lecture 10- assessment in old age and dementia Flashcards
activities of daily living (ADLs)
- Basic activities of daily living (ADLs)
- Feeding, continence, bathing, personal
grooming, movement. - Instrumental activities of daily living (IADLs):
functional abilities - Shopping, cooking, managing finances, reading, news awareness, transport.
- Assessed using self-report or performance-
based tasks - Measure functional independence
assessment of ADLs
observe performance on everyday tasks
E.g. make cup of tea, get dressed
More ecologically valid and not
reliant on self-report
Time and resource intensive, not
standardised
Self-report/informant-report: e.g.
Barthel index of basic ADL
Questionnaire/interview format
Covers feeding, bathing, dressing etc.
Inter-rater reliability > .9, test-retest >.8,
Good construct & predictive validity
Lack of awareness, and reporting biases
assessing instrumental activities of daily living (IADL)
- Lawton IADL assessment most commonly used
- Self- or informant- report
- 8 domains: telephone, shopping, food prep,
housekeeping, laundry, transport, medication,
finances - Reliability and validity of IADL assessment
- Good reliability: Inter-rater > .8; Cronbach’s alpha > .9
- Good construct validity: Factor analysis confirmed 1 factor
-Criterion validity: IADL predicts healthy, mild cognitive impairment (MCI), dementia
- Convergent validity with other measure of functional status BUT few studies
diagnosis of dementia (probable Alzheimer’s disease): DSM V
Must meet all of the following criteria:
- Evidence of significant cognitive decline:
- Concern of the individual, informant or clinician; and
- Substantial impairment in standardized neuropsychological testing in memory
plus at least one other cognitive domain. - Cognitive deficits interfere with everyday activities.
- Cognitive deficits not attributable to delirium or other mental disorder (e.g.,
major depressive disorder, schizophrenia) or other aetiology (e.g. stroke). - Insidious onset and gradual progression of impairment.
neurological assessment procedures in suspected dementia
- Medical background and
personal history - Mental state assessment
Current cognitive functioning
* Memory and language
* Attention and executive function
- Premorbid ability
- Mood
- ADLs
- Importance of assessing change
over time
assessment of mental state
- Quick assessment of orientation, memory, thought, feeling, judgement.
- Indication of basic global cognitive function
- Key test: Mini Mental State Exam (MMSE)
- Scored out of 30: healthy adults score 27-30.
Mini Mental State Examination
Folstein, Folstein & McHugh, 1975.
- Orientation: What is the year/season/date/day/month?
- Registration & recall: Repeat 3 words, later given surprise recall test
- Attention: Serial 7s
- Language: Name objects and repeat sentence.
- Motor abilities: copy drawing
MMSE evaluation
- Good reliability: e.g. test-retest = .8
- Good sensitivity to dementia (predictive validity):
=>Using cut off score <24, 80-90% accurate
distinguishing dementia from healthy controls - Poor specificity: Numerous reasons for low scores
- E.g. very old age, stroke, delirium, depression…..
Not very sensitive to:
* Early/mild dementia
* Dementia in highly educated people
-Does not assess executive function, problem-solving
-Basic screening test
* Needs to be interpreted in relation to other tests and demographic factors
Zarit & Zarit (2007), Arevalo-Rodriguez et al. (2015)
Rey Auditory Verbal Learning Test (RAVLT):
Verbal episodic memory performance in AD
Patterns of RAVLT performance in AD
* Learning impaired: Flat learning curve across repeated trials
* Recall impaired, but recognition also deteriorates
* More false memories and intrusion errors
* Greater recency and less primacy: more reliance on short term memory
=> Busse et al (2017)
- Test-retest reliability = 0.68, Cronbach’s alpha = 0.80
=>De Sousa Magalhaes et al. (2012)
-Good predictive validity of dementia diagnosis 2 years later
* Estevez-Gonzalez et al. (2003)
language in AD
- Garrard et al. (2004)
- Analysis of Iris Murdoch’s final novel showed reduced vocabulary and simpler sentences
- Mild dementia:
- Word-finding difficulties, naming problems,
circumlocution - Moderate dementia:
-Content of language more vague, verbal perseveration, syntax simplified - Key screening test = semantic fluency
- E.g. Name as many animals as you can in one minute
Klimova et al. (2015) Clinical Interventions in Aging
Premorbid ability: Dementia and word
reading ability
- If word reading tasks like NART are a valid measure of premorbid ability, should be insensitive to dementia
- Morris (2004):
- No differences between mild dementia and matched controls on NART
- But: Weinborn et al. (2018)
-Longitudinal study of 995 older adults
-Ability to read irregularly spelt words (Wechsler Test of Adult Reading, WTAR)
adversely affected by AD - Questions construct validity of word reading tests as measure of premorbid
ability.
Weinborn et al. (2018): https://doi.apa.org/doiLanding doi=10.1037%2Fpas0000565
Assessment of change is essential to diagnose
Alzheimer’s disease: A case study
Cognitive impairment in a chess player
* Archer et al. (2005).
* 73 year old retired academic
* Avid chess player, chess skills declining.
* Reported memory problems but functioning
well.
* Neuropsychological testing:
* WAIS: verbal IQ =117, perceptual reasoning IQ
= 126, Digit span = 5.
* Memory and naming a little below average.
* How decide if dementia/AD?
differential diagnosis of dementia
- Differentiating Alzheimer’s Disease from:
- Other types of dementia
- e.g. Frontotemporal dementia,
Vascular dementia. - Other types of illness
- e.g. delirium, stroke, Korsakoff’s
disease - Cognitive decline in normal aging
- Mild cognitive impairment (MCI)
- Mood disorders
differential diagnosis of dementia and depression
- Lezak: “Probably the knottiest problem of
differential diagnosis is that of separating
depressed dementia patients … from
psychiatrically depressed patients in the depths
of their depression.” - Different prognosis and treatment
implications - Depressed mood common in people with
dementia - Cognitive pattern in depressed older adults:
- Poor memory
- Low MMSE scores
- Poor attention and speed.
summary
- Key assessments in old age:
- Mental state, current cognitive function, premorbid ability, mood, ADLs
- Longitudinal assessment
- Mental state assessment
- First assessment of older adult, MMSE
- Diagnosis of dementia
- Reliant on neuropsychological testing
- Exclusion criteria and differential diagnosis
- Importance of assessing mental state and cognitive functioning over time
27
