display screens for memory impared made in china

Digital methods allow for capturing response times accurately, which are not easy to capture with paper-and-pencil tests. Participants with MCI and dementia require a longer time in the clock-setting test, which might reflect problems in processing speed and executive functions. The traditional method of the clock-drawing test requires more precise fine motor control, especially when drawing on a tablet. In contrast, the clock-setting test requires less fine motor control and is thus easier for older adults, which minimizes the confounding effects of physical constraints and poor motor dexterity. The diagnostic performance of the clock-setting test was slightly better than that determined for the clock-drawing test in a pilot study [28]. Therefore, the digital clock-setting test was used in the EC-Screen. We used a digital delayed recognition test instead of a traditional method of the delayed free recall test because current voice recognition technology is not yet able to automatically understand a stranger’s voice correctly. Therefore, the digital version of the delayed recognition test was considered to be more practical for use in community settings than the digital version of the delayed free recall test. Delayed recognition tests are commonly used for cognitive screening. Previous studies have shown that the diagnostic performance of the digital version of delayed recognition tests effectively detected both MCI and dementia [20,29]. Both the raw score and time spent in the 5-word delayed recognition test were statistically significant in the regression model, indicating that problems in memory retrieval and processing efficiency are important markers of cognitive disorders. Impairment of delayed memory recognition could reflect problems in encoding, consolidation, or storage, which together comprise a cardinal feature of Alzheimer disease. Therefore, performance on delayed recognition may serve as a more sensitive marker than delayed free recall for identifying patients with early cognitive decline at risk for progression to Alzheimer disease [30]. The question of the story test is not the exact content of the story and requires the participant to convert a fact that a landmark belongs to a given district. Therefore, the story test can assess the mental ability to switch between two concepts.

Some older adults may be aware of their memory decline, and some family members may worry about their parents or grandparents with potential signs of cognitive decline; thus, the EC-Screen can help them to decide whether it is necessary to seek medical and professional advice. Older adults can obtain the cognitive screening assessment from community centers or elderly centers. Therefore, the EC-Screen can promote timely assessment for older adults at risk in the community.

A digital cognitive test can capture behavioral data accurately. Some studies found that drawing time or drawing process can be a predictive factor for cognitive impairment [31,32]. In the last decade, some multidomain digital cognitive tests have been investigated, including Brain on Track [13] and Computerized Cognitive Screen [33]. These digital cognitive tests assess memory, attention, processing speed, and executive functions, and the administration time is around 20 to 25 minutes. The AUC of Brain on Track for the detection of MCI was 0.86 and the AUC of the Computerized Cognitive Screen for the detection of MCI and dementia was 0.78. There are some commercially available computerized cognitive test batteries such as the Computer assessment for Mild Cognitive Impairment (CAMCI) [34] and CNS Vital Signs [35]. However, the administration time of these tests is longer (>20 minutes) and the costs are rather high. The EC-Screen showed comparable diagnostic performance with a simpler design. Further evaluation of the EC-Screen in a larger cohort of older people recruited from various sources in the community is ongoing.

Previous studies have reported that the performance on cognitive tests such as the MoCA is affected by education [36-38]. Such education effects are more obvious in Asian countries, as elderly people in these countries are generally less educated [36,38]. The EC-Screen has an adapted version with illiterate options for administration of the test. Twenty-two participants chose the illiterate version in this study. The design of the illiterate version is tailor-made for participants with a very low education level. However, the administration time of this version is longer than that of the standard version, and therefore we excluded the participants who used the illiterate version from this analysis. We are currently planning to separately analyze the participants who took the illiterate version when a larger sample is obtained.

While several telephonic screening tools have been validated in dementia populations, the literature is limited on their utility in preclinical disease stages. We reported on the development of the Memory Assessment Telephone Screen (MATS), an instrument designed to screen individuals with mild cognitive impairment and/or significant complaints about cognition. The MATS contains a 10 item list-learning test with a delayed recall condition-- the variable previously shown to have the strongest predictive accuracy for amnestic MCI [38]. The encoding phase of the list-learning test consists of three learning trials (instead of one trial) to maximize the potential for elaborate encoding and to reduce the likelihood that brief attentional lapses will contribute to poor performance. We also include a forced-choice recognition condition to enable further examination of retrieval (as opposed to encoding) deficits and evaluation of response bias.

The MATS was not modeled after the MMSE and excludes items known to lack sensitivity in preclinical groups (e.g., orientation to person or place, basic expressive language, praxis). In addition to the objective memory test, the MATS contains a forced-choice subjective memory questionnaire to reflect current conceptualizations of MCI, which tend to place greater emphasis on memory complaints and perceived decline in memory ability [26, 64]. In addition, researchers have begun to study a group of individuals with a history of cognitive complaints (CC) and mildly declining function, who do not yet perform 1.5 SD below the mean of healthy controls on psychometric memory tests. Research from our lab and others [57, 65] indicates these individuals show structural and functional brain changes intermediate between MCI and HCs, and may be classified as “pre MCI.” Therefore, inclusion of both objective and subjective memory assessments may confer an advantage over existing screens in terms of the ability to detect and characterize a wider spectrum of older adults presenting with significant cognitive complaints and/or actual performance deficits.

The MATS was well-tolerated in our group of 135 nondepressed older adults, and did not show a ceiling effect (even in cognitively intact controls). Moderate stability of learning, delayed recall, and delayed recognition conditions was observed for Form 1 over a 12-month period in HCs, suggesting that the MATS is not particularly susceptible to explicit learning effects. The moderate associations with various CVLT variables provided preliminary evidence of concurrent validity. With the exception of Total Learning score, the MATS did not show a significant relationship with age on either the objective or subjective variables. Similar findings were reported for the 12-item HVLT and may reflect the relative ease of the MATS as compared to the lengthier CVLT, on which age is correlated with both learning and delayed recall trials [66]. Another possibility is that the relatively high education level of our participants obscured expected age-related declines often seen on episodic memory tests. While education, gender, and depressive symptoms did not significantly influence current results, future research will examine relations between the MATS and these variables in a more diverse sample.

