Understanding barriers and optimizing socio-cognitive assessment in the diagnosis of neurocognitive disorders.

Diagnostic Utility of Montreal Cognitive Assessment in the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders: Major and Mild Neurocognitive Disorders

Neurocognitive disorders (NCD) are a growing health issue and the importance of diagnosis is still debated despite the benefits of making a diagnosis appearing to be greater than the risks. The aim of the present study was to explore the perception of the main benefits and risks to perform a diagnosis workup of NCD in a population of general practitioners (GPs), specialized physicians (SPs), other healthcare professionals (OHPs), and informal caregivers (ICs), and to identify the lowest perceived benefits and the highest perceived risks that could be levers to promote a diagnosis of NCD. A standardized questionnaire was submitted to GPs, SPs, OHPs, and ICs aiming to evaluate the importance of eight benefits and eight risks related to NCD diagnosis (selected from the literature) for four prototypical clinical cases at different stages of the disease: subjective cognitive impairment/mild NCD, major NCD at mild/moderate stage, moderate stage with behavioral and psychotic symptoms, and severe stage. The lowest perceived benefits of making an NCD diagnosis were "access to medical research", "patient's right to know", and "initiation of symptomatic drug treatment". The highest perceived risks of making an NCD diagnosis were "negative psychological impact for the patient", "absence of disease-modifying treatment", and "absence of suitable institution". This study highlights the lowest perceived benefits and the highest perceived risks of making an NCD diagnosis. These benefits and risks could be modified to become levers to promote a personalized diagnosis of NCD.

Individuals with neurocognitive disorders (NCD) frequently experience psychotic symptoms, such as delusions. Delusions can contribute to other behavior problems, create dangers for patients and caregivers, and contribute to inpatient hospitalization of individuals with NCD. The current study aimed to identify cognitive symptoms associated with the presence of delusions and to differentiate delusion types based on cognitive profiles among hospitalized older adults with NCD. A review of electronic medical records of hospitalized older adults from an inpatient geriatric psychiatry setting yielded 185 patients with a diagnosis of mild or major NCD who had a neuropsychological evaluation during their admission and whose documentation described a clear delusion. We identified a comparison group of 185 patients without delusions well matched for age, education, and sex, and similar in global cognitive status. Exclusion criteria included delirium and history of a psychotic disorder. We first compared the groups’ performances on a dementia battery. Then, cognitive performances of subgroups with specific delusion types (harm, theft, jealousy, and misidentification) were each compared to the remainder of the delusion-positive group. Exploratory analyses revealed that the delusion-positive group had a greater rate of discontinuation on Trails B and performed worse than the delusion-negative group on Trails A, Behavioral Dyscontrol Scale, Semantic Fluency, and Hopkins Verbal Learning Test-Revised (HVLT-R) initial registration. Theft delusions were associated with worse performance on HVLT-R recognition, misidentification delusions were associated with worse performance on Trails B, and harm delusions were associated with worse performance on a verbal generativity test. The presence of delusions in hospitalized older adults with NCD was associated with worse performance on several cognitive tasks with many being suggestive of associated with frontal-subcortical network integrity. Delusions of theft may be a consequence of reduced integrity of medial temporal lobe memory system.

Etiological diagnosis of neurocognitive disorders of middle-old age relies on biomarkers, although evidence for their rational use is incomplete. A European task force is defining a diagnostic workflow where expert experience fills evidence gaps for biomarker validity and prioritization. We report methodology and preliminary results. Using a Delphi consensus method supported by a systematic literature review, 22 delegates from 11 relevant scientific societies defined workflow assumptions. We extracted diagnostic accuracy figures from literature on the use of biomarkers in the diagnosis of main forms of neurocognitive disorders. Supported by this evidence, panelists defined clinical setting (specialist outpatient service), application stage (MCI-mild dementia), and detailed pre-assessment screening (clinical-neuropsychological evaluations, brain imaging, and blood tests). The Delphi consensus on these assumptions set the stage for the development of the first pan-European workflow for biomarkers' use in the etiological diagnosis of middle-old age neurocognitive disorders at MCI-mild dementia stages. Rational use of biomarkers in neurocognitive disorders lacks consensus in Europe. A consensus of experts will define a workflow for the rational use of biomarkers. The diagnostic workflow will be patient-centered and based on clinical presentation. The workflow will be updated as new evidence accrues.

