FAB Frontal Assessment Battery- www.stvincents.ie/dynamic/File/Frontal%20Assessment%20Battery_SVUH_MedEl_tool.doc
EXIT Executive Interview www.dementia-assessment.com.au/frontotemporal/EXIT25_Executive_Interview.pdf
D-KEFS Delis-Kaplan Executive Function Test http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8091-108&Mode=summary
NPI Neuropsych Inventory (and variant forms) http://npitest.net/download.html
FBI Frontal behavior inventory http://www.chumneurologie.org/conferences/FBI/FBI.pdf
Sunday, December 26, 2010
Sunday, September 19, 2010
Neuropsych abnormalities in pre-HD
from Duff et al. Neurology 2010; 75:500-507
Authors found linear trends with SDMT affected first, then episodic memory (trial four or delay trial of HVLT, with facial recognition less affected and Color Trails less affected. Authors used raw scores, and found most patients had nonamnestic MCI in a single domain, not multiple domain. Conclusion was that these tests are important markers for future trials of neuroprotection.
Wednesday, July 28, 2010
ADC Uniform Dataset (UDS): The Neuropsychologic test battery
Minimum data set in making for over ten years. A spanish version of the UDS is available at https://www.alz.washington.edu. Standard scoring is available at UDS Guidebook and Appendix, and later Neuropsychological Test Instructions, distributed to ADC's. Version 2 differs in that logical memory story 2 delayed recall is done at 20 not 30 minutes with cueing with one detail from story now given. Visuospatial measures were not used. Focus of initial battery was Attention, speed of processing, executive function, episodic memory, and language. Tests were selected by the panel with comments. Tests utilized, with mean, sd, Q25, Q75, median and range for normals indicated:
1. MMSE with a separate score for orientation out of ten -- note that its insensitive for dementia but is useful to tag milestones once dementia is established. MMSE 29,1.3, 28, 30, 29, 17-20; Orientation items only: 9.7, 0.9, 10,10,10, 0-10.
2. Digit Span Test from WMS -R, with 2 scores derived, namely total trials and longest digit sequence reproduced.
Digit span forward total trials: 8.6,2.1, 7,10,9, 1-12.
Digit span forward longest sequence: 6.7, 1.1, 6,8, 7, 0-8.
Digit span backwards total trials: 6.9, 2.2, 5,8,7,-12
Digit span backwards longest sequence: 5, 1.2, 4,6,5,1-7
3. Trailmaking Test Parts A and B with standard rules but time limits of 150 seconds for Part A and 300 seconds for Part B.
Part A Time in seconds: 34.6, 15.4, 25,40,31, 11-150.
Part B in seconds: 90.3, 50, 59, 105, 10-300
4. Digit Symbol Coding from WAIS-R standard, with the score the total number of items completed in 90 seconds. Usually WMS R was used.
5. Logical memory stories--Immediate recall, and delayed recall. Test required at least 20 minute delay for delayed recall with notation of amount of time used for the delay. Cue was given for second story.
logical memory A total units, immediate recall 13.9 , 3.9, 11,17,14, 0-25
logical memory A delayed recall 12.6, 4.3, 10,16,13, 0-25
6. Word lists were not used due to variability in implementation but centers were encouraged to use one and study its relationship to logical memory stories.
7. Boston Naming Test short version using odd items, with discontinuation after six consecutive failures. The score was the number named within a 20 second time limit plus the number named correctly with a semantic cue.
27.2 , 3.2, 26, 29, 28, 2-30
8. Verbal fluency was assessed using animal and vegetable list generation in one minute.
animals in 60 seconds: 20 , 5.6, 16,24, 20, 1-54
vegetable: 14.7, 4.4, 12,17,15,1-63.
9. Additional items used: FAQ (functional assessment questionnaire), behavioral symptoms from NPI-Q short form), and Geriatric Depression Scale.
10.Inability to respond due to physical barriers was noted.
The non public domain items (most of test) were given in cooperation with manufacturers and consent. Entire battery required 3-40 minutes was given annually. Paper gives normal values. Ceiling effects were obtained with perfect or nearly perfect scores on digit span forward and backwards (cannot exceed 8 and 7 respectively), BNT, MMSE orientation score, and total score. On other tests some outlier scores were found (584/3268 had one or two outlier scores, 61 had 3 or more).
Age, sex and education (demographics) were associated with nearly all results. Males and females differed on more than half of test results. Future tests will take into account additional qualitative information such as number of incorrect lines on the TMT. Longitudinal studies will help separate abnormal from peak performance
Monday, July 26, 2010
CVLT performance by patients with focal frontal lesions
Alexander MP et al., Brain 2003.
