Today, I link to and excerpt from Diagnostic Precision in the Detection of Mild Cognitive Impairment: A Comparison of Two Approaches [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Am J Geriatr Psychiatry. 2022 Jan;30(1):54-64. doi: 10.1016/j.jagp.2021.04.004. Epub 2021 Apr 14.
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Abstract
Objective: This study compared diagnostic rates and clinical predictors of discrepancies between diagnoses conferred via: 1) a comprehensive neuropsychological evaluation and National Institute on Aging-Alzheimer’s Association (NIA-AA) criteria versus 2) a cognitive screener and Diagnostic Statistical Manual of Mental Disorders (DSM-5) criteria.
Design: Cross-sectional examination of baseline data from the Prevention of Alzheimer’s dementia (AD) using Cognitive remediation and transcranial direct current stimulation in Mild Cognitive Impairment (MCI) and Depression (PACt-MD; ClinicalTrials.gov Identifier: NCT02386670) trial.
Setting: Five geriatric psychiatry and memory clinics located at academic hospitals affiliated with the Department of Psychiatry, University of Toronto.
Participants: Older adults (N = 431) with a history of major depressive disorder (MDD) in remission, MCI, or both.
Measurements: Main outcome was a comparison of NIA-AA diagnostic rates of MCI or dementia versus DSM-5 rates of mild or major neurocognitive disorder. Secondary analyses examined demographic, race, gender, premorbid intellectual ability, psychosocial, health-related, and genetic predictors of discrepancy between DSM-5 and NIA-AA diagnoses.
Results: There were 103 (23.8%) discrepant cases, with most (91; 88.3%) of these discrepant cases reflecting more impairment with the detailed neuropsychological testing and NIA-AA criteria. Discrepancies were more likely in individuals with a history of MDD or who had at least one ApoE4 allele.
Conclusion: The NIA-AA criteria, in conjunction with comprehensive neuropsychological testing, identified a greater prevalence of cognitive impairment than DSM-5 criteria, in conjunction with the Montreal Cognitive Assessment. Detailed neuropsychological evaluations are recommended for older adults who have a history of MDD or a genetic vulnerability to dementia.
Keywords: Alzheimer’s; cognition; dementia; mild cognitive impairment.
Copyright © 2021. Published by Elsevier Inc.
Highlights.
The primary question addressed by this study: This study compared diagnostic rates and clinical predictors of discrepancies between diagnoses conferred via: 1) a comprehensive neuropsychological evaluation and National Institute on Aging−Alzheimer’s Association (NIA-AA) criteria versus 2) a cognitive screener* and Diagnostic Statistical Manual of Mental Disorders (DSM-5) criteria.
*The cognitive screener used was the Montreal Cognitive Assessment (MOCA)
The main finding of this study: There were 103 (23.8%) discrepant cases, with most (91; 88.3%) of these discrepant cases reflecting more impairment with the detailed neuropsychological testing and NIA-AA criteria. Discrepancies were more likely in individuals with a history of major depressive disorder (MDD) or who had at least one ApoE4 allele.
The meaning of the finding: The NIA-AA criteria, in conjunction with comprehensive neuropsychological testing, identified a greater prevalence of cognitive impairment than DSM-5 criteria, in conjunction with the Montreal Cognitive Assessment. Detailed neuropsychological evaluations are recommended for older adults who have a history of MDD or a genetic vulnerability to dementia.
INTRODUCTION
Accurate classification of early cognitive decline is needed to inform intervention efforts to prevent or delay progression to dementia. Multiple diagnostic classification systems for detecting cognitive decline have been developed, contributing to variability in the operationalization of early cognitive decline. The term Mild Cognitive Impairment (MCI) has commonly been used to describe the intermediary stage between normal cognitive aging and dementia. Current research criteria for a clinical diagnosis of MCI are based on the 2011 National Institute of Aging and Alzheimer’s Association (NIA-AA) workgroup guidelines.1 Criteria include 1) evidence of a concern regarding change in cognition; 2) objective evidence of mild impairment in one or more cognitive domains (1−1.5 standard deviations [SD] below normative expectations); 3) relative preservation of functional independence; and 4) no dementia. The 2013 fifth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-5) contains criteria for the diagnosis of mild neurocognitive disorder (NCD) that are similar to, but distinct from, the NIA-AA MCI criteria. A diagnosis of mild NCD requires evidence of: 1) concern regarding change in cognition; 2) objective cognitive impairment using a broader window of cognitive performance relative to NIA-AA criteria (1−2 SD below normative expectations); and 3) relative preservation of functional independence.
Research Neuropsychological Assessment
All participants completed a comprehensive neuropsychological test battery consisting of standardized clinical measures that have established reliability and are sensitive to cognitive changes in both MCI and MDD. The battery assessed the following five DSM-5 cognitive domains: Attention or speed of processing (WAIS-III Digit Symbol Substitution Test;14 Trail Making Test Part A;15 computerized Paced Auditory Serial Addition Test,16 Continuous Performance Test, N-Back Task, executive functioning (clock drawing; Trail Making Test Part B;15,17 Stroop Neuropsychological Screening Test)18, verbal memory (California Verbal Learning Test, Second Edition)18, visual memory (Brief Visual Memory Test, Revised)19, language (Boston Naming Test;20 Category Fluency; Letter Fluency21), and visuospatial processing (Judgment of Line Orientation,22 Brief Visual Memory Test, Revised, copy condition).19 Premorbid verbal intellectual ability was estimated by the Wide Range Achievement Test − 4th edition Reading Subtest (WRAT-Reading).23 Concern regarding cognitive decline was established quantitatively using participant and informant reports of the everyday cognition questionnaire (E-COG), based on established cut-off scores.24 Independence in everyday activities was evaluated quantitatively using select tasks from the Performance Assessment of Self-care Skills (PASS) (shopping, bill paying, checkbook balancing, mailing, medication management) that have been shown to discriminate between normal cognition and MCI.25
Other Demographic, Psychosocial, and Health-Related Assessments
We recorded age, education, race, ethnicity, occupational history, and languages spoken. Psychiatric diagnoses were characterized with the Structured Clinical Interview for DSM-IV (SCID).26 Physical illness burden was measured with the Cumulative Illness Rating Scale-Geriatric (CIRS-G).27 ApoE genotype was determined using a combination of variants rs7412 and rs429358 that were genotyped at CAMH using standard TaqMan protocols (Life Technologies, Burlington, ON) in accordance with manufacturer’s directions. ApoE status was unknown at the time of the consensus conference.
