556373 research-article2014
JHI0010.1177/1460458214556373Health Informatics JournalAbdolahi et al.
Original Article
A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders
Health Informatics Journal 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460458214556373 jhi.sagepub.com
Amir Abdolahi and Michael T Bull University of Rochester, USA
Kristin C Darwin
Johns Hopkins School of Medicine, USA
Venayak Venkataraman
Duke University School of Medicine, USA
Matthew J Grana
Lake Erie College of Osteopathic Medicine, USA
E Ray Dorsey and Kevin M Biglan University of Rochester, USA
Abstract Remote assessments of individuals with a neurological disease via telemedicine have the potential to reduce some of the burdens associated with clinical care and research participation. We aim to evaluate the feasibility of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. A pilot study derived from two telemedicine trials was conducted. In total, 17 individuals with movement disorders (8 with Parkinson disease and 9 with Huntington disease) had Montreal Cognitive Assessment examinations evaluated in-person and remotely via web-based video conferencing to primarily determine feasibility and potential barriers in its remote administration. Administering the Montreal Cognitive Assessment remotely in a sample of movement disorder patients with mild cognitive impairment is feasible, with only minor common complications associated with technology, including delayed sound and corrupted imaging for participants with low connection speeds. The Montreal Cognitive Assessment has the potential to be used in remote assessments of patients and research participants with movement disorders.
Corresponding author: Amir Abdolahi, University of Rochester, 265 Crittenden Blvd., CU 420644, Rochester, NY 14642, USA. Email: [email protected]
Downloaded from jhi.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
2
Health Informatics Journal
Keywords feasibility, Montreal Cognitive Assessment, remote, telemedicine, validity
Introduction Individuals with a neurological disease generally require routine doctor visits, consisting of motor and cognitive assessments, which overtime may become burdensome to the individual and their caregivers. Participation in clinical research studies also becomes an added challenge for these individuals, particularly with travel and time as major barriers, subsequently hindering recruitment and retention. At-home assessments via web-based video conferencing may reduce such inconveniences by eliminating travel and wait times, reducing caregiver burden, and providing a comfortable environment applicable to the subject’s daily living, while still having the face-to-face interaction with the clinician. Additionally, the utilization of telemedicine for remote web-based assessments could substantially decrease administrative costs and permit the use of a single centralized rater for important clinical trial outcomes. Recent studies among individuals with neurodegenerative disease have demonstrated the feasibility of conducting motor assessments remotely1,2 and have been shown to be effective in enhancing enrollment into research studies and trials.3 These clinical assessments, modified when conducted remotely to only include items that can be evaluated visually,4 demonstrated excellent reliability and validity when compared to the in-person assessment. Cognitive assessments are also important clinical tools used frequently in this population. The Montreal Cognitive Assessment (MoCA) is a common and simple screening tool for detecting mild cognitive impairment, consisting of visual (visuospatial/executive, naming) and verbal (attention, language, abstraction, delayed recall, orientation) portions.5 Although the MoCA has been deemed reliable and well validated in individuals with movement disorders such as Parkinson disease (PD)6–9 and Huntington disease (HD),10–12 the feasibility of remote administration has yet to be reported in this population. Therefore, using web-based video conferencing, we evaluated the feasibility and potential validity of assessing the MoCA remotely in patients with PD and HD.
Methods This was a feasibility study derived from two separate PD13 and HD14 telemedicine trials evaluating patient symptoms longitudinally using remote monitoring. Study participants were recruited from the HD Society of America 2012 annual convention in Las Vegas, NV, as well as regionally at the University of Rochester’s movement disorder clinic. Patients who had a clinical diagnosis of PD or HD and had access to a printer and computer with high-speed internet were eligible to participate. The initial baseline study visit was conducted in-person during which participants were consented and asked information on demographics and medical history. Among those with PD, the study’s movement disorder specialists evaluated baseline scores for the Unified Parkinson’s Disease Rating Scale (UPDRS), Parkinson’s disease questionnaire (PDQ-39; a quality of life measure), Hoehn and Yahr, and the MoCA. Among participants with HD, the total functional capacity (TFC) and motor portions of the Unified Huntington’s Disease Rating Scale (UHDRS) were assessed along with the MoCA. Follow-up MoCA exams were conducted remotely, by the same baseline rater, via web-based video conferencing at 7 months for PD participants and at 3 months for HD participants. These time points were set prior to the initiation of this study as part of the initial PD13 and HD14 telemedicine trials. Significant changes in cognition were not anticipated to occur over the two follow-up
Downloaded from jhi.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
3
Abdolahi et al.
