Article

Italian version and normative data of Addenbrooke's Cognitive Examination III

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Abstract

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.

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... Validation studies performed in English, Spanish, Chinese, Italian, and Portuguese have shown the high diagnostic accuracy of this scale in different clinical settings. [15][16][17][18][19][20] The previous validation study of the Chinese version of ACE-III (Wang et al., 2017 18 ) established its optimal cutoff score for dementia. Since early diagnoses of both MCI and dementia are important, screening for both conditions using a single scale would be more efficient and convenient for detecting and monitoring cognitive impairment. ...
... Our results showed older age and lower education levels were associated with lower ACE-III scores, similarly as did the previous studies. [15][16][17][18]20 Since the dementia group in our study had a lower education level (9.68±4.27 vs. 11.3± 1.4 years) and were older (74.89±6.90 vs. 71.9±7.8 years) than the subjects in the study of Wang et al., 18 it was reasonable that the optimal cutoff score was lower in the present study. ...
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Background and purpose: There are only a few cognitive screening tests for the Chinese-speaking population, and so this study aimed to validate the Chinese version of Addenbrooke's Cognitive Examination III (ACE-III) for detecting mild cognitive impairment (MCI) and mild dementia. Its diagnostic accuracy was compared with the Chinese versions of the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). Methods: The 176 included individuals were divided into 3 groups: mild dementia group, MCI group, and normal control group. MMSE, MoCA, and ACE-III were administered to all participants by researchers who were blinded to the clinical grouping. The receiver operating characteristic (ROC) curves were analyzed. Results: ACE-III exhibited good internal consistency and convergent validity. Age and education level significantly influenced the total ACE-III scores. When screening MCI, the area under the ROC curve (AUC) was significantly larger for ACE-III than for MMSE (0.88 vs. 0.72, p<0.05) and MoCA (0.88 vs. 0.76, p<0.05). ACE-III showed higher sensitivity (0.75) and specificity (0.89) than MMSE (0.64 and 0.63, respectively) and MoCA (0.67 and 0.77) at the optimal cutoff score of 88/89. For detecting mild dementia, ACE-III yielded satisfactory sensitivity (0.94) and specificity (0.83) at the optimal cutoff score of 74/75. The AUC of ACE-III was 0.95, which was comparable to those of MMSE (0.95) and MoCA (0.91). In participants with ≥12 years of education, the AUC was significantly larger for ACE-III than for MMSE when detecting MCI (0.90 vs. 0.68, p<0.05) and mild dementia (0.97 vs. 0.90, p<0.05). Conclusions: The present study has verified that ACE-III is a reliable and accurate tool for screening MCI and mild dementia in the Chinese-speaking population, and is significantly superior to MMSE and MoCA for detecting MCI.
... 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. Level of education has been observed to have an effect on the accuracy of this screening test in the diagnosis of dementia 15,[37][38][39][40] and may be attributable to the presence of items dependent on the level of education or literacy, 40 such as the use of irregular words, phonemic verbal fluency, 41 naming task, 42 and constructional abilities. ...
... 44 ,45 Thus, different cut points have been proposed depending on years of education 44 and correction factors have been proposed to adjust the raw scores and equivalent scores with cutoff values. 46 Age It has been found that people over 75 years old score less on the ACE-R in comparison with younger people. 47,48 Interpretation of the cognitive profile is thus limited by age, suggesting that age is an independent predictor of performance. ...
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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.
... With respect to anagraphic-demographic predictors, MoCA-O scores proved not to be influenced by education in the present study. This finding diverges from previous ones regarding not only the MoCA [10], but also other cognitive screening tests [43,44]. Similarly, although males were found as performing better than females on MoCA-A and -VS, when sex was tested individually, no such differences have been yielded from models additionally accounting for age and education, contrarily to Santangelo et al.'s [10] study. ...
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This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the diagnostic accuracy of the MMSE at various thresholds for detecting individuals with MCI at baseline who would clinically convert to Alzheimer and CloseCurlyQuote;s disease dementia or other forms of dementia at follow-up To assess the heterogeneity of test accuracy by population (e.g. memory clinics, community settings) and MMSE thresholds, amongst other factors. © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Book
This revised and updated second edition provides a practical and structured overview of some of the most commonly used and easily available cognitive screening instruments applicable in the outpatient clinic and bedside setting. It now includes additional chapters on AD8 and also methodological aspects of systematic cognitive screening instrument assessment from the Cochrane Dementia and Cognitive Improvement Group. Expert authors from around the world equip the reader with clear instructions on the usage of each screening instrument, its strengths and weaknesses, and the time required for administration. Rules on scoring are also provided, such as how to correct for variations in the patient’s age or education, and suggested cut-off scores. Cognitive Screening Instruments: A Practical Approach, Second Edition is aimed at both clinicians and professionals in disciplines allied to medicine who are called upon to assess patients with possible cognitive disorders, including neurologists, old age psychiatrists, neuropsychologists, primary care physicians, dementia support workers, and members of memory assessment teams.
