key: cord-0902509-1ifttbnx authors: Katz, Mindy J.; Wang, Cuiling; Nester, Caroline O.; Derby, Carol A.; Zimmerman, Molly E.; Lipton, Richard B.; Sliwinski, Martin J.; Rabin, Laura A. title: T‐MoCA: A valid phone screen for cognitive impairment in diverse community samples date: 2021-02-05 journal: Alzheimers Dement (Amst) DOI: 10.1002/dad2.12144 sha: 80be91b8ab50356c48a25e40cabc69b8e7c78d5c doc_id: 902509 cord_uid: 1ifttbnx INTRODUCTION: There is an urgent need to validate telephone versions of widely used general cognitive measures, such as the Montreal Cognitive Assessment (T‐MoCA), for remote assessments. METHODS: In the Einstein Aging Study, a diverse community cohort (n = 428; mean age = 78.1; 66% female; 54% non‐White), equivalence testing was used to examine concordance between the T‐MoCA and the corresponding in‐person MoCA assessment. Receiver operating characteristic analyses examined the diagnostic ability to discriminate between mild cognitive impairment and normal cognition. Conversion methods from T‐MoCA to the MoCA are presented. RESULTS: Education, race/ethnicity, gender, age, self‐reported cognitive concerns, and telephone administration difficulties were associated with both modes of administration; however, when examining the difference between modalities, these factors were not significant. Sensitivity and specificity for the T‐MoCA (using Youden's index optimal cut) were 72% and 59%, respectively. DISCUSSION: The T‐MoCA demonstrated sufficient psychometric properties to be useful for screening of MCI, especially when clinic visits are not feasible. Given the rapidly expanding older adult population, 1,2 remotely administered, validated screening tools for cognitive impairment are increasingly necessary and have far-reaching applications, including use with rural-living individuals, for ease of follow-up and disease monitoring, and for continuity of care. Telephone [17] [18] [19] and videoconferencing-based [20] [21] [22] [23] [24] versions of the MoCA-30 have been developed, but their performance has not been assessed in diverse samples at increased risk for cognitive impairment based on age, race, and socioeconomic status. In addition, the broad applicability of videoconferencing is questionable because it relies on expensive technological resources (including high-speed internet and access to a computer, smartphone, or tablet and a printer) and technological proficiency. This greatly reduces the applicability of this method for detecting dementia risk in under-resourced individuals, or for evaluating older adults who do not have access to technology or who are already cognitively impaired. Telephone-based screening has the potential to address many of these limitations. However, there is a need to establish the validity of telephone screens, especially in the age of the COVID-19 pandemic, when clinicians and researchers alike are turning to remotely administered measures. [25] [26] [27] The telephone MoCA (T-MoCA) generates a total score with a max- 17, 18 or in patients with atrial fibrillation. 19 In these samples, the T-MoCA has demonstrated similar sensitivity for identifying MCI as the Telephone Interview for Cognitive Status (TICS), 17, 18 which correlates highly with the MMSE. 28 The TICS is the most widely translated and validated telephone screen. 29 However, a broader literature has revealed that the TICS may be unreliable for distinguishing MCI from normal cognition. [30] [31] [32] Given that the MoCA outperforms the MMSE 7 for detecting mild cognitive difficulties, the T-MoCA is a promising measure for use in less impaired samples when remote testing is required. To date, very few studies have independently validated the T-MoCA, 18, 19 and no validation studies have been conducted in representative, diverse, community-residing samples of older adults. Prior research has found that performance on the T-MoCA is highly influenced by education level, 19 although it remains unclear how other relevant demographic variables impact performance for the T-MoCA. This is a notable gap in knowledge, as evidence suggests that performance on the in-person MoCA-30 is associated with such factors as age, 33, 34 race/ethnicity, 35, 36 literacy, 37 educational attainment, [33] [34] [35] 37, 38 auditory and visual sensory loss, 40 background noise, 41 and depression. 42 Further, no study has directly examined the equivalence of the T-MoCA with the original, in-person MoCA-30. (Table S1 ). The T-MoCA is a modified version of the MoCA-30 (version 7.1) 45 administered by phone, 17 with minor modifications to scoring (Table S1 ). Just as with the MoCA-22, this phone version excludes items that require visual stimuli and pencil and paper drawing, with the same maximum score (Table S1 ). At baseline, two alternate versions of the MoCA were administered: version 7.1 was administered on the telephone and the alternate form (version 7.2) was administered in-person. Demographic information included self-reported race/ethnicity as defined by the US Census Bureau in 1994, number of years of education, gender, and age. The Geriatric Depression Scale (GDS, short form) was used to screen for depressive symptoms. The GDS ranges from 0 to 15 with scores of 6 or above suggestive of clinically significant depressive symptoms. 