cognitive screening of psychiatric patients

.I p~'l¢lliat Re~., V o l 29. No . 1. p p 13 22, 1995 Elsevier Science L id n _ rergamon Pr in ted in G r e a t Br i t a in

0022-3956(94)00037-9

COGNITIVE S C R E E N I N G OF PSYCHIATRIC PATIENTS

M A U R A M I T R U S H I N A , * t { JOSE A B A R A t and A R N O L D B L U M E N F E L D * : ~

*UCLA School of Medicine/NPl, C8-747, 760 Westwood Plaza, Los Angeles, CA 90024, U.S.A.; tCalifornia State University, 18111 Nordhoff Str., Northridge, CA 91330, U.S.A.: and +Olive View'UCLA Medical Center.

14445 Olive View Drive, Sylmar, CA 91342, U.S.A.

(Received ~r publication 25 Auqust 1994)

Summary The goal of the present study was to explore characteristic cognitive profiles which distinguish between psychiatric patients with and without organic mental disorder (OMD), using Neurobehavioral Cognitive Status Examination (NCSE), a brief screening battery. A mild degree of cognitive deficits was found to be common in the Non-OMD psychiatric group. The deficit wits especially pronounced in the Memory domain. Patients m the OMD group demonstrated a higher frequency of moderate and severe impairment. The best discriminator was the scale assessing visuospatial constructional ability and visual memory. Verbal memory deficit in OMD patients wits more severe than in Non-OMD patients. Implications for improving diagnostic sensitivity of cognitive screening are discussed.

In t roduct ion

Screening of psychiatric patients to identify individuals with cognitive impairment sugges- tive o f organic pa thology has been described in the literature as a difficult and, possibly, hopeless task (Chandler & Gerndt , 1988). However, accurate identification o f etiological factors contr ibut ing to the patient 's symptomato logy is o f critical importance in facilitating physical recovery and in directing the clinician's efforts to hamper psychiatric symptoms. Use o f extensive neuropsychological evaluations for screening of a large number o f psychiatric patients is not feasible considering time and economic constraints, as well as low tolerance, high fatigability, anxiety or apprehension, low motiYation and poor coopera t ion o f these patients.

Brief screening measures which are frequently used in the assessment of psychiatric patients include Mini-Mental Status Examinat ion (Folstein et al., 1975), Short Portable Mental Status Questionnaire (Pfeiffer, 1975), Mental Status Questionnaire (Kahn et al., 1960), Cognit ive Capaci ty Screening Exam (Jacobs et al., 1977), and Blessed Informat ion- Memory-Concen t ra t ion Test, short form (Katzman et al., 1983). These measures provide a gross quanti tat ive index of overall cognitive status, which limits their sensitivity to organic pathology in psychiatric samples.

Sensitivity o f a screening instrument can be improved if in addit ion to a gross index of overall cognitive status, the instrument would provide specitic information on strengths and weaknesses within different cognitive domains. This would allow us to distinguish

Correspondence to: Maura Mitrushina, Ph.D., UCLA/NPI, C8-747, 760 Westwood Plaza, Los Angeles, CA 90024, U.S.A.

13

14 M. Mitrushina et al.

cognitive profiles of patients with different etiology of disturbance even though their overall scores might be the same.

The Neurobehavioral Cognitive Status Examination (NCSE) (Kiernan et al., 1987) meets the above criterion in that, it provides a profile of cognitive status across 10 cognitive domains: orientation, attention, comprehension, repetition, naming, construction, memory, calculation, similarities and judgment. The test administration is based on screen and metric approach which minimizes assessment of intact abilities and assures in-depth assessment of impaired areas of cognitive functioning. Each section except for Memory and Orientation begins with a screening item which is rather demanding (according to the test authors, failing rate in the normal population is 20 %). If an examinee passes the screen, the particular skill represented by this item is considered to be intact and the examiner proceeds to assess another skill. If the screening item is failed, questions of graded difficulty are administered to assess the level of competence in this particular skill. The screen and metric approach allows one to reduce administration time for intact individuals to 5 min, according to the test authors. A detailed description of the test is provided by Kiernan et al. (1987) and Mueller (1988).

