Development of a Swedish short version of the Montreal Cognitive Assessment for cognitive screening in patients with stroke
Keywords:cognitive function, disorder, Montreal Cognitive Assessment, sensitivity, specificity, stroke
Objective: The primary objective was to develop a Swedish short version of the Montreal Cognitive Assessment (s-MoCA-SWE) for use with patients with stroke. Secondary objectives were to identify an optimal cut-off value for the s-MoCA-SWE to screen for cognitive impairment and to compare its sensitivity with that of previously developed short forms of the Montreal Cognitive Assessment.
Design: Cross-sectional study.
Subjects/patients: Patients admitted to stroke and rehabilitation units in hospitals across Sweden.
Methods: Cognition was screened using the Montreal Cognitive Assessment. Working versions of the s-MoCA-SWE were developed using supervised and unsupervised algorithms.
Results: Data from 3,276 patients were analysed (40% female, mean age 71.5 years, 56% minor stroke at admission). The suggested s-MoCA-SWE comprised delayed recall, visuospatial/executive function, serial 7, fluency, and abstraction. The aggregated scores ranged from 0 to 16. A threshold for impaired cognition ≤ 12 had a sensitivity of 97.41 (95% confidence interval, 96.64–98.03) and positive predictive value of 90.30 (95% confidence interval 89.23–91.27). The s-MoCA-SWE had a higher absolute sensitivity than that of other short forms.
Conclusion: The s-MoCA-SWE (threshold ≤ 12) can detect post-stroke cognitive issues. The high sensitivity makes it a potentially useful “rule-out” tool that may eliminate severe cognitive impairment in people with stoke.
Stroke survivors have an increased risk of developing cognitive impairment, a common consequence of stroke. Therefore, many international guidelines recommend cognitive screening for all patients admitted to hospital with stroke. The Montreal Cognitive Assessment (MoCA) has been recommended as an appropriate cognitive test to be applied in stroke units. Although the administration of MoCA takes approximately 15 min, the screening can take longer in patients with acute stroke. Therefore, this study aimed to develop a Swedish short version of the Montreal Cognitive Assessment (s-MoCA-SWE) based on data from a large Swedish sample of acute and early subacute stroke survivors. The current study analysed data from 3,276 patients and suggest an s-MoCA-SWE that comprised the following tasks: delayed recall, visuospatial/executive function, serial 7, fluency, and abstraction. The s-MoCA-SWE could identify cognitive impairment in 97% of patients. In conclusion, s-MoCA-SWE has the potential to rule out severe cognitive impairment.
Lanctôt KL, Lindsay MP, Smith EE, Sahlas DJ, Foley N, Gubitz G, et al. Canadian stroke best practice recommendations: mood, cognition and fatigue following stroke, 6th edition update 2019. Int J Stroke 2020; 15: 668–688. DOI: 10.1177/1747493019847334 DOI: https://doi.org/10.1177/1747493019847334
Verdelho A, Wardlaw J, Pavlovic A, Pantoni L, Godefroy O, Duering M, et al. Cognitive impairment in patients with cerebrovascular disease: a white paper from the links between stroke ESO Dementia Committee. Eur Stroke J 2021; 6: 5–17. DOI: 10.1177/23969873211000258 DOI: https://doi.org/10.1177/23969873211000258
Stolwyk RJ, Mihaljcic T, Wong DK, Chapman JE, Rogers JM. Poststroke cognitive impairment negatively impacts activity and participation outcomes: a systematic review and meta-analysis. Stroke 2021; 52: 748–760. DOI: 10.1161/STROKEAHA.120.032215 DOI: https://doi.org/10.1161/STROKEAHA.120.032215
Elliott E, Drozdowska BA, Taylor-Rowan M, Shaw RC, Cuthbertson G, Quinn TJ. Who is classified as untestable on brief cognitive screens in an acute stroke setting? Diagnostics (Basel) 2019; 9: 10.3390. DOI: 10.3390/diagnostics9030095 DOI: https://doi.org/10.3390/diagnostics9030095
Chiti G, Pantoni L. Use of Montreal Cognitive Assessment in patients with stroke. Stroke 2014; 45: 3135–3140. DOI: 10.1161/STROKEAHA.114.004590 DOI: https://doi.org/10.1161/STROKEAHA.114.004590
Lees RA, Hendry Ba K, Broomfield N, Stott D, Larner AJ, Quinn TJ. Cognitive assessment in stroke: feasibility and test properties using differing approaches to scoring of incomplete items. Int J Geriatr Psychiatry 2017; 32: 1072–1078. DOI: 10.1002/gps.4568 DOI: https://doi.org/10.1002/gps.4568
Horton DK, Hynan LS, Lacritz LH, Rossetti HC, Weiner MF, Cullum CM. An abbreviated Montreal Cognitive Assessment (MoCA) for dementia screening. Clin Neuropsychol 2015; 29: 413–425. DOI: 10.1080/13854046.2015.1043349 DOI: https://doi.org/10.1080/13854046.2015.1043349
