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Global estimates suggest 17 million people are diagnosed with cancer each year. Up to 80% of these patients report confusion, memory lapses, attention deficits, and an overall feeling of mental fog. Most patients recover within a year of cancer treatment, but up to 35% of cancer survivors continue to experience lasting symptoms. Fortunately, early detection is helping clinicians understand the mechanisms and risk factors underlying cancer-related cognitive impairments. By identifying deficits and introducing tailored therapies as soon as possible, we can offer patients a better long-term prognosis.

How does cancer affect cognition?

Cancer-related cognitive impairment manifests in a number of ways, with potential symptoms including:

• Difficulty focusing and “brain fog”
• Shortened attention span
• Information processing delays
• Memory-related deficits
• Difficulty learning new information
• Inability to organize tasks or multitask

From a testing standpoint, signs of cancer-related cognitive impairment are milder than those seen with people who have dementia or Alzheimer’s disease, but they are no less disruptive to a patient’s quality of life.

Who experiences cognitive impairment with cancer—and why?

The term “chemo brain” is a misnomer, as cognitive impairment can also affect patients undergoing radiation, hormone therapy, bone marrow transplant, and surgery. Patients reporting “a foggy sensation” may notice symptoms resolve within six to 12 months of successful treatment, suggesting that—at least in some capacity—the cognitive impairment is related to the body’s inflammatory response and the cancer itself. Studies show up to one-third of patients exhibit cognitive symptoms even before they receive treatment for their cancer.

In the mid-2000s, animal studies revealed that chemotherapy drugs could pass through the blood-brain barrier. Neuroimaging studies confirmed that chemotherapy patients had to work harder during memory recall tests due to alteration of their neural networks. Other possible mechanisms for cognitive impairment include damage of white and gray matter, as well as vascular changes that restrict blood flow.

Because not all cancer patients undergoing chemotherapy experience cognitive effects, researchers are examining risk based on genetic and lifestyle factors as well. For instance, some studies suggest blood-brain barrier genes may allow or prevent chemotherapies’ access to the brain. The gene ApoE4—also implicated in Alzheimer’s disease risk—is a key gene variant currently being studied. In pediatric patients, nutrition and poverty can be predictors of long-term cognitive functioning. Comorbidities like anxiety, depression, diabetes, hypertension, and chronic fatigue can worsen cognition. The type of cancer, tumor location, and malignancy presumably protect against or predispose a patient to cognitive impairment, though more research is needed.

Screen for cancer-related cognitive impairment with MoCA

Research confirms the wide-ranging impact of cancer on cognitive functioning. Some patients encounter temporary “chemo brain” that improves over time, while others witness progressive decline. For these patients, quality of life suffers and they are at greater risk of mortality. Screening for cancer-related cognitive impairment is the first step to a potentially life-saving intervention.

MoCA has 90% sensitivity and 87% specificity in assessing cognition compared to clinical judgment. MoCA takes just 10 minutes to administer and is available in multiple languages and formats. Versions for those with sight or hearing impairment, low education, and phone or teleconference availability offer clinicians the flexibility they need to assess every patient. The traditional paper test does not assess processing speed, although a new tablet-based app can. All versions of the test cover domains affected by cancer-related cognitive impairment with high validation and correlation compared to the Functional Assessment of Cancer Therapy (FACT).

Multiple peer-reviewed studies validate the use of MoCA to screen for cognitive impairment related to cancer or chemotherapy:

• “Known discrepancies between objective findings and perceived cognitive impairment highlight the importance of utilizing both performance-based measures and self-report measures to identify cognitive problems.” Objective screening for cancer-related cognitive impairment is a necessary first step to providing treatment. After conducting a comprehensive review of scientific literature, researchers concluded that interventions such as cognitive rehabilitation, cognitive behavioral therapy, and mindfulness exercises were effective at improving patient perceptions and objective cognitive functioning.¹
• “One quarter of the five-year breast cancer survivors had a declining trajectory in cognitive performance.” Researchers at the Portuguese Institute of Oncology used MoCA to assess the cognitive function of breast cancer survivors at one year, three years, and five years. They noted two trajectories: some patients declined in cognitive function and others increased. Patients with comorbidities such as anxiety, depression, and poor sleep quality were among the cohort with the greatest need for interventions to prevent and address cognitive decline.²
• “The MoCA test seems to be most relevant to screen for cognitive impairment in older patients with cancer.” In studying 66 patients with cancer who were over 70 years old, clinicians noted a median MoCA score of 24 (on a scale from 8 to 30). Patients were also screened with the MMSE, which was less sensitive in detecting cognitive changes. Over all, 55 patients tested positive on both scores, 32 tested positive on MoCA only, and one patient tested positive with MMSE only.³
• “During the two years following cancer treatment initiation, older patients with a cognitive impairment were up to six times more likely to die than patients without.” For this study, researchers looked at the outcome of 357 patients 65 or older admitted for breast, prostate, or colorectal cancer surgery. Researchers concluded that older patients should be routinely screened for cognitive impairments at the start of their cancer treatment to enable interventions that reduce morbidity and mortality.⁴
• “Probable Cognitive Impairment was as frequent in patients recently diagnosed with Prostate Cancer as in the general population.” More research is needed, but scientists hypothesize that prostate cancer may be associated with a lower prevalence of cognitive impairment compared to other types of cancer.⁵

Treating cognitive impairment leads to better results for patients with cancer

Pharmacological studies have yielded few clues as to how we may boost patients’ cognitive skills. However, Kevin Krull, PhD, a neuroscientist at St. Jude Children’s Research Hospital, has found in preliminary studies that 15-minute sessions of low-voltage transcranial direct current stimulation stimulates the neural network in chemotherapy patients for a two-hour window of cognitive skills training. Patients have shown significant improvements in executive function after just 10 sessions. While this area of research holds promise, more studies are needed to validate its use before it’s offered as a mainstream treatment option.

Other studies have explored positive impact from neural feedback technology, attention retraining, and promotion of healthy lifestyle factors. Krull says what is needed is a multi-pronged approach and use of compensatory strategies—the earlier the better.

“Why do we wait until the problems start?” he asks. “We should be working from a preventative approach and starting to use these technologies to help enhance the skills and functions in those patients before they start experiencing deficits.”

MoCA is a helpful tool to detect symptoms early so an effective treatment regimen may begin. Learn more.

References:

1 Chao, D., Hale, A., Henry, N.L. et al. (2021) Cancer-Related Cognitive Impairment or “Chemobrain:” Emerging Assessments, Treatments, and Targets for Intervention. Curr Phys Med Rehabil Rep. https://doi.org/10.1007/s40141-021-00319-2

2 N Araujo, L Lopes-Conceição, F Fontes, M Severo, T Dias, V Tedim-Cruz, L Ruano, S Pereira, N Lunet, Trajectories of cognitive performance over 5 years in a cohort of breast cancer patients (NEON-BC), European Journal of Public Health, Volume 30, Issue Supplement_5, September 2020, ckaa166.1128, https://doi.org/10.1093/eurpub/ckaa166.1128

3 Rambeau A, Beauplet B, Laviec H, Licaj I, Leconte A, Chatel C, Le Bon P, Denhaerynck J, Clarisse B, Frenkiel N, Lange M, Joly F. Prospective comparison of the Montreal Cognitive Assessment (MoCA) and the Mini Mental State Examination (MMSE) in geriatric oncology. J Geriatr Oncol. 2019 Mar;10(2):235-240. doi: 10.1016/j.jgo.2018.08.003. Epub 2018 Aug 24. PMID: 30150019. https://pubmed.ncbi.nlm.nih.gov/30150019/

4 Libert, Yves, et al. “Vulnerabilities in Older Patients when Cancer Treatment is Initiated: Does a Cognitive Impairment Impact the Two-Year Survival?” PLoS ONE, vol. 11, no. 8, 1 Aug. 2016, p. e0159734. Gale Academic OneFile, Accessed 4 May 2022. link.gale.com/apps/doc/A459740969/AONE?u=googlescholar&sid=bookmark-AONE&xid=974898da.

5 N Araujo, A Costa, L Lopes-Conceição, A Ferreira, F Carneiro, J Oliveira, S Morais, L Ruano, S Pereira, N Lunet, Prevalence of cognitive impairment before treatments for prostate cancer, European Journal of Public Health, Volume 31, Issue Supplement_3, October 2021, ckab165.259, https://doi.org/10.1093/eurpub/ckab165.259

Globally, 10% of the population is affected by Chronic Kidney Disease (CKD). In people ages 65-74, an estimated 1 in 5 men and 1 in 4 women have CKD. Prevalence is rising along with increases in hypertension, diabetes, and obesity. Recently, scientists drew connections between declining kidney function and dementia, highlighting the need for early cognitive testing to improve medical outcomes.

Exploring the connection between end-stage renal disease and dementia

A 10-year cohort study published in Age and Aging revealed:

• Cognitive impairment is common among patients with end-stage renal disease undergoing dialysis.
• There is a graded association between CKD severity and cognitive impairment.
• The mean age of renal patients with dementia was 65.8.
• The eGFR < 60 threshold that denotes risk of CKD can also be used to predict risk of dementia.
• The risk increase was not attributable to stroke or other cardiometabolic conditions.

“The kidneys and the brain, both being end organs, are thought to be susceptible to vascular damage due to similar anatomic and hemodynamic features,” researchers posited, though the exact underlying mechanisms remain unclear.

They added, “While cardiovascular disease and reduction in life expectancy are recognized adverse outcomes of CKD, it is possible that dementia is also part of the risk associated with CKD.”

Treating cognitive deficits can improve patient quality of life and outcomes

Incorporating cognitive testing as part of chronic kidney disease care may have several implications:

• Medication to prevent worsening cognition. Abnormalities in brain capillaries are found in patients with dementia as well as patients with albuminuria, a condition where there is excess albumin blood protein in the urine. Researchers theorize that diabetes or high blood pressure triggers kidney damage, which causes excess protein in the urine and vascular changes in the brain. Patients with albuminuria were found to be at a 50% increased risk of dementia in one study. Early results suggest that treating CKD patients with ACE inhibitors and angiotensin-receptor blockers may have a protective effect on the kidneys and the mind.
• Lifestyle recommendations may be advised to reduce cognitive aging: Some research is looking into the potential for exercise to reduce cognitive decline and depression in patients who have renal impairment. A pilot study found folic acid and thiamine supplements could potentially improve cognitive performance in hemodialysis patients.
• A more paternal stance toward care may be taken. Increasingly, the onus is put on patients to self-manage their treatment. However, multi-domain cognitive impairment is a key factor contributing to why patients decide to withdraw from dialysis, undermining the shift from paternalistic to patient-driven models of care. Adherence to treatment protocols is especially important in patients who receive transplants.
• Diagnosis may aid prognosis. A patient’s prognosis may change when CKD and dementia are both present, as at least one study suggests higher mortality rates in this cohort.
• Support services can be arranged for at-risk patients. Researchers found 70% of patients with CKD and cognitive declines self-reported functional dependence in daily living, indicating a need for assistance with everyday tasks or the inability to drive safely.
• Kidney impairment will be detected and treated earlier. The general odds of a patient with CKD having reduced cognitive ability increases by 23% — with worsening mental function among patients with more advanced stage kidney disease. However, even those with milder forms of kidney impairment were at increased risk of cognitive impairment, suggesting the need for earlier intervention.

MoCA screening tools validated to test CKD patients for cognitive decline

Multiple peer-reviewed studies have validated the effectiveness of MoCA in detecting cognitive declines and dementia in patients with diminished renal function, including:

• “A significant association between the visuospatial executive function domain score of the Montreal Cognitive Assessment and the maximum arteriolar dilation as response of retinal arterioles to the flicker light stimulation was obtained.” The MoCA cut-off was set at 24 for patients on hemodialysis, as validated by two studies. Further, researchers noted an approximately three-fold higher prevalence of adverse outcomes (including increased mortality).¹
• “Older adults with preclinical cognitive impairment and CKD had different cognitive and vascular function than those without CKD, and an indicator of vascular function may have a relationship with cognitive function in older adults.” Scientists explored the possibility of vascular dysfunction as a mechanism for cognitive decline in older patients with CKD.²

• “Hemodialysis patients with cognitive impairment treated with thiamin and folic acid had a significant improvement in MoCA score.” Studying patients who scored 26 or lower on MoCA, researchers found the proportion of adverse events among the group treated with thiamin and folic acid supplements was “substantially lower.”³

• “The Montreal Cognitive Assessment, a widely available and brief cognitive screening tool, showed high sensitivity and moderate specificity in detecting severe cognitive impairment in patients on maintenance hemodialysis.” Researchers assessed cognitive function in a cohort of 150 patients on hemodialysis. Of the 150 participants, 21% had normal cognitive function, 17% had mild cognitive impairment, 33% had moderate impairment, and 29% had severe impairment. The study found a sensitivity of 86% and specificity of 55% for severe impairment. The MMSE and Mini-Cog had lower predictive performances.⁴

Early cognitive impairment detection and treatment is a crucial first step, as keeping patients cognitively intact ensures that they are able to follow their physician’s instructions and live healthier, happier lives.

MoCA offers highly sensitive, highly specific tools for assessing cognitive decline and dementia in renal patients. Visit us online for more information and adapted testing content.

References:

1 . Angermann, Susanne et al. “Cognitive impairment and microvascular function in end-stage renal disease.” International journal of methods in psychiatric research vol. 31,2 (2022): e1909. doi:10.1002/mpr.1909. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9159686/.