Purpose Digital tools are currently being developed to help with the diagnosis of neurocognitive disorder (NCD).Their use in primary care as screening tools could optimize referral to specialized teams.We aimed to develop a simple, easy-to-use neurocognitive screening tool on a touchscreen tablet to distinguish between people with major NCD, those with mild NCD and those with no NCD.We hypothesize that, depending on cognitive impairment, differences in correct responses and response times differ significantly.Method We implemented selfquestionnaires and tasks for touch-screen tablets self-questionnaires inspired from conventional cognitive tools relevant to screen cognitive impairment.They comprised simple cognitive tasks like immediate and delayed recall of 3 words, temporal orientation questions, categorizations.Response times for tasks were also recorded.The screens have been designed to be used by the participant alone or with the help of a supervisor.Finally, we composed a battery of self-questionnaires and cognitive tasks that can be completed in 10-15 minutes.This battery was offered to 77 consecutive patients from a memory clinic and 28 volunteers without cognitive complaints recruited from a citizens' association.Cognitive diagnoses were based on DSM-5 criteria.Variables were compared using the Kruskal-Wallis test and Pearson's chi2 test and the level of significance was 0.05.Results and Discussion Among the 105 participants, there were 79 women (75%) and 26 men (25%) and aged 79.9 +/-7.5 years; 40 were free from NCD, 40 had a major NCD and 25 a mild NCD.All the participants realized the full battery of tests on tablets.Success for each task and response times are shown in Table 1.Four variables were found to discriminate cognitive patient and will be combined to the battery.The feasibility of our digital tablet battery for older adults is excellent, and initial results show promising aspects for cognitive screening.

The Sound of Music: Short-term Effects of Live Music Performance on the Cognitive and Emotional Statuses of Residential Patients with Major Neurocognitive Disorder

The diagnosis of neurocognitive diseases is an important health issue for patients, families and healthcare professionals. The need to develop rapid, high-performance screening tools would improve access to care. The Clock Drawing Test (CDT) is widely used and validated with the older adults, and its digital version is becoming increasingly widespread. We propose to confirm its validity in a population of old patients hospitalized in a geriatric unit, and secondly to verify its performance in comparison with the reference diagnosis made by a specialized team in a memory consultation. CDTs were collected from older hospitalized patients, both in paper form and digitally on a touchscreen tablet. The results show good agreement between the paper and digital versions (kappa coefficient = 0.81). Sensitivity and specificity of the digital CDT were 0.84 and 0.59 respectively for the diagnosis of major cognitive disorders. The corresponding values were 0.72 and 0.59 for the diagnosis of mild neurocognitive disorders. User questionnaires indicate that older participants find the digital tablet easy to use. However, they prefer to use paper, even if they are open to learning how to use the tablet.

Tremendous advancement has been made in biomarker assessment, molecular neuroimaging and disease modifying therapy in neurodegenerative cognitive disorders. China is lacking clinical cohorts that deeply profile patients from memory clinic that integrate both comprehensive clinical assessment and multi-modal biomarker examinations. The Shanghai Memory Study (SMS) is an ongoing prospective hospital-based cohort study. Participants underwent extensive clinical and neuropsychological assessments, genotyping, multimodal magnetic resonance imaging (MRI), positron emission tomography (PET) imaging, and various biospecimen collection. In this article, the rationale, aims, study design, data collection, and future directions of SMS were summarized. Preliminary analyses including plasma biomarker assay using the Simoa platform, molecular neuroimaging of Aβ PET and tau PET were performed across different diagnostic groups. A total of 2,001 participants with cognitive complaints were enrolled, including 115 with subjective cognitive decline (SCD), 938 with mild cognitive impairment (MCI), and 948 with dementia. The proportions of individuals with A+/T+ in PET scans were 15.8% in SCD cases, 51.2% in MCI cases, and 100% in AD dementia. And the proportions of individuals with A+/T- in PET scans were 5.3% in SCD cases and 3.3% in MCI cases. In the analysis with plasma biomarkers, as the CDR score increased, Aβ40, Aβ42, and Aβ42/Aβ40 ratio exhibited a decreasing trend, whereas t-tau, NfL, and p-tau181 showed an increasing trend. In a subcohort of 251 patients with amnestic MCI (aMCI), during a median follow-up of 4.7 years, 88 (35.1%) progressed to AD dementia, 8 developed non-AD dementia. Individuals with low Aβ42/Aβ40 and high p-tau181 at baseline demonstrated the highest risk of developing AD (hazard ratio=4.83, 95% CI 2.37-9.86). By offering an integrated framework for investigating cognitive disorders, SMS will facilitate the exploration of AD pathogenesis and deepen the understanding of cognitive disorders.

