Touchscreen games to detect cognitive impairment in senior adults. A user-interaction pilot study.
Valladares-Rodriguez Sonia,Fernández-Iglesias Manuel J,Anido-Rifón Luis,Facal David,Rivas-Costa Carlos,Pérez-Rodríguez Roberto
International journal of medical informatics
INTRODUCTION:Alzheimer's disease is a degenerative brain disease and the most common cause of dementia. Today, 47 million people live with dementia worldwide. This number is projected to increase to more than 131 million by 2050, as populations age. Therefore, the World Health Organization considers serious cognitive deterioration a public health priority. OBJECTIVES:Advanced cognitive evaluation mechanisms are needed to help make an early diagnosis. These new mechanisms should overcome the limitations of current neuropsychological tests, including delayed detection; being perceived as intrusive; being non-ecological; being dependent on confounding factors; or their administration being expensive, among others. A promising novel approach consists of the introduction of serious games based on virtual reality and machine learning able to assess cognitive traits relevant to the diagnosis of mild cognitive impairment and Alzheimer's disease. METHODS:As a result of a preliminary pilot experiment, promising evidence was obtained about the predictive power of this solution. However, for these new serious games to be effective, evidence has to be gathered on the player experience by senior adults, avoiding the limitations of traditional tests at the same time. This study addresses these aspects with the participation of 74 senior users and 15 test administrators. RESULTS:Main findings confirm the usability and playability of Panoramix, a game battery designed according to the principles discussed above, its technological acceptability and its accessibility. For example, in relation to acceptability, the game battery was scored 4.39 in a 5-point scale, while its average usability score was 4.45 regardless of socio-cultural level or previous experience with digital technologies. In addition, health professionals confirm both, usability and playability, levels with an average score of 6.5 in a 7-point scale. Participants' willingness of using this kind of systems for cognitive evaluation was also confirmed. CONCLUSION:Promising results obtained pave the way for additional work to confirm the diagnostic validity according to clinical standards of these new cognitive assessment tools.
Remote Assessment of Cognitive Impairment Level Based on Serious Mobile Game Performance: An Initial Proof of Concept.
Jung Hee-Tae,Daneault Jean-Francois,Lee Hyunsuk,Kim Kwangwook,Kim Byeongil,Park Sungji,Ryu Taekyeong,Kim Yangsoo,Ivan Lee Sunghoon
IEEE journal of biomedical and health informatics
Individuals with cognitive impairments are evaluated using clinically validated cognitive assessment tools, which need to be administered by trained therapists. This serves as a major barrier for frequent and longitudinal monitoring of patients' cognitive impairment level. We introduce Neuro-World, a set of six mobile games designed to challenge visuospatial short-term memory and selective attention, which allows one to self-administer the assessment of his/her cognitive impairment level. Game performance is analyzed to estimate a widely accepted clinical measure, the mini mental state examination (MMSE), which highlights the translational impact of the system in real-world settings. We collected game-specific performance data from 12 post-stroke patients at baseline and a three-month follow-up, which were used to train supervised machine learning models to estimate the corresponding MMSE scores. The results presented herein show that the proposed approach can estimate the MMSE scores with a normalized root mean square error of 5.75%. We also validate the system's responsiveness to longitudinal changes in cognitive impairment level and demonstrate the system's positive usability in cognitively impaired individuals and their willingness to adhere to the longitudinal use. This study demonstrates that Neuro-world has great potential to be used to evaluate the cognitive impairment level and monitor its long-term change. This study enables new clinical and research opportunities for accurate, longitudinal assessment of cognitive function via mobile games.
Timely Detection of Mild Cognitive Impairment in Italy: An Expert Opinion.
