Development and validation of the Montreal cognitive assessment for people with hearing impairment (MoCA-H).

BACKGROUND: Hearing impairment is common among older adults and affects cognitive assessments for identification of dementia which rely on good hearing function. We developed and validated a version of the Montreal Cognitive Assessment (MoCA) for people with hearing impairment. METHODS: We adapted existing MoCA 8.1 items for people with hearing impairment by presenting instructions and stimuli in written rather than spoken format. One Attention domain and two Language domain items required substitution by alternative items. Three and four candidate items respectively were constructed and field-tested along with the items adapted to written form. We used a combination of individual item analysis and item substitution to select the set of alternative items to be included in the final form of the MoCA-H in place of the excluded original items. We then evaluated the performance and reliability of the final tool, including making any required adjustments for demographic factors. RESULTS: One hundred and fifty-nine hearing-impaired participants, including 76 with normal cognition and 83 with dementia, completed the adapted version of the MoCA. A further 97 participants with normal hearing completed the standard MoCA as well as the novel items developed for the MoCA-H to assess score equivalence between the existing and alternative MoCA items and for independence from hearing impairment. Twenty-eight participants were retested between 2-4 weeks after initial testing. After the selection of optimal item set, the final MoCA-H had an area under the curve of 0.973 (95% CI 0.952-0.994). At a cut-point of 24 points or less sensitivity and specificity for dementia was 92.8% and 90.8%, respectively. The intraclass correlation for test-retest reliability was 0.92 (95%CI 0.78-0.97). CONCLUSION: The MoCA-H is a sensitive and reliable means of identifying dementia among adults with acquired hearing impairment.

Tools for App- and Web-Based Self-Testing of Cognitive Impairment: Systematic Search and Evaluation.

BACKGROUND: Tools for app- and Web-based self-testing for identification of cognitive impairment are widely available but are of uncertain quality. OBJECTIVE: The objective of this study was to undertake a scoping review of app- and Web-based self-tests for cognitive impairment and determine the validity of these tests. METHODS: We conducted systematic searches in electronic databases, including Google search, Google Play Store, and iPhone Operating System App Store, using the search terms "Online OR Internet-based AND Memory OR Brain OR Dementia OR mild cognitive impairment OR MCI AND Test OR Screen OR Check." RESULTS: We identified 3057 tools, of which 25 were included in the review. Most tools meeting the inclusion criteria assessed multiple cognitive domains. The most frequently assessed domains were memory, attention, and executive function. We then conducted an electronic survey with the developers of the tools to identify data relating to development and validation of each tool. If no response to the survey was received, Google (to identify gray literature), Google Scholar, and Medical Literature Analysis and Retrieval System Online were searched using key terms "(name of developer, if available)" AND "(the name of the tool)" to identify any additional data. Only 7 tools had any information concerning psychometric quality, and only 1 tool reported data on performance norms, reliability, validity, sensitivity, and specificity for the detection of cognitive impairment. CONCLUSIONS: The number of cognitive self-assessment electronic health tools for cognitive impairment is increasing, but most are of uncertain quality. There is a need for well-validated tools and guidance for users concerning which tools provide reliable information about possible cognitive impairment that could warrant further investigation.

Erratum: Author Correction: eHealth tools for the self-testing of visual acuity: a scoping review.

[This corrects the article DOI: 10.1038/s41746-019-0154-5.].

eHealth tools for the self-testing of visual acuity: a scoping review.

Uncorrected refractive error is a major cause of vision impairment, and is indexed by visual acuity. Availability of vision assessment is limited in low/middle-income countries and in minority groups in high income countries. eHealth tools offer a solution; two-thirds of the globe own mobile devices. This is a scoping review of the number and quality of tools for self-testing visual acuity. Software applications intended for professional clinical use were excluded. Keyword searches were conducted on Google online, Google Play and iOS store. The first 100 hits in each search were screened against inclusion criteria. After screening, 42 tools were reviewed. Tools assessed near and distance vision. About half (n = 20) used bespoke optotypes. The majority (n = 25) presented optotypes one by one. Four included a calibration procedure. Only one tool was validated against gold standard measures. Many self-test tools have been published, but lack validation. There is a need for regulation of tools for the self-testing of visual acuity to reduce potential risk or confusion to users.

