Development of the Brazilian version of the Mini-Addenbrooke Cognitive Examination (M-ACE BR) to screen for cognitive impairment in older adults

Okada-Oliveira, Maira; Carthery-Goulart, Maria Teresa; César-Freitas, Karolina Gouveia; Nitrini, Ricardo; Brucki, Sonia Maria Dozzi

doi:10.1055/s-0044-1788585

Maira Okada-Oliveira Address for correspondence Maira Okada de Oliveira (email:maira.okada@gmail.com).

conceptualization and design of the work

data acquisition

analysis and interpretation

writing

review of the manuscript

approved the final version of the manuscript and agree to be responsible for all aspects of the work

Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.

Hospital Santa Marcelina, Departamento de Neurologia, São Paulo SP, Brazil.

https://orcid.org/0000-0001-8423-9876

Maria Teresa Carthery-Goulart

data acquisition

analysis and interpretation

writing

review of the manuscript

approved the final version of the manuscript and agree to be responsible for all aspects of the work

Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.

Universidade Federal do ABC, Centro de Matemática, Computação e Cognição, Santo André SP, Brazil.

https://orcid.org/0000-0002-2751-4541

Karolina Gouveia César-Freitas

data acquisition

analysis and interpretation

writing

review of the manuscript

approved the final version of the manuscript and agree to be responsible for all aspects of the work

Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.

https://orcid.org/0000-0001-9617-9567

Ricardo Nitrini

data acquisition

review of the manuscript

approved the final version of the manuscript and agree to be responsible for all aspects of the work

Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.

https://orcid.org/0000-0002-5721-1525

Sonia Maria Dozzi Brucki

conceptualization and design of the work

data acquisition

analysis and interpretation

writing

review of the manuscript

approved the final version of the manuscript and agree to be responsible for all aspects of the work

Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.

Hospital Santa Marcelina, Departamento de Neurologia, São Paulo SP, Brazil.

https://orcid.org/0000-0002-8303-6732

Address for correspondence Maira Okada de Oliveira (email:maira.okada@gmail.com).

Conflict of Interest

The authors have no conflict of interest to declare.

Figures (2)
Tables (4)

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Figure 1
Different versions of the ACE: the ACE-R was published in 2006 by Mioshi et al.,⁷7 Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Adden-brooke's Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006; 21(11):1078–1085. Doi:10.1002/gps.161
https://doi.org/10.1002/gps.161... and, in 2007, Carvalho and Caramelli⁸8 Carvalho VA, Caramelli P. Brazilian adaptation of the Addenbrooke's cognitive examination-revised (ACE-R). Dement Neuropsychol 2007;1(02):212–216. Doi:10.1590/S1980-57642008DN10200015
https://doi.org/10.1590/S1980-57642008DN... translated and adapted the Brazilian version. This version was used to create the M-ACE BR. In 2013, Hsieh et al.⁴³43 Hsieh S, Schubert S, Hoon C, Mioshi E, Hodges JR. Validation of the Addenbrooke's Cognitive Examination III in frontotemporal dementia and Alzheimer's disease. Dement Geriatr Cogn Disord 2013;36(3-4):242–250. Doi:10.1159/000351671
https://doi.org/10.1159/000351671... created the ACE-III, a similar version of the ACE-R, but without the MMSE items. In 2015, Hsieh et al.¹²12 Hsieh S, McGrory S, Leslie F, et al. The Mini-Addenbrooke's Cognitive Examination: a new assessment tool for dementia. Dement Geriatr Cogn Disord 2015;39(1-2):1–11. Doi:10.1159/000366040
https://doi.org/10.1159/000366040... extracted items from the ACE-III using the Mokken analysis and creating M-ACE, and, in 2018, Miranda et al.³⁷37 Miranda DDC, Brucki SMD, Yassuda MS. The Mini-Addenbrooke's Cognitive Examination (M-ACE) as a brief cognitive screening instrument in Mild Cognitive Impairment and mild Alzheimer's disease. Dement Neuropsychol 2018;12(04):368–373. Doi:10.1590/1980-57642018dn12-040005
https://doi.org/10.1590/1980-57642018dn1... translated and adapted the M-ACE for a Brazilian version.

