Addenbrooke's Cognitive Examination

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Addenbrooke's Cognitive Examination
Purposetest cognitive impairment

The Addenbrooke's Cognitive Examination (ACE) and its subsequent versions (Addenbrooke's Cognitive Examination-Revised, ACE-R [1] and Addenbrooke's Cognitive Examination III, ACE-III) are neuropsychological tests used to identify cognitive impairment in conditions such as dementia.

Contents

History

The Addenbrooke's Cognitive Examination [2] was originally developed as a theoretically motivated extension of the Mini-Mental State Examination (MMSE) [3] which attempted to address the neuropsychological omissions and improve the screening performance of the latter. [4]

The ACE encompassed tests of five cognitive domains: attention/orientation, memory, language, verbal fluency, and visuospatial skills. [2] It is scored out of 100, with a higher score denoting better cognitive function. At the recommended cut-off scores of 88 and 83, the ACE was reported to have good sensitivity and specificity for identifying different forms of dementia and other impairments of memory and judgement (0.93 and 0.71; 0.82 and 0.96, respectively). [5] The ACE also incorporated the MMSE, such that this score (out of 30) might also be generated. [2] [4]

The ACE-R [1] was a development of the earlier ACE which also incorporated the MMSE, but had clearly defined subdomain scores.

The ACE-III [6] was developed to improve the performance of certain parts of the test and also to avoid a potential copyright violation by replacing the elements shared with the MMSE. [7]

Addenbrooke's Cognitive Examination-III

The current version of the test is the Addenbrooke's Cognitive Examination-III (ACE-III). This consists of 19 activities which test five cognitive domains: attention, memory, fluency, language and visuospatial processing.

Attention

Attention is tested by asking the patient for the date including the season and the current location; repeating back three simple words; and serial subtraction. An example is something like "subtract seven from 100 and then continue subtracting seven away from each new number."

Memory

Memory is tested by asking the patient to recall the three words previously repeated; memorising and recalling a fictional name and address; and recalling widely known historical facts. The memory section is split into five sections scattered throughout the tests. [8]

Fluency

Fluency is tested by asking the patient to say as many words as they can think of starting with a specified letter within one minute; and naming as many animals as they can think of in one minute. An example of this would be the tester asking the test taker to list every word they can think of that starts with the letter C.

Language

Language is tested by asking the patient to complete a set of sequenced physical commands using a pencil and piece of paper such as "place the paper on top of the pencil"; to write two grammatically-complete sentences; to repeat several polysyllabic words and two short proverbs; to name the objects shown in 12 line drawings, and answer contextual questions about some of the objects; and to read aloud five commonly-mispronounced words. Language involves ascribing meaning to words and statements so this section consists of simple directions that may involve movements, such as the example of placing the paper on top of the pencil, to see how well they apply meaning. Because language is valuable and important to functioning in society, this section is the longest consisting of seven separate parts. [9]

Visuospatial

Visuospatial skills are used almost daily to remember directions, addresses, and layout of familiar places. [10] Visuospatial abilities are tested by asking the patient to copy two diagrams; to draw a clock face with the hands set at a specified time; to count sets of dots; and to recognize four letters which are partially obscured.

Scoring

The results of each activity are scored to give a total score out of 100 (18 points for attention, 26 for memory, 14 for fluency, 26 for language, 16 for visuospatial processing). The score needs to be interpreted in the context of the patient's overall history and examination, but a score of 88 and above is considered normal; below 83 is abnormal; and between 83 and 87 is inconclusive.

Validity

In the initial validation study [6] the cohort examined (n = 86; AD 28, FTD 33, controls 25) found the ACE-III to be acceptable and relatively quick to administer (15 min). The ACE-III and ACE-R were highly correlated (r = 0.99), and at the previously recommended cut-off scores (88 and 82) the ACE-III was both highly sensitive and specific (at 88/100: 1.00 and 0.96 respectively; at 82/100: 0.93 and 1.00 respectively). At the cut-off of 88, Elamin and colleagues [11] found the ACE-III distinguished early-onset dementia from healthy controls with high sensitivity (0.915) and specificity (0.964), and also from subjective memory impairment with high sensitivity (0.915) and specificity (0.867). The ACE-III has been validated against standard neuropsychological tests and has been shown to be a valid cognitive screening tool for dementia syndromes. [6] [12]