An important study goal was to investigate the MATS" ability to detect differences in older adults with varying degrees of cognitive compromise. The MATS objective memory test was sensitive to group differences, with MCI participants scoring approximately 1.5 SDs below the mean of HCs across memory test conditions (clinically impaired range). The CC group showed an intermediate level of performance, generally scoring about .7 SDs below the mean of HCs, which is considered within normal limits clinically (low average to average range). When 15 mild AD patients were included in the alternate forms phase of the study, the pattern of group differences was as follows: HC, CC > MCI > AD, with ADs generally scoring more than 2 SDs below the mean of HCs (clinically impaired range). On the subjective memory questionnaire, CC and MCI participants endorsed approximately twice as many complaints as HCs, as expected based on study criteria. Overall, findings supported the validity of the MATS as an indicator of cognitive impairment in our clinical groups. Longitudinal follow-up of MCI and CCs also will be necessary to confirm the MATS" diagnostic value and to monitor rates of progression from CC to MCI or MCI to AD, in order to determine which variables best predict clinical conversion. It is important to note that the MATS would likely be less sensitive to early cognitive impairment that presents primarily in the form of nonamnestic deficits (e.g., visuospatial dysfunction, constructional apraxias). Future research should examine the MATS in other MCI subtypes (e.g., multiple domain) [67] or patient populations (e.g., vascular dementia, delirium), and modify test items as required. Notably, the MATS has been utilized successfully with patients in more advanced disease stages (i.e., various forms of dementia), and adapted for our other clinical samples such as traumatic brain injury and breast cancer.

In order to avoid practice-related measurement error of participants undergoing serial testing as part of our longitudinal study, we developed three alternate forms of the MATS objective memory test (yielding a total of four forms). The words selected matched the original list on various criteria (e.g., syllables, frequency of usage), and were easy to pronounce and distinguish over the telephone. Analyses of the learning, delayed recall, and recognition conditions indicated that all four forms were interchangeable, confirming their utility in research requiring repeated testing of verbal episodic memory. Additionally, group differences generally held across the four versions, with the exception of MCI who tended to show improved performance on the alternate test forms. Future research should employ a larger sample of MCI patients and apply a between-subjects design to ascertain whether the higher scores reflect a true form difference or are attributable to other factors (e.g., artifact of small sample size, differential benefit in MCI from the short test-retest interval related to anticipatory effects or use of external aids). Further, the test-retest interval for the two alternate forms was shorter than the interval between the original and alternate forms. While this was unavoidable in our current longitudinal study, future research should attain a more consistent time interval between all test versions.

The MATS shares limitations with some existing telephone instruments in that level of motivation, listening and privacy conditions, and auditory deficits may affect performance. While telephone interviewers should acquire an ability to attend to issues like disinterest, distractibility, or cheating (e.g., writing down memory test items, receiving assistance), in our experience, these potential problems are detectable and manageable. We did not directly compare the MATS with existing telephone instruments such as the TICS-m and therefore cannot determine if the MATS is more useful in actual practice. Additionally, we applied strict entry criteria and our sample was predominantly Caucasian, limiting the generalizability of our results. Use of the MATS in more diverse groups may change its validity, and future research should determine the degree to which medical and demographic variables affect response levels; appropriate adjustments or norms for specific groups may be required. Administration time for the MATS is approximately 20 minutes, and may be too lengthy for certain settings. If some of the information-gathering sections are omitted, the time required for the memory assessments (including the delay) could be reduced to approximately 15 minutes. Based on our experience, however, the history sections are useful for gathering relevant patient information and for establishing rapport. Finally, screening instruments help identify individuals with a high probability of having a problem who would benefit from in-person evaluation; they are not meant to provide a definitive diagnosis or substitute for comprehensive assessment.

Some additional directions for research warrant mention. Alternative communication modes such as videoconferencing and computer-automated or computer-assisted telephone screening, while at an early stage of development, show promise for the future [68-70]. Although it might be possible to adapt the MATS to one of these formats, it remains to be seen whether these technologies become widely available, cost-effective, and readily embraced by older adults. It is also important to note that the MATS may not be appropriate for all individuals. For example, in those with significant auditory difficulties, hearing amplification devices may be required for successful administration. Individuals with more advanced cognitive decline may require informant rather than patient versions of telephone screens. Mintzer et al. [71] found that a dementia screening tool based on caregiver responses showed high reliability with subsequent clinical evaluation in a small community-based sample. To this end, all MATS items, with the exception of the objective memory test, can be administered using a reliable informant. While we have analyzed key variables from the MATS, consideration may be given to additional information such as primacy and recency effects, direct comparison of recall versus recognition scores, and responses to specific subjective memory questions. Incorporation of this type of information into the scoring system may allow for the identification of more discrete cognitive constructs. Finally, we hope to determine the classification accuracy of the MATS and develop cutoff scores with high sensitivity and specificity. Our preliminary findings suggest that a cutoff score of ≤ 33 of 50 points on the objective memory yields the best sensitivity/specificity for MCI. This value, however, will likely need to be adjusted in other settings, in research applying different diagnostic criteria for MCI (e.g., the European Consortium on Alzheimer"s Disease [64] or Alzheimer"s Disease Neuroimaging Initiative [72]), or in studies of frank dementia.

Telephone testing provides a practical and efficient mechanism for screening of cognitive impairment in elderly populations, where factors such as physical impairment, financial limitations, or geographic dispersion may affect the feasibility of in-person contact during recruitment or longitudinal follow. The MATS, with its ease of administration and scoring, tolerability, reliability, and discriminative validity can help identify individuals in the preclinical or mild stages of dementia, when treatment that prevents or slows cognitive decline can exert the strongest impact. In addition to the subjective and objective memory assessments, the MATS gathers qualitative information about a variety of medical, psychological, and social issues that may be useful in clinical or research settings, and which can be administered telephonically or in-person by physicians, psychologists, nurses, or other trained personnel. Moreover, the existence of four comparable MATS forms enables serial testing. While initial cross sectional results are encouraging, only upon subsequent follow-up will it be possible to determine the predictive validity of the MATS for cognitive progression in our clinical groups.

