Tablet-Based Cognitive Impairment Screening for Adults With HIV Seeking Clinical Care: Observational Study

Abstract

Background: Neurological complications including cognitive impairment persist among people with HIV on antiretrovirals; however, cognitive screening is not routinely conducted in HIV clinics.

Objective: Our objective for this study was 3-fold: (1) to determine the feasibility of implementing an iPad-based cognitive impairment screener among adults seeking HIV care, (2) to examine the psychometric properties of the tool, and (3) to examine predictors of cognitive impairment using the tool.

Methods: A convenience sample of participants completed Brain Baseline Assessment of Cognition and Everyday Functioning (BRACE), which included (1) Trail Making Test Part A, measuring psychomotor speed; (2) Trail Making Test Part B, measuring set-shifting; (3) Stroop Color, measuring processing speed; and (4) the Visual-Spatial Learning Test. Global neuropsychological function was estimated as mean T score performance on the 4 outcomes. Impairment on each test or for the global mean was defined as a T score ≤40. Subgroups of participants repeated the tests 4 weeks or >6 months after completing the first test to evaluate intraperson test-retest reliability and practice effects (improvements in performance due to repeated test exposure). An additional subgroup completed a lengthier cognitive battery concurrently to assess validity. Relevant factors were abstracted from electronic medical records to examine predictors of global neuropsychological function.

Results: The study population consisted of 404 people with HIV (age: mean 53.6 years; race: 332/404, 82% Black; 34/404, 8% White, 10/404, 2% American Indian/Alaskan Native; 28/404, 7% other and 230/404, 58% male; 174/404, 42% female) of whom 99% (402/404) were on antiretroviral therapy. Participants completed BRACE in a mean of 12 minutes (SD 3.2), and impairment was demonstrated by 34% (136/404) on Trail Making Test A, 44% (177/404) on Trail Making Test B, 40% (161/404) on Stroop Color, and 17% (67/404) on Visual-Spatial Learning Test. Global impairment was demonstrated by 103 out of 404 (25%). Test-retest reliability for the subset of participants (n=26) repeating the measure at 4 weeks was 0.81 and for the subset of participants (n=67) repeating the measure almost 1 year later (days: median 294, IQR 50) was 0.63. There were no significant practice effects at either time point (P=.20 and P=.68, respectively). With respect for validity, the correlation between global impairment on the lengthier cognitive battery and BRACE was 0.63 (n=61; P<.001), with 84% sensitivity and 94% specificity to impairment on the lengthier cognitive battery.

Conclusions: We were able to successfully implement BRACE and estimate cognitive impairment burden in the context of routine clinic care. BRACE was also shown to have good psychometric properties. This easy-to-use tool in clinical settings may facilitate the care needs of people with HIV as cognitive impairment continues to remain a concern in people with HIV.

Keywords: HIV; cognitive complications; digital assessment; people with HIV; screening; tablet.

Figure 1

Performance on iPad cognitive assessment tool of people with HIV seeking clinical care. The red line indicates the mean, the grey shaded section indicates the score is in the range of impairment (T score <40); the dotted grey line is T score=35 (1.5 SD below the mean). TMT: Trail Making Test; VSLT: Visual Spatial Learning Test.

Figure 2

Percentage impairment in study population of people with HIV seeking clinical care. TMT: Trail Making Test; VSLT: Visual Spatial Learning Test.

Figure 3

Associations between global neuropsychological function assessed with the tool at the initial time point and 30 days later in 26 people with HIV assessed via the gold standard neuropsychological battery in 61 people with HIV.

Figure 4

Associations between global neuropsychological function assessed with the tool at the initial time point and almost 1 year later in 67 people with HIV assessed via the gold standard neuropsychological battery in 61 people with HIV.

Figure 5

Associations between global neuropsychological function assessed with the tool at the initial time point and global neuropsychological function assessed via the gold standard neuropsychological battery in 61 people with HIV.

Figure 6

Correlation heatmap between the individual outcomes assessed with the tool and the gold standard neuropsychological test battery. ***P<.001; **P<.01; *P<.05. SDMT: Symbol Digit Modalities Test; DMT: Symbol Digit Modalities Test; TMT: Trial Making Test; HVLT: Hopkins Verbal Learning Test-Revised; SEMFLU: semantic fluency; GPEG-D: Grooved Pegboard dominant hand; GPEG-ND: Grooved Pegboard nondominant hand; VSLT:Visual Spatial Learning Test.

Figure 7

Performance (T scores) on the Brain Baseline Assessment of Cognition and Everyday Functioning iPad cognitive assessment as a function of global neuropsychological impairment (normal vs impaired based on a z score <1) using the gold standard neuropsychological test battery in people with HIV. ***P<.001. TMT: Trail Making Test; VSLT: Visual Spatial Learning Test.