Based on the results of a 2019 Cochrane meta-analysis of available studies the ACE-III should only be used as an adjunct to a full clinical assessment and not alone for the screening of dementia or mild cognitive impairment in patients presenting with or at risk for cognitive decline. [13]

Translations and localised versions

The ACE-III questionnaire has been translated into 19 languages. The English-language version has been localised for users in Australia, India, the United States, the United Kingdom, and New Zealand. [14]

Mini-ACE

In 2014, a shorter version of the ACE-III, the Mini-ACE (M-ACE), was developed and validated. [15] It comprises tests of attention, memory (7-item name and address), letter fluency, clock drawing, and memory recall, and takes under five minutes to administer. The M-ACE is scored out of 30, with a higher score indicating better cognitive function, and has two recommended cut-off scores (25 and 21). The higher cut-off score has both high specificity and sensitivity and is at least five times more likely to have come from a dementia patient than without. A score of 21 or less is almost certainly diagnostic of a dementia syndrome regardless of the clinical setting. [15] It has been found to be superior to the MMSE in diagnostic utility. [16] [17]

Based on the results of a 2019 Cochrane meta-analysis of available studies the Mini-ACE should only be used as an adjunct to a full clinical assessment and not alone for the screening of dementia or mild cognitive impairment in patients presenting with or at risk for cognitive decline. [13]

Related Research Articles

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is the general name for a decline in cognitive abilities that impacts a person's ability to do everyday activities. This typically involves problems with memory, thinking, and behavior. Aside from memory impairment and a disruption in thought patterns, the most common symptoms include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, caregivers, and on social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than what is caused by normal aging.

Vascular dementia (VaD) is dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease. Restricted blood supply (ischemia) leads to cell and tissue death in the affected region, known as an infarct. The three types of vascular dementia are subcortical vascular dementia, multi-infarct dementia, and stroke related dementia. Subcortical vascular dementia is brought about by damage to the small blood vessels in the brain. Multi-infarct dementia is brought about by a series of mini-strokes where many regions have been affected. The third type is stroke related where more serious damage may result. Such damage leads to varying levels of cognitive decline. When caused by mini-strokes the decline in cognition is gradual. When due to a stroke the cognitive decline can be traced back to the event.

<span class="mw-page-title-main">Neuropsychological test</span> Assess neurological function associated with certain behaviors and brain damage

Neuropsychological tests are specifically designed tasks that are used to measure a psychological function known to be linked to a particular brain structure or pathway. Tests are used for research into brain function and in a clinical setting for the diagnosis of deficits. They usually involve the systematic administration of clearly defined procedures in a formal environment. Neuropsychological tests are typically administered to a single person working with an examiner in a quiet office environment, free from distractions. As such, it can be argued that neuropsychological tests at times offer an estimate of a person's peak level of cognitive performance. Neuropsychological tests are a core component of the process of conducting neuropsychological assessment, along with personal, interpersonal and contextual factors.

<span class="mw-page-title-main">Cognitive disorder</span> Mental health condition affecting cognitive functions

Cognitive disorders (CDs), also known as neurocognitive disorders (NCDs), are a category of mental health disorders that primarily affect cognitive abilities including learning, memory, perception, and problem-solving. Neurocognitive disorders include delirium, mild neurocognitive disorders, and major neurocognitive disorder. They are defined by deficits in cognitive ability that are acquired, typically represent decline, and may have an underlying brain pathology. The DSM-5 defines six key domains of cognitive function: executive function, learning and memory, perceptual-motor function, language, complex attention, and social cognition.

The mini–mental state examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. It is commonly used in medicine and allied health to screen for dementia. It is also used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time; thus making it an effective way to document an individual's response to treatment. The MMSE's purpose has been not, on its own, to provide a diagnosis for any particular nosological entity.

The Abbreviated Mental Test score (AMTS) is a 10-point test for rapidly assessing elderly patients for the possibility of dementia. It was first used in 1972, and is now sometimes also used to assess for mental confusion and other cognitive impairments.

