7.07 Neuropsychological Assessment of the Elderly

JOHN R. CRAWFORD and ANNALENA VENNERI University of Aberdeen, UK and RONAN E. O'CARROLL University of Stirling, UK

7.07.1 THE AIMS OF NEUROPSYCHOLOGICAL ASSESSMENT 134 7.07.2 SOME SPECIFIC CONSIDERATIONS IN NEUROPSYCHOLOGICAL ASSESSMENT OF THE ELDERLY 135 7.07.3 THE NEUROPSYCHOLOGICAL INTERVIEW 136 7.07.4 BASIC PSYCHOMETRIC ISSUES 137 7.07.4.1 The Rationale of Deficit Measurement in Clinical Practice 137 7.07.4.2 Converting Scores to a Common Measurement Scale 137 7.07.4.3 Reliability 138 7.07.4.4 Reliable vs. Abnormal Differences 138 7.07.4.5 Monitoring Change 139 7.07.5 APPROACHES TO ASSESSMENT IN CLINICAL NEUROPSYCHOLOGY 140 7.07.6 SCREENING TESTS FOR MENTAL STATUS 141 7.07.7 MEASURES OF CURRENT INTELLECTUAL ABILITY 141 7.07.7.1 Use of the WAIS-R with the Elderly 141 7.07.7.2 Analysis of Subtest Profiles 142 7.07.7.3 WAIS-R Factor Scores 144 7.07.8 SPECIFIC METHODS FOR THE ESTIMATION OF PREMORBID ABILITY 145 7.07.9 AGING AND MEMORY 146 7.07.9.1 Introduction to Aging and Memory 146 7.07.9.2 Age-associated Memory Impairment 147 7.07.9.3 Does Memory Functioning in Dementia Represent Accelerated Aging? 147 7.07.9.4 Commonly Used Memory Tests: Implications for use with Elderly Subjects 147 7.07.9.4.1 The Auditory Verbal Learning Test 147 7.07.9.4.2 The California Verbal Learning Test 148 7.07.9.4.3 The Wechsler Memory Scale-Revised 148 7.07.9.4.4 The Rivermead Behavioural Memory Test 149 7.07.9.4.5 The Rey Complex Figure Test 149 7.07.9.4.6 The Recognition Memory Test 149 7.07.9.4.7 The Doors and People Test 149 7.07.10 ASSESSING LANGUAGE DYSFUNCTION 150

133 134 Neuropsychological Assessment of the Elderly

7.07.10.1 Naming 150 7.07.10.2 Vocabulary 151 7.07.10.3 Discourse 151 7.07.10.4 Verbal Comprehension 152 7.07.11 ASSESSING VISUOPERCEPTUAL DYSFUNCTION 152 7.07.11.1 Visual Recognition 152 7.07.11.2 Visual Organization 153 7.07.11.3 Visuoconstructional Ability 153 7.07.11.4 Visual Interference 153 7.07.12 ASSESSMENT OF ATTENTION 153 7.07.12.1 Unilateral Neglect 153 7.07.12.2 The Anterior Attention System 154 7.07.13 ASSESSMENT OF EXECUTIVE FUNCTIONS 156 7.07.13.1 Frontal Hypotheses 156 7.07.13.2 Verbal Fluency 156 7.07.13.3 Nonverbal Fluency 157 7.07.13.4 Behavioral Assessment of the Dysexecutive Syndrome 158 7.07.14 THE DIFFERENTIAL DIAGNOSIS OF DEMENTIA VS. DEPRESSION 159 7.07.14.1 Delayed Verbal Recall Impairment as an Indicator of Early DAT? 159 7.07.14.2 Kendrick Cognitive Tests for the Elderly 160 7.07.14.3 Effortful vs. Automatic Processing and Memory 161 7.07.14.4 Is Poor Memory Test Performance in Elderly Depressed Patients an Artifact of Poor Motivation? 161 7.07.14.5 Future Directions 161 7.07.14.6 Recommendations and Conclusions for the Differential Diagnosis of Dementia vs. Depression 162 7.07.15 REFERENCES 162

