In this study, we developed a new tool for screening cognitive impairment in patients with stroke and heart failure, VasCog Screen, which has good sensitivity, specificity and diagnostic accuracy, and is superior to MMSE, MoCA and short MoCA in detecting cognitive impairment, which is helpful for early detection of cognitive impairment and corresponding intervention in patients with stroke and heart failure.
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Vascular cognitive impairment is common in people with stroke and heart failure and encompasses all forms of cognitive impairment, from mild cognitive impairment to dementia. More than 33% of stroke patients and 25%-80% of heart failure patients have vascular cognitive impairment, and early detection of cognitive impairment is essential for disease management and recovery. This study aims to develop a new screening tool, VasCog Screen, to better detect cognitive impairment in patients with stroke and heart failure.
Research Methods:
A total of 327 patients with non-aphasia and 100 patients with heart failure after stroke were included in the study to assess cognitive function, including the Mini-Mental State Scale (MMSE), the Montreal Cognitive Assessment Scale (MoCA), and conventional neuropsychological tests. The VasCog Screen test was created by deriving a short MoCA and combining it with a symbolic digital analog test (SDMT). At the same time, the ability of different test methods to identify cognitive impairment was compared, and the optimal cut-off value was established to evaluate the short MoCA including SDMT.
Findings:
Cognitive impairment is defined by local routine neuropsychological testing. The prevalence of cognitive impairment was similar in patients with stroke (n=187, 57.2%) and heart failure (n=44, 44.0%). Among patients with cognitive impairment of stroke and heart failure, the most common neuropsychological disorder was visuomotor speed (n=116, 62.0% vs. n=27, 61.4%), followed by visual memory (n=110, 58.8% vs. n=21, 47.7%) and visual construction ability (n=106, 56.7% vs. n=21, 47.7%).
Because patients with stroke and heart failure had similar features of neuropsychological disorders, data from the two were combined for analysis. In the pooled sample, 73.0% (n=311) were male, 69.7% (n=297) were Chinese, and 54.0% (n=230) were cognitively impaired. Compared with patients without cognitive impairment, patients with cognitive impairment were older (64.3±11.1 years vs. 53.9±8.5 years, p<0.001), shorter years of schooling (6.6±3.8 years vs. 9.8±4.1 years, p<0.001), MMSE score (24.4±3.6 vs. 27.8±1.8, p<0.001), MoCA score (19.9±4.8 vs. 25.3±2.5, p<0.001) and SDMT score (20.5±11.8 vs. 39.7±11.3, p<0.001).
A total of 10 items were screened for short MoCA with a discriminating index ≥ 1.4 for short MoCA, including 3 directional items (country, year, location; 3 points), and 2 visual/ Executive ability item (wired test and copy cube; 2 points), 2 abstract items (train-bike, watch-ruler; 2 points), 1 attention item (continuous subtraction; 3 points), 1 language item (language fluency; 1 point), and 1 naming ability item (elephant; 1 point) (Table 1). The short MoCA is then combined with SDMT to form the VasCog Screen test.
Table 1 Screening items for short MoCA
The optimal cut-off value for short MoCAs <9, which is similar to the classification accuracy of standard MoCAs (Table 2). Patients who did not pass the short MoCA or SDMT test were diagnosed with cognitive impairment. Based on the diagnostic classification of conventional neuropsychological tests, VasCog Screen was found to outperform MMSE (area under the curve [AUC]: 0.82 vs. 0.74, p<0.001), MoCA (AUC: 0.82 vs. 0.76, p=0.02), and short MoCA (AUC: 0.82 vs. 0.76, p<0.001) in detecting cognitive impairment.
表2 MMSE、MoCA、短MoCA、SDMT和VasCog Screen的区分指数
a, bWhen AUC was compared with VasCog Screen, P<0.001; c SDMT impairment was defined as <14 and <33 for participants with years of primary education (≤6 years) and years of secondary/tertiary education (≥7 years) according to local norms. NPV: negative predictive value, PPV: positive predictive value, SEN: sensitivity, SPEC: specificity
The short MoCA in this study was compared to the short MoCA of Bocti et al. and the NINDS-CSN short MoCA (Table 3). When Bocti et al.'s short MoCA was used in this study to detect cognitive impairment, the AUC was reduced from 0.87 to 0.71, the sensitivity was reduced from 91% to 58%, and the specificity was maintained well (83% vs. 84% now), and when Bocti et al.'s NINDS-CSN short MoCA was used in this study to detect cognitive impairment, the AUC decreased from 0.82 to 0.67, the sensitivity decreased from 87% to 48%, and the specificity was good (74% vs. 87% now).
Table 3 The short MoCA of this study is distinguished from the short MoCA and NINDS-CSN short MoCA of Bocti et al., and the index after binding to SDMT
aWhen AUC was compared with VasCog Screen, P<0.001; b SDMT impairment was defined as <14 and <33 for participants with years of primary education (≤6 years) and years of secondary/tertiary education (≥7 years) according to local norms.
VasCog Screen在检测认知障碍方面优于Bocti等人的短MoCA（AUC：0.82 vs. 0.71，p<0.001）和NINDS-CSN短MoCA（AUC：0.82 vs. 0.67，p<0.001）（表3）。
Bocti et al.'s short MoCA and NINDS-CSN short MoCA were combined with SDMT to detect whether the inclusion of the information processing speed project would sustainably improve diagnostic accuracy. The results showed that the AUC, sensitivity, and diagnostic accuracy of Bocti et al.'s short MoCA and NINDS-CSN short MoCA increased with good specificity and no significant difference from VasCog Screen when conjugated to SDMT (Table 3).
conclusion
VasCog Screen provides a new cognitive impairment screening tool for stroke and heart failure patients with good sensitivity, specificity, and diagnostic accuracy. In addition, the screening tool is easy to implement in the clinic, which helps patients to detect cognitive impairment early and adopt corresponding interventions.
文献索引：Chen NYC, Tan MYL, Xu J, Zuo L, Dong Y. VasCog Screen test: sensitive in detecting cognitive impairment in patients who had a stroke or with heart failure. Stroke Vasc Neurol. 2024 Apr 22:svn-2023-002701. doi: 10.1136/svn-2023-002701. Epub ahead of print. PMID: 38649196.
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