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BackgroundThe Clock Drawing Test (CDT) is commonly used in the detection of cognitive disorder. Easily administered in both clinical and non‐clinical settings and well accepted by patients, this test is a good candidate for use in early detection of dementia with older Aboriginal Australians. This study aimed to: (i) compare three CDT scoring methods and their reliability/validity in detecting mild cognitive impairment (MCI) and dementia in Aboriginal communities; (ii) determine the optimal CDT sensitivity, specificity and cut‐off scores; (iii) investigate the relative and combined performance of the CDT with other cognitive screening tools [Kimberly Indigenous Cognitive Assessment (KICA); Mini Mental State Examination (MMSE); Rowland Universal Dementia Assessment Scale (RUDAS)].MethodA subset of participants (n=153; aged 60‐93) recruited for the Koori Growing Old Well Study completed neurocognitive evaluation as part of a comprehensive medical assessment and were diagnosed by expert consensus as intact, MCI or dementia. CDT responses originally scored as part of the Addenbrooke’s Cognitive Examination Revised (ACE‐R) were rescored using the Mendez and Sunderland methods by an assessor blind to diagnosis.ResultThere were strong positive correlations between all three CDT scoring methods (r s range=.895‐.924). All methods differentiated dementia from MCI and intact participants (p<.001), but not intact from MCI (Mendez p=.712; Sunderland p=.545; ACE‐R p=.094). There was no significant difference between scoring methods in diagnostic validity for dementia (AUC=.739‐.756); however, the simple ACE‐R method had the highest positive and negative predictive values (PPV=0.643; NPV=0.862), with optimal cut‐off score <3.The MMSE outperformed all other screening tests in detecting cognitive impairment (MCI or dementia; AUC=.851) and was superior to both the KICA and CDT in distinguishing MCI from intact participants, but comparable to the RUDAS. Combining the CDT with other screening tools did not significantly improve their diagnostic performance for either cognitive impairment or MCI.ConclusionCDT alone is not an adequate screening tool for MCI; however, has potential for detecting moderate to severe cognitive impairment in older Aboriginal Australians. Relative to other screening tools, the MMSE performed well for detecting both cognitive impairment and MCI; the addition of the CDT did not significantly improve other tests’ performance.

Aim: to study the role of amyloid-beta 40 (Aβ 40) in the development of cognitive impairment in acute ischemic stroke.Materials and methods. The study included 70 patients aged 33–86 years, 46 men and 24 women. In patients with acute ischemic stroke cognitive status was assessed with Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Test (MoCA), Frontal Assessment Battery (FAB), Schulte tables, Clock Drawing Test, Test for Semantic Verbal Fluency and Five Words Test. The concentration of Aβ 40 in the cerebrospinal fluid was determined. Morphometric (size of the infarct and leukoaraiosis area, volume of the brain ventricles and hippocampus) and diffusion-tensor parameters of MRI (fractional anisotropy of putamen, thalamus, hippocampus, corpus callosum, limbs of the internal capsule, the cingulate, the superior longitudinal and inferior fronto-occipital tracts) were studied.Results. The concentration of Aβ 40 in the cerebrospinal fluid was 436,4 (226,0–514,0) pg/ml. The protein level was associated with the result of subtests «Orientation» (MMSE) and «Attention» (MoCA), as well as indirect recall with cues in MoCA. Patients with MMSE score of 24–27 points were characterized by a lower concentration of Aβ 40 as compared to patients with a score less than 24 points. Aβ 40 concentration more than 436,4 pg/mL was associated with a more severe somatic co-morbidity of stroke (hypertension, lower hemoglobin and albumin level, higher erythrocyte sedimentation rate), a smaller volume of the brain ventricles, lower fractional anisotropy of the thalamus, cingulate tracts and contralateral hippocampus. Aβ 40 concentration more than 436,4 pg/mL was also associated with a lower global cognitive status (according to the MMSE and MoCA), as well as the reduction in certain cognitive functions, namely, attention, visual-spatial functions and memory.Conclusions. The concentration of Aβ 40 in the cerebrospinal fluid is a biological marker of severity type of post-stroke cognitive impairment. This interaction is probably due to the damage to the hippocampus, thalamus and cingulate tracts. In our opinion, the biomarker reflects both ischemic and neurodegenerative components of the pathogenesis of cognitive impairment in acute ischemic stroke.