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Article
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.
Article
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.
Chapter
The Addenbrooke’s Cognitive Examination (ACE) was originally developed as a theoretically motivated extension of the Mini-Mental State Examination (MMSE) which attempted 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, ACE and its subsequent iterations, ACE-R and ACE-III, have proved easy to use, acceptable to patients, and have shown excellent diagnostic utility in identifying dementia and cognitive impairment in a variety of clinical situations (Alzheimer’s disease, frontotemporal lobar degenerations, Parkinsonian syndromes, stroke and vascular dementia, brain injury). The most recent development, the Mini-Addenbrooke’s Cognitive Examination (M-ACE), takes no more time to administer than the MMSE but, like the longer versions, is superior to MMSE in diagnostic utility. The utility of ACE/ACE-R has prompted translation into various languages, and this trend is anticipated to continue for ACE-III and M-ACE.
Article
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.
Article
To examine the validity of Addenbrooke's Cognitive Examination III (ACE-III) in detecting early dementia in UK memory clinic patients aged 75-85 years. The ACE-III was administered to 59 patients prior to diagnosis. The extent to which scores predicted the membership of the dementia or no-dementia group was explored using receiver operating characteristic curve analysis and other parameters of diagnostic performance. Thirty-three participants (55.9%) were diagnosed with dementia (Alzheimer's disease = 56.3%, Alzheimer's disease with cerebrovascular disease = 31.3%, and vascular dementia = 12.5%). The optimal cut-off for detecting dementia was 81/100 (scores <81 indicating dementia with a sensitivity of 0.79, a specificity of 0.96, and a positive predictive value of 0.96), with superiority over published cut-offs (88/100 and 82/100) at medium and lower prevalence rates. The number of years of full-time education had a significant positive relationship to total ACE-III scores (r = 0.697, p < 0.001) for the no-dementia group. Exploratory analysis indicated that optimal cut-offs were different for higher versus lower education groups. The ACE-III has excellent accuracy for the detection of dementia in day-to-day clinical practice. Lower cut-offs than those specified in the index paper, and the consideration of the patients' years of full-time education may be necessary for optimal diagnostic performance. © 2015 S. Karger AG, Basel.
Article
Test norms enable determining the position of an individual test taker in the group. The most frequently used approach to obtain test norms is traditional norming. Regression-based norming may be more efficient than traditional norming and is rapidly growing in popularity, but little is known about its technical properties. A simulation study was conducted to compare the sample size requirements for traditional and regression-based norming by examining the 95% interpercentile ranges for percentile estimates as a function of sample size, norming method, size of covariate effects on the test score, test length, and number of answer categories in an item. Provided the assumptions of the linear regression model hold in the data, for a subdivision of the total group into eight equal-size subgroups, we found that regression-based norming requires samples 2.5 to 5.5 times smaller than traditional norming. Sample size requirements are presented for each norming method, test length, and number of answer categories. We emphasize that additional research is needed to establish sample size requirements when the assumptions of the linear regression model are violated. © The Author(s) 2015.
Article
Background: Dementia is a progressive global cognitive impairment syndrome. In 2010, more than 35 million people worldwide were estimated to be living with dementia. Some people with mild cognitive impairment (MCI) will progress to dementia but others remain stable or recover full function. There is great interest in finding good predictors of dementia in people with MCI. The Mini-Mental State Examination (MMSE) is the best-known and the most often used short screening tool for providing an overall measure of cognitive impairment in clinical, research and community settings. Objectives: To determine the diagnostic accuracy of the MMSE at various thresholds for detecting individuals with baseline MCI who would clinically convert to dementia in general, Alzheimer's disease dementia or other forms of dementia at follow-up. Search methods: We searched ALOIS (Cochrane Dementia and Cognitive Improvement Specialized Register of diagnostic and intervention studies (inception to May 2014); MEDLINE (OvidSP) (1946 to May 2014); EMBASE (OvidSP) (1980 to May 2014); BIOSIS (Web of Science) (inception to May 2014); Web of Science Core Collection, including the Conference Proceedings Citation Index (ISI Web of Science) (inception to May 2014); PsycINFO (OvidSP) (inception to May 2014), and LILACS (BIREME) (1982 to May 2014). We also searched specialized sources of diagnostic test accuracy studies and reviews, most recently in May 2014: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). No language or date restrictions were applied to the electronic searches and methodological filters were not used as a method to restrict the search overall so as to maximize sensitivity. We also checked reference lists of relevant studies and reviews, tracked citations in Scopus and Science Citation Index, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on MMSE for dementia diagnosis to try to locate possibly relevant but unpublished data. Selection criteria: We considered longitudinal studies in which results of the MMSE administered to MCI participants at baseline were obtained and the reference standard was obtained by follow-up over time. We included participants recruited and clinically classified as individuals with MCI under Petersen and revised Petersen criteria, Matthews criteria, or a Clinical Dementia Rating = 0.5. We used acceptable and commonly used reference standards for dementia