Wesner Eric, Etzkorn Lacey, Bakre Shivani, Chen Jinyu, Davis Alexander, Zhang Yifan, Yasar Sevil, Rao Aruna, Luciano Mark, Wang Jiangxia, Moghekar Abhay
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States.
Front Neurol. 2022 May 23;13:887669. doi: 10.3389/fneur.2022.887669. eCollection 2022.
We sought to estimate reliable change thresholds for the Montreal Cognitive Assessment (MoCA) for older adults with suspected Idiopathic Normal Pressure Hydrocephalus (iNPH). Furthermore, we aimed to determine the likelihood that shunted patients will demonstrate significant improvement on the MoCA, and to identify possible predictors of this improvement.
Patients ( = 224) presenting with symptoms of iNPH were given a MoCA assessment at their first clinic visit, and also before and after tap test (TT) or extended lumbar drainage (ELD). Patients who were determined to be good candidates for shunts ( = 71, 31.7%) took another MoCA assessment following shunt insertion. Reliable change thresholds for MoCA were derived using baseline visit to pre-TT/ELD assessment using nine different methodologies. Baseline characteristics of patients whose post-shunt MoCA did and did not exceed the reliable change threshold were compared.
All nine of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 16 to 22 (38.4% of patients). Furthermore, a majority of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 14 to 25. Reliable change thresholds varied across methods from 4 to 7 points for patients outside of this range. 10.1% had at least a 5-point increase from baseline to post-TT/ELD. Compared to patients who did not receive a shunt, patients who received a shunt did not have lower average MoCA at baseline ( = 0.88) or have better improvement in MoCA scores after the tap test ( = 0.17). Among shunted patients, 23.4% improved by at least 5 points on the MoCA from baseline to post-shunt. Time since onset of memory problems and post-TT/ELD gait function were the only clinical factors significantly associated with having a reliable change in MoCA after shunt insertion ( = 0.019; = 0.03, respectively).
In patients with iNPH, clinicians could consider using a threshold of 5 points for determining whether iNPH-symptomatic patients have experienced cognitive benefits from cerebrospinal fluid drainage at an individual level. However, a reliable change cannot be detected for patients with a baseline MoCA of 26 or greater, necessitating a different cognitive assessment tool for these patients.
我们试图估算疑似特发性正常压力脑积水（iNPH）的老年人蒙特利尔认知评估量表（MoCA）的可靠变化阈值。此外，我们旨在确定接受分流手术的患者在MoCA上表现出显著改善的可能性，并确定这种改善的可能预测因素。
对出现iNPH症状的患者（n = 224）在首次门诊就诊时、腰穿试验（TT）或延长腰大池引流（ELD）前后进行MoCA评估。被确定为分流手术合适人选的患者（n = 71，31.7%）在分流手术后进行了另一次MoCA评估。使用九种不同方法，根据基线访视至TT/ELD前评估得出MoCA的可靠变化阈值。比较分流后MoCA超过和未超过可靠变化阈值的患者的基线特征。
所有九种可靠变化方法均表明，对于基线MoCA为16至22分的患者（占患者的38.4%），MoCA提高5分是可靠的。此外，大多数可靠变化方法表明，对于基线MoCA为14至25分的患者，MoCA提高5分是可靠的。对于该范围之外的患者，可靠变化阈值在不同方法中为4至7分。从基线到TT/ELD后，10.1%的患者至少提高了5分。与未接受分流手术的患者相比，接受分流手术的患者在基线时的平均MoCA没有更低（P = 0.88），在腰穿试验后的MoCA评分改善也没有更好（P = 0.17）。在接受分流手术的患者中，从基线到分流后，23.4%的患者在MoCA上至少提高了5分。记忆问题出现后的时间和TT/ELD后的步态功能是与分流后MoCA有可靠变化显著相关的仅有的临床因素（分别为P = 0.019；P = 0.03）。
在iNPH患者中，临床医生在个体层面确定有iNPH症状的患者是否从脑脊液引流中获得认知益处时，可以考虑使用5分的阈值。然而，对于基线MoCA为26分或更高的患者，无法检测到可靠变化，因此需要为这些患者使用不同的认知评估工具。
