Validation of Spatial Orientation Screening questionnaire for use in memory clinic patients

Abstract

Background

Spatial orientation is required for independent mobility in society. Deficits in spatial orientation can be an early symptom of Alzheimer's disease and other dementias, and there is a need for brief assessment tools to identify impairments.

Objective

The aim of this study was to evaluate the construct and known-group validity of our newly developed Spatial Orientation Screening (SOS) questionnaire.

Methods

We included 132 patients with subjective cognitive decline (n = 16), mild cognitive impairment (n = 32), or all-cause dementia (n = 84) from a memory clinic and a reference group of cognitively unimpaired older adults (n = 108). The patients and their next-of-kin answered the self- and proxy-rated versions of the 4-item SOS (0–8 points) and the 10-item Questionnaire of Everyday Navigational Ability (QuENA, 0–30 points). The patients also performed the Floor Maze Test (FMT) for performance-based spatial abilities.

Results

Mean ages (SD) of the patient and reference groups were 68.6 (±7.6) years and 73.7 (±6.7) years, respectively. Construct validity between self-rated versions of the SOS and QuENA was satisfactory with r_s= 0.66, between the proxy-rated versions r_s= 0.61, and between the proxy-reported SOS and FMT r_s= 0.49 (all p < 0.001). Known-group validity was also acceptable, with significantly higher median (IQR) SOS self-reported scores in patients 1.0 (2.0) compared to the reference group 0.2 (0.5) points, (p < 0.001). Informants reported more severe impairments compared to the patients’ self-reports on both SOS and QuENA (both p < 0.001).

Conclusions

The SOS had satisfactory validity for use as a screening instrument for assessment of spatial orientation in memory clinic patients.

Keywords

Alzheimer's disease cognition dementia orientation questionnaire

Introduction

Spatial orientation, defined as the person's knowledge of where one is in the environment and the ability to navigate in that environment,¹ is essential for independent mobility in the society. Humans use two different reference frames for navigation: the egocentric and the allocentric.² The egocentric reference frame uses a self-centred strategy where directions and objects are related to the persons’ current position. The allocentric reference frame is characterized as world-centred, wherein directions and objects are placed in relation to each other irrespective of the persons’ location.³ For successful navigation, it is necessary to combine these reference frames in a flexible manner.² Deficits in spatial abilities can be an early symptom of subsequent development of dementia,^4,5 and may serve as supportive diagnostic markers. Further, spatial navigation, particularly the allocentric strategy, is associated with structures in the medial temporal lobe, where in most cases the first neuropathological changes related to Alzheimer's disease (AD) occur.^3,4,6 However, while less explored than in AD, spatial impairments are also observed in persons with dementia with Lewy bodies,⁷ vascular cognitive impairment,⁸ and in Parkinson's disease.⁹

Getting lost is the ultimate consequence of spatial disorientation. Two-thirds of home-dwelling persons with AD experienced getting lost in familiar surroundings in a study with 2.5-year follow-up.¹⁰ While some such events have a harmful or fatal outcome,¹¹ others trigger the need for institutional care in nursing home.¹² Episodes where a person is getting lost are associated with distress for both persons with dementia and caregivers.¹³ Declined spatial orientation ability is also reported to be a barrier for being physically active by home-dwelling persons with mild AD.¹⁴

Despite the importance of spatial orientation for safe and independent mobility and potentially being an early sign of neurodegenerative disease, relevant assessments are not part of standard memory clinic test batteries.¹⁵ Spatial abilities are most often assessed through pencil and paper tests such as figure-copying, which may have limited relevance for orientation in real life surroundings.¹⁶ Other approaches for assessment of spatial abilities include virtual reality tools, which may not be available in most clinical settings. In a review of spatial navigation performance, the Floor Maze test (FMT) demonstrated the largest effect size in differentiating older adults with cognitive decline from healthy older adults.¹⁷ Within the memory clinic setting, there are also some comprehensive questionnaires for self- and informant reported impairments of spatial navigation, such as the 10-item Questionnaire on Everyday Navigational Ability (QuENA),¹⁸ and the 15-item Subjective Spatial Navigation Complaints Questionnaire.¹⁹ The QuENA has been validated for identification of persons at risk for getting lost.¹⁸ The informant reported versions of these two questionnaires distinguished cognitively healthy controls from persons with amnestic mild cognitive impairment (MCI) and mild dementia.²⁰ However, to ensure spatial disorientation is routinely addressed by clinicians, both in the diagnostic process and in post-diagnostic care, a valid and brief screening tool would be of great value. Such a tool can enable the clinicians to advise on abilities to maintain independent mobility and to identify concerns that may require intervention, such as use of GPS trackers.

