Rónán O'Caoimh

Comparison of the quick mild cognitive impairment (Qmci) screen and the SMMSE in screening for mild cognitive impairment.

Introduction: differentiating mild cognitive impairment (MCI) from normal cognition (NC) is difficult. The AB Cognitive Screen (ABCS) 135, sensitive in differentiating MCI from dementia, was modified to improve sensitivity and specificity, producing the quick mild cognitive impairment (Qmci) screen. Objective: this study compared the sensitivity and specificity of the Qmci with the Standardised MMSE and ABCS 135, to differentiate NC, MCI and dementia. Methods: weightings and subtests of the ABCS 135 were changed and a new section ‘logical memory’ added, creating the Qmci. From four memory clinics in Ontario, Canada, 335 subjects (154 with MCI, 181 with dementia) were recruited and underwent comprehensive assessment. Caregivers, attending with the subjects, without cognitive symptoms, were recruited as controls (n = 630). Results: the Qmci was more sensitive than the SMMSE and ABCS 135, in differentiating MCI from NC, with an area under the curve (AUC) of 0.86 compared with 0.67 and 0.83, respectively, and in differentiating MCI from mild dementia, AUC of 0.92 versus 0.91 and 0.91. The ability of the Qmci to identify MCI was better for those over 75 years. Conclusion: the Qmci is more sensitive than the SMMSE in differentiating MCI and NC, making it a useful test, for MCI in clinical practice, especially for older adults.

Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia

Objectives There is growing evidence that antihypertensive agents, particularly centrally acting ACE inhibitors (CACE-Is), which cross the blood–brain barrier, are associated with a reduced rate of cognitive decline. Given this, we compared the rates of cognitive decline in clinic patients with dementia receiving CACE-Is (CACE-I) with those not currently treated with CACE-Is (NoCACE-I), and with those who started CACE-Is, during their first 6 months of treatment (NewCACE-I). Design Observational case–control study. Setting 2 university hospital memory clinics. Participants 817 patients diagnosed with Alzheimers disease, vascular or mixed dementia. Of these, 361 with valid cognitive scores were included for analysis, 85 CACE-I and 276 NoCACE-I. Measurements Patients were included if the baseline and end-point (standardised at 6 months apart) Standardised Mini-Mental State Examination (SMMSE) or Quick Mild Cognitive Impairment (Qmci) scores were available. Patients with comorbid depression or other dementia subtypes were excluded. The average 6-month rates of change in scores were compared between CACE-I, NoCACE-I and NewCACE-I patients. Results When the rate of decline was compared between groups, there was a significant difference in the median, 6-month rate of decline in Qmci scores between CACE-I (1.8 points) and NoCACE-I (2.1 points) patients (p=0.049), with similar, non-significant changes in SMMSE. Median SMMSE scores improved by 1.2 points in the first 6 months of CACE treatment (NewCACE-I), compared to a 0.8 point decline for the CACE-I (p=0.003) group and a 1 point decline for the NoCACE-I (p=0.001) group over the same period. Multivariate analysis, controlling for baseline characteristics, showed significant differences in the rates of decline, in SMMSE, between the three groups, p=0.002. Conclusions Cognitive scores may improve in the first 6 months after CACE-I treatment and use of CACE-Is is associated with a reduced rate of cognitive decline in patients with dementia.

Effects of centrally acting angiotensin converting enzyme inhibitors on functional decline in patients with Alzheimer's disease.

BACKGROUND Centrally acting angiotensin converting enzyme inhibitors (CACE-Is) are associated with reduced rates of cognitive decline in patients with dementia. CACE-Is may also improve exercise tolerance in functionally impaired older adults with normal cognition, suggesting that CACE-Is may positively influence activities of daily living (ADL) in dementia. OBJECTIVE To compare rates of decline in patients with mild to moderate Alzheimers disease (AD) receiving CACE-Is to those not currently treated with CACE-Is (NoCACE-I), included in the Doxycycline and Rifampicin for Alzheimers Disease study (n = 406). METHODS Patients were included if baseline and end-point (twelve months apart) scores were available for measures including the Standardized Alzheimers Disease Assessment Scale - Cognitive Subscale; Quick Mild Cognitive Impairment screen; Clinical Dementia Rating Scale (CDR-SB), and Lawton-Brody ADL Scale. RESULTS There was a significant, 25% difference (median one-point) in the 12-month rate of decline in ADL scores in patients taking CACE-Is (n = 91), compared to the NoCACE-I group (n = 274), p = 0.024. This remained significant after adjusting for age, gender, education, and blood pressure, p = 0.034. When individual CACE-Is were compared to the NoCACE-I group, a significant reduction in the rate of decline in ADLs (median one versus four points), were only observed for perindopril, p = 0.01. The CDR-SB was also reduced (median one-point) for the perindopril compared to the NoCACE-I group, p = 0.04. CONCLUSION This observational study suggests that CACE-Is, and potentially perindopril in particular, are associated with a reduced rate of functional decline in patients with AD, without an association with mood or behavior. This suggests that CACE-Is may slow disease progression in AD.

