skill development for assessing cognitive impairment in elderly 24 nov15

Skill Development for Assessing Skill Development for Assessing Cognitive Impairment in ElderlyCognitive Impairment in Elderly

Dr Rakesh Kumar Tripathi, Dr Rakesh Kumar Tripathi, M Phil, PhDM Phil, PhD Assistant Professor cum Clinical PsychologistAssistant Professor cum Clinical Psychologist

Department of Geriatric Mental Health Department of Geriatric Mental Health King George’s Medical UniversityKing George’s Medical University

Lucknow -226003 (India)Lucknow -226003 (India)

(In house Skill Development Program, 24 Nov to 30 Nov, 2014)

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Skill Development for Assessing Skill Development for Assessing Cognitive Impairment in ElderlyCognitive Impairment in Elderly

Learning Objectives:Learning Objectives: Concept and purpose of psychological Concept and purpose of psychological

assessmentassessment Areas of assessment for elderly Areas of assessment for elderly Practical exposure to assess Cognitive Practical exposure to assess Cognitive

ImpairmentImpairment Scoring and interpretation of administered test Scoring and interpretation of administered test Basic skills for assessmentBasic skills for assessment Screening and detailed assessment testsScreening and detailed assessment tests

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Concept Concept Psychological Assessment vs TestPsychological Assessment vs Test

Assessment is more than testing Psychological testing occurs as Psychological testing occurs as partpart of the of the

process of psychological assessment. process of psychological assessment. Psychological assessment includes:Psychological assessment includes: Clinical interview Clinical interview Demographic information Demographic information Medical information Medical information Personal history Personal history Observations by others Observations by others Thus, the results of a psychological test Thus, the results of a psychological test are rarely used on their own. are rarely used on their own.

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Concept (contd.)Concept (contd.)

Psychological AssessmentPsychological Assessment "An extremely complex process of solving "An extremely complex process of solving

problems (answering questions) in which problems (answering questions) in which psychological tests are often used as one psychological tests are often used as one of the methods of collecting relevant data" of the methods of collecting relevant data" (Maloney & Ward, 1976)(Maloney & Ward, 1976)

Psychological TestingPsychological Testing "An objective and standardized measure "An objective and standardized measure

of a sample of behaviour" (Anastasi, 1990)of a sample of behaviour" (Anastasi, 1990)

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Psychological Assessment of ElderlyPsychological Assessment of Elderly

Purpose of Assessment:Purpose of Assessment: DiagnosisDiagnosis CertificationCertification Severity of symptomsSeverity of symptoms Management/RehabilitationManagement/Rehabilitation ImprovementImprovement PrognosisPrognosis ResearchResearch

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Psychological Assessment of ElderlyPsychological Assessment of ElderlyAreas of assessmentAreas of assessment Cognitive:Cognitive:

Orientation, Calculation, Memory, Language etc.Orientation, Calculation, Memory, Language etc. Behavioral:Behavioral:

Irritation, Suspiciousness, Muttering, Smiling to self Irritation, Suspiciousness, Muttering, Smiling to self Violence, etc.Violence, etc.

Psychological:Psychological: Intelligence, Personality, Conflicts, PsychopathologyIntelligence, Personality, Conflicts, Psychopathology

Functional:Functional: ADLADL

Quality of life:Quality of life: Physical, Psychological, Environmental, Social, Physical, Psychological, Environmental, Social,

spiritualspiritual Carer’s Burden:Carer’s Burden:

Physical, Psychological, Financial, SocialPhysical, Psychological, Financial, Social

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Neuropsychological TestsPsychological approaches for the assessment of brain pathology

Multifactorial Unitory

assumption of functional unity of the brain as a whole (mass action and equipotentiality)

Assessed by psychological tests of Unitory functions such as

test for Intelligence, Memory,Perceptuomotor Functions,

Nahar- Benson test, WCST etc.