Therefore, the Spatial Orientation Screening (SOS), a brief questionnaire for impairments in spatial orientation was developed by G.G.T. The aim of our study was to explore relevant aspects of validity of the SOS in a heterogenous memory clinic population. As there is no obvious gold standard for assessment of spatial orientation in memory clinic patients, we mainly focused on construct validity.²¹ We aimed to study the construct validity by examining the strength and direction of correlations between the SOS questionnaire, the QuENA and the FMT. Our five corresponding hypotheses were 1) that the self-reported versions of SOS and QuENA would have a strong, positive correlations, 2) that the proxy-reported versions of the SOS and the QuENA would have a strong, positive correlations, 3) the self-reported SOS would have a weak, positive correlation with the FMT, 4) the proxy-reported SOS would have moderate positive correlation with the FMT, and 5) the self-reported and proxy-reported SOS were expected to have a weak positive correlation. Our second aim was to explore known-group validity by comparing the results on the SOS in memory clinic patients with a cognitively healthy reference group. Our three hypotheses were: 1) the memory clinic patients would have higher scores on the SOS self-report than the reference group, that both that the 2) self-reported SOS scores and 3) proxy-reported SOS scores would be higher in the dementia group compared to the SCD and the MCI group. In addition, we also explored how the self-reported and the proxy-reported scores on the SOS and the QuENA correspond in a memory-clinic population.

Methods

Study participants and ethics

In this cross-sectional validation study, we included patients from the Memory clinic at Oslo University Hospital, Ullevål from January 2017 to February 2023 (with a pause due to Covid-19, 2020–2022). If the patients met together with an informant, the informants were also invited to the study, however patients without a proxy were also included. All participants signed informed written consent for participation in the study. The study is approved by the Regional Committee for Medical and Health Research Ethics South-East Norway (ref. 2016/1119).

The Memory clinic patients were part of The Norwegian registry of persons assessed for cognitive symptoms (NorCog).¹⁵ Our inclusion criteria: the patients should have a tentative diagnosis of subjective cognitive decline (SCD), MCI, or dementia, be home-dwelling, and not need walking aids. Exclusion criteria: the need for a translator during assessments. As part of the comprehensive standardized NorCog protocol, clinical interviews with the patients and their informants were conducted; further, the patients completed a comprehensive cognitive test battery, a physical examination, as well as imaging (MRI or, if not feasible, CT), blood, and cerebrospinal fluid examination.¹⁵ The patients were retrospectively classified according to the National Institute of Aging and the Alzheimer's Association (NIA-AA)—core criteria for MCI²² and dementia.²³ SCD was diagnosed according to the Jessen criteria.²⁴ Further, patients were subclassified for probable or possible AD or AD with mixed pathology according to etiological diagnoses using the NIA-AA-criteria. For DLB the revised criteria from the DLB Consortium²⁵ was used, for primary progressive aphasia the recommendations from Gorno-Tempini et al. were used.²⁶

We also included data from a reference group of cognitively healthy older adults recruited from 2012–2013 at Oslo University Hospital and Diakonhjemmet Hospital in Oslo.²⁷ The reference group consists of persons admitted for elective surgery in spinal anaesthesia, aged ≥65 years.²⁷ Exclusion criteria were known diseases likely to influence cognition. Prior to surgery, they underwent cognitive testing using partly the same test battery as NorCog. This cohort has been followed annually with cognitive assessments and MRIs every other year after baseline to ensure there was no cognitive impairment.²⁸ The SOS questionnaire was part of the 3-year assessment. The QuENA, the FMT and the proxy-version of the SOS questionnaire were not part of this cohort study.

Data collection and procedures

Demographic information, as well as the Clinical Dementia Rating scale (CDR)²⁹ and the Mini-Mental State Examination-Norwegian revision (MMSE-NR),³⁰ both used to describe global cognitive functioning of the sample, were obtained from NorCog. Procedures: The SOS was conducted before the QuENA and the FMT. Patients and informants completed the SOS and the QuENA independently of each other, and these results were not available to the physicians when the diagnosis was made.