McDicken JA, Elliott E, Blayney G, Makin S, Ali M, Larner AJ, et al. Accuracy of the short-form Montreal Cognitive Assessment: systematic review and validation. Int J Geriatr Psychiatry 2019; 34: 1515–1525. DOI: 10.1002/gps.5162 DOI: https://doi.org/10.1002/gps.5162
Pendlebury ST, Welch SJ, Cuthbertson FC, Mariz J, Mehta Z, Rothwell PM. Telephone assessment of cognition after transient ischemic attack and stroke: Modified telephone interview of cognitive status and telephone Montreal Cognitive Assessment versus face-to-face Montreal Cognitive Assessment and neuropsychological battery. Stroke 2013; 44: 227–229. DOI: 10.1161/STROKEAHA.112.673384 DOI: https://doi.org/10.1161/STROKEAHA.112.673384
Wittich W, Phillips N, Nasreddine ZS, Chertkow H. Sensitivity and specificity of the Montreal Cognitive Assessment modified for individuals who are visually impaired. J Vis Impair Blind 2010; 104: 360–368. DOI:10.1177/0145482X1010400606 DOI: https://doi.org/10.1177/0145482X1010400606
Cameron JD, Gallagher R, Pressler SJ, McLennan SN, Ski CF, Tofler G, et al. Sensitivity and specificity of a five-minute cognitive screening test in patients with heart failure. J Card Fail 2016; 22: 99–107. DOI: 10.1016/j.cardfail.2015.08.343 DOI: https://doi.org/10.1016/j.cardfail.2015.08.343
Kaur D, Kumar G, Singh AK. Quick screening of cognitive function in Indian multiple sclerosis patients using Montreal Cognitive Assessment test-short version. Ann Indian Acad Neurol 2013; 16: 585–589. DOI: 10.4103/0972-2327.120478 DOI: https://doi.org/10.4103/0972-2327.120478
Lim JS, Oh MS, Lee JH, Jung S, Kim C, Jang MU, et al. Prediction of post-stroke dementia using NINDS-CSN 5-minute neuropsychology protocol in acute stroke. Int Psychogeriatr 2017; 29: 777–784. DOI: 10.1017/S1041610216002520 DOI: https://doi.org/10.1017/S1041610216002520
Lin H-F, Chern C-M, Chen H-M, Yeh Y-C, Yao S-C, Huang M-F, et al. Validation of NINDS-VCI neuropsychology protocols for vascular cognitive impairment in Taiwan. PloS One 2016: 11: e0156404. DOI: 10.1371/journal.pone.0156404 DOI: https://doi.org/10.1371/journal.pone.0156404
Wei J, Jin X, Chen B, Liu X, Zheng H, Guo R, et al. Comparative study of two short-form versions of the Montreal Cognitive Assessment for screening of post-stroke cognitive impairment in a Chinese population. Clin Interv Aging 2020; 15: 907–914. DOI: 10.2147/CIA.S248856 DOI: https://doi.org/10.2147/CIA.S248856
Abzhandadze T, Lundström E, Buvarp D, Eriksson M, Quinn TJ, Sunnerhagen KS. Development of a short-form Swedish version of the Montreal Cognitive Assessment (s-MoCA-SWE): protocol for a cross-sectional study. BMJ Open 2021; 11: e049035. DOI: 10.1136/bmjopen-2021-049035 DOI: https://doi.org/10.1136/bmjopen-2021-049035
Noel-Storr AH, McCleery JM, Richard E, Ritchie CW, Flicker L, Cullum SJ, et al. Reporting standards for studies of diagnostic test accuracy in dementia: The STARDdem Initiative. Neurology 2014; 83: 364–373. DOI: 10.1212/WNL.0000000000000621 DOI: https://doi.org/10.1212/WNL.0000000000000621
Lundström E, Isaksson E, Näsman P, Wester P, Mårtensson B, Norrving B, et al. Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2020; 19: 661–669. DOI: 10.1016/S1474-4422(20)30219-2 DOI: https://doi.org/10.1016/S1474-4422(20)30219-2
Asplund K, Eriksson M, Riks-Stroke Collaboration. Inflammation, poststroke depression and statins. Int J Stroke 2011; 6: 567–568. DOI: 10.1111/j.1747-4949.2011.00691.x DOI: https://doi.org/10.1111/j.1747-4949.2011.00691.x
Bernhardt J, Hayward KS, Kwakkel G, Ward NS, Wolf SL, Borschmann K, et al. Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce. Int J Stroke 2017; 12: 444–450. DOI: 10.1177/1747493017711816 DOI: https://doi.org/10.1177/1747493017711816
Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005; 53: 695–699. DOI: 10.1111/j.1532-5415.2005.53221.x DOI: https://doi.org/10.1111/j.1532-5415.2005.53221.x
Kasner SE, Chalela JA, Luciano JM, Cucchiara BL, Raps EC, McGarvey ML, et al. Reliability and validity of estimating the NIH stroke scale score from medical records. Stroke 1999; 30: 1534–1537. DOI: 10.1161/01.str.30.8.1534 DOI: https://doi.org/10.1161/01.STR.30.8.1534
Fischer U, Baumgartner A, Arnold M, Nedeltchev K, Gralla J, De Marchis GM, et al. What is a minor stroke? Stroke 2010; 41: 661–666. DOI: 10.1161/STROKEAHA.109.572883 DOI: https://doi.org/10.1161/STROKEAHA.109.572883
Child D. Essentials of factor analysis. New York: Continuum; 2006.
