Addenbrooke’s Cognitive Examination-Revised (ACE-R)
ACE-R is a brief battery that provides evaluation of six cognitive domains (orientation, attention, memory, verbal fluency, language and visuospatial ability) (Mioshi et al., 2006). It is useful for detecting dementia and mild cognitive impairment. It is also effective for differentiating the subtypes of dementia, such as Alzheimer’s disease, frontotemporal dementia, progressive supranuclear palsy, and other forms of dementia associated with parkinsonism (Rittman et al., 2013). ACE-R has recently been used in two PD studies (Komadina et al., 2011; Robben et al., 2010), revealing discriminative properties compared with neuropsychological evaluation as a reference for the diagnosis of dementia in this disease (Rittman et al., 2013).
The first study with ACE-R in Brazil has determined two cut-off points in differentiating normal controls and mild Alzheimer’s disease patients, according to schooling: <68 points for participants with less than 11 years of formal education and < 78 points in those with 11 or more years of schooling. In this study the mean total score for the controls was 83.63 (±7.90) (Carvalho et al., 2010). In the normative study, education was the most important factor of influence on all ACE-R sub scores. The performance was strongly influenced by schooling and, to a lesser degree, by age (Carvalho & Caramelli, 2012). In this study the minimum education was four years.
In a recent publication Rocha et al. (2014) studied 70 idiopathic PD patients, with a mean (SD) age of 64.1 (9.3) years and low educational level with an average schooling of 5.9 (3.4) years, matched for education and age to controls. There was a significant difference between PD patients and controls on MMSE scores and ACE-R scores for total and on all sub-items. The ACE-R total score was of 79.7 (7.5) in controls. Twenty-seven patients (38.3%) had a diagnosis of PD dementia according to Movement Disorder Society (MDS) criteria. Mean scores on the ACE-R were 54.7 (12.8) points for patients with PD dementia, and 76 (9.9) for PD patients without dementia.
In this sample healthy controls had a mean score of 79.7 (1.8) points, less than the average performance on normative Brazilian study, but with lower education level. The area under the receiver operating curve, taking the MDS diagnostic procedures as a reference, was 0.93 [95% CI, 0.87-0.98; p<0.001] for ACE-R. The optimal cut-off value for ACE-R was <72 points [sensitivity 90%; specificity 85%; Kappa concordance (K) 0.79].
A comprehensive neuropsychological evaluation usually has a two-hour duration; the ACE-R takes about 20-25 minutes to complete, being a significant less time-consuming test with a good accuracy in detecting dementia in Parkinson’s disease patients, and it seems a good option considering low education patients as well. It is available in many different languages, besides the original version in English (Portuguese, Spanish, Korean, German, Greek, and Dutch).
Amaral-Carvalho V, Caramelli P. Normative data for healthy middle-aged and elderly performance on the Addenbrooke Cognitive Examination Revised. Cogn Behav Neurol 2012; 25: 72-76.
Carvalho VA, Barbosa MT, Caramelli P. Brazilian version of the Addenbrooke Cognitive Examination-revised in the diagnosis of mild Alzheimer disease. Cogn Behav Neurol. 2010; 23: 8–13.
Komadina NC, Terpening Z, Huang Y, Halliday GM, Naismith SL, Lewis SJ. Utility and limitations of Addenbrooke’s Cognitive Examination-Revised for detecting mild cognitive impairment in Parkinson’s disease. Dement Geriatr Cogn Disord 2011;31:349-357.
Mioshi E, Dawson K, Mitchell J, et al. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry. 2006; 21: 1078–1085.
Rittman T, Ghosh BC, McColgan P, et al. The Addenbrooke’s Cognitive Examination for the differential diagnosis and longitudinal assessment of patients with parkinsonian disorders. J Neurol Neurosurg Psychiatry 2013; 84: 544-551.
Robben SH, Sleegers MJ, Dautzenberg PL, van Bergen FS, ter Bruggen JP, Rikkert MG. Pilot study of a three-step diagnostic pathway for young and old patients with Parkinson’s disease dementia: screen, test and then diagnose. Int J Geriatr Psychiatry 2010; 25: 258-265.
Rocha MSG, Bassetti EM, Oliveira MO et al. Addenbrooke’s Cognitive Examination-Revised is accurate for detecting dementia in Parkinson’s disease with low educational level. Dement Neuropsychol 2014; 8: 20-25.
Sonia M. Dozzi Brucki, MD
Excerpted article as reprint from IPA’s newsletter, the IPA Bulletin, Volume 31, Number 3