Development of the SOS questionnaire

The SOS questionnaire was developed in a multi-step process, in a group of researchers with clinical experience from working with people with dementia (physiotherapist, nurses): 1) determination of the purpose and target group; 2) search for existing questionnaires and relevant literature; 3) formulating questions; 4) pilot testing; 5) adjustments based on pilot. These steps were conducted as follows: 1) The aim of the questionnaire was decided to be to identify early impairments in spatial orientation relevant for independent mobility in home-dwelling persons with cognitive impairment. The impairments should go beyond the natural individual variations in spatial orientation. 2) In 2015, we searched the literature for suitable questionnaires about spatial orientation aimed at our target group. The QuENA was the only questionnaire we found that was targeted towards our population and that fit our aim.¹⁸ The QuENA was, however, more comprehensive than what we wanted. As we failed to find a short questionnaire suitable for screening purposes, we proceeded with creating the SOS. 3) After reading through the existing questionnaires, we chose to create our own items. We formulated four questions aimed at obtaining information considered relevant for safe and independent mobility in society, in line with the aim we agreed upon in step 1. Influenced by the QuENA's approach to evaluating spatial deficits with respect to the degree of familiarity, three of our items were aimed to capture information about difficulties experienced in familiar or unfamiliar surroundings. The fourth question targets the daily consequences of restricted independent activity out of worry about disorientation. We also included scoring the severity of the impairments. Further, we developed a corresponding version for obtaining proxy information, exchanging “I” with “he/she”. 4) A short pilot session was conducted with individual interviews with four persons with and without cognitive impairment, where their comments and questions were noted. 5) Based on feedback from the pilot, we included examples in questions 1 and 2 to clarify what was meant by familiar and unfamiliar surroundings. The final version is scored from 0–8, with a higher score denoting more severe impairment (see Supplemental Material).^31,32

The self-reported version of the SOS should be conducted as a structured interview to ensure that respondents with cognitive impairment have understood the questions and the scoring alternatives. We formulated the questions so that one could answer yes or no. If a respondent answers “yes” to one of the questions, one proceeds by asking about severity or frequency to distinguish if the scoring should be 1 or 2 accordingly. The proxy-version should be feasible to fill out without help from health personnel.

To address the construct validity of the SOS, we included the self- and proxy-report versions of the QuENA.¹⁸ Both versions have 10 items that are scored 0–3, maximum score is 30 points; and a higher score indicates more severe impairment. The QuENA was developed to capture four different aspects of topographical disorientation in memory clinic patients and is considered reliable and valid for assessment of the possibility of getting lost in persons with AD.¹⁸ We translated the QuENA into Norwegian according to standard guidelines for back-to-back translation.³³

For performance-based assessment of spatial navigation, we used the FMT.³⁴ This test was designed as a clinically practical examination of spatial navigation during walking, particularly thought to focus on allocentric navigation.³⁴ The FMT was made from a 2.1-by-3.0 m solid dark blue wax cloth with white tape indicating the lines of the maze. The patients were positioned at the entry of the maze, the exit was pointed to, and then the patient was instructed to start planning how they should walk to reach the exit. When they had decided, they were told to walk through the maze. The patients were allowed to correct any wrong turns during walking, and if a patient asked for advice during the walk, the initial instructions were repeated. FMT total time is the combined time to plan and walk through the maze. The test-retest reliability of the FMT has not been established, but the correlation between the first attempt and a second attempt 10 min later was r = 0.76 in the original study.³⁴ The FMT has been previously shown to predict onset of predementia syndromes in adults without dementia,³⁵ to predict conversion to dementia from SCD and MCI,⁴ and being associated with biomarkers of AD and neurodegeneration in patients with SCD and MCI.⁴

Statistical analysis

Comparisons between groups were done with t-tests, Mann Whitney U-tests, chi-square tests or Fisher exact tests dependent on variable characteristics. Paired comparisons were done with the Wilcoxon signed rank test for continuous variables and McNemar's test for categorical variables. Correlation analyses were done using Spearman rho.

To evaluate construct validity, we formulated five hypotheses about the strength of correlations between both versions of the SOS and the QuENA and FMT. Correlations between 0.10–0.30 were defined as weak, 0.30–0.50 as moderate, and >0.50 as strong.³⁶ Known-group validity was analysed through comparisons between groups based on cognitive status. All hypotheses were formulated before the data analyses. Assumptions about the strength of correlation were based on whether the outcomes were thought to represent the same or related constructs, the possible impact of patients’ recall bias with more severe cognitive impairment, and the expected differences between self-reported or proxy-reported and performance-based tests.

Internal consistency was assessed by calculating Cronbach's alpha and inter-item correlation. Agreement between self-report and proxy-report was calculated using Cohen's Kappa, where higher values indicate better agreement.