There are several articles reporting utility of the NCSE in assessment of cognitive dysfunction in neurological and medical patients. In addition to standardization data for 119 healthy adults and 30 neurosurgical patients provided by the test authors (Kiernan et al., 1987; Schwamm et al., 1987), usefulness of the NCSE has been documented in the following clinical situations: in detecting cognitive impairment and predicting improvement in rehabilitation for 38 post-CVA patients (Mysiw et al., 1989); in detecting post-operative cognitive improvement in 11 neurosurgical patients (Cammermeyer & Evans, 1988); in differentiation between patients with right and left unilateral strokes vs. orthopedic patients (N = 12 for each group, Osmon et al., 1992).

The following studies reported usefulness of the NCSE in non-neurological samples: in assessing the relationship between cognitive impairment and pain problems in the group of 73 adults with musculoskeletal pain (Kewman et al., 1991); in assessment of cognitive status and treatment success in 34 patients of the substance abuse rehabilitation facility (Meek et al., 1989).

Studies of the utility of the NCSE in cognitive screening of psychiatric patients provide somewhat controversial findings. Lamarre and Patten (1994) reported excellent sensitivity, but low specificity of NCSE in a sample of 72 adult psychiatric inpatients. The authors concluded that the NCSE is a valuable instrument for the assessment of cognitive function, but questioned its usefulness as a screening or case-finding instrument in psychiatric population. Other studies exploring properties of NCSE in geropsychiatric inpatient samples (Fields et al., 1992; Osato et al., 1993) concurred with the findings of high sensitivity, but low specificity of the NCSE.

Logue et al. (1993), however, described the NCSE as a moderately valid screening instrument for cognitive impairment based on a sample of 866 adult psychiatric in-patients. Similarly, the test authors suggested that clinical use of the NCSE resulted in improved diagnostic accuracy of organic mental syndromes and in better understanding of origins of abnormal behavior in patients referred for psychiatric consultation (Kiernan et al., 1987; Van Dyke et al., 1987).

Cognitive Screening 15

The goal of the present study is to explore characteristic cognitive profiles which distinguish between psychiatric patients with and without Organic Mental Disorder (OMD). Whereas a number of studies addressing this question are available in the literature, they are based on extensive neuropsychological evaluations. In contrast, the present study purports to improve diagnostic accuracy using a brief screening instrument, which can be widely used in screening a large number of patients.

Methods

Subjects The sample consisted of 192 patients admitted to the psychiatric wards and Mental

Health Emergency Room of a county hospital. Subjects ranged in age between 14 and 75 with a mean age of 33.5 years (SD = 13.5). The sample was comprised of 46% males and 54% females, 88% of whom were right-handed by self-report of the preferred hand for majority of activities, 9% were left-handed, and 3% were ambidextrous. Their education ranged from 8 to 20 years with mean education of 12 years (SD = 2.8). Forty-seven per cent of subjects were unemployed.

Eighty-four per cent of subjects were native English speakers. The remaining 16% of the sample were bilingual with Spanish being a primary language for the majority. In all cases, adequate mastery of English and ability to comprehend and follow simple instructions was required for inclusion in the study. Patients with conditions which might affect their performance on the test, such as less than 8 years of education, altered level of consciousness, mental retardation and gross sensory-motor deficits, were not included in the sample. Less than five per cent of the patients approached by the examiners refused to cooperate or were incoherent, which precluded their participation in the study. Six subjects completed only part of the test. All partial completers were in the Non-OMD group and their data were not included in the analyses.

The subjects were diagnosed by their treating psychiatrists according to the DSM-III-R criteria prior to obtaining the NCSE results. Primary Axis I diagnoses were: Unipolar Depression, 32%; Bipolar Affective Disorder: Depressed, 4%, Manic, 12%, Mixed, 3%; Schizophrenia, 14%; Schizoaffective Disorder, 13%; Psychotic Disorder NOS, 19%; and Impulse Control Disorders, 3%. Psychosis was present in 78% of subjects. The most frequent concurrent diagnoses on Axis II were borderline and mixed personality disorders. Forty-seven per cent of the sample were chronic psychiatric patients with multiple previous psychiatric admissions, for the remaining 53%, current hospitalization was the first psychiatric admission.

Ten per cent of the sample suffered from seizure disorder and received anticonvulsant medications. Thirty per cent of the subjects were heavy alcohol and polysubstance abusers for a period of at least 2 years. Ninety-six per cent were on psychotropic medications at the time of evaluation. Fifty-two per cent of them were also receiving anti-parkinsonian medications.