DIAGNOSING COGNITIVE DECLINE: COMPARING NIA-AA TO DSM-5 APPROACHES

Diagnostic tools for general practitioners and specialists

Neurocognitive diseases are diagnosed in specialized centers such as memory clinics, where the waiting time can be long. The reference assessment involves a battery of tests carried out by a specialized team. Facilitating screening in primary care using new technologies could make it possible to appropriately direct care pathways towards specialist care. This work aimed to set up a battery of questionnaires, cognitive and manual dexterity tests on a digital tablet to screen people with cognitive impairment. Three groups of people are recruited from a memory consultation: people with major neurocognitive disorders, people with mild neurocognitive disorders and people with no cognitive impairment. Initial results in geriatric settings show that the digital tablet assessment test is feasible and well accepted, but that manual dexterity assessment needs to be adapted to the bodily particularities of the very old.

Objective We investigated whether the addition of Alzheimer’s disease-signature region cortical thickness (AD-Ct) and hippocampal volume (Hv) obtained from brain MRI to subjective memory complaints and informant-reports of cognitive decline enhances the screening accuracy for cognitive disorders in a memory clinic setting. Methods 120 participants (40 cognitively normal, 40 MCI, 40 dementia) underwent clinical evaluation, neuropsychological assessment, and brain MRI. The Subjective Memory Complaints Questionnaire (SMCQ) and Seoul Informant-Report Questionnaire for Dementia (SIRQD) were applied to assess subjective memory complaints and informant-reports of cognitive decline respectively. Logistic regression and ROC curve analyses were conducted to compare the screening abilities of SMCQ+SIRQD, SMCQ+SIRQD+Hv, and SMCQ+SIRQD+AD-Ct models for cognitive disorders. Results SMCQ+SIRQD+Hv model indicated better screening accuracy for MCI and overall cognitive disorder (CDall) than SMCQ+ SIRQD model. SMCQ+SIRQD+AD-Ct model had superior screening accuracy for dementia in comparison to SMCQ+SIRQD model. ROC curve analyses revealed that SMCQ+SIRQD+Hv model had the greatest area under the curve (AUC) for screening MCI and CDall (AUC: 0.941 and 0.957), while SMCQ+SIRQD+AD-Ct model had the greatest AUC for screening dementia (AUC: 0.966). Conclusion Our results suggest that the addition of regional quantitative MRI data enhances the screening ability of subjective memory complaints and informant-reports of cognitive decline for MCI and dementia.

BackgroundThe detection rate of people with neurocognitive disorder is low (20‐50%) even in highly developed countries. Early detection is a global priority (Aim 4 of WHO Global Action Plan on Dementia). Among the barriers to timely diagnosis in Europe is the migration status, which is currently increasing in prevalence, limiting access to specific assessments and care due to language barriers.MethodsWithin a wider European Alzheimer’s Disease Consortium (EADC) – ISTAART survey aimed at exploring the implementability of standard neuropsychological assessment in memory clinics, we examined the frequency and modality of assessments of foreign patients across tertiary memory clinics in Europe.ResultsPreliminary data show that in over 50% of EADC memory clinics, for which we have survey returns, foreign patients are assessed frequently (3 of 49 responding sites report daily, and 24/49 report monthly foreign assessments). Countries with more frequent requests are Belgium (4/4 Belgium responders report assessing foreign patients often, i.e. daily or monthly), Croatia (1/1), Czech Republic (1/1), Denmark (1/1), France (3/5), Germany (7/8), Sweden (2/2), Switzerland (4/4), and the United Kingdom (1/2). Only 9/49 centers reported using an interpreter often (>60% of assessed foreign cases). The majority (33/49) translate local tests; however, as many as 19 centers do use culture‐ and language‐specific tests for foreign patients. Discussion: In tertiary European memory clinics, requests for assessments in a foreign language are very frequent, but the testing practices used for this purpose vary across sites. Our survey was conducted in centers of excellence and may not be fully representative: non‐academic centers are expected to be even more heterogeneous in their practices. This survey allows us to define more specific investigations, and to devise interventions to improve detection of neurocognitive disorders among foreign patients.ConclusionActions specifically dedicated to proper assessment of foreign people may contribute to improve early detection of neurocognitive disorders.

