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Normative data for the ACE-R in an Italian population sample



The Addenbrooke's Cognitive Examination Revised (ACE-R) is a brief cognitive screening instrument also proposed to detect mild cognitive impairment, a high-risk condition for Alzheimer's disease and other forms of dementia. In this study, we report normative data on the ACE-R-Italian version, collected on a sample of 264 Italian healthy subjects aging between 60 and 93 years, and with a formal education from 1 to 19 years. The global normal cognition was established in accordance with the Italian version of the Mini-Mental State Examination score and with exclusion criteria derived by a consensus process. Linear regression analysis was performed to evaluate the effect of age, gender, and education on the ACE-R total performance score. We provide correction grids to adjust raw scores and equivalent scores with cut-off value to allow comparison between ACE-R performance and others neuropsychological test scores that can be administered to the same subject.
Normative data for the ACE-R in an Italian population sample
Martina Pigliautile
Francesca Chiesi
Sonia Rossetti
Manuela Conestabile della
Monica Ricci
Stefano Federici
Dora Chiloiro
Caterina Primi
Patrizia Mecocci
Received: 17 April 2015 / Accepted: 6 July 2015
ÓSpringer-Verlag Italia 2015
Abstract The Addenbrooke’s Cognitive Examination
Revised (ACE-R) is a brief cognitive screening instrument
also proposed to detect mild cognitive impairment, a high-
risk condition for Alzheimer’s disease and other forms of
dementia. In this study, we report normative data on the
ACE-R-Italian version, collected on a sample of 264 Italian
healthy subjects aging between 60 and 93 years, and with a
formal education from 1 to 19 years. The global normal
cognition was established in accordance with the Italian
version of the Mini–Mental State Examination score and
with exclusion criteria derived by a consensus process.
Linear regression analysis was performed to evaluate the
effect of age, gender, and education on the ACE-R total
performance score. We provide correction grids to adjust
raw scores and equivalent scores with cut-off value to
allow comparison between ACE-R performance and others
neuropsychological test scores that can be administered to
the same subject.
Keywords ACE-R Normative data Screening
The revised version of the Addenbrooke’s Cognitive
Examination (ACE-R) [1] is a screening test that takes
between 12 and 20 min to be administered and with a score
specifically developed to improve sensibility and speci-
ficity of the Addenbrooke’s Cognitive Examination (ACE)
[2] for detecting dementia. It consists by a 100 points scale
assessing attention, memory, fluency, language, and visu-
ospatial cognitive domains. The ACE-R has been proposed
to detect mild cognitive impairment from cognitive chan-
ges of normal aging [1], to diagnose of different forms of
dementia [3] and to differentiate diagnosis early dementias
versus affective disorders [4].
The ACE-R has been validated into different languages
[5], and a meta-analysis demonstrated its superior diag-
nostic accuracy respect to the Mini Mental State Exami-
nation (MMSE) [6].
The use of the ACE-R has been considered as a poten-
tially useful tool by the Scottish Intercollegiate Guidelines
Network [7], and it is recommended in both modest (gen-
eral hospital and primary care) and high prevalence settings
(memory clinics) [6].
In 2006, Pigliautile et al. [8] translated the test,
instructions for administration and scoring into Italian. The
Italian ACE-R has high sensitivity and specificity and it is
indicated as a useful tool to detect mild dementia in the
elderly population (young-old and old-old population) but
to date Italian normative data are still lacking.
The aim of the present study was to collect normative
data for the ACE-R Italian version in a sample of
&Martina Pigliautile
Section of Gerontology and Geriatrics, Department of
Medicine, University of Perugia, Perugia, Italy
Department of Neuroscience, Psychology, Drug Research,
and Child’s Health (NEUROFARBA)-Section of Psychology,
University of Florence, Florence, Italy
Unit of Clinical Psychology, Azienda Sanitaria Locale,
Taranto, Italy
ARC Centre of Excellence in Cognition and its Disorders,
Macquarie University, Sydney, Australia
Social and Human Sciences and Education, Department of
Philosophy, University of Perugia, Perugia, Italy
Neurol Sci
DOI 10.1007/s10072-015-2330-y
cognitively healthy Italian subjects ranging from 60 to
93 years of age.
Effects of age, gender, and education on performance
were considered, and the raw scores were transformed into
equivalent score (ES) so that scores achieved on the ACE-
R can be easily comparable with those obtained in other
tests, allowing, therefore, a better characterisation of
patient profile.
The study included 264 (147 woman, 117 men) cognitively
healthy subjects aged 60–93 years (mean 72.91 ±7.96).
Years of schooling ranged from 1 to 19 years (mean
9.74 ±4.80). Subjects were recruited from recreation
centers for the elderly in Perugia, from community or
among friends/spouses/relatives of subjects attending Sec-
tion of Gerontology and Geriatrics, Department of Medi-
cine, University of Perugia and Unit of Clinical
Psychology, Azienda Sanitaria Locale of Taranto. Subjects
were recruited on a voluntary basis from September 2011
to June 2014.