Bianchetti Angelo,Ferrara Nicola,Padovani Alessandro,Scarpini Elio,Trabucchi Marco,Maggi Stefania
Journal of Alzheimer's disease : JAD
Mild cognitive impairment (MCI) generally evolves in a gradually progressive decline in memory and non-memory cognitive domains that may eventually decay to dementia. This process might be preventable by improving early detection of the MCI syndrome followed by proper and timely interventions. The aim of this work was providing helpful indications for a standardized early diagnosis of MCI, mainly focusing on the Italian elderly population. We reviewed here MCI epidemiology and classification, as well as the most recent advancements in early detection of the patient with MCI in the Italian scenario. Specialist centers in connection with general practitioners (GPs) have been established across the country and designated as Centers for Cognitive Disorders and Dementia (CDCD). CDCDs are dedicated to the diagnosis and management of patients for all forms of dementia across all the complex staging spectrum. New tools were made available by the advancements of imaging techniques and of the research on biomarkers, leading to novel approaches based on the combination of imaging and biomarker detection, to improve accuracy and effectiveness in the early diagnosis of MCI. Moreover, patient genotyping, alone or in combination with other techniques, was also revealed as a promising method in evaluating and preventing MCI progression. We recommend the introduction of all these novel tools in the diagnostic practice of the specialist centers and that further efforts and resources are spent into the research of the most effective techniques and biomarkers to be introduced as first-level tests into the practice of early diagnosis of MCI.
Smart Home Technology: A New Approach for Performance Measurements of Activities of Daily Living and Prediction of Mild Cognitive Impairment in Older Adults.
Lussier Maxime,Adam Stéphane,Chikhaoui Belkacem,Consel Charles,Gagnon Mathieu,Gilbert Brigitte,Giroux Sylvain,Guay Manon,Hudon Carol,Imbeault Hélène,Langlois Francis,Macoir Joel,Pigot Hélène,Talbot Lise,Bier Nathalie
Journal of Alzheimer's disease : JAD
BACKGROUND:Functional assessment is of paramount importance when mild cognitive impairment is suspected, but common assessment tools such as questionnaires lack sensitivity. An alternative and innovative approach consists in using sensor technology in smart apartments during scenario-based assessments of instrumental activities of daily living (IADL). However, studies that investigate this approach are scarce and the technology used is not always transposable in healthcare settings. OBJECTIVE:To explore whether simple and wireless technology used in two different smart environments could add value to performance and rater-based measures of IADL when it comes to predicting mild cognitive impairment (MCI) in older adults. METHODS:Twenty-six (26) cognitively healthy older adults (CH) and 22 older adults with MCI were recruited. Functional performance in a set of five scripted tasks was evaluated with sensor-based observations (motion, contact, and electric sensors) and performance-based measures (rated with videotapes). The five tasks could be performed in any order and were detailed on an instruction sheet given to participants. RESULTS:Sensor-based observations showed that participants with MCI spent more time in the kitchen and looking into the fridge and kitchen cabinets than CH participants. Moreover, these measures were negatively associated with memory and executive performances of participants and significantly contributed to the prediction of MCI. CONCLUSION:Simple, wireless, and sensor-based technology holds potential for the detection of MCI in older adults as they perform daily tasks. However, some limits are discussed and we offer recommendations to improve the usefulness of this innovative approach.
Early diagnosis of mild cognitive impairment and mild dementia through basic and instrumental activities of daily living: Development of a new evaluation tool.