The existing screening batteries assessing multiple neuropsychological functions are not specific to amyotrophic lateral sclerosis (ALS) patients and are limited to their physical dysfunctions, whereas category cognitive tests are too time-consuming to assess all the domains. The Edinburgh Cognitive and Behavioural ALS Screen (ECAS) was recently developed as a fast and easy cognitive screening tool specifically designed for patients. The purpose of the study was to validate the effectiveness of the Chinese version in Chinese ALS populations.

Eighty-four ALS patients and 84 age-, gender- and education-matched healthy controls were included in this cross-sectional study. All the participants took the ECAS, Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB). Primary caregivers of patients were interviewed for behavioural and psychiatric changes.

Significant differences were noted in language (p = 0.01), fluency, executive function, ALS-specific functions, and ECAS total score (p<0.01) between ALS patients and controls. The cut-off value of the total ECAS score was 81.92. Cognitive impairment was observed in 35.71% of patients, and 27.38% exhibited behavioural abnormalities. The ECAS total score had a medium correlation with education year. Memory was more easily impaired in the lower education group, whereas verbal fluency and language function tended to be preserved in the higher education group. The average time of ECAS was only 18 minutes.

The Chinese version of the ECAS is the first screening battery assessing multiple neuropsychological functions specially designed for the ALS population in China, which provides an effective and rapid tool to screen cognitive and behavioural impairments.

Amyotrophic lateral sclerosis (ALS) is a multiple-system neurodegenerative disease, and its extra-motor disorders have received increasing concern in recent years. Frontotemporal dementia (FTD) has been known to overlap with ALS. Strong et al. proposed the concept of ALS cognitive impairment (ALS-ci) and behaviour impairment (ALS-bi) [1]. Researchers subsequently found that 10 to 60% of patients had the diagnosis of ALS-ci [2]. Executive difficulty is a typical ALS cognitive domain of which we are familiar [3]. However, non-executive cognitive dysfunctions are also present in ALS [4–6]. These dysfunctions include language, memory and some cases of psychiatric change [7–11]. Thus, different scales are necessary to conduct a comprehensive assessment. Some groups have already undergone screening [12,13], and some measurements have been created [14–20]. However, a single domain cannot reflect the entire profile of cognitive and behavioural change. It is too time-consuming to assess all the domains. Thus, a screening battery assessing multiple neuropsychological functions is needed. Unfortunately, classical measurements, such as the Mini-Mental State Examination (MMSE) [21] and Montreal Cognitive Assessment (MOCA) [22], are not sensitive for the ALS population and have significant limitations for those with physical dysfunctions.

The Edinburgh Cognitive and Behavioural ALS Screen (ECAS) [23] is a brief assessment tool that was designed specifically for ALS patients. The screen includes ALS-specific functions (language, verbal fluency and executive functions) and ALS-non-specific functions (memory and visuospatial functions). Furthermore, primary caregivers completed a questionnaire for five-domain characteristic behavioural changes of FTD and three psychotic questions. The ECAS provides a rapid measurement of cognitive and behavioural functions for ALS, which is not influenced by physical disorders and reflects the severity and nature of the disease. Abrahams’s group later validated the ECAS against a gold standard extensive neuropsychology assessment and demonstrated that the ECAS was a screening tool with high sensitivity and specificity characteristic ALS impairments [24]. The German/Swiss-German version also demonstrated that the ECAS was a fast and easy cognitive screening instrument that was sensitive for ALS-specific dysfunctions and behavioural changes [25].

Regarding the Chinese population, cognitive changes are obviously different between cultures and languages [26]. However, limited assessments have been made in Chinese ALS patients. Yuan et al. investigated the cognition function in 22 early phase patients [27]. Wei et al. [28] screened 145 patients using the MMSE and the revised Addenbrooke’s Cognitive Examination (ACE-R). Cui et al. [29] conducted a neuropsychological investigation between ALS and progressive muscular atrophy (PMA) patients. However, the measurement tools used were time-consuming and potentially restricted by physical dysfunction. Thus, a rapid assessment tool designed especially for Chinese ALS patients is urgent.

All of the interviews were performed by clinical neurologists. The total interview lasted approximately 25 to 50 minutes, depending on the physical state of the participants.

This study was approved by the Research Ethics Committee of Peking University Third Hospital. All patients were included after informed written consent obtained from patients or their guardians and controls were informed written consent by themselves, as set forth by the Declaration of Helsinki. The consent procedure was approved by ethics committees.

We translated the Chinese version from the ECAS English version after the authors granted permission, and performed a back-translation by another clinical doctor of neurology who never read the original English version before. Although there were language and cultural differences, we attempted to maintain consistency with the original document. The ECAS Chinese version still contained ALS-specific functions, including language, fluency and executive sections, and ALS-non-specific functions, including memory and visuospatial sections. In addition, five domains of FTD and three domains of psychotic changes were included to interview caregivers in a behavioural screen.

