Due to the high variability of cognitive measures in impaired patients, clinicians can be misled by mild cognitive improvements ( 10). Thus, clinicians still lack a validated metric for determining what is considered a “significant” cognitive improvement for individual patients. However, these studies have focused on comparing mean differences across groups, such as gait-responders vs. Research has shown that, for some patients, cognition does significantly improve following CSF drainage either from a TT or ELD and following shunt surgery ( 5– 9). In addition to changes in the patient's gait, clinicians also consider improvements in their cognition when diagnosing iNPH ( 3, 4). Hence, iNPH diagnosis guidelines recommend that clinicians conduct a Tap Test (TT) or extended lumbar drainage (ELD) and consider changes in their patients gait primarily when determining the likelihood of iNPH. The symptomatology of iNPH has considerable overlap with more common age-related disorders, such as Alzheimer's Disease (AD). This wide range of incidence rates reflect the challenges in diagnosing iNPH. Recently, the largest study to evaluate the incidence rates of iNPH reported it to be 14.65 in 100,000 adults age 70 or older ( 2). iNPH is most common among older adults, however, incidence rates vary widely between studies based on the methods and operational definitions used ( 1). Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible neurological condition due to altered cerebrospinal fluid dynamics, manifesting primarily in impaired gait and balance, as well as cognitive decline and urinary incontinence. However, a reliable change cannot be detected for patients with a baseline MoCA of 26 or greater, necessitating a different cognitive assessment tool for these patients. Time since onset of memory problems and post-TT/ELD gait function were the only clinical factors significantly associated with having a reliable change in MoCA after shunt insertion ( p = 0.019 p = 0.03, respectively).Ĭonclusions: In patients with iNPH, clinicians could consider using a threshold of 5 points for determining whether iNPH-symptomatic patients have experienced cognitive benefits from cerebrospinal fluid drainage at an individual level. Among shunted patients, 23.4% improved by at least 5 points on the MoCA from baseline to post-shunt. Compared to patients who did not receive a shunt, patients who received a shunt did not have lower average MoCA at baseline ( p = 0.88) or have better improvement in MoCA scores after the tap test ( p = 0.17). 10.1% had at least a 5-point increase from baseline to post-TT/ELD. Reliable change thresholds varied across methods from 4 to 7 points for patients outside of this range. Furthermore, a majority of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 14 to 25. Results: All nine of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 16 to 22 (38.4% of patients). Baseline characteristics of patients whose post-shunt MoCA did and did not exceed the reliable change threshold were compared. Reliable change thresholds for MoCA were derived using baseline visit to pre-TT/ELD assessment using nine different methodologies. Patients who were determined to be good candidates for shunts ( N = 71, 31.7%) took another MoCA assessment following shunt insertion.

Methods: Patients ( N = 224) presenting with symptoms of iNPH were given a MoCA assessment at their first clinic visit, and also before and after tap test (TT) or extended lumbar drainage (ELD). Furthermore, we aimed to determine the likelihood that shunted patients will demonstrate significant improvement on the MoCA, and to identify possible predictors of this improvement. Objectives: We sought to estimate reliable change thresholds for the Montreal Cognitive Assessment (MoCA) for older adults with suspected Idiopathic Normal Pressure Hydrocephalus (iNPH). 3Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.2Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States.

1Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Eric Wesner 1 * Lacey Etzkorn 2 * Shivani Bakre 2 Jinyu Chen 2 Alexander Davis 1 Yifan Zhang 2 Sevil Yasar 1 Aruna Rao 1 Mark Luciano 3 Jiangxia Wang 2 Abhay Moghekar 1

Moca test memory index score