The primary source of subjects for this study was patients consecutively admitted to the psychiatric wards. The prevalence of OMD in this group was 23 out of 126 patients (18%). This rate is higher than the 6% reported by Folstein et al. (1975) and Hinton and Withers


(1971), or the 7% reported by Chandler and Gerndt (1988). This discrepancy might be explained by different composition of diagnoses and severity of disturbance between the samples. The majority of our patients had severe affective disturbance or psychotic conditions which increase the risk of OMD. In contrast, other samples cover a broader spectrum of psychiatric disturbances including eating disorders, somatization disorder, etc.

An additional source of patients for our study was referrals from the Mental Health Emergency Room. Those patients who manifested neurobehavioral disturbances consistent with suspected organic pathology were referred for evaluation prior to their admission to the psychiatric ward, discharge or transfer to another hospital. Among 66 patients seen in the Emergency Room who were included in the study, 27 patients (41%) had organic factors qualifying them for inclusion in the OMD category, which was concurred by their attending psychiatrist.

Comparison of demographic characteristics and distribution of psychiatric diagnoses between the patients from these two referral sources did not reveal any differences which would bias the results or limit generalizability of the findings. Therefore, both samples were merged for further analyses, yielding a prevalence of OMD in our sample of 27%.

Procedure

The NCSE was administered as part of a clinical diagnostic work-up to all patients consecutively admitted to the psychiatric wards within 3 to 7 days from admission. In addition, patients with suspected organic pathology, who were referred by the Mental Health Emergency Room for evaluation, were included in this study.

Testing was conducted by trained psychometricians majoring in psychology or by neuropsychology predoctoral trainees under the supervision of an experienced neuro- psychologist. The NCSE was administered according to the procedures described in the test manual (see Kiernan et al., 1987). Interrater reliability established for several groups of 20 to 30 patients proved to be above .9 for each comparison, owing to the use of highly standardized instructions for test administration and scoring. The examiners were blind to the subjects' diagnoses at the time of the test administration and scoring.

After coding the test results was completed, subjects' medical records including history, laboratory findings, radiological reports and neurology consultations were carefully reviewed. This allowed us to identify those with a history of head injury, dementias of different etiology and systemic illnesses affecting the central nervous system, which resulted in neurobehavioral deficits documented in the medical records. The above factors are associated with transient or permanent brain dysfunction, which is classified by the DSM- III-R into a category of Organic Mental Disorders (OMD). Based on this information, Ss were classified into OMD vs non-OMD groups. The raters did not have access to the NCSE results during this process.

Results

Comparison of OMD and Non-OMD 9roups

Patients included in the OMD group were assumed to have organic pathology secondary to the following factors: head injury with prolonged loss of consciousness (58%), stroke


(8%), a rapidly growing brain tumor (4%), aneurysm (1%), frontal lobectomy due to gunshot wound (0.5%), probable Alzheimer's (6%), multi-infarct dementia (4.5%), AIDS dementia (7%), metabolic imbalance (9%), and lupus erythematosus (2%).

There were no significant differences between OMD (N = 50) and Non-OMD (N = 136) groups in gender distribution, native language, education, or presence of psychosis. OM D subjects, however, were somewhat older than Non-OMD, with mean age 37.6 and 32.1 years for each group, respectively (F = 6.07, p = .015). Incidence of seizure disorder was significantly higher in the OMD group (X 2 = 24.96, p < .0001). There was a trend for higher frequency of recreational drug abuse in the OMD group, which, however, did not reach a statistically significant level (X 2 = 3.55, p = .059).

Group d!ffk, rences in the performance pattern across the N C S E scales

A majority of the scores obtained by the Non-OMD subjects fell within average range (see Table 1). If impairment was demonstrated by these subjects, it fell mostly within the mild or moderate category. In contrast, the OMD subjects demonstrated a dis- proportionately high frequency of severe impairment on several scales.

Subjects' scores were averaged within each group and plotted on the graph developed by the test authors, which facilitates integration and interpretation of the scores across 10 scales.

As follows from Fig. la, psychiatric patients without organic pathology did not show consistent deficits on 9 out of 10 scales. It should be kept in mind, however, that scores, averaged across subjects, fell below optimal level on each scale, which indicates that a substantial number of subjects performed within the impaired range on one or several scales. Mild memory deficit was consistently demonstrated by many subjects and can be viewed as typical for this diagnostic group. These results are consistent with a large body of literature which reflects a consensus between investigators that impairment in memory represents a salient feature of cognitive profile in schizophrenia and other psychotic conditions (McKenna et al., 1990; Saykin et al., 1991: Tamlyn et al., 1992).

