Routine Cognitive Screening Research Articles

Routine cognitive screening for older people undergoing major elective surgery: Benefits, risks and costs.

Cognitive impairment and older age are major risk factors for postoperative delirium. Professional societies have advocated preoperative screening to identify at-risk individuals for implementation of interventions, which have moderate effectiveness in preventing delirium. However, it remains unclear from the guidelines whether screening should be completed routinely for all older individuals or targeted, and also which specific screening tool is preferred. In addition, the responsibility for screening remains undesignated in the guidelines provided. We reviewed the benefits and risks of routine screening. We also performed a cost-benefit analysis of routine screening (versus no screening). Furthermore, we summarised the sensitivities and specificities of commonly used screening tools and reviewed evolving screening tools that may have an increasing role in future practice. We concluded that routine screening is useful and appears to be cost-effective for reducing postoperative delirium, with a cost-benefit ratio of 2.89 (adjusted ratio of 2.34), and has additional advantages over other approaches such as targeted screening or routine intervention.

DEMENTIA-RELATED STIGMA, KNOWLEDGE, AND WILLINGNESS TO UNDERGO COGNITIVE SCREENING AMONG OLDER ADULTS

Abstract Screening for dementia such as Alzheimer’s Disease may be most beneficial at the earliest detectable stages of disease presentation, yet there is no definitive recommendation for routine cognitive impairment screening and dementia remains underdiagnosed. Identifying perceptions of cognitive screening, stigmatized beliefs, and misconceptions about dementia could be beneficial for creating interventions that promote dementia knowledge to improve early screening and diagnosis and empower older adults to seek treatment sooner. Thus, we examined the extent to which attitudes, beliefs, and knowledge about cognitive screening and dementia predict willingness to undergo screening and subsequent screening behavior. 295 subjects aged ≥ 60 years completed online surveys containing the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire to assess attitudes about dementia screening and diagnosis, as well as the Alzheimer’s Disease Knowledge Scale (ADKS). Participants were then invited to complete the Montreal Cognitive Assessment in a university psychology laboratory. 94% of participants reported willingness to undergo screening, but only 69% completed one. Logistic regression analysis revealed that the screening acceptance scale of the PRISM-PC significantly predicted reported willingness to undergo screening but not the pursuit of screening. The other PRISM-PC subscales (perceived benefits of dementia screening, stigma of dementia screening, suffering from dementia screening, and impact of dementia screening on patient’s independence) and the ADKS did not predict willingness or pursuit of screening. While most were willing to undergo screening, significantly fewer completed screening within the study. The factors that predict pursuit of cognitive screening require further investigation.

Evaluating Prevalence of Cognitive Impairment in Older People Living with HIV Served by a Community‐Based Organization in Colorado, USA

AbstractBackgroundOlder people living with HIV (PLWH) experience unique pathophysiology contributing to accelerated and accentuated aging when compared to older adults living without HIV. Indeed, cognitive dysfunction is a significant age‐related risk exacerbated by HIV. This study investigated prevalence of Mild Cognitive Impairment (MCI) in older PLWH by employing the Montreal Cognitive Assessment (MoCA), which has a high sensitivity for assessing cognitive performance, and its relationship with HIV health, socioeconomic status, and functional aptitude.MethodA cross‐sectional study was conducted in older PLWH ≥50 years receiving HIV‐related care and services at a Community‐Based Organization (CBO) between June and October 2022. The MoCA English Version (8.1) was used to screen cognitive performance. MCI was defined as MoCA scores 18‐26; 10‐17 for moderate cognitive impairment (MoCI); and ≤9 for dementia. Functional aptitude was measured by participants’ Ryan White Part A Wellness acuity scores (0‐41), where higher scores are indicative of lower functional aptitude.ResultDuring the study period, 31 participants were screened; 64.5% were male and 88.9% had virologic suppression. The median age was 60.7 (standard deviation [SD] 6.3) and the median years living with HIV was 23 years (SD 8.9). The median MoCA score was 23 (SD 3.5): 21 (67.7%) with MCI; 3 (9.7%) with MoCI. The median acuity score was 18 (SD 11.9): 21 (SD 11.8) for MCI; 28 (SD 8.5) for MoCI. Multivariable linear regression analysis revealed that a lower MoCA score was associated with lower educational attainment (≤12 years) (r = 0.671, p = 0.0276) and low annual income (r = 0.789, p = 0.0043). A higher acuity score was not significantly associated with MoCA scores.ConclusionA majority of older PLWH screened were within range for M/MoCI. Thus, it is both necessary and ethically responsible for CBO’s serving older PLWH to integrate routine cognitive screening to identify early and pre‐symptomatic stages of impairment, providing prompt services to reduce symptoms and improve health outcomes.