The amendment in the Chinese version compared to the original English version is listed as Table 2. During the translation, two pictures in the “naming” section and the story in the “memory” section were altered according to Chinese culture. The characters chosen for the “spelling” section followed these principles: 1) different structures: left-right structure (跨kua4, 增zeng1, 秽hui4, 短duan3, 颁ban1), top-down structure (管guan3, 焚fen2, 藏cang2), and surrounding structure (廉lian2, 固gu4, 闻wen2, 囵lun2); 2) different component: one part’s pronunciation is the same as the character (夸kua-跨kua, 官guan-管guan, 古gu-固gu, 仑lun-囵lun); one part’s pronunciation is similar to the character but not the same: (曾ceng-增zeng, 岁sui-秽hui, 臧zang-藏cang, 兼jian-廉lian); the character gets its meaning from two parts but not the pronunciation [闻(门door-耳ear-闻hear), 颁(分give-页head-颁give), 焚(木wood-火fire-焚burn), 短(矢measurement unit-豆bean pod-短short)]; 3) frequency of character: high frequency (管0.6194, 增0.3473, 固0.2008, 藏0.1217), middle frequency (短0.02063, 闻0.0089, 跨0.00376, 廉0.00149, 颁0.00144), low frequency (秽0.00044, 焚0.00044, 囵0.00006). The number was the frequency of characters according to the Modern Chinese Frequency Dictionary [31]. Verbal fluency scores were normalized according to the performance of 40 healthy subjects in the preliminary experiment (see Abrahams et al. [23] and guidelines published https://www.era.lib.ed.ac.uk/handle/1842/6592). “发fa1, 开kai1” were chosen in the Chinese version. For the “alternation” section, we chose twelve well-known Chinese zodiac signs. However, except for the two examples of “1-rat, 2-cattle law”, only 10 animals remained. Thus, the total score for this part could only be 10. An additional 2 scores were added to the “sentence completion” section. Thus, the total score for the executive function was 48.

Kolmogorov-Smirnov test was used for analyzing normal distribution. To compare clinical features (age and education), score of each section between patients and controls, total ECAS score between different sex and whether bulbar involved, two sided t-test was used if the variables were normally distributed and Mann Whitney U-test was used if not. One-way ANOVA was used to compare total ECAS score between different diagnostic levels and sites of onset. Categorical variable (sex between patients and controls) was compared using a chi-square test. To analyse relationship between the scores of ECAS and other neuropsychological tests, ECAS total score and clinical features (education, age, ALSFRS-R and duration of illness), correlation coefficients were determined via Pearson correlation analysis when the data were continuous, normally distributed and had a linear relationship. Otherwise, Spearman correlation analysis was performed. Cut-off scores were defined as two standard deviations below the mean of the healthy controls according to the work of Abrahams[23]. A Cronbach’s alpha test was used to evaluate reliability. A threshold of p<0.05 was used for statistical inference. Statistical analysis was performed using SPSS 18.0 statistical software.

We identified significant differences in language, fluency, executive function, ALS-specific functions, and the total ECAS score between ALS patients and controls, whereas no differences in memory, visuospatial and ALS-non-specific functions were noted. However memory (p = 0.07) and ALS-non-specific functions (p = 0.06) seem to have trend to be significant. The mean time of the ECAS was only 18 minutes (Table 3).

The executive function was the most common domain, with approximately half of patients performing below the cut-off score, followed by fluency (20.24%) and language (15.48%). Approximately one-third of patients had cognitive impairments according to the total ECAS score (Table 4).

The total ECAS score and education year exhibited a moderate correlation (r = 0.61, p<0.01). However, no obvious relationship was noted between the total ECAS score and age (r = -0.23, p = 0.04), ALSFRS-R (r = 0.28, p = 0.01). Although p<0.05 here, r<0.3 implied no relationship for correlation analysis. There was also no correlation between total ECAS score and duration of illness (r = 0.07, p = 0.54). No significant differences were found in the total ECAS scores between different sexes, diagnostic levels, sites of onset, and bulbar involvement (p>0.05).

Interestingly, in the lower education group, significant differences were noted in memory (z = -1.99, p = 0.04) and ALS-non-specific functions (z = -2.15, p = 0.03). Language (t = -3.21, p<0.01), verbal fluency (z = -5.24, p<0.01), executive (t = -9.55, p<0.01), ALS-specific function (t = -9.54, p<0.01), and total ECAS score (t = -8.84, p<0.01) still differed between patients and controls; however, the visuospatial function did not (z = -1.50, p = 0.13).

However, in the higher education group, no differences were observed in language (t = -1.16, p = 0.25) and verbal fluency (t = -1.23, p = 0.23). Differences were noted in executive (t = -5.04, p<0.01), ALS-specific function (t = -4.46, p<0.01), and the total ECAS score (t = -4.31, p<0.01), whereas memory (z = -0.82, p = 0.41), visuospatial (z = 0.00, p = 1.00) and ALS-non-specific functions (z = -0.78, p = 0.44) did not differ.

A significant difference in the total ECAS score was noted between patients and controls, indicating that this metric is potentially an index for cognitive assessment. We anticipated differences in the language, verbal fluency, executive function, and ALS-specific functions, whereas language was not as obvious as the others. Although language impairment was reported to be more common than executive function [10], no ALS language study has been specifically performed with the Chinese population. Spelling might be the largest difference between Chinese and English. Recent research has demonstrated that orthographic skills and morphological awareness were important contributors to Chinese reading and spelling development and that memory of these character stroke orders was important for character spelling in Chinese [33]. However, these functions might not be as sensitive as the executive function in ALS patients. However, the results provided a clue for further study of ALS language disorders in the Chinese population. Memory has also been shown to be affected in recent years [8,11]. Although the p values for memory and ALS-non-specific functions were >0.05, we noticed that it approached significance. It is worth mentioning that the average time for the ECAS was only approximately 18 minutes, which made it possible to use the Chinese version of the ECAS in the clinic as a routine test.

The cut-off value of the total ECAS score was 81.92 according to the method of Abrahams; 35.71% of patients performed below the value and were thought to have cognitive impairment. This percentage is consistent with previously reported data [2] and is slightly higher than 30.34%, which was observed by another Chinese group using ACE-R[28]. Notably, approximately half of patients exhibited executive impairment, which may cause the highly abnormal proportion of ALS-specific functions. According to unpublished data from our group, 20.0% of patients had this disorder when we screened 110 ALS patients and 96 controls for their executive functions [34]. Abnormality on more than two distinct tests that were sensitive to executive functions was used for diagnosing according to Strong’s criteria[1] in this screen. However, in the ECAS Chinese version, the executive category included digital span, alternation, sentence completion, and social recognition. Overlapping these four parts might enhance the sensitivity of the tool.