The study was approved by the local ethics committees
and performed in accordance with the Helsinki
Inclusion criteria were (a) a MMSE [9] score C24;
(b) no history of traumatic brain injury; (c) no history of
stroke; (d) no history of neurological disorders; (e) no
history of psychiatric disorders; and (f) no clinical evidence
or history of depression.
The inclusion criteria (b)–(d) were assessed by a brief
In order to avoid selecting a sample of ‘‘supernormal’’
subjects, we did not exclude individuals with pharmaco-
logical well-compensated hypertension, diabetes, and
anxious/depressive symptoms, and corrected sensory defi-
cits were allowed.
In order to ensure the normal cognitive functioning in
the oldest old (subjects aging C80 years), a detailed neu-
ropsychological assessment was carried out using an
extensive battery of cognitive tests comprehensive of test
with high ecological validity (see below). In this subsam-
ple, minimal supervision at the basic activities of daily
living or minimal disabilities in instrumental activities of
daily living due to physical problems were allowed.
Materials and procedure
All subjects were assessed by a trained psychologist in a
quiet and comfortable room. After a clinical interview, the
Italian version of the ACE-R [8], embedding the MMSE,
was administered.
The oldest old assessment was conducted by means of a
neuropsychological battery administered according to
standard instructions and procedures in order to obtain a
cognitive profile in attention/executive function (Visual
Search Test, Trail Making Test A and B, items of the Test
of Everyday Attention), short-term memory (Digit Span
Forward task), working memory (Digit Span Backward
task), memory (Rey Auditory Verbal Learning Test, story
recall, Rivermead Behavioral Memory Test—Third Edi-
tion), language (letter and category fluency task, Token
Test and Communicative Abilities of Daily Living—Se-
cond Edition), visuospatial functions (copy drawing test),
intelligence (Raven’s Colored Progressive Matrices and
verbal task). Administration procedures and Italian nor-
mative data for score adjustment for age and education as
well as normality cut-off scores are available [10].
Statistical methods
The scores of control subjects were analyzed by means of
simultaneous multiple regression, to check the influence
of age, gender, and education. Before running the linear
regression analyses, univariate distributions of the quan-
titative predictors and outcome variable were examined
for assessment of normality. Normality was checked by
means of skewness and kurtosis. If skewness and kurtosis
indices fall within the range of -1to?1, the departures
from normality can be considered not significant [11], and
the linear regression model can be applied without the
need of mathematical transformations. Otherwise, the
better mathematical transformation (e.g., square root, log,
inverse) should be applied to the data to more closely
meet the assumptions of the normality of distributions for
the linear regression model, and to select the most robust
Then, for the ACE-R test, we evaluated the best fitting
linear regression model that could be used to adjust the
original scores according to the demographic variables. To
this aim, we estimated a linear model able to calculate the
score expected for a given subject on the basis of his/her
age, gender, and education. The simultaneous regression
included the variables that resulted significant when con-
sidered one at the time. At this stage, the effect of each
predictor variable was studied partialling out the effect held
in common with the other terms of the model. Taking this
model as a basis, we calculated from the raw score an
adjusted score, by adding or subtracting the contribution
given by each significant concomitant variable in the final
correction model. Following this approach, scores can be
directly confronted across subjects of different demo-
graphic data.
Neurol Sci
Adjusted scores were then ranked, and we used a non-
parametric procedure to determine the lower (outer) and
upper (inner) limit of the tolerance interval for test per-
formance with a confidence level of 95 % [12]. Above the
outer tolerance limit, one expects to find at least 95 % of
the normal population (with 95 % confidence): hence,
when a score is below the outer tolerance limit, the subject
can be declared ‘‘not normal’’ with 95 % confidence.
Above the inner tolerance limit, one expects to find at most
95 % of the population (with 95 % confidence): hence,
when a score is above the inner tolerance limit, the subject
can be declared ‘‘normal’’ with 95 % confidence.
When a score falls between the outer and inner tolerance
limits, no inferentially controlled judgment is possible.
Given our sample size (N=264), the outer limit, under
which a performance may be considered abnormal, corre-
sponds to the 8th scalar observation and the inner limit,
above which a performance may be considered normal, to
the 20th worst observation. To avoid errors due to the fixed
upper limit of the test scores, no adjustment was made to
scores of 100/100. The adjusted scores were classified into
five categories (equivalent scores) endowed at least with an
ordinal relationship: 0 =scores lower than the outer 5 %
tolerance limits; 4 =scores higher than the median value
of the sample; 1, 2, and 3 =intermediate scores between
the central value and the pathology threshold on a quasi-
interval scale (i.e., scores equal/lower than 10.2, 25.4, and
50 % of the normative sample distribution, respectively).
Demographic distribution of the study population is
reported in Table 1.
Examining the distribution of variables to check for non-
normally distributed variables, we found that skewness and
kurtosis indices were within the acceptable range of -1to
?1. Thus, departures from normality can be considered
irrelevant [11], and the linear regression analyses were run
without the need of mathematical transformations to the
The results of the regression analyses are shown in
Table 2. The influence of age and education was signifi-
cant, whereas there was not an effect of gender.