2 . Hannan M, Collins EG, Phillips SA, Quinn L, Steffen A, Bronas UG. Cognitive and vascular function in older adults with and without CKD. Aging Clin Exp Res. 2021 Jul;33(7):1885-1894. doi: 10.1007/s40520-020-01695-w. Epub 2020 Sep 9. PMID: 32902822; PMCID: PMC8171583. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32902822/

3 . Lu R, Fang Y, Zhou Y, Che M, Shen J, Liu Q, Zhang H, Pan S, Lin Y, Wang Q, Mou S, Ni Z, Gu L. A pilot study of thiamin and folic acid in hemodialysis patients with cognitive impairment. Ren Fail. 2021 Dec;43(1):766-773. doi: 10.1080/0886022X.2021.1914656. PMID: 33913373; PMCID: PMC8901284. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/33913373/

4 . Evaluation of Screening Tests for Cognitive Impairment in Patients Receiving Maintenance Hemodialysis. David A. Drew, Hocine Tighiouart, Jasmine Rollins, Sarah Duncan, Seda Babroudi, Tammy Scott, Daniel E. Weiner and Mark J. Sarnak. JASN April 2020, 31 (4) 855-864; DOI. Retrieved from: https://jasn.asnjournals.org/content/31/4/855

Additional Resources:

^{https://www.ajmc.com/view/poor-kidney-function-significantly-linked-with-dementia-incidence}

^{https://www.kidney.org/kidneydisease/global-facts-about-kidney-disease}

Substance abuse and withdrawal can trigger mental disorders that are temporary—lasting up to a month after abstinence—or more permanent. One study found that 31% of patients using alcohol, cannabis, or stimulants scored below the cognitive impairment threshold for memory and visuospatial abilities. Prevalence studies conducted at residential rehabilitation facilities have found 52 to 80% of patients checking in had some form of cognitive impairment.

Neurocognitive disorders can not only adversely affect cognition, but lead to relapses when treatment protocols are overly complex. Adequate care for patients with co-occurring substance abuse and cognitive deficits requires a multidisciplinary team who understands how to increase success rates in this specific cohort.

Interventions for patients with substance abuse and cognitive deficits

Patients with a substance abuse disorder who are also struggling with a cognitive deficit differ from patients who may be experiencing short-term psychological distress like anxiety, paranoia, depression, or attention deficits that often accompany withdrawal. Individuals with permanent cognitive impairments may have difficulty remaining abstinent due to distractibility and lack of insight. They may grapple with processing complex instructions and coping with the rigors of long-term recovery.

However, there are many ways clinicians can help patients understand and navigate this situation, such as:

• Explaining what substance use related impairment means.
• Educating clients with step-by-step life skills training.
• Encouraging patients to allow ample time to complete tasks, recheck their work, and use memory aids.
• Showing patients how to use alarms, voice recorders, notepads, calculators, and calendars.
• Helping to establish cues to remember information and daily living routines.
• Teaching how to make cost-benefit analysis lists as part of the decision-making process.
• Developing practical daily living routines to aid in functioning.
• Considering the use of cognitive enhancing medicines, exercise, and transcranial magnetic stimulation.
• Assuring clients it’s okay to ask for help when needed.
• Referring clients for psychological assessment and treatment of specific mental disorders.

Adjustments to Help Substance Abuse Patients with Cognitive Deficits

Behavioral interventions are rarely one-size-fits-all, so it helps to assess the level of cognitive functioning before starting a new treatment protocol. Practitioners may consider:

• Scheduling sessions that are shorter, but more frequent.
• Using multiple modes for communication (including oral, visual, auditory).
• Engaging in positive, strength-based feedback approaches that offer immediate, direct benefits.
• Repeating information and asking clients to paraphrase.
• Supporting the use of humor, mindfulness, or hobbies as coping strategies.
• Coordinating with care teams that may include neurological doctors, vocational services, or specialists.

MoCA picks up on substance abuse disorder related cognitive impairment

Most clinicians have used MoCA to specifically screen for cognitive impairments, but one of the lesser-known use cases is to screen substance use disorder patients to predict the likelihood of a successful intervention. Clinicians will better understand their patients by separating short-term psychological distress from long-term substance abuse-triggered cognitive decline.

Multiple peer-reviewed studies validate the use of MoCA for cognitive screening in substance abuse cases:

• “Substance Use Disorder (SUD) patients should routinely be screened for cognitive impairment, as it predicts dropout. Screenings should be ensued by appropriate adaptations to treatment and further assessment. The MoCA is a useful screening tool for this, independent of psychological distress. Future studies should replicate our findings, investigate specific interventions, and establish SUD population norms for the MoCA.” MoCA can be a more sensitive screening tool than other methods like the SCL-10. In this study, researchers found patients scoring below the MoCA cut-off rate had a higher risk of dropping out of treatment programs, even if they were not exhibiting outward signs of psychological distress and passed the SCL-10. ¹
• “These findings indicate that the MoCA provides a time-efficient and resource-conscious way to identify patients with SUDs and neuropsychological impairment, thus addressing a critical need in the addiction treatment research community.” Scientists studied the 10-minute MoCA screening test compared to the widely recognized 45-minute Neuropsychological Assessment Battery-Screening Module and found 75% agreement. The MoCA showed 83.3% sensitivity and 72.9% specificity for the identification of cognitive impairment.²
• “Our findings are consistent with previous research showing that MoCA provides a time- and resource-efficient assessment for identifying MCI in patients with SUD. Our study indicates that the results of the MoCA are independent of concurrent psychological distress, while the BRIEF-A GEC is significantly associated with psychological distress, as  measured by the SCL-90-R. We, therefore, suggest that performance-based assessment, such as the MoCA, could reduce the influence of psychological distress on cognitive screening.” In this study, 34/6% of participants scored below the threshold for cognitive impairment in patients with Substance Use Disorder. Researchers found a significant correlation between the SCL-90R GSI score and the BRIEF-A GEC, but no significant correlation between those tests and MoCA. In other words, MoCA is a more objective scale for multi-drug users, as it reduces the impact of psychological distress in screening compared to traditional tools³
• “A positive MoCA screening for cognitive impairments among post-detoxification Severe Alcohol Use Disorder (SAUD) patients could also be related to comorbid agoraphobia and depressive episodes rather than to SAUD itself. A comprehensive psychiatric assessment must be performed in SAUD patients so that other potential causes of cognitive deficits, in particular with regard to mood and anxiety disorders, can be identified and treated.” Researchers looked at 100 recently detoxified patients with SAUD and found that MoCA was effective at identifying subjects with cognitive deficits, which could reduce the efficacy of therapeutic interventions, potentially resulting in dropout and relapse.⁴

Due to the significant link between substance abuse disorder and cognitive impairment, MoCA is a useful screening tool in the treatment toolkit. Its relative sensitivity can help flag potential issues that may arise in treatment interventions sooner rather than later.

References: 

1 Sømhovd, M., Hagen, E., Bergly, T., & Arnevik, E. A. (2019). The Montreal Cognitive Assessment as a predictor of dropout from residential substance use disorder treatment. Heliyon, 5(3), e01282. https://pubmed.ncbi.nlm.nih.gov/31025003/

2 Copersino, M. L., Fals-Stewart, W., Fitzmaurice, G., Schretlen, D. J., Sokoloff, J., & Weiss, R. D. (2009). Rapid cognitive screening of patients with substance use disorders. Experimental and clinical psychopharmacology, 17(5), 337. https://pubmed.ncbi.nlm.nih.gov/19803633/

3 Egon Hagen, Mikael Sømhovd, Morten Hesse, Espen Ajo Arnevik, Aleksander H. Erga,. Measuring cognitive impairment in young adults with polysubstance use disorder with MoCA or BRIEF-A – The significance of psychiatric symptoms. Journal of Substance Abuse Treatment, Volume 97, 2019, Pages 21-27. https://pure.au.dk/ws/files/140318722/Measuring_cognitive_impairment_in_young_adults_with_polysubstance_use_disorder_with_MoCA_or_BRIEF_A.pdf

4 D’Hondt, F., Lescut, C., Maurage, P., Menard, O., Gibour, B., Cottencin, O., … & Rolland, B. (2018). Psychiatric comorbidities associated with a positive screening using the Montreal Cognitive Assessment (MoCA) test in subjects with severe alcohol use disorder. Drug and Alcohol Dependence. https://psycnet.apa.org/record/2018-47161-033

Before the COVID-19 pandemic, depression was already the leading cause of disability worldwide, and its reach only widened during many months of lockdowns and social isolation. According to the World Health Organization, the pandemic spurred a 25% increase in global prevalence of depression and anxiety. An estimated 280 million people around the world have depression, accounting for 3.8% of the global population.

The effects of depression, however, can go far beyond worsened mood. Pain, inflammation, fatigue, headache, and even risk of heart disease have been linked to the illness, as have cognitive impairments. In the Diagnostic and Statistical Manual of Mental Disorders (DSM), cognitive disorders are listed as core symptoms of depression. Its criteria for major depressive disorder include impairments in thinking, concentration, and decision making, demonstrating a strong link between cognition and the mood-related symptoms typically associated with the condition.

The impact of depression on cognitive domains  

A number of the processes that constitute human cognition can be affected by depression, including:

• Attention and focus: Out of all the potential cognitive side effects of depression, diminished attention and focus are perhaps the most widely recognized. Depressed patients often report distractibility and an inability to concentrate, both of which can affect their ability to participate in the workplace or school. Clinicians attempting to determine whether attention and concentration deficits are the result of depression should first rule out pre-existing attention deficit disorder or side effects from anti-depression medications.
• Memory: Patients experiencing depression can also suffer from memory loss, although the relationship between the two is not entirely understood. Pattern separation, or the delineation of similar events in the mind, has been shown to be negatively influenced by depression. Depression is also tied to reduced performance in declarative memory, or the intentional remembering of facts.
• Executive functioning: Executive functioning—including the ability to complete tasks, plan, and make decisions—can suffer due to depression. Compared to a healthy control group, students with depression, stress, and anxiety demonstrated impaired decision making.

Unfortunately, it’s not uncommon for cognitive impairments like those above to continue after other symptoms of depression have subsided. The most common antidepressants—Lexapro, Zoloft, and Effexor—have shown to be largely ineffective in combating depression-related cognitive decline. According to one study, 95% of patients saw no improvement in cognitive function even after successful treatment of mood symptoms on these medications.

Given this understanding, new multimodal antidepressants are emerging that treat cognition and function. At the moment, cognitive behavioral therapy and cognitive remediation therapy are thought to be effective methods of treating depression-related cognitive issues.

A prodromal stage of dementia

There’s a considerable amount of debate surrounding the nature of depressive cognitive impairment, especially concerning its relation to dementia. Depression-related cognitive impairment has been referred to as pseudodementia by some researchers, but it has yet to be included in the classification system for dementia.

For elderly patients, depression has been shown to double the risk of eventual dementia onset. While only 18% of depressed elderly patients with strong cognitive health developed dementia, 70% of those with depressive pseudodementia eventually develop dementia.

Still, not all depression-related cognitive impairment is a prodromal stage of dementia. More and more research indicates that younger adults can be impacted by cognitive impairment. A study of adults under the age of 65 with major depressive disorder found that 38% meet the criteria for cognitive impairment in one domain, and 20% in two or more.

MoCA for depression  

According to clinical psychology researcher Maria Semkovska, PhD, at the Health Research Institute, University of Limerick in Ireland, it’s not uncommon to see patients who no longer meet the clinical criteria for depression but find their cognitive function and work is still suffering after recovery.

“I believe that after recovering from a depressive episode, cognitive function needs to be assessed routinely before returning to normal everyday life to prevent these negative effects of persisting cognitive difficulties impacting on psychosocial recovery,” Semkovska told Medpage Today. “Even if no treatment could be implemented and/or if issues are minor, it is better to be aware of one’s objective cognitive function before returning to normal everyday life.”

Recognizing the importance of testing for cognitive impairment, researchers have successfully used MoCA to identify its presence in patients with depression. The following studies demonstrate MoCA’s efficacy in revealing depressive cognitive impairments and more:

• “We found that the MoCA total score is able to predict the presence of suicidal ideation in depressed elderly patients in a fair-to-good manner. As late-life depression is already established as a potential prodrome of dementia, longitudinal follow-up may determine whether depressed individuals with suicidal ideation are at higher risk of converting to dementia.” Researchers administered MoCA and several mental health indexes to elderly participants to assess their cognitive abilities. They found that participants dealing with suicidal ideation performed worse on the MoCA than those who weren’t, pointing to MoCA’s potential to predict suicidal tendencies in elderly patients.¹
• “After ECT, the MoCA and MMSE total scores were comparable, but the MoCA detected more impairments than did the MMSE for visuo-executive, memory and language subscores.” Researchers sought to determine whether MoCA could help evaluate the cognitive states of patients receiving electroconvulsive therapy (ECT) for depression. They found that MoCA was a useful tool for monitoring cognitive function during ECT and detected more patients with cognitive deficits than the MMSE.²

• “Present findings confirm available evidence about patterns of cognitive impairment in mood disorders, in terms of prevalence and persistence beyond remission in most severe cases. Moreover, a longer DUI was associated with worse cognitive performance during depression, and consequently with poorer outcome, underlining the importance of prompt treatment of these disorders also in light of a cognitive perspective.” Setting out to determine how cognitive impairment evolves in patients with major depressive disorder or bipolar disorder, researchers administered MoCA to patients during a major depressive episode and after remission. Comparing the scores, they found that 50% of the sample met the criteria for mild cognitive impairment during the episode. They also witnessed improved cognition after remission, although some effects still lingered, and observed a relationship between the duration of untreated illness (DUI) and poor cognitive performance.³

• “In this naturalistic sample of patients with TRD in our clinical service, repeated ketamine infusions significantly decreased depression symptoms without impairing cognitive performance. The baseline cognition may positively predict antidepressant responses of repeated ketamine treatment.” Researchers conducted a retrospective chart review to determine the impact of repeated ketamine infusion treatments on neurocognition in patients with treatment resistant depression. They used MoCA to monitor cognitive effects and the 16-item Quick Inventory of Depressive Symptomatology-Self Report Scale to assess depressive symptoms, and found no evidence of cognitive impairment.⁴

By screening for potential cognitive effects of depression, clinicians can identify impairment and treat patients for the full spectrum of their condition. In turn, patients can more quickly re-engage in their occupations, relationships, and daily lives.

In addition to depression, MoCA can screen for dementia, diabetes, heart disease, early-onset Alzheimer’s, and more—and supports a range of languages and formats. Learn more on our website.