Assessed by Comprehensive Batteries of tests such as Luria Nebraska,

Halstead and Reitan, NIMHANS-BBD, PGI-BBD, AIIMS comprehensive

Neuropsychological Battery inHindi, PGI battery for assessment of mental efficiency in the elderly

Based on the functional autonomy of the structure (Localization)


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Scoring:0- 4: Severe, 5-14: Mod. 15-19: Mild Dementia; 20-24: MCI, 25-28 Age related Cog Impairment, 29-30:Normal

Scoring:0- 4: Severe, 5-14: Mod. 15-19: Mild Dementia; 20-24: MCI, 25-28 Age related Cog Impairment, 29-30:Normal

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Bender Gestalt (BG) Test:Bender Gestalt (BG) Test: Lauretta Bender,1938; Lauretta Bender,1938;

Brannigan et al.2004 (BG-II) 9 figures asked to copy on 9 figures asked to copy on

a blank papera blank paper Pencil with erasurePencil with erasure Admn. Time- 7-10 min.Admn. Time- 7-10 min. Used as screening test for Used as screening test for

brain damagebrain damage Score more than 12 Score more than 12

indicates cognitive indicates cognitive impairmentimpairment

Scoring Systems by- Hutt, Scoring Systems by- Hutt, Lacks, Koppitz,Lacks, Koppitz,

Psychological Assessment of ElderlyPsychological Assessment of ElderlyScreeningScreening

Sign on BGT Score

Perseveration, Rotation/reversal, Concretism

4 each

Added angles, Separation of lines, Overlap, Distortion

3 each

Embolishments, Partial rotation

2 each

Omission, Abbreviation, Separation, Absence of erasure, Closure, Point of contact

1 each

Basic communication Skill for Basic communication Skill for Assessment of ElderlyAssessment of Elderly

Calm, reassuring tone of voiceCalm, reassuring tone of voice Explain what you are going to do prior to Explain what you are going to do prior to

moving into the patient’s personal space to moving into the patient’s personal space to implement care/assessmentimplement care/assessment

Use a non-threating postureUse a non-threating posture Do not approach the patient from behindDo not approach the patient from behind Touch and care should be in a respectful, Touch and care should be in a respectful,

careful and unhurried mannercareful and unhurried mannerSing I & Tripathi SM (2013). Management of BPSD. In Tiwari SC & Pandey NM (eds.) Geriatric Mental Health at a Glance ,pp 81-95. Ahuja Publishing House , New Delhi , India.

Basic communication Skill for Basic communication Skill for Assessment (Contd.)Assessment (Contd.)

Use short words and simple sentencesUse short words and simple sentences Ask one question at a timeAsk one question at a time Don’t ask ‘why’Don’t ask ‘why’ Give adequate time for responseGive adequate time for response Repeat questions and instructions if Repeat questions and instructions if

necessarynecessary Speak slowly and clearly Speak slowly and clearly Use of aids (hearing, vision, physical) by the Use of aids (hearing, vision, physical) by the

patientpatientSing I & Tripathi SM (2013). Management of BPSD. In Tiwari SC & Pandey NM (eds.) Geriatric Mental Health at a Glance ,pp 81-95. Ahuja Publishing House , New Delhi , India.