91 Remote Smartphone-Based Assessment Predicts Standard Neuropsychological Test Performance and Cerebral Amyloid Status in Cognitively Normal Older Adults

Objective:Routine cognitive screening in the elderly may facilitate earlier diagnosis of neurodegenerative diseases and access to care and resources for patients and families. However, despite growing rates of Alzheimer's and related disorders (ADRD), the availability and implementation of cognitive screening for older adults in the US remains quite limited. Remote cognitive assessment via smartphone app may reduce several barriers to more widespread screening. We examined the validity of a remote app-based cognitive screening protocol in healthy older adults by examining remote task convergence with standard-person assessments and cerebral amyloid (Aß) status as an AD biomarker.Participants and Methods:Participants (N =117) were cognitively unimpaired adults aged 60-80 years (67.5% female, 88% White, 75% education > 16 years). A portion had Aß PET imaging results available from prior research participation [(Aß positive (Aß+) n =26, and Aß negative (Aß-) n = 44]. A modified Telephone Interview for Cognitive Status (TICSm) cutoff score of >34 was used to establish unimpaired cognition. Participants completed 8 consecutive assessment days using Mobile Monitoring of Cognitive Change (M2C2), a smartphone app-based testing platform developed as part of the National Institute of Aging's Mobile Toolbox initiative. Brief (i.e., 3-4 minute) M2C2 sessions were assigned daily within morning, afternoon, and evening time windows. Tasks included measures of visual working memory (WM), processing speed (PS), and episodic memory (EM) (see Thompson et al., 2022). Participants then completed a battery of standard neuropsychological assessments in-person at a follow-up visit.Results:Participants completed 22.6 (SD = 2.6) out of 24 assigned sessions (3 sessions x 8 days) on average. Performance on all M2C2 tasks decreased significantly with age. Women performed significantly better on WM and EM tasks relative to men. There were no detectable significant differences in performance by race or education. Shorter mean reaction time on M2C2 PS trials predicted faster Trails A and B completion (ß = .26, p < .01, 95% CI [3.8, 23.3] and ß = .20, p < .05, 95% CI [.23, 6.8], respectively). Greater mean M2C2 WM accuracy predicted longer maximum backward digital span (ß = .24, p = .01, 95% CI [.02, .16]). Greater mean M2C2 EM accuracy predicted stronger Logical Memory delayed recall (ß = .33, p < .001, 95% CI [.004, .012]) and total immediate recall on the Free and Cued Selective Reminding Test (ß = .19, p < .05, 95% CI [.000, .006]). Moreover, EM significantly distinguished Aß- and Aß+ individuals (t (68) = 3.0, p < .01) with fair accuracy (AUC = .72).Conclusions:Mean performance across 8-days on each M2C2 task predicted same-domain cognitive task performance on a standard assessment battery, with medium effect sizes. Performance on the EM task was also sensitive to cerebral Aß status, consistent with subtle memory changes implicated in the preclinical stage of AD. These findings support the validity of this remote testing protocol in healthy older adults, with implications for future efforts to facilitate accessible and sensitive cognitive screening for early detection of ADRD. Limitations include the restricted generalizability of this primarily white and college educated sample.