CVLT has many measures.
Immediate free recall-- posterior LDF (dorsolateral frontal) performed worse, than other frontal areas
List A first trial-- posterior LDF and PMF (posterior medial frontal) were most impaired
Trial by groups-- left LDF had flattest learning curve.
Primacy/recency and serial position had no effects by group.
List B-- proactive interference was not present in any group
Recognition memory-- posterior LDF group and posterior RDF group performed worst. Recognition hits were not different, difference was due to more false alarms.
Discriminibility and response bias-- the post LDF performed worse than all except post RDF.
Short delayed free recall-- post LDF was worse than controls. Ant RDF & PMF were different than controls.
Long delay free recall-- post LDF worse than all groups except ant LDF & PMF.
Long delay cued recall similar to above.
Intrusions and double recalls-- no significant differences.
Inconsistency score-- post LDF was worse than all except post RDF
Subjective semantic organization-- RDF post worse.
Summary-- Immediate free recall was worse post LDF> PMF (esp bilateral involving septal area)> post RDF. This was also true for delayed free recall short and long, and for learning curve for trial 1-5. For recognition only LDF was impaired due to more false alarms.
In a prior study, Stuss et al. found more double recalls in post. RDF group, not seen in this study although p=0.11. Abnormalities cannot be attributed to PI, to serial position effect, or defective primary memory.
CVLT has many measures.
Immediate free recall-- posterior LDF (dorsolateral frontal) performed worse, than other frontal areas
List A first trial-- posterior LDF and PMF (posterior medial frontal) were most impaired
Trial by groups-- left LDF had flattest learning curve.
Primacy/recency and serial position had no effects by group.
List B-- proactive interference was not present in any group
Recognition memory-- posterior LDF group and posterior RDF group performed worst. Recognition hits were not different, difference was due to more false alarms.
Discriminibility and response bias-- the post LDF performed worse than all except post RDF.
Short delayed free recall-- post LDF was worse than controls. Ant RDF & PMF were different than controls.
Long delay free recall-- post LDF worse than all groups except ant LDF & PMF.
Long delay cued recall similar to above.
Intrusions and double recalls-- no significant differences.
Inconsistency score-- post LDF was worse than all except post RDF
Subjective semantic organization-- RDF post worse.
Summary-- Immediate free recall was worse post LDF> PMF (esp bilateral involving septal area)> post RDF. This was also true for delayed free recall short and long, and for learning curve for trial 1-5. For recognition only LDF was impaired due to more false alarms.
In a prior study, Stuss et al. found more double recalls in post. RDF group, not seen in this study although p=0.11. Abnormalities cannot be attributed to PI, to serial position effect, or defective primary memory.
MS as a disconnection syndrome
Dineen RA et al. Disconnection as a mechanism for cognitive dysfunction in multiple sclerosis. Brain 2009;132: 239-249
Authors use DTI MRI and neuropsychology to try to correlate white matter specific disconnections with cognitive disorders in MS.Without delving into methodology, PASAT scores correlated with splenium and body of corpus callosum, parieto-occipital radiations of the forceps major, left cingulum, the right inferior longitudinal fasciculus running into the left temporal lobe, parietal tracts and portions of the left superior longitudinal fasciculus, and the parietal arcs of the arcuate fasciculi bilaterally.
The Benton Visual Retention Test correlated with lesions in splenium and body of the corpus callosum, the parietal and occipital projections of the forceps major bilaterally, the left inferior longitudinal fasciculus running into the temporal lobe, the left arcuate fasciculus, the left cingulum, the anterior portion and tail of the fornix, the white matter of the right parietal and medial occipital lobes. Te right temporal lobe figured prominently with adjustment for IQ.
CVLT II-- correlations with the body and splenium of the corpus callosum, the parietal and occipital projections of the forceps major bilaterally, the parietal portion of the left superior longitudinal fasciculus, the left inferior longitudinal fasciculus and arcuate fasciculus, the left posterior fornix and cingulum running from the temporal lobe.
No correlations found for the following tests: JLO, COWAT, DST CS.
Authors use DTI MRI and neuropsychology to try to correlate white matter specific disconnections with cognitive disorders in MS.Without delving into methodology, PASAT scores correlated with splenium and body of corpus callosum, parieto-occipital radiations of the forceps major, left cingulum, the right inferior longitudinal fasciculus running into the left temporal lobe, parietal tracts and portions of the left superior longitudinal fasciculus, and the parietal arcs of the arcuate fasciculi bilaterally.
