow for continuous assessment of invalid performance throughout neuropsychological test batteries. This study evaluated the utility of the Wechsler Memory Scale-Fourth Edition (WMS-IV) Logical Memory (LM) Recognition score as an embedded PVT using the Advanced Clinical Solutions (ACS) for WAIS-IV/WMS-IV Effort System. This mixed clinical sample was comprised of 97 total participants, 71 of whom were classified as valid and 26 as invalid based on three well-validated, freestanding criterion PVTs. Overall, the LM embedded PVT demonstrated poor concordance with the criterion PVTs and unacceptable psychometric properties using ACS validity base rates (42% sensitivity/79% specificity). Moreover, 15-39% of participants obtained an invalid ACS base rate despite having a normatively-intact age-corrected LM Recognition total score. Receiving operating characteristic curve analysis revealed a Recognition total score cutoff of < 61% correct improved specificity (92%) while sensitivity remained weak (31%). Thus, results indicated the LM Recognition embedded PVT is not appropriate for use from an evidence-based perspective, and that clinicians may be faced with reconciling how a normatively intact cognitive performance on the Recognition subtest could simultaneously reflect invalid performance validity.

Detecting memory performance validity with DETECTS: A computerized performance validity test.

Evaluating performance validity is essential in neuropsychological and forensic assessments. Nonetheless, most psychological assessment tests are unable to detect performance validity and other methods must be used for this purpose. A new Performance Validity Test (DETECTS - Memory Performance Validity Test) was developed with several characteristics that enhance test utility. Moreover, precise response time measurement was added to DETECTS. Two groups of participants (normative and simulator group) completed DETECTS and three memory tests from the Wechsler Memory Scale III. Simulators achieved considerably lower scores (hits) and higher response times in DETECTS compared with the normative group. All participants in the normative group were classified correctly and no simulator was classified as having legitimate memory deficits. Thus, DETECTS seems to be a valuable computerized Performance Validity Test with reduced application time and effective cut-off scores as well as high sensitivity, specificity, and positive and negative predictive power values. Lastly, response time may be a very useful measure for detecting memory malingering.

Effects of Delay Duration on the WMS Logical Memory Performance of Older Adults with Probable Alzheimer's Disease, Probable Vascular Dementia, and Normal Cognition.

OBJECTIVE: To examine how the duration of time delay between Wechsler Memory Scale (WMS) Logical Memory I and Logical Memory II (LM) affected participants' recall performance. METHOD: There are 46,146 total Logical Memory administrations to participants diagnosed with either Alzheimer's disease (AD), vascular dementia (VaD), or normal cognition in the National Alzheimer's Disease Coordinating Center's Uniform Data Set. RESULTS: Only 50% of the sample was administered the standard 20-35 min of delay as specified by WMS-R and WMS-III. We found a significant effect of delay time duration on proportion of information retained for the VaD group compared to its control group, which remained after adding LMI raw score as a covariate. There was poorer retention of information with longer delay for this group. This association was not as strong for the AD and cognitively normal groups. A 24.5-min delay was most optimal for differentiating AD from VaD participants (47.7% classification accuracy), an 18.5-min delay was most optimal for differentiating AD versus normal participants (51.7% classification accuracy), and a 22.5-min delay was most optimal for differentiating VaD versus normal participants (52.9% classification accuracy). CONCLUSIONS: Considering diagnostic implications, our findings suggest that test administration should incorporate precise tracking of delay periods. We recommend a 20-min delay with 18-25-min range. Poor classification accuracy based on LM data alone is a reminder that story memory performance is only one piece of data that contributes to complex clinical decisions. However, strict adherence to the recommended range yields optimal data for diagnostic decisions.

Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study.

INTRODUCTION: screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment. AIM: to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice. METHODS: a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD). RESULTS: we assessed 500 patients, mean age 83 years (range = 66-101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identified as definite or possible dementia. For diagnosis of definite delirium, AMT-4 (cut-point < 3/4) had a sensitivity of 92.7% (95% confidence interval (CI): 84.8-97.3), with a specificity of 53.7% (95% CI: 48.1-59.2); AMT-10 (<4/10), MOTYB (<4/12) and SQiD showed similar performance. bCAM had a sensitivity of 70.3% (95% CI: 58.5-80.3) with a specificity of 91.4% (95% CI: 87.7-94.3). 4AT (>4/12) had a sensitivity of 86.7% (95% CI: 77.5-93.2) and specificity of 69.5% (95% CI: 64.4-74.3). CONCLUSIONS: short screening tools such as AMT-4 or MOTYB have good sensitivity for definite delirium, but poor specificity; these tools may be reasonable as a first stage in assessment for delirium. The 4AT is feasible and appears to perform well with good sensitivity and reasonable specificity.

Clinical validation of three short forms of the Dutch Wechsler Memory Scale-Fourth Edition (WMS-IV-NL) in a mixed clinical sample.

The reliability and validity of three short forms of the Dutch version of the Wechsler Memory Scale-Fourth Edition (WMS-IV-NL) were evaluated in a mixed clinical sample of 235 patients. The short forms were based on the WMS-IV Flexible Approach, that is, a 3-subtest combination (Older Adult Battery for Adults) and two 2-subtest combinations (Logical Memory and Visual Reproduction and Logical Memory and Designs), which can be used to estimate the Immediate, Delayed, Auditory and Visual Memory Indices. All short forms showed good reliability coefficients. As expected, for adults (16-69 years old) the 3-subtest short form was consistently more accurate (predictive accuracy ranged from 73% to 100%) than both 2-subtest short forms (range = 61%-80%). Furthermore, for older adults (65-90 years old), the predictive accuracy of the 2-subtest short form ranged from 75% to 100%. These results suggest that caution is warranted when using the WMS-IV-NL Flexible Approach short forms to estimate all four indices.