Cognitive impairment and outcomes in older adults with non-ST-elevation acute coronary syndrome

ObjectiveThis study aimed to explore the prognostic impact of cognitive impairment on the long-term risk of major adverse cardiovascular events (MACEs) in older patients with non-ST-elevation acute coronary syndrome (NSTEACS)...

Role of Neuropsychological Tests in Early Detection of Alzheimer's Disease

Longitudinal studies using neuropsychological tests have reported that cognitive changes may be observed up to 20 years before diagnosis of dementia. These findings suggest that neuropsychological tests may serve as potential screening tools during the preclinical phase of Alzheimer's disease. However, routine cognitive screening tests show limited sensitivity for prediction of dementia. Therefore, careful selection of appropriate neuropsychological tests is essential for effective screening of dementia during the preclinical stages.

Barriers and facilitators to cognitive impairment screening among older adults with diabetes mellitus and hypertension by primary healthcare providers in rural Uganda.

The burden of non-communicable diseases and cognitive impairment exhibit a linear rise in sub-Saharan Africa due to the increase in life expectancy. Non-communicable diseases like diabetes mellitus and hypertension increase the risk for cognitive impairment. To improve our understanding of the underpinnings of the cognitive impairment screening, this study explored the barriers and facilitators of routine cognitive impairment screening in a primary healthcare setting guided by the Capacity, Opportunity, Motivation Behavioral change (COM-B) model. This was a descriptive qualitative study with primary healthcare providers who provide care to older adults with diabetes mellitus and hypertension at three primary healthcare centers in Mbarara district southwestern Uganda. In-depth interviews were conducted using a semi structured interview guide. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework approach along the COM-B components. Each COM-B component factors were categorized as barriers and facilitators. We conducted 20 in-depth interviews with clinical officers, enrolled nurses, and a psychiatric nurse. The questions were guided by the Capacity, Opportunity and Motivation Behavioral change (COM-B) framework to identify barriers and facilitators to cognitive impairment screening. The factors that negatively affected the screening were considered as barriers, while the positive as facilitators. Capacity related barriers to cognitive impairment screening included chronic understaffing, primary healthcare provider non-involvement, lack of training/skills, lack of knowledge and awareness in screening, absence of caretakers, lack of patient awareness of cognitive problems; while facilitators were staff recruitment, primary healthcare provider involvement, and specialized training. Opportunity related barriers to screening included patient overload, infrastructure shortage, and time constraints. Motivation related barriers included lack of screening guidance and policy, while the facilitators were availability of mentorship programs for primary healthcare providers. Integrating cognitive impairment screening in primary health care requires engagement of relevant stakeholders with the focus on addressing implementation challenges through capacity development. Timely cognitive impairment screening at the first point of care initiates a cascade of interventions for timely enrollment into care, thus arresting the progress of cognitive impairment that leads to dementia.

Screening for Dementia in Audiology Clinics – Advantages, Pitfalls, and Recommendations

Screening for Dementia in Audiology Clinics – Advantages, Pitfalls, and Recommendations

Multidisciplinary collaboration to develop a digital health solution for early detection of cognitive decline in primary care.