The Benton Visual Retention Test correlated with lesions in splenium and body of the corpus callosum, the parietal and occipital projections of the forceps major bilaterally, the left inferior longitudinal fasciculus running into the temporal lobe, the left arcuate fasciculus, the left cingulum, the anterior portion and tail of the fornix, the white matter of the right parietal and medial occipital lobes. Te right temporal lobe figured prominently with adjustment for IQ.
CVLT II-- correlations with the body and splenium of the corpus callosum, the parietal and occipital projections of the forceps major bilaterally, the parietal portion of the left superior longitudinal fasciculus, the left inferior longitudinal fasciculus and arcuate fasciculus, the left posterior fornix and cingulum running from the temporal lobe.
No correlations found for the following tests: JLO, COWAT, DST CS.
Sunday, July 25, 2010
Localizaiton of tests within frontal lobes
Stuss DT. Levine B. Adult clinical neuropsychology: lessons from studies of frontal lobes. Ann Rev Psychol 2002; 53: 401-433.
Long article, a few (random) points distilled out, heavily tilted towards localization of neuropsych tests within frontal lobes.
Anatomically, the ventral prefrontal cortex is dissociated from the dorsolateral prefrontal cortex (DLPFC). The former, is associated with emotional regulation, evolutionarily emerged from orbitofrontal and olfactory cortex and limbic nuclei. It also is important for inhibition, emotion and reward processing. By contrast, the DLPFC evolutionarily comes from archicortical trend of hippocampus, and is involved in spatial and conceptual processing, including executive functioning. The frontal poles are more recently evolved and are involved in self awareness, autonoetic consciousness, and humor.
By function:
Frontal lobe language (key reference is Alexander MP et al., 1989 Brain Lang. ) excluding articulation and Broca's aphasia, frontal language function and dysfunction is grouped under activation and formulation (paralinguistics). Dynamic aphasia, or trouble activating language, occurs after damage to SMA or ACC. TMA, with truncated language, occurs after damage to left DLPFC. (in other publications, Alexander refers to 'subbcallosal fasciculus'). Usually this is tested using letter fluency. In Stuss 1998 (JINS) rview of 74 local lesion patients, left DLPFC patients were most impaired, right DLPFC and VPFC patients were not impaired. However left parietal lesioned patients also were impaired and could not be differentiated from left DLPFC patients. Superior medial damage on either side (SMA) was associated with poor productions, and posterior superior lateral temporal lesions were implicated . The latter could be teased out by switching between letter and semantic fluency tasks. All above are left sided lesions (except SMA). Discourse lesions that are left sided include simplification, perseveration and omissions. Right sided lesions may cause amplification of details, wandering from topic, insertion of irrelevancies, and dysprosody, leading to incoherence.
Control of Memory:
Its important to differentiate between basic associative cue-engram processes (medial temporal lobe/hippocampal structures) and strategic processes that may be more top down such as coordination, elaboration and interpretation of these processes. Wechsler Memory Scale and many others tap both processes but make no effort to dissociate them. Author cites CVLT as an example of the "Boston approach" that includes efforts to measure serial position learning, semantic organization, interference effects, cued recall, recognition and response bias. Most recent WMS revision has semantically unrelated words, precenting analysis of semantic clustering. Stuss et al. 1994 Psychology showed right DLPFC lesion patients had more intralist repetitions due to response monitoring defect. Left frontal caused problems with encoding, retrieval and recognition. Frontal lobes are important to retrieval involving monitoring, verification, & placement of information especially in spatial and temporal contexts, with lesions causing reduplication, confabulation and retrograde amnesia. There is a right hemispheric bias in retrieval, but also a DLPFC/VPFC wherein latter is involved in retrieval cue specification and former in higher level postretrieval monitoring (see Fletcher, 1998 Brain, also Petrides).
Working Memory:
Original idea jacobsen 1936 monkeys with frontal lesions could not make decisions once stimulus was removed from view. Frontal lobe involvement keeps information online while other areas (slave systems) perform operations. Frontal involvement increases with interference . DLPFC monitors and manipulates, whereas VPFC maintains, controls interference and inhibition. Digit span/spatial span give information about working memory storage capacity but not rehearsal or executive control. Frontal lesions in one study did not affect digit span. Reverse digit span measures manipulation of above. Brown-Peterson technique taps interference. Supraspan tests measure processing when capacity is exceeded. Not standard.
Anterior attention processes
Attentional switching: WCST and TMT, part B. WCST originally shown by Milner to be response to frontal damage. New problem solving Dias et al. (J Neurosci 1997). . WCST shifts are extradimensional eg. color to form, on basis of feedback, or intradimensional, eg within a color red to blue. Extradimensional shifts are due to DLPFC in healthy adults. VPFC damage does not affect extradimensional shifting. However, VPFC lesions could contribute to the relatively rare error of loss of set due to susceptibility to interference. DLPFC patients also had loss of set due to loss of sustained attention.Posterior damage also can affect WCST.