References: https://mocacognition.com/reference/

1. Stéphane Richard-Devantoy, Icoquih Badillo-Amberg, Kyle T. Greenway, Maria Di Tomasso, Gustavo Turecki, J.A. Bertrand, Low MoCA performances correlate with suicidal ideation in late-life depression, Psychiatry Research, Volume 301, 2021, 113957, ISSN 0165-1781, https://doi.org/10.1016/j.psychres.2021.113957.
2. Rémi Moirand, Filipe Galvao, Maxime Lecompte, Emmanuel Poulet, Frédéric Haesebaert, Jerome Brunelin,Usefulness of the Montreal Cognitive Assessment (MoCA) to monitor cognitive impairments in depressed patients receiving electroconvulsive therapy, Psychiatry Research, Volume 259, 2018, Pages 476-481, ISSN 0165-1781, https://doi.org/10.1016/j.psychres.2017.11.022. (https://www.sciencedirect.com/science/article/pii/S0165178117315834)

3. Cesare Galimberti, Monica Francesca Bosi, Martina Volontè, Francesca Giordano, Bernardo Dell’Osso & Caterina Adele Viganò (2020) Duration of untreated illness and depression severity are associated with cognitive impairment in mood disorders, International Journal of Psychiatry in Clinical Practice, 24:3, 227-235, DOI: 10.1080/13651501.2020.1757116
4. Dai, D., Miller, C., Valdivia, V. et al. Neurocognitive effects of repeated ketamine infusion treatments in patients with treatment resistant depression: a retrospective chart review. BMC Psychiatry 22, 140 (2022). https://doi.org/10.1186/s12888-022-03789-3

Diabetes is most commonly diagnosed between the ages of 45 and 64. However, because the chance of having multiple comorbidities increases with age, the disease often appears alongside other conditions, which can complicate treatment and reduce successful patient outcomes.

Beyond vascular complications of diabetes, there’s a need for greater awareness regarding associated cognitive dysfunction like brain fog, dementia, and neurodegeneration. Impaired brain function is of particular concern, as it impacts self-care abilities and overall quality of life.

For these reasons, compassionate and successful diabetes care begins with a cognitive screening to determine the starting point for treatment.

What is the link between cognitive impairment and diabetes?

Diabetes impacts various organs—including the brain—and can result in conditions ranging from mild brain fog to severe dementia. While these effects are well-documented, more research is needed to uncover the exact mechanism of cognitive decline in patients with diabetes. One theory among many is that blood sugar or insulin may harm the brain by damaging blood vessels and brain cells, imbalancing brain chemicals, triggering inflammation and immune response, atrophying muscle, and causing clumps of toxic proteins to build up.

Improper blood sugar levels contribute to brain fog

Brain fog is a general term to describe feeling mentally fuzzy, slow, and spaced out. Poorly managed blood sugar levels—one of the hallmarks of diabetes—can trigger brain fog in the following ways:

• Hyperglycemia: When blood sugar levels are high, excess sugar accumulates in the bloodstream. Blood vessels become damaged over time, resulting in poor blood circulation to the brain. Serotonin and other neurotransmitter activity also increases with excess blood sugar, which can have a negative effect on nerve cell damage, inflammation, and brain impairment.
• Hypoglycemia: When the body doesn’t produce enough insulin, brain cells malfunction and the body can’t convert sugar into energy. Similarly, people who have intense workouts, skip meals, or take too much insulin can experience low blood sugar side effects such as fatigue, headaches, mood swings, memory lapses, and diminished concentration.

Diabetes and dementia risk

Though not fully understood, the connection between diabetes and dementia is compelling:

• The risk of dementia is 5 to 2.5 times higher in patients with type 1 or type 2 diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
• Gray matter loss is observed in Alzheimer’s and dementia patients. After 10 years of type 2 diabetes, gray matter diminishes significantly, affecting regions of the brain associated with memory, emotions, decision-making, and self-control.
• According to one study, a 70-year-old man with diabetes has a 27 percent probability of developing dementia; a woman has a 35 percent chance.
• Other research found a 56 percent increased risk of Alzheimer’s disease in people with type 2 diabetes.
• A 2021 study showed older adults with type 1 diabetes hospitalized for high and low blood sugar extremes were six times more likely to later develop dementia.

Treating patients with both diabetes and cognitive impairment

Diabetes is a condition associated with a high degree of noncompliance regarding treatment protocols. Early detection and increased awareness about cognitive decline in this cohort can help clinicians treat patients with greater compassion and understanding, which may improve overall outcomes. For instance:

• Patients with memory loss may forget to monitor glucose levels, exercise, take insulin injections and other medications, eat on time, or attend clinical appointments. Clinicians can help by reducing self-monitored care and shifting the responsibility to supportive caregivers. They may need to prescribe longer-acting medications. Coordinating scheduled meal deliveries and supervised exercise programs can increase a patient’s odds of success.
• Clinicians may have difficulty communicating self-care instructions to patients with cognitive impairments. Understanding the mental comorbidities that often accompany diabetes can help clinicians resist the urge to label a patient “stubborn” or “noncompliant.” Instead, clinicians may need to repeat directions, simplify complex regimens, and emphasize the importance of making one small change at a time.
• Declines in cognition may make it difficult to stop unhealthy behaviors and adopt new therapies. It’s important to enlist the help of caregivers to support and remind patients of necessary lifestyle or regimen changes. Clinicians should avoid making too many changes to the routine in short succession and may need to restrict insulin access if patients are overmedicating.
• Difficulty with mental flexibility may lead to anxiety about failing treatment plans. Clinicians can offer support with a simplified routine. They may consider tailoring recommendations about frequent snacking or other aspects of treatment where adherence remains a challenge.

How do we recognize cognitive dysfunction?

Medicare guidelines recommend that all patients over 65 undergo routine screening for declines in cognition. Early stages of cognitive dysfunction can be subtle in diabetes patients and are often missed by tests like the Mini-Mental State Examination (MMSE). Instead of waiting until caregivers notice odd behaviors resulting from moderate-to-severe decline, clinicians can use the highly sensitive MoCA (Montreal Cognitive Assessment) to detect early signs of impairment.

The use of MoCA for screening patients with diabetes has been validated by numerous studies:

• “MoCA appears to be a better screening tool than SMMSE for MCI in the diabetic population.” Researchers in Alberta, Canada testing patients with diabetes for mild cognitive impairment found MoCA had 67% sensitivity, compared to the SSMSE’s 13% sensitivity. Difficulties in drawing the hands of a clock, visuospatial function, and delayed five word recall make this test a better screening procedure, according to researchers.¹
• “The Montreal Cognitive Assessment, previously validated as a brief cognitive screening tool, may be useful as an adjunct to assess the self-care capacity of older individuals with diabetes.” Researchers in Israel found MoCA to be a useful tool to assess different cognitive domains in older people with diabetes. They found patients with diabetes tended to perform worse in cognitive function than patients without diabetes. A systematic review found MoCA was superior to other commonly used tests.²
• “Participants with midlife type 2 diabetes were more than twice as likely to make an error on the Montreal Cognitive Assessment test.” Researchers in Ireland found MoCA was more sensitive at detecting mild cognitive impairments in middle-aged patients with diabetes compared to a detailed neuropsychological assessment battery. Small cognitive declines can help determine the risk of later cognitive decline and plan interventions, they concluded.³
• “Poor blood sugar control was associated with a significant decline in insulin resistance for ‘naming’, ‘read list of letters’, and ‘delayed recall’ Montreal Cognitive Assessment (MoCA) subscale scores.” MoCA scores correlated with magnetic resonance imaging scans showing periventricular hyperintensity and deep white matter hyperintensity.⁴

A study of the middle-aged population indicates that tight glycemic control in midlife may protect against subsequent cognitive decline. While there is no evidence that improving blood glucose, blood pressure, or cholesterol levels can reduce cognitive impairment in older populations where structural damage has occurred, developing a better understanding of a patient’s cognitive dysfunctions remains an important step in establishing a compassionate and effective treatment regimen, and can better help caregivers understand their roles in supporting a loved one with both diabetes and cognitive impairment.

References:

1 Alagiakrishnan, K., Zhao, N., Mereu, L., Senior, P., & Senthilselvan, A. (2013). Montreal cognitive assessment is superior to standardized mini-mental status exam in detecting mild cognitive impairment in the middle-aged and elderly patients with type 2 diabetes mellitus. BioMed Research International. https://www.hindawi.com/journals/bmri/2013/186106/

2 Mordenfeld, N., Gayus, N., Azmon, M., Guri-Twito, O., Yahalom Peri, T., Natovich, R., & Cukierman-Yaffe, T. (2020). Determining the Optimal Cognitive Screening Tool in Older People With Diabetes. Frontiers in Endocrinology, 11, 322. https://www.frontiersin.org/articles/10.3389/fendo.2020.00322/full

3 Dyer, A. H., McKenna, L., Gamage, G., Bourke, N. M., Killane, I., Widdowson, M., … & Kennelly, S. P. Cognitive performance in midlife type 2 diabetes: results from the ENBIND study. Diabetic Medicine, e14412. https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.14412

4 Hishikawa, N., et al. “Cognitive and affective functions in diabetic patients associated with diabetes related factors, white matter abnormality and aging.” European Journal of Neurology (2014). https://onlinelibrary.wiley.com/doi/10.1111/ene.12568

As suppliers of critical oxygen and nutrients to the brain, blood vessels can have a profound impact on cognitive health. When there’s an issue with a blood vessel—whether it be blocked, narrowed, or ruptured—brain cells can’t receive the oxygen and nutrients they need, causing them to die off. Cognitive functions can suffer as a result, in a phenomenon known as vascular dementia.

Understanding vascular dementia 

According to the Mayo Clinic, vascular dementia is “a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain.” Any damage to arteries—from brain hemorrhaging to narrowed blood vessels—can lead to the development of vascular dementia overtime, but it can also onset suddenly after a stroke or major surgery.

Vascular dementia’s symptoms span from incontinence and mood changes to slowed and disorganized thinking. While vascular dementia is seemingly similar to Alzheimer’s disease, the two are distinct, with vascular dementia being more commonly linked to difficulties in thinking and problem-solving opposed to memory loss.

That said, Alzheimer’s and vascular dementia often coexist. The same cardiovascular diseases that cause vascular dementia—obesity, high cholesterol, high blood pressure, and diabetes—are thought to increase the likelihood of developing Alzheimer’s disease. Other risk factors for vascular dementia are smoking, atrial fibrillation, and atherosclerosis.

Interventions for post-stroke cognitive impairment 

Strokes frequently lead to the development of vascular dementia and cognitive impairment. Research indicates that approximately 30% of patients develop dementia within the first year of having a stroke, and over 40% develop post-stroke cognitive impairment (PSCI), making stroke the second most common cause of both dementia and cognitive impairment.

Due to the high frequency of cognitive impairment after stroke, it’s important to properly screen patients after one occurs. When cognitive impairment is identified early on, occupational therapists and neuropsychologists can work with patients to manage the effects they’re experiencing.

Cognitive remediation, also known as cognitive rehabilitation, is one approach for helping patients with cognitive impairments recover. By targeting memory, processing speed, and attention, cognitive remediation interventions can help patients use the areas of their brain that are working well in order to compensate for new challenges and improve problem areas. While cognitive remediation varies depending on the needs of the individual, possible interventions include:

• Mnemonic strategies like acronyms, rhymes, and acrostics to remember important information
• Virtual reality programs to improve short-term and sustained memory, as well as selected and divided attention, such as Saebo VR, BrightBrainer, and Reh@City
• Task analysis and breakdown to make daily tasks easier
• Memory aids like agendas, calendars, labels, and reminders

With proper interventions and early screening, stroke patients can improve executive functions and overall cognition, and hopefully lower their risk for developing dementia over the long-term.

Screening stroke patients with MoCA  

MoCA is a cognitive screening tool in both paper and digital formats that can quickly and accurately test patients for mild cognitive impairment (MCI), including impairment that onsets after stroke. The test is available in over 100 languages and dialects, and comes in a variety of versions to meet the needs of specific patient populations.

The following peer reviewed studies have demonstrated MoCA’s sensitivity for detecting cognitive impairment in stroke survivors:

• “From the studies we reviewed, the use of MoCA as a brief cognitive tool in both the acute/subacute and chronic poststroke periods seems overall feasible.” Researchers reviewed studies concerning MoCA use with stroke patients, and found that the test reliably predicts PSCI for both the acute (2 weeks after the event) and chronic (12-24 weeks after the event) post-stroke periods.¹
• “All three of the Montreal cognitive assessment visuoexecutive sub-tests detected more abnormalities than the mini-mental state examination pentagon copying and thus contributed to the over 10-fold superiority of Montreal cognitive assessment…” Interested in whether MoCA or the mini-mental state examination (MMSE) is better at detecting visuoexecutive dysfunction in transient ischemic attack (TIA) and stroke patients, researchers compared the tests and found MoCA to be more successful than MMSE in detecting abnormalities.² 
• “This approach could facilitate clinical care pathways and patient selection for research.” This study sought to establish an approach for identifying moderate to severe CI in patients, and ultimately found that grouping patients into three categories—high-, intermediate-, and low-risk—with MoCA could help with clinical care and research.³
• “Early cognitive testing by MoCA predicts long-term cognitive outcome, functional outcome, and mortality after stroke. Our results support routine use of the MoCA in stroke patients.” Researchers set out to determine whether MoCA could predict long-term CI, functional outcome, and mortality when given to patients within the first week of a stroke, and found the test to be successful in doing so.⁴

Given the high prevalence of stroke around the world, screening for PSCI can help dramatically improve the daily lives of countless stroke survivors. Learn more about MoCA and other adapted testing content to screen for cognitive impairment caused by a wide range of conditions.

References: 

1 Chiti, G. & Pantoni, L. Use of Montreal cognitive assessment in patients with stroke. Stroke 45, 3135–3140. https://doi.org/10.1161/STROKEAHA.114.004590 (2014).

2 Mai LM, Sposato LA, Rothwell PM, Hachinski V, Pendlebury ST. A comparison between the MoCA and the MMSE visuoexecutive sub-tests in detecting abnormalities in TIA/stroke patients. International Journal of Stroke. 2016;11(4):420-424. doi:10.1177/1747493016632238

3 Swartz, Richard H., et al. “Validating a Pragmatic Approach to Cognitive Screening in Stroke Prevention Clinics Using the Montreal Cognitive Assessment.” Stroke (2016): STROKEAHA-115.