Developing digital healthcare solutions that facilitate rapid identification and effective management of patients with Alzheimer disease and related disorders (ADRD) is an area of intense study. A critical juncture for these efforts involves the early detection of cognitive decline. Because primary care providers (PCPs) are the first line of medical care, they are often the first to hear concerns about cognitive decline. However, under-diagnosis of ADRD in primary care settings is widely recognized, as are the many barriers to routine cognitive screening. While information about brief cognitive screening tools for detecting ADRD is plentiful, PCPs remain uncertain about which patients to assess, which tools to use and how to use them, and how to communicate results. The goal of this project was to design a risk assessment and cognitive screening (RACS) application that specifically addressed the needs and concerns of PCPs to facilitate identification of cognitive decline in primary care settings. We employed a multi-modal assessment approach in designing the RACS app, which first assesses risk for cognitive impairment and then assesses cognitive functioning using a working memory/processing speed task in combination with four speech/language tasks. We assembled a multidisciplinary team with the following expertise to develop and test the app: biostatistics, computational linguistics, computer science, computerized cognitive assessment, gaming/app development, engineering, neurology, neuropsychology, neuroscience, primary care, psychometrics, and speech-language pathology. Programming of app features and pilot testing with people with ADRD was completed in 3 months. Initial development of the connected speech analysis pipeline was completed in 4 months with ongoing testing. Data collection of 50 cognitively normal, 50 mild cognitive impairment, and 50 mild dementia participants is approximately 50% completed within 6 months. Preliminary results based on cognitive performance alone show good ability to discriminate groups. Reduction of speech-language variables for inclusion in a final cognitive performance score is underway using a variety of machine learning techniques, including the elastic net and random forests. The RACS app shows promise as a digital health solution to facilitate early detection of cognitive decline in primary care and may prove useful in other busy clinical settings.

A promising cognitive screener in multiple sclerosis: The NIH toolbox cognition battery concords with gold standard neuropsychological measures

Background: Routine cognitive screening is a priority in MS clinical care. The National Institutes of Health Toolbox (NIHTB) Cognition Battery is a 30-min instrument validated in neurological populations excluding MS. Objectives: To assess construct validity of NIHTB tests and compare classification of cognitive impairment with gold-standard tests. To evaluate relationships between fluid cognition and clinical measures. Methods: Eighty-seven individuals, aged 30–59 years, completed the NIHTB, Minimal Assessment of Cognitive Function in MS (MACFIMS), Wechsler Adult Intelligence Scale-IV subtests, and measures of disease severity, depression, and fatigue. Results: The NIHTB showed adequate convergent validity for processing speed, working memory, and episodic memory. Although fluid cognition scores from the NIHTB and MACFIMS classified a similar proportion of participants as cognitively impaired, the two batteries differed in which individuals were classified as impaired versus preserved. NIHTB fluid cognition was inversely correlated with disease severity but not related to depression or fatigue. Conclusions: The NIHTB concords with gold-standard measures, and classifies cognitive impairment at similar rates to the MACFIMS. Adjusted NIHTB fluid cognition was negatively associated with disease severity suggesting clinical utility. Psychometric validation of the NIHTB in clinical practice will elucidate its promise as a cognitive screener in MS.

The Montreal cognitive assessment as a cognitive screening tool in sickle cell disease: Associations with clinically significant cognitive domains.

SummaryAdults with sickle cell disease (SCD) are at risk for cognitive impairment, which causes significant morbidity. Guidelines support routine cognitive screening, but no screening test is validated in this population. We explored the Montreal Cognitive Assessment (MoCA) as a possible screening test in SCD. We administered the MoCA; a literacy test, the Wide Range Achievement Test, fourth edition (WRAT‐4); and a health literacy test, the Shortened Test of Functional Health Literacy in Adults (S‐TOFHLA) to adults with SCD and gathered clinical variables through chart review. Spearman's rho, Mann–Whitney, and Kruskal–Wallis tests and quantile regression models were used. Among our sample of 49 adults with SCD, the median MoCA score was 25.0 [interquartile range (IQR) 22.0–28.0]. Higher educational attainment was associated with MoCA scores (p = 0.001). In multivariable models, MoCA scores were associated with S‐TOFHLA (p = 0.001) and WRAT‐4 Reading (p = 0.002) scores, and overt stroke (p = 0.03) at the median. This pilot study adds to the limited literature of cognitive screening tests in adults with SCD and demonstrates a relationship between MoCA scores and measures of literacy and health literacy. The MoCA is a promising option for briefly screening for cognitive impairment in adults with SCD, though further study is needed to confirm its validity.