Protocol for the development of versions of the Montreal Cognitive Assessment (MoCA) for people with hearing or vision impairment.

INTRODUCTION: Hearing and vision impairments are highly prevalent among older adults and impact commonly used cognitive assessment tools for the identification of dementia. Adaptations of such tests for people with hearing or vision impairment have not been adequately validated among populations with such sensory impairment. METHODS AND ANALYSIS: We will develop two versions of the Montreal Cognitive Assessment (MoCA) for people with acquired hearing impairment (MoCA-H) or vision impairment (MoCA-V). The MoCA-H and MoCA-V will exclude the existing MoCA items that are presented in spoken or visual format, respectively, and include new suitably adapted items. Participants (n=792) with combinations of hearing, vision and cognitive impairment will complete standard or adapted versions of the MoCA across three language sites (English, French and Greek). Development of the MoCA-H and the MoCA-V will be based on analysis of adapted and standard MoCA items following model-based development to select the combination of items for the MoCA-H and MoCA-V that provide optimal sensitivity and specificity for detection of dementia. ETHICS AND DISSEMINATION: The study has received ethical approval from respective centres in the UK, France, Greece and Cyprus. The results of the study will be disseminated through peer-reviewed publication, conference presentations, the study website (https://www.sense-cog.eu/), the SENSE-Cog Twitter account (@sense_cog) and the MoCA test website (https://www.mocatest.org/). The main outputs of the study will be versions of the MoCA that are appropriate for use with adults with acquired hearing or vision impairment and will contribute significantly to the clinical care of older people.

Improving hearing and vision in dementia: protocol for a field trial of a new intervention.

INTRODUCTION: Quality of life and other key outcomes may be improved by optimising hearing and vision function in people living with dementia. To date, there is limited research assessing the efficacy of interventions aimed at improving hearing and vision in people with dementia. Here, we outline a protocol to field test a newly developed home-based intervention, designed to optimise sensory functioning in people with dementia in three European sites. The results of this study will inform the design and conduct of a full-scale randomised controlled trial (RCT) in five European sites. METHODS AND ANALYSIS: In this multisite, single arm, open label, feasibility study, participants with dementia (n=24) will be assessed for hearing and vision impairments and be prescribed a hearing aid and/or glasses. Each participant will have a study partner ('dyads'). A subset of dyads will receive 'sensory support' from a 'sensory support therapist', comprising home visits over 12 weeks. The therapist will offer the following intervention: adherence support for corrective devices; adaptations to the home environment to facilitate sensory function; communication training; and referral to community-based support services. The primary outcomes will be process measures assessing the feasibility, tolerability and acceptability of: (1) the intervention components; (2) the method of implementation of the intervention and (3) the study procedures, including outcome assessment measures. Quantitative data will be collected at baseline and follow-up. Qualitative data using semistructured interviews will be collected postintervention and weekly, using participant diaries. Finally, we will explore a model of cost-effectiveness to apply in the subsequent full-scale trial. This feasibility study is a necessary step in the development of a complex, individualised, psychosocial intervention. The data gathered will allow logistical and theoretical processes to be refined in preparation for a full-scale RCT. ETHICS AND DISSEMINATION: Ethical approval was obtained in all three participating countries. Results of the field trial will be submitted for publication in a peer-reviewed journal.

Research protocol for a complex intervention to support hearing and vision function to improve the lives of people with dementia.