4 Zietemann V, Georgakis MK, Dondaine T, Müller C, Mendyk AM, Kopczak A, Hénon H, Bombois S, Wollenweber FA, Bordet R, Dichgans M. Early MoCA predicts long-term cognitive and functional outcome and mortality after stroke. Neurology. 2018 Nov 13;91(20):e1838-e1850. doi: 10.1212/WNL.0000000000006506. Epub 2018 Oct 17. PMID: 30333158.

Declines in sight and hearing are a natural part of aging, but they can also be associated with mild cognitive impairment and dementia. Some researchers believe dementia alters the way the brain interprets sensory data, while others suspect that the loss of eye and ear nerve impulses is what accelerates cognitive decline. More research is needed to clarify the relationship between dual sensory loss and dementia, but recent studies affirm the connection—and provide hope that early intervention can potentially slow or stop cognitive decline.

Study finds risk of dementia is 86% higher in patients with dual sensory loss

Dementia risk is substantially higher among elderly patients with dual sensory loss, according to Phillip Hwang, MPH and colleagues at the University of Washington. Researchers tracked 2,051 people, ages 75 or older, enrolled in the Gingko Evaluation of Memory Study for seven years and found:

• 11% increased risk of dementia among patients with visual or hearing impairment.
• 86% increased risk of dementia among patients with dual sensory impairment.

Hwang and colleagues concluded that concurrent hearing and vision loss late in life is “strongly associated” with the development of dementia, including Alzheimer’s, and assessing sensory function may help identify those at highest risk of cognitive decline.

Even mild multisensory impairment is associated with cognitive decline 

In another study of 1,810 patients ages 70-79, University of California San Francisco researchers identified a link between low sensory function scores and increased risk of cognitive decline and dementia.

• Dementia risk was nearly seven times greater for those in the bottom 25% sensory function scores.
• Just a four point difference in score (out of 12 points) was associated with 68% higher risk of dementia.

Lead researcher Willa D. Brenowitz, PhD, MPH, suggested that treating or correcting some forms of hearing and vision loss early may provide an opportunity for intervention that could reduce or prevent cognitive decline.

Sensory loss intervention may delay or prevent the onset of dementia

Existing research is limited, but University of Michigan researchers associated sensory impairment intervention with better patient outcomes. Elham Mahmoudi, M.B.A, Ph.D. and colleagues tracked 115,000 people over age 66 with hearing loss from 2008 and 2016, with findings published in the Journal of the American Geriatrics Society.

Those treated with hearing aids had:

• 18% lower risk of dementia after three years.
• 13% lower risk of fall-related injury.
• 11% lower risk of depression and anxiety.

Awareness is particularly important, as only 12% of people with diagnosed hearing loss receive hearing aids. Researchers added that it was difficult to tell whether the hearing aid cohort’s results were due to increased physical nerve stimulation in the brain, improvements in social interaction and independence, or both.

To get better patient outcomes, we need better testing

When testing for cognitive decline, particularly in the elderly, there can be confusion as to whether there is mild cognitive impairment or sensory difficulties with the test itself. This experience is not only frustrating for patients, but inconclusive for clinicians. Screening for hearing and sight loss prior to administering a test for cognitive decline is a critical step toward alleviating bias in our testing and ensuring accurate results.

Two MoCA tests differentiate cognitive impairment from sensory issues 

While you may have been using the Full MoCA for years, were you aware we offer test adaptations for hearing and visual impairment? If you already know and appreciate MoCA, be sure to check out these versions of the test:

• MoCA-HI: a test designed for patients with hearing impairment
• MoCA-Blind/Telephone: in-person or by-phone testing for patients with visual impairment

Updated test instructions will help you identify subtle differences between mild cognitive impairment and sensory impairments. Like the MoCA you’re using now, these adaptations have been rigorously tested and validated by independent studies.

Researchers affirm the importance and effectiveness of MoCA-HI and MoCA-Blind:

• “The results indicated that the specificity was excellent.” Researchers testing for signs of Alzheimer’s found sensitivity—the ability to correctly identify mild cognitive impairment—decreased slightly without the visual components. However, the 87% specificity—the ability to correctly identify people who did not have mild cognitive impairment—was excellent. Using the recommended adjusted cutoff values provides better sensitivity, researchers noted; MoCA-Blind has a max score of 22, with 19+ considered “normal,” compared to Full MoCA, where patients need to score 26 out of 30 for a normal rating.¹
• “MoCA-HI is easy to administer and reliable for screening cognitive impairment in the severely hearing impaired.” Canadian researchers found that the MoCA test adaptation for the hearing impaired was an effective screening tool, requiring no conversion factor.³
• “Misunderstanding of verbal instructions, cognitive changes, and delayed central processes may lead to a false diagnosis in up to 16% of subjects with hearing loss.” Hearing assessments are not always done as routine parts of geriatric assessment. Yet, researchers from Ruhr-University Bochum found failing to account for sensory impairment in standardized testing can create unfair biases. The use of MoCA-HI can minimize bias in testing people with hearing loss.⁴

Patients with varying degrees of visual or hearing impairment can be effectively tested for signs of Alzheimer’s, dementia, long COVID, heart disease, and ADHD with a high degree of sensitivity using MoCA’s adapted testing content. Visit us online to download our free cognitive screening tools, MoCA-Blind/Telephone for people with visual impairment and MoCA-HI for people with hearing impairment.

References:

1 Walter Wittich, Natalie Phillips, Ziad Nasreddine, Howard Chertkow. Sensitivity and specificity of the Montreal Cognitive Assessment modified for individuals who are visually impaired. Journal of Visual Impairment & Blindness, June 2010, 104(6), 360-368.

2 Kate Dupuis, M. Kathleen Pichora-Fuller, Alison L. Chasteen, Veronica Marchuk, Gurjit Singh & Sherri L. Smith (2015) Effects of hearing and vision impairments on the Montreal Cognitive Assessment, Aging, Neuropsychology, and Cognition, 22:4, 413-437, DOI: 10.1080/13825585.2014.968084

3 Lin, V.Y.W., Chung, J., Callahan, B.L., Smith, L., Gritters, N., Chen, J.M., Black, S.E. and Masellis, M. (2017), Development of cognitive screening test for the severely hearing impaired: Hearing-impaired MoCA. The Laryngoscope, 127: S4-S11. https://doi.org/10.1002/lary.26590

4 Völter, C., Götze, L., Dazert, S., Wirth, R., & Thomas, J. P. (2020). Impact of Hearing Loss on Geriatric Assessment. Clinical interventions in aging, 15, 2453–2467. https://doi.org/10.2147/CIA.S281627

Basic reading, writing, and counting skills are critical in our everyday lives, but many of us take these skills for granted. Around the world, there are still 773 million adults who lack basic literacy skills—and in the U.S, in particular, 21% of adults lack the English literacy skills necessary to make simple inferences, paraphrase, or compare and contrast information.

What are the consequences of low literacy and education, beyond poor reading comprehension? People who are illiterate are less likely to be employed than those who are, more likely to be incarcerated, and earn less on average. What’s more, a lack of literacy skills can result in lower self esteem and feelings of shame, as well as alienation from school and society. People with lower education levels also experience more factors that correlate with depression onset than those with higher education, including daily stressors, a lack of resilience, and low sense of control.

Health impacts of low literacy and education 

In addition to the psychosocial impacts, low literacy is linked to low health literacy. The CDC defines health literacy as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.” Without the skills necessary to read and comprehend information about their own health or health issues in general, patients with low literacy can suffer in the long term.

For example, low-literacy patients can have a hard time reading and following written instructions on medications, in turn lowering the efficacy of these regimens. Another study found that men with low health literacy who were diagnosed with low- to intermediate-risk prostate cancer were 7 times less likely to choose active surveillance over immediate treatment for prostate cancer after receiving a particular type of gene test, even when treatment might not be necessary. This research points to the critical need for counseling and education tools developed with these patients in mind.

The connection between literacy and age 

Low literacy is disproportionate among a few demographics, including the elderly. According to the National Center for Educational Statistics, adults ages 65 and older have lower health literacy skills, on average, than those under the age of 65.

Combined with this age group’s increased risk for a number of health conditions—including mild cognitive impairment (MCI), Alzheimer’s disease (AD), and Parkinson’s disease—it’s important that these patients are given extra time and attention by medical professionals. MoCA has taken steps to ensure these patients can receive the care they need when it comes to screening for cognitive decline.

Benefits of MoCA Basic 

MoCA Basic is a cognitive assessment test that’s been validated as accurate and effective at screening people with low education and literacy for mild cognitive impairment (MCI) across cultures. It’s offered in a number of languages.

Multiple peer-reviewed studies have validated the effectiveness of MoCA Basic, such as:

• “MoCA-Basic appears to have excellent validity and addresses an unmet need…” In 2015, researchers in Thailand investigated MoCA Basic’s efficacy in screening elderly adults with low education and literacy for MCI. They found that MoCA Basic scores didn’t significantly vary with literacy levels, and had little correlation to age or education, indicating the test’s validity.¹
• “…the MoCA-Basic, despite being an easier task, is likely capable of detecting impairments in various cognitive domains with better sensitivity than the MMSE…” A number of normative studies are currently underway to assess the efficacy of MoCA and MoCA Basic within different cultures. In this 2020 study, researchers studied the validity of MoCA Basic, as well as the standard MoCA, on community-dwelling Saudi Arabians. They found that, while future research is needed to determine cut-offs in the Arabic version, both tests are “useful tools for detecting cognitive impairment” and likely more effective than the MMSE.²
• “The Chinese version of the MoCA-Basic (MoCA-BC), translated with cultural modifications from the original English version, has shown excellent validity and accuracy…” Researchers set out to determine if the MoCA-BC could identify early MCI and mild and moderate AD in Chinese elderly with various levels of education. They found that the test “had high sensitivity” and could successfully discriminate between MCI, mild AD, and moderate-severe AD.³

While literacy rates continue to improve around the globe, remaining sensitive to the constraints those who lack literacy skills may face will be critical. For more information about MoCA Basic, as well as the original MoCA and other versions of the test sensitive to a wide range of patient populations, visit our website.

References: 

1 Julayanont, P., Tangwongchai, S., Hemrungrojn, S., Tunvirachaisakul, C., Phanthumchinda, K., Hongsawat, J., …& Nasreddine, Z.S. (2015). The Montreal Cognitive Assessment—Basic: A Screening Tool for Mild Cognitive Impairment in Illiterate and Low-Educated Elderly Adults. Journal of the American Geriatrics Society. doi : 10.1111/jgs.13820

2 Muayqil, T. A., Alamri, N. K., Alqahtani, A. M., Julaidan, S. S., Alsuhaibani, R., Nafisah, I., … & Alanazy, M. H. (2021). Normative and Equated Data of the Original and Basic Versions of the Montreal Cognitive Assessment among Community Dwelling Saudi Arabians. Behavioural Neurology, 2021.

3 Zhang, Y. R., Ding, Y. L., Chen, K. L., Liu, Y., Wei, C., Zhai, T. T., … & Dong, W. L. (2019). The items in the Chinese version of the Montreal cognitive assessment basic discriminate among different severities of Alzheimer’s disease. BMC Neurology, 19(1), 1-7.

Though there have been more than half a billion reported cases of COVID-19 worldwide to date, we have much to learn about the underlying mechanisms of associated cognitive impairment.

Exploring COVID-19’s short- and long-term cognitive effects
The connection between severe illness and cognitive impairment has been well-established. Two-thirds of patients who spend time in the ICU develop cognitive effects from inflammation, changes in blood pressure, and medication side effects. However, most cases of post-viral cognitive impairment resolve naturally over the course of a few months.

However, COVID-19 illness is unique in that a subset of patients develop persistent cognitive deficits. One study found that 25% of COVID patients had difficulty with memory encoding, 23% struggled with memory recall, and 18% had trouble processing information seven months later.

Severe COVID-19 may cause cognitive impairment on par with aging 20 years or dropping 10 IQ points, according to another study, but even mild cases of COVID have resulted in what’s referred to as “long COVID,” characterized by brain fog, inattentiveness, memory loss, depression, anxiety, fatigue, disturbed sleep, and executive function impairment.

Potential cause of long COVID-19 cognitive impairment
Autopsy brain samples have suggested that a late and heightened immune response may trigger inflammation and microglia dysregulation in COVID patients, similar to what people experience on the chemotherapy drug methotrexate. Follow-up studies identified two heightened inflammatory markers in the cerebrospinal fluid of COVID patients with cognitive symptoms compared to those without. Researchers believe this type of cognitive impairment could potentially be reversible and remain hopeful that therapies in development for “chemobrain” may one day help patients with long COVID brain fog.

Can COVID-19 related brain changes become permanent?
It’s still too early to know the full implications of widespread cognitive impairment, but scans have shown structural changes to the brain, including widespread tissue damage and 0.2-2% more gray matter loss than what is observed through normal aging. Scientists said the long-term implications were unclear and it was unknown whether these effects could be reversed.

Further, the University of Missouri School of Medicine’s assessment of 10,403 patients with COVID-19 related pneumonia found a 1.5% higher rate of new onset dementia compared to patients with other types of pneumonia. All told, 3% of hospitalized patients with COVID-19 pneumonia—particularly those over 70—developed dementia affecting memory, self-regulation, and the ability to perform daily tasks.

Testing leads to helpful interventions
So far, clinicians have noted a number of interventions that prove helpful among patients with long COVID cognitive impairments, such as:

• 90 minute group therapy sessions focusing on self-management techniques to cope with fatigue, brain fog, sleep habits, activity pacing, and energy conservation
• Pursed lip breathing to increase oxygenation and decrease physical exertion
• Use of adaptive equipment like long-handle dressing equipment and reachers
• Graded exposure of endurance activities under direct supervision
• Use of a pulse oximeter to monitor oxygen saturation zone
• Multidisciplinary physical therapy, recreational therapy, and holistic wellness counseling

Screen patients for COVID-19 cognitive impairment with MoCA
MoCA can be used for the early detection of COVID-related neurological issues such as brain fog, mild cognitive impairment related to pneumonia, and increased risk of dementia.

