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Tablet-Based Cognitive Impairment Screening for Adults With HIV Seeking Clinical Care: Observational Study
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Sept 2021 - Leah H Rubin1, MPH, PhD; Joan Severson2, MS; Thomas D Marcotte3, PhD; Micah J Savin4, BS; Allen Best2, JD;Shane Johnson2, PhD; Joshua Cosman5, PhD; Michael Merickel2, MS; Alison Buchholz1, PhD; Victor A Del Bene6,PhD; Lois Eldred1, MPH, DrPH; Ned C Sacktor1, MD; Joelle-Beverlie Fuchs1, BA; Keri N Althoff1, MPH, PhD;Richard D Moore1, MD
Abstract
Background: Neurological complications including cognitive impairment persist among people with HIV on antiretrovirals; however, cognitive screening is not routinely conducted in HIV clinics.
Objective: Our objective for this study was 3-fold: (1) to determine the feasibility of implementing an iPad-based cognitive impairment screener among adults seeking HIV care, (2) to examine the psychometric properties of the tool, and (3) to examine predictors of cognitive impairment using the tool.
Methods: A convenience sample of participants completed Brain Baseline Assessment of Cognition and Everyday Functioning (BRACE), which included (1) Trail Making Test Part A, measuring psychomotor speed; (2) Trail Making Test Part B, measuring set-shifting; (3) Stroop Color, measuring processing speed; and (4) the Visual–Spatial Learning Test. Global neuropsychological function was estimated as mean T score performance on the 4 outcomes. Impairment on each test or for the global mean was defined as a T score ≤40. Subgroups of participants repeated the tests 4 weeks or >6 months after completing the first test to evaluate intraperson test–retest reliability and practice effects (improvements in performance due to repeated test exposure). An additional subgroup completed a lengthier cognitive battery concurrently to assess validity. Relevant factors were abstracted from electronic medical records to examine predictors of global neuropsychological function.
Results: The study population consisted of 404 people with HIV (age: mean 53.6 years; race: 332/404, 82% Black; 34/404, 8% White, 10/404, 2% American Indian/Alaskan Native; 28/404, 7% other and 230/404, 58% male; 174/404, 42% female) of whom 99% (402/404) were on antiretroviral therapy. Participants completed BRACE in a mean of 12 minutes (SD 3.2), and impairment was demonstrated by 34% (136/404) on Trail Making Test A, 44% (177/404) on Trail Making Test B, 40% (161/404) on Stroop Color, and 17% (67/404) on Visual-Spatial Learning Test. Global impairment was demonstrated by 103 out of 404 (25%). Test–retest reliability for the subset of participants (n=26) repeating the measure at 4 weeks was 0.81 and for the subset of participants (n=67) repeating the measure almost 1 year later (days: median 294, IQR 50) was 0.63. There were no significant practice effects at either time point (P=.20 and P=.68, respectively). With respect for validity, the correlation between global impairment on the lengthier cognitive battery and BRACE was 0.63 (n=61; P<.001), with 84% sensitivity and 94% specificity to impairment on the lengthier cognitive battery.
Conclusions: We were able to successfully implement BRACE and estimate cognitive impairment burden in the context of routine clinic care. BRACE was also shown to have good psychometric properties. This easy-to-use tool in clinical settings may facilitate the care needs of people with HIV as cognitive impairment continues to remain a concern in people with HIV.
Introduction
Thirty-six years into the HIV epidemic, North America has had markedly improved clinical outcomes and prolonged life. Death from non-AIDS comorbidities is now more common than AIDS-related death, and life-expectancy has increased markedly among those on antiretroviral therapy [1-5]. Similarly, AIDS-related comorbidities are now less common than noncommunicable, age-related comorbidities. Cognitive impairment among people with HIV persists despite effective antiretroviral therapy [6-9]. Cognitive impairment in the current treatment era is often mild and not readily detectable to the practicing clinician. At present, only clinical criteria and neuropsychological testing are used to diagnose cognitive impairment, and no single laboratory test or biomarker has been established to effectively detect mild cognitive impairment. Current screening measures (eg, the International HIV Dementia Scale [10], Montreal Cognitive Assessment [11], HIV Dementia Scale [12]) lack sensitivity for detecting milder forms of cognitive impairment [13-18], and the resources (eg, time, cost, training) required for comprehensive neuropsychological assessments limits their widespread use during routine clinic visits.
Thus, there is a pressing need for brief screening measures that could be easily implemented into routine clinic care in order to determine persons in need of comprehensive neuropsychological evaluation.
Tablet computing tools, such as the Apple iPad, are increasingly ubiquitous and offer an opportunity to potentially implement an intuitive interface for primarily self-directed brief cognitive assessments with automated scoring, data aggregation, and preliminary screening of impairment in real time, thus minimizing clinician and staff burden and increasing the opportunity to identify individuals in need of neuropsychological evaluation. Recently, a brief iPad tool was developed to screen cognitive impairment. The testing platform has automated data aggregation, which provides global data to facilitate and or support computational epidemiological applications, pharmaceutical development, and clinical trial monitoring, including monitoring of the effectiveness of antiretroviral therapy and nonantiretroviral therapy medications on cognitive impairment in the context of clinical care. The largely self-administered testing, survey, and automated reporting has the potential to be used as a model for the design and development of mobile app to quantify cognition, behavior, mental health, and mobility in the clinic and through emerging mobile technologies worldwide.
Herein we first aimed to determine the feasibility of using an iPad-based tool (BRACE, Brain Baseline Assessment of Cognition and Everyday Functioning) to screen for cognitive impairment among adults with HIV seeking clinical care in Baltimore, Maryland. Second, we aimed to examine the psychometric properties of the iPad-based cognitive screener including test–retest reliability and practice effects (improvement in performance from repeated exposures to testing materials) as well as validity. Third, we aimed to understand predictors (sociodemographic, clinical, and behavioral data) of cognitive impairment using the iPad-based tool among people with HIV.
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