Montreal Cognitive Assessment (MoCA) screening mild cognitive impairment in patients with chronic kidney disease (CKD) pre-dialysis

Paraizo, Marilise de Andrade; Almeida, Ana Laura Maciel; Pires, Leopoldo Antônio; Abrita, Renata Silva Almeida; Crivellari, Mary Hellen Teixeira; Pereira, Beatriz dos Santos; Fernandes, Natália Maria da Silva; Bastos, Marcus Gomes

doi:10.5935/0101-2800.20160006

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Brazilian Journal of Nephrology

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Original Articles, Chronic Kidney Disease • J. Bras. Nefrol. 38 (1) • Jan-Mar 2016 • https://doi.org/10.5935/0101-2800.20160006 copy

Montreal Cognitive Assessment (MoCA) screening mild cognitive impairment in patients with chronic kidney disease (CKD) pre-dialysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Individuals with chronic kidney disease (CKD) are at higher risk of developing cognitive impairment (CI), initially mild (MCI), potentially identifiable, but still poorly diagnosed and treated. The Montreal Cognitive Assessment (MoCA) has been indicated for MCI screening in CKD.

Objective:

To assess MCI in patients with CKD not yet on dialysis.

Methods:

Study conducted in 72 non-elderly subjects with pre-dialysis CKD. The neuropsychological assessment included: The global cognitive assessment test MoCA; the clock drawing (CD); the digit span forward (DSF) and reverse (DSR); phonemic verbal (VF) fluency (FAS) and semantics (animals); the fist-edge-palm (FEP); and the memory 10 pictures.

Results:

The average age of the participants was 56.74 ± 7.63 years, with predominance of male sex (55.6%), mainly with ≥ 4 years of education (84.3%), with CKD cathegories 1, 2 and 3a and 3b (67.6%), hypertension (93.1%) and diabetes mellitus (52.1%). MCI (MoCA ≤ 24) was observed in 73.6% of the patients. We did not find association among MCI with demographic and clinical variables, but a tendency to association with age (p = 0.07), educational level (p = 0.06) and diabetes (0.06). The executive function tests CD, DS-reverse and FEP, individually were able to identify CI with good sensibility and negative predictive value compared to MoCA and together, showed the same capability to identify MCI when compared to MoCA.

Conclusion:

The MCI is common in non-elderly patients with CKD not yet on dialysis. Together, the CD, DSR and FEP showed similar performance in identify MCI in this population when compared to MoCA, suggesting impairment of executive functions.

Keywords:
kidney failure, chronic; mild cognitive impairment; neuropsychological tests