TMT Part B ostensibly uses Part A as an internal control for factors other than switching, but has been criticized as not well matched to Part B in other respects. Stuss et al. found time correlated with frontal pathology, but effect was eliminated when score was corrected for TMT Part A. DLPFC patients were distinguished from Part A based on errors but not time.
Selective attention: Stroop test
Stuss found deficit in left sided lesions was due to problems in color naming, not interference. (Stuss et al., Neuropsychologia 2001). Patients with superior medial lesions showed errors due to importance of area in maintaining an activated intention. Inferior medial patients were normal.
Sustained attention:
Continuous performance tests are sensitive to frontal damage especially with increased complexity (eg. respond to "O" after "x". The Sustained Attention to Response Tast (SART, Robertson 1997 Neuropsychologia) and the Elevator Counting Test (Robertson 1991 the Test of Everyday Attention)
VPFC important in acquiring and reversing stimulus/reward. The Iowa Gambling Test (Bechara et al.) is based on Somatic Marker Hypothesis, that reasoning is constrained based on previous conditioning, mediated by ventromedial frontal lobes. VPFC lesions cause "self regulatory disorder" or "SRD." Another test is the Strategy Application Test, based on the Six Element Test of Shallice and Burgess. Every patient with focal VPFC damage, especially on right was impaired. It correlated with outcome questionnaires.
Frontal Pole: Autobiographical Memory Test. (Kopelman, 1989J Clin Exper Neuropsychol). Also, Dysexecutive Questionnaire (Burgess et al, 1996
Long article, a few (random) points distilled out, heavily tilted towards localization of neuropsych tests within frontal lobes.
Anatomically, the ventral prefrontal cortex is dissociated from the dorsolateral prefrontal cortex (DLPFC). The former, is associated with emotional regulation, evolutionarily emerged from orbitofrontal and olfactory cortex and limbic nuclei. It also is important for inhibition, emotion and reward processing. By contrast, the DLPFC evolutionarily comes from archicortical trend of hippocampus, and is involved in spatial and conceptual processing, including executive functioning. The frontal poles are more recently evolved and are involved in self awareness, autonoetic consciousness, and humor.
By function:
Frontal lobe language (key reference is Alexander MP et al., 1989 Brain Lang. ) excluding articulation and Broca's aphasia, frontal language function and dysfunction is grouped under activation and formulation (paralinguistics). Dynamic aphasia, or trouble activating language, occurs after damage to SMA or ACC. TMA, with truncated language, occurs after damage to left DLPFC. (in other publications, Alexander refers to 'subbcallosal fasciculus'). Usually this is tested using letter fluency. In Stuss 1998 (JINS) rview of 74 local lesion patients, left DLPFC patients were most impaired, right DLPFC and VPFC patients were not impaired. However left parietal lesioned patients also were impaired and could not be differentiated from left DLPFC patients. Superior medial damage on either side (SMA) was associated with poor productions, and posterior superior lateral temporal lesions were implicated . The latter could be teased out by switching between letter and semantic fluency tasks. All above are left sided lesions (except SMA). Discourse lesions that are left sided include simplification, perseveration and omissions. Right sided lesions may cause amplification of details, wandering from topic, insertion of irrelevancies, and dysprosody, leading to incoherence.
Control of Memory:
Its important to differentiate between basic associative cue-engram processes (medial temporal lobe/hippocampal structures) and strategic processes that may be more top down such as coordination, elaboration and interpretation of these processes. Wechsler Memory Scale and many others tap both processes but make no effort to dissociate them. Author cites CVLT as an example of the "Boston approach" that includes efforts to measure serial position learning, semantic organization, interference effects, cued recall, recognition and response bias. Most recent WMS revision has semantically unrelated words, precenting analysis of semantic clustering. Stuss et al. 1994 Psychology showed right DLPFC lesion patients had more intralist repetitions due to response monitoring defect. Left frontal caused problems with encoding, retrieval and recognition. Frontal lobes are important to retrieval involving monitoring, verification, & placement of information especially in spatial and temporal contexts, with lesions causing reduplication, confabulation and retrograde amnesia. There is a right hemispheric bias in retrieval, but also a DLPFC/VPFC wherein latter is involved in retrieval cue specification and former in higher level postretrieval monitoring (see Fletcher, 1998 Brain, also Petrides).