HIV-associated neurocognitive disorders (HAND) are neurological disorders associated with HIV infection and AIDS. It is a syndrome of progressive deterioration of memory, cognition, behavior, and motor function in HIV-infected individuals during the late stages of the disease, when immunodeficiency is severe. HAND may include neurological disorders of various severity. HIV-associated neurocognitive disorders are associated with a metabolic encephalopathy induced by HIV infection and fueled by immune activation of macrophages and microglia. These cells are actively infected with HIV and secrete neurotoxins of both host and viral origin. The essential features of HIV-associated dementia (HAD) are disabling cognitive impairment accompanied by motor dysfunction, speech problems and behavioral change. Cognitive impairment is characterised by mental slowness, trouble with memory and poor concentration. Motor symptoms include a loss of fine motor control leading to clumsiness, poor balance and tremors. Behavioral changes may include apathy, lethargy and diminished emotional responses and spontaneity. Histopathologically, it is identified by the infiltration of monocytes and macrophages into the central nervous system (CNS), gliosis, pallor of myelin sheaths, abnormalities of dendritic processes and neuronal loss.

NEPSY is a series of neuropsychological tests authored by Marit Korkman, Ursula Kirk and Sally Kemp, that is used in various combinations to assess neuropsychological development in children ages 3–16 years in six functional domains.

Cognitive impairment is an inclusive term to describe any characteristic that acts as a barrier to the cognition process or different areas of cognition. Cognition, also known as cognitive function, refers to the mental processes of how a person gains knowledge, uses existing knowledge, and understands things that are happening around them using their thoughts and senses. A cognitive impairment can be in different domains or aspects of a person's cognitive function including memory, attention span, planning, reasoning, decision-making, language, executive functioning, and visuospatial functioning. The term cognitive impairment covers many different diseases and conditions and may also be symptom or manifestation of a different underlying condition. Examples include impairments in overall intelligence ,specific and restricted impairments in cognitive abilities, neuropsychological impairments, or it may describe drug-induced impairment in cognition and memory. Cognitive impairments may be short-term, progressive or permanent.

Mild cognitive impairment (MCI) is a neurocognitive disorder which involves cognitive impairments beyond those expected based on an individual's age and education but which are not significant enough to interfere with instrumental activities of daily living. MCI may occur as a transitional stage between normal aging and dementia, especially Alzheimer's disease. It includes both memory and non-memory impairments. The cause of the disorder remains unclear, as well as both its prevention and treatment, with some 50 percent of people diagnosed with it going on to develop Alzheimer's disease within five years. The diagnosis can also serve as an early indicator for other types of dementia, although MCI may remain stable or even remit.

Pseudodementia is a condition where mental cognition can be temporarily decreased. The term pseudodementia is applied to the range of functional psychiatric conditions such as depression, schizophrenia and hysteria that may mimic organic dementia, but are essentially reversible on treatment. Pseudodementia typically involves three cognitive components: memory issues, deficits in executive functioning, and deficits in speech and language. Specific cognitive symptoms might include trouble recalling words or remembering things in general, decreased attentional control and concentration, difficulty completing tasks or making decisions, decreased speed and fluency of speech, and impaired processing speed. People with pseudodementia are typically very distressed about the cognitive impairment they experience. With in this condition, there are two specific treatments that have been found to be effective for the treatment of depression, and these treatments may also be beneficial in the treatment of pseudodementia. Cognitive behavioral therapy (CBT) involves exploring and changing thought patterns and behaviors in order to improve one's mood. Interpersonal therapy focuses on the exploration of an individual's relationships and identifying any ways in which they may be contributing to feelings of depression.

The NINCDS-ADRDA Alzheimer's Criteria were proposed in 1984 by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association and are among the most used in the diagnosis of Alzheimer's disease (AD). These criteria require that the presence of cognitive impairment and a suspected dementia syndrome be confirmed by neuropsychological testing for a clinical diagnosis of possible or probable AD; while they need histopathologic confirmation for the definitive diagnosis. They specify as well eight cognitive domains that may be impaired in AD. These criteria have shown good reliability and validity.

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire that can be filled out by a relative or other supporter of an older person to determine whether that person has declined in cognitive functioning. The IQCODE is used as a screening test for dementia. If the person is found to have significant cognitive decline, then this needs to be followed up with a medical examination to determine whether dementia is present.