Testing cognitive impairment with MoCA has been validated by multiple peer-reviewed studies:

• “Our meta-analysis revealed that people with COVID-19 had poorer general cognitive functioning compared to people without COVID-19 in the acute phase and 6 months after infection. MoCA was the most commonly used tool in the studies reported in this review.” Post-COVID, researchers found more than half of the 290 patients studied showed evidence of memory impairment, semantic verbal fluency, attention, and executive functions. This study highlighted the importance of systematic cognitive screening in COVID-19 patients after illness.1

• “We found lower total MoCA scores in survivors of COVID-19 compared with control patients. A subgroup of survivors… were significantly associated with improvement six months later.” A case-control study of 85 COVID patients found a mean MoCA score of 19.2 at discharge, which improved to a mean score of 26.1 six months later.2

• “Based on our results, MoCA was more sensitive in detecting cognitive functions impairments…. MoCA, which includes more testing of cognitive subdomains than MMSE, was thus designed to be more sensitive and may therefore represent a superior screening instrument to detect wide ranges of cognitive impairments.” Analysis of 87 COVID-19 patients showed significant cognitive impairments in memory, attention, abstraction, and space-time orientation. One month after discharge, 70% of patients showed signs of dysfunction and 25% needed specialized rehabilitation plans. One month after infection, many patients improved performance in language abilities, but memory dysfunctions commonly persisted. MoCA’s sensitivity was better suited to detect visuospatial and executive function impairments than the MMSE.3

• “Asymptomatic COVID-19 subjects secured lower scores in certain domains of the MoCA in comparison with the controls. The domains were visuoperception, naming and fluency. Also, older aged COVID-19 positive subjects scored lower in the MoCA when compared to the younger people.” This study of 93 asymptomatic COVID patients and 102 controls highlights the importance of testing to ensure that elderly patients received the daily living care and monitoring they need to navigate cognitive impairments. The study also found younger and asymptomatic COVID-19 subjects had cognitive deficits in certain subdomains, suggesting the need for detailed psychometric assessments to ensure they receive support to successfully return to work.4

• “Rural residents were willing to participate in telephone-based health-seeking activities during quarantine, and the Moca-Telephone was useful in identifying cognitive risk.” Telephone-based screening and education sessions took off during the COVID-19 pandemic. Of the 60 patients who completed the MoCA-T telehealth screening, 25% were found to be at risk for memory impairment. Of those at-risk patients, 12/15 followed up with their health care providers, showing promise for the use of telehealth tools to deliver better post-COVID care.s

The importance of cognitive impairment screening in the coming years cannot be overstated as we continue to assess how the novel coronavirus impacts our patients in the long term. We remain hopeful that early testing and therapeutic interventions can improve functioning and quality of life, despite these impairments. At the very least, understanding a patient’s baseline ensures we set patients up with appropriate care, monitoring, and referrals in the post-acute rehabilitation stage of recovery.

References:

1 Crivelli, L, Palmer, K, Calandri, I, et al. Changes in cognitive functioning after COVID-19: A systematic review and meta-analysis. Alzheimer’s Dement. 2022; 1 20. https://doi.org/10.1002/alz.12644

2 Nersesjan V, Fonsmark L, Christensen RHB, et al. Neuropsychiatric and Cognitive Outcomes in Patients 6 Months After COVID-19 Requiring Hospitalization Compared With Matched Control Patients Hospitalized for Non–COVID-19 Illness. JAMA Psychiatry. Published online March 23, 2022. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2790554

3 Pistarini C, Fiabane E, Houdayer E, Vassallo C, Manera MR, Alemanno F. Cognitive and Emotional Disturbances Due to COVID-19: An Exploratory Study in the Rehabilitation Setting. Front Neurol. 2021;12:643646. Published 2021 May 17. doi:10.3389/fneur.2021.643646 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165252/

4 Amalakanti, S., Arepalli, K.V.R. & Jillella, J.P. Cognitive assessment in asymptomatic COVID-19 subjects. VirusDis. 32, 146–149 (2021). https://link.springer.com/article/10.1007/s13337-021-00663-w

5 Wiese, L.A.K., Williams, I.C., Schoenberg, N.E., Galvin, J.E. and Lingler, J.H. (2021), Employing the Moca-T (telephone) as a means of cognitive screening in a rural, ethnically diverse population during Covid-19 restrictions. Alzheimer’s Dement., 17: e055624. https://alz-journals.onlinelibrary.wiley.com/doi/abs/10.1002/alz.055624

As healthcare professionals, we have all experienced profound changes to the way we deliver services following the sudden onset of the COVID-19 pandemic. Telemedicine rose up out of necessity during lockdowns—its use in April 2020 was 78 times higher than the February 2020 baseline, according to McKinsey. Two years later, this trend persists: telemedicine use is still 38 times higher than pre-COVID levels, prompting McKinsey’s assertion that $250 billion in healthcare services could potentially be virtualized.

Telemedicine is more than a trend born out of convenience. It can be a lifeline for patients—expanding access to previously unavailable care and providing a comfortable, immediate, affordable, and satisfying experience. It can also be a lifeline for healthcare providers—helping us keep a closer eye on patients, improve health outcomes, and do more, with fewer resources.

Telemedicine growth predicted to continue well beyond COVID crisis

Virtual healthcare is a win-win for everyone, according to Doximity’s second State of Telemedicine Report published in February 2022. Most clinicians surveyed (67%) said telemedicine helps “build or maintain trust with patients from marginalized communities,” and 55% of patients—up from 40% in 2020—believe telemedicine provides “comparable or better quality of care as in-person visits.” Over 73% of patients surveyed plan to continue receiving care through telemedicine in the coming years.

Through the pandemic, Doximity found the top uses for telemedicine covered everything from endocrinology, cardiology, immunology and neurology, to family medicine, geriatrics, pulmonology, and psychiatry.” More recently, clinicians are recognizing the benefits of telemedicine in autism care and occupational therapy.

With increased government support and reimbursement, telemedicine will only become more entrenched. For instance, U.S. legislators introduced a bipartisan bill in November that would permanently expand Medicare reimbursement for telehealth services provided by audiologists, occupational therapists, physical therapists, speech language pathologists, and potentially others. “Particularly in our rural communities, telehealth is no longer just an innovative option for accessing services, it has become a vital lifeline to care,” Senator Steve Daines (R-MT) explained in a statement.

A complex, but promising, path forward

Telemedicine has come a long way, but there’s still a long way to go. For instance, McKinsey has found there’s a gap in consumer interest (76%) and actual use of telemedicine (46%)—signifying a need to educate patients about telehealth offerings and healthcare providers whose services are offered virtually.

Further, the clinicians McKinsey surveyed remain wary of overreliance on technology, citing concerns about security, workflow integration, future reimbursement, and the effectiveness of telehealth compared to in-person visits.

MoCA via telemedicine provides results comparable to in-person testing

Fortunately, the telemedicine solutions clinicians need are sometimes simple—and already available.

MoCA offers telemedicine-adapted versions of the standard paper test, including:

• T-MoCA or MoCA Blind, the visually impaired test version (conducted by phone)
• MoCA 5 Minute, the abbreviated test version (conducted by phone)
• MoCA via Audiovisual Conference, the full-version test (conducted by video conference)

Updated test instructions enable clinicians to build trust with patients and deliver fast, reliable results.

Multiple peer-reviewed studies have validated the effectiveness of remote MoCA testing, including:

• “Videoconference-administered MoCA appears viable as an alternative to face-to-face- MoCA.” In 2020, researchers from Japan studied cognitive decline in 73 patients over age 60 to assess for cognitive decline. After comparing the results of MoCA teleconference and in-person follow-ups at two weeks and three months, they concluded videoconference tests were a viable alternative.¹
• “The agreement between remote and in-person administration of the visual component of the MoCA was excellent.” A randomized controlled trial validated the use of MoCA administered by videoconference for remote neurocognitive testing associated with Parkinson’s disease (PD) and obstructive sleep apnea (OSA). In-person follow-up at three months showed “fair to good” or “excellent” agreement with the teleconference baseline.²

• “The MoCA 5-minute protocol is a free, valid, and reliable cognitive screen for stroke and transient ischemic attack.” Researchers at The National Institute of Neurological Disorders and Stroke came to this conclusion after using the MoCA 5-minute protocol by phone to assess 104 patients with stroke or transient ischemic attack, including 53 with normal cognition. One month later, patients were retested using MoCA standard paper tests, which yielded a reliable 0.89 intraclass correlation coefficient.³
• “All participants completed every item in the MoCA when administered remotely… All patients expressed a positive experience with the rater and using the web-based video conferencing tool.” Research published in the Health Informatics Journal found that remote MoCA screenings were effectively deployed for patients with Parkinson’s and Huntington’s diseases. The reduced burden on caregivers and reduced time commuting or waiting in offices were cited as benefits of remote assessment, without sacrificing accuracy.⁴
• “Implementation of the T-MoCA in a telemedicine-based PAT setting is feasible.” Researchers at the Montefiore Medical Center in the Bronx used telephone MoCA assessments to screen for cognitive impairment as a risk factor for postoperative delirium. This postoperative complication—associated with increased hospitalization stays and mortality—affects up to 70% of patients over 60 years old. In the study’s cohort, most patients who consented to the test completed it, and more than half scored positively, which had implications for pre-operative planning and post-operative recovery.⁵
• “Researchers are actively developing normative data to support MoCA by videoconference.” For example, 230 participants, all 50 years and older, were recruited in Quebec, Canada for a recent study which provided normative data that was in line with existing published data for in-person MoCA assessments.⁶

Telemedicine is here to stay for many healthcare professionals. The use of telehealth allows clinicians the opportunity to evaluate neurologic function at the earliest possible time. With a few minor adjustments, clinicians can conduct routine MoCA screening tests in a new way that streamlines the efficiency of their offices, reduces risks during periods of outbreak, and provides a convenient option for patients with mobility issues.

References:

1 Iiboshi, K., Yoshida, K., Yamaoka, Y., Eguchi, Y., Sato, D., Kishimoto, M., … & Kishimoto, T. (2019). A Validation Study of the Remotely Administered Montreal Cognitive Assessment Tool in the Elderly Japanese Population. Telemedicine and e-Health.

2 Lajoie, A. C., Crane, J., Robinson, A. R., Lafontaine, A. L., Benedetti, A., Kimoff, R. J., & Kaminska, M. (2021). Feasibility of remote neurocognitive assessment: pandemic adaptations for a clinical trial, the Cognition and Obstructive Sleep Apnea in Parkinson’s Disease, Effect of Positive Airway Pressure Therapy (COPE-PAP) study. Trials, 22(1), 910. https://doi.org/10.1186/s13063-021-05879-1

3 Wong, Adrian et al. “Montreal Cognitive Assessment 5-minute protocol is a brief, valid, reliable, and feasible cognitive screen for telephone administration.” Stroke vol. 46,4 (2015): 1059-64. doi:10.1161/STROKEAHA.114.007253

4 Abdolahi, A., Bull, M. T., Darwin, K. C., Venkataraman, V., Grana, M. J., Dorsey, E. R., & Biglan, K. M. (2016). A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. Health informatics journal, 22(2), 304-311.

5 Nick C. Yu, Denzel Zhu, Kara L. Watts, Nitya Abraham, Curtis Choice, Implementation of the telephone montreal cognitive assessment in a telemedicine based pre-admission testing clinic during COVID-19, Perioperative Care and Operating Room Management, Volume 24, 2021, 100191, ISSN 2405-6030,
https://doi.org/10.1016/j.pcorm.2021.100191

⁶ Gagnon, C., Olmand, M., Dupuy, E.G. et al. Videoconference version of the Montreal Cognitive Assessment: normative data for Quebec-French people aged 50 years and older. Aging Clin Exp Res (2022). https://doi.org/10.1007/s40520-022-02092-1

Background

Epigenetic changes may contribute importantly to cognitive decline in late life including Alzheimer’s disease (AD) and vascular dementia (VaD). Bromodomain and extra-terminal (BET) proteins are epigenetic “readers” that may distort normal gene expression and contribute to chronic disorders.

Objective

To assess the effects of apabetalone, a small molecule BET protein inhibitor, on cognitive performance of patients 70 years or older participating in a randomized trial of patients at high risk for major cardiovascular events (MACE).

Methods

The Montreal Cognitive Assessment (MoCA) was performed on all patients 70 years or older at the time of randomization. 464 participants were randomized to apabetalone or placebo in the cognition sub-study. In a prespecified analysis, participants were assigned to one of three groups: MoCA score≥26 (normal performance), MoCA score 25–22 (mild cognitive impairment), and MoCA score≤21 (dementia). Exposure to apabetalone was equivalent in the treatment groups in each MoCA-defined group.

Results

Apabetalone was associated with an increased total MoCA score in participants with baseline MoCA score of≤21 (p = 0.02). There was no significant difference in change from baseline in the treatment groups with higher MoCA scores. In the cognition study, more patients randomized to apabetalone discontinued study drug for adverse effects (11.3% versus 7.9%).

Conclusion

In this randomized controlled study, apabetalone was associated with improved cognition as measured by MoCA scores in those with baseline scores of 21 or less. BET protein inhibitors warrant further investigation for late life cognitive disorders.
Citation

Cummings, Jeffrey et al. ‘Cognitive Effects of the BET Protein Inhibitor Apabetalone: A Prespecified Montreal Cognitive Assessment Analysis Nested in the BETonMACE Randomized Controlled Trial’. 1 Jan. 2021 : 1 – 13.