Table 3reports the correction grid for the most frequent
combinations of age and education. Intermediate values
can be obtained by interpolation or using the original linear
models reported in Table 2. Inner and outer tolerance
limits are also reported: subjects with scores below the
outer limit should be considered pathological, while those
with scores above the inner limit can be considered normal.
Subjects with scores included between the outer and the
inner limits are better viewed as ‘‘borderline’’ cases.
Finally, the values delimiting the Equivalent Scores (ES)
are reported in Table 4.
In order to illustrate the raw score adjustment, we took
into account the case of a 65-year-old respondent with
13 years of schooling. The original raw score achieved on
ACE-R was 82/100; the adjusted score becomes
82 ?(-5.36) =76.64 so that the corresponding ES is 2.
The ACE-R has had a large diffusion in the last years, since
it is able to provide information on a wide range of cog-
nitive domains. In addition, it has high sensitivity and
specificity to differentiate people with and without
Table 1 Demographic
distribution of the sample Age and education 60–64 65–69 70–74 75–79 80–84 85?TOT
\5 – 4723521
5 11111911 7 665
6–8 9 12 15 8 6 6 56
9–13 16 19 16 17 7 5 80
[13 610958442
TOT 42 56 66 43 31 26 264
Table 2 The effects of age,
education (expressed as years of
schooling), and gender within
the linear regression model of
the Italian ACE-R
Simple regression Simultaneous regression
Age: F (1262) =23.41, p\0.001 Age (education partialled out): F (1261) =25.15, p\0.001
Education: F (1262) =90.59, p\0.001 Education (age partialled out): F (1261) =92.51, p\0.001
Sex: F (1262) =0.757, ns
Adjusted score: raw score ?0.293 (age -72.91) -0.932 (education -9.74)
Neurol Sci
cognitive impairment [5]. The ACE-R is somewhat supe-
rior in diagnostic accuracy compared to the MMSE and it
has been recommended in primary care, general hospital,
and memory clinic [6].
In a recent review—dedicated to identify brief cognitive
tests for people with suspected dementia, and determine
their level and quality of evidence in clinical settings—the
ACE-R has been associated to the best level of evidence
However, recent studies have shown that a great caution
is needed in using neuropsychological tests in subjects
from cultural background different from the one that pro-
vided the normative data [14,15].
In fact, the ACE-R performance varies according to age
and education, and different classification criteria (cut-off)
were found in different cultural contexts. In the Italian
ACE-R validation study, two cut-offs have been estab-
lished for young-old and old-old subjects, and these values
are lower than those proposed for English-speaking popu-
lations (United Kingdom and Australia). For example, if
we adopt the original English criteria [1], the 35 % (cut-off
82) or the 65 % (cut-off 88) of the Italian healthy sample
[8] would have been classified as cognitively
So, normative data represent an important aspect for the
clinical use of any psychometric instrument, and this study
provides the Italian ACE-R normative data.
To our knowledge, the present study is the first to pro-
vide age and education adjusted scores and equivalent
scores on the ACE-R.
On the basis of this study, Italian clinicians will be able
to use ACE-R taking into account the main demographic
aspects by means of the proposed correction grid. More-
over, thanks to the equivalent scores, it will be possible to
compare the performance on Italian ACE-R with other tests
for which equivalent scores are available, allowing direct
comparison of performance across the tests, independently
of the difficulty of the single task.
We propose a single cut-off point (66.92) to distinguish
subjects with or without cognitive impairment.
Similarly to the original study [1], gender does not affect
the performance on the ACE-R total score. However, we
found an effect of both age and education that confirms the
results reported in recent publications on normative data
In particular, accordingly to other studies, we found that
younger participants showed a better total ACE-R score
than older individuals, and those with higher education had
better scores than those with lower education.
As in the Brazilian normative study [16], the Italian
normative data take into account the neuropsychological
evaluation of oldest old subjects—a segment of population
at higher risk of developing cognitive problems— which is
estimated to increase quickly in the next future [19].
The new cut-off value (66.92) is lower than those pro-
posed for the ACE-R (88, 82, and 75) [5], an aspect that
may depend on the different socio-demographic variables
in the Italian population.
The main limit of our study is the relatively small size of
the study sample. But, on the other hand, study subjects
have been recruited in different Italian regions and are
widely distributed across ages and education classes.
Considering the neuropsychological value of the Italian
ACE-R, it is noteworthy that it embeds the MMSE, still
Table 3 Adjustments to be
added to, or subtracted from, the
ACE-R raw scores according to
age and education (expressed as
years of schooling)
Education Age
60 65 70 75 80 85 90
\5 1.60 3.02 4.49 5.95 7.42 8.88 10.35
5 0.64 2.10 3.57 5.03 6.50 7.96 9.43
8-2.16 -0.70 0.77 2.23 3.70 5.16 6.63
13 -6.82 -5.36 -3.89 -2.43 -0.96 0.50 1.97
18 -11.48 -10.02 -8.55 -7.09 -5.62 -4.16 -2.69
Table 4 Equivalent scores (ES)
classification of adjusted scores
of the Italian ACE-R
Equivalent scores (ES) Score interval Density Cumulative frequency
0B66.92 8 8
1 66.93–73.94 19 27
2 73.95–79.86 40 67
3 79.87–84.93 65 132
4[84.93 132 264
ES =0 corresponds to an inferentially controlled judgement of being below the norm; 4 is equal or better
than the 50th percentile; 1, 2, and 3 are intermediate between 0 and 4 on a quasi-interval scale
Neurol Sci
recently defined as the ‘‘benchmark against which all
newer tools can be measured’’ [20].