A verbal fluency test is a kind of psychological test in which a participant is asked to produce as many words as possible from a category in a given time. This category can be semantic, including objects such as animals or fruits, or phonemic, including words beginning with a specified letter, such as p, for example. The semantic fluency test is sometimes described as the category fluency test or simply as "freelisting", while letter fluency is also referred to as phonemic test fluency. The Controlled Oral Word Association Test (COWAT) is the most employed phonemic variant. Although the most common performance measure is the total number of words, other analyses such as number of repetitions, number and length of clusters of words from the same semantic or phonemic subcategory, or number of switches to other categories can be carried out.

The General Practitioner Assessment of Cognition (GPCOG) is a brief screening test for cognitive impairment introduced by Brodaty et al. in 2002. It was specifically developed for the use in the primary care setting.

<span class="mw-page-title-main">Montreal Cognitive Assessment</span> Screening assessment for detecting cognitive impairment

The Montreal Cognitive Assessment (MoCA) is a widely used screening assessment for detecting cognitive impairment. It was created in 1996 by Ziad Nasreddine in Montreal, Quebec. It was validated in the setting of mild cognitive impairment (MCI), and has subsequently been adopted in numerous other clinical settings. This test consists of 30 points and takes 10 minutes for the individual to complete. The original English version is performed in seven steps, which may change in some countries dependent on education and culture. The basics of this test include short-term memory, executive function, attention, focus, and more.

The Saint Louis University Mental Status Exam was developed in 2006 at the Division of Geriatric Medicine, Saint Louis University School of Medicine in affiliation with the Veterans Association as a screening tool for detecting mild cognitive impairment. The test was initially developed using a veteran population, but has since been adopted as a screening tool for any individual displaying signs of mild cognitive impairment. The intended population typically consists of individuals 60 years and above that display any signs of cognitive deficit. The SLUMS consists of 11 questions. Areas of assessment include: attention, immediate recall, immediate recall with interference, delayed recall with interference, numerical calculation, registration, digit span, visual spatial, executive function, extrapolation and orientation.

Semantic amnesia is a type of amnesia that affects semantic memory and is primarily manifested through difficulties with language use and acquisition, recall of facts and general knowledge. A patient with semantic amnesia would have damage to the temporal lobe.

The Cambridge Behavioural Inventory (CBI) and its revised version, Cambridge Behavioural Inventory-Revised (CBI-R), are informant-based questionnaires that evaluate the emergence of behavioural symptoms in neurodegenerative brain disorders, including Alzheimer's disease (AD), Huntington's disease (HD), Parkinson's disease (PD), and frontotemporal dementia (FTD).