46 As part of the telephone screen, nine questions about self-perceived cognitive changes/difficulties were posed to the participant and a summary score was derived (potential range 0 to 18, Table S2 in supporting information). The interview also noted and coded five possible difficulties during the telephone assessment including hearing difficulty, suboptimal hearing conditions, poor attention/motivation, unauthorized use of external sources, and anxiety about performance. The difficulties are termed "telephone administration difficulties" and were scored as "present" by the phone interviewer if at least one difficulty occurred (binary variable; Table S3 in supporting information). In addition to the MoCA-30, the in-person clinic assessments included A diagnosis of dementia was an exclusion criterion for these analyses. During the initial telephone screen, the MIS telephone version was used to screen for severe cognitive impairment. Among those who passed the initial eligibility screen and who attended the in-person clinic visit, dementia diagnosis was based on DSM-IV standardized clinical criteria, 51 (1) impaired scores, defined as >1 SD below the age, gender, and education adjusted normative mean, on both measures within at least one cognitive domain (i.e., memory, language, or speed/executive function); or (2) one impaired score, defined as >1 SD below the age, gender, and education adjusted normative mean, in each of three of the five cognitive domains measured. If neither of these criteria was met, a score of 4, indicating the number of items of functional inability on all four instrumental activities of daily activities items (IADL: Table S4 in supporting information) on the Lawton Brody scale 53 must occur for an individual to be classified as MCI. Otherwise, an individual was considered to be NC. 54 Equivalence testing was first introduced in pharmacokinetics to show that a generic drug has a profile equivalent to an existing drug. 55, 56 Subsequently recommended in many research areas, 57 The equipercentile equating analysis was conducted in R 4.0.1 64 using the "equate" package. 65 All other analyses were performed using SAS statistical software version 9.4 (SAS Institute, Inc.). Table 3 , which summarizes the operating characteristics of TA B L E 2 ** Association of MoCA-22, T-MoCA, and the difference between the T-MoCA and MoCA-22 with demographics, depression, subjective concerns, and issues related to telephone administration Table 4 Remotely administered cognitive screening tools are increasingly used in research and health-care settings. 27 screen that can be used to detect MCI when in-clinic assessment is not available. Often appealing and efficient for health-care professionals and researchers, remotely administered assessment tools like the T-MoCA are also well accepted by older adult patients and study participants. This is critical for when patients or study participants initially seen in person can no longer attend in-person visits due to health problems; have moved; or as we have seen recently, have safety concerns related to a pandemic. Using the conversion scores derived from the log-linear smoothing method presented in Table 4 , participant scores on the T-MoCA can be expressed in the terms of the MoCA-30. This is especially useful for clinicians when in-person assessments are not feasible. In addition, in research settings when harmonization across studies is necessary, relevant covariates should be considered. The Poisson equation affords the opportunity to take account of these factors (e.g., in the current study, education was a significant covariate, which is therefore included in the Poisson equation). The optimal cut score for discriminating between those classified as MCI versus those with normal cognition depends upon the clinical, research, or public health context. The optimal rule is based on Youden's index, which selects the cut score that maximizes the sum of sensitivity and specificity, maximizing the number of correctly classified individuals. This index indicates that the in-person MoCA-30 and MoCA-22 perform the best using this index; however, the T-MoCA is adequate. The current investigation also provides cut scores to achieve at least 80% sensitivity or 80% specificity. If the objective is to use telephone-administered screens to identify individuals who may have MCI for a low-cost, low-risk intervention, a cut score that emphasizes sensitivity may be optimal. In addition, if a positive telephone screen is to be followed by a safe and more specific test for definitive diagnosis, sensitivity may be more important than specificity, to maximize identification of individuals with MCI. Setting sensitivity to be at least In a screening context in which sensitivity matters, the T-MoCA could be used to identify individuals who warrant further evaluation. MCI is difficult to target because diagnosis is assigned based on thresholds of cognitive performance on tests with imperfect retest reliabilities. In addition, back conversion from MCI to cognitive normality ranges from 16% to 39% of diagnosed cases in community-based studies. [71] [72] [73] the telephone administration (such as hearing problems), and overall did not find that any of these variables affected T-MoCA performance. This should be reassuring to those seeking to use this measure in diverse populations. Finally, this study is novel in its presentation of conversion scores between test modalities. We used a robust statistical approach with equipercentile equating with log-linear transformation to establish a normal distribution of scores without irregularities due to sampling and the Poisson equation to include education as an influential factor when harmonization across studies is necessary. Our study is not without limitations. We did not validate the T-MoCA against other widely used telephone screens, such as the TICS. Giraldi, and Sylvia Alcala for assistance with clinical and neuropsychological assessments; and Michael Potenza for assistance with data management. All authors contributed to and approved the final manuscript. The authors report no competing interests. Handbook of the Economics of Population Aging Saxena S. 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