Lesion symptom mapping of domain-specific cognitive impairments using routine imaging in stroke

IntroductionThis large-scale lesion-symptom mapping study investigates the necessary neuro-anatomical substrates of 5 cognitive domains frequently affected post stroke: Language, Attention, Praxis, Number, and Memory. This study aims to demonstrate the validity of using routine clinical brain imaging and standard bedside cognitive screening data from a large, real-world patient cohort for lesion-symptom mapping. Patients and methodsBehavioural cognitive screening data from the Oxford Cognitive Screen and routine clinical neuroimaging from 573 acute patients was used in voxel-based lesion-symptom mapping analyses. Patients were classed as impaired or not on each of the subtests within 5 cognitive domains. ResultsDistinct patterns of lesion damage were associated with different domains. Language functions were associated with damage to left hemisphere fronto-temporal areas. Visuo-spatial functions were associated with damage to posterior occipital areas (Visual Field) and the right temporo-parietal region (Visual Neglect). Different memory impairments were linked to distinct voxel clusters within the left insular and opercular cortices. Deficits which were not associated with localised voxels (e.g. executive function, praxis) represent distributed, bilateral functions. DiscussionThe standardised, brief Oxford Cognitive Screen was able to reliably differentiate distinct neural correlates critically involved in supporting domain-specific cognitive abilities. ConclusionBy demonstrating and replicating known brain anatomy correlates within real-life clinical cohorts using routinely collected scans and standard bedside screens, we open up VLSM techniques to a wealth of clinically relevant studies which can capitalise on using existing clinical data.

Patient, Family Caregiver, and Provider Perceptions on Self-Assessment Screening for Cognitive Impairment in Primary Care: Findings From a Qualitative Study.

The purpose of this study was to evaluate patient, family, and provider perspectives on routine cognitive screening of older adults in primary care using a novel self-assessment tool for detection of early cognitive impairment (CI). We conducted four virtual focus groups with patients aged 65 and older with no CI (n = 18) and family caregivers of patients with CI (n = 5) and interviews with primary care providers (n = 11). Patient and family caregiver participants felt that early detection of CI was important in primary care and may facilitate planning for the future including finances, living arrangements, and advance care planning. Providers reported that they do not use a standardized tool to routinely screen patients for CI yet endorsed the use of a self-assessment CI screening tool. These results suggest that routine screening of older adults using a brief, self-assessment screening tool for CI in primary care may be acceptable to patients, family caregivers, and providers. The findings from this study will inform the development of a brief self-assessment CI screening tool for use in primary care.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment.

The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis. Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations. There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes. These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment.

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.

Investigation of dementia awareness among stroke patients in China: A cross-sectional study

Abstract Objective To provide guidelines for the prevention of post-stroke dementia, we investigated whether stroke patients were aware of post-stroke dementia and their level of dementia-related knowledge. Methods Five dementia-related questions were designed. A field survey was conducted in a question-and-answer method using the designed questions. The surveys assessed 3000 stroke patients (2 weeks–6 months after stroke attacks) from 14 hospitals/clinical centers in 7 provinces and cities across China. Results Among 3000 stroke patients, 80.5% had heard of dementia, 39.1% knew that stroke can lead to dementia, 55.7% believed dementia can be prevented, 50.8% thought dementia can be cured, and only 8.8% had ever seen a doctor because of memory deterioration. Then, patients were classified into three groups, including a no cognitive impairment (NCI) group, a mild cognitive impairment (MCI) group, and a mild dementia (MD) group. Among the MCI and MD groups, only 8.7% (75/861) and 9.9% (64/649) of patients, respectively, had ever seen a doctor because of memory deterioration. According to our results, patients with a higher level of cognitive impairment had a lower awareness of dementia (P Conclusion The awareness of dementia in stroke patients in China is low, and the consultation rate is even lower. Moreover, patients with a higher level of cognitive impairment have a lower awareness of dementia. To improve public awareness and improve prevention, more emphasis should be put on education regarding post-stroke dementia. Routine cognitive function screening should be conducted on stroke patients as an effective way to assess dementia.

Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction According to Cognitive Status: The SILVER-AMI Study

BackgroundWhile survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors’ risk for these outcomes is limited. Methods3041 patients aged ≥75 years hospitalized with acute myocardial infarction (mean age 82 ± 5 years, 56% male) recruited from 94 US hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment, respectively. Readmissions and death at 6 months post-discharge were ascertained via participant report and medical record review. Associations between cognition and outcomes were evaluated with multivariable-adjusted logistic regression. ResultsMild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort, respectively. Readmission and death at 6 months occurred in 41% and 9% of participants, respectively. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (odds ratio [OR] 1.36; 95% confidence interval [CI], 1.08-1.72 and OR 1.58; 95% CI, 1.18-2.12, respectively) and death (OR 2.19; 95% CI, 1.54-3.11 and OR 3.82; 95% CI, 2.63-5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death (OR 1.69; 95% CI, 1.10-2.59) persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression, but not for readmissions. ConclusionsModerate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes who may benefit from closer oversight and support in the post-discharge period.

Rates of Cognitive and Functional Impairments Among Sheltered Adults Experiencing Homelessness.

This study examined rates of objective cognitive and functional impairments and associations between cognitive performance and performance-based functional capacity in a well-characterized sample of adults experiencing homelessness. One hundred participants completed a brief neuropsychological and functional capacity assessment and self-report questionnaires. Cognitive impairment rates were determined by comparing mean scores with published normative data, as well as by examining frequency of scores >1 SD below the mean. Pearson correlations were used to examine associations between cognitive and functional capacities. Overall, 65% of the study participants had scores in the cognitively impaired range on a brief cognitive screening test, 30% had impaired processing speed, and 11% met cognitive criteria for intellectual disability. Furthermore, 48% of the sample met functional impairment criteria, and poorer cognitive performance was strongly associated with poorer performance-based functional capacity (p<0.001). Cognitive and functional impairments are common among sheltered adults experiencing homelessness, underscoring the need for routine objective cognitive screening and rehabilitation services.

Primary Care Provider Attitudes and Perceptions of Routine Cognitive Screening in Older Adults

The 2011 Annual Wellness Visit (AWV) Medicare benefit includes a cognitive screening component intended to improve screening of older adults. However, available literature only presents physician perspectives on cognitive screening prior to 2011. The purpose of this study was to explore primary care provider (PCP) attitudes and perceptions of cognitive screening in older adults. An Internet-based survey link was sent to Virginia professional organizations and clinics to distribute to PCPs serving older adults. Likert scale, multiple choice, and free response questions were used to understand current attitudes, perceptions, and practices. The sample (N=39) was comprised of 26 nurse practitioners (NPs), 9 physicians, and four who did not disclose role. Most participants were aware of the AWV (n=31, 88.6%) and agreed that early detection “promotes earlier diagnosis and access to resources” (mean ± standard deviation,1.58±0.69). However, less than half of NPs screened annually (n=10/26, 38.5%) and even less conducted screening during an AWV (n=7/26, 26.9%). About half of MDs conducted cognitive screening during an AWV (n=5/9, 55.6%). Although NPs screened less, they more strongly agreed that screening should occur annually (1.92±1.15 vs. 2.67±1.23) and “additional training would improve [screening] ability” (2.04±1.0 vs. 3.22±1.20). Also, few NPs independently managed impairment (n=5/26, 19.2%) compared to MDs (n=5/9, 55.6%). Our findings demonstrate that NPs screen less and feel less prepared to conduct cognitive screenings. It is important to provide additional resources and training for all PCPs, but especially NPs who are rapidly entering primary care to help improve identification and management of cognitive impairment.