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ScreeningScreening Mini Mental State Examination (MMSE) Mini Mental State Examination (MMSE) (Folstein et al. 1975)(Folstein et al. 1975) Hindi Mental State Examination (HMSE) Hindi Mental State Examination (HMSE) (Ganguli et al. 1995)(Ganguli et al. 1995) Hindi Cognitive Screening Test Hindi Cognitive Screening Test (Tiwari and Tripathi, 2011) (Tiwari and Tripathi, 2011) St. Louis University Mental State (SLUMS) Exm. St. Louis University Mental State (SLUMS) Exm. (JE Morley, 2000)(JE Morley, 2000) Clock Drawing Test (CDT) Clock Drawing Test (CDT) (Shulman et al. 1993)(Shulman et al. 1993) Bender Gestalt Test (BGT) Bender Gestalt Test (BGT) (Lauretta Bender, 1938) (Lauretta Bender, 1938) Hachinski Ischemic Scale Hachinski Ischemic Scale (1975)(1975) 7 Minute Neurocognitive Screening Battery 7 Minute Neurocognitive Screening Battery (Solomon et al. 1998)(Solomon et al. 1998) Short Portable Mental State Questionnaire Short Portable Mental State Questionnaire (E. Pfieffer, 1975)(E. Pfieffer, 1975) Community Screening Instrument for Dementia Community Screening Instrument for Dementia (Hall et al. 1993)(Hall et al. 1993) Brief Cognitive Rating Scale (BCRS) Brief Cognitive Rating Scale (BCRS) (Reisberg and Ferris, 1998)(Reisberg and Ferris, 1998) Functional Assessment Staging (FAST) Functional Assessment Staging (FAST) (Reisberg, 1988)(Reisberg, 1988) Global Deterioration Scale (GDS) Global Deterioration Scale (GDS) (Reisberg, 1988)(Reisberg, 1988) Cognistat Cognistat (Northern California Neurobehavioural Group, 1995 )(Northern California Neurobehavioural Group, 1995 ) Indian adaptation of Cognistat Indian adaptation of Cognistat (Gupta and Kumar, 2009)(Gupta and Kumar, 2009) Addenbrooke’s Cognitive Examination Addenbrooke’s Cognitive Examination (2005 to 2012)(2005 to 2012) Montreal Cognitive Assessment Montreal Cognitive Assessment (Nasreddine, 1996)(Nasreddine, 1996)


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Detailed Assessment Survey Psychiatric Assessment Schedule (Bond et al. 1980) CAMDEX-R (Roth et al. 1986, 1998-R) Alzheimer's Disease Assessment Scale (Rosen et al. 1984) Schedule for Clinical Assessment in Neuropsychiatry (SCAN)

(WHO, 1996) Clinical Dementia Rating (Morris, 1993) Blessed Dementia Scale (Blessed, 1968) BEHAVE-AD (Reisberg et al. 1987) Geriatric Mental State Schedule (GMSS) (Copeland et al. 1976) Dementia Rating Scale (DRS) (Mattis, 1988) DRS-2 (Jurica et al. 2001) Neuropsychiatric Inventory (NPI) (Cummings et al. 1994) Everyday Abilities Scale for India (EASI) (Fillenbaum et al. 1999) Thai Activities of Daily Living Scale (Senanarong et al. 2003) Senior Apperception Test (Choudhury Uma, 1978)


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Neuropsychological Test Batteries (NPB): Halstead and Reitan NPB (1940s) Luria Nebraska NPB Wechsler Adult Intelligence Scale (WAIS in

1939) PGI Battery of Brain Dysfunction (PGIBBD) PGI Assessment of Mental Efficiency in Elderly

(PGIAMEE) NIMHANS NPB AIIMS Comprehensive NPB in HindiRorschach Psychodiagnostics

Psychological Assessment of Elderly Psychological Assessment of Elderly Detailed Assessment (contd.)Detailed Assessment (contd.)

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Sensitivity: 0.93

Specificity: 0.96

Reliability (r): -0.87

with Brief Cognitive Rating Scale (Reisberg & Ferris, 1988)

IAGMH/Intas Award 2011 at 3rd place.

Development of an Education and Culture Fair Hindi Cognitive Screening Test (HCST) for the

Elderly Population of India S. C. Tiwari and Rakesh Kumar Tripathi (2011)

Department of Geriatr ic Mental HealthKing George’s Medical University, U P, Lucknow, India

Indian Journal of Geriatric Mental Health, 7(2), 83-96, 2011.Hindi Cognitive Screening Test (HCST) (Tiwari and Tripathi, 2011)

ON HCST (items may change according to Literacy language and culture) No.