In fact, despite its reported limits and disadvantages [13,
21], the MMSE remains the most widely used brief cog-
nitive test, an aspect also related to the so-called ‘‘test
inertia’’—the clinician’s reluctance to move beyond tradi-
tional tests [22]—that guarantees a long-lasting life to well-
known tools.
After many years from its publication, most of the
clinicians have familiarity with the MMSE administration,
scoring, and interpretation. Moreover, MMSE score allows
to classify dementia severity, to share information between
clinicians and researchers, and to compare population data.
With this perspective, incorporating the MMSE items,
ACE-R represents an optimal approach to introduce inno-
vation without breaking with the past.
Unfortunately, the MMSE is protected by copyright in
English-speaking countries [23], and significant costs are
now associated with its use [13].
Recently, the Addenbrooke’s Cognitive Examination III
(ACE III) [24] has been published. The ACE III is a
revision of the ACE-R that does not embed the MMSE and
contains different items, in order to improve the psycho-
metric properties of the test maintaining 100 as maximum
score evaluating the same cognitive domains. The ACE III
allows higher psychometric properties than ACE-R and
cuts down costs derived from the MMSE.
However, until a new test will be able to replace the
MMSE, the use of the ACE-R seems to remain the most
accepted solution in research settings.
Acknowledgments The authors acknowledge the control subjects
and all the physicians at the Santa Maria della Misericordia Hospital
in Perugia and the psychologists at the Clinical Psychology and
Psychotherapy Adult and Developmental Ages in Taranto for their
involvement in this study.
Compliance with ethical standards
Conflict of interest The authors declare that the research was
conducted in the absence of any commercial or financial relationships
that could be construed as a potential conflict of interest.
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... In this setting, normative data are necessary to avoid false positives and false negatives, especially with aging. The validation of the Spanish version of the ACE-III and other studies of previous versions of the test [5][6][7] showed an influence of age and education on the performance of the test. For this reason, the aim of this study was to provide normative data for the Spanish version of the ACE-III for age, education and gender. ...
... We found that all subscores of the ACE-III were influenced by age and education. These results are in agreement with the main normative studies performed in different populations and languages with previous versions of the ACE [5][6][7] . However, the correlation of age with the attention domain was lower than that with the other subscores of the test. ...
... Overall, the influence of gender on the ACE-III and its subscores, although significant, is generally low. This is consistent with previous normative studies in other versions of the test, in which the influence of gender was low but present in the ACE-III or some subscores [5][6][7][19][20][21] . However, according to the results of the multiple regression analysis, we have decided to include a gender correction to provide the most accurate calculation of the normalized scores. ...
Background: Addenbrooke's Cognitive Examination III (ACE-III) is a cognitive test that has been validated for the diagnosis of cognitive disorders. The aim of this study was to provide normative data for the ACE-III for age, education and gender. Methods: The Spanish version of the ACE-III was administered to a group of 273 healthy subjects in a multicenter study in Spain. Correlation and determination coefficients for age, education and gender were estimated. The overlapping interval strategy and linear regression analyses were used to provide adjusted norms for demographic factors and to explore the potential influence of these factors in the performance of the test. Results: Age and education correlated significantly with the total score and with all the domains. Gender correlated only with the domains of attention and visuospatial skills. Norms for the total score and for cognitive domains (attention, memory, fluency, language, and visuospatial skills) are provided. Conclusion: This study confirms the influence of demographic factors (especially age and education) on the performance in the ACE-III and provides normative data for the Spanish version of the ACE-III.
... The Italian version maintained good sensitivity and specificity for identifying early dementia in the young-old and old-old population [19]. Recently, the normative data for the total score of ACE-R Italian version have been derived from a sample of cognitively healthy subjects ranging from 60 to 93 years [20], whereas normative data for sub-scores are not available yet. ...
... Last, although we excluded participants affected by severe medical conditions, we included in our sample patients with mild hypertension or non-complicated diabetes to avoid assessing a ''hyper-normal'' sample [24]. In the first validation study of the ACE-R Italian version, two cut-offs have been established for young-old and old-old subjects (79 and 60) [19], whereas in a subsequent study a single age-and education-adjusted cut-off point B66.92 for ACE-R total score has been proposed, but this only applies to subjects aged 60-93 years [20]. The cut-off value of B71.78 for ACE-R total score found in the present study is higher than that reported in the original study on older subjects (B66.92) ...
