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Research

Validation and diagnostic accuracy of predictive curves for age-associated longitudinal cognitive decline in older adults

Patrick J. Bernier, Christian Gourdeau, Pierre-Hugues Carmichael, Jean-Pierre Beauchemin, René Verreault, Rémi W. Bouchard, Edeltraut Kröger and Robert Laforce
CMAJ December 04, 2017 189 (48) E1472-E1480; DOI: https://doi.org/10.1503/cmaj.160792
Patrick J. Bernier
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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Christian Gourdeau
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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Pierre-Hugues Carmichael
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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Jean-Pierre Beauchemin
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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René Verreault
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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Rémi W. Bouchard
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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Edeltraut Kröger
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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Robert Laforce Jr.
Services Gériatriques Spécialisés (Bernier), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale; CÉGEP de Limoilou (Gourdeau); Centre d’excellence sur le vieillissement de Québec (Carmichael, Verreault, Kröger); Institut universitaire de cardiologie et de pneumologie de Québec (Beauchemin); Faculté de médecine (Verreault, Laforce), Université Laval; Clinique interdisciplinaire de mémoire (Bouchard, Laforce), Centre hospitalier universitaire (CHU) de Québec; Faculté de pharmacie (Kröger), Université Laval, Québec, Que.
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  • For correspondence: robert.laforce@fmed.ulaval.ca
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    Figure 1:

    The cognitive charts. Each solid parallel line represents a percentile: 99th percentile (blue), 85th percentile (light brown), 65th percentile (turquoise), 43rd percentile (purple), 22nd percentile (green) and 10th percentile (red). These colours were chosen from colour palettes for colour-blindness. The grey zone at the bottom represents the cut-off zone. Points on the chart at baseline that fall within the cut-off zone (or any single point within that zone) or, subsequently, that represent a decline greater than the allotted width of 1 percentile zone from the initial measurements, indicate potential cognitive problems. Note: QuoCo = cognitive quotient, SA = standardized age.

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    Figure 2:

    Receiver operating characteristic curve for the MMSE and diagnostic accuracy of QuoCo. These plots are the estimated ROC curves for the MMSE in predicting cognitive status for participants in the databases of CSHA and NACC. The dashed curve is a 95% bootstrap CI for the ROC curve.27 In each plot, A represents diagnostic performance with 95% CI for the QuoCo and B shows the diagnostic performance of the MMSE cut-off (< 24). Lines C and D are the positive and negative likelihood ratios, respectively. The area defined by B–C–D illustrates where any test would be more suitable for confirming the absence of disease than the MMSE cut-off score (see Biggerstaff26), and is the region where the QuoCo lies. Altogether, the graphs show that the QuoCo algorithm is better than the MMSE cut-off for confirming absence of disease, a highly desirable characteristic for a screening test. However, the slightly better overall diagnostic accuracy of the MMSE cut points over the cognitive curves on the graphs is likely related to selection bias (i.e., the CSHA used a cut-off for participant selection). Note: CI = confidence interval, CSHA = Canadian Study of Health and Aging,22 MMSE = Mini-Mental State Examination, NACC = National Alzheimer’s Coordinating Center’s Uniform Data Set, QuoCo = cognitive quotient, ROC = receiver operating characteristic.

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    Figure 3:

    Variations in sensitivity and specificity, by population subgroups. Interpretation of MMSE classification (QuoCo v. Cut-off) was accomplished in 3 separate ways: proximity to the external frame, which shows better performance; SE/SP equilibrium, which is most centred as shown in the graph; and stability of performances in subgroups as shown by the regularity of the continuous line. This graph illustrates the stability of the QuoCo and its balanced SE/SP, whereas the cut-off SP remains superior. Note: Educ = years of education, MMSE = Mini-Mental State Examination, QuoCo = Cognitive quotient, SE = sensitivity, SP = specificity.

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    Table 1:

    Characteristics of the study populations

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    Table 2:

    Estimates and confidence intervals for the initial prediction model for Mini-Mental State Examination scores

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    Table 3:

    Accuracy of the cognitive charts for identifying participants with dementia in the training sample population (Canadian Study of Health and Aging)22

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    Table 4:

    Accuracy of the cognitive charts for identifying participants with dementia in the validation sample population (National Alzheimer’s Coordinating Center’s Uniform Data Set25)*

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    Table 5:

    Comparison of the cognitive quotient method and the Mini-Mental State Examination cut-off method for identifying participants with dementia, by sample population*

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    Table 6:

    Net reclassification improvement of the cognitive quotient over the Mini-Mental State Examination cut-off score* of < 24, by sample population

    Table 6:
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In this issue

Canadian Medical Association Journal: 189 (48)
CMAJ
Vol. 189, Issue 48
4 Dec 2017
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Validation and diagnostic accuracy of predictive curves for age-associated longitudinal cognitive decline in older adults
Patrick J. Bernier, Christian Gourdeau, Pierre-Hugues Carmichael, Jean-Pierre Beauchemin, René Verreault, Rémi W. Bouchard, Edeltraut Kröger, Robert Laforce
CMAJ Dec 2017, 189 (48) E1472-E1480; DOI: 10.1503/cmaj.160792

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Validation and diagnostic accuracy of predictive curves for age-associated longitudinal cognitive decline in older adults
Patrick J. Bernier, Christian Gourdeau, Pierre-Hugues Carmichael, Jean-Pierre Beauchemin, René Verreault, Rémi W. Bouchard, Edeltraut Kröger, Robert Laforce
CMAJ Dec 2017, 189 (48) E1472-E1480; DOI: 10.1503/cmaj.160792
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