We allowed up to three missing items on QuENA, which were given a score of 0 (four proxy participants). For the SOS, we allowed one missing item, and this item was scored as 0 (one proxy participant). We excluded two proxy-reported SOS from the sum score because they had two items missing. We imputed the time of the slowest finisher (i.e., 317 s) on the FMT total time to the 21 patients who gave up completing the FMT.

Post hoc analyses were conducted for each of the hypotheses using only the AD cases among the patient group. Also, we performed post hoc correlation analyses between the SOS, QuENA and the FMT with MMSE and CDR. The threshold for statistical significance for all analyses was set at p < 0.05.

Results

Characteristics are presented in Table 1. Among the 84 patients with a dementia diagnosis, 55 (65.5%) had AD or AD mixed, 22 (26.2%) had DLB, 4 (4.8%) had primary progressive aphasia, and 3 (3.6%) had other dementia subtypes. Patients with an informant (110 (83%)) had significantly lower MMSE scores than patients without an informant; median (IQR) MMSE score was 25.0 (8) versus 28.5 (3), p = 0.004. Most informants were spouses or partners (n = 86 (78.2%)), 19 (17.3%) were children, and 5 (4.5%) had other relations to the patient. Of the informants, 89 (80.9%), lived with the patient. There were no significant differences in age, sex, or scores on the SOS between patients with and without an informant. The reference group was significantly older than the patients from the memory clinic. The patients reported more impairments than the reference group on each item of the self-reported SOS version (all p < 0.05) (Table 2).

Table 1.

Participants characteristics for memory clinic sample and for reference group.

	All patients, n = 132	n	SCI n = 16	MCI n = 32	Dementia n = 84	Reference group n = 108
Age, y, mean (SD)	68.6 (7.6)	132	65.4 (9.2)	67.3 (8.0)	69.8 (6.9)	73.7 (6.6)
Range	47–85		47–78	47–85	54–84	64–89
Men, n (%)	74 (56.1%)	132	9 (56.3%)	17 53.1%)	45 (59.2%)	48 (44.4%)
Education, y	14.2 (3.5)	115	15.1 (2.7)	13.9 (4.2)	14.1 (3.3)	14.0 (3.7)
Range	6–23		12–20	7–23	6–21	0–23
MMSE, points	26.5 (7)	128	30.0 (1)	29.0 (3)	24.0 (6)	30.0 (1.0)
Range	9–30		28–30	19–30	9–30	23–30
Living alone, n (%)	30 (24.4%)	123	6 (42.9%)	9 (28.1%)	15 (19.5%)	47 (43.5%)
SOS self-report	1.0 (2.0)	132	1.0 (1.8)	1.3 (2.0)	1.7 (2.8)	0.2 (0.5)
Range	0–8		0–4	0–5	0–8	0–3
SOS proxy-report	2.0 (3.0)	106	1.4 (2.5)	1.2 (1.3)	3.2 (2.0)	NA
Range	0–8		0–6	0–5	0–8	NA
QuENA self-report	3.0 (5.25)	126	4.0 (4.0)	4.4 (4.8)	3.0 (7.0)	NA
Range	0–18		0–9	0–16	0–18	NA
QuENA proxy-report	8.0 (7.0)	106	2.0 (12.3)	6.0 (7.0)	9.0 (6.0)	NA
Range	0–24		0–15	0–11	0–24	NA
FMT total time, sec	86 (160)	113	32 (31)	66 (38)	155 (243)	NA
Range	15–317		15–81	20–317	26–317	NA

All median (interquartile range) if not stated otherwise. MMSE: Mini-Mental State Examination (0–30, higher score indicates better performance); SOS: Spatial Orientation Screening (0–8); QuENA: Questionnaire on Everyday Navigational Abilities (0–30); FMT: Floor Maze test. For SOS, QuENA and FMT lower values indicates better performance. NA: not applicable

Table 2.

Distributions of scores on the SOS self-report and comparisons between memory clinic patients and reference group.

