Validity of the Montreal Cognitive Assessment and the HIV Dementia Scale in the assessment of cognitive impairment in HIV-1 infected patients

Abstract

The gold standard for evaluating cognitive impairments in HIV-infected patients is to administer an extensive neuropsychological assessment. This may, however, be time-consuming and hence not always feasible in the clinic. Therefore, several brief screening tools have been developed. This study determined the validity of the Montreal Cognitive Assessment (MoCA) and the HIV Dementia Scale (HDS) in detecting cognitive impairment using both the Frascati and cognitive impairment, no dementia (CIND) criteria to classify cognitive impairment in HIV-1 infected patients. The MoCA, HDS, and an extensive neuropsychological assessment, covering nine cognitive domains, were administered in a group of 102 HIV-infected patients who were all on cART and virologically suppressed for at least 1 year. Results show that the areas under the curve (AUCs) for both the MoCA and the HDS were statistically significant, using both the Frascati and the CIND criteria as gold standard. However, the AUCs for the MoCA and HDS did not differ significantly, regardless of the used classification criteria (Frascati: z = 0.37, p = 0.35; CIND: z = −0.62, p = 0.27). Sensitivity of both the MoCA and HDS were low for the recommended cutoff scores (Frascati: MoCA (<26) = 0.56, HDS (<11) = 0.26; CIND: MoCA (<26) = 0.55, HDS (<11) = 0.36). Cutoff scores with good sensitivity and adequate specificity could not be determined for both screening instruments. Therefore, the HDS and MoCA are not recommended as sole instruments to diagnose HIV-associated cognitive impairment.

Screening for neurocognitive impairment in HIV-positive adults aged 50 years and older: Montreal Cognitive Assessment relates to self-reported and clinician-rated everyday functioning

“…We found a cut-off of ≤26 as the most optimal balance of sensitivity and specificity, which is somewhat higher than the ≤25 cut-point found in other studies in HIV (Chartier et al, 2015; Hasbun et al, 2012; Janssen et al, 2015; Ku et al, 2014; Milanini et al, 2014; Overton et al, 2013). Moreover, the optimal MoCA cut-off remained the same when participants with significant confounding neuromedical factors (e.g., history of stroke, severe head injury) were excluded from analyses.…”

“…Therefore, patients identified as having possible impairment by the MOCA should be referred for a comprehensive evaluation to more accurately characterize and diagnose neurocognitive abilities. By some criteria (as used in the Janssen et al, 2015 study), sensitivities less than 80% and specificities less than 60% are not considered adequate (Blake, McKinney, Treece, Lee, & Lincoln, 2002; Janssen et al, 2015). Thus, using those criteria, while our sensitivity (i.e., 84%) would be considered adequate, our specificity (i.e., 56%) was below the threshold.…”

“…In contrast, the other published study examining the MoCA in older HIV+ adults (Milanini et al, 2014) found suboptimal sensitivity (i.e., 72%) and adequate specificity (i.e., 67%) with a cut-off of ≤25. Similarly, in a sample of adults with HIV (mean age = 48), the cut-off of ≤26 also yielded suboptimal sensitivity (i.e., 56%) but acceptable specificity (i.e., 63%; (Janssen et al, 2015). Some of the differences in results across studies may at least partly be explained by sample differences in terms of age ranges, MoCA ranges (which were not provided for previous studies), and education/cohort differences.…”

“…The latter is particularly important in determining the clinical relevance and ecological validity of the MoCA. Some studies converge to support the MoCA as a practical and valid neurocognitive screening tool in HIV+ adults (Brouillette et al, 2015; Chartier et al, 2015; Hasbun et al, 2012; Koski et al, 2011; Ku et al, 2014; Overton et al, 2013; Robbins et al, 2013; Valcour, 2011), although not sufficient as a stand-alone tool for diagnosing HAND (Chartier et al, 2015; Janssen, Bosch, Koopmans, & Kessels, 2015). To our knowledge, only one study has examined the MoCA as a neurocognitive screener in older HIV+ adults and found the MoCA moderately sensitive and specific for HIV+ adults aged 60 and older, yielding 72% sensitivity and 67% specificity with a cut-off of ≤25 (Milanini et al, 2014).…”

Evidence-based perspectives on the implementation of screening for neurocognitive impairment in HIV

“…A study in the US found results close to those of Joska, 109 while work in the Netherlands showed similar high sensitivity and low specificity only when used at a cut-off of 28.5; at standard cut-off, both statistics were closer to 60%. 110 In the Dutch study, the area under the receiver-operator curve suggested that the MoCA was diagnostically similar to the HDS. In contrast, several other studies, including one recruiting only participants aged >60 years and one using a locally modified version in Korea, have also reported lower sensitivity but higher specificity.…”