... The cut-off value of B71.78 for ACE-R total score found in the present study is higher than that reported in the original study on older subjects (B66.92) [20], but such values are considerably lower than the three cut-offs identified in literature for English-speaking populations (88, 82 and 75) [33]. These discrepancies may depend on cultural and linguistic factors related to the Italian translation of original ACE-R, whereas the higher cut-off value observed in our study, compared to previous Italian normative study [20] might depend on younger age of our sample (mean age 52.33 vs 72.91). ...
Full-text available
The Addenbrooke’s Cognitive Examination Revised (ACE-R) is a rapid screening battery, including five sub-scales to explore different cognitive domains: attention/orientation, memory, fluency, language and visuospatial. ACE-R is considered useful in discriminating cognitively normal subjects from patients with mild dementia. The aim of present study was to provide normative values for ACE-R total score and sub-scale scores in a large sample of Italian healthy subjects. Five hundred twenty-six Italian healthy subjects (282 women and 246 men) of different ages (age range 20–93 years) and educational level (from primary school to university) underwent ACE-R and Montreal Cognitive Assessment (MoCA). Multiple linear regression analysis revealed that age and education significantly influenced performance on ACE-R total score and sub-scale scores. A significant effect of gender was found only in sub-scale attention/orientation. From the derived linear equation, a correction grid for raw scores was built. Inferential cut-offs score were estimated using a non-parametric technique and equivalent scores (ES) were computed. Correlation analysis showed a good significant correlation between ACE-R adjusted scores with MoCA adjusted scores (r = 0.612, p < 0.001). The present study provided normative data for the ACE-R in an Italian population useful for both clinical and research purposes.
... The present study aimed to develop an Italian version of ACE-III and to provide regression-based normative data. Previously, the Italian ACE-R was proposed in 2011 (Pigliautile et al., 2011) and Italian normative data were published (Pigliautile et al., 2015;Siciliano et al., 2016). However, normative data for ACE-III are missing for the Italian population. ...
... A previous study observed that, incorporating the MMSE items, ACE-R represents an optimal approach to introduce innovation without breaking with the past (Pigliautile et al., 2015). In fact, despite the lack of evidence supporting a substantial role of the MMSE in the identification of mild cognitive impairment or dementia (Tombaugh and McIntyre, 1992;Arevalo-Rodriguez et al., 2015;Hodges and Larner, 2017;Shiroky et al., 2007), the MMSE value is immediate in sharing information and compare population data. ...
Objectives Addenbrooke's Cognitive Examination III (ACE-III) is a brief cognitive screening tool to assess five cognitive domains: attention/orientation, verbal fluency, memory, language, and visuospatial abilities. This study aimed to provide normative data (for total score and subscale scores) of the Italian version of ACE-III for gender, age, and education. Methods A total of 574 healthy Italian participants (mean age 68.70 ± 9.65; mean education 9.15 ± 4.04) were recruited from the community and included in the study. Linear regression analysis was performed to evaluate the effects of age, gender, and education on the ACE-III total performance score. Results Age and education exerted a significant effect on total and subscale ACE-III scores, whereas gender was on attention/orientation, language, and visuospatial subscale scores. From the derived linear equation, correction grids to adjust raw scores and equivalent scores (ESs) with cut-off values were provided. Conclusions The present study provided normative data, correction grids, and ESs for ACE-III in an Italian population.
... Normative data from a test can be defined in different ways by using various methods and scoring techniques (Maroof, 2012). In order to align the method of definition of our norms with those of other neuropsychological test (Bianchi & Dai Prà, 2008;Laiacona, Barbarotto, Baratelli, & Capitani, 2016;Pigliautile et al., 2015;Santangelo, Lagravinese, et al., 2017;Santangelo, Raimo, et al., 2017;Spinnler & Tognoni, 1987;Trojano et al., 2015), and independently from the shape of distribution, the non-parametric 95% tolerance interval with 95% confidence limits was taken as a reference. Results are shown in Table 4. ...
In brain damage patients with unilateral spatial neglect (USN), the differential diagnosis between the presence and absence of a unilateral visual half-field deficit (VHFD) is hampered by the similarity of their phenomenology. The absence of stimuli detection in the contralateral visual field, indeed, can be due to the co-occurrence of USN and VHFD or the sole presence of the USN. The disentangling of the two conditions is required to devise more specific rehabilitation programmes. Daini et al. [2002. Exploring the syndrome of spatial unilateral neglect through an illusion of length. Experimental Brain Research, 144(2), 224–237.] reported a difference in performance for the two conditions when the tasks required the bisection of Brentano illusory stimuli. Only when USN and VHFD co-occurred, the leftward illusory effect was disrupted. Based on previous findings, in this cross-sectional study, we developed the Brentano Illusion Test (BRIT), a clinical tool that helps the identification of VHFD in USN patients. The BRIT is a simple behavioural test of lines bisection aimed at verifying the presence or absence of implicit processing in USN and thus helping the diagnosis of VHFD in USN patients; it also provides normative data for the line bisection task and the length effect.