7.07.1 THE AIMS OF plead in criminal cases (i.e., could a client with NEUROPSYCHOLOGICAL known or suspected neuropsychological defi- ASSESSMENT cits follow a legal argument against her/him and have an appreciation of its import), and In the early days of clinical neuropsychol- evaluation of pleas of diminished responsi- ogy, most neuropsychological assessment was bility (i.e., did pre-existing neuropsychological aimed at answering questions concerning deficits impair a client's responsibility for her/ differential diagnosis and lesion location. With his actions?). the rapid advances in brain imaging tech- In broad terms, neuropsychological assess- nology the importance of this aim has ment is aimed at answering the following diminished; the focus of assessment has moved questions: to identifying the cognitive and behavioral (i) Which components of the cognitive sys- consequences of cerebral dysfunction whether tem are dysfunctional, how severe is this this be for rehabilitative or medico-legal dysfunction, and also, just as importantly, purposes. However, the neuropsychologist which components have been spared? continues to play a valuable role in these (ii) To what extent has there been change in former areas, most notably in the diagnosis of mood, comportment, and personality; to what dementing illnesses. In addition, although most extent are these likely to be a direct effect of neuropsychologists work in acute neurological/ neurological damage as opposed to a psycho- neurosurgical services or rehabilitation set- logical reaction to any injury or illness? tings, most also take direct referrals from (iii) What are the implications of any general medical and psychiatric services. As a changes in cognition, mood, and comportment result of this they are often the first to establish for a client's every day functioning now and in evidence for the presence of a neurological the foreseeable future? disorder. (iv) Based on the pattern of cognitive Medico-legal assessments constitute a sig- strengths and weaknesses and changes in mood nificant part of many neuropsychologists' and comportment, what practical advice can be workloads. Areas of particular relevance to given regarding the design of any formal the elderly in which a neuropsychological rehabilitation and what advice can be given opinion is sought include issues of guardian- to the client and significant others to help them ship (e.g., is a client competent enough to adjust to any deficits? manage their own financial affairs?) and These questions are answered by integrating fitness to hold a driving license. Other areas information gained from the medical notes, an include personal injury litigation, fitness to interview with the client (and whenever possible Some Specific Considerations in Neuropsychological Assessment of the Elderly 135 a relative or close acquaintance), and the Test fatigue can be an issue with the elderly qualitative and quantitative findings from for- and requires avoiding long test sessions. The mal neuropsychological testing. neuropsychologist should also be sensitive to the possibility of effects arising from the order of test administration when examining test 7.07.2 SOME SPECIFIC profiles. Clinicians experienced in working with CONSIDERATIONS IN individuals with dementia, particularly those in NEUROPSYCHOLOGICAL the early stages, will also be aware of their ASSESSMENT OF THE ELDERLY ability to ªlift their gameº for short periods sometimes to the frustration of their relatives There is a strong relationship between who have sought an appointment because of sensory deficits and cognitive function in elderly concerns over cognitive deterioration. populations. For example, Lindenberger and As the result of more elderly people taking an Baltes (1994) conducted structural equation increased interest in their health and the risks modeling of the relationship between age, associated with aging, the neuropsychologist cognitive test performance, and sensory func- can play an important role in establishing tioning in an elderly sample (age range 70±103) objective evidence of adequate performance, and found that visual and auditory acuity thereby providing reassurance to clients. accounted for 49% of the total and 93% of the Prior to 1990, there was a lack of adequate age-related variance in cognitive performance. normative data on neuropsychological tests for They evaluated a number of causal hypotheses the elderly. However, as governments have to explain this relationship and concluded that it digested the implications of the change in the arose because both cognitive performance and age structure of their populations, resources acuity were indicators of the underlying phy- have been allocated to large-scale studies such siological integrity of the aging brain. However, as the Australian Longitudinal Study of Ageing an additional possibility not considered by (e.g., Bryan, Luszcz, & Crawford, 1997), the Lindenberger and Baltes is that sensory deficits Cambridge Ageing Project (see Huppert, 1994), impose an additional central processing load, the Mayo Older Americans Normative Study resulting in poorer performance on cognitive (e.g., Ivnik et al., 1992), and the Canadian Study tasks. Consistent with this possibility, Rabbit of Health and Aging (e.g., Tuokko & Wood- (1990) has reported that elderly subjects with ward, 1996) among others. As a result, it will 35±50 db hearing loss could repeat aloud soon be possible to have better norms for the flawlessly words read out to them but showed elderly than for other age groups. poor recall relative to age and IQ-matched The conventional approach to norming of controls with good hearing. In contrast, they tests is to obtain a sample which has been had no such problem when the words were screened carefully to exclude potential partici- presented visually. This effect can be modeled in pants with any medical conditions which may young subjects with good hearing when they have a detrimental effect on cognitive perfor- have to process words heard through white mance. The case for an alternative approach has noise. Rabbitt (1968) found that, under these been well made by Huppert and colleagues. For conditions, the words were repeated successfully example, Huppert (1994) has argued that but recall was poor. It would appear, then, that ªRather than excluding individuals with risk the extra effort expended on making out the factors which might affect performance, nor- material places demands on processing re- malisation samples should be based on un- sources which would otherwise be free for selected population samples and the effects of rehearsal or elaborative encoding, etc. This has these risk factors should be examinedº far-reaching implications for the interpretation (pp. 315±316). These two approaches are best of neuropsychological test results in the elderly seen as complimentary rather than