BACKGROUND: Hearing and vision impairments are among the most common and disabling comorbidities in people living with dementia. Intervening to improve sensory function could be a means by which the lives of people living with dementia may be improved. However, very few studies have tried to ameliorate outcomes in dementia by improving sensory function. This paper describes the multi-step development of a new intervention designed to support hearing and vision function in people living with dementia in their own homes. At the end of the development programme, it is anticipated that a 'sensory support' package will be ready for testing in a full scale randomised controlled trial. METHODS: This programme is based on the process of 'intervention mapping' and comprises four integrated steps, designed to address the following: (1) scoping the gaps in understanding, awareness and service provision for the hearing and/or vision impairment care needs of people with dementia using a systematic literature review and Expert Reference Group; (2) investigating the support care needs through a literature search, stakeholder surveys, focus groups, semi-structured interviews and an Expert Reference Group, leading to a prototype sensory support package; (3) refining the prototype by additional input from stakeholders using focus groups and semi-structured interviews; and (4) field testing the draft intervention using an open-labelled, non-randomised feasibility study, integrating feedback from people with dementia and their significant others to develop the final intervention ready for full scale definitive trialling. Input from the 'patient and public voice' is a cornerstone of the work and will interlink with each step of the development process. The programme will take place in study centres in Manchester, Nicosia and Bordeaux. DISCUSSION: Quantitative and qualitative data analyses will be employed, dependent upon the sub-studies in question. Data from the steps will be integrated with consideration given to weighting of evidence for each step of the programme. This programme represents the logical development of a complex intervention to fulfil an unmet need. It is based on a theoretical framework and will lead to a subsequent full scale efficacy trial. The challenges in integrating the data and addressing the contextual issues across study sites will be scrutinised.

Screening tools for the identification of dementia for adults with age-related acquired hearing or vision impairment: a scoping review.

BACKGROUND: Cognitive screening tests frequently rely on items being correctly heard or seen. We aimed to identify, describe, and evaluate the adaptation, validity, and availability of cognitive screening and assessment tools for dementia which have been developed or adapted for adults with acquired hearing and/or vision impairment. METHOD: Electronic databases were searched using subject terms "hearing disorders" OR "vision disorders" AND "cognitive assessment," supplemented by exploring reference lists of included papers and via consultation with health professionals to identify additional literature. RESULTS: 1,551 papers were identified, of which 13 met inclusion criteria. Four papers related to tests adapted for hearing impairment; 11 papers related to tests adapted for vision impairment. Frequently adapted tests were the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MOCA). Adaptations for hearing impairment involved deleting or creating written versions for hearing-dependent items. Adaptations for vision impairment involved deleting vision-dependent items or spoken/tactile versions of visual tasks. No study reported validity of the test in relation to detection of dementia in people with hearing/vision impairment. Item deletion had a negative impact on the psychometric properties of the test. CONCLUSIONS: While attempts have been made to adapt cognitive tests for people with acquired hearing and/or vision impairment, the primary limitation of these adaptations is that their validity in accurately detecting dementia among those with acquired hearing or vision impairment is yet to be established. It is likely that the sensitivity and specificity of the adapted versions are poorer than the original, especially if the adaptation involved item deletion. One solution would involve item substitution in an alternative sensory modality followed by re-validation of the adapted test.

Evidence for a supra-modal representation of emotion from cross-modal adaptation.

Successful social interaction hinges on accurate perception of emotional signals. These signals are typically conveyed multi-modally by the face and voice. Previous research has demonstrated uni-modal contrastive aftereffects for emotionally expressive faces or voices. Here we were interested in whether these aftereffects transfer across modality as theoretical models predict. We show that adaptation to facial expressions elicits significant auditory aftereffects. Adaptation to angry facial expressions caused ambiguous vocal stimuli drawn from an anger-fear morphed continuum to be perceived as less angry and more fearful relative to adaptation to fearful faces. In a second experiment, we demonstrate that these aftereffects are not dependent on learned face-voice congruence, i.e. adaptation to one facial identity transferred to an unmatched voice identity. Taken together, our findings provide support for a supra-modal representation of emotion and suggest further that identity and emotion may be processed independently from one another, at least at the supra-modal level of the processing hierarchy.