Abstract:
Parkinson disease (PD) is the second most common neurodegenerative disorder, affecting >1% of the population ≥65 years of age and with a prevalence set to double by 2030. In addition to the defining motor symptoms of PD, multiple non-motor symptoms occur; among them, cognitive impairment is common and can potentially occur at any disease stage. Cognitive decline is usually slow and insidious, but rapid in some cases. Recently, the focus has been on the early cognitive changes, where executive and visuospatial impairments are typical and can be accompanied by memory impairment, increasing the risk for early progression to dementia. Other risk factors for early progression to dementia include visual hallucinations, older age and biomarker changes such as cortical atrophy, as well as Alzheimer-type changes on functional imaging and in cerebrospinal fluid, and slowing and frequency variation on EEG. However, the mechanisms underlying cognitive decline in PD remain largely unclear. Cortical involvement of Lewy body and Alzheimer-type pathologies are key features, but multiple mechanisms are likely involved. Cholinesterase inhibition is the only high-level evidence-based treatment available, but other pharmacological and non-pharmacological strategies are being tested. Challenges include the identification of disease-modifying therapies as well as finding biomarkers to better predict cognitive decline and identify patients at high risk for early and rapid cognitive impairment.

Abstract:

This study investigated the effects of vortioxetine on cognitive function in adults with mild cognitive impairment (MCI). This single-arm, open-label, phase II study enrolled 111 adults with MCI without depressive symptoms to receive 5–10 mg/day vortioxetine for 6months. Main outcomes assessed: cognitive function [Montreal Cognitive Assessment (MoCA); Digit Symbol Substitution Test (DSST)], disease severity [Clinical Dementia Rating (CDR)], clinician-assessed improvement and safety. Mean MoCA score increased from 24.2 points (baseline) to 29.7 points (month6), placing most subjects within the cognitively normal range (≥26 points). Compared with baseline, MoCA and DSST scores were significantly improved at months 1, 3 and 6 (P<0.001 for all). Global CDR scores significantly improved from baseline to month6 (mean change −0.37 points; P<0.001), representing an improvement from very mild impairment (0.50 points) to cognitively normal status (0.13 points), mainly in CDR memory scores. At month 6, 89.6% of subjects had improved disease severity. Adverse events and adverse drug reactions were reported in 9.9% (n=11) and 2.7% (n=3) of subjects, respectively. Vortioxetine treatment was associated with significant improvement in cognitive function and a favorable safety profile in community-dwelling older adults with MCI. Given the lack of evidence for efficacious pharmacologic interventions for MCI, our results are encouraging and warrant further investigation

Title:
Hyposmia Is Associated with Reduced Cognitive Function in COVID-19: First Preliminary Results

Background:
Hyposmia is frequently reported as an initial symptom in coronavirus disease 2019 (COVID-19).

Objective:
As hyposmia accompanies cognitive impairment in several neurological disorders, we aimed to study whether hyposmia represents a clinical biomarker for both neurological involvement and cognitive impairment in mild COVID-19. We aimed to study whether olfactory dysfunction (OD) represents a clinical biomarker for both neurological involvement and cognitive impairment in mild COVID-19.

Methods:
Formal olfactory testing using the Sniffin’Sticks® Screening test, neuropsychological assessment using the Montreal Cognitive Assessment (MoCA), and detailed neurological examination were performed in 7 COVID-19 patients with mild disease course and no history of olfactory or cognitive impairment, and 7 controls matched for age, sex, and education. Controls were initially admitted to a dedicated COVID-19 screening ward but tested negative by real-time PCR.

Results:
The number of correctly identified odors was significantly lower in COVID-19 than in controls (6 ± 3, vs. 10 ± 1 p = 0.028, r = 0.58). Total MoCA score was significantly lower in COVID-19 patients than in controls (20 ± 5 vs. 26 ± 3, p = 0.042, r = 0.54). Cognitive performance indicated by MoCA was associated with number of correctly identified odors in COVID-19 patients and controls (COVID-19: p = 0.018, 95% CI = 9–19; controls: p = 0.18, r = 0.63, 95% CI = 13–18.5 r = 0.64).

Discussion/Conclusion:
OD is associated with cognitive impairment in controls and mild COVID 19.OD may represent a potentially useful clinical biomarker for subtle and even subclinical neurological involvement in severe acute respiratory distress syndrome coronavirus-2 infection.

Citation
Pirker-Kees A, Platho-Elwischger K, Hafner S, Redlich K, Baumgartner C. Hyposmia Is Associated with Reduced Cognitive Function in COVID-19: First Preliminary Results. Dement Geriatr Cogn Disord. 2021 Apr 14:1-6. doi: 10.1159/000515575. Epub ahead of print. PMID: 33853062.

Title:
Slow but evident recovery from neocortical dysfunction and cognitive impairment in a series of chronic COVID-19 patients

Background:
Cognitive impairment is a frequent complaint in coronavirus disease-19 (COVID-19) and can be related to cortical hypometabolism on 18F-FDG PET at the subacute stage. However, it is unclear if these changes are reversible.

Methods:
We prospectively assessed Montreal Cognitive Assessment (MoCA) and 18F-FDG PET scans in 8 COVID-19 patients at the subacute (as no longer infectious) and chronic stages (approximately six months after symptom onset). The expression of the previously established COVID-19-related covariance pattern was analyzed at both stages to examine the time course of post-COVID-19 cognitive impairment. For further validation, we also conducted a conventional group analysis.

Results:
Follow-up 18F-FDG PET revealed a significant reduction of initial frontoparietal and, to a lesser extent, temporal glucose hypometabolism that was accompanied by a significant improvement in cognition. The expression of the previously established COVID-19-related pattern was significantly lower at follow-up and correlated inversely with MoCA performance. However, both 18F-FDG PET and cognitive assessment suggest a residual impairment. Conclusions: Although a significant recovery of regional neuronal function and cognition can be clearly stated, residuals are still measurable in some patients six months after the manifestation of COVID-19. Given the current pandemic situation and tremendous uncertainty concerning the long-term effects of COVID-19, the present study provides novel insights of highest medical and socioeconomic relevance.

Citation:
Blazhenets G, Schröter N, Bormann T, Thurow J, Wagner D, Frings L, Weiller C, Meyer PT, Dressing A, Hosp JA. Slow but evident recovery from neocortical dysfunction and cognitive impairment in a series of chronic COVID-19 patients. J Nucl Med. 2021 Mar 31:jnumed.121.262128. doi: 10.2967/jnumed.121.262128. Epub ahead of print. PMID: 33789937.

Title:
Cannabis Use and Cognitive Impairment Among Male Adolescents A Case-control Study

Abstract:
Cannabis use by adolescents is a public health problem because it can cause cognitive impairment and educational deterioration. The objective of this study was to assess the prevalence and correlates of cognitive impairment among male adolescents with cannabis use in comparison with a control group. This is a case-control study that included 1682 adolescents who just finished their secondary school. A drug screen was made for all participants. Cognitive assessment using Montreal Cognitive Assessment (MoCA) scale was carried out for adolescents with positive urine screen for cannabis and a control group of adolescents with negative urine screen for drugs. The prevalence of cannabis use among adolescents was 2.14%. About one third of the cases started to use cannabis before the age of 15 years. Fifty-six percent used cannabis frequently (>4 times/wk). Adolescents with cannabis use were more likely to have cognitive impairment based on MoCA than controls (78% vs. 44%, P=0.004). Cases were more likely to have impairment in naming, abstraction, orientation, and total MoCA score than controls. Adolescents who started cannabis use early (below 15 y) had impairment in visuospatial/executive, attention, language, abstraction, delayed recall, and total MoCA score compared with those who started late (above 15 y). In addition, adolescents who use cannabis frequently had impairment in all cognitive domains except naming compared with those who used it occasionally. To conclude, the current study found that adolescents with cannabis use were more likely to have cognitive impairment than controls and this impairment was associated with age of onset and frequency of cannabis use.

Citation:
Bassiony, Medhat MBBCh, MSc, MD; Ammar, Haidy K. MBBCh, MSc; Khalil, Yomna MBBCh, MSc, MD Cannabis Use and Cognitive Impairment Among Male Adolescents, Addictive Disorders & Their Treatment: March 24, 2021 – Volume Publish Ahead of Print – Issue – doi: 10.1097/ADT.0000000000000257

Title:
Longitudinal changes in MoCA performances in patients with mild cognitive impairment and small vessel disease. Results from the VMCI-Tuscany Study

Objectives:
The Montreal Cognitive Assessment (MoCA) is a cognitive screening test largely employed in vascular cognitive impairment, but there are no data about MoCA longitudinal changes in patients with cerebral small vessel disease (SVD). We aimed to describe changes in MoCA performance in patients with mild cognitive impairment (MCI) and SVD during a 2-year follow-up, and to evaluate their association with transition to major neurocognitive disorder (NCD).

Materials and Methods:
Within the prospective observational VMCI-Tuscany Study, patients with MCI and SVD underwent a comprehensive clinical, neuropsychological, and functional evaluation at baseline, and after 1 and 2 years.

Results:
Among the 138 patients (mean age 74.4 ± 6.9 years; males: 57%) who completed the study follow-up, 44 (32%) received a major NCD diagnosis. Baseline MoCA scores (mean±SD) were lower in major NCD patients (20.5 ± 5) than in reverter/stable MCI (22.2 ± 4.3), and the difference approached the statistical threshold of significance (p=.051). The total cohort presented a decrease in MoCA score (mean±SD) of -1.3 ± 4.2 points (-2.6 ± 4.7 in major NCD patients, -0.7 ± 3.9 in reverter/stable MCI). A multivariate logistic model on the predictors of transition from MCI to major NCD, showed MoCA approaching the statistical significance (OR=1.09, 95% CI=1.00–1.19, p=.049).

Discussion:
In our sample of MCI patients with SVD, longitudinal changes in MoCA performances were consistent with an expected more pronounced deterioration in patients who received a diagnosis of major NCD. MoCA sensitivity to change and predictive utility need to be further explored in VCI studies based on larger samples and longer follow-up periods.

Title:
Cognitive decline among individuals with history of mild symptomatic SARS-CoV-2 infection: A longitudinal prospective study nested to a population cohort.

Background and purpose:
Neurological complications of SARS-CoV-2 infection are noticed among critically ill patients soon after disease onset. Information on delayed neurological sequelae of SARS-CoV-2 infection is nil. Following a longitudinal study design, the occurrence of cognitive decline among individuals with a history of mild symptomatic SARS-CoV-2 infection was assessed.

Methods:
Stroke- and seizure-free Atahualpa residents aged ≥40 years, who had pre-pandemic cognitive assessments as well as normal brain magnetic resonance imaging and electroencephalogram recordings, underwent repeated evaluations 6 months after a SARS-CoV-2 outbreak infection in Atahualpa. Patients requiring oxygen therapy, hospitalization, and those who had initial neurological manifestations were excluded. Cognitive decline was defined as a reduction in the Montreal Cognitive Assessment (MoCA) score between the post-pandemic and pre-pandemic assessments that was ≥4 points greater than the reduction observed between two pre-pandemic MoCAs. The relationship between SARS-CoV-2 infection and cognitive decline was assessed by fitting logistic mixed models for longitudinal data as well as exposure-effect models.

Results:
Of 93 included individuals (mean age 62.6 ± 11 years), 52 (56%) had a history of mild symptomatic SARS-CoV-2 infection. Post-pandemic MoCA decay was worse in seropositive individuals. Cognitive decline was recognized in 11/52 (21%) seropositive and 1/41 (2%) seronegative individuals. In multivariate analyses, the odds for developing cognitive decline were 18.1 times higher among SARS-CoV-2 seropositive individuals (95% confidence interval 1.75-188; p = 0.015). Exposure-effect models confirmed this association (β = 0.24; 95% confidence interval 0.07-0.41; p = 0.006).

Conclusions:
This study provides evidence of cognitive decline among individuals with mild symptomatic SARS-CoV-2 infection. The pathogenesis of this complication remains unknown.

Citation:
Del Brutto OH, Wu S, Mera RM, Costa AF, Recalde BY, Issa NP. Cognitive decline among individuals with history of mild symptomatic SARS-CoV-2 infection: A longitudinal prospective study nested to a population cohort. Eur J Neurol. 2021 Feb 11:10.1111/ene.14775. doi: 10.1111/ene.14775. Epub ahead of print. PMID: 33576150; PMCID: PMC8014083.

Title:
T‐MoCA: A valid phone screen for cognitive impairment in diverse community samples

Introduction:
There is an urgent need to validate telephone versions of widely used general cognitive measures, such as the Montreal Cognitive Assessment (T‐MoCA), for remote assessments.

Methods:
In the Einstein Aging Study, a diverse community cohort (n = 428; mean age = 78.1; 66% female; 54% non‐White), equivalence testing was used to examine concordance between the T‐MoCA and the corresponding in‐person MoCA assessment. Receiver operating characteristic analyses examined the diagnostic ability to discriminate between mild cognitive impairment and normal cognition. Conversion methods from T‐MoCA to the MoCA are presented.

Results:
Education, race/ethnicity, gender, age, self‐reported cognitive concerns, and telephone administration difficulties were associated with both modes of administration; however, when examining the difference between modalities, these factors were not significant. Sensitivity and specificity for the T‐MoCA (using Youden’s index optimal cut) were 72% and 59%, respectively.

Discussion:
The T‐MoCA demonstrated sufficient psychometric properties to be useful for screening of MCI, especially when clinic visits are not feasible.

Citation:
Mindy J. Katz Cuiling Wang Caroline O. Nester Carol A. Derby Molly E. Zimmerman Richard B. Lipton Martin J. Sliwinski Laura A. Rabin First published: 05 February 2021 https://doi.org/10.1002/dad2.12144

Title:
COVID-19 severity impacts on long-term neurological manifestation after hospitalisation

Background:
Preclinical and clinical investigations have argued for nervous system involvement in SARS-CoV-2 infection and for long term sequalae including neurological manifestations

Methods:
A sample of 208 previously hospitalized COVID-19 patients, 165 patients were re-assessed at 6 months according to a structured standardized clinical protocol. Premorbid comorbidities and clinical status, severity of COVID-19 disease, complications during and after hospitalization were recorded.

Results:
At 6-month follow-up after hospitalisation due to COVID-19 disease, patients displayed a wide array of neurological symptoms, being fatigue (34%), memory/attention (31%), and sleep disorders (30%) the most frequent. Subjects reporting neurological symptoms were affected by more severe respiratory SARS-CoV-2 infection parameters during hospitalisation. At neurological examination, 37.4% of patients exhibited neurological abnormalities, being cognitive deficits (17.5%), hyposmia (15.7%) and postural tremor (13.8%) the most common. Patients with cognitive deficits at follow-up were comparable for age, sex and pre-admission comorbidities but experienced worse respiratory SARS-CoV-2 infection disease and longer hospitalization.