Item	All patients n = 132	SCI n = 16	MCI n = 32	Dementia n = 84	Reference group n = 108
1) Do you have difficulties finding your way in familiar surroundings (such as when visiting the home of close friends, or when walking or driving in your neighborhood)?
0: No, no difficulties	123 (93.2)	16 (100)	29 (90.6)	78 (92.9)	108 (100)
1: Yes, sometimes	8 (6.1)	0 (0)	3 (9.4)	5 (6.0)	0 (0)
2: Yes, several times	1 (0.8)	0 (0)	0 (0)	1 (1.2)	0 (0)
2) Do you have difficulties learning to find your way in new surroundings (such as when traveling or in new shopping centers)?
0: No, no difficulties	67 (50.8)	10 (62.5)	17 (53.1)	40 (47.6)	100 (92.6)
1: Yes, to some degree	52 (39.4)	6 (37.5)	12 (37.5)	34 (40.5)	8 (7.4)
2: Yes, significant difficulties	13 (9.8)	0 (0)	3 (9.4)	10 (11.9)	0 (0)
3) Have you ever failed to recognize places you have previously visited?					100
0: No, never	90 (68.2)	11 (68.8)	22 (68.8)	57 (67.9)	100 (92.6)
1: Yes, a few times	37 (28.0)	5 (31.3)	10 (31.3)	22 (26.2)	8 (7.4)
2) Yes, several times	5 (3.8)	0 (0)	0 (0)	5 (6.0)	0 (0)
4) Have you ever refrained from traveling or from participating in activities by yourself because you were worried about finding your way?
0: No, never	89 (67.4)	13 (81.3)	24 (75.0)	52 (61.9)	103 (95.4)
1: No, but spends times planning	17 (12.9)	1 (6.3)	4 (12.5)	12 (14.3)	2 (1.9)
2: Yes	26 (19.7)	2 (12.5)	4 (12.5)	20 (23.8)	3 (2.8)

SOS: Spatial Orientation Screening. All patients versus reference group: Item 1) p = 0.009, items 2–4) p < 0.001. Item 1 and 3 using Fisher Exact test, items 2 and 4 using Chi-square test.

Construct validity hypotheses

We confirmed all the five hypotheses we had formulated related to construct validity (Table 3), with satisfactory correlations between self-rated versions of the SOS and QuENA (r_s= 0.66), between the proxy-rated versions (r_s= 0.61), and between the proxy-reported SOS and FMT r_s= 0.49 (all p < 0.001). Further, the SOS self-report had a weak, positive correlation with the FMT (r_s= 0.28, p = 0.003), and with the proxy-reported SOS (r_s= 0.29, p = 0.002) (Table 4).

Table 3.

A priori hypotheses, with results, for the associations between SOS questionnaires, the QuENA and FMT.

Construct validity, using Spearman's rho (r_s)	r _s	Confirmed
1) SOS self-report versus QuENA self-report: strong, positive correlation because expected to represent same construct.	0.66**	Yes
2) SOS self-report versus FMT: weak, positive correlation, because expected to represent related but not identical constructs, and recall bias likely most prominent in persons with most severe cognitive impairment/worst performance on FMT	0.28*	Yes
3) SOS self-report versus SOS proxy-report: Weak positive correlation, same construct, different source	0.29*	Yes
4) SOS proxy-report versus QuENA proxy-report: strong, positive correlation because expected to represent same construct	0.61**	Yes
5) SOS proxy-report versus FMT: moderate positive correlation with FMT: related but not identical constructs and recall bias is not an issue for this association.	0.49**	Yes
Known-group validity, using Mann Whitney U-test	Z	Confirmed
6) The memory clinic patients would have higher scores on the SOS self-report than the reference group.	−7.7**	Yes
7) Self-reported SOS scores would be higher in the dementia group compared to the SCD and the MCI groups.	NS	No
8) Proxy-reported SOS scores would be higher in the dementia group compared to the SCD and the MCI groups.	−2.6 /−4.5	Yes

SOS: Spatial Orientation Screening; QuENA: Questionnaire on Everyday Navigational Abilities; FMT: Floor Maze test; NS: not significant, **p < 0.01, *p < 0.05.

Table 4.

Correlation matrix between outcomes of spatial orientation and severity of cognitive impairment, Spearman's Rho coefficient and p value in brackets, significant (p < 0.05) results in bold.