... Previous studies with the ACE-R have shown that the cutoff points are influenced by sociodemographic variables. 35,36 In several studies, with the ACE-III in several studies, the influence of demographic variables has been considered as seen to be an important variable to take into account when interpreting the suggested cutoff points and to improve diagnostic accuracy. 9,38,40,44,46 Years of education The years of education are an important variable that must be taken into account in order to correctly interpret the cutoff points of the ACE III. ...
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Addenbrooke’s cognitive examination III is a screening test that is composed of tests of attention, orientation, memory, language, visual perceptual and visuospatial skills. It is useful in the detection of cognitive impairment, especially in the detection of Alzheimer’s disease and fronto-temporal dementia. The aim of this study is to do a critical review of the Addenbrooke’s cognitive examination III. The different language versions available and research about the different variables that have relationship with the performance of the subject in the ACE-III are listed. The ACE-III is a detection technique that can differentiate patients with and without cognitive impairment, is sensitive to the early stages of dementia, and is available in different languages. However, further research is needed to obtain optimal cutoffs for the different versions and to evaluate the impact of different age, gender, IQ, and education variables on the performance of the test.
... After 3 months his PaO 2 breathing unassisted in ambient air was 75 and PaCO 2 44 mmHg ( Table 2). Quality of life parameters were measured and at discharge thanks to the EuroQoL (EQ-5D) [17] and the World Health Organization Quality of Life Questionnaire (WHO-QOL-Bref) [18], the patient used the IAPV 8 h/day with improved mood (assessed by the Hospital Anxiety and Depression Scale (HADS) [19]) and cognition (as assessed by the Mini Mental Status Examination [20] and the Addenbrooke's Cognitive Examination Revised (ACE-R) [21] ( Table 3). Moreover, three months later he reported that the IAPV was still effectively relieving his former daytime dyspnoea but that he had achieved up to 6 h/d of autonomous breathing without dyspnoea or tachypnea. ...
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Non-invasive ventilation (NIV) is the treatment of choice for patients symptomatic for respiratory muscle dysfunction. It can normalize gas exchange and provide up to continuous non-invasive ventilator support (CNVS) as an alternative to intubation and tracheotomy. It is usually provided via non-invasive facial interfaces or mouthpieces, but these can be uncomfortable and uncosmetic. The intermittent abdominal pressure ventilator (IAPV) has been used for diurnal ventilatory support since 1938 but has been off the market since about 1990. Now, however, with greater emphasis on non-invasive management, a new IAPV is available. A patient with chronic ventilatory insufficiency post-ischemic cervical myelopathy, dependent on sleep NVS since 2003, developed symptomatic daytime hypercapnia for which he also used diurnal NVS via nasal pillows. However, he preferred not having to use facial interfaces. When not using diurnal NVS he was becoming dyspnoeic. Diurnal use of an IAPV was introduced. Arterial blood gas analysis using the IAPV decreased his blood pH from 7.45 to 7.42, PaCO2 from 58 to 37 mmHg, and improved PaO2 from 62 to 92 mmHg. At discharge, the patient used the IAPV 8 h/day with improved mood and quality of life. Consequently, he returned to work as a painter.
... Third, we did not exclude individuals affected by chronic vascular or metabolic illnesses, which are very frequent in the aged people. These enrolment criteria choices might have contributed to age-related decrease in MoCA scores but are shared with most Italian normative studies (e.g., [42][43][44]). We conformed to this practice, also for the sake of consistency among Italian normative data. ...
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Objective The Montreal Cognitive Assessment (MoCA) is a screening test widely used in clinical practice and suited for detection of Mild Cognitive Impairment. Alternate forms of the MoCA were developed to avoid “learning effect” in serial assessments, and the present study aimed at investigating inter-form parallelism and at providing normative values for the Italian versions of MoCAs 2 and 3. Method Three separate convenience samples were recruited: the first (n = 78) completed three alternate MoCA versions for ascertaining inter-form parallelism; the second (n = 302) and the third (n = 413) samples were administered MoCA 2 or 3 to compute normative data. Results A three-step procedure complemented by confirmatory factor analysis and a mixed factorial ANOVA suggested that the three MoCA versions are not strictly parallel. Multiple linear regression analysis revealed that age and education significantly influenced MoCA 2 and 3 total scores. No significant effect of sex was found. From the derived linear equation, correction grids for MoCA 2 and 3 raw scores were built and equivalent scores computed. Inferential cutoff for adjusted scores, estimated using a non-parametric technique, were 17.49 for MoCA 2 and 18.34 for MoCA 3. Correlation analysis showed strong correlations of MoCA 2 (r = 0.69, p < .001) and MoCA 3 (r = 0.61, p < .001) adjusted total scores with MMSE adjusted scores. Conclusion The three MoCA forms are not strictly parallel. Specifically developed normative data must be adopted for using MoCA in serial cognitive assessments for clinical and research studies.
... These choices might have contributed to age-related decrease in TMT performances. However, many Italian normative studies followed these methodological procedures (e.g., [41][42][43]), and we conformed to this practice, also for the sake of consistency among Italian normative data. Second, our power analysis required enrollment of at least 222 participants, and we planned to enroll at least 32 individuals for each decade between 20 and 89 years, with participants evenly distributed across gender and education levels. ...