Working Memory:
Original idea jacobsen 1936 monkeys with frontal lesions could not make decisions once stimulus was removed from view. Frontal lobe involvement keeps information online while other areas (slave systems) perform operations. Frontal involvement increases with interference . DLPFC monitors and manipulates, whereas VPFC maintains, controls interference and inhibition. Digit span/spatial span give information about working memory storage capacity but not rehearsal or executive control. Frontal lesions in one study did not affect digit span. Reverse digit span measures manipulation of above. Brown-Peterson technique taps interference. Supraspan tests measure processing when capacity is exceeded. Not standard.
Anterior attention processes
Attentional switching: WCST and TMT, part B. WCST originally shown by Milner to be response to frontal damage. New problem solving Dias et al. (J Neurosci 1997). . WCST shifts are extradimensional eg. color to form, on basis of feedback, or intradimensional, eg within a color red to blue. Extradimensional shifts are due to DLPFC in healthy adults. VPFC damage does not affect extradimensional shifting. However, VPFC lesions could contribute to the relatively rare error of loss of set due to susceptibility to interference. DLPFC patients also had loss of set due to loss of sustained attention.Posterior damage also can affect WCST.
TMT Part B ostensibly uses Part A as an internal control for factors other than switching, but has been criticized as not well matched to Part B in other respects. Stuss et al. found time correlated with frontal pathology, but effect was eliminated when score was corrected for TMT Part A. DLPFC patients were distinguished from Part A based on errors but not time.
Selective attention: Stroop test
Stuss found deficit in left sided lesions was due to problems in color naming, not interference. (Stuss et al., Neuropsychologia 2001). Patients with superior medial lesions showed errors due to importance of area in maintaining an activated intention. Inferior medial patients were normal.
Sustained attention:
Continuous performance tests are sensitive to frontal damage especially with increased complexity (eg. respond to "O" after "x". The Sustained Attention to Response Tast (SART, Robertson 1997 Neuropsychologia) and the Elevator Counting Test (Robertson 1991 the Test of Everyday Attention)
VPFC important in acquiring and reversing stimulus/reward. The Iowa Gambling Test (Bechara et al.) is based on Somatic Marker Hypothesis, that reasoning is constrained based on previous conditioning, mediated by ventromedial frontal lobes. VPFC lesions cause "self regulatory disorder" or "SRD." Another test is the Strategy Application Test, based on the Six Element Test of Shallice and Burgess. Every patient with focal VPFC damage, especially on right was impaired. It correlated with outcome questionnaires.
Frontal Pole: Autobiographical Memory Test. (Kopelman, 1989J Clin Exper Neuropsychol). Also, Dysexecutive Questionnaire (Burgess et al, 1996
Saturday, July 24, 2010
NPH questionnaires for initial evaluation
from The Neurologist 2010 Wilson et al.
Gait
Gait
- Do you have a problem getting in or out of a seat, walking, or maintaining your balance?
- How long has it been since you first had this problem?
- Do you have a problem getting in and out of a car?
- Do you have a problem starting to walk, as though your feet are stuck to the floor?
- Do you shuffle or scuff your feet as you walk?
- Do you have trouble turning?
- Do you have trouble stepping over a curb or walking on an uneven surface such as grass?
- Do you touch walls, surfaces or countertops when you walk?
- In the past month, how often have you fallen?
- Do you use a cane, walker or wheelchair?
- Do you urinate more frequently than you used to?
- Do you lose a little urine before reaching the toilet?
- Do you lose control of your bladder (incontinence)?
- Do you wear a pad, undergarment or Depends for protection?
- Do you have trouble with your thinking or memory?
- How long have you had the trouble?
- Do you have trouble with forgetfulness (repeating questions, difficulty learning, short term memory loss)
- Do you have trouble with orientation ( getting lost, disoriented, losing track of time, not recognizing familiar places or persons)
- Do yo have problems with judgment or solving everyday problems at home such as managing medications, money, cooking, or understanding explanations?
- Do yo have trouble caring for yourself, for example, bathing, using the toilet, dressing or eating?
- Do you have trouble organizing your schedule or routine?
