The validity of the Addenbrooke’s Cognitive Examination-Revised (ACE-R) in acute stroke

Abstract

Purpose: The purpose was to examine the validity of the Addenbrooke’s Cognitive Examination Revised (ACE-R) as a screening measure to detect cognitive impairment after stroke. Methods: Stroke patients in hospital were recruited and the ACE-R, which includes the Mini-Mental Status Examination (MMSE), was administered, followed by a battery of neuropsychological tests, which served as the ‘gold standard’ for classification of cognitive impairment. The diagnostic validity of the ACE-R was determined by ROC analysis. Results: Of the 101 patients who completed the ACE-R, 61 also completed the neuropsychological assessment. Both the MMSE and the ACE-R were found to have inadequate diagnostic validity for the detection of overall cognitive impairment (MMSE AUC = 0.53, p > 0.05; ACE-R AUC = 0.53, p > 0.05). The ACE-R subscales predicted impairment in specific cognitive domains significantly better than chance; Visuospatial (AUC = 0.71, p < 0.05), Fluency (AUC = 0.72, p< 0.05) and Attention and Orientation (AUC = 0.80, p < 0.05). However, no cut-off score for any subscale gave both adequate levels of sensitivity and specificity for the detection of impairment in specific areas of cognitive functioning. Conclusions: The ACE-R was not a suitable measure to screen for overall cognitive impairment in acute stroke patients, but was able to detect impairment in visuospatial, attention and executive domains.

Implications for Rehabilitation

• Cognitive impairments are common after stroke.

• Brief screening measures are needed to detect cognitive problems.

• The Addenbrooke’s cognitive examination–revised (ACE-R) was more accurate for detecting cognitive impairment after stroke than the Mini-Mental State Examination (MMSE), but neither was a satisfactory measure.

• Stroke specific screening measures need to be developed.

Keywords::

• ACE-R
• cognitive impairment
• MMSE
• screening
• stroke

Acknowledgments

We would like to thank Kimberley Fletcher, Daniel Stark, Heather Fergusson and Carmen von Mickwitz (Assistant Psychologists) for their contribution to data collection, Vanessa Dale for supervising some of the assistants and to the staff and patients of Nottingham University Hospitals NHS Trust Stroke Service for their support of this study.

Declaration of interest: The authors report no conflicts of interest.