Cognitive screening with functional assessment improves diagnostic accuracy and attenuates bias

Abstract

Introduction Cognitive screening measures often lack sensitivity and are hampered by inequities across ethnoracial groups. A multitrait multimethod (MTMM) classification may attenuate these shortcomings. Methods A sample of 7227 participants across the diagnostic spectrum were selected from the National Alzheimer's Coordinating Center cohort. Random forest ensemble methods were used to predict diagnosis across the sample and within Black American ( n = 1025) and non‐Hispanic White groups ( n = 5263) based on: (1) a demographically corrected Montreal Cognitive Assessment (MoCA), (2) MoCA and Functional Assessment Questionnaire (FAQ), (3) MoCA and FAQ with demographic correction. Results The MTMM approach with demographic correction had the highest diagnostic accuracy for the cognitively unimpaired (area under curve [AUC] [95% confidence interval (CI)]): 0.906 [0.892, 0.920]) and mild cognitive impairment (AUC: 0.835 [0.810, 0.860]) groups and reduced racial disparities. Discussion With further validation, the MTMM approach combining cognitive screening and functional status assessment may serve to improve diagnostic accuracy and extend opportunities for early intervention with greater equity.

Blood biomarkers for cognitive decline and clinical progression in a Mexican American cohort

“…This is particularly relevant for diverse ethnoracial groups given inherent biases in cognitive tests due to variances in educational quality, linguistic background, and culture. 7 , 45 …”

Methodological Issues in Advancing the Status of Functional Cognitive Assessment

“…We recommend that functional cognitive and neurocognitive measures be used in tandem to create a comprehensive understanding of cognitive function. There is ample evidence supporting a multi-level approach that combines neurocognitive data with functional data to improve identification of individuals with both cognitive impairment and functional cognitive deficits (Dham et al, 2020; Foster et al, 2022; Gonzalez et al, 2021). However, the use of brief global screening measures (e.g., Mini Mental State Exam, the Montreal Cognitive Assessment [MOCA], and the Neurobehavioral Cognitive Status Examination; Folstein et al, 1975; Kiernan et al, 1987; Nasreddine et al, 2005) to infer real-world IADL performance capacity is beyond the scope of the original purpose of the measures (Burgess et al, 2006).…”

Free-Cog reformulated: analyses as independent or stepwise tests of cognitive and executive function

“…This may involve not only more than one cognitive test but also a combination of cognitive and other tests, including functional assessment. 4,5 Another approach to cognitive screening is stepwise case finding in which only those participants screening positive or negative on an initial test are then subjected to further testing. Examples of this approach include the UK Dementia CQUIN (Commissioning for Quality and Innovation) single question screener as a prelude to further referral or testing, 6 and a similar single question designated the progressive forgetfulness question (PFQ).…”

“…This may involve not only more than one cognitive test but also a combination of cognitive and other tests, including functional assessment. 4,5…”