The Brain Health Assessment for Detecting and Diagnosing Neurocognitive Disorders. J Am Geriatr Soc. 2018 Jan;66(1):150-156. ⢠Fountoulakis K, Iacovides A, ...
A two-tiered cost-efficient computerized cognitive screening protocol. Stelios Zygouris, MSc1,2,3, Katherine Possin, PhD4, Magda Tsolaki, MD, PhD2,5 1. Senior Atlantic Fellow at GBHI, UCSF 2. Medical School, Aristotle University of Thessaloniki, Greece 3. Network Aging Research, University of Heidelberg, Germany 4. University of California San Francisco Memory and Aging Center, USA 5. Greek Association of Alzheimer’s Disease and Related Disorders
Background
Progress and expected outcomes
The rapid aging of the global population is placing an increasing burden upon societies and healthcare services worldwide. The need for early detection and intervention and the increasing number of older adults that must be screened and monitored call for effective screening, assessment and follow-up strategies based on brief, reliable and scientifically robust instruments.
The project has received institutional review board (IRB) ethics approval and is currently progressing ahead of schedule. Staff training has been completed and 20 participants have already been examined with the full study protocol. At the same time 25 caregivers of patients with cognitive disorders have been examined with the A -IADLQ-SV.
Information and communication technology (ICT) has been used extensively to diagnose and support patients with cognitive disorders. ICT-based tools allow for easier and more consistent administration as well as automated scoring and reporting therefore there is considerable interest in their implementation in brain health assessment and monitoring.
Expected outcomes – Next steps
Scope of the project The aim of this project is the validation of new ICT-based tools that can be used to detect and assess the severity of early cognitive impairment. The goal is to promote savings of costs and time in cognitive assessment and enable more older adults to examine their brain health regularly.
The ICT-based tools that will be validated are: • Freely available in order to allow for implementation even in areas with limited resources
Successful validation of all three instruments being tested will lead to the creation of a suite of tools covering a wide range of assessment from self-screening to subsequent assessment of cognition and functional issues thus enabling better care planning while minimizing costs. To ensure the wider dissemination of project results and the integration of the newly validated tools in healthcare the project team is undertaking the following steps: • A collaboration with GAADRD and CERTH/ITI for the wider distribution of the VST. The main goal is the wider distribution of this self-screening instrument through collaborations with healthcare institutions/ companies and state authorities. The focus is on creating a viable distribution model with no costs for the end user. • A collaboration with the 1 st University Neurology Clinic of Aristotle University of Thessaloniki for testing the BHA and the A-IADL-Q-SV in a “real world” hospital environment. The main goal is collecting feedback from healthcare professionals, patients and caregivers concerning the acceptability of these new instruments and the steps that must be undertaken for their integration in everyday clinical practice.
• Compatible with existing ICT equipment and not reliant on proprietary hardware • Administered by non-specialists or self-administered where appropriate • Easy to use in primary care but also useful for longitudinal assessment or monitoring
Instruments to be tested The Pilot Project is centered around the validation of two screening tests. Additionally a computerized functional assessment questionnaire will be validated in a separate study conducted in parallel with the Pilot Project.
The Virtual Supermarket Test (VST) The Virtual Supermarket Test (VST) leverages the positive attitude of older adults towards self -administered serious games to increase their willingness to be screened for cognitive decline. Created in collaboration with the Center for Research and Technology Hellas/ Information Technologies Institute (CERTH/ITI), it is an ecologically valid test, based on a common everyday activity, which comprises a fully self-administered serious game routine with embedded instructions and training sessions. The user has to navigate inside a virtual supermarket using specific waypoints, buy the products indicated in a shopping list and pay the correct amount at the cashier desk. The current VST version features an interactive training session followed by three test sessions. It includes new metrics and a refined protocol which allow for more detailed assessment through the use of trajectory analysis and measurement of practice effects. A CE class 1 medical device approval for the VST is pending. Previous versions of the VST have achieved classification accuracy of over 85% in differentiating between MCI patients and healthy controls .
Virtual Supermarket Test (VST)
Brain Health Assessment BHA
The latest VST version features interactive instructions allowing the user to learn how to operate the exercise before proceeding to the test administrations
The BHA tasks can be administered through the userfriendly and secure TabCAT computerized testing platform
Amsterdam IADL Questionnaire Short Version (A-IADL-Q-SV)
The Pilot Project team
The Brain Health Assessment (BHA) The BHA is a 10-minute tablet-based cognitive assessment battery designed by the UCSF Memory and Aging Center (MAC) and administered through the TabCAT software platform. TabCAT is a secure and friendly platform that is utilized on several international clinical and research sites. The BHA includes tests of memory, executive function, language, and visuospatial skills, and an informant survey, and features automated scoring and guidance for medical follow-up. It has been validated with support from a Global Brain Health Institute (GBHI) project and has shown excellent sensitivity and specificity in detecting mild cognitive impairment (MCI) and dementia. It has been designed as a multilingual test battery and preliminary data support the feasibility of its alternate language versions .
The Amsterdam Instrumental Activities of Daily Living Questionnaire Short Version (A-IADL-QSV) The A-IADL-Q-SV is the short version of the only currently available computerized questionnaire designed to assess impairments in instrumental activities of daily living (IADL) in MCI and dementia. Created by Vrije Universiteit Amsterdam Medical Center (VUmc) it is completed by a caregiver who acts as an informant, rating the patient’s functional issues. It has been demonstrated to be both a reliable and valid instrument for the evaluation of dementia with good diagnostic accuracy and the ability to track change over time. The A-IADL-Q-SV consists of 30 items and can be administered in the span of 10-15 minutes. It has been found that the A-IADL-Q-SV maintains the psychometric qualities of the original (70 item) version of the questionnaire.