As FAB was designed especially for assessing executive function and ECAS is more focused on executive function, it is easy to understand why correlations existed between the total ECAS score, ALS-specific functions score and FAB score. The MMSE is a general scale that contains different domains of cognition. Thus, this screen could have a relationship with the total ECAS score, ALS-specific functions and ALS-non-specific functions score. However, the correlations might not be as strong as FAB score given lacking pertinence. ALS-non-specific functions included memory and visuospatial, whereas FAB was used for executive function. Thus, the scores of these tests were not closely related. Given that all the results could be explained, this might enhance the reliability of the Chinese version of the ECAS.

Interestingly, memory was more easily impaired in the lower education group, whereas verbal fluency and language function tended to be preserved in the higher education group. A cross-sectional and longitudinal study revealed that memory decline was faster in less-educated people [36].In the ALS population, this phenomenon might be similar. There was substantial evidence of an association between higher educational levels and a decreased incidence of dementia in various populations and studies. The main hypothesis was that clinical manifestations of cognitive disorders related to brain lesions were delayed in more highly educated people [37]. The preservation of brain lesions might minimize the differences in verbal fluency and language function in ALS patients. However, this hypothesis must be proven. As a general scale, ECAS is advantageous in testing different profiles of ALS cognitive impairments and could help to further explore the nature of the disease.

The proportion of behavioural disorders was 27.38%. This result is slightly higher than our group’s previous study, which reported 20.9% with cut-off values from the Frontal Behavioural Inventory (FBI) and Neuropsychiatric Inventory (NPI) scores [34]. Only one patient exhibited impairment in three domains, which met the clinical features of FTD according to Neary’s criteria [38]. However, during the study period, there were another four ALS/FTD patients who had impairment in at least three behavioural domains. Since they had severe cognitive dysfunction, interfere with daily life and had abnormal MRI, fulfilling the dementia criteria of ICD-10, they were excluded from the 84 ALS patients when performing the cognitive test. If these four patients had been added, the FTD percentage would have reached 5.68%, which was in the range of 5 to 15% according to the literature [2,39].

The Chinese ECAS version is the first general scale specifically designed for the Chinese ALS population. This test is an effective and rapid tool to screen cognitive and behavioural impairments in ALS patients. The Chinese ECAS may be more sensitive for assessing executive function and can help to further detect the nature of the disease. However, limitations of this research should be noted, including the lack of information about occupation, social economic status and inventories to evaluate a patient’s mood. Additionally, the Chinese ECAS version requires further validation regarding sensitivity and specificity.

The authors would like to thank all the ALS patients and their caregivers for participating in this research. The authors also thank Professors Sharon Abrahams and Thomas H. Bak for providing guidance during the translation and performance testing. We would like to thank Professors Albert C. Ludolph and Dorothee Lule for their advice during the results analysis.

Conceived and designed the experiments: SY YJ DF. Performed the experiments: SY YJ JH CL XL DF. Analyzed the data: SY CL DF. Contributed reagents/materials/analysis tools: SY CL JH DF. Wrote the paper: SY DF.

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We presented normative data for a novel, tablet-based brief cognitive assessment aiming to sensitively detect fine-grained impairments within ageing adults. Age group specific cutoffs were established for each of the OCS-Plus subtasks, based on data from a cohort of neurologically healthy older adults. The validity of the OCS-Plus subtasks was then evaluated against a series of analogous standard neuropsychological assessments. The OCS-Plus subtasks were found to have good divergent validity. Performance on many OCS-Plus subtasks was found to correlate with performance on analogous standard measures, though some of the convergent validity in this healthy ageing cohort was relatively low. The OCS-Plus was found to have good test–retest reliability. The present paper and data present the first step towards building clinically valid tools and further research is underway on the more easily distributable Android app to expand the normative data and allow both age and education specific norms. Importantly, further research into OCS-Plus validation in clinical groups is required.

The UK and German cohort of healthy ageing adults included in this investigation were collectively found to perform well on the OCS-Plus subtasks. The lack of floor effects and significant variance present within the normative scores for most subtasks are promising signs of a sensitive test. Equally, OCS-Plus includes more straightforward tasks like Picture Naming, Orientation and Episodic Recognition, where healthy participants" performance was found to reach ceiling with a comparatively small range of potential total score outcomes. These tasks are included to allow assessment across a range of abilities, and these are more likely to be of interest in screening for a more apparent cognitive impairment. When these scores are considered in the broader context of OCS-Plus performance, they may allow excluding a more severe impairment diagnosis or identifying larger changes in cognitive abilities over time. For example, they might be useful for differentiation of patients with slight and specific vs. more severe and global deficits.

Performance on OCS-Plus subtasks was found to be significantly different between various age groups, and normative cut offs for ages < 60, 60–70 and > 70 are provided. The grouping according to age happened post-hoc to split the data across age groups of comparable sizes and this initial normative data did not span the entire education spectrum. Our sample was unequally distributed for full age-and education combined cut offs. And though only small differences between the two education levels appeared present at this time, visualization of the data as well as findings of age and education associations with OCS-Plus tasks in a large cohort in rural South Africa spanning the full spectrum of education

The OCS-Plus subtasks were found to demonstrate good test–retest reliability at the group level, despite the wide range of test–retest intervals. Values for some subtasks were low due to inherent low variance. However, performance on OCS-Plus subtasks, overall, was found to be stable across time within this investigation’s neurologically healthy ageing participant sample. Internal consistency per task was generally good for tasks of larger range (e.g., not Picture Naming, Orientation, Semantics etc.) with most Cronbach alpha values exceeding 0.70). It is worth noting that these simple tasks are included as basic checks whether participants and patients are able to name pictures of stimuli, select pictures based on presented words, and orient themselves. This is to establish a baseline performance of core general abilities to then more sensitively assess executive functioning and memory. In addition, starting the testing session with these subtasks ensures a low barrier of entry and makes participants feel comfortable with the testing situation and interacting with the tablet.