Conclusions:
Long-term neurological manifestations after hospitalization due to COVID-19 infection affect one-third of survivors. Multiple neurological abnormalities including mild cognitive impairment are associated with the severity of respiratory SARS-CoV-2 infection.

Citation:
Andrea Pilotto, Viviana Cristillo, Stefano Cotti Piccinelli, Nicola Zoppi, Giulio Bonzi, Davide Sattin, Silvia Schiavolin, Alberto Raggi, Antonio Canale, Stefano Gipponi, Ilenia Libri, Martina Frigerio, Michela Bezzi, Matilde Leonardi, Alessandro Padovani
medRxiv 2020.12.27.20248903; doi: https://doi.org/10.1101/2020.12.27.20248903

Title:
Medium-term effects of SARS-CoV-2 infection on multiple vital organs, exercise capacity, cognition, quality of life and mental health, post-hospital discharge

Background:
The medium-term effects of Coronavirus disease (COVID-19) on organ health, exercise capacity, cognition, quality of life and mental health are poorly understood.

Methods:
Fifty-eight COVID-19 patients post-hospital discharge and 30 age, sex, body mass index comorbidity-matched controls were enrolled for multiorgan (brain, lungs, heart, liver and kidneys) magnetic resonance imaging (MRI), spirometry, six-minute walk test, cardiopulmonary exercise test (CPET), quality of life, cognitive and mental health assessments.

Findings:
At 2–3 months from disease-onset, 64% of patients experienced breathlessness and 55% reported fatigue. On MRI, abnormalities were seen in lungs (60%), heart (26%), liver (10%) and kidneys (29%). Patients exhibited changes in the thalamus, posterior thalamic radiations and sagittal stratum on brain MRI and demonstrated impaired cognitive performance, specifically in the executive and visuospatial domains. Exercise tolerance (maximal oxygen consumption and ventilatory efficiency on CPET) and six-minute walk distance were significantly reduced. The extent of extra-pulmonary MRI abnormalities and exercise intolerance correlated with serum markers of inflammation and acute illness severity. Patients had a higher burden of self-reported symptoms of depression and experienced significant impairment in all domains of quality of life compared to controls (p<0.0001 to 0.044).

Interpretation:
A significant proportion of patients discharged from hospital reported symptoms of breathlessness, fatigue, depression and had limited exercise capacity. Persistent lung and extra-pulmonary organ MRI findings are common in patients and linked to inflammation and severity of acute illness.

Citation:
Betty Raman, Mark Philip Cassar, Elizabeth M. Tunnicliffe, Nicola Filippini, Ludovica Griffanti, Fidel Alfaro-Almagro, et al.
Published: January 07, 2021 DOI: https://doi.org/10.1016/j.eclinm.2020.100683

Title:
Utility of a Screening Test (MoCa) to Predict Amyloid Physiopathology in Mild Cognitive Impairment

Introduction:
The MoCa (Montreal Cognitive Assessment) Screening test has become relevant in recent years in the screening of patients with Mild Cognitive Impairment (MCI). It is important to seek and study simple and reliable tools in clinical practices that correlate with biological markers that have been used to predict conversion from MCI to AD.

Objective:
To analyze the MOCA and its cognitive sub-scores and the relationship with Amyloid pathophysiology in Alzheimer’s Disease.

Methodology:
32 patients with MCI were studied, they were separated according positive (n: 20) and negative (n: 12) underlying amyloid pathology. The patients performed a extensive cognitive assessment that included MoCa Test.

Results:
MoCa Total Scores showed significantly different results between groups (p <0.001) as well as the Memory Score (MoCa MIS), the Executive (MoCa EIS), the Attentional Score (MoCa AIS)) (p < 0.001) and the Orientation Score (MoCa OIS)) (p < 0.05) with worse performance of patients with amyloid pathophysiology. Score of MoCa a cut-off point of < 24 was established, since the diagnostic sensitivity at this point was 83% and the specificity 70%.

Conclusions:
The MoCa is a useful tool to differentiate biomarker status in MCI. Future studies should study this tool in the prodromal phases of the disease.

Citation:
Adela Fendrych Mazancova, Evžen Růžička, Robert Jech, Ondrej Bezdicek, Test the Best: Classification Accuracies of Four Cognitive Rating Scales for Parkinson’s Disease Mild Cognitive Impairment, Archives of Clinical Neuropsychology, Volume 35, Issue 7, October 2020, Pages 1069–1077, https://doi.org/10.1093/arclin/acaa039

“It is important to note that no significant differences in global cognition evaluated by the MMSE were observed between prefrail and non-frail groups in the present study. However, cognitive differences between the groups were sensitively captured by using the MoCA. This finding suggests that there may be cognitive performance problems related to frailty that are not detectable by the global measurement of the MMSE alone. In this sense, efforts to detect and further understand frailty should include a consistent measurement of specific cognitive domains employing comprehensive neuropsychological testing.”

Title:
Test the Best: Classification Accuracies of Four Cognitive Rating Scales for Parkinson’s Disease Mild Cognitive Impairment.

Objective:
A progressive cognitive impairment is one of the frequent non-motor symptoms during Parkinson’s disease (PD) course. A short and valid screening tool is needed to detect an incipient cognitive deficit at the mild cognitive impairment stage in Parkinson’s disease (PD–MCI).

Method:
The present study aims to evaluate the classification accuracies of four cognitive screenings: Montreal Cognitive Assessment (MoCA), Mattis Dementia Rating Scale second edition (DRS–2), Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) in a cohort of PD patients (PD–MCI, n = 46; and Parkinson’s disease with normal cognition, PD-NC, n = 95) and Controls (n = 66). All subjects underwent a standard neuropsychological battery as recommended by the International Parkinson and Movement Disorder Society and underwent all four screening tools.

Results:
In the detection of PD-MCI versus PD-NC, the MoCA showed a sensitivity of 84% and a specificity of 66% with a screening cutoff score at ≤25 points. The MoCA’s AUC was 86% (95% CI 78.7–93.1). In the detection of PD-MCI versus Controls, the FAB displayed 84% sensitivity and 79% specificity with a cutoff ≤16 points, to screen. The FAB’s AUC was 87% (79.0–95.0).

Conclusions:
Our results show that the MoCA is the most discriminative tool for screening MCI in the PD population.

Citation:
Adela Fendrych Mazancova, Evžen Růžička, Robert Jech, Ondrej Bezdicek, Test the Best: Classification Accuracies of Four Cognitive Rating Scales for Parkinson’s Disease Mild Cognitive Impairment, Archives of Clinical Neuropsychology, Volume 35, Issue 7, October 2020, Pages 1069–1077, https://doi.org/10.1093/arclin/acaa039

Title:
Study names best-performing cognitive impairment screening test for patients on dialysis

Background:
Neurocognitive testing shows that cognitive impairment is common among patients receiving maintenance hemodialysis. Identification of a well performing screening test for cognitive impairment might allow for broader assessment in dialysis facilities and thus optimal delivery of education and medical management.

Methods:
From 2015 to 2018, in a cohort of 150 patients on hemodialysis, we performed a set of comprehensive neurocognitive tests that included the cognitive domains of memory, attention, and executive function to classify whether participants had normal cognitive function versus mild, moderate, or severe cognitive impairment. Using area-under-the-curve (AUC) analysis, we then examined the predictive ability of the Mini Mental State Examination, the Modified Mini Mental State Examination, the Montreal Cognitive Assessment, the Trail Making Test Part B, the Mini-Cog test, and the Digit Symbol Substitution Test, determining each test’s performance for identifying severe cognitive impairment.

Results:
Mean age was 64 years; 61% were men, 39% were black, and 94% had at least a high-school education. Of the 150 participants, 21% had normal cognitive function, 17% had mild cognitive impairment, 33% had moderate impairment, and 29% had severe impairment. The Montreal Cognitive Assessment had the highest overall predictive ability for severe cognitive impairment (AUC, 0.81); a score of ≤21 had a sensitivity of 86% and specificity of 55% for severe impairment, with a negative predictive value of 91%. The Trails B and Digit Symbol tests also performed reasonably well (AUCs, 0.73 and 0.78, respectively). The other tests had lower predictive performances.

Conclusions:
The Montreal Cognitive Assessment, a widely available and brief cognitive screening tool, showed high sensitivity and moderate specificity in detecting severe cognitive impairment in patients on maintenance hemodialysis.

Citation:
Drew DA, et al. J Am Soc Nephrol. 2020;
doi:10.1681/ASN.2019100988.

Title:
Prediction of cognitive progression in Parkinson’s disease using three cognitive screening measures

Introduction:
Cognitive impairment is a common complication of Parkinson’s disease (PD) and identifying risk factors for progression to Parkinson’s disease dementia (PDD) is important. However, little research has been done comparing the utility of commonly used cognitive screening tests in predicting cognitive progression in PD.

Methods:
We retrospectively reviewed data from patients with PD enrolled in the Pacific Udall Center who had baseline and longitudinal neuropsychological and global cognitive screening tests. The diagnostic accuracies of 3 common screening tests were compared: Montreal Cognitive Assessment (MoCA), Mattis Dementia Rating Scale (DRS-2), and Mini Mental Status Examination (MMSE). Cognitive diagnoses of PD with mild cognitive impairment (PD-MCI) and PDD were based on full neuropsychological testing and established Movement Disorder Society criteria. Logistic regression and Cox proportional hazards regression models were used to examine predictors of cognitive decline.

Results:
Four hundred seventy patients for whom scores on all 3 screening tests were available from the same assessment were included in a cross-sectional analysis. The MoCA demonstrated the best overall diagnostic accuracy for PD-MCI (AUC = 0.79, sensitivity = 76.4%) and for PDD (AUC = 0.89, sensitivity = 81.0%) compared to the DRS-2 and MMSE.

A longitudinal analysis was performed on the subset of patients (316/470; 67.2%) who were nondemented at baseline and had undergone two or more assessments. After controlling for covariates, the MoCA was the only test associated with progression to PDD (OR = 1.27 95% CI 1.1–1.5, p = 0.001) and faster time to dementia (HR = 1.3, 95% CI 1.1–1.4, p < 0.0001).

Conclusions:
This study provides additional support for the use of the MoCA as a primary screening tool for cognitive impairment in PD and is the first to show that the MoCA is a predictor of conversion to PDD.

Citation:
Hojoong M. Kim, Carter Nazor, Cyrus P. Zabetian, Joseph F. Quinn, Kathryn A. Chung, Amie L. Hiller, Shu-Ching Hu, James B. Leverenz, Thomas J. Montine, Karen L. Edwards, Brenna Cholerton, Prediction of cognitive progression in Parkinson’s disease using three cognitive screening measures, Clinical Parkinsonism & Related Disorders, Volume 1, 2019, Pages 91-97, ISSN 2590-1125,
https://doi.org/10.1016/j.prdoa.2019.08.006.

Title:
Cognitive screening instruments to identify vascular cognitive impairment: A systematic review

Introduction:
Vascular cognitive impairment (VCI) is common and important to detect as controlling risk factors, particularly hypertension, may slow onset and progression. There is no consensus as to which cognitive screening instrument (CSI) is most suitable for VCI. We systematically reviewed the psychometric properties of brief CSIs for vascular mild cognitive impairment (VMCI) and vascular dementia (VaD).

Methods:
Literature searches were performed using scholarly databases from inception until 31 May 2018. Studies were eligible if participants were aged 18 or older, interviewed face‐to‐face, and standard diagnostic criteria for VCI were applied, excluding those specifically identifying post‐stroke dementia. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

Results:
Fifteen studies were identified including eight types of CSIs (27 subtests/variants) and 4575 participants (1015 with VCI), mean age range: 51.6 to 75.5 years. Most studies compared more than one instrument. Five papers examined clock‐drawing; four, the Montreal Cognitive Assessment (MoCA) and Mini‐Mental State Examination (MMSE); and three used the Brief Memory and Executive Test (BMET). The MoCA (AUC > 0.90) and MMSE (AUC: 0.86‐0.99) had excellent accuracy in differentiating VaD from controls; the MoCA had good internal consistency (Cronbach’s α: .83‐.88). The MoCA (AUC: 0.87‐0.93) and BMET (AUC: 0.94) had the greatest accuracy in separating VMCI from controls. Most studies had low to moderate risk of bias in all domains of the QUIPS. Data were heterogeneous, precluding a meta‐analysis.

Conclusions:
Although few studies were available and further research is required, data suggests that the MoCA is accurate and reliable for differentiating VaD and VMCI from controls.

Citation:
Mohd Zaquan Arif Abd Ghafar, Hayatul Nawwar Miptah, Rónán O’Caoimh
First published: 02 May 2019
https://doi.org/10.1002/gps.5136

Title:
Brief cognitive screening instruments for early detection of Alzheimer’s disease: a systematic review

Objectives:
The objective of this systematic review was (1) to give an overview of the available short screening instruments for the early detection of Alzheimer’s disease (AD) and (2) to review the psychometric properties of these instruments.

Methods:
First, a systematic search of titles and abstracts of PubMed and Web of Science was conducted between February and July 2015 and updated in April 2016 and May 2018. Only papers written in English or Dutch were considered. All full-text papers about cognitive screening instruments for the early detection of AD were included, resulting in the identification of 38 pencil and paper tests and 12 computer tests. In a second step, the psychometric quality of these instruments was evaluated. Therefore, the same databases were searched again to identify papers that described the psychometric properties of the instruments meanwhile applying diagnostic criteria for the diagnostic groups included.

Results:
Out of 1454 papers, 96 clearly discussed the psychometric properties of the instruments. Eighty-nine papers discussed pencil and paper tests of which 80 were validated in a memory clinic setting. Based on the number of studies (31 articles) and the sensitivity (84%) and specificity (74%) values, the Montreal Cognitive Assessment (MoCA) seems to be a promising (pencil and paper) screening test for memory clinic testing as well as for population screening. Regarding computer tests, validation studies were only available for 7 out of 12 tests.