Areas (Score) Total score: 30

Items

1. Orientation to Time (5) Year (of any calendar), weather, month, date, day

Either ‘which Place is this’, or ‘whose house is this’ depending on whether the testing was conducted in a home or healthcare centre or other location in the village/muhalla/town

Police Station or Tehsil or Post office

District State

2. Orientation to Place (5)

Country 3. Registration (3) Mango (or any local fruit), Chair, Rupee 4. Attention and

Calculation (5) Items exchangeable to the literacy level: • For illiterate: days backward Serial subtractions: • Up to 5th : 3 starting at 20. • Up to 10th: 4 starting at 40 . More than 10th : 7 starting at 100

5. Recall (3) Mango, Chair, Rupee

6. Naming (2) Pen, wristwatch/ Mobile phone

7. Repetition (1) ‘Neither this nor that’ 3 stage Follow command (3)

Give the individual a plain piece of paper and say, “Take the paper in your hand, fold it in half, and put it on the floor.”

8.

Read & Follow Command (1)

• Item exchangeable to the literacy level according to MMSE and HMSE ‘Close your eyes’ for Literate; and Examiner says ‘Look at me and do exactly what I do’ and then closes his own eyes for three seconds for illiterate.

9. Sentence (1) Items exchangeable to the literacy level according to MMSE and HMSE. Writing a sentence for literate and ‘Tell me something about your house’ for illiterate

10. Copying (1) Items exchangeable to the literacy level according to MMSE and HMSE

Up to 5th : Diamond More than 5th: Two Pentagons Total Score: 30 Cut off Score: At or below 23: Screen positive (Cognitive Impairment)

Score: 24 and above: No cognitive impairment

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High School Education

Clinical Clinical ConditionCondition

Less ThanHigh SchoolEducation

27-30 Normal 25-30

21-26 MNCD* 20-24

1-20 Dementia 1-19

St. Louis University Mental State Examination (SLUMS St. Louis University Mental State Examination (SLUMS Exam.) Morley JE, 2000Exam.) Morley JE, 2000

• It is a simple 11 items toolIt is a simple 11 items tool

* Mild Neurocognitive Disorder * Mild Neurocognitive Disorder •Takes about 5-10 minutes in Takes about 5-10 minutes in administrationadministration• SLUMS is more sensitive in detecting SLUMS is more sensitive in detecting MCI and dementia than Mini MentalMCI and dementia than Mini Mental State ExaminationState Examination

Psychological Assessment of Older AdultsPsychological Assessment of Older AdultsScreening (contd.)Screening (contd.)

Features Score1. Abrupt 22. Stepwise deterioration 13. Fluctuating course 24. Nocturnal confusion 15. Relative preservation of personality

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6. Depression 17. Somatic Complaints 18. Emotional incontinence 1

Features Score9. History or presence of hypertension

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10. History of strokes 211. Evidence of associated atherosclerosis

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12. Focal neurologic symptoms

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13. Focal neurologic sign 2Total Score 18

Psychological Assessment of ElderlyPsychological Assessment of ElderlyScreening (contd.)Screening (contd.)

Hachinski Ischemic Scale (1975)Hachinski Ischemic Scale (1975)

Scoring 0-4: Alzheimer's Dementia; 5-6: diagnosis unclear; 7 or more : Vascular Dementia

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Psychological Assessment of Elderly Psychological Assessment of Elderly Screening (contd.)Screening (contd.)

Clock drawing Test Score Error(s)1 No error2 Minor visuospatial

error3 Inaccurate

representation of “10 past 11”

4 Moderate visuospatial disorganization of times

5 Several disorganization

6 No reasonable representation of a clock

Score≥ 3: Cognitive deficit

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Montreal Cognitive Assessment

(Nasreddine, 1996)

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Clinical Dementia Rating (CDR) (Morris, 1993)Clinical Dementia Rating (CDR) (Morris, 1993)

1.1. Memory Memory 2.2. Orientation Orientation 3.3. Judgment & Problem Judgment & Problem

Solving Solving 4.4. Community AffairsCommunity Affairs5.5. Home & Hobbies Home & Hobbies

6.6. Personal CarePersonal Care


Global measure of dementia by a clinician.Global measure of dementia by a clinician.CDR scale describes five degrees of impairment in six CDR scale describes five degrees of impairment in six different categories of cognitive impairment:different categories of cognitive impairment:

Degrees of Impairment:0 0 -Normal-Normal0.5 -Questionable 0.5 -Questionable

impairmentimpairment11 -Mild impairment-Mild impairment22 -Moderate impairment-Moderate impairment33 -Severe impairment-Severe impairment

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Executive functionExecutive function Wisconsin Card Sort Test, Wisconsin Card Sort Test, Nelson HE. Nelson HE.

