ACEbajaeducacion
ACEbajaeducacion
ACEbajaeducacion
SUMMARY
Background The Addenbrookes Cognitive Examination (ACE) is a brief cognitive test battery designed to detect and
differentiate Alzheimers disease (AD) and frontotemporal dementia (FTD). Translations of this instrument into French
and Malayalam have been recently published.
Objective To adapt and validate the ACE into Spanish in a rural population of low-educational level.
Subjects A clinical group, composed of 70 patients affected by dementia and 25 patients with memory complaints without
dementia, was compared with 72 controls matched for gender, age and educational level.
Method The clinical group was studied with standard neuropsychological instruments, all patients underwent neuroimaging [Computerized Tomography (CT) or Magnetic Resonance Imaging (MRI), and Single Photon Emission Tomography
(SPECT) in all cases of suspected FTD], as well as routine neurological examination. Both groups were studied with the
ACE and Clinical Dementia Rating scale (CDR). Sensitivity, specificity, area under curve, reliability and Verbal-Language/
Orientation-Memory (VLOM) ratio were calculated. Subsequently, the sample was stratified regarding educational level in
two groups. Receiver Operating Characteristics (ROC) curves were calculated for these conditions. Different cut-off points
were calculated addressing educational level.
Results ROC curves demonstrated the superiority of the ACE in the sub sample of patients that finished school at over
14 years old. VLOM ratio confirmed its usefulness for differential diagnosis between AD and FTD.
Conclusion The Spanish version of the ACE is a useful instrument for dementia diagnosis. In our sample VLOM ratio
results were useful for differential diagnosis between AD and FTD. Different cut-off points must be used for different
educational levels. Copyright # 2006 John Wiley & Sons, Ltd.
key words Addenbrookes; ACE; Frontotemporal dementia; Alzheimers disease; cognitive evaluation; education;
Spanish
INTRODUCTION
Early detection of dementia is an important challenge
for the physician, especially after the introduction of
disease-modifying treatments.
*Correspondence to: Dr. A. Garca-Caballero, Servicio de Psiquiatra, Complexo Hospitalario de Ourense. R/Ramon Puga no. 54,
32005, Ourense, Spain. Tel: 988-218990. Fax: 988-218991.
E-mail: Alejandro.Garcia.Caballero@sergas.es
Contract/grant sponsor: Direccion Xeral de Investigacion e
Desenvolvemento, Xunta de Galicia; contract/grant number:
PGIDIT 03SAN 92302.
Copyright # 2006 John Wiley & Sons, Ltd.
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Table 1. Comparison of control, dementia and non dementia groups on demographics and ACE and MMSE mean (SD) scores in the
complete sample
Clinic group
Dementia
(n 70)
Female sex (%)*
Age, years**
Education (years at
finishing school)***
MMSE (30)
ACE (100)
Non dementia
(n 25)
Control
(n 72)
38 (54.3)
74.19 (5.54)
17 (68)
74.64 (5.57)
42 (58.3)
72.58 (5.99)
13.13 (2.36)
20.10 (4.25)
51.87 (11.73)
12.96 (2.09)
25.48 (2.57)
67.68 (6.87)
13.36 (2.98)
28.04 (1.46)
83.51 (7.39)
ND
Control
****
****
****
****
*Pearson Chi-Square p 0.490, **Kruskal-Wallis Test p 0.165, ***Kruskal-Wallis Test p 0.665, ****MannWhitney U test, two-tailed
p < 0.001.
patients included in the clinical group (68.6%) presented a CDR 1 and 100% presented a CDR 2.
Within the complete sample an ACE cut-off score
of 68/100 points represented a value two SDs below
the mean composite score for the control group. Even
though this cut-off score was lower than the original
British one (83/100), the psychometric properties of
the ACE remained remarkable: sensitivity 92%, specificity 86%, area under roc curve 0.957; but only
slightly better than the MMSE with the standard
cut-off point (< 24) in the same population (sensitivity 82%, specificity 98%, area under roc curve (AUC)
0.944). Reliability of the ACE was measured in terms
of internal consistency, using Cronbachs alpha coeficient. The Cronbachs alpha for the ACE was 0.8201
(> 0.8 is considered excellent). A comparison of ROC
curves of ACE and MMSE, calculated for the complete sample is shown in Figure 1.
1,00
,75
Non dementia
MCI
Mood disorder
Subjective Mnestic Claim
25
13
9
3
Dementia
AD
FTD
VaD
DLB
HAS
,25
Reference Line
MMSE
0,00
ACE
0,00
,25
,50
,75
1,00
1 - Specificity
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Table 3. Comparison of control, dementia and non dementia groups on demographics and ACE and MMSE mean (SD) scores in the
stratified samples
Clinic group
Dementia
14
n 30
Age, years*
73.40 (5.86)
Education (age in years
at finishing school)**
15 (2.39)
MMSE (30)
21.03 (4.96)
ACE (100)
54.80 (13.14)
Non dementia
Control
< 14
n 40
14
n 11
< 14
n 14
14
n 40
74.78 (5.29)
72.23 (6.04)
75.43 (4.91)
70.97 (5.96)
74.59 (5.47)
11.73 (0.96)
19.40 (3.54)
49.67 (10.19)
14.91 (1.30)
26.00 (2.72)
70.81 (7.20)
11.43 (1.02)
25.07 (2.46)
65.21 (5.68)
15.33 (2.34)
28.40 (1.26)
86.37 (5.83)
10.91 (1.49)
27.59 (1.58)
79.93 (7.64)
ND
Control
***
***
***
***
< 14
n 32
Table 3 summarizes the socio-demographic characteristics and mean (SD) composite score on the ACE
and MMSE for dementia, non dementia and control
groups in the stratified samples.
ROC curves demonstrated the superiority of the
ACE (AUC 0.960) over the MMSE (AUC 0.922)
0.922) in the higher-educational level sub sample
(Fig. 2). Conversely, they demonstrated the absence
of differences between these instruments in the
lower-educational level sub sample (AUCACE
0.963, AUCMMSE 0.967) (Fig. 3).
Within the low-educational sub sample a cut-off
score two SDs below the mean of the control group
( 65/100) obtained a sensitivity of 90% and a specificity of 83%. These results were similar to those
obtained with the previously quoted cut-off score of
1,00
,75
,50
Sensitivity
Reference Line
MMSE
ACE
0,00
0,00
,25
,50
,75
1,00
1 - Specificity
0.90
0.86
0.25
0.42
0.62
0.73
0.92
0.82
0.21
0.36
0.56
0.69
0.95
0.73
0.16
0.28
0.47
0.6
0.96
0.85
0.25
0.42
0.62
0.73
0.96
0.65
0.11
0.21
0.37
0.50
0.90
0.79
0.18
0.32
0.52
0.65
0.90
0.83
0.22
0.37
0.57
0.69
0.95
0.79
0.19
0.33
0.53
0.66
0.85
0.96
0.53
0.70
0.84
0.90
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