periods based on recent evidence demonstrating non-significant changes on the total MoCA per year;15 however, results were stratified by disease group to eliminate potential biases. Administration and scoring of the MoCA was identical to its original instructions (www.mocatest.org) with slight adaptations in administering the visual portion in order to accommodate remote administration. Namely, the visuospatial/executive subsection (including the alternating trail making task, copying the cube, and drawing the clock) as well as the naming subsection (naming of three animals—lion, rhinoceros, and camel—pictured on the scale) were emailed to and printed by the participants immediately before the web-based assessment began. The rater gave verbal instructions for completing these subsections and then asked participants to hold the paper in front of the web-camera, which was captured as a screenshot by the rater for evaluation (see Figure 1). The naming subsection was administered by instructing the participant to name each animal pictured on the form one at a time from left to right. Participants were also asked to either scan and email or mail the hard copy of the visual portion to the rater to ensure accuracy. The remaining subsections in the verbal portion of the exam were conducted orally as they would be in person. The telemedicine trials13,14 in which the data originate from were approved by the University of Rochester’s Institutional Review Board. For the in-person and remote assessments, the mean and standard deviation (SD) of the sum of each subsection, the visual and verbal portions, and the total MoCA score were computed. All analyses were done using SAS version 9.3 (SAS Institute, Inc., Cary, NC, USA).
Psychometric analyses As a secondary outcome of this study, we conducted a crude assessment of the remote MoCA scale properties. To estimate the reliability and agreement between the in-person MoCA and remote MoCA, the intraclass correlation coefficient (ICC) and 95 per cent confidence intervals (CIs) were calculated. We defined the threshold for reliability as follows: excellent agreement (ICC ≥ 0.75), fair to good agreement (0.40
JHI0010.1177/1460458214556373Health Informatics JournalAbdolahi et al.
Original Article
A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders
Health Informatics Journal 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460458214556373 jhi.sagepub.com
Amir Abdolahi and Michael T Bull University of Rochester, USA
Kristin C Darwin
Johns Hopkins School of Medicine, USA
Venayak Venkataraman
Duke University School of Medicine, USA
Matthew J Grana
Lake Erie College of Osteopathic Medicine, USA
E Ray Dorsey and Kevin M Biglan University of Rochester, USA
Abstract Remote assessments of individuals with a neurological disease via telemedicine have the potential to reduce some of the burdens associated with clinical care and research participation. We aim to evaluate the feasibility of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. A pilot study derived from two telemedicine trials was conducted. In total, 17 individuals with movement disorders (8 with Parkinson disease and 9 with Huntington disease) had Montreal Cognitive Assessment examinations evaluated in-person and remotely via web-based video conferencing to primarily determine feasibility and potential barriers in its remote administration. Administering the Montreal Cognitive Assessment remotely in a sample of movement disorder patients with mild cognitive impairment is feasible, with only minor common complications associated with technology, including delayed sound and corrupted imaging for participants with low connection speeds. The Montreal Cognitive Assessment has the potential to be used in remote assessments of patients and research participants with movement disorders.
