Addenbrooke's Cognitive Examination
The Addenbrooke’s Cognitive Examination (ACE) was originally developed as a theoretically motivated extension of the Mini-Mental State Examination (MMSE) which attempted to address the neuropsychological omissions and improve the screening performance of the latter. Though taking longer to administer than the MMSE, and therefore best suited to specialist settings, the ACE and its subsequent iterations, ACE-R and ACE-III, have proved easy to use, acceptable to patients, and have shown excellent diagnostic utility in identifying dementia and cognitive impairment in a variety of clinical situations (Alzheimer’s disease, frontotemporal lobar degenerations, Parkinsonian syndromes, stroke and vascular dementia, and brain injury). The ACE is used worldwide and is available in a number of languages.
The ACE encompassed tests of five cognitive domains: attention/orientation, memory, language, verbal fluency, and visuospatial skills. It is scored out of 100, with a higher score denoting better cognitive function. At the recommended cut-off scores of 88 and 83, the ACE was reported to have good sensitivity and specificity for identifying dementia (0.93 and 0.71; 0.82 and 0.96, respectively). The ACE also incorporated the MMSE, such that this score (out of 30) might also be generated.
The ACE-R was a development of the earlier ACE which also incorporated the MMSE, but had clearly defined subdomain scores. Like the ACE, the overall ACE-R score was 100, from which domain scores for attention/orientation, memory, fluency, language and visuospatial abilities could be generated. Test reliability was very good as judged by its internal consistency (Cronbach alpha coefficient = 0.8). This version introduced cut-off scores of 88 and 82, which were reported to have good sensitivity and specificity for identifying dementia (0.94 and 0.79; 0.84 and 1.00, respectively).
The ACE-III was developed to expunge the MMSE items in the ACE and ACE-R. In the ACE-III, these MMSE items were substituted like for like as far as possible, for example, the intersecting pentagons were replaced with interlocking infinity loops. In the index study the cohort examined (n = 86; AD 28, FTD 33, controls 25) found the ACE-III to be acceptable and relatively quick to administer (15 min). The ACE-III and ACE-R were highly correlated (r = 0.99), and at the previously recommended cut-off scores (88 and 82) the ACE-III was both highly sensitive and specific (at 88/100: 1.00 and 0.96 respectively; at 82/100: 0.93 and 1.00 respectively). At the cut-off of 88, Elamin and colleagues found the ACE-III distinguished early-onset dementia from healthy controls with high sensitivity (0.915) and specificity (0.964), and also from subjective memory impairment with high sensitivity (0.915) and specificity (0.867). The ACE-III has been validated against standard neuropsychological tests and has been shown to be a valid cognitive screening tool for dementia syndromes.
The ACE-III has also been made available as an iPad based app, which is available cost-free via iTunes and at http://www.acemobile.org/. The automated scoring and the clear instructions are designed to reduce errors in administration and scoring.
In 2014, a shorter version of the ACE-III, the Mini-ACE (M-ACE), was developed and validated. It comprises tests of attention, memory (7-item name and address), letter fluency, clock drawing, and memory recall, and takes under five minutes to administer. The M-ACE is scored out of 30, with a higher score indicating better cognitive function, and has two recommended cut-off scores (25 and 21). The higher cut-off score has both high specificity and sensitivity and is at least five times more likely to have come from a dementia patient than without. A score of 21 or less is almost certainly diagnostic of a dementia syndrome regardless of the clinical setting. It has been found to be superior to the MMSE in diagnostic utility.
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- Hodges, J. R., & Larner, A. J. (2017). Addenbrooke’s Cognitive Examinations: ACE, ACE-R, ACE-III, ACEapp, and M-ACE. Cognitive Screening Instruments (pp. 109-137): Springer.
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- Mioshi, E., Dawson, K., Mitchell, J., Arnold, R., & Hodges, J. R. (2006). The Addenbrooke's Cognitive Examination Revised (ACE‐R): a brief cognitive test battery for dementia screening. International journal of geriatric psychiatry, 21(11), 1078-1085.
- Hsieh, S., Schubert, S., Hoon, C., Mioshi, E., & Hodges, J. R. (2013). Validation of the Addenbrooke's Cognitive Examination III in frontotemporal dementia and Alzheimer's disease. Dementia and geriatric cognitive disorders, 36(3-4), 242-250.
- Matías-Guiu, J. A., Fernández-Bobadilla, R., Fernández-Oliveira, A., Valles-Salgado, M., Rognoni, T., Cortés-Martínez, A., . . . Matías-Guiu, J. (2016). Normative data for the Spanish version of the Addenbrooke's Cognitive Examination III. Dementia and geriatric cognitive disorders, 41(5-6), 243-250.
- Pigliautile, M., Ricci, M., Mioshi, E., Ercolani, S., Mangialasche, F., Monastero, R., . . . Mecocci, P. (2011). Validation study of the Italian Addenbrooke’s Cognitive Examination Revised in a young-old and old-old population. Dementia and geriatric cognitive disorders, 32(5), 301-307.
- Raimondi, C., Gleichgerrcht, E., Richly, P., Torralva, T., Roca, M., Camino, J., & Manes, F. (2012). The Spanish version of the Addenbrooke's Cognitive Examination—Revised (ACE-R) in subcortical ischemic vascular dementia. Journal of the neurological sciences, 322(1), 228-231.
- Yoshida, H., Terada, S., Honda, H., Kishimoto, Y., Takeda, N., Oshima, E., . . . Uchitomi, Y. (2012). Validation of the revised Addenbrooke's Cognitive Examination (ACE-R) for detecting mild cognitive impairment and dementia in a Japanese population. International Psychogeriatrics, 24(1), 28-37.
- Elamin, M., Holloway, G., Bak, T. H., & Pal, S. (2016). The utility of the Addenbrooke's Cognitive Examination version three in early-onset dementia. Dementia and geriatric cognitive disorders, 41(1-2), 9-15.
- Matias-Guiu, J. A., Cortés-Martínez, A., Valles-Salgado, M., Rognoni, T., Fernández-Matarrubia, M., Moreno-Ramos, T., & Matías-Guiu, J. (2017). Addenbrooke's Cognitive Examination III: diagnostic utility for mild cognitive impairment and dementia and correlation with standardized neuropsychological tests. International Psychogeriatrics, 29(1), 105-113.
- Hsieh, S., McGrory, S., Leslie, F., Dawson, K., Ahmed, S., Butler, C. R., . . . Hodges, J. R. (2015). The Mini-Addenbrooke's Cognitive Examination: a new assessment tool for dementia. Dementia and geriatric cognitive disorders, 39(1-2), 1-11.
- Larner, A. J. (2015). Mini‐Addenbrooke's Cognitive Examination: a pragmatic diagnostic accuracy study. International journal of geriatric psychiatry, 30(5), 547-548.
- Larner, A. J. (2015). Mini‐Addenbrooke's cognitive examination diagnostic accuracy for dementia: reproducibility study. International journal of geriatric psychiatry, 30(10), 1103-1104.
- The ACE-III – freely available