To estimate the six-month prevalence of dementia with Lewy bodies (DLB) in a Colombian memory clinic using the Lewy Body Composite Risk Score (LBCRS) and interdisciplinary consensus diagnosis, and to describe the scale's clinical performance parameters. We analyzed data from 850 patients evaluated over six months at the Intellectus Memory Clinic in Bogotá, Colombia (HUSI). The LBCRS was applied in addition to a standardized interdisciplinary assessment that included clinical, paraclinical, and neuropsychological evaluations. Final diagnoses were established by consensus based on current international criteria for DLB. LBCRS data were available for 592 participants (69.6%). Of these, 42 (7.1%) screened positive (score ≥3), but only 5 (0.84%) received a consensus diagnosis of probable DLB. Six screened-positive patients were diagnosed with Parkinson's disease dementia (PDD); in three, cognitive symptoms developed within one year of motor onset and could alternatively be classified as DLB, increasing the number of DLB cases to 8. The remaining LBCRS-positive patients were diagnosed with Alzheimer's disease, vascular dementia, mild cognitive impairment, or no cognitive disorder. LBCRS performance in this setting demonstrated a sensitivity of 100%, specificity of 94.2%, positive predictive value of 19%, and negative predictive value of 100%. The low incidence of DLB identified by interdisciplinary assessment, together with the discrepancy between LBCRS screening and final diagnoses, underscores the need for further research on the applicability and predictive value of LBCRS in Latin America.

BackgroundThe relationships of left atrial (LA) dysfunction with cognition are poorly understood. We investigated the associations of LA function with cognitive impairment, etiologic‐subtype (neurodegenerative vs. vascular[VCI]), neuroimaging markers of cerebrovascular disease (CeVD) and circulating biomarkers, in subjects without AF.MethodIn this prospective cohort study of subjects recruited from memory clinics with brain magnetic resonance imaging (MRI), neuropsychological assessments, circulating biomarker measurements, LA strain (reservoir [LASr], conduit [LAScd], contractile) was determined using 2D speckle‐tracking echocardiography. VCI was defined as vascular dementia or cognitive impairment no dementia(CIND)/Alzheimer’s dementia with significant CeVD, and neurodegenerative defined as CIND/dementia without significant CeVD on neuroimaging.ResultAmong 251 subjects (age 75±8years, 59% female, 178(71%) had cognitive impairment (37% dementia, 14% moderate CIND, 20% mild CIND), of which 58% were VCI and 42% neurodegenerative. LAScd was the only LA strain parameter independently associated with more severe (moderate CIND/dementia vs. mild CIND/no cognitive impairment) grades of cognitive impairment (lowest vs. highest tertile: adjusted odds ratio[AOR] 2.50, p=0.015), and worse MMSE scores, visuomotor construction and memory on neuropsychological testing (p<0.05). LAScd was independently associated with VCI (vs. neurodegeneration) (lowest vs. highest tertile: AOR 3.16, p=0.006), and showed no associations with markers of neurodegeneration, including circulating pTau‐181 and strictly lobar cerebral microbleeds (p>0.05). LAScd and LASr were both associated with increased burden of CeVD including intracranial stenoses, cortical infarcts, lacunes, cerebral microinfarcts, microbleeds and white matter hyperintensities and correlated with cardiac‐specific biomarkers (p<0.05), but LAScd correlated additionally with a broader range of circulating biomarkers reflecting inflammation, neurotrophic processes and neuronal damage (p<0.05).ConclusionReduced LA conduit function was associated with more severe cognitive impairment, primarily due to CeVD. LA strain, particularly LAScd, may be a useful biomarker of cognitive impairment in at‐risk subjects without AF.