Kline P. An easy guide to factor analysis. London: Routledge; 1994.
Kuhn M, Silge J. Tidy Modeling with R. "O'Reilly Media, Inc."; 2022 Jul 12.
Chen T, Guestrin C. Xgboost: A scalable tree boosting system. InProceedings of the 22nd acm sigkdd international conference on knowledge discovery and data mining 2016; Aug 13, (pp. 785–794). DOI: https://doi.org/10.1145/2939672.2939785
Mandrekar JN. Receiver operating characteristic curve in diagnostic test assessment. J Thorac Oncol 2010; 5: 1315–1316. DOI: 10.1097/JTO.0b013e3181ec173d DOI: https://doi.org/10.1097/JTO.0b013e3181ec173d
Roalf DR, Moore TM, Wolk DA, Arnold SE, Mechanic-Hamilton D, Rick J, et al. Defining and validating a short form Montreal Cognitive Assessment (s-MoCA) for use in neurodegenerative disease. J Neurol Neurosurg Psychiatry 2016; 87: 1303–1310. DOI: 10.1136/jnnp-2015-312723 DOI: https://doi.org/10.1136/jnnp-2015-312723
Bezdicek O, Červenková M, Moore TM, Stepankova Georgi H, Sulc Z, Wolk DA, et al. Determining a short form Montreal Cognitive Assessment (s-MoCA) Czech version: validity in mild cognitive impairment Parkinson’s disease and cross-cultural comparison. Assessment 2020; 27: 1960–1970. DOI: 10.1177/1073191118778896 DOI: https://doi.org/10.1177/1073191118778896
Cecato JF, Martinelli JE, Izbicki R, Yassuda MS, Aprahamian I. A subtest analysis of the Montreal Cognitive Assessment (MoCA): which subtests can best discriminate between healthy controls, mild cognitive impairment and Alzheimer’s disease? Int Psychogeriatr 2016; 28: 825–832. DOI: 10.1017/S1041610215001982 DOI: https://doi.org/10.1017/S1041610215001982
Abzhandadze T, Reinholdsson M, Sunnerhagen KS. NIHSS is not enough for cognitive screening in acute stroke: a cross-sectional, retrospective study. Sci Rep 2020; 10: 534–534. DOI: 10.1038/s41598-019-57316-8 DOI: https://doi.org/10.1038/s41598-019-57316-8
Lees R, Selvarajah J, Fenton C, Pendlebury ST, Langhorne P, Stott DJ, et al. Test accuracy of cognitive screening tests for diagnosis of dementia and multidomain cognitive impairment in stroke. Stroke 2014; 45: 3008–3018. DOI: 10.1161/STROKEAHA.114.005842 DOI: https://doi.org/10.1161/STROKEAHA.114.005842
Abzhandadze T, Buvarp D, Lundgren-Nilsson Å, Sunnerhagen KS. Barriers to cognitive screening in acute stroke units. Sci Rep 2021; 11: 19621. DOI: 10.1038/s41598-021-98853-5 DOI: https://doi.org/10.1038/s41598-021-98853-5
Chan E, Khan S, Oliver R, Gill SK, Werring DJ, Cipolotti L. Underestimation of cognitive impairments by the Montreal Cognitive Assessment (MoCA) in an acute stroke unit population. J Neurol Sci 2014; 343: 176–179. DOI: 10.1016/j.jns.2014.05.005 DOI: https://doi.org/10.1016/j.jns.2014.05.005
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