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Figure 2
Representing the creation of the M-ACE BR: the Brazilian version of the ACE-R was applied in the epidemiological study (pre-reduction sample).²2 César KG, Brucki SM, Takada LT, et al. Prevalence of Cognitive Impairment Without Dementia and Dementia in Tremembé, Brazil. Alzheimer Dis Assoc Disord 2016;30(03):264–271. Doi:10.1097/WAD.0000000000000122
https://doi.org/10.1097/WAD.000000000000... The M-ACE BR was reduced using a Mokken analysis, which provided the test item's difficulty and the discriminatory capacity. The items identified after the Mokken analysis were applied to the sample of an outpatient population (post-reduction sample).

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Table 1
Pre- and post-reduction sample's demographic characteristics and ACE-R performance (mean and standard deviation) by group

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Table 2
Performance on the M-ACE BR items by group

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Table 3
Diagnostic parameter values for CIND cut-off score

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Table 4
Comparison of the M-ACE BR with the MMSE

Prereduction		CU n = 232	CIND n = 82	Dementia n = 38	p-value
Demographics	Age (years)	70.04 (7.19)^† † CU > D	71.94 (6.81)^‡ ‡ CU > CIND	76.95 (7.86)	< 0.001^* Notes: * Kruskal-Wallis Test
	Education (years)	5.96 (5.17)	5.38 (4.55)	3.11 (3.52)	< 0.001^* Notes: * Kruskal-Wallis Test
	Sex (male:female)	95:137	38:44	18:20	0.587^ Chi-squared test
ACE-R	Attention/orientation	15.75 (2.23)^§ § CIND > D	14.44 (6.11)	10.79 (3.91)	< 0.001^* Notes: * Kruskal-Wallis Test
	Memory	17.42 (5.39)^§ § CIND > D	13.21 (5.25)	8.05 (4.57)	< 0.001^* Notes: * Kruskal-Wallis Test
	Fluency	7.78 (2.68)^§ § CIND > D	5.45 (2.69)	3.87 (2.60)	< 0.001^* Notes: * Kruskal-Wallis Test
	Language	20.97 (4.91)^§ § CIND > D	18.56 (5.11)	14.42 (5.97)	< 0.001^* Notes: * Kruskal-Wallis Test
	Visuospatial	12.09 (2.96)^§ § CIND > D	11.02 (2.91)	8.66 (3)	< 0.001^* Notes: * Kruskal-Wallis Test
	Total	74.08 (15.50)^§ § CIND > D	62.67 (15.01)	46.11 (17.46)	< 0.001^* Notes: * Kruskal-Wallis Test
Postreduction		CU n = 25	CIND n = 88	Dementia n = 4	p-value
Demographics	Age (years)	73.68 (6)	71.97 (6.14)	75 (5.72)	0.325^* Notes: * Kruskal-Wallis Test
	Education (years)	13.84 (4.09)^† † CU > D	10.81 (5.2)	7.75 (5.19)	0.011^* Notes: * Kruskal-Wallis Test
	Sex (male:female)	6: 19	16: 72	2: 2	0.271^ Chi-squared test
ACE-R	Attention/orientation	16.96 (1.10)	16.75 (1.59)	16.50 (1.30)	0.763^* Notes: * Kruskal-Wallis Test
	Memory	22.08 (3.25)^¶ ¶ CU > CIND > D	19.60 (4.66)	13.25 (3.87)	< 0.001^* Notes: * Kruskal-Wallis Test
	Fluency	10.92 (1.85)^† † CU > D ,^‡ ‡ CU > CIND	9.65 (2.42)	8.00 (0)	0.014^* Notes: * Kruskal-Wallis Test
	Language	24.44 (1.92)	23.22 (2.67)	21.50 (5.75)	0.047^* Notes: * Kruskal-Wallis Test
	Visuospatial	15.12 (1.33)^† † CU > D	14.19 (2.04)	12.50 (3)	0.027^* Notes: * Kruskal-Wallis Test
Total		89.52 (5.94) ^¶ ¶ CU > CIND > D	83.41 (9.28)	71.75 (9.18)	< 0.001 ^* Notes: * Kruskal-Wallis Test