in general, Alzheimer's dementia, Lewy body dementia, vascular dementia and frontotemporal dementia. Data collection and analysis: We screened all titles generated by the electronic database searches. Two review authors independently assessed the abstracts of all potentially relevant studies. We assessed the identified full papers for eligibility and extracted data to create two by two tables for dementia in general and other dementias. Two authors independently performed quality assessment using the QUADAS-2 tool. Due to high heterogeneity and scarcity of data, we derived estimates of sensitivity at fixed values of specificity from the model we fitted to produce the summary receiver operating characteristic curve. Main results: In this review, we included 11 heterogeneous studies with a total number of 1569 MCI patients followed for conversion to dementia. Four studies assessed the role of baseline scores of the MMSE in conversion from MCI to all-cause dementia and eight studies assessed this test in conversion from MCI to Alzheimer´s disease dementia. Only one study provided information about the MMSE and conversion from MCI to vascular dementia. For conversion from MCI to dementia in general, the accuracy of baseline MMSE scores ranged from sensitivities of 23% to 76% and specificities from 40% to 94%. In relationship to conversion from MCI to Alzheimer's disease dementia, the accuracy of baseline MMSE scores ranged from sensitivities of 27% to 89% and specificities from 32% to 90%. Only one study provided information about conversion from MCI to vascular dementia, presenting a sensitivity of 36% and a specificity of 80% with an incidence of vascular dementia of 6.2%. Although we had planned to explore possible sources of heterogeneity, this was not undertaken due to the scarcity of studies included in our analysis. Authors' conclusions: Our review did not find evidence supporting a substantial role of MMSE as a stand-alone single-administration test in the identification of MCI patients who could develop dementia. Clinicians could prefer to request additional and extensive tests to be sure about the management of these patients. An important aspect to assess in future updates is if conversion to dementia from MCI stages could be predicted better by MMSE changes over time instead of single measurements. It is also important to assess if a set of tests, rather than an isolated one, may be more successful in predicting conversion from MCI to dementia.
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The Index of ADL was developed to study results of treatment and prognosis in the elderly and chronically ill. Grades of the Index summarize over-all performance in bathing, dressing, going to toilet, transferring, continence, and feeding. More than 2,000 evaluations of 1,001 individuals demonstrated use of the Index as a survey instrument, as an objective guide to the course of chronic illness, as a tool for studying the aging process, and as an aid in rehabilitation teaching. Of theoretical interest is the observation that the order of recovery of Index functions in disabled patients is remarkably similar to the order of development of primary functions in children. This parallelism, and similarity to the behavior of primitive peoples, suggests that the Index is based on primary biological and psychosocial function, reflecting the adequacy of organized neurological and locomotor response.
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To review the evidence relating to the diagnostic accuracy and clinical utility of the Addenbrooke's Cognitive Examination (ACE) and its updated version, the Addenbrooke's Cognitive Examination-Revised (ACE-R) in relation to the diagnosis of dementia. A systematic search of relevant databases was conducted, covering the period 2000 to April 2010. Specific journals and reference lists were hand searched. Identified studies that fulfilled the inclusion criteria were reviewed using a tailored, methodological quality rating checklist. The systematic search process identified nine studies for review (seven relating to the ACE, two on the ACE-R). Strengths and weaknesses across studies are considered, and diagnostic accuracy measures are presented for six out of the nine studies. The evidence suggests that the ACE/ACE-R is capable of providing information on a range of cognitive domains and of differentiating well between those with and those without cognitive impairment. Further research examining how the tools distinguish between dementia subtypes and mild cognitive impairment will further benefit the evidence base.
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The purpose of this paper is to provide a comprehensive review of information accumulated over the past 26 years regarding the psychometric properties and utility of the Mini-Mental State Examination (MMSE). The reviewed studies assessed a wide variety of subjects, ranging from cognitively intact community residents to those with severe cognitive impairment associated with various types of dementing illnesses. The validity of the MMSE was compared against a variety of gold standards, including DSM-III-R and NINCDS-ADRDA criteria, clinical diagnoses, Activities of Daily Living measures, and other tests that putatively identify and measure cognitive impairment. Reliability and construct validity were judged to be satisfactory. Measures of criterion validity showed high levels of sensitivity for moderate-to-severe cognitive impairment and lower levels for mild degrees of impairment. Content analyses revealed the MMSE was highly verbal, and not all items were equally sensitive to cognitive impairment. Items measuring language were judged to be relatively easy and lacked utility for identifying mild language deficits. Overall, MMSE scores were affected by age, education, and cultural background, but not gender. In general, the MMSE fulfilled its original goal of providing a brief screening test that quantitatively assesses the severity of cognitive impairment and documents cognitive changes occurring over time. The MMSE should not, by itself, be used as a diagnostic tool to identify dementia. Suggestions for the clinical use of the MMSE are made.