References

  1. 1 2 Mioshi, Eneida; Dawson, Kate; Mitchell, Joanna; Arnold, Robert; Hodges, John R. (November 2006). "The Addenbrooke's Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening". International Journal of Geriatric Psychiatry. 21 (11): 1078–1085. doi:10.1002/gps.1610. PMID   16977673. S2CID   6307453.
  2. 1 2 3 Mathuranath, P. S.; Nestor, P. J.; Berrios, G. E.; Rakowicz, W.; Hodges, J. R. (12 December 2000). "A brief cognitive test battery to differentiate Alzheimer's disease and frontotemporal dementia". Neurology. 55 (11): 1613–1620. doi:10.1212/01.wnl.0000434309.85312.19. PMID   11113213. S2CID   14413715.
  3. ↑ Hodges, John R.; Larner, Andrew J. (2017). "Addenbrooke's Cognitive Examinations: ACE, ACE-R, ACE-III, ACEapp, and M-ACE". Cognitive Screening Instruments. pp. 109–137. doi:10.1007/978-3-319-44775-9_6. ISBN   978-3-319-44774-2.
  4. 1 2 Folstein, Marshal F.; Folstein, Susan E.; McHugh, Paul R. (November 1975). "Mini-mental state". Journal of Psychiatric Research. 12 (3): 189–198. doi:10.1016/0022-3956(75)90026-6. PMID   1202204.
  5. ↑ Parasuraman, Raja; Greenwood, Pamela M.; Haxby, James V.; Grady, Cheryl L. (1992). "Visuospatial attention in dementia of the Alzheimer type". Brain. 115 (3): 711–733. doi:10.1093/brain/115.3.711. PMID   1628198.
  6. 1 2 3 Hsieh, Sharpley; Schubert, Samantha; Hoon, Christopher; Mioshi, Eneida; Hodges, John R. (2013). "Validation of the Addenbrooke's Cognitive Examination III in Frontotemporal Dementia and Alzheimer's Disease". Dementia and Geriatric Cognitive Disorders. 36 (3–4): 242–250. doi:10.1159/000351671. PMID   23949210. S2CID   28570736.
  7. ↑ Noone, Peter (17 July 2015). "Addenbrooke's Cognitive Examination-III". Occupational Medicine. 65 (5): 418–420. doi: 10.1093/occmed/kqv041 . PMID   26187808.
  8. ↑ https://www.helpguide.org/articles/alzheimers-dementia-aging/age-related-memory-loss.htm Smith, Melinda; Robinson, Lawrence; Segel, Roberts. (July 2019). Age-Related Memory loss. HelpGuide.
  9. ↑ Johnson-Laird, P. N. (1 March 1987). "The mental representation of the meaning of words". Cognition. 25 (1): 189–211. doi:10.1016/0010-0277(87)90009-6. PMID   3581726. S2CID   18197576.
  10. ↑ https://www.neuronup.com/en/areas/functions/visuospatial. Neuron Up. (2012). Visuospatial Skills. Neuron Up.
  11. ↑ Elamin, Marwa; Holloway, Guy; Bak, Thomas H.; Pal, Suvankar (2016). "The Utility of the Addenbrooke's Cognitive Examination Version Three in Early-Onset Dementia" (PDF). Dementia and Geriatric Cognitive Disorders. 41 (1–2): 9–15. doi:10.1159/000439248. hdl: 20.500.11820/33fda45e-7f30-4e63-a429-981f723541c7 . PMID   26473749. S2CID   36717441.
  12. ↑ Matias-Guiu, Jordi A.; Cortés-Martínez, Ana; Valles-Salgado, Maria; Rognoni, Teresa; Fernández-Matarrubia, Marta; Moreno-Ramos, Teresa; Matías-Guiu, Jorge (29 September 2016). "Addenbrooke's cognitive examination III: diagnostic utility for mild cognitive impairment and dementia and correlation with standardized neuropsychological tests". International Psychogeriatrics. 29 (1): 105–113. doi:10.1017/S1041610216001496. PMID   27682860. S2CID   3620808.
  13. 1 2 Beishon, Lucy C.; Batterham, Angus P.; Quinn, Terry J.; Nelson, Christopher P.; Panerai, Ronney B.; Robinson, Thompson; Haunton, Victoria J. (17 December 2019). "Addenbrooke's Cognitive Examination III (ACE-III) and mini-ACE for the detection of dementia and mild cognitive impairment". The Cochrane Database of Systematic Reviews. 12 (12): CD013282. doi:10.1002/14651858.CD013282.pub2. ISSN   1469-493X. PMC   6916534 . PMID   31846066.
  14. ↑ "Dementia test - Brain and Mind Centre". University of Sydney. 2018-05-30. Retrieved 2018-06-28.
  15. 1 2 Hsieh, Sharpley; McGrory, Sarah; Leslie, Felicity; Dawson, Kate; Ahmed, Samrah; Butler, Chris R.; Rowe, James B.; Mioshi, Eneida; Hodges, John R. (2015). "The Mini-Addenbrooke's Cognitive Examination: A New Assessment Tool for Dementia". Dementia and Geriatric Cognitive Disorders. 39 (1–2): 1–11. doi:10.1159/000366040. PMC   4774042 . PMID   25227877.
  16. ↑ Larner, A. J. (May 2015). "Mini-Addenbrooke's Cognitive Examination: a pragmatic diagnostic accuracy study". International Journal of Geriatric Psychiatry. 30 (5): 547–548. doi:10.1002/gps.4258. PMID   25855207. S2CID   30492876.
  17. ↑ Larner, A. J. (October 2015). "Mini-Addenbrooke's cognitive examination diagnostic accuracy for dementia: reproducibility study". International Journal of Geriatric Psychiatry. 30 (10): 1103–1104. doi:10.1002/gps.4334. PMID   26376107. S2CID   5153449.
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