PRoBaND Launch Event:
Cognitive Assessment
David J Burn
(david.burn@ncl.ac.uk)
Why Are We Doing This?
• Dementia occurs in up to 80% of people with
PD
• Better treatment of motor complications has
“right-shifted the curve”
• Early recognition of high risk phenotypes (&
genotypes) will enable better use of targeted
interventions
• Remember: dementia < 1 year of motor
symptom onset is NOT PD
Mild Cognitive Impairment in PD
• Mild cognitive impairment in PD (PD-MCI) is common
– mean prevalence 27%, range 19-38%
• PD-MCI
– is associated with development of PDD
– has a heterogeneous clinical profile
• Non-amnestic, single domain impairment may be most
common sub-type
• Few studies have evaluated the relationship between
specific PD-MCI subtypes & development of PDD
• Generalizability of findings limited by use of prevalent
samples & widely varying disease durations
Relevant Study Hypotheses
• Cognitive decline in PD can be predicted
from the pattern of early cognitive
performance
• Genetic factors contribute to cognitive
decline & may determine the profile of
early cognitive impairment in PD
How Will Cognition Be Assessed?
• Montreal Cognitive Assessment (MoCA)
• Semantic Fluency
• Interlocking pentagons
Montreal Cognitive Assessment
• Rapid screening assessment (3 parallel versions)
• Assesses
–
–
–
–
–
attention & concentration
executive functions
memory & language
visuoconstructional skills
conceptual thinking, calculations & orientation
• Time to administer ~ 10 mins
• Max score = 30 (> 26 considered normal)
http://www.mocatest.org
Visuospatial / Executive Function
One point allocated if:
drawing is 3D & all lines
drawn (but nil added)
lines ~ parallel & same
length
One point if successfully
draws 1-A-2-B-3-C-4-D-5-E,
without lines that cross
Contour: circle (minor
distortion permitted)
Numbers: All clock
numbers present
Hands: indicate correct
time & hour hand shorter
Naming & Memory
The examiner reads a list of 5 words at a rate of one per second, giving the following
instructions: “This is a memory test. I am going to read a list of words that you will have
to remember now and later on. Listen carefully. When I am through, tell me as many
words as you can remember. It doesn’t matter in what order you say them”.
Attention & Language
“I am going to read a sequence of letters. Every time I say the letter A, tap your
hand once. If I say a different letter, do not tap your hand”.
“Tell me as many words as you can think of that begin with a certain letter of the
alphabet that I will tell you in a moment. You can say any kind of word you want,
except for proper nouns (like Bob or Boston), numbers, or words that begin with
the same sound but have a different suffix, for example, love, lover, loving. I will
tell you to stop after one minute. Are you ready? [Pause] Now, tell me as many
words as you can think of that begin with the letter F.”
Abstraction, Delayed Recall &
Orientation
The examiner gives the following instruction: “I read some words to you earlier,
which I asked you to remember. Tell me as many of those words as you can
remember.” Make a check mark ( √ ) for each of the words correctly recalled
spontaneously without any cues, in the allocated space.
Allocate 1 point for each word recalled freely without any cues.
Additional Tests
Interlocking Pentagons
Score 0/1
Semantic Fluency
• Tell me as many animals as you
can. It doesn't matter what letter
they start with. However, please
try to avoid giving me lots of
different breeds of the same animal
or different versions of the same
animal.
• Just try to think of as many different
animals as you can.
• You will have 90 seconds before I
tell you to stop. Do you have any
questions?
• Score: Total count, set-loss &
repetition errors
Cognitive Testing Frequency
• Diagnosis < 3 years
– V1 (0 months), V4 (18 months) & V7 (36
months)
• Onset < 50 years age
– V1 (0 months) only
• Relatives
– V0 (screening) & V1 (36 months)
NINDS CDE Workgroup-Cognitive
Recommended Scales
• Each scale rated based on its utility in each
of 4 usage categories:
1. as a screening instrument for initial identification
of a possible disorder or population of interest
2. as a rating scale for measurement of severity of
the disorder or performance within the domain
of interest
3. as a scale that is sensitive to longitudinal
change
4. as a diagnostic instrument that can categorize
individuals into those with & without a disorder
NINDS CDE Scale Assessment
Rating Scale Usage
Instrument Name
Screening Instrument
Severity
Longitudinal
Diagnostic
Instrument
Administration
Time
ADAS COG
2
2
N/A
2
30 min
Addenbrooke’s Cognitive ExaminationRevised (ACE-R)
1.5
2
3
2
15-20 min
2
2
2
2
25-30 min
N/A
N/A
2
N/A
40 min
1
1
1
1
30-50 min
3
2.5
3
10-12 min
1.5
1.5
N/A
2
10-15 min
2
2
N/A
2.5
8-20 min
2
2
N/A
2
17-26 min
2
1.25
N/A
3
10-15 min
3
N/A
N/A
N/A
5 min
CAMCOG-R
Clinician Global Impression of Change
Mattis DRS-2
MMSE
Montreal Cognitive Assessment
PANDA
PD-CRS
SCOPA-COG
Short Portable Mental Status
Questionnaire
http://www.commondataelements.ninds.nih.
gov/PD.aspx#stds
2
CamPaIGN Study
17% incident patients developed dementia over 5 yrs
Williams-Gray 2009
CamPaIGN: Risk Factors for PDD
Variable
P value
OR (95% CI)
MAPT H1/H1 genotype
0.03
12.1 (1.3-117.6)
Age ≥ 72
0.03
4.8 (1.1-20.2)
Semantic fluency <20
0.02
6.89 (1.3-36.6)
Pentagon copying (0 vs. 1 vs. 2)
0.05
2.8 (1.0-7.7)
Non-TD motor phenotype
0.09
3.9 (0.8-19.6)
Williams-Gray 2009
Conclusion
• Cognitive test battery not
comprehensive
• Balances what is known
with pragmatic approach to
assessment
• Estimated completion time
~ 15 mins
• Strength in numbers, other
assessments & follow-up