(1976)(1976) This test is a well-known paradigm of This test is a well-known paradigm of

abstraction and cognitive flexibility. abstraction and cognitive flexibility. Studies report that apart from Studies report that apart from executive functions it also elicits a executive functions it also elicits a distinct pattern of cerebral blood flow distinct pattern of cerebral blood flow velocityvelocity

Stroop Test, Stroop Test, Stroop JR. (1935)Stroop JR. (1935) Tests the ability to selectively Tests the ability to selectively

process only one visual feature while process only one visual feature while continuously suppressing the others. continuously suppressing the others. http://cognitivefun.net/test/2http://cognitivefun.net/test/2

In the areas of Cognitive FunctioningIn the areas of Cognitive Functioning


http://cognitivefun.net/test/2

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Intelligence Intelligence Wechsler Adult Intelligence Scale (WAIS), Wechsler Adult Intelligence Scale (WAIS), Wechsler Wechsler

D. (1981) D. (1981) Widely applicable test for IQ measurement over 16 years .Widely applicable test for IQ measurement over 16 years . Can also be used for diagnosing organic brain syndromesCan also be used for diagnosing organic brain syndromes It has It has 6 verbal:6 verbal: information, comprehension, arithmetic, information, comprehension, arithmetic,

similarities, digit span and vocabulary and similarities, digit span and vocabulary and 5 performance:5 performance: picture completion, Block design, picture arrangement, object picture completion, Block design, picture arrangement, object assembly and digit symbol tests. The test generates a verbal assembly and digit symbol tests. The test generates a verbal IQ, a performance IQ and a full scale or combined IQ. IQ, a performance IQ and a full scale or combined IQ.

A difference between the verbal and performance IQ scores A difference between the verbal and performance IQ scores of greater than 10 points is suggestive of organic brain of greater than 10 points is suggestive of organic brain syndrome. syndrome.

Neuropsychological Test


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Neuropsychological Tests (contd.)PGI Battery of Brain Dysfunction(PGIBBD),

Dwarka Pershad and S.K. Varma, 1990: PGI Memory Scale Revised Bhatia’s Short Battery of

Performance Test of Intelligence Verbal Adult Intelligence Scale (VAIS) Nahar-Benson Test Bender Visual Motor Gestalt Test (BGT)

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AIIMS Comprehensive Neuropsychological Battery in Hindi (Adult form) (AIIMS-CNBH), Surya Gupta et al. 2000:

Based on Luria,s functional approach in the detection, lateralization, localization of discrete brain lesions

Useful for both in diagnosis and rehabilitation 160 items and 13 subscales Total raw score converted into t scores High t score than expected – organic brain syndrome t score R. hem. - t score L. hem. Found positive then right

hemisphere dysfunction and if, negative then left hemisphere dysfunction.

Neuropsychological Tests (contd.)

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13 Subscales: Motor Scale Tactile Scale Visual scale Receptive speech Expressive Speech Reading Scale Writing scale

Neuropsychological Tests (contd.)AIIMS-CNBH (Contd.)

Arithmetic Scale Memory scale Intellectual processes

scale Pathognomonic Scale Left hemisphere scale Right Hemispheric

Scale

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Piotrowoski’s signs for organic brain disorders:10 Response less than 15 IRT > 60 seconds Less than 2 human movement response F+% < 70% Popular response <4 One or more colour naming (overlap with sch.) Perseveration of response Impotence Perplexity Automatic phrasesMinimum any 5 signs are required for diagnosis.

Rorschach Psychodiagnostics

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King George’s Medical University,King George’s Medical University, Lucknow, U.P., INDIA Lucknow, U.P., INDIA

Contact: R K Tripathi [email protected]

91+9454202905

mailto:[email protected]

skill development for assessing cognitive impairment in elderly 24 nov15

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