BackgroundThe Digital Clock Test (DCT) is a novel, computerized version of the clock drawing test (CDT). It has been shown to discriminate well between mild cognitive impairment and Alzheimer's disease (AD) dementia and has been associated with AD biomarkers (i.e., amyloid, tau), similar to widely used screening batteries such as the Preclinical Alzheimer's Cognitive Composite (PACC5) and Mini Mental Status Exam (MMSE). As mood symptoms (e.g., anxiety, depression) are common in older adults and can impact cognition, it is important to determine whether such symptoms impact scores on the DCT relative to other measures/batteries. We sought to examine whether mood symptoms are associated with lower DCT scores and/or impaired performance and compare relationships to the MMSE and PACC5.MethodAll participants were older adults (n = 241, mean age=77.60, 80.10% cognitively normal) enrolled in the Harvard Aging Brain Study. Participants completed neuropsychological assessments (i.e., DCT, PACC5, MMSE; lower scores=worse performance) alongside self‐report questionnaires: the 30‐item Geriatric Depression Scale (GDS) and the 20‐item Geriatric Anxiety Inventory (GAI) (higher scores = greater symptoms for both measures). Separate cross‐sectional linear regression models assessed whether GDS/GAI score predicted DCT, MMSE, and PACC5 scores. Separate ordinal regression models were used to determine whether GDS/GAI score predicted impaired DCT (<75), MMSE (<27), and PACC5 (<‐1.5) scores. Analyses controlled for age, sex, and education.ResultHigher GDS scores, but not GAI scores, were associated with lower scores on all cognitive measures (Figure 1). Higher GDS scores were also associated with increased odds of having impaired MMSE and PACC5 scores, but not impaired DCT scores (Table 1). Additionally, higher GAI scores were significantly associated with increased odds of an impaired PACC5 score, but not impaired MMSE or DCT scores (Table 2).ConclusionIn older adults, greater depressive symptoms were associated with worse performance on both the DCT and standard cognitive screens (MMSE, PACC5). In contrast, both depressive and anxiety symptoms were associated with “impaired” scores on PACC5 and/or MMSE, but not on the DCT. This could suggest that the DCT is a sensitive cognitive screen for AD and related dementias in clinical settings where patients present with co‐occurring mood disturbances.

Prospective Evaluation of Quality of Life and Neurocognitive Effects in Patients With Multiple Brain Metastases Receiving Whole-Brain Radiotherapy With or Without Thalidomide on Radiation Therapy Oncology Group (RTOG) Trial 0118

The aim of the study. To study clinical, psychological and neuroimaging characteristics of chronic tension headache (CTH) in the elderly.Materials and methods. 92 patients with CHTHN (37 men and 55 women aged 55–74 years) were examined. The control group consisted of 53 people (22 men and 31 women of the same age) who did not have neurological complaints, including headache. Pain intensity was assessed on a 10-point visual analogue scale. The severity of neurological symptoms was determined using the NIH-NINDS scale. For the study of cognitive functions, a short scale for assessing mental status was used Mini Mental State Examination (MMSE) and a frontal assessment battery (FAB). Memory was assessed according to the results of the memory subtest MMSE and the 10 words test. The level of attention was studied using the Schulte table, speech fluency – in the «fluency of speech» subtest of the FAB and in the test of verbal associations, visuospatial functions were assessed using the clock drawing test. Memory was assessed by the results of the subtest of memory MMSE and the 10-words test. The level of attention was studied using the Schulte table, the fluency of speech – in the subtest ‘fluency of speech’ FAB and in the verbal association test, visuospatial functions were assessed using the clock drawing test. Magnetic resonance imaging of the head was performed on a Magnetom Impact Expert (Siemens, Germany) tomograph with a magnetic field strength of 1.5 Tesla in T1 and T2 modes. The localization and severity of leukoaraiosis, signs of external and internal atrophy of the brain were determined, the linear dimensions of the anterior horns and central sections of the bodies of the lateral ventricles were measured, and the indices of the anterior horns and bodies of the lateral ventricles were calculated.Results. Patients with chronic tension headache were characterized by clinical and cognitive heterogeneity: frequent «non-standard» characteristics of headache, severe polymorphism of algic manifestations, high frequency of comorbid disorders, cognitive dysfunction and somatic burden, high representation of leukoaraiosis, external and internal hydrocephalus according to MRI study.