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Objectives The Trail Making Test (TMT) is widely used to assess psychomotor speed and attentional set-shifting. Since the regression-based norms and equivalent scores (ESs) for the TMT Italian version trace back to more than 20 years ago, we aimed at providing updated normative data for basic (Part A and Part B) and derived (Score B-A and Score B/A) TMT scores collected in a larger sample with an extended age range. Methods Three hundred fifty-five Italian volunteers stratified for sex (166 men), age decades (age range 20–90 years), and educational level (from primary school to university) completed the TMT and the Montreal Cognitive Assessment (MoCA). Results Multiple linear regression analyses revealed that age and educational level significantly influenced performances on basic and derived TMT scores except for B/A, which was associated only with the educational level. From the derived linear equations, correction grids for basic and derived TMT raw scores were developed. Inferential cutoff scores, estimated using a non-parametric technique, and ES were computed. Basic and derived TMT scores showed a good test–retest reliability (all rs ≥ 0.50); Part B (rs = − 0.48, p < 0.001) and Score B-A (rs = − 0.49, p < 0.001) were moderately associated with MoCA total score. Conclusions This study confirms the association of basic and derived TMT raw scores with sociodemographic variables and provides updated correction grids and ES for assessing the attentional/executive functions in clinical and research fields.
Background: Cognitive screening tests (CSTs) are crucial to neuropsychological diagnostics, and thus need to be featured by robust psychometric and diagnostic properties. However, CSTs happen not to meet desirable statistical standards, negatively affecting their level of recommendations and applicability. This study aimed at (a) providing an up-to-date compendium of available CSTs in Italy, (b) report their psychometric and diagnostic properties, and (c) address related limitations. Methods: This review was implemented by consulting Preferred Reporting Items for Systematic Reviews and Meta-Analyses and pre-registered on the International Prospective Register of Systematic Reviews. Standardization and usability studies focusing on norms, validity, reliability, or sensitivity/specificity (and derived metrics) in adults were considered for eligibility. Quality assessment was performed by means of an ad hoc checklist collecting information on sampling, psychometrics/diagnostics, norming, and feasibility. Results: Sixty studies were included out of an initial N = 683. Identified CSTs (N = 40) were classified into general, domain-, and disease-specific (N = 17, 7, and 16, respectively), the latter being less statistically robust than remaining categories. Validity and reliability evidence was provided for 29 and 26 CSTs, respectively, sensitivity/specificity for 20 and norms for 33. Prevalence- and post-test-based diagnostic metrics were seldomly represented; factorial structures, ceiling/floor effects, and acceptability rarely investigated; content, face, and ecological validity never assessed. Discussion: Although available Italian CSTs overall met basic psychometric/diagnostic requirements, their statistical profile often proved to be poor on several properties that are desirable for clinical applications, with a few exceptions among general and domain-specific ones.
The purposes of this review were to give the optimal cutoffs of the Montreal Cognitive Assessment (MoCA) by comparing sensitivity and specificity under different cutoffs and compare the MoCA with other screening tools in post-stroke cognitive impairment (PSCI) determined by a neuropsychological evaluation. Articles were derived from a systematic search in PubMed, Web of science, Embase, and CINAHL and were assessed for internal validity by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The figure of risk of bias was made by Review Manager 5.3, and data of selected studies were synthesized by MetaDisc 1.4. Twelve diagnostic studies, involving 2130 patients, were included. The area under the curve (AUC) under cutoffs of 20v19, 21v20, and 26v25 are 0.90, 0.90, and 0.95, showing high predictive validity for PSCI screening within 1 month. When the sensitivity and specificity are equal important, the optimal cutoff is 20v19 (Youden Index = 0.58). Compared to the Mini-Mental State Examination (MMSE), the MoCA has higher sensitivity but lower specificity. The optimal cutoff differs in different stages of stroke. Both the MMSE and MoCA are appropriate screening tools for PSCI, and the use of these two tools should be in accordance with the aim of screening. The Addenbrooke’s Cognitive Examination-Revised (ACE-R) can act as a supplement for the MoCA.
Background/aims: The aims of this study were to validate the newly developed version of the Addenbrooke's Cognitive Examination (ACE-III) against standardised neuropsychological tests and its predecessor (ACE-R) in early dementia. Methods: A total of 61 patients with dementia (frontotemporal dementia, FTD, n = 33, and Alzheimer's disease, AD, n = 28) and 25 controls were included in the study. Results: ACE-III cognitive domains correlated significantly with standardised neuropsychological tests used in the assessment of attention, language, verbal memory and visuospatial function. The ACE-III also compared very favourably with its predecessor, the ACE-R, with similar levels of sensitivity and specificity. Conclusion: The results of this study provide objective validation of the ACE-III as a screening tool for cognitive deficits in FTD and AD.