Conclusions:
A large number of screening tests for AD are available. However, most tests are only validated in a memory clinic setting and description of the psychometric properties of the instruments is limited. Especially, computer tests require further research. The MoCA is a promising instrument, but the specificity to detect early AD is rather low.

Citation:
De Roeck et al. Alzheimer’s Research & Therapy (2019) 11:21 https://doi.org/10.1186/s13195-019-0474-3

Title:
Early MoCA predicts long-term cognitive and functional outcome and mortality after stroke

Objective:
To examine whether the Montreal Cognitive Assessment (MoCA) administered within 7 days after stroke predicts long-term cognitive impairment, functional impairment, and mortality.

Methods:
MoCA was administered to 274 patients from 2 prospective hospital-based cohort studies in Germany (n = 125) and France (n = 149). Cognitive and functional outcomes were assessed at 6, 12, and 36 months after stroke by comprehensive neuropsychological testing, the Clinical Dementia Rating (CDR) scale, the modified Rankin Scale (mRS), and Instrumental Activities of Daily Living (IADL) and analyzed with generalized estimating equations. All-cause mortality was investigated by Cox proportional hazard models. Analyses were adjusted for demographic variables, education, vascular risk factors, premorbid cognitive status, and NIH Stroke Scale scores. The additive predictive value of MoCA was examined with receiver operating characteristic curves.

Results:
In pooled analyses, a baseline MoCA score 2 (OR 5.03, 95% CI 2.20–11.51) and by IADL score 2, 0.88 vs 0.84, p = 0.047).

Conclusion:
Early cognitive testing by MoCA predicts long-term cognitive outcome, functional outcome, and mortality after stroke. Our results support routine use of the MoCA in stroke patients.

Citation:
Vera Zietemann, Marios K. Georgakis, Thibaut Dondaine, Claudia Müller, Anne-Marie Mendyk, Anna Kopczak, Hilde Hénon, Stéphanie Bombois, Frank Arne Wollenweber, Régis Bordet, Martin Dichgans
Neurology Nov 2018, 91 (20) e1838-e1850; DOI: 10.1212/WNL.0000000000006506

Title:
Comparing the Electronic and Standard Versions of the Montreal Cognitive Assessment in an Outpatient Memory Disorders Clinic: A Validation Study

The Montreal Cognitive Assessment (MoCA) has become widely used as a brief test of cognitive function in patients with neurological disease. More convenient application of the MoCA might increase its use and enhance its utility. An electronic version of the MoCA has recently been developed. To establish validity of the electronic version (eMoCA), discrepancy scores, concordance correlation coefficients (CCC), and root mean squared differences (RMSD) were calculated between each administration method in a sample of 43 new adult patients presenting with primary memory complaints. The CCC was 0.84 and the RMSD was 2.27, with 76% of the sample having a difference score within 2 points. Overall, this study establishes adequate convergent validity between the MoCA and eMoCA among an adult population presenting with memory concerns.

Citation:
Jody-Lynn Berg, January Durant, Gabriel C. Léger, Jeffrey L. Cummings, Ziad Nasreddine, and Justin B. Millera.
J Alzheimers Dis. 2018; 62(1): 93–97.
Published online 2018 Feb 6. doi: 10.3233/JAD-170896

Title:
Performance of Screening Tests for Cognitive Impairment in Systemic Lupus Erythematosus

Objective:
There is a need for a cognitive function screening test that can be administered to patients with systemic lupus erythematosus (SLE) in clinic. The objectives of this study were to determine (1) prevalence of cognitive impairment (CI) in SLE by the Montreal Cognitive Assessment (MoCA), Mini Mental State Examination (MMSE), in relation to the Hopkins Verbal Learning Test–Revised (HVLT-R), and Perceived Deficits Questionnaire 5-Item (PDQ-5); and (2) associated factors with CI.

Methods:
Consecutive patients followed at a single center were recruited. HVLT-R, MoCA, and MMSE were administered. Sensitivity/specificity, positive (PPV)/negative (NPV) predictive values, and positive likelihood ratio (LR+) of MoCA/MMSE were determined (compared to HVLT-R). A test on intellectual ability and questionnaires on anxiety, depression, and perceived cognitive deficits were completed. Regression analyses determined associations with CI.

Results:
Of 98 patients, 48% had CI using MoCA and 31% using HVLT-R. Sensitivity was higher for MoCA (73%) compared to MMSE (27%), though MMSE was more specific (90%) than MoCA (63%). PPV and LR+ were similar in MoCA and MMSE (PPV: 47%, 53%; LR+: 2.0, 2.6, respectively), but NPV was higher in MoCA (84%) than MMSE (74%). PDQ-5 predicted objective CI (HVLT-R: sensitivity 100%, specificity 89%). Although CI was associated with depression in univariate analyses, it did not hold in the multivariate analysis, while longer SLE disease duration and more years of education remained significant.

Conclusion:
CI is highly prevalent and MoCA may be a useful tool to screen for CI in SLE. Patients with more years of education were less likely to have CI.

Citation:
Stephanie G. Nantes, Jiandong Su, Ashneet Dhaliwal, Kenneth Colosimo and Zahi Touma
The Journal of Rheumatology September 2017, jrheum.161125; DOI: https://doi.org/10.3899/jrheum.161125

Title:
Cognitive Tests to Detect Dementia A Systematic Review and Meta-analysis

Importance:
Dementia is a global public health problem. The Mini-Mental State Examination (MMSE) is a proprietary instrument for detecting dementia, but many other tests are also available.

Objective:
To evaluate the diagnostic performance of all cognitive tests for the detection of dementia.

Data Sources:
Literature searches were performed on the list of dementia screening tests in MEDLINE, EMBASE, and PsychoINFO from the earliest available dates stated in the individual databases until September 1, 2014. Because Google Scholar searches literature with a combined ranking algorithm on citation counts and keywords in each article, our literature search was extended to Google Scholar with individual test names and dementia screening as a supplementary search.

Study Selection:
Studies were eligible if participants were interviewed face to face with respective screening tests, and findings were compared with criterion standard diagnostic criteria for dementia. Bivariate random-effects models were used, and the area under the summary receiver-operating characteristic curve was used to present the overall performance.

Main Outcomes and Measures:
Sensitivity, specificity, and positive and negative likelihood ratios were the main outcomes.

Results:
Eleven screening tests were identified among 149 studies with more than 49 000 participants. Most studies used the MMSE (n = 102) and included 10 263 patients with dementia. The combined sensitivity and specificity for detection of dementia were 0.81 (95% CI, 0.78-0.84) and 0.89 (95% CI, 0.87-0.91), respectively. Among the other 10 tests, the Mini-Cog test and Addenbrooke’s Cognitive Examination–Revised (ACE-R) had the best diagnostic performances, which were comparable to that of the MMSE (Mini-Cog, 0.91 sensitivity and 0.86 specificity; ACE-R, 0.92 sensitivity and 0.89 specificity). Subgroup analysis revealed that only the Montreal Cognitive Assessment had comparable performance to the MMSE on detection of mild cognitive impairment with 0.89 sensitivity and 0.75 specificity.
Conclusions and Relevance
Besides the MMSE, there are many other tests with comparable diagnostic performance for detecting dementia. The Mini-Cog test and the ACE-R are the best alternative screening tests for dementia, and the Montreal Cognitive Assessment is the best alternative for mild cognitive impairment.

Citation:
Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(9):1450–1458. doi:10.1001/jamainternmed.2015.2152

Title:
Validation of the Montreal Cognitive Assessment Versus Mini-Mental State Examination Against Hypertension and Hypertensive Arteriopathy After Transient Ischemic Attack or Minor Stroke

Background and Purpose:
Lack of reduced cognitive impairment with blood pressure (BP) lowering in trials may reflect use of the Mini-Mental State Examination (MMSE), which is insensitive to mild cognitive impairment after cerebrovascular events compared with the Montreal Cognitive Assessment. We determined relationships between impairment on MMSE versus Montreal Cognitive Assessment (MoCA) with the major physiological determinant of vascular cognitive impairment: hypertension and hypertensive arteriopathy.

Methods:
Cognitive impairment in consecutive patients 6 months after transient ischemic attack or minor stroke was defined as significant, mild, or none (MMSE<23, 23–26, ≥27; MoCA<20, 20–24, ≥25) and related to 20 premorbid systolic BP readings, home BP measurement (3 measurements, 3×daily for 1 month), and hypertensive arteriopathy (creatinine, stroke versus transient ischemic attack, leukoaraiosis) by ordinal regression.

Results:
Of 463 patients, 45% versus 28% had at least mild cognitive impairment on the MoCA versus MMSE (P<0.001). Hypertensive arteriopathy was more strongly associated with cognitive impairment on the MoCA than MMSE (creatinine: odds ratio=3.99; 95% confidence interval, 2.06–7.73 versus 2.16, 1.08–4.33; event: 1.53, 1.06–2.19 versus 1.23, 0.81–1.85; leukoaraiosis: 2.09, 1.42–3.06 versus 1.34, 0.87–2.07). Premorbid and home BP measurement systolic BP were more strongly associated with impairment on vascular subdomains of the MoCA than MMSE (odds ratio/10 mm Hg: visuospatial 1.29 versus 1.05; attention 1.18 versus 1.07; language 1.22 versus 0.91; naming 1.07 versus 0.86).

Conclusions:
The stronger relationship between impairment on the MoCA with hypertensive arteriopathy, independent of age, indicates a greater sensitivity for vascular-origin cognitive impairment. Use of MoCA should improve sensitivity for cognitive impairment and treatment effects in future studies.

Citation:
Validation of the Montreal Cognitive Assessment Versus Mini-Mental State Examination Against Hypertension and Hypertensive Arteriopathy After Transient Ischemic Attack or Minor Stroke
Alastair J.S. Webb, DPhil, Sarah T. Pendlebury, DPhil, Linxin Li, DPhil, Michela Simoni, DPhil, Nicola Lovett, MRCP, Ziyah Mehta, DPhil, and Peter M. Rothwell, FMedSci

Title:
The MoCA: well-suited screen for cognitive impairment in Parkinson disease

Objective:
To establish the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) when screening externally validated cognition in Parkinson disease (PD), by comparison with a PD-focused test (Scales for Outcomes in Parkinson disease-Cognition [SCOPA-COG]) and the standardized Mini-Mental State Examination (S-MMSE) as benchmarks.

Methods:
A convenience sample of 114 patients with idiopathic PD and 47 healthy controls was examined in a movement disorders center. The 21 patients with dementia (PD-D) were diagnosed using Movement Disorders Society criteria, externally validated by detailed independent functional and neuropsychological tests. The 21 patients with mild cognitive impairment (PD-MCI) scored 1.5 SD or more below normative data in at least 2 measures in 1 of 4 cognitive domains. Other patients had normal cognition (PD-N).

Results:
Primary outcomes using receiver operating characteristic (ROC) curve analyses showed that all 3 mental status tests produced excellent discrimination of PD-D from patients without dementia (area under the curve [AUC], 87%-91%) and PD-MCI from PD-N patients (AUC, 78%-90%), but the MoCA was generally better suited across both assessments. The optimal MoCA screening cutoffs were <21/30 for PD-D (sensitivity 81%; specificity 95%; negative predictive value [NPV] 92%) and <26/30 for PD-MCI (sensitivity 90%; specificity 75%; NPV 95%). Further support that the MoCA is at least equivalent to the SCOPA-COG, and superior to the S-MMSE, came from the simultaneous classification of the 3 PD patient groups (volumes under a 3-dimensional ROC surface, chance = 17%: MoCA 79%, confidence interval [CI] 70%-89%; SCOPA-COG 74%, CI 62%-86%; MMSE-Sevens item 56%, CI 44%-68%; MMSE-World item 62%, CI 50%-73%).

Conclusions:
The MoCA is a suitably accurate, brief test when screening all levels of cognition in PD. MoCA is well-suited screen for cognitive impairment in Parkinson disease.

Citation:
Dalrymple-Alford JC, MacAskill MR, Nakas CT, Livingston L, Graham C, Crucian GP, Melzer TR, Kirwan J, Keenan R, Wells S, Porter RJ, Watts R, Anderson TJ. The MoCA: well-suited screen for cognitive impairment in Parkinson disease. Neurology. 2010 Nov 9;75(19):1717-25. doi: 10.1212/WNL.0b013e3181fc29c9. PMID: 21060094.

Title:
National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards

Background and purpose:
One in 3 individuals will experience a stroke, dementia or both. Moreover, twice as many individuals will have cognitive impairment short of dementia as either stroke or dementia. The commonly used stroke scales do not measure cognition, while dementia criteria focus on the late stages of cognitive impairment, and are heavily biased toward the diagnosis of Alzheimer disease. No commonly agreed standards exist for identifying and describing individuals with cognitive impairment, particularly in the early stages, and especially with cognitive impairment related to vascular factors, or vascular cognitive impairment.

Methods:
The National Institute for Neurological Disorders and Stroke (NINDS) and the Canadian Stroke Network (CSN) convened researchers in clinical diagnosis, epidemiology, neuropsychology, brain imaging, neuropathology, experimental models, biomarkers, genetics, and clinical trials to recommend minimum, common, clinical and research standards for the description and study of vascular cognitive impairment.

Results:
The results of these discussions are reported herein.

Conclusions:
The development of common standards represents a first step in a process of use, validation and refinement. Using the same standards will help identify individuals in the early stages of cognitive impairment, will make studies comparable, and by integrating knowledge, will accelerate the pace of progress.

Citation:
Hachinski V, Iadecola C, Petersen RC, Breteler MM, Nyenhuis DL, Black SE, Powers WJ, DeCarli C, Merino JG, Kalaria RN, Vinters HV, Holtzman DM, Rosenberg GA, Wallin A, Dichgans M, Marler JR, Leblanc GG. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke. 2006 Sep;37(9):2220-41. doi: 10.1161/01.STR.0000237236.88823.47. Epub 2006 Aug 17. Erratum in: Stroke. 2007 Mar;38(3):1118. Wallin, Anders [added]. PMID: 16917086.