Corresponding author: Amir Abdolahi, University of Rochester, 265 Crittenden Blvd., CU 420644, Rochester, NY 14642, USA. Email: [email protected]
Downloaded from jhi.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
2
Health Informatics Journal
Keywords feasibility, Montreal Cognitive Assessment, remote, telemedicine, validity
Introduction Individuals with a neurological disease generally require routine doctor visits, consisting of motor and cognitive assessments, which overtime may become burdensome to the individual and their caregivers. Participation in clinical research studies also becomes an added challenge for these individuals, particularly with travel and time as major barriers, subsequently hindering recruitment and retention. At-home assessments via web-based video conferencing may reduce such inconveniences by eliminating travel and wait times, reducing caregiver burden, and providing a comfortable environment applicable to the subject’s daily living, while still having the face-to-face interaction with the clinician. Additionally, the utilization of telemedicine for remote web-based assessments could substantially decrease administrative costs and permit the use of a single centralized rater for important clinical trial outcomes. Recent studies among individuals with neurodegenerative disease have demonstrated the feasibility of conducting motor assessments remotely1,2 and have been shown to be effective in enhancing enrollment into research studies and trials.3 These clinical assessments, modified when conducted remotely to only include items that can be evaluated visually,4 demonstrated excellent reliability and validity when compared to the in-person assessment. Cognitive assessments are also important clinical tools used frequently in this population. The Montreal Cognitive Assessment (MoCA) is a common and simple screening tool for detecting mild cognitive impairment, consisting of visual (visuospatial/executive, naming) and verbal (attention, language, abstraction, delayed recall, orientation) portions.5 Although the MoCA has been deemed reliable and well validated in individuals with movement disorders such as Parkinson disease (PD)6–9 and Huntington disease (HD),10–12 the feasibility of remote administration has yet to be reported in this population. Therefore, using web-based video conferencing, we evaluated the feasibility and potential validity of assessing the MoCA remotely in patients with PD and HD.
Methods This was a feasibility study derived from two separate PD13 and HD14 telemedicine trials evaluating patient symptoms longitudinally using remote monitoring. Study participants were recruited from the HD Society of America 2012 annual convention in Las Vegas, NV, as well as regionally at the University of Rochester’s movement disorder clinic. Patients who had a clinical diagnosis of PD or HD and had access to a printer and computer with high-speed internet were eligible to participate. The initial baseline study visit was conducted in-person during which participants were consented and asked information on demographics and medical history. Among those with PD, the study’s movement disorder specialists evaluated baseline scores for the Unified Parkinson’s Disease Rating Scale (UPDRS), Parkinson’s disease questionnaire (PDQ-39; a quality of life measure), Hoehn and Yahr, and the MoCA. Among participants with HD, the total functional capacity (TFC) and motor portions of the Unified Huntington’s Disease Rating Scale (UHDRS) were assessed along with the MoCA. Follow-up MoCA exams were conducted remotely, by the same baseline rater, via web-based video conferencing at 7 months for PD participants and at 3 months for HD participants. These time points were set prior to the initiation of this study as part of the initial PD13 and HD14 telemedicine trials. Significant changes in cognition were not anticipated to occur over the two follow-up
Downloaded from jhi.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
3
Abdolahi et al.
periods based on recent evidence demonstrating non-significant changes on the total MoCA per year;15 however, results were stratified by disease group to eliminate potential biases. Administration and scoring of the MoCA was identical to its original instructions (www.mocatest.org) with slight adaptations in administering the visual portion in order to accommodate remote administration. Namely, the visuospatial/executive subsection (including the alternating trail making task, copying the cube, and drawing the clock) as well as the naming subsection (naming of three animals—lion, rhinoceros, and camel—pictured on the scale) were emailed to and printed by the participants immediately before the web-based assessment began. The rater gave verbal instructions for completing these subsections and then asked participants to hold the paper in front of the web-camera, which was captured as a screenshot by the rater for evaluation (see Figure 1). The naming subsection was administered by instructing the participant to name each animal pictured on the form one at a time from left to right. Participants were also asked to either scan and email or mail the hard copy of the visual portion to the rater to ensure accuracy. The remaining subsections in the verbal portion of the exam were conducted orally as they would be in person. The telemedicine trials13,14 in which the data originate from were approved by the University of Rochester’s Institutional Review Board. For the in-person and remote assessments, the mean and standard deviation (SD) of the sum of each subsection, the visual and verbal portions, and the total MoCA score were computed. All analyses were done using SAS version 9.3 (SAS Institute, Inc., Cary, NC, USA).
Psychometric analyses As a secondary outcome of this study, we conducted a crude assessment of the remote MoCA scale properties. To estimate the reliability and agreement between the in-person MoCA and remote MoCA, the intraclass correlation coefficient (ICC) and 95 per cent confidence intervals (CIs) were calculated. We defined the threshold for reliability as follows: excellent agreement (ICC ≥ 0.75), fair to good agreement (0.40
