MoCA as a Screening Test in SLE
Assessing the utility of the Montreal Cognitive Assessment (MoCA)
By Oshrat E. Tayer-Shifman, MD, Kimberley Yuen, BSc, MD, & Zahi Touma, MD, PhD, FACP, FACR
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Explore This IssueNovember 2022
Why was this study done? Cognitive impairment is a common manifestation of systemic lupus erythematosus (SLE), with a prevalence of 40% based on objective measures. The ACR Neuropsychological Battery (ACR-NB) is the gold standard test for cognitive impairment screening and diagnosis in adult SLE patients; however, it is not widely available. The Montreal Cognitive Assessment (MoCA) was developed to screen for neurocognitive disorder in the older population, but no evidence exists of its validity to accurately identify cognitive impairment in patients with SLE. We studied the utility of the MoCA as a screening test for cognitive impairment compared with the ACR-NB.
What were the study methods? Two hundred and eighty-five adults with SLE were administered the ACR-NB and the MoCA. For the ACR-NB, patients were classified as cognitively impaired with a Z-score of ≤-1.5 in two or more domains. The area under the curve (AUC) and sensitivities/specificities were determined. A discriminant function analysis was also applied.
What were the key findings? Cognitive impairment was not accurately identified by the MoCA, compared with the ACR-NB (AUC of 0.66). Sensitivity and specificity were poor, at 50% and 69%, respectively for the MoCA recommended cutoff of 26, and 80% and 45%, respectively for a higher cutoff of 28. The discriminant function analysis demonstrated low ability of the MoCA to identify different cognitive impairment status.
What were the main conclusions? This large study evaluated the MoCA as a screening test for cognitive impairment in patients with SLE. Compared with the ACR-NB, the MoCA failed to show the sensitivity and specificity needed.
What are the implications for patients and clinicians? When screening for cognitive impairment in patients with SLE, the healthcare team should use a test that has evidence for validity in SLE. The MoCA can neither diagnose cognitive impairment nor rule out cognitive impairment in patients with SLE. The low specificity of the MoCA may lead to over-diagnosis and concern among patients. We have shown in a previous work that the Automated Neuropsychological Assessment Metrics (ANAM) can be used to screen for cognitive impairment in SLE.1
The study: Tayer-Shifman OE, Yuen K, Green R et al. Assessing the utility of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment in patients with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2022 Jun 22. Online ahead of print.
- Tayer-Shifman OE, Green R, Beaton DE, et al. Validity evidence for the use of automated neuropsychologic assessment metrics as a screening tool for cognitive impairment in systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2020 Dec;72(12):1809–1819.
Cumulative Social Disadvantage
A cross-sectional analysis of the National Survey of Children’s Health
By William Daniel Soulsby, MD
Why was this study done? Health disparities in juvenile idiopathic arthritis (JIA) are poorly understood. Existing studies examine social determinants of health as independent risk factors, although we hypothesize increased exposure to social disadvantage may be associated with higher risk. Combined scoring systems have been used to investigate social determinants in diseases, such as hypertension and diabetes. We investigated the role of cumulative social disadvantage on childhood arthritis diagnoses, as well as severity of disease.
What were the study methods? A cross-sectional analysis was performed across four years of the National Survey of Children’s Health (NSCH)—a nationally representative survey examining child health across the U.S. A cumulative social disadvantage score was created on the basis of existing proposed risk factors in JIA, including adverse childhood experiences, poverty, public or lack of insurance, and guardian education. This score was used to analyze the association with childhood arthritis among all survey respondents, as well as moderate-to-severe disease among those with reported arthritis.
What were the key findings? Cumulative social disadvantage was associated with a childhood arthritis diagnosis, highest among those with exposure to all four social variables with an adjusted odds ratio (aOR) of 12.4 (95% confidence interval [95% CI] 2.9–53.3). It was also associated with moderate-to-severe disease, also highest for those with the highest score of 4, with an aOR of 12.4 (95% CI 1.8–82.6)
What were the main conclusions? Cumulative social disadvantage is associated with childhood arthritis diagnoses among a nationally representative sample of U.S. children and associated with increased disease severity, suggesting the presence of a social gradient in childhood arthritis.
What are the implications for patients? Children with increased exposure to social disadvantage may have higher odds of having arthritis and may have higher disease severity.
What are the implications for clinicians? Our findings suggest that implementation of social disadvantage screening in the pediatric rheumatology clinic may have the potential to identify patients at risk for higher disease severity who may benefit from targeted services, such as patient navigation programs and social services.
The study: Soulsby WD, Lawson E, Pantell MS. Cumulative social disadvantage is associated with childhood arthritis: A cross-sectional analysis of the National Survey of Children’s Health. Arthritis Care Res (Hoboken). 2022 Jul 29. Epub ahead of print.
Surgical Weight Loss Interventions
Their cost effectiveness for patients with knee OA & class III obesity
By Aleksandra Kostic, BSE, Valia Leifer, MA, & Elena Losina, PhD, MSC
Why was this study done? Weight loss can alleviate knee osteoarthritis (OA) related pain for patients with knee OA and obesity. However, current knee OA treatment guidelines do not address weight loss strategies other than diet and exercise. Bariatric surgery can yield substantial, sustainable weight loss among individuals with class III obesity (BMI ≥40 kg/m2), but its value for patients with knee OA is uncertain due to concerns about cost, efficacy and adverse events.
What were the study methods? We used the Osteoarthritis Policy Model (OAPol) to evaluate the effects of Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) bariatric surgery on lifetime costs and quality of life in patients with class III obesity and moderate knee OA. Each bariatric surgery strategy was considered in conjunction with usual knee OA care, which consisted of nonsteroidal anti-inflammatory drugs, physical therapy, intra-articular corticosteroid injections, tramadol, oxycodone, total knee replacement and revision total knee replacement. We calculated incremental cost-effectiveness ratios (ICERs), discounted at 3% per year, which represent the difference in lifetime costs to the difference in quality adjusted life years (QALYs) between the two treatment strategies. We performed sensitivity analyses to evaluate the effect of uncertainty in model inputs on results.
What were the key findings? Compared with usual care only, both RYGB and LSG reduced opioid utilization and increased total knee replacement (TKR) utilization. LSG yielded less benefit at a higher cost than RYGB (most likely due to lower and less sustainable weight loss). RYGB yielded a very favorable ICER ($5,300/QALY).
What were the main conclusions? Bariatric surgery provides substantial weight loss and other clinical benefits. Our results suggest RYGB offers a better value than LSG for a population with class III obesity and knee OA.
What are the implications for patients? Patients with class III obesity and knee OA may consider bariatric surgery to alleviate knee OA-related symptoms. They should discuss the risks and benefits of different weight loss strategies with their providers.
What are the implications for clinicians? Patients with class III obesity and moderate knee OA may benefit from bariatric surgery, which may reduce future opioid use. It is reasonable to discuss bariatric surgery as a weight loss strategy with this patient population.
The study: Kostic AM, Leifer VP, Gong Y, et al. The cost-effectiveness of surgical weight loss interventions for patients with knee osteoarthritis and class III obesity. Arthritis Care Res (Hoboken). 2022 Jun 3. Epub ahead of print.