However, reliability statistics could not be validly calculated for subtasks with restricted possible total scores as participants" scores were at ceiling. Collectively, the reliability analyses conducted in this study suggest that the OCS-Plus represents a reliable neuropsychological assessment battery.

The convergent and divergent validity of the OCS-Plus subtasks was evaluated by comparing performance on these tasks to performance on analogous, standardized neuropsychological measures, and correcting the correlation coefficient for the reliability of the tests/subtasks. The majority of these comparisons had comparatively low (< 0.50) correlation coefficients, possible due to low variance in ceiling type performance of the control participants. However, in terms of size of the convergent correlations most were at or above an acceptable level of convergence seen in validations of other widely used similar screens used in this investigation, i.e., > 0.20 (e.g.

Some difference in performance between OCS-Plus and pen-and-paper tasks is expected, as the stimuli, experimental design, and difficulty level are similar, but not identical across these assessments. Further research in clinical groups, with larger variance across both OCS-Plus and standardized convergent validity tasks is called for. As a whole, OCS-Plus subtasks were found to have good divergent validity versus assessments aiming to test theoretically unrelated constructs.

The OCS-Plus outputs a detailed, task-specific performance summary following the completion of each patient assessment in a brief overview snapshot (see Fig. 1). We have also suggested one potential method for combining test scores across cognitive domains and have provided normative data cut-offs for using this alternate scoring approach. This method is described as one of many potential alternative clinician-focused OCS-Plus scoring systems. Future research is needed to investigate the utility of any domain scoring system, particularly in relation to specific clinical groups and to identify other informative alternate scoring methods.

The OCS-Plus is not meant to provide a method for separating the spectrum of cognitive decline into arbitrary impairment classification groups. Instead, it is designed as a tool for briefly measuring more detailed cognitive performance metrics for individual patients, which can then be employed to inform clinical decision making. The boundaries distinguishing normal, age-related cognitive decline from abnormal cognitive deficits are not clearly established and the OCS-Plus in its current state is not an appropriate tool for allocating patients to specific clinical groups. Further research is required into OCS-Plus validation for cohorts diagnosed with specific pathologies.

The OCS-Plus outputs a wide range of performance metrics, a subset of which were introduced and evaluated in the present paper. Most OCS-Plus subtasks record detailed information including the x, y coordinates and timestamps of each participant response as well as audio recordings of each task (recordings start when a subtask is begun and end when a subtask is finished). These more complex performance metrics can be analyzed to provide a more detailed analysis of participant performance. For example, spatial search strategy could be quantified based on responses within the selection and figure copy task and this data could be analyzed to evaluate task planning and organizational abilities. Additional research is needed to explore these potentially informative extensions of OCS-Plus functionality.

Further, four characteristics our sample potentially hamper generalizing the results on a population level. First, our sample was highly educated, as such this restricts confident interpretation of an individual’s performance where they have low levels of education. Indeed, we have previously found very clear age and education effects in the rural South African cohort

OCS-Plus will be made available as an Android app to be downloaded on various tablet types. We anticipate that updated versions will include even larger age-education normative comparison groups as data collection is ongoing and the Android app is already set up for these updates as it facilitates anonymized data sharing. All the current data has been made openly available on the Open Science Framework, and we intend to update this data in a transparent and open way.

The comparison of general information and standard neuropsychological tests among the four groups is presented in Table 1. There were no significant differences in age, sex and education among the four groups (P>0.05).No significant differences were seen for MMSE between the aMCI-sd and aMCI-md groups, for delayed memory between the aMCI-md and mild AD, or for BNT, CFT-Copy, CWT-CR and TMT-part B between the aMCI-sd and NC groups (p>0.05). The testing confirmed the clinical features of patients with aMCI-sd and aMCI-md.

Correlation analyses were carried out for the NCs. Age was significantly related with the three indicators of MES (p<0.05). When a person was older, s/he obtained a lower score. According to age, four subgroups were determined for NCs. There were 23 persons aged 50–59, 87 aged 60–69, 74 aged 70 –79, and 13 aged 80–89. The total scores for the MES were 84.0, 83.0, 80.5, and 77.9, respectively. There were distinct differences among subgroups (F=2.972, P=0.033), yet education level had no relationship with the test (p>0.05). No differences were found between male and female in the total scores and factor scores of the MES. In contrast, age and education significantly correlated with the MMSE score (correlation coefficients were −0.233 and 0.304, respectively, p<0.01).

Correlation analyses were done for all participants. The correlation coefficients were 0.892 for MES-5R and MES total score (p<0.01), 0.882 for MES-EX and MES total score (p<0.01), and 0.573 for MES-5R and MES-EX (p<0.01).

The coefficients were 0.663 for MES-5R and AVLT-total score (p<0.01), 0.523 for MES-5R and CFT-delay recall, 0.554 for MES-EX and the SCWT- interference effects, and 0.381for MES-EX and time scores of the TMT-part B (p<0.01).

For NCs, the proportions obtaining the maximum score on the MES-5R, MES-EX and MES total were 4.1%, 20.3% and 2.5%. For mild AD subjects, 2.2% scored zero in the subtest of MES-5R, but no one scored zero in the MES-EX and MES-total. The scores of MCI patients were intermediate between the NC and AD groups. This demonstrated that there were no obvious ceiling and floor effects.

The average administration times were 421.14±168.31 seconds, about seven minutes, for the MES test, and 363.20±144.47 seconds, about six minutes, for the MMSE.

For the elderly from the community who were the NCs, 4% rejected finishing the cognitive testing, but when subjects were willing to finish the MMSE, they also finished the MES. The outpatients were examined by a trained rater in the neuropsychological department. The completion rate of the patients with MCI and mild AD was 100%.

The scores of the four groups are presented in Table 2. The results of patients with aMCI were intermediate between the NC and AD groups. For the aMCI-sd group, the memory functions declined obviously, while the decrease of executive function was relatively slight. For the aMCI-md group, the executive function was inferior to that of the aMCI-sd group, as was memory function. In general, the cognitive deficits of the aMCI-md group were more serious than those of the aMCI-sd group. The pattern of cognitive deficits for aMCI-md was similar to that of mild AD.