Objective: The coronavirus disease 2019 infection may have multisystemic manifestations including neurological involvement. The number of recognized neurologic manifestations of severe acute respiratory syndrome coronavirus 2 infection is rapidly accumulating, including neurocognitive decline. This study aimed to evaluate and monitor the temporal course of the neurocognitive status of patients who had been infected with the coronavirus disease 2019. Methods: A total of 49 patients were included. Sex, demographics, and atherosclerotic risk factors were noted. The patients’ global cognitive state performance was evaluated with Mini-Mental State Examination, Clock Drawing Test, Beck’s Depression Inventory, and Barthel Activities of Daily Living index. The patients were evaluated 2 times within a 6-month interval. Results: Of the patients, 53.1% were male, and the mean age was 43.3 ± 13.8 years. About 32.6% of the cases were found to have atherosclerotic risk factors at the first admission, and 34.7% of the patients needed to be hospitalized due to their symptoms. Mini-Mental State Examination score was found to be lower in patients with atherosclerotic risk factors (P = .023) and hospitalized patients compared to those in home quarantine (P = .016). In addition, lower points in Mini-Mental State Examination-1 scores were found in patients who needed to use steroids and tocilizumab (P values 0.029 and 0.022, respectively). Mini-Mental State Examination-1 and Mini-Mental State Examination-2 points of cumulative Mini-Mental State Examination change groups were significantly different (P &lt; .001 and P = .002, respectively). In multiple comparisons, Mini-Mental State Examination-1 points of No change and Better were different (P &lt; .001). Also Mini-Mental State Examination-2 points of No change and Worsened were different in multiple comparisons (P = .002). Conclusion: Cognitive status should be closely monitored especially in elderly patients and patients with atherosclerotic risk factors. Cite this article as: Çerikan MD, Güleç B, Acar HC, et al. Evaluation of postinfectious neurocognitive status in COVID-19 patients. Cerrahpaşa Med J. 2023;47(1):95-99.

An early and a quick identification of dementia is desirable to improve the overall care to the affected persons in the developing countries. The aim of this study was to evaluate the discriminative abilities of the Mini Mental State Examination (MMSE) and the Clock Drawing Test (CDT) in differentiating the demented patients from the controls and also the differentiation between the different types of dementia. This study was designed to evaluate the patients with varied types and severities of dementia, who were diagnosed by using the Clinical Dementia Rating (CDR) scale. All the patients completed the MMSE and the simplified CDT. This study included 197 patients with an age range of 43-79 years. Fifty-one patients (25.9%) were diagnosed with Alzheimer Dementia (AD), 37 patients (18.8%) with Vascular Dementia (VD), 23 patients (11.7%) with Parkinson's Disease Dementia (PDD) and 86 patients (43.6%) with other variants of dementia. The total MMSE score of the enrolled patients was significantly lower as compared to that of the control subjects, with a non-significant difference between the varied diagnoses. The total CDT scores were significantly lower in the patients as compared to those in the controls, with significantly lower scores in the PDD group as compared to those in the AD group. The patients who had AD showed non-significantly higher CDT scores as compared to the patients who had vascular and other types of dementia. A combined application of both MMSE and CDT can identify the persons with a cognitive affection and this may be a useful tool for the diagnosis of the non Alzheimer's type of dementia.

Context: Subjective memory complaints, before mild cognitive impairment (MCI), constitute the chief symptoms during the development of Alzheimer’s disease (AD) and are generally the initial signs for identifying the disease. Objective: The objective was to explore executive functions capacities in differentiating patients with AD from those with MCI as well as from that exempt from any cognitive deficit (CO). This study enabled us to compare the cognitive and specifically executive functioning of three participant groups (AD, MCI and CO) to determine an optimal measure(s) for differential diagnosis. Methods: A total of 116 participants were recruited (32 AD, 40 MCI, and 44 CO). To estimate executive function capacities, the Clock Drawing Test (CDT), the Trail Making Test Part A and B (TMT A and B) as well as the Verbal Fluency Tests - Alphabetic (VFT-A) and Category (VFT-C) were used. To exclude patients with depression, the Geriatric Depression Scale (GDS) with cut-off score was used. Furthermore, the Mini Mental State Examination (MMSE) was used to make between groups comparison on general cognition. Results: A significant mean score difference was observed between the MCI and CO groups on all executive function measures, except for the VFT-A. In contrast to other groups, the AD group performed significantly worst on all executive function measures. Conclusion: Herein, a significant difference between AD, MCI, and CO groups on executive functioning tasks, where AD group underperformed was reported. This warrants the use of executive functioning assessment as a way to help differential diagnosis.