	SOS self-report	SOS proxy-report	QuENA self-report	QuENA proxy-report	Floor Maze test	MMSE
SOS proxy-report	0.29 (0.002)	—
QuENA self-report	0.66 (<0.001)	−0.02 (0.83)	—
QuENA proxy-report	0.17 (0.08)	0.61 (<0.001)	0.09 (0.37)	—
Floor Maze test	0.28 (0.003)	0.49 (<0.001)	−0.06 (0.55)	0.24 (0.02)	—
MMSE	−0.06 (0.48)	−0.45 (<0.001)	0.19 (0.04)	−0.25 (0.01)	−0.64 (<0.001)	—-
CDR	0.22 (0.02)	0.58 (<0.001)	−0.08 (0.39)	0.31 (0.002)	0.59 (<0.001)	−0.63 (<0.001)

SOS: Spatial Orientation Screening; QuENA: Questionnaire on Everyday Navigational Abilities; MMSE: Mini-Mental State Examination; CDR: Clinical Dementia Rating

Known-group validity hypotheses

For the known-group validity, two out of the three hypotheses were confirmed (Table 3). The memory clinic patients had higher scores on the self-reported SOS than the reference group (p < 0.001), and the proxy-reported scores were higher in the dementia group compared to the SCD and the MCI group (both p < 0.001). The hypothesis that was not confirmed was that we found no statistically significant differences between the SCD, MCI, and dementia groups on the self-reported SOS.

Correspondence self- and proxy report

The total score on the self-reported SOS was significantly lower than the proxy-reported SOS, with median (IQR) at 1.0 (2.0) versus 2.0 (3.0) (Table 5). Self-reported scores on each item per se were significantly lower than proxy scores on items 1–3, while for item 4 (avoiding independent traveling), there was no significant difference (p = 0.26). Kappa was very low for all four items on SOS (0.05–0.21), as well as for the QuENA (−0.001–0.20). Still, 21 (19.8%) of the memory clinic patients reported higher scores on the SOS than their proxy (eight with AD, six with DLB and seven with MCI). These patients had significantly better score on the MMSE than those who reported less symptoms than their proxy (MMSE median (IQR) 27.0 (7) versus 24.0 (8)). For the QuENA, the self-reported scores were significantly lower than the proxy-reported version, with 2.0 (6.0) versus 8.0 (7.0), respectively.

Table 5.

Paired comparisons of self-reported and proxy-reported scores on SOS and QuENA (n = 110).

SOS items, abbreviated	Self-report	Proxy-report	p	Kappa
Familiar surroundings, n (%)			<0.001^b	0.10
0: No, no difficulties	101 (91.8)	78 (72.2)
1: Yes, sometimes	8 (7.3)	26 (24.1)
2: Yes, several times	1 (0.9)	4 (3.6)
New surroundings, n (%)			<0.001^b	0.18
0: No, no difficulties	55 (50)	23 (21.9)
1: Yes, to some degree	45 (40.9)	65 (61.9)
2: Yes, significant difficulties	10 (9.1)	17 (16.2)
Recognize places, n (%)			<0.001^b	0.05
0: No, never	74 (67.3)	41 (38.7)
1: Yes, a few times	32 (29.1)	56 (52.8)
2) Yes, several times	4 (3.6)	9 (8.5)
Refrained from travel/activities, n (%)			0.26^b	0.21
0: No, never	74 (67.3)	65 (60.7)
1: No, but spends times planning	14 (12.7)	10 (9.3)
2: Yes	22 (20.0)	32 (29.9)
SOS sumscore	1.0 (2.0)	2.0 (3.0)	<0.001^a	NA
QuENA sumscore	2.0 (6.0)	8.0 (7.0)	<0.001^a	NA

Valid percents are presented, n varies per item between 106–110. ^aWilcoxon signed rank Test, ^bMcNemar's test.

Cronbach's alpha was 0.66 for the self-reported SOS and 0.71 for the proxy version, and both alphas would be lower if items were deleted. For the Norwegian translation of the QuENA self-report and proxy-report, the Cronbach's alphas were 0.80 and 0.86, respectively.

In the post hoc analyses using only the AD cases among the patient group, all five hypotheses related to construct validity were confirmed. The correlation between the self-reported versions of SOS and QuENA increased from r_s= 0.66 (entire sample) to r_s= 0.75 (only AD), while the correlation between the SOS self-reported and proxy-reported versions of SOS decreased from r_s= 0.29 (entire sample) to r_s= 0.11 (only AD). For the known-group validity, the hypothesis regarding memory clinic patients having higher scores on the self-reported SOS than the reference group was still confirmed (p < 0.001), and proxy-reported SOS scores was higher in the dementia group than the MCI group. Separate comparisons with the SCD group were not relevant because of sample size.

The proxy-reported SOS had higher correlations with the CDR and MMSE than the proxy-reported QuENA; r_s= 0.58 versus 0.31 with the CDR, and r_s= −0.45 versus −0.25 with the MMSE (Table 4). Self-reported SOS was significantly, but low correlated with CDR (r_s= 0.22, p = 0.02), and not correlated with MMSE (r_s= −0.06, p = 0.48). Self-reported QuENA was not correlated with CDR (r_s= −0.08, p = 0.39) and weakly correlated with MMSE (r_s= 0.19, p = 0.04).