Questionnaires and neuropsychological tests	Description, assessed functions, and cutoff scores
Pfeffer Functional Activities Questionnaire²¹21 Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:713-9. DOI: http://dx.doi.org/10.1590/S0004-282X2005000400033 http://dx.doi.org/10.1590/S0004-282X2005...	Ten questions about activities o daily living and cognitive-social functions answered by the caregiver.
	Scores from 0 to 30.
	≥ 5 points = functional impairment.
MINI Plus²²22 Amorim P. Mini International Neuropsychiaric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Rev Bras Psiquiatr 2000;22:106-15. DOI: http://dx.doi.org/10.1590/S1516-44462000000300003 http://dx.doi.org/10.1590/S1516-44462000... ^ May be used by general practitioners. The document can be copied and reproduced by researchers or physicians working at universities, hospitals, and government institutions.22	Diagnostic interview based on the DSM-IV and ICD-10, subdivided into 12 sections in which YES/NO answers are added into an algorithm to provide a YES/NO diagnostic outcome.
Montreal Cognitive Assessment (MoCA)¹⁷17 Tiffin-Richards FE, Costa AS, Holschbach B, Frank RD, Vassiliadou A, Krüger T, et al. The Montreal Cognitive Assessment (MoCA) - a sensitive screening instrument for detecting cognitive impairment in chronic hemodialysis patients. PLoS One 2014;9:e106700. DOI:http://dx.doi.org/10.1371/journal.pone.0106700 http://dx.doi.org/10.1371/journal.pone.0... ^* ***** Available at www.mocatest.org	Global cognitive assessment: visuospatial skills, executive functions, language, memory, attention and orientation, calculation, abstraction.
	Scores from 0 to 30.
	≤ 24 = CI^* * The neuropsychological tests presented herein may be applied by trained health care workers. They have to be interpreted by someone with specific training in neuropsychology. CI = Cognitive impairment
Clock drawing test (CDT)²³23 Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000;15:548-61. DOI:http://dx.doi.org/10.1002/1099-1166(200006)15:6<548::AID-GPS242>3.0.CO;2-U http://dx.doi.org/10.1002/1099-1166(2000...	Patients are asked to draw a clock with all numbers and hands showing the time of 11:10.
	The test assesses visuospatial skills and executive functions.
	Scores from 0 to 5.
	0 = cannot draw;
	1 = severe visuospatial disorganization;
	2 = moderate disorganization, incorrect time shown, perseveration, confusion between left and right, numbers missing, repeated numbers, clock with no hands, clock with too many hands;
	3 = Right visuospatial distribution but clock showing the wrong time;
	4 = Minor spatial errors with number; time shown correctly;
	5 = Perfect clock, with no mistakes.
	≤ 2 = CI.
Forward digit span (DS) test²¹21 Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:713-9. DOI: http://dx.doi.org/10.1590/S0004-282X2005000400033 http://dx.doi.org/10.1590/S0004-282X2005...	Patients are asked to repeat a forward sequence of numbers in the inverse order as presented by the examiner.
	The test assesses verbal attention and working memory.
	< 5 = CI.
Backward digit span (DS) test²¹21 Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:713-9. DOI: http://dx.doi.org/10.1590/S0004-282X2005000400033 http://dx.doi.org/10.1590/S0004-282X2005...	Patients are asked to repeat a forward sequence of numbers in the inverse order as presented by the examiner.
	The test assesses attention, working memory, and executive functions.
	< 3 = CI.
Phonemic verbal fluency (FAS)²⁴24 Machado TH, Fichman HC, Santos EL, Carvalho VA, Fialho PP, Koenig AM, et al. Normative data for healthy elderly on the phonemic verbal fluency task - FAS. Dement Neuropsychol 2009;3:55-60.	Patients are asked to say as many words as they can with the letter F for one minute.
	The same is done with letter A and S.
	The test assessed verbal memory and executive functions.
	< 13 for schooling 1-3 years = CI
	< 20 for schooling 4-7 years = CI
	< 23 for schooling 8-11 years = CI
	< 31 for schooling greater than 12 years = CI
	Scores of the 25^th percentile for people aged 60-69 years
Semantic verbal fluency category animals²¹21 Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:713-9. DOI: http://dx.doi.org/10.1590/S0004-282X2005000400033 http://dx.doi.org/10.1590/S0004-282X2005...	Patients are asked to list as many animals as they can in one minute.
	The test assesses semantic memory and executive functions.
	≤ 9 for schooling < 8 = CI;
	≤ 13 for schooling ≥ 8 years = CI.
Fist-Edge-Palm (FEP)²⁵25 Beato RG, Nitrini R, Formigoni AP, Caramelli P. Brazilian version of the frontal assessment battery (FAB). Dement Neuropsychol 2007;1:59-65.	Patients are asked to observe the examiner show three sequences of hand movements and perform three other movements.
	The tests assesses dynamic praxie and executive functions.
	Scores from 0 to 3.
	0 = unable to perform;
	1 = did three movements with the examiner;
	2 = did at least three series of movements alone;
	3 = did all six series of movements correctly.
	< 3 = CI.
10-picture memory test²¹21 Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:713-9. DOI: http://dx.doi.org/10.1590/S0004-282X2005000400033 http://dx.doi.org/10.1590/S0004-282X2005...	The patient is presented 10 pictures and is then asked to name and recall them.
	The test assessed:
	Visual perception < 9 = CI.
	Naming < 9 = CI. Incidental memory < 5 = CI.
	Immediate memory 1 (after 30" looking at the pictures) < 6 = CIC.
	Immediate memory 2 (after + 30" looking at the pictures) < 6 = CI.
	Recall (5 minutes after seeing the pictures + distractor) < 5 = CI.
	Recognition among other pictures < 9 = CI.