Which part of the Quick mild cognitive impairment screen (Qmci) discriminates between normal cognition, mild cognitive impairment and dementia?

Introduction: the Qmci is a sensitive and specific test to differentiate between normal cognition (NC), mild cognitive impairment (MCI) and dementia. We compared the sensitivity and specificity of the subtests of the Qmci to determine which best discriminated NC, MCI and dementia. Objective: the objective was to determine the contribution each subtest of the Qmci makes, to its sensitivity and specificity in differentiating MCI from NC and dementia, to refine and shorten the instrument. Methods: existing data from our previous study of 965 subjects, testing the Qmci, was analysed to compare the sensitivity and specificity of the Qmci subtests. Results: all the subtests of the Qmci differentiated MCI from NC. Logical memory (LM) performed the best (area under the receiver operating curve of 0.80), registration the worst, (0.56). LM and verbal fluency had the largest median differences (expressed as percentage of total score) between MCI and NC, 20 and 25%, respectively. Other subtests did not have clinically useful differences. LM was best at differentiating MCI from NC, irrespective of age or educational status. Conclusion: the Qmci incorporates several important cognitive domains making it useful across the spectrum of cognitive impairment. LM is the best performing subtest for differentiating MCI from NC.

The Quick Mild Cognitive Impairment screen correlated with the Standardized Alzheimer's Disease Assessment Scale–cognitive section in clinical trials

OBJECTIVES The Alzheimers Disease Assessment Scale-cognitive section and its standardized version (SADAS-cog) are the current standard for assessing cognitive outcomes in clinical trials of dementia. This study compares a shorter cognitive instrument, the Quick Mild Cognitive Impairment (Qmci) screen, with the SADAS-cog as outcome measures in clinical trials. STUDY DESIGN AND SETTING The SADAS-cog, Qmci, Clinical Dementia Rating (CDR) scale, and the Lawton-Brady activities of daily living (ADL) scale were assessed at multiple time points, over 1 year in a multicenter randomized clinical trial of 406 patients with mild to moderate Alzheimers dementia. Correlations were estimated using regression at each time point, all time points, and mean values across time. Responsiveness was assessed using the standardized response mean (SRM). RESULTS Regression for pooled time points showed strong and significant correlation between the SADAS-cog and Qmci (r = -0.75, P < 0.001). Correlations remained strong for mean values across time and at each time point. The SADAS-cog and Qmci also correlated with CDR and ADL scores. There was no difference in SRMs between the SADAS-cog and Qmci [t(357) = -0.32, P = 0.75]. CONCLUSION The Qmci correlated strongly with the SADAS-cog and both were equally responsive to deterioration. We suggest that clinicians and investigators can substitute the shorter Qmci for the SADAS-cog.

Renin Angiotensin aldosterone system inhibition in controlling dementia-related cognitive decline.

With the rising prevalence of cognitive impairment worldwide, clinicians are facing important challenges managing dementia, particularly Alzheimers disease, the most prevalent dementia subtype. Given that current treatments mainly offer symptomatic improvement, without altering disease progression, the challenge now is to identify and integrate new therapeutic strategies. Hypertension is increasingly recognized as a modifiable risk factor for mild cognitive impairment (MCI), the precursor of dementia. The renin angiotensin aldosterone system (RAAS) is central to blood pressure regulation and medications targeting RAAS inhibition are associated with reduced rates of both cognitive and functional decline in those with MCI and dementia. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers are widely prescribed anti-hypertensives acting on the RAAS, and there is growing evidence that they act centrally, possibly exerting their effects independent of their blood pressure lowering properties. The relationship is complex however, and given the risks associated with hypotension particularly in older adults, treatment with these agents may not benefit all. Additionally, current evidence is limited to preclinical and observational studies such that there is now a pressing need to confirm preliminary studies with properly conducted randomized control trials. Here, we review some of the salient and complex aspects of these observations to date.

The Community Assessment of Risk Instrument: Investigation of Inter-Rater Reliability of an Instrument Measuring Risk of Adverse Outcomes.