Pilot Project study outline The VST, and the BHA will be validated on a sample of 50 healthy older adults and 50 MCI patients recruited from the two day centers of the Greek Association of Alzheimer’s Disease and Related Disorders (GAADRD) in Thessaloniki, Greece. Persons aged between 60 and 75 years old with at least 9 years of formal education and basic smartphone/ tablet familiarity will be included in the study sample. The VST, BHA and Montreal Cognitive Assessment (MoCA) will be administered to the participants. Assessment of participants will be conducted by the personnel of the GAADRD and it will include a comprehensive neuropsychological test battery, neurological examination and informant interview. The neuropsychological battery that will be used includes the following scales: Mini Mental State Examination (MMSE), Ray Auditory Verbal Learning Test (RAVLT), a Greek version of the “FAS” verbal fluency test, Rey-Osterrieth Complex Figure Test (ROCFT), Rivermead Behavioural Memory Test (RBMT), Test of Everyday Attention (TEA) items 1, 4 & 6, Trail Making Test part B, Functional Rating Scale for Symptoms of Dementia (FRSSD), Functional Cognitive Assessment Scale (FUCAS), Clinical Dementia Rating (CDR), Beck Anxiety Inventory (BAI) and Geriatric Depression Scale (GDS). Final diagnosis will be conferred by a neurologist based on this data and consultation with the neuropsychologist administering the battery. The VST and the BHA will be validated against the established instruments included in the GAADRD neuropsychological test battery and their diagnostic accuracy will be calculated (using the patient’s diagnoses as a gold standard reference) and compared to the diagnostic accuracy of the MoCA in the same sample. Furthermore a simulated two-tiered assessment protocol will also be assessed. The protocol will utilize both the VST and the BHA; participants who are characterized as having possible cognitive impairment by the VST will be further examined with the BHA to validate the diagnosis.
Amsterdam IADL Questionnaire Short Version study outline 80-100 caregivers of patients with cognitive disorders ranging from MCI to various forms of dementia will be recruited for that study. They will be administered the A-IADL-Q-SV and the Center for Epidemiological Studies Depression (CES-D) scale. Only caregivers who can provide reliable information about patients being monitored regularly at the two day centers of the Greek Association of Alzheimer’s Disease and Related Disorders (GAADRD) in Thessaloniki, Greece will be included in the study. Those patients will have been examined with the GAADRD test battery. Subsequent analysis will establish the diagnostic accuracy of A-IADL-Q-SV for the detection of dementia and possible correlations with the CES-D and established instruments included in the GAADRD test battery including functional scales and scales of general cognition. The aim is to assess whether A-IADL-Q-SV is affected by caregiver depression and if it correlates with established measures of patients’ cognition and functioning.
The A-IADL-Q-SV is web administered through any device with an internet connection allowing for its use in various settings
The pilot project team is based at the Saint John day center of the Greek Association of Alzheimer’s Disease and Related Disorders in Thessaloniki, Greece
References • Zygouris S, Giakoumis D, Votis K, Doumpoulakis S, Ntovas K, Segkouli S, Karagiannidis C, Tzovaras D, Tsolaki M. Can a virtual reality cognitive training application fulfill a dual role? Using the virtual supermarket cognitive training application as a screening tool for mild cognitive impairment. J Alzheimers Dis. 2015;44(4):1333 -47. • Zygouris S, Ntovas K, Giakoumis D, Votis K, Doumpoulakis S, Segkouli S, Karagiannidis C, Tzovaras D, Tsolaki M. A Preliminary Study on the Feasibility of Using a Virtual Reality Cognitive Training Application for Remote Detection of Mild Cognitive Impairment. J Alzheimers Dis. 2017;56(2):619-627. • Zygouris S, Tsolaki M (2015) New technologies and neuropsychological evaluation of older adults: Issues and challenges. In Handbook of Research on Innovations in the Diagnosis and Treatment of Dementia, Bamidis PD, Tarnanas I, Hadjileontiadis L, Tsolaki M, eds. IGI Global, USA, pp. 1-17. • Possin KL, Moskowitz T, Erlhoff SJ, Rogers KM, Johnson ET, Steele NZR, Higgins JJ, Stiver J, Alioto AG, Farias ST, Miller BL, Rankin KP. The Brain Health Assessment for Detecting and Diagnosing Neurocognitive Disorders. J Am Geriatr Soc. 2018 Jan;66(1):150-156. • Fountoulakis K, Iacovides A, Kleanthous S, Samolis S, Kaprinis SG, Sitzoglou K, St Kaprinis G, Bech P. Reliability, validity and psychometric properties of the Greek translation of the Center for Epidemiological Studies-Depression (CES-D) Scale. BMC Psychiatry. 2001;1:3. Epub 2001 Jun 20. • Jutten RJ, Peeters CFW, Leijdesdorff SMJ, Visser PJ, Maier AB, Terwee CB, Scheltens P, Sikkes SAM. Detecting functional decline from normal aging to dementia: Development and validation of a short version of the Amsterdam IADL Questionnaire. Alzheimers Dement (Amst). 2017 Mar 31;8:26-35. • Sikkes SA, Pijnenburg YA, Knol DL, de Lange-de Klerk ES, Scheltens P, Uitdehaag BM. Assessment of instrumental activities of daily living in dementia: diagnostic value of the Amsterdam Instrumental Activities of Daily Living Questionnaire. J Geriatr Psychiatry Neurol. 2013 Dec;26(4):244-50.