The link between sarcopenia and cognitive impairment has not yet been thoroughly evaluated, especially among older adults. To evaluate the relationship between probable sarcopenia and cognitive impairment among community-dwelling older adults in two Brazilian cities. Probable sarcopenia was assessed using the EWGSOP2 (2018) criteria. Thus, participants were classified as probably having sarcopenia if they had SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs and Falls) ≥4 points and low grip strength. Cognitive function was evaluated through the Mini-Mental State Examination (MMSE), verbal fluency (VF) and clock drawing test (CDT). In a sample of 529 older adults (mean age 80.8±4.9 years; mean education 4.2±3.67 years; 70.1% women), 27.3% of the participants had SARC-F≥4, 38.3% had low grip strength and 13.6% were classified as probable sarcopenia cases. After adjusting for possible confounders (age, sex, education, depression, diabetes, hypertension, leisure-time physical activity and obesity), probable sarcopenia was found to be associated with impairment in the MMSE (OR 2.52; 95%CI 1.42‒4.47; p=0.002) and in VF (OR 2.17; 95%CI 1.17‒4.01; p=0.014). Low grip strength was found to be associated with impairment in the MMSE (OR 1.83; 95%CI 1.18‒2.82; p=0.006) and in the CDT (OR 1.79; 95%CI 1.18‒2.73; p=0.006). SARC-F scores were found to be associated with impairment in the MMSE (OR 1.90; 95%CI 1.18‒3.06; p=0.008). The results suggested that probable sarcopenia and its components present a significant association with cognitive deficits among community-dwelling older adults. Future longitudinal studies will further explore the causal relationship.

Cognitive domains related to attention and executive functions (a set of cognitive processes that regulate, control, and manage other cognitive abilities) seem to influence the recognition of facial expressions in people with Alzheimer's disease (AD). We examined the relationship between facial expression recognition, global cognition and executive function in people with AD according to their cognitive level. In a cross-sectional design, we included 130 participants with AD divided into three groups based on their Mini-Mental State Examination (MMSE) scores: MMSE 1 (scores 23-28), MMSE 2 (scores 17-22), and MMSE 3 (scores 11-16). Facial expression recognition ability was analyzed using the Faces Test. Executive function was analyzed using the Trail Making Test (TMT), the Verbal Fluency Test (VFT), the Semantic Fluency Test (SFT), the Digit Span Forward (DSF) and Backward (DSB) tests, and the Clock Drawing Test (CDT). In MMSE 1 group difficulties in divided attention and cognitive flexibility impacted the accuracy of facial expression recognition. In the MMSE 2 group, facial expression recognition was related to impairment in working memory. In the MMSE 3 group, the impact on facial expression recognition was directly related to visuoconstructive abilities. We observed that the executive resources involved in each evaluated group differed in terms of facial recognition task performance efficacy. Interventions at stimulating executive and visuoconstructive abilities in people with AD may contribute to better preservation of facial expression recognition.

The effect of radiotherapy on the long-term cognitive performance of patients treated for intracranial neoplasm is a major concern to clinicians and patients, particularly as long-term survival or cure is possible for a small minority of patients. To assess the effects of cranial radiotherapy and chemotherapy on the cognitive performance of high-grade glioma patients, we analyzed cognitive performance data collected in a series of prospective clinical trials. We studied 701 high-grade brain tumor patients entered onto two consecutive North Central Cancer Treatment Group (NCCTG) randomized treatment trials designed to compare radiotherapy and carmustine (BCNU) versus radiotherapy and 1-(2-chloroethyl)-3(2,6 dioxo-l-piperidyl)-1-nitrosource a (PCNU) (first trial) and radiotherapy and BCNU and interferon alfa (IFN) versus radiotherapy and BCNU (second trial). Folstein Mini-Mental Status Exam (MMSE) score and Eastern Cooperative Oncology Group (ECOG) performance score (PS) recorded at baseline and 6, 12, 18, and 24 months were analyzed to assess cognitive and physical function over time. Patients who did not demonstrate tumor progression within 60 days of the assessment time were considered nonprogressors at that evaluation. A loss of greater than 3 points on the MMSE was considered significant deterioration. The number of patients who experienced a greater than 3-point decrease in MMSE from baseline was 13 of 119 nonprogressors (10.9%; 95% confidence interval [CI], 6.3% to 18.9%) at 6 months, three of 54 nonprogressors (5.5%; 95% CI, 0.5% to 12.8%) at 12 months, three of 30 nonprogressors (10%; 95% CI, 2.1% to 26.5%) at 18 months, and four of 22 nonprogressors (18.2%; 95% CI, 5.2% to 40.3%) at 24 months. The CIs at all times overlapped, which indicates no statistically significant increase in the percentage of patients who experienced a significant decrease in their MMSE score. Patients who demonstrated a significant decrease in their MMSE score were significantly older than those who did not (P = .0017) at 6 months and remained so throughout follow-up; moreover, they had a significantly shorter time to progression and death. ECOG PS was strongly negatively correlated with MMSE score throughout the study, and MMSE score at all time intervals was correlated with baseline PS. In this population of glioma patients who received radiotherapy, there is no clear trend to cognitive worsening. Factors such as older age, poorer PS, and subclinical tumor progression may be more significant factors in those patients who did demonstrate a significant cognitive decline.