Cornelis Elise,Gorus Ellen,Beyer Ingo,Bautmans Ivan,De Vriendt Patricia
BACKGROUND:Assessment of activities of daily living (ADL) is paramount to determine impairment in everyday functioning and to ensure accurate early diagnosis of neurocognitive disorders. Unfortunately, most common ADL tools are limited in their use in a diagnostic process. This study developed a new evaluation by adopting the items of the Katz Index (basic [b-] ADL) and Lawton Scale (instrumental [i-] ADL), defining them with the terminology of the International Classification of Human Functioning, Disability and Health (ICF), adding the scoring system of the ICF, and adding the possibility to identify underlying causes of limitations in ADL. METHODS AND FINDINGS:The construct validity, interrater reliability, and discriminative validity of this new evaluation were determined. From 2015 until 2016, older persons (65-93 y) with normal cognitive ageing (healthy comparison [HC]) (n = 79), mild cognitive impairment (MCI) (n = 73), and Alzheimer disease (AD) (n = 71) underwent a diagnostic procedure for neurocognitive disorders at the geriatric day hospital of the Universitair Ziekenhuis Brussel (Brussels, Belgium). Additionally, the ICF-based evaluation for b- and i-ADL was carried out. A global disability index (DI), a cognitive DI (CDI), and a physical DI (PDI) were calculated. The i-ADL-CDI showed high accuracy and higher discriminative power than the Lawton Scale in differentiating HC and MCI (area under the curve [AUC] = 0.895, 95% CI .840-.950, p = .002), MCI and AD (AUC = 0.805, 95% CI .805-.734, p = .010), and HC and AD (AUC = 0.990, 95% CI .978-1.000, p < .001). The b-ADL-DI showed significantly better discriminative accuracy than the Katz Index in differentiating HC and AD (AUC = 0.828, 95% CI .759-.897, p = .039). This study was conducted in a clinically relevant sample. However, heterogeneity between HC, MCI, and AD and the use of different methods of reporting ADL might limit this study. CONCLUSIONS:This evaluation of b- and i-ADL can contribute to the diagnostic differentiation between cognitively healthy ageing and neurocognitive disorders in older age. This evaluation provides more clarity and nuance in assessing everyday functioning by using an ICF-based terminology and scoring system. Also, the possibility to take underlying causes of limitations into account seems to be valuable since it is crucial to determine the extent to which cognitive decline is responsible for functional impairment in diagnosing neurocognitive disorders. Though further prospective validation is still required, the i-ADL-CDI might be useful in clinical practice since it identifies impairment in i-ADL exclusively because of cognitive limitations.
Addenbrooke's Cognitive Examination III (ACE-III) and mini-ACE for the detection of dementia and mild cognitive impairment.
Beishon Lucy C,Batterham Angus P,Quinn Terry J,Nelson Christopher P,Panerai Ronney B,Robinson Thompson,Haunton Victoria J
The Cochrane database of systematic reviews
BACKGROUND:The number of new cases of dementia is projected to rise significantly over the next decade. Thus, there is a pressing need for accurate tools to detect cognitive impairment in routine clinical practice. The Addenbrooke's Cognitive Examination III (ACE-III), and the mini-ACE are brief, bedside cognitive screens that have previously reported good sensitivity and specificity. The quality and quantity of this evidence has not, however, been robustly investigated. OBJECTIVES:To assess the diagnostic test accuracy of the ACE-III and mini-ACE for the detection of dementia, dementia sub-types, and mild cognitive impairment (MCI) at published thresholds in primary, secondary, and community care settings in patients presenting with, or at high risk of, cognitive decline. SEARCH METHODS:We performed the search for this review on 13 February 2019. We searched MEDLINE (OvidSP), Embase (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science Core Collection (ISI Web of Knowledge), PsycINFO (OvidSP), and LILACS (BIREME). We applied no language or date restrictions to the electronic searches; and to maximise sensitivity we did not use methodological filters. The search yielded 5655 records, of which 2937 remained after we removed duplicates. We identified a further four articles through PubMed 'related articles'. We found no additional records through reference list citation searching, or grey literature. SELECTION CRITERIA:Cross-sectional studies investigating the accuracy of the ACE-III or mini-ACE in patients presenting with, or at high risk of, cognitive decline were suitable for inclusion. We excluded case-control, delayed verification and longitudinal studies, and studies which investigated a secondary cause of dementia. We did not restrict studies by language; and we included those with pre-specified thresholds (88 and 82 for the ACE-III, and 21 or 25 for the mini-ACE). DATA COLLECTION AND ANALYSIS:We extracted information on study and participant characteristics and used information