As shown in Table 3, according to the area of the ROCs, the MES total score was more helpful for aMCI-sd and aMCI-md discrimination than was the MMSE. The MES-5R identified aMCI-sd better than the MES-EX, whereas for aMCI-md, the MES-EX was superior to the MES-5R.

In terms of the MES total score, 75–62 appears to be the range for patients with aMCI. Subjects exceeding 75 were usually considered as NCs, and subjects scoring less than 62 may be suspected as having dementia. In the range 75–62, the lower the score, the more likely the diagnosis of aMCI-md, while the higher the score, the more likely the diagnosis of aMCI-sd.

The ROC analyses performed on the aMCI-sd group yielded 0.89 for the area under the curve (AUC) (95% CI, 0.85–0.92) for the MES-total score, with sensitivity of 0.795 and specificity of 0.828 , and 81% correct classification rate when the cut-off was less than 75. The MMSE had 0.66 AUC (95% CI, 0.60–0.73), with sensitivity of 0.67 and specificity of 0.61, and 65% correct classification rate when the cut-off was less than 28. The AUC of the MES-total score was significantly higher than that of the MMSE (Z=6.948,P < 0.0001). The ROC graphs are presented in Figure 1.

The ROC analyses performed on the aMCI-md group yielded 0.95 for the area under the curve (AUC) (95% CI, 0.93–0.97) for the MES-total score, with sensitivity of 0.87 and specificity of 0.91, and 90% correct classification rate when the cut-off was less than 72. The MMSE had 0.71 AUC (95% CI, 0.66–0.76), with sensitivity of 0.67 and specificity of 0.70, and 69% correct classification rate when the cut-off was less than 28. The AUC of the MES-total score is significantly higher than that of the MMSE (Z=9.732,P < 0.0001). The ROC graphs are presented in Figure 2.

The ROC analyses performed on the mild AD group yielded 0.99 for the area under the curve (AUC) (95% CI, 0. 99–1.00) for the MES-total score, with sensitivity of 0.99 and specificity of 0.97, and 98% correct classification rate when the cut-off was less than 62. The MMSE had 0.985 AUC (95% CI, 0.97–0.99), with sensitivity of 0.91 and specificity of 0.98, and 95% correct classification rate when the cut-off was less than 25. The AUC of the MES-total score is significantly higher than that of the MMSE (Z=2.866,P =0.0042). The ROC graphs are presented in Figure 3.

Screening for dementia, much like screening for other diseases or chronic conditions, is a good way to detect the changes that can be signs of the onset of disease or other change in cognition. Memory screening and early detection provide:The ability to make lifestyle and other beneficial changes earlier in the disease process when they have the greatest potential for positive effect.

Time to connect with community-based information and supportive services prior to a potential crisis situation related to the needs of the person with dementia or the caregiver.

To enable people with dementia and their caregivers to benefit from memory screening and early detection, a community-based memory screening program was developed by the Wisconsin Department of Health Services and the Wisconsin Alzheimer’s Institute using the Animal Naming Screen, the Mini-cog, and the AD8.

The Animal Naming and Mini-cog tools were selected after a pilot study in Portage County in 2009. The Wisconsin Alzheimer’s Institute, the Aging and Disability Resource Center (ADRC) of Portage County, and DHS demonstrated the acceptability and effectiveness of using the Animal Naming and Mini-cog screens in a community setting. The Animal Naming screen is attached as Appendix C (PDF) and the Mini-cog as Appendix D (PDF)

Results from the pilot demonstrated ADRC customers’ high level of acceptance of screening. The offer of a memory screen was accepted by 243 out of 254 people, a 96% acceptance rate. This result contradicts the idea that people do not want to be screened for dementia. The tools were also effective in detecting cognitive issues. Of the 243 people who were screened, 150 (63%) had results that indicated they should follow up with their physician. This result may seem surprisingly high, but screens were only offered to individuals who expressed a concern about their memory, so those with cognitive issues self-selected into the study. Of those 150 people, 120 or 80% agreed to have the results sent to their physician.

The Animal Naming and Mini-cog screens were selected not only for their acceptability and effectiveness, but also because they are brief, easy to administer and score, and are sensitive to early cognitive changes. Some screens must be administered by physicians or psychologists and can take more than an hour. The minimum level of training required and the short length of time necessary to administer the screens was a critical component in their acceptance for use by ADRC staff.

The screens were also selected because they have documented utility as dementia screens and tap key skills likely to be affected in mild to moderate dementia. The Animal Naming screen involves retrieval from semantic memory and executive function, two areas of cognition that reliably decline in people with Alzheimer’s disease. In a study of memory clinic clients with a high base rate of dementia, the Animal Naming screen was shown to have 85% sensitivity and 88% specificity for differentiating Alzheimer’s disease and other dementia from normal cognition. The Mini-cog screen tests memory as well as visuoconstruction and executive function, with studies showing sensitivity for dementia of 76% to 99% and specificity of 83% to 93% in analyses that excluded patients with mild cognitive impairment.

Memory screens are voluntary, so there will be individuals who decline to participate. On these occasions, if family caregivers are uncertain whether their concerns about the person they are caring for are valid, the AD8 screen can help determine whether a visit to the doctor is recommended. The AD8 (PDF) tool is available in both English and Spanish. This screen is intended to help the caregiver think through the changes they see in a family member, and may help them to realize it is time to take action. The screen can be provided to the family caregiver to complete on their own, or the questions can be asked by the screener in a private setting. The AD8 has sensitivity for dementia of greater than 84% and a specificity of greater than 80%.

In 2020, the Montreal Cognitive Assessment (MoCA) tool was added to the approved tools for use by dementia care specialists (DCS). This tool is not for use by ADRC staff other than the DCS. The intention behind the addition of the MoCA screen is to give DCS an additional tool for situations that are more complex. While the Mini-cog and the Animal Naming screens are more sensitive to earlier changes than other screens, they are limited to a few areas of cognition. The MoCA covers a wider variety of cognitive tasks and provides additional insight into possible cognitive impairment when the Animal Naming and Mini-cog results do not reflect the changes in cognition and behavior reported by the individual or their family.