Sunday, June 13, 2010
Uniform Data Set for Neuropsychological Battery and Select Informant Measures
Neuropsychological Assessment for possible Alzheimer's disease
Domain assessed Assessment Tools Substitute Tool/additional tool
Multidomain screening tool MMSE MoCa
Verbal episodic memory WMS R, Log mem IA imm
Delayed verbal episodic memory WMS R, Log mem IIA delayed
Attention Digit Span forward and backward
Executive function Trailmaking Test Part B additional: COWAT, category fluency
Psychomotor speed Trailmaking Test Part A
WAIS R digit symbol SDMT
Language Boston Naming Test (30 item) additional: BNT (60 item)
Token Test, finger naming, color
naming, right-left orientation, reading
writing, spelling
Functional Status Clinical Dementia Rating
Functional Assessment Questionnaire
Behavioral Assessment Geriatric Depression Scale Zung Depression/Anxiety Scales
Neuropsychiatric Inventory Questionnaire
Source Morris JC, Weintraub S, Chui HC et al. The Uniform Data Set (UDS) clinical and cognitive variables and descriptive data from Alzheimer's disease centers. Alz Dis Assoc Disord 2006; 20: 210-216.
Third column represents solely my own substitutions and additions
Other useful standard tests
Caregiver Burden Index (Zarit)
Praxis: test limb and oral praxis from Behavioral Neurology Index
Nonverbal memory: Rey O CFT, copy, immediate and delayed
Domain assessed Assessment Tools Substitute Tool/additional tool
Multidomain screening tool MMSE MoCa
Verbal episodic memory WMS R, Log mem IA imm
Delayed verbal episodic memory WMS R, Log mem IIA delayed
Attention Digit Span forward and backward
Executive function Trailmaking Test Part B additional: COWAT, category fluency
Psychomotor speed Trailmaking Test Part A
WAIS R digit symbol SDMT
Language Boston Naming Test (30 item) additional: BNT (60 item)
Token Test, finger naming, color
naming, right-left orientation, reading
writing, spelling
Functional Status Clinical Dementia Rating
Functional Assessment Questionnaire
Behavioral Assessment Geriatric Depression Scale Zung Depression/Anxiety Scales
Neuropsychiatric Inventory Questionnaire
Source Morris JC, Weintraub S, Chui HC et al. The Uniform Data Set (UDS) clinical and cognitive variables and descriptive data from Alzheimer's disease centers. Alz Dis Assoc Disord 2006; 20: 210-216.
Third column represents solely my own substitutions and additions
Other useful standard tests
Caregiver Burden Index (Zarit)
Praxis: test limb and oral praxis from Behavioral Neurology Index
Nonverbal memory: Rey O CFT, copy, immediate and delayed
Saturday, May 8, 2010
Localization of JLO and FRT
FRT (facial recognition test) of Benton localizes most strongly to the right posterior inferior parietal and right ventral occipital temporal (fusiform areas)
Judgment of Line Orientation localizes best to right posterior parietal area.
references
1) Tranel and Levin, in press JCEN
Judgment of Line Orientation localizes best to right posterior parietal area.
references
1) Tranel and Levin, in press JCEN
Monday, March 8, 2010
Validity of MOCA and MMSE in Parkinsons disease
Hoops S et al. Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. Neurology 2009; 73:1738-1745.
MoCA is better than MMSE in MCI and AD in general population. Using a cutoff score of less than or equal to 25 on the MoCA in PD found that 52 % of patients with normal MMSE had impairment using this point. MoCA has good test-retest reliability, interrater reliability, and convergent validity with a neuropsychological battery ina small sample of patients with PD. This study looked at discriminant validity using 132 subjects (NC 92, mci 23, pdd 17). MoCA and MMSE performance for subjects with cognitive deficits on neuropsych testing without self report of cognitive decline showed no differences between the 2 tests. HOWEVER, EXAMINING MoCA SUBSCORE, PATIENTS WITH MCI OR PDD HAD SIGNIFICANTLY LOWER VISUOSPATIA/EXECUTIVE, ATTENTION, LANGUAGE, DELAYED RECALL, AND ORIENTATION SUBSCORES.
Discussion-- MoCA has good discriminant validity and performs similarly to MMSE overall, but is superior as a screening instrument. The optimal screening point cutoff for detection of any cognitive disorder for MoCA had greater specificity (.53)
MoCA is better than MMSE in MCI and AD in general population. Using a cutoff score of less than or equal to 25 on the MoCA in PD found that 52 % of patients with normal MMSE had impairment using this point. MoCA has good test-retest reliability, interrater reliability, and convergent validity with a neuropsychological battery ina small sample of patients with PD. This study looked at discriminant validity using 132 subjects (NC 92, mci 23, pdd 17). MoCA and MMSE performance for subjects with cognitive deficits on neuropsych testing without self report of cognitive decline showed no differences between the 2 tests. HOWEVER, EXAMINING MoCA SUBSCORE, PATIENTS WITH MCI OR PDD HAD SIGNIFICANTLY LOWER VISUOSPATIA/EXECUTIVE, ATTENTION, LANGUAGE, DELAYED RECALL, AND ORIENTATION SUBSCORES.