BACKGROUND Frailty is increasingly common in community dwelling older adults and increases their risk of adverse outcomes. Risk assessment is implicit in the Aged Care Assessment Teams process, but few studies have considered the factors that influence the assessors decision making or explored the factors that may contribute to their interpretation of risk. OBJECTIVE to examine the inter-rater reliability of the Community Assessment of Risk Instrument (CARI), which is a new risk assessment instrument. DESIGN A cohort study was used. SETTING AND PARTICIPANTS A sample of 50 community dwelling older adults underwent comprehensive geriatric assessment by two raters: a geriatrician and a registered nurse. Procedure and measurements: Each participant was scored for risk by the two raters using the CARI. This instrument ranks risk of three adverse outcomes, namely i) institutionalisation, ii) hospitalisation and iii) death within the next year from a score of 1, which is minimal risk to 5, which is extreme risk. Inter-rater reliability was assessed with Gamma, Spearman correlation and Kappa statistics. Internal consistency was assessed with Cronbachs alpha. RESULTS There were 30 female (mean age 82.23 years) and 20 male (mean age 81.75 years) participants. Items within domains showed good-excellent agreement. The gamma statistic was >0.77 on 6/7 Mental State items, 14/15 items in the Activities of Daily Living domain. In the Medical domain, 6/9 items had Gamma scores >0.80. The global domain scores correlated well, 0.88, 0.72 and 0.87. Caregiver network scores were 0.71, 0.73 and 0.51 for the three domains. Inter-rater reliability scores for global risk scales were 0.86 (institutionalisation) and 0.78 (death). The gamma statistic for hospitalisation was 0.29, indicative of lower inter-rater reliability. Cronbachs alpha was 0.86 and 0.83 for the Activities of Daily Living domain, 0.51 and 0.42 for the Mental state domain and 0.23 and 0.10 for the Medical state domain. CONCLUSIONS Overall, the instrument shows good inter-rater reliability. Poor correlations on some items relate to poor communication of clinical data and variable interpretation based on professional background. Lack of internal consistency in the medical condition domain confirms the discrete nature of these variables.

Technology Use and Frequency and Self‐Rated Skills: A Survey of Community‐Dwelling Older Adults

Many older adults are using technology regularly, but the vast majority still rate their technology skills as poor or average,reflecting their low usage of less-familiar items such as tablet computers. Despite moves toward increasing the use of ICT in the care, rehabilitation, and monitoring of older adults, baseline use of such devices is low. Further study is required to investigate how peoples attitudes toward and experience with ICT influence its utility in clinical practice

Comparison of the Quick Mild Cognitive Impairment (Qmci) screen to the Montreal Cognitive Assessment (MoCA) in an Australian geriatrics clinic

The Montreal Cognitive Assessment (MoCA) accurately differentiates mild cognitive impairment (MCI) from mild dementia and normal controls (NC). While the MoCA is validated in multiple clinical settings, few studies compare it with similar tests also designed to detect MCI. We sought to investigate how the shorter Quick Mild Cognitive Impairment (Qmci) screen compares with the MoCA.

Long-term Results of Combined LASIK and Monocular Small-Aperture Corneal Inlay Implantation.

PURPOSE To evaluate the long-term effectiveness and safety of combined LASIK and small-aperture intracorneal inlay implantation (KAMRA; AcuFocus, Irvine, CA) for the surgical compensation of presbyopia and refractive errors. METHODS Retrospective chart review of all ametropic, presbyopic patients who underwent combined LASIK and KAMRA inlay implantation at a single clinic. Demographic data and preoperative uncorrected and corrected monocular and binocular near and distance visual acuity (UNVA, UDVA, and CDVA) with manifest refractive spherical equivalent (MRSE) were collected and analyzed. All perioperative adverse events were recorded. RESULTS In total, 132 patients were available (median age: 56 years; interquartile range (IQR) ± 5; range: 44 to 68 years). Median preoperative MRSE was +1.37± 1.20 diopters (D). The majority (113; 85%) were hypermetropic. Preoperative median UNVA improved from N24 (J13) ±6 to N6 (J5) ±1 by day 1 postoperatively, remaining stable throughout follow-up. At last follow-up, 97% of patients achieved UNVA of N5 (J3) or better. Median UDVA (implanted eye) improved from 20/40 (0.50 ± 0.41 on the decimal chart) preoperatively to 20/25 (0.80 ± 0.13) at month 12. Binocular UDVA was 20/20 in 88%, with CDVA unchanged for 84% at 12 months. No patient lost more than one line of CDVA. MRSE was also stable, albeit +0.25 D off-target refraction (-0.75 D). Two inlays were explanted due to suboptimal adaptation/corneal haze. CONCLUSIONS The results of this follow-up study show that combined insertion of a small-aperture corneal inlay with LASIK in presbyopic patients improves near vision with a slight compromise in distance vision in the implanted eye. Overall, it appears to be a safe, effective procedure for the treatment of presbyopia. [J Refract Surg. 2016;32(6):379-384.].