Discussion

We developed and validated the SOS, a brief questionnaire to assess impairments in spatial orientation, and our results show that the SOS has satisfactory validity for use in a memory clinic setting. The self-reported scores on the SOS from the patients were lower than the corresponding proxy-reported scores.

Based on agreement with the pre-defined hypotheses, we found that the construct validity of the SOS was highly satisfactory. The SOS versions were strongly correlated with the corresponding QuENA versions, despite being very brief in comparison. Further, it should be noted that the SOS versions were more strongly correlated with the performance-based FMT than the QuENA versions. Although neither the QuENA nor the FMT can be regarded as gold standards for assessments of real-life spatial orientation abilities, there are sound studies proving their relevance. The QuENA discriminated well between patients with and without episodes of getting lost in a sample of patients with AD.¹⁸ The FMT was associated with hippocampal volume and cortical thickness of the parahippocampal and inferior parietal regions in patients with SCD and MCI.⁴ Further, the FMT predicted the onset of predementia syndromes in cognitively healthy older adults³⁵ and the conversion to dementia in patients with SCD and MCI.⁴

The reference group reported fewer impairments in spatial orientation on the SOS than each of the patient groups as well as the memory clinic sample as a whole. Also, in line with our hypothesis, the informants reported more severe impairments on the SOS with increasing severity of cognitive impairment. However, our hypothesis that self-reported SOS scores would be higher in the dementia group compared to the SCD and MCI groups was not confirmed. Awareness of cognitive decline is reported to be poorer throughout the continuum from pre-dementia stages to severe dementia.³⁷ Still, as our group of persons with dementia has a rather mild degree of dementia, we did not expect reduced awareness to influence the patients’ self-reported scores in the dementia group to the degree that they would report a comparable level of impairment to the SCD and MCI groups. However, the patients with SCD and MCI have sought medical help due to concern regarding decline in cognitive function without meeting the criteria for dementia. Thus, they may have an increased awareness of their own cognitive impairments. In line with our findings is a recent study which included patients from a memory clinic and used three different questionnaires to evaluate spatial navigation. Their results showed no statistically significant differences among groups with mild dementia, amnestic MCI, and SCD in the self-reported versions, while the proxy-reported versions had significantly higher scores in groups with more severe cognitive impairment.²⁰

The proxy-reported scores were higher than the self-reported scores on both the SOS and the QuENA, and the kappa values per item were also very low on both questionnaires. This discrepancy could be due to recall bias, a lack of awareness of cognitive dysfunction, or both. In any case, these findings are consistent with previous results about spatial orientation using the QuENA¹⁸ and also other more comprehensive questionnaires targeting spatial navigation²⁰ as well as from a study on general cognitive function using the Cognitive Function Instrument.³⁸ The proxy-reported SOS was also more closely correlated with the performance-based FMT than the self-reported SOS. Still, it is important to keep in mind that one in five patients reported more severe impairments than their proxy, and these patients had better MMSE scores than patients who reported less symptoms than their proxy. Thus, we will recommend that, when possible, clinicians should obtain information from both the patient and an informant.

When the SOS was conducted as an interview with the memory clinic patients and the reference group, we had no missing data. The informants filled out the SOS questionnaire by themselves, and there were just two missing items on those. This indicates that the questions were clear and that the scoring alternatives covered most probable answers. Not all informants observe their relatives closely in all relevant situations, so some missing items were expected. Scores on the SOS were overall low, even in the patient sample, indicating a floor effect. Still, it is important to underline that we aimed to identify impairments of spatial orientation and not to capture variation in spatial orientation abilities in cognitively healthy older adults. Overall, the SOS performed equally well as the far more comprehensive QuENA questionnaire, the SOS was more closely correlated with the performance-based FMT than the QuENA, and the proxy-reported SOS had higher correlations with CDR and MMSE representing degree of cognitive decline than the proxy-reported QuENA. The Cronbach's Alpha for the SOS should be considered satisfactory, given that the Alpha is highly influenced by the number of items.