Discussion-- MoCA has good discriminant validity and performs similarly to MMSE overall, but is superior as a screening instrument. The optimal screening point cutoff for detection of any cognitive disorder for MoCA had greater specificity (.53)
Saturday, March 6, 2010
Concerns about the WAIS 4 and WMS 4
Loring DW, Bauer RM. Cautions and concerns regarding the newWechsler IQ and Memory Scales. Neurology 74: 685-690 2010.
The new tests have fundamental changes from the old versions and are not established in various populations that they intend to serve. Although the guidelines require neuropsychologists to use the "most current" tests, Bauer and Loring argue that the old tests are better validated and should be used preferentially in many cases.They compare the new versions of the WMS and WAIS to Windows Vista software release-- those who wish to run Windows XP should not be prevented from doing so.
Authors note the WAIS traditional scores of VIQ and PIQ are not truly measures of verbal and nonverbal intelligence as originally conceived, but cluster into 4 domains of verbal comprehension, perceptual reasoning, working memory, and processing speed. VIQ contains measures of verbal abstraction (Similarities) and knowledge (Information), also attention and working memory (Digit Span). PIQ shows visuospatial problem solving (Block Design) and processing speed (Digit Symbol). In WAIS III, 4 factor composites could be calculated, along with PIQ and VIQ.
In WAIS 4, only FSIQ can be calculated, with VIQ and PIQ eliminated. VCI and PCI are "substituted" for VIQ and PIQ for "decision making." VCI and PCI exclude working memory and processing speed, which account for 40 % of the variance of FSIQ. The General Abilities Index (GAI) is introduced, which also excludes working memory and processing speed. GAI does not replace FSIQ, and VCI and PCI do not measure the same things as VIQ and PIQ.
The WAIS subsets have been changed to decrease emphasis on speeded tests, so that they are less sensitive to diseases that show psychomotor slowing (such as Parkinson's disease) and slowed information processing (such as multiple sclerosis). The new WAIS will most likely have less patients with FSIQ under 70, leading to epidemiologic mismatches and skews in historical studies and less people qualifying for disabilities. This is because many diseases with disability depend on the measurement of psychomotor slowing. The ostensible reason for the new version, to recalibrate the average IQ to 100, may not be met since the amount of change in the FSIQ mean is less than the variance of the test.
The WMS-4 incorporates changes, but many previous changes have fallen flat and then been eliminated in the "next" edition of the test. The most important change since 1945 is the inclusion of the 30 minute delayed recall of the Logical Memory and Visual Reproduction subtests. In the WMS 3, previous concerns that were addressed failed to hold up under clinical experience and subsequently had to be dropped, analagous to a new software release. In the WMS-4, the second trial for repetition of one of the to Logical Memory stories is inexplicably dropped, even though one of the reasons for the failure to find material specific memory impairments is the use of single trial memory tasks instead of learning over trials. New nonverbal memory test within a grid may prove beneficial, because it requires remembering both visual and spatail information, but that has yet to be determined empirically. Moreover, validity of the tests to specific diseases and prediction of clinical outcome is absent with the new tests. For example, only 8 patients who had undergone temporal lobectomy were in the sample. In some clinical trials, the HVLT or RVLT have been chosen because they are unlikely to be revised. Test retest data also does not exist, and will not for many years, with the new forms of the tests, because data was not obtained prior to publication.
Authors conclude that the old tests are not outdated, but proven useful, and that the new versions of the old tests do not deserve to be considered automatically current without further validation.
The new tests have fundamental changes from the old versions and are not established in various populations that they intend to serve. Although the guidelines require neuropsychologists to use the "most current" tests, Bauer and Loring argue that the old tests are better validated and should be used preferentially in many cases.They compare the new versions of the WMS and WAIS to Windows Vista software release-- those who wish to run Windows XP should not be prevented from doing so.
Authors note the WAIS traditional scores of VIQ and PIQ are not truly measures of verbal and nonverbal intelligence as originally conceived, but cluster into 4 domains of verbal comprehension, perceptual reasoning, working memory, and processing speed. VIQ contains measures of verbal abstraction (Similarities) and knowledge (Information), also attention and working memory (Digit Span). PIQ shows visuospatial problem solving (Block Design) and processing speed (Digit Symbol). In WAIS III, 4 factor composites could be calculated, along with PIQ and VIQ.
In WAIS 4, only FSIQ can be calculated, with VIQ and PIQ eliminated. VCI and PCI are "substituted" for VIQ and PIQ for "decision making." VCI and PCI exclude working memory and processing speed, which account for 40 % of the variance of FSIQ. The General Abilities Index (GAI) is introduced, which also excludes working memory and processing speed. GAI does not replace FSIQ, and VCI and PCI do not measure the same things as VIQ and PIQ.