There is a clear need for brief, but sensitive and specific, cognitive screening instruments as evidenced by the popularity of the Addenbrooke's Cognitive Examination (ACE). We aimed to validate an improved revision (the ACE-R) which incorporates five sub-domain scores (orientation/attention, memory, verbal fluency, language and visuo-spatial). Standard tests for evaluating dementia screening tests were applied. A total of 241 subjects participated in this study (Alzheimer's disease=67, frontotemporal dementia=55, dementia of Lewy Bodies=20; mild cognitive impairment-MCI=36; controls=63). Reliability of the ACE-R was very good (alpha coefficient=0.8). Correlation with the Clinical Dementia Scale was significant (r=-0.321, p<0.001). Two cut-offs were defined (88: sensitivity=0.94, specificity=0.89; 82: sensitivity=0.84, specificity=1.0). Likelihood ratios of dementia were generated for scores between 88 and 82: at a cut-off of 82 the likelihood of dementia is 100:1. A comparison of individual age and education matched groups of MCI, AD and controls placed the MCI group performance between controls and AD and revealed MCI patients to be impaired in areas other than memory (attention/orientation, verbal fluency and language). The ACE-R accomplishes standards of a valid dementia screening test, sensitive to early cognitive dysfunction.
The authors describe the profile of performance of patients whose cognitive complaint is due to dementia, affective disorder, or combinations thereof on the Addenbrooke's Cognitive Examination (ACE) test battery. Authors tested 90 subjects with dementia (63 Alzheimer disease [AD]; 27 fronto-temporal dementia [FTD]), 60 subjects with "pure" affective disorder (23 major depression [MDD], 37 whose affective symptoms did not meet criteria for major depression [Affective]); 22 patients with symptoms of affective disorder and organic dementia (Mixed); and 127 healthy volunteers (NC). The total ACE scores for the AD, FTD, and Mixed groups were significantly lower than for the NC group. Likewise, on total score, the AD and FTD groups scored significantly lower than either of the "pure" affective-disorder groups. Within the dementia group, the AD group scored significantly lower than the fronto-temporal group. The profile of performance on the ACE of patients with dementia is different from that of patients suffering from affective illness. Mild impairment in the total ACE score, along with a low score on the memory domain tasks and letter fluency (in contrast to normal category fluency), are strongly indicative of an affective, as opposed to organic, pathology. A total score of <88 in suspected dementia patients with affective symptoms appears strongly predictive of an underlying organic disorder.
The notions of ecological validity and everyday cognition emerged predominantly from three sources in psychology. These were the study of practical intelligence in cognitive psychology (Sternberg, 1977; Neisser, 1982), the study of everyday cognition in gerontology (Acker, 1986; Poon, 1986; West, 1985) and the prediction of everyday functioning in neuropsychological rehabilitation settings (Chelune & Moehle, 1986; Hart & Hayden, 1986). Movements in all of these areas were at least partially motivated by a reaction to the general psychometric, trait-oriented theories of intelligence and the arcane style of intellectual and neuropsychological tests which had developed largely since the second world war. The following is a very brief history of these movements, a review of the current ideas subsumed under the term ecological validity and a future program of test development which will presumably combine these new ideas with the best from the past.
The Mini-Mental State Examination (MMSE) is the most commonly used brief cognitive tool in the assessment of a variety of cognitive disorders. The tool comprises a short battery of 20 individual tests covering 11 domains and totalling 30 points. Typical completion time is 8 min in cognitively unimpaired individuals rising to 15 min in those with dementia. Internal consistency appears to be moderate and test-retest reliability good. However, the main psychometric issue concerns the MMSE’s diagnostic validity against dementia, mild cognitive impairment, and delirium. This chapter updates previous meta-analytic summary analyses for the performance of the MMSE in specialist and nonspecialist settings. Summary sensitivity, specificity, positive, and negative predictive values are presented. Results suggest against dementia, mild cognitive impairment, and delirium it did not perform well as a confirmatory (case-finding) tool, but it did perform adequately in a rule-out (screening) capacity. In clinical practice, this means that a high score on the MMSE would lead to about a 10 % false negative rate, and further, a low (positive) score must be followed by more extensive neuropsychological or clinical evaluation. The MMSE is neither the most accurate nor more efficient tool with which to evaluate cognitive disorders, but it has provided a benchmark against which all newer tools can be measured.
The Addenbrooke’s Cognitive Examination (ACE) and its revised version (ACE-R) are theoretically motivated revisions of the Mini-Mental State Examination (MMSE) which attempt to address the neuropsychological omissions and improve the screening performance of the latter. Though taking longer to administer than the MMSE, and therefore best suited to specialist settings, both ACE and ACE-R have proved to be acceptable to patients and have shown excellent performance in identifying cognitive impairment in a variety of clinical situations (Alzheimer’s disease, frontotemporal lobar degenerations, parkinsonian syndromes, stroke and vascular dementia, brain injury). Subscores of the ACE/ACE-R may be useful for the differentiation of Alzheimer’s disease from frontotemporal lobar degeneration (the VLOM ratio) and of Alzheimer’s disease from semantic dementia (the SI index). ACE/ACE-R utility has prompted translation into various languages.