In contrast, a consistent pattern of multiple cognitive deficits was seen in psychiatric

Table 1. Frequency o['Four Per[ormance Levels on Each Scale Jor Patients with and without O M D

Scale 1"

Orientation 117 Attention 125 Comprehension 132 I Repetition 120 12 Naming 123 10 Construction 117 7 Memory 69 36 Calculations 107 17 Similarities 107 8 Judgment 119 7

Non-OMD (N = 136) OMD ( N - 50) 2 3 4 I 2 3 4

12 5 2 27 14 4 5 9 1 1 42 5 3 0

2 1 42 3 0 5 4 0 36 4 5 5 3 0 40 7 2 I 8 4 2l 1 16 12

15 16 14 8 10 18 9 3 32 8 6 4 7 14 26 4 4 16 7 3 35 2 4 9

* 1 : Average range; 2: mild impairment; 3: moderate impairment: 4: severe impairment.

18 M. M i t r u s h i n a et al.

(a)

| AVG I

Mild -IMP- -8- -4-

Moderate 4- -2-

Severe 4- -O-

Write in X lower scores

ATI" - Attention CALC - Calculations COMP - Comprehension CONST- Constructions IMP -Impaired

IOC OR/ ATT Language CONSr [MEM CAL£ Reasoning COMP REP NAM SIM JUD

-6- -8- -6-

-Ak=t- -t2- -(5)8- -(5)6- -(5)- -(5)- -0)5- -12- -(5)4- -0)6- -(5)5-

~ J ° - - - --'¢k~ --10-- ---8--- ~ . / ~ _..w~ j *

-I0- -6- -5- -11- -7- -I0-. -5- -4-

4- -9- -5- -3- -8-

-3- -7- -3- -2- -6-

-2- -5- -2- -0- 4-

X Abbreviations

JUD Judgement LOC Level of

consciousness MF2d - Memory NAb/ - Naming

-2- .4- -3-

-i- -3- -2-

-0- -2- -I-

!

OR/ - Orientation R ~ - l tq~i t ion S - Screen SIM - Similarities

NOn-OMD

IAVG I R a n ~

(b)

IOC OR/ ATF:

Mild -IMP- -8- 4-

Moderate 4- -2-

Laaguage cowsr MEM CALC Reasoning

COMP REP NAM !SIM KID

-6- -8- -6-

-Aim- -t2- -(5)8- -(5)6- -(5)- -(5)- -(5)5- -t2- -(5)4- -(5)6- -(5)5-

-12- -8-

4- -~ -5- ~ ~ -3-

-3- -7- -3- -2- -6- -1- -3- -2-

Severe -4- -0- -2- -5- -2- 4)- -4- -0- -2- -i-

Write in " ~ ~ lower scores

Abbreviations

ATI" - Attention JUD Judgement OR/ - Orientation CALC - Calculations LOC Level of REP - Repetition COMP - Comprehension consciousness S - Screen CONST- Constructions MEM - Memory SIM - Similarities IMP - Impaired NAM Naming

OMD

Figure 1. Cogni t ive profiles across 10 N C S E scales for N o n - O M D and O M D groups .


patients with O M D (see Fig. 1 b). Scores on four scales: Orientation, Repetition, Calculation and Judgment were within borderline range. Score on Similarities fell in the mildly impaired range and scores on Construction and Memory fell in the moderately impaired range.

Analysis of demographic factors and their effect on performance on different scales revealed a weak relationship of education with Attention and Repetition scores (Spearman r = . 16, p < .05; and r = .21, p < .01, respectively). Age negatively correlated with the score on the Memory scale (r = - . 1 7 , p < .05). It should be noted that correlations are quite modest and none of the above correlations accounted for more than 5% of the variance in the NCSE scores. A M a n , W h i t n e y test on the use of recreational drugs revealed effect of drug use on the score on the Attention scale at .01 significance level. Scores an all other scales were not affected by the history of drug use.

Ability of the NCSE to predict O M D based on the pattern of performance across l0 scales was tested using Stepwise Multiple Logistic Regression (BMDP LR). Raw scale scores entered the analysis in a stepwise progression determined by the maximum likelihood ratio method with enter and remove limits o f . 10 and . 15, respectively.