Items	CU (n = 25)		CIND (n = 88)		D (n = 4)		p-value
Items	Mean (SD)	Median (IQR)	Mean (SD)	Median (IQR)	Mean (SD)	Median (IQR)	p-value
Spatial orientation	5 (0)	(5–5)	4.95 (0.21)	5 (5–5)	5 (0)	5 (5–5)	0.512
Anterograde memory	6.80 (0.5) ^† † CU > D; p < 0.05.	7 (7–7)	6.42 (0.93)	7 (6–7)	5.5 (1)	6 (5–6)	0.013
Retrograde memory	3.76 (0.52) ^† † CU > D; p < 0.05.	4 (4–4)	3.25 (1.17)	4 (3–4)	2.5 (1.3)	3 (2–4)	0.034
Recall	4.68 (2.12) ^† † CU > D; p < 0.05.	5 (3–6)	3.64 (2.45)	4 (2–6)	1 (1.41)	1 (0–2)	0.010
Recognition	4.48 (0.77) ^† † CU > D; p < 0.05.	5 (4–5)	4.20 (1.1)	5 (4–5)	3 (0.82)	3 (3–4)	0.030
Letter verbal fluency	5.40 (1.3)	5 (5–6)	4.75 (1.30)	5 (4–6)	4.5 (1)	4 (4-5)	0.068
Repetition- 4 words	1.76 (0.52)	2 (2–2)	1.56 (0.68)	2 (1–2)	1.6 (0.66)	2 (1–2)	0.230
Naming	9.12 (1.17)	9 (9–10)	8.64 (1.6)	9 (8–10)	8 (2.71)	9 (7–10)	0.252
Comprehension	3.76 (0.6) ^† † CU > D; p < 0.05.	4 (4–4)	3.51 (0.71)	4 (3–4)	2.75 (1.9)	4 (2–4)	0.037

Cut-off/51	Sensitivity (%)	Specificity (%)	+LR (%)	-LR (%)	+PV (%)	-PV (%)
< 26	0.00	100		1.00		22.1
≤ 30	9.09	100		0.91	100	23.8
≤ 31	9.09	96.00	2.27	0.95	88.9	23.1
≤ 32	11.36	96.00	2.84	0.92	90.9	23.5
≤ 34	15.91	92.00	1.99	0.91	87.5	23.7
≤ 38	31.82	92.00	3.98	0.74	93.3	27.7
≤ 39	38.64	88.00	3.22	0.70	91.9	28.9
≤ 40	45.45	88.00	3.79	0.62	93.0	31.4
≤ 41	48.86	84.00	3.05	0.61	91.5	31.8
≤ 42	54.55	84.00	3.41	0.54	92.3	34.4
≤ 43	59.09	80.00	2.95	0.51	91.2	35.7
≤ 44	63.64	68.00	1.99	0.53	87.5	34.7
≤ 45	70.45	60.00	1.76	0.49	86.1	36.6
≤ 46	77.27	44.00	1.38	0.52	82.9	35.5
≤ 47	85.23	24.00	1.12	0.62	79.8	31.6
≤ 48	94.32	4.00	0.98	1.42	77.6	16.7
≤ 49	97.73	4.00	1.02	0.57	78.2	33.3
≤ 50	100	0.00	1.00		77.9

Test	Optimal cutoff	AUC	Sensitivity (%)	95% CI	Specificity (%)	95% CI	+LR (%)	-LR (%)	+PV (%)	-PV (%)
M-ACE BR	≤ 43/51	0.692	59.10	48.1–69.5	80	59.3–93.2	2.95	0.51	91.2	35.7
MMSE	≤ 26/30	0.601	27.27	18.33–37.8	88	68.8–97.5	2.27	0.83	0.83	88.9

[1] Address for correspondence Maira Okada de Oliveira (email:maira.okada@gmail.com).

Brasil

Brasil

Development of the Brazilian version of the Mini-Addenbrooke Cognitive Examination (M-ACE BR) to screen for cognitive impairment in older adults

Desenvolvimento da versão brasileira do Mini-Addenbrooke Cognitive Examination (M-ACE BR) para rastreio de comprometimento cognitivo em idosos

Abstract

Background

Objective

Methods

Results

Conclusion