Comparison between participants with and without CI
Variable	N	Mean ± SD Median (p25-p75) %	MoCA ≤ 24 N	MoCA ≥ 25 N	p
Age (years)	72	56.74 ± 7.63 58 (54-62)
< 40	4	5.6	2	2	0.075
40-49	2	2.8	1	1
50-59	38	52.8	25	13
60-65	28	38.9	25	3
Gender
Male	32	44.4	23	9	0.76
Female	40	55.6	30	10	0.76
Marital status
Married or state-registered domestic partnership	44	61.1	34	10	0.54
Single	7	9.7	15	6
Widow(er) or separated	21	29.9	15	6
Years of schooling	72	5,66 ± 2,91 4 (4-8)
Schooling (%)
Illiterate	2	2.9	2	0	0.06
1-3 years	9	12.9	9	0
4 years	28	40	22	6
5-8 years	20	28.6	14	6
> 8 years	11	15.7	6	5
< 4 years	11	15.7	11	0	0.009
≥ 4 years	59	84.3	42	17	0.009
CKD stage
≤ 3b	48	67.6	36	12	0.922
4 and 5	23	32.4	17	6	0.922
Drinking (%)	5	7.4	1	4	0.01
Smoking (%)	15	21.7	12	3	0.45
Comorbidities (%)
Systemic hypertension	67	93.1	50	17	0.49
DM	37	52.1	31	6	0.06
CVD	22	36.1	16	6	0.089
Hypothyroidism	9	14.5	4	5	0.04
Depression	17	23.6	11	5	0.35
Loss of function	5	7.6	4	1	0.81
Medication (%)
Benzodiazepines	12	17.6	8	4	0.47
Antidepressants	11	16.2	10	1	0.14
Hypnotic drugs	1	1.5	1	0	0.45
Anticonvulsants	1	1.5	1	0	0.44
Erythropoiesis-stimulating agents	1	1.6	1	0	0.44
Iron	2	3.2	1	1	0.44
Ace inhibitors	28	44.4	21	7	0.94
Beta-blockers	33	52.4	27	6	0.16
Diuretics	53	84.1	43	10	0.01
Statin	31	49.2	22	9	0.51
Vitamin D	14	22.2	13	1	0.05
Hypoglycemic drugs	33	51.1	29	4	0.01
Thyroid hormone	5	7.9	2	3	0.08

Tests	Mean ± DP Median (p25-p75)	% of patients with alteration
MoCA (≤ 24) (n = 72)	21.83 ± 4.16 23 (19-25)	73.6
MoCA (≤ 24) Schooling < 4 years excluded (n = 59).		74.60
CDT (Shulman) ≤ 2	0.08 ± 1.19 (4-5)	15.30
Forward DS test	4.69 ± 0.94	45.80
Backward DS test	3.21 ± 1.12	22.20
Phonemic verbal fluency FAS		29.00
F	9.33 ± 3.79
A	7.25 ± 3.66
S	7.28 ± 3.45
FAS	23.89 ± 9.62
Semantic fluency - category animals	13.90 ± 4.07	15.30
Fist-Edge-Palm (%)		29.1
Did three with examiner n = 5	6.9
Did up to three alone n = 16	22.2
Did six alone n = 51	70.8
10-picture memory test (n = 50)
Incidental memory	5.78 ± 0.07	10
Recognition	9.60 ± 0.60	6

Variable	MoCA ≤ 24	MoCA > 24	p
CDT	3.94 ± 1.24	4.47 ± 0.96	0.097
Forward DS test	4.53 ± 0.89	5.16 ± 0.95	0.012
Backward DS test	3.02 ± 1.15	3.74 ± 0.87	0.01
FAS	21.68 ± 8.57	30.05 ± 9.88	0.001
Semantic fluency - animals	13.38 ± 3.93	15.37 ± 4.17	0.07
10-picture memory test
Immediate memory 1	7.36 ± 0.47	8.29 ± 1.38	0.049
Recall	7.58 ± 1.40	8.29 ± 0.99	0.094

Variable	R	p
CDT	0.495	< 0.0001
Forward DS test	0.352	0.002
Backward DS test	0.558	< 0.0001
FAS	0.452	< 0.0001
Semantic fluency - animals	0.235	0.047
Fist-Edge-Palm^* * Non-parametric ordinal variable (Spearman's rank correlation coefficient)	0.223	0.059
10-picture memory test
Naming/visual perception	0.363	0.01
Recall	0.386	0.006
MoCA subtests
Visuospatial/executive	0.463	< 0.0001
Naming	0.311	0.008
Attention	0.405	< 0.0001
Language	0.401	< 0.0001
Abstraction	0.389	0.001
Memory recall	0.404	0.001
Orientation	0.202	0.089

Variable	Sensitivity	Specificity	Accuracy	PPV	NPV	VR
CDT^* * When combined with others, these tests matched the MoCA capability of screening patients for CI.	81.0	27.0	9.23	16.9	89.4	1.13
Backward DS^* * When combined with others, these tests matched the MoCA capability of screening patients for CI.	93.7	32.1	15.25	28.3	94.7	1.38
FAS	64.5	4.3	31	58.4	5.5	67.5
FEP^* * When combined with others, these tests matched the MoCA capability of screening patients for CI.	95.2	35.2	20.25	37.7	94.7	1.47

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[1] Correspondence to: Marilise de Andrade Paraizo. Universidade Federal de Juiz de Fora Fundação Instituto Mineiro de Ensino e Pesquisas em Nefrologia. Rua Waldemar Bracher, n° 145, Bairro Cidade Universitária, Juiz de Fora, MG, Brazil. CEP: 36037-035. E-mail: mariliseparaizo@gmail.com