on dementia and MCI prevalence, sensitivity, specificity, and sample size to generate 2×2 tables in Review Manager 5. We assessed methodological quality of included studies using the QUADAS-2 tool; and we assessed the quality of study reporting with the STARDdem tool. Due to significant heterogeneity in the included studies and an insufficient number of studies, we did not perform meta-analyses. MAIN RESULTS:This review identified seven studies (1711 participants in total) of cross-sectional design, four examining the accuracy of the ACE-III, and three of the mini-ACE. Overall, the majority of studies were at low or unclear risk of bias and applicability on quality assessment. Studies were at high risk of bias for the index test (n = 4) and reference standard (n = 2). Study reporting was variable across the included studies. No studies investigated dementia sub-types. The ACE-III had variable sensitivity across thresholds and patient populations (range for dementia at 82 and 88: 82% to 97%, n = 2; range for MCI at 88: 75% to 77%, n = 2), but with more variability in specificity (range for dementia: 4% to 77%, n = 2; range for MCI: 89% to 92%, n = 2). Similarly, sensitivity of the mini-ACE was variable (range for dementia at 21 and 25: 70% to 99%, n = 3; range for MCI at 21 and 25: 64% to 95%, n = 3) but with more variability specificity (range for dementia: 32% to 100%, n = 3; range for MCI: 46% to 79%, n = 3). We identified no studies in primary care populations: four studies were conducted in outpatient clinics, one study in an in-patient setting, and in two studies the settings were unclear. AUTHORS' CONCLUSIONS:There is insufficient information in terms of both quality and quantity to recommend the use of either the ACE-III or mini-ACE for the screening of dementia or MCI in patients presenting with, or at high risk of, cognitive decline. No studies were conducted in a primary care setting so the accuracy of the ACE-III and mini-ACE in this setting are not known. Lower thresholds (82 for the ACE-III, and 21 for the mini-ACE) provide better specificity with acceptable sensitivity and may provide better clinical utility. The ACE-III and mini-ACE should only be used to support the diagnosis as an adjunct to a full clinical assessment. Further research is needed to determine the utility of the ACE-III and mini-ACE for the detection of dementia, dementia sub-types, and MCI. Specifically, the optimal thresholds for detection need to be determined in a variety of settings (primary care, secondary care (inpatient and outpatient), and community services), prevalences, and languages.
Validity of screening instruments for the detection of dementia and mild cognitive impairment in hospital inpatients: A systematic review of diagnostic accuracy studies.
Hwang Aljoscha Benjamin,Boes Stefan,Nyffeler Thomas,Schuepfer Guido
INTRODUCTION:As the population ages, Alzheimer's disease and other subtypes of dementia are becoming increasingly prevalent. However, in recent years, diagnosis has often been delayed or not made at all. Thus, improving the rate of diagnosis has become an integral part of national dementia strategies. Although screening for dementia remains controversial, the case is strong for screening for dementia and other forms of cognitive impairment in hospital inpatients. For this reason, the objective of this systematic review was to provide clinicians, who wish to implement screening, an up-to-date choice of cognitive tests with the most extensive evidence base for the use in elective hospital inpatients. METHODS:For this systematic review, PubMed, PsycINFO and Cochrane Library were searched by using a multi-concept search strategy. The databases were accessed on April 10, 2019. All cross-sectional studies that utilized brief, multi-domain cognitive tests as index test and a reference standard diagnosis of dementia or mild cognitive impairment as comparator were included. Only studies conducted in the hospital setting, sampling from unselected, elective inpatients older than 64 were considered. RESULTS:Six studies met the inclusion criteria, with a total of 2112 participants. Diagnostic accuracy data for the Six-Item Cognitive Impairment Test, Cognitive Performance Scale, Clock-Drawing Test, Mini-Mental Status Examination, and Time & Change test were extracted and descriptively analyzed. Clinical and methodological heterogeneity between the studies precluded performing a meta-analysis. DISCUSSION:This review found only a small number of instruments and was not able to recommend a single best instrument for use in a hospital setting. Although it was not possible to estimate the pooled operating characteristics, the included description of instrument characteristics, the descriptive analysis of performance measures, and the critical evaluation of the reporting studies may contribute to clinician's choice of the screening instrument that fits best their purpose.
Reliability of three questions for the screening of advanced cognitive impairment in polypathological patients.
