Discussing Advantages, Potential of the SAGE Test for Early Dementia Detection


Douglas Scharre, MD, provided an overview of the pen-and-paper and digital versions of the test, which do not require an administrator.

Douglas Scharre, MD, director, Division of Cognitive and Memory Disorders, department of neurology, the Ohio State Wexner Medical Center.

Douglas Scharre, MD

Early identification of patients who are at-risk for dementia is pivotal, allowing health care providers and specialists to start treatment and effectively manage the condition. Several tests exist to facilitate this identification, including the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment, and the Self-Administered Gerocognitive Examination (SAGE) test, which has shown success in a recent longitudinal study.

Compared with the pen-and-paper, non-self-administered MMSE, the SAGE test was found to detect mild cognitive impairment conversion to dementia at least 6 months sooner. Patients that were identified as being likely to develop dementia had a 2- to 3- point decline in SAGE scores 12-18 months from baseline, which was noted by investigators as a significant decline.

To learn more about study findings and the genesis of its development, we sat down with lead author Douglas Scharre, MD, director, Division of Cognitive and Memory Disorders, department of neurology, the Ohio State Wexner Medical Center. Speaking with NeurologyLive®, Scharre outlined the motivations behind the SAGE test and its applications, further highlighting the use of BrainTest, a digital companion test that can be performed on a tablet or a touchscreen computer.

NeurologyLive®: How was the SAGE test developed?

Douglas Scharre, MD: The SAGE test stands for Self-Administered Gerocognitive Examination, so it's a pen-and-paper test designed to measure cognitive assessment and designed to try to identify individuals with mild cognitive impairment, or early signs of cognitive impairment, as soon as possible.

The reason I developed and invented this test was because, as a neurologist, seeing cognitively impaired patients and/or with memory disorders, the number of individuals that would come into our clinic that had had issues for 3, 4 years by the time they actually came to see us. It was clear to me that patients weren't right on top of it all the time and primary care doctors weren't always referring, and we're thinking maybe it's normal aging, maybe it's bad day for them, everyone forgets. So, there was a delay in identified people with cognitive issues, and therefore a delay in appropriate treatments and therapies. That's how the idea came about, and we developed this test, called SAGE, validated it against neuropsychological measures and published that, and then have done more and more work with it. 

The current article that just came out was really involved with longitudinal change over time with SAGE. We know it works well; it correlates well with being [able to] identify cognitive impairment early, but how does it change over time? What we found in this study was that if you drop with the SAGE test about 2 to 3 points, in about 12 to 18 months, it identified individuals who would eventually develop dementia. The study showed evidence that SAGE was sensitive to change over time.

What are the major differences between the pen-and-paper version of the test and the digital version?

We developed a digital form of SAGE called BrainTest, and it's the exact test questions of [the pen-and-paper] SAGE. People can use a tablet or a touchscreen computer to register their answers, as opposed to pen and paper. We validated the 2 tests to find that they were equivalent, so that you could take a score paper-wise, or if you liked digital, you could do a digital, if you didn't have a tablet, you could do the paper. They're basically equivalent tests. 

The [pen-and-paper] SAGE test is downloaded from the website; it can be free for anyone to use it. If you use a digital test, called BrainTest, that is commercialized and so there is a cost to using the digital version. The advantage is that it will score it automatically for you. For both tests, if you take it at home, take it into your doctor so that they can evaluate it and store it in your health files and electronic medical system. The digital test will automatically score it for you, so the doctor doesn’t have to do it. SAGE test, you have to have someone to score it for you, [or] you can do it yourself. There are easy scoring instructions on the website to identify that, but otherwise, they're really identical tests.

They're both self-administered, so you do not need an administrator, which is one of the biggest advantages of this test. Unlike the Mini-Mental State [Examination] or other tests where you needed an administrator, the SAGE test, the BrainTest are self-administered, and it takes away administrator bias. Some people are good at administering tests and other people not so good. 

People don't mind taking the test as much as an administered test because you don't have someone staring at you and asking you questions and making you feel stressed out. You can take it on your own, go back and forth with the pages, go back and forth with a tablet. Once you've finished, you turn it in, there's no time limit. On the average, it takes about 13 minutes—so about 10 to 15 minutes to take either the tests, and it measures domains of memory and language, visual spatial executive calculations, abstractions. It gives us a global, brief, multidomain cognitive assessment that can be compared over time.

Is there a way to use this test in the clinical setting? Does it offer a way to better stratify patients?

One of the biggest issues we have with clinical trials is identifying people—at least if the clinical trial is looking at mild cognitive impairment—to identify those people early on. It's usually easy enough for the doctor to say, "Okay, yeah, you have moderate dementia." That's easy to pick out, but what is not easy to pick out is the thousands, or maybe millions of these people out in the world, and certainly in the US, that have mild cognitive impairment, but don't going to a doctor. They're out there, but we can't find them for clinical trials, and so the trick has always been an effective screening tool, which we believe SAGE/BrainTest is, to be able to identify mild cognitive impairment. 

It was designed to identify mild cognitive impairment, not designed to identify, say, dementia. It was designed to pick up people earlier, and that's why it does better than, say, the Mini-Mental State [Examination], because it's a little harder, and you can pick up more subtle deficits earlier with this test. There's lots of great cognitive tests out there that one can use; the advantage of SAGE/BrainTest is that it's self-administered, and so it could be done at home, or if you see an ad for a study, you could get online and take the test.

For example, it would be a great case-finding tool—and that's sort of where it's best fit. You’ll see [patients who] are sort of in that sweet spot for a potential trial and say, “Let me tell you what's out there here in your area or 50 miles away. We could get you hooked up to that memory center group,” for example. [The test] has a lot of advantages for clinical trials. When I recruit for clinical trials, if I have a mild cognitive impairment study, we can go out to an alumni group or a senior group at a senior center and give a talk about memory, and I can take the SAGE test out there and pass out this test. Since there's 4 different forms, you can avoid cheating because they'll have a different form if they're sitting in chairs, and they're all equivalent forms. Then in 15 minutes, if 100 people showed up, I have 100 data points, whereas if you did a Mini-Mental [State Examination], or a book, or one of these others that is administered, after 10-15 minutes, you got 1 data point, and you’ve got to do the next one, you got to have a huge group out there to test all these people. [With the SAGE test], they could do it simultaneously in large groups. Eighty percent of these people will be normal, and about 10% will be really demented in these sort of community groups, and you'll have 10-15%, who are screened, ideal patients for maybe a mild cognitive impairment study. We may ask them, "We have these studies available, if you're interested." If they say yes, [we ask], "Do you have a pacemaker? Do you have cancer?" [We ask if there is anything] that would exclude them, [using] a little a short checklist. If they're still interested, we give them an informed consent [form]. It's a way to be able to identify and recruit more easily for mild cognitive impairment.

With the digital test it's even easier because you could actually do it at home and submit it; it's automatically graded, so that sponsors may know where they are. It's not a perfect test, but it really narrows down and gets rid of the people that are doing perfectly well that probably aren't qualifying, [and] the people that are in the dementia classification, which usually are also are not qualified.

Transcript edited for clarity.

Scharre DW, Chang S, Nagaraja HN, Wheeler NC, Kataki M. Self-Administered Gerocognitive Examination: longitudinal cohort testing for the early detection of dementia conversion. Alzheimers Res Ther. 2021;13(1):192. doi:10.1186/s13195-021-00930-4
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