One of the study's limitations is that the assessment battery of the reference group did not contain the FMT, the QuENA, or proxy-reported SOS. There is also a lack of proper gold-standard tools for assessment of real-life navigation in persons with cognitive impairment, although the FMT and the QuENA are among the best-established tools. The small sample sizes in the subgroups of SCD and MCI mean that the results from these subgroups should be interpreted with caution. Since the SOS was developed as a screening tool, with limited scoring range, it may not be suitable for monitoring disease progression over time or to differentiate between early stages of cognitive impairment. Future studies should explore spatial orientation across the different diagnoses of dementia. In our study, the conclusions remained consistent in the post hoc analyses that included only patients with AD. However, the most significant knowledge gap likely concerns the performance and responses of patients with dementia diagnoses other than AD on tasks and questionnaires related to spatial orientation. The strengths of the study include that the self- and proxy-reported SOS and QuENA were filled out independently of each other, and the results from these forms and FMT were not available for the clinicians setting the diagnosis. The reference group was followed very closely annually, and through the comprehensive assessments we are certain that these older adults are cognitively healthy, providing certainty for the known-group validity analyses.

Conclusions

The brief SOS questionnaires are valid and feasible tools to assess impairments in spatial orientation in a memory clinic setting. We recommend that both versions of the SOS, the self-report and the proxy-report, are used to capture complementary information about impairments in spatial orientation. Spatial orientation is a critical cognitive skill for independent and safe mobility in the society, and it is therefore imperative that clinicians screen for impairments.

Supplemental Material

sj-pdf-2-alz-10.1177_13872877241308877 - Supplemental material for Validation of Spatial Orientation Screening questionnaire for use in memory clinic patients

Supplemental material, sj-pdf-2-alz-10.1177_13872877241308877 for Validation of Spatial Orientation Screening questionnaire for use in memory clinic patients by Gro Gujord Tangen, Knut Engedal, Karin Persson, Geir Selbæk, Shams Dakhil, Riona McArdle, Marit Mjørud, Janne Røsvik, Anne Marit Mengshoel and Anne Brita Knapskog in Journal of Alzheimer's Disease

Supplemental Material

sj-pdf-3-alz-10.1177_13872877241308877 - Supplemental material for Validation of Spatial Orientation Screening questionnaire for use in memory clinic patients

Supplemental material, sj-pdf-3-alz-10.1177_13872877241308877 for Validation of Spatial Orientation Screening questionnaire for use in memory clinic patients by Gro Gujord Tangen, Knut Engedal, Karin Persson, Geir Selbæk, Shams Dakhil, Riona McArdle, Marit Mjørud, Janne Røsvik, Anne Marit Mengshoel and Anne Brita Knapskog in Journal of Alzheimer's Disease

Footnotes

Acknowledgments

The authors thank the participants from both the NorCog and from the reference group. We want to acknowledge the Norwegian registry of persons assessed for cognitive symptoms (NorCog), for providing access to patient data. We have used OpenAI's language model GPT-3 for grammar verification in parts of this manuscript.

ORCID iDs

Gro Gujord Tangen

Shams Dakhil

Authors contributions

Gro Gujord Tangen (Conceptualization; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Writing – original draft; Writing – review & editing); Knut Engedal (Writing – review & editing); Karin Persson (Investigation; Writing – review & editing); Geir Selbæk (Investigation; Project administration; Supervision; Writing – review & editing); Shams Dakhil (Investigation; Writing – review & editing); Riona McArdle (Writing – review & editing); Marit Mjørud (Writing – review & editing); Janne Røsvik (Writing – review & editing); Anne Marit Mengshoel (Writing – review & editing); Anne Brita Knapskog (Investigation; Writing – review & editing).

Funding

The Southern and Eastern Norway Regional Health Authority supported the data collection through funding for Gro Gujord Tangen (grant number 2016099). Riona McArdle is funded by the National Institute for Health Research (NIHR) for her fellowship (NIHR 301677) and supported by the National Institute for Health and Care Research (NIHR) Newcastle Biomedical Research Centre based at The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University and the Cumbria, Northumberland and Tyne and Wear (CNTW) NHS Foundation Trust.

Declaration of conflicting interests

Karin Persson reports work with Novo Nordisk NN6535-4730 trial outside the submitted work.

Geir Selbæk has participated at advisory board meetings for Roche and Eisai concerning monoclonal antibody drugs for treatment of Alzheimer's disease.

Anne Brita Knapskog has contributed to clinical trials for Roche (BN29553), Boehringer-Ingelheim (1346.0023), Novo Nordisk (NN6535-4730), and GSK (219867).

Knut Engedal is an Editorial Board Member of this journal but was not involved in the peer-review process of this article nor had access to any information regarding its peer-review.

The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The full data set is, due to ethical restrictions, only available to the reader upon request to the corresponding author.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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