Blog – Advances in digital cognitive assessments for dementia diagnosis

Historically, cognitive assessments for dementia diagnosis have relied on pencil and paper measures administered by a clinician. These tests are designed to evaluate various cognitive domains, such as memory, visuospatial abilities, and language, and should indicate whether there are potential signs of dementia. However, performance on these tests can be strongly influenced by other factors, such as cultural background or educational level. There are questions relating to whether such tests have the sensitivity to detect early stages of diseases, like Alzheimer’s, which is crucial if this is when treatments are most effective. In this blog I will discuss how technology is being used to advance cognitive assessments used in dementia diagnosis.

The most obvious way technology can be applied to cognitive assessments is to simply adapt traditional measures into digital versions that can be used on computers or other electronic devices. These digital versions can allow performance to be scored in real-time, rather than post-hoc, which can allow patients quicker access to the care and support they may need. Those which may be available online or on a mobile device can greatly improve the accessibility of receiving an assessment for those who prefer to be assessed at home, or for those who may be in a care home, for example. Digital cognitive assessments which can be carried out remotely, such as on a patient’s own device through online access or a downloaded app, allow for multiple assessments across timepoints which is more likely to reflect the variability in human cognitive performance which can be influenced by fluctuations in mood, energy, and concentration levels, for example. Remote assessments can be carried out in environments that are familiar to patients which is more likely to yield results which closely reflect cognitive performance than a clinical setting. However, digital cognitive assessments need to demonstrate the same level of reliability and validity as traditional tests; that is, they should produce comparable results across consistent conditions, and they should measure what they are designed to measure. Various factors can affect the degree of reliability and validity of digital assessments, such as the type of electronic device being used. If it is a standard device given to a patient by a clinician, a patient’s familiarity with how the device is used can impact on performance. But digital cognitive assessments that allow patients to use their own devices can also affect performance because different devices can vary in terms of display time, screen size, and whether it’s touchscreen. In addition, the use of personal devices risks exacerbating disparities for those who may not have access to such devices or be less digitally literate.

Beyond creating digital adaptations of traditional cognitive assessments, significant advances in recent years have also been made in the development of virtual reality tests which typically measure cognitive domains in a computer-generated environment. For example, the Four Mountains test is designed to measure spatial memory by presenting various views of a landscape. The test has been shown to have potential as an easy-to-administer screening tool for determining whether full neuropsychological assessment is required. Sea Hero Quest is another example of a virtual reality test designed to measure spatial navigation impairment as an early cognitive marker for Alzheimer’s disease. The test was built as an online game which could be accessed on a personal device and is built on the concept of “citizen science”, which relies on members of the public acting as research collaborators by collecting their own data through participation in the game. Early reports have identified performance differences in individuals with a genetic risk for Alzheimer’s disease, despite no presence of cognitive impairments that would be detectable on traditional tests. Sea Hero Quest therefore shows potential as a sensitive measure that can detect early impairment in hippocampal function, of which spatial navigation is dependent.

Digital assessments of cognitive domains do not necessarily have to be designed with the intention of replacing existing neuropsychological tests but may better act as initial screening tools which can be administered quickly and frequently, helping to identify at-risk individuals before clinical symptoms become apparent. These types of digital tests should focus on cognitive skills which we know are vulnerable to decline early in diseases like Alzheimer’s, measuring changes in spatial navigation or episodic memory. Measuring these cognitive skills in traditional assessments involve learning and recalling information, but research has shown that memory encoding and recall strategies vary depending on cultural factors or educational level. Digital assessments which assess spatial or episodic memory without relying on complex information or recalling lists of words, such as those which use computerised displays or virtual reality, can therefore provide more sensitive and accurate measures of these cognitive skills.

As technology advances so too does how we interact with the world around us. It is therefore necessary for cognitive assessments for dementia diagnosis to reflect our changing environment and adapt to provide accurate measures of the cognitive changes that occur with dementia. However, it is important that rigorous research establishes the reliability and validity of any newly adapted cognitive assessments before clinical use.

Dr Kamar Ameen-Ali

Author

Dr Kamar Ameen-Ali is a Lecturer in Biomedical Science at Teesside University & Affiliate Researcher at Glasgow University. In addition to teaching, Kamar is exploring how neuroinflammation following traumatic brain injury contributes to the progression of neurodegenerative diseases that lead to dementia. Having first pursued a career as an NHS Psychologist, Kamar went back to University in Durham to look at rodent behavioural tasks to completed her PhD, and then worked as a regional Programme Manager for NC3Rs.

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