New dementia care specialists should become very familiar with the Animal Naming and Mini-cog tools prior to adding the MoCA to their toolkit. There are some similarities and some differences between the activities of the Animal Naming and Mini-cog and those in MoCA. Learning all the screens at the same time can be confusing, so it is advised for new staff to focus on the Animal Naming and Mini-cog screens, as well as the AD8, prior to becoming certified to provide the MoCA screen. Training and certification for the MoCA, and the approved form, are available from the official MoCA website. There is a cost to the training and certification for the MoCA. The MoCA is not required to be provided as a part of this program but is available as a supplemental tool.

The primary intent of this memory screening protocol is to enable and enhance conversations about memory concerns. The screens are not diagnostic tools and do not make any determinations about mental status. The screens are similar to a blood pressure check, in that a high blood pressure reading does not mean an individual has cardiovascular disease, but is a signal to talk to a physician about the results. The screens can be a reason to bring up the topic of memory issues because they can be offered in the moment. A referral to the physician can be more meaningful if an objective tool verifies that an individual’s concerns with memory and cognition should be further assessed.

It is appropriate to offer a memory screen when one is requested, or when working with a customer who displays signs of possible memory loss or confusion. ADRC specialists are able to offer the screening program during a visit for another purpose, if time allows. It is preferable to address the concerns around memory at the time, rather than putting off the discussion for another appointment. Memory screening is always voluntary.

Staff members may feel uncomfortable offering a memory screen if they are not used to asking and answering questions about memory and dementia. It is important that staff who are offering the screens understand why screening is important and helpful to the customer. Practicing offering the screen to coworkers and family members can be a good way to become more comfortable. Staff must be trained to follow the guidance in this manual before performing memory screens with the public.

If other people are present for the screening, let them know they will need to remain quiet and not help the person answer the questions. Ensure the participant cannot easily view and copy a clock in the room.

Begin with Animal Naming. It is critical to read the instructions for each task on both screens exactly as they are written. Do not explain how the screen is scored prior to performing the screen, and only afterwards if the individual asks you to do so. To adhere to the fidelity of the tools, they must be performed exactly the same way every time to ensure the results are valid. Read the instructions to the participant: “Please name as many animals as you can think of as quickly as possible.” Be prepared for the person to start listing animals immediately or, if they do not, prompt them with “Go.”

Once the person begins to name animals, start the timer and record all the animals named within 60 seconds in the spaces provided on the worksheet. If the person is speaking quickly, write as much of the word as needed to remember what was said and fill in the remaining letters afterward. If the person falls silent, follow the prompting instructions. Once the Animal Naming screen is done, administer the Mini-cog, even if the score of the Animal Naming screen was very high. The two screens should always be used together.

The Memory Screening in the Community program is intended for the Animal Naming tools and the Mini-cog tool to be used in combination. In this non-clinical program, the standard Mini-cog tool available online has been adapted to work in concert with the Animal Naming Tools. Refer to Appendix D to access the form to record results.

Begin the Mini-cog by telling the participant, “I am going to say three words I want you to remember,” and repeat the three words listed on the worksheet. Be sure to read the instructions exactly as they are written. It is important to the fidelity of the screen to use the same three words every time the screen is performed. Give the participant three chances to repeat the words back. If the participant does not repeat the words, or does not repeat them correctly, the screener can repeat the words up to three times until the words are repeated correctly. If they are not correct after the third time, move on to the clock draw.

Provide a blank, standard, letter-size sheet of paper for the participant to draw on and a writing utensil. This can be the back of the Animal Naming worksheet or another blank sheet. Allow the participant time to adjust to the new task, pick up the writing utensil, and adjust the paper. Once the participant is settled, read the instructions for the clock draw exactly as they are written, pausing when indicated to allow the participant to complete the task. Move on from this task if the clock is not complete within three minutes.

There will be individuals that frequently request to be screened. If they express the desire for an alternate set of words used for the three-word recall portion, refer to the words listed in the Health Equity section for Hmong translation. The need for an alternative set of words was first identified in the need for the translation of the words into Hmong. they do not easily translate into that language, so an alternative set of words was identified for that purpose. That substitution can also be applied for individuals who request frequent screening.

The AD8 can be administered to the person with possible memory loss, but often individuals with dementia lose insight into their condition and are not reliable self-reporters. The questions on the screen can either be read aloud or a caregiver can fill out the form on their own. In situations where the person with possible memory loss is together with the caregiver, allowing the caregiver to fill out the questionnaire silently may be less upsetting for the person with possible memory loss than if the questions are asked aloud. The caregiver may also provide different answers if the person with possible memory loss is listening to the answers.

The MoCA tool, including training, certification, and the downloadable version of the paper tool can be found on the MoCA website. The MoCA is also available to be used digitally. Instructions for how the MoCA tool is scored are a part of the training and certification process.

The Memory Screening in the Community program was adapted in 2020 during the COVID-19 pandemic for use when screening was required to be completed virtually. The ability to provide screening virtually for dementia risk has been identified as an ongoing need. Please consult Section IV: Accessibility and Health Equity Considerations for a description of the adaptation for virtual access.

The use of the Animal Naming and Mini-cog tools in the Memory Screening in the Community Program is different than as a part of Wisconsin’s Long-Term Care Functional Screen (LTCFS). The purposes for the use of these tools in the Memory Screening in the Community Program are to enable a conversation and assist in determining whether speaking to a physician is advisable. The LTCFS uses the tools to represent “memory loss” if the individual being screened states that they have memory loss but do not have an accompanying diagnosis of dementia. The LTCFS is used to determine functional eligibility for long-term care programming and uses the results of the screens independently. The scoring key for the Memory Screening in the Community Program to determine if a referral is recommende