Memoro: Evaluation of core psychometric properties and usability of a new self-administered web-based neuropsychological test platform
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A sustainable health care system needs access to high quality and cost efficient tools for assessment and monitoring of cognitive health in order to provide the best possible habilitation, treatment, rehabilitation, and follow-up of persons with conditions that may affect cognitive function. Researchers need flexible and accessible tools that can be administered on a large scale to create the evidence-based and personalized treatments of tomorrow to prevent or ameliorate cognitive deficits. The traditional neuropsychological tests used today put high demand on resources for administration and scoring, and further have geographical and methodological constraints reducing their applicability. Self-administered web-based neuropsychological test platforms can mitigate these problems, but there is a need to document psychometric properties such as validity and reliability, and the usability of these new tools. The overarching aim of this thesis was to evaluate core psychometric properties and the usability of Memoro, a new selfadministered web-based neuropsychological test platform developed by me and my supervisor in collaboration with members of the Trondheim fMRI group. In Paper 1 the aims were to investigate validity, effects of computer familiarity, education, age, and the feasibility of Memoro-administered tests in healthy older and senior adult volunteers. By comparing Memoro tests to traditional neuropsychological tests it was found moderate correlations indicating acceptable and good concurrent validity. Further, factor analyses indicated similar factor structures in the Memoro and traditional tests. Across the two samples in this study small to moderate effects of age and education was detected as expected. Furthermore, associations between computer familiarity and test performance on both the Memoro and traditional tests were present. However, these associations diminished after adjusting for potential confounding of age and education. More participants preferred Memoro over the traditional tests after completing both batteries. Some technical problems which led to missing data was encountered which were rectified for future administration by adjusting test stop criteria and keyboard functionality. In Paper 2 the aims were to investigate the reliability and practice effects of Memoro tests in older adults, and to establish how different reliability estimation methods can lead to differences in results. The Memoro tests showed similar test-retest reliability estimates to that of other computerized and web-based tests in previous studies. Moderate practice effects were found on all cognitive measures. The level of practice effects was not found to be related to demographic variables or level of computer familiarity. Further, large variations in reliability estimates were encountered across the different estimation methods, highlighting the importance of using the study-appropriate method and making it clear to readers how reliability was estimated and which measures that are reported. In Paper 3 Memoro facilitated the assessment of cognitive function in a sample of adult and older adult patients with diabetes type 1 and healthy controls. The aims of the study were to compare the cognitive function of subgroups of the patients that have impaired awareness of hypoglycemia (low blood sugar) to those who have normal awareness, and to assess if cognitive function in patients with impaired awareness of hypoglycaemia was related to their historical SHburden. It was found that the patients having impaired awareness of hypoglycemia showed lower performance on tests dependent on hippocampus and dentate gyrus function. These are interesting findings since these brain areas have been shown to be particularly sensitive to the effects of severe hypoglycemia. Further, it was found that greater severe hypoglycemia burden was associated with more misunderstanding of instructions and invalid test results. The findings indicate that patients with diabetes type 1 and impaired awareness of hypoglycemia have reduced cognitive function due to exposure to more episodes of severe hypoglycemia. Summarized, the findings of the three studies included in this thesis demonstrate that Memoro include both valid and reliable measures of cognitive function and that Memoro can be used for administration of neuropsychological tests in large cohorts and clinical populations. Several specific areas that may be further improved to optimize the psychometric properties and usability of Memoro were identified. Some of these may also be of relevance for new, as well as existing web-based tests. The biggest challenges ahead are neither the technology nor user acceptability, but rather in development and quality control.