The WAIS subsets have been changed to decrease emphasis on speeded tests, so that they are less sensitive to diseases that show psychomotor slowing (such as Parkinson's disease) and slowed information processing (such as multiple sclerosis). The new WAIS will most likely have less patients with FSIQ under 70, leading to epidemiologic mismatches and skews in historical studies and less people qualifying for disabilities. This is because many diseases with disability depend on the measurement of psychomotor slowing. The ostensible reason for the new version, to recalibrate the average IQ to 100, may not be met since the amount of change in the FSIQ mean is less than the variance of the test.
The WMS-4 incorporates changes, but many previous changes have fallen flat and then been eliminated in the "next" edition of the test. The most important change since 1945 is the inclusion of the 30 minute delayed recall of the Logical Memory and Visual Reproduction subtests. In the WMS 3, previous concerns that were addressed failed to hold up under clinical experience and subsequently had to be dropped, analagous to a new software release. In the WMS-4, the second trial for repetition of one of the to Logical Memory stories is inexplicably dropped, even though one of the reasons for the failure to find material specific memory impairments is the use of single trial memory tasks instead of learning over trials. New nonverbal memory test within a grid may prove beneficial, because it requires remembering both visual and spatail information, but that has yet to be determined empirically. Moreover, validity of the tests to specific diseases and prediction of clinical outcome is absent with the new tests. For example, only 8 patients who had undergone temporal lobectomy were in the sample. In some clinical trials, the HVLT or RVLT have been chosen because they are unlikely to be revised. Test retest data also does not exist, and will not for many years, with the new forms of the tests, because data was not obtained prior to publication.
Authors conclude that the old tests are not outdated, but proven useful, and that the new versions of the old tests do not deserve to be considered automatically current without further validation.
Sunday, January 31, 2010
Merkfahigkeit
investigation of memory from studying retention of an increasingly long series of rote elements
Friday, January 22, 2010
Tests by domain Hodges
Orientation--standard 5-10 items are not specific. One author (Hodges) suggests adding time of day as even mildly demented will show confusion of time of day esp. AM for PM
Language-- Aspects to cover in screening are fluency in conversation, and level of comprehension (oral and written). Also, naming, repetition, reading and writing. If abnormal , tests should be supplemented by additional testing.
Spatial abilities-- Draw a clock or copy Necker cube is more sensitive than the interlocking pentagons of the MMSE. (Add so is CFT).
Perception-- authors suggest testing telling time from analog clock faces.
Frontal lobe functions-- Proverbs are positive in nondemented noneducated patients. Suggests Luria's Three Hand Test. Notes localization not specific could also be subcortical. I also use F,A,S test routinely.
Psychomotor speed- easy screening test-- ask the patient to write alphabet as quickly as possible. Score shold be less than 20 seconds.
Language-- Aspects to cover in screening are fluency in conversation, and level of comprehension (oral and written). Also, naming, repetition, reading and writing. If abnormal , tests should be supplemented by additional testing.
Spatial abilities-- Draw a clock or copy Necker cube is more sensitive than the interlocking pentagons of the MMSE. (Add so is CFT).
Perception-- authors suggest testing telling time from analog clock faces.
Frontal lobe functions-- Proverbs are positive in nondemented noneducated patients. Suggests Luria's Three Hand Test. Notes localization not specific could also be subcortical. I also use F,A,S test routinely.
Psychomotor speed- easy screening test-- ask the patient to write alphabet as quickly as possible. Score shold be less than 20 seconds.
Saturday, January 16, 2010
Motor tests from Lezak second edition
Finger Oscillation Test (finger tapping). p 529
Each hand makes 5 ten second trials, and the score is the average for the five trials for each hand. Men perform faster than women in all age groups.
Grooved pegboard-- is part of the Wisconsin Neuropsychological Test Battery and the Lafayette Clinical Repeatable Neuropsychological Test Batter (p 532). Its sensitive for following improvement after stroke. Can use preferred hand, opposite hand or both hands, norms not well established, key point is it can be used to look at improvement with intervention.
Each hand makes 5 ten second trials, and the score is the average for the five trials for each hand. Men perform faster than women in all age groups.
Grooved pegboard-- is part of the Wisconsin Neuropsychological Test Battery and the Lafayette Clinical Repeatable Neuropsychological Test Batter (p 532). Its sensitive for following improvement after stroke. Can use preferred hand, opposite hand or both hands, norms not well established, key point is it can be used to look at improvement with intervention.
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