Background and PurposeAlthough the clock drawing test (CDT) is a widely used cognitive screening instrument, there have been inconsistent findings regarding its utility with various scoring systems in patients with mild cognitive impairment (MCI) or dementia. The present study aimed to identify whether patients with MCI or dementia exhibited impairment on the CDT using three different scoring systems, and to determine which scoring system is more useful for detecting MCI and mild dementia.MethodsPatients with amnestic mild cognitive impairment (aMCI), vascular mild cognitive impairment (VaMCI), mild Alzheimer's disease (AD), mild vascular dementia (VaD), and cognitively normal older adults (CN) were included. All participants were administered the CDT, the Korean-Mini Mental State Examination (K-MMSE), and the Clinical Dementia Rating scale. The CDT was scored using the 3-, 5-, and 15-point scoring systems.ResultsOn all three scoring systems, all patient groups demonstrated significantly lower scores than the CN. However, while there were no significant differences among patients with aMCI, VaMCI, and AD, those with VaD exhibited the lowest scores. Area under the Receiver Operating Characteristic curves revealed that the three CDT scoring systems were comparable with the K-MMSE in differentiating aMCI, VaMCI, and VaD from CN. In differentiating AD from CN, however, the CDT using the 15-point scoring system demonstrated the most comparable discriminability with K-MMSE.ConclusionsThe results demonstrated that the CDT is a useful cognitive screening tool that is comparable with the Mini-Mental State Examination, and that simple CDT scoring systems are sufficient for differentiating patients with MCI and mild dementia from CN.

El test del reloj en la evaluación forense

Although cognitive decline in with extracranial atherosclerotic artery stenosis (ECAS) may be improved by carotid revascularization, 1 the effect of stenting on cognitive dysfunction in patients with intracranial atherosclerosis (ICAS) remains unknown. Although stent placement was not effective in improving overall outcomes of patients with ICAS, 2 the value of stenting may have to be reconsidered if the procedure alleviates cognitive dysfunction. We aimed to evaluate changes in cognitive function and perfusion after stent placement in ICAS patients.

Background: Chagas disease (CD) is a major cause of stroke and cardiomyopathy in Latin America. Brain atrophy has been associated with CD independently of stroke or cardiac disease, but cognitive effects of this finding has not been explored. Our objective was to compare cognitive impairment in patients with CD and non-CD cardiomyopathy; and to correlate these findings with quantification of brain and cerebellar volumes. Methods: Consecutive patients from a cardiomyopathy clinic without a history of stroke were submitted to a structured interview including clinical information and cognitive tests (Mini Mental State Exam - MMSE, digit span, clock drawing test, delayed memory test). Brain MRI was performed and brain and cerebellar volumes quantified by ITK-SNAP software. MR spectroscopy quantified N-acetylaspartate (NAA)-, choline- and myoinositol-to-creatine ratios. Results: 118 patients were recruited; mean age 54 +/- 12 years, 53% female, 49% with CD. Despite a better systolic cardiac function by echocardiography (ejection fraction 45 vs 38%, P=0.006), patients with CD performed worse on various cognitive tests (MMSE, delayed memory test and clock drawing test, P&lt;0.01). Cerebellar volumes, but not brain volumes, were significantly smaller in CD vs non-CD cardiomyopathy (125 vs 136ml, P=0.035) and correlated with clock drawing test results (rS=0.219, P=0.024). In a multivariable analysis, delayed memory impairment, NAA/creatine ratio and cerebellar volumes were independently associated with Chagas disease. Conclusions: Cognitive dysfunction in CD occurred independently of cardiac disease severity and was associated with cerebellar atrophy.