Two variables were included in the model. As follows from Table 2, presence of Construc- tion, which entered the analysis at step 1, improved the prediction over the constant in step 0 ( Improvement X 2 = 35.1, p < .0001). Memory entered the model at step 2. Although its contribution is less remarkable than that of Construction, its presence improved the prediction over the previous step (Improvement X 2 = 10.2, p < .001). No other variables entered the model. The ratios of regression coefficients to their respective standard errors, which can be treated as t-statistics, are reasonably high for all terms included in the model (see Table 2). This indicates usefulness of these terms in estimation of outcome probability. The resulting formula for estimating probability of O M D outcome is as follows:

1 + exp{ - [2.261 - . 507(construction) - . 169(memory)]}"

Since the prevalence of O M D in our sample is higher than that in random psychiatric population, use of this formula will require adjustment of the constant respective to the prevalence of O M D in the population at hand.

Figure 2 depicts percentage of correct classifications as a function of the cutoff. As it follows from the graph, a cutoff of .225 yields an approximately equal number of correct classifications in both groups with total accuracy equal 69.4%. This indicates that use of the NCSE makes only modest incremental validity contribution in psychiatric evaluation.

Table 2. Summary of Regression Coefficients from Logistic Regression Analysis

Regression Standard CoeffÉcient Improvement Term coefficient error SE X "2 p-value

Construction - .507 .111 - 4.59 35.1 .000 I Memory - . 169 .054 - 3.16 10.2 .001 Constant 2.261 .577 3.92


80

. . . . . .

I " / . . . . - . . . . . - k . oi5 0 I I I I I I I - "- ~'m'~n'nn,,,

0.058 0.175 0 . 2 7 5 0 . 3 7 5 0 . 4 7 5 0 . 5 7 5 0 . 6 7 5 0.775 0.875

C u t p o i n t

Figure 2. Percentage of Ss correctly classified by logistic regression.

It also should be pointed out that the accuracy of classification is likely to deteriorate in a second sampling.

In choosing a cutoff, we consider the cost of two types of misclassifications. The false positive errors are less problematic sinc6 they allow further investigation of the validity of abnormal findings. False negative errors, however, preclude timely intervention and may have detrimental consequences for effectiveness of treatment and prognosis.

Therefore, we adjusted our cutoff in an attempt to minimize probability of false negative errors. This resulted in increased number of correct classifications for OMD group and in decline in correct classifications for Non-OMD group. At this adjusted cutoff, sensitivity was .74, specificity was .62 and efficiency coefficient was .65 (see Fig. 2).

Discussion

The results of this study indicate that the profile of cognitive functioning obtained with the NCSE differentiates between psychiatric patients without OMD and those with organic pathology. Performance of Non-OMD subjects did not indicate gross deficits in any of the cognitive domains. It should be taken into consideration, however, that NCSE provides only a gross level of assessment and a reasonably intact individual is expected to pass screens and obtain optimal scores on a majority of the scales. It was clear from the results of this study that a number of psychiatric patients without OMD performed within mildly and even moderately impaired range on one or several scales. This indicates that on the whole, some degree of cognitive deficit is common for the psychiatric population. This deficit is especially pronounced in the memory domain.

In contrast, performance of patients with organic pathology is expected to result in higher frequency of moderate and severe impairment. The best discriminator is the scale assessing visuospatial constructional ability and visual memory. Verbal memory deficit in OMD patients is typically more severe than in Non-OMD patients. In addition to these salient indices, OMD patients tend to have some deficit in abstract reasoning and demonstrate borderline performance on several other scales.


The above analysis provides important information on differences in performance pat- terns between the two groups. Results of this study, however, are viewed only as general guidelines. In clinical practice, patients' cognitive profiles should be interpreted within the context of their demographic characteristics, history, level of everyday functioning and severity of psychiatric symptomatology.

The cognitive profile in each individual case may vary depending on localization of brain lesion or specific psychiatric diagnosis. The latter aspect of variability in cognitive functioning calls for further investigation.

Acknowledgements The authors acknowledge the contribution of Corinne Schneider, Pamela Rosenberg, Annette Oved and Tal Solomon in data collection. The assistance and cooperation of staff of Olive View Medical Center in data collection for this study are greatly appreciated. Requests for reprints should be sent to Maura Mitrushina. Ph.D., UCLA/NPI, C8-747,760 Westwood Plaza, Los Angeles, CA 90024-1759.

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cognitive screening of psychiatric patients

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