Evidence of Educational Bias in Cognitive Screening of Adults with Sickle Cell Disease: Comparison of Available Tools and Possible Strategies for Mitigation

Background: Cognitive impairment is a dreaded complication of sickle cell disease (SCD) that impacts quality of life, school performance and employment. In 2020, the American Society of Hematology issued a strong recommendation that clinicians supervising the care of adults with SCD conduct surveillance for cognitive impairment using simplified signaling questions (DeBaun, 2020). However, guidance on the optimal screening strategy is lacking and several available tools are biased by language and education. The Rowland Universal Dementia Assessment Scale (RUDAS) was specifically designed for cognitive screening in multicultural populations (Storey, 2004). In the general elderly population, RUDAS is less biased by education than the Montreal Cognitive Assessment (MoCA) (Naqvi, 2015). Hypothesis: In adults with SCD, performance on the RUDAS is less influenced by educational attainment when compared to the MoCA. Our primary aim was to estimate the prevalence of suspected cognitive impairment using RUDAS and MoCA in adult SCD patients. The secondary aims were to examine for the presence of educational bias and to develop mitigation strategies in case of such a bias. Methods: Study design: cross-sectional study at UMGRR clinic at Henri Mondor Hospital, Créteil (France). Inclusion criteria: out-patients ≥18 years-old; all SCD phenotypes. Exclusion criteria: inability to obtain informed consent and/or follow study instructions. Intervention: Cognitive screening was performed using the RUDAS (translated to French by Philippe Desmarais), MoCA (third alternative version) and an additional visuospatial task of copying overlapping triangles (from the French BEC96 assessment). RUDAS and MoCA scores &amp;lt;28 and &amp;lt;26, respectively, were considered suggestive of cognitive impairment per previous studies (Basic, 2009 and Nasredinne, 2005) and patients were referred for definite neuropsychological evaluation. Survey on demographics and screening for depression and anxiety using Hospital Anxiety Depression Scale (HADS) were completed by the participants. Educational attainment was scored based on the number of years of schooling for the highest completed diploma. Statistical plan: linear regression was performed to identify possible associations between RUDAS, MoCA and social determinants of health. Results: Among the first 45 consecutive adult SCD patients undergoing routine cognitive screening, the median age was 39 (range 19-67). RUDAS and MoCA scores suggestive of mild cognitive impairment were found in 33/45 (73.3%) and 29/45 (64.4%) participants, respectively. There was a strong correlation between both tests (r=0.48, p=0.001). Both RUDAS and MoCA scores increased significantly with increasing level of education (r=0.36, p=0.015 and r=0.39, p=0.007, respectively), but were not significantly influenced by the HADS score. RUDAS and MoCA test items most biased by education were visuoconstructional tasks. Tasks assessing executive functioning and language were also biased in MoCA. Substituting the 3D visuospatial task of the RUDAS by a 2D task reduced the educational bias (r=0.20, p=0.045). Adding 1 point for highest level of education £ 12 years after kindergarten did significantly mitigate the effect of education on the RUDAS but only partially for the MoCA (r=0.23, p=0.131 and r=0.30, p=0.047). Conclusions: Overall, these results suggest there is an educational bias in the neurocognitive screening of adult SCD patients using available tools such as the RUDAS and MoCA. Although RUDAS was less biased overall, visuospatial assessment remained biased. The task often considered more "culture-fair" is still subject to the impact of educational potential (Statucka, 2019). We provide different strategies to mitigate education bias when assessing with RUDAS. Thus, the RUDAS adjusted by the educational level allows to systematically identify SCD patients in need of comprehensive neurocognitive testing. Prospective validation is ongoing. Disclosures Forté: Canadian Hematology Society: Research Funding; Pfizer - Global Medical Grants: Research Funding. Soulieres:Novartis: Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees. Kuo:Pfizer: Consultancy, Research Funding; Celgene: Consultancy; Alexion: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Bioverativ: Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bluebird Bio: Consultancy; Apellis: Consultancy. Bartolucci:Roche: Consultancy; Innovhem: Other; AGIOS: Consultancy; Bluebird: Consultancy; Emmaus: Consultancy; Addmedica: Research Funding; Fabre Foundation: Research Funding; Novartis: Research Funding; Bluebird: Research Funding; GBT: Consultancy; ADDMEDICA: Consultancy; HEMANEXT: Consultancy; Novartis: Consultancy.