Díez-Manglano Jesús,Espuelas-Monge María,Gomes-Martín Javier,Lerín-Sánchez Javier,Odriozola-Grijalba Mónica,Piqueras-Serrano Carmen,Sánchez-Rubio-Lezcano Pablo,Zamora-Mur Alfredo
Geriatrics & gerontology international
AIM:To determine whether answering three questions erroneously ("what is the date today?," "when were you born?" and "how old are you?") allows for the detection of advanced cognitive impairment in polypathological patients. METHODS:A cross-sectional study of patients admitted to the internal medicine and geriatrics departments was carried out. Advanced cognitive impairment was diagnosed when patients made 7-10 errors in the Short Portable Mental Status Questionnaire. RESULTS:We included 441 polypathological patients, 330 of them from the internal medicine departments and 111 from the geriatrics department. Their mean age was 80.8 years (8.9 years). Of them, 141 (32.0%) answered one question incorrectly, 58 (13.1%) answered two and 89 (20.2%) answered all three questions incorrectly. The prevalence of advanced cognitive impairment was 27.7%. The sensitivity, specificity, and positive and negative predictive values of the test were 0.705, 0.991, 0.966 and 0.898, respectively. The accuracy of the test was 0.912. The area under the receiver operating characteristic curve was 0.947, 95% CI 0.923-0.970. CONCLUSIONS:The three questions test has very good specificity and positive predictive value, and it can be used for the screening of advanced cognitive impairment in polypathological patients. Geriatr Gerontol Int 2018; 18: 441-447.
The Digital Tree Drawing Test for Screening of Early Dementia: An Explorative Study Comparing Healthy Controls, Patients with Mild Cognitive Impairment, and Patients with Early Dementia of the Alzheimer Type.
Robens Sibylle,Heymann Petra,Gienger Regine,Hett Andreas,Müller Stephan,Laske Christoph,Loy Roland,Ostermann Thomas,Elbing Ulrich
Journal of Alzheimer's disease : JAD
The digital tree drawing test (dTDT) is a newly developed screening tool for the early detection of Alzheimer's disease. It is performed with a digitizing pen, recording each pen stroke with temporal and spatial precision. It was hypothesized that movement characteristics recorded during the painting process contribute to the identification of patients with mild cognitive impairment (MCI) and early dementia of the Alzheimer type (eDAT). The study population consisted of 187 participants (67 healthy controls, 64 MCI, and 56 eDAT patients) with a mean age of 68.6±10.6 years. Between-group comparisons of the dTDT-variables were conducted with analysis of variance. The diagnostic power of dTDT variables was analyzed with stepwise logistic regressions and areas under curve (AUC) of receiver operating control curves. Cognitively impaired persons used less colors and line widths and changed them less often than healthy subjects (p-values ≤0.05). Compared to control, eDAT patients had larger not-painting periods, were slower, and their pictures had less contrast, image size, and complexity (p-values ≤0.01). Logistic regression models of stepwise selected dTDT variables resulted in an AUC of 0.84 (95% confidence interval (CI) [0.79, 0.90], sensitivity = 0.78, specificity = 0.77) for discriminating healthy subjects from all cognitive impaired, an AUC of 0.77. (95% CI [0.69; 0.85], sensitivity = 0.56, specificity = 0.83) for discriminating healthy controls from MCI patients and an AUC of 0.90 (95% CI [0.84, 0.96], sensitivity = 0.86, specificity = 0.82) for discriminating controls from eDAT patients. The results suggest that digital recording of pen-stroke data during the drawing process can contribute to the screening of cognitive impaired patients.
Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.
Patnode Carrie D,Perdue Leslie A,Rossom Rebecca C,Rushkin Megan C,Redmond Nadia,Thomas Rachel G,Lin Jennifer S
Importance:Early identification of cognitive impairment may improve patient and caregiver health outcomes. Objective:To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force. Data Sources:MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019. Study Selection:Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers. Data Extraction and Synthesis:Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis. Main Outcomes and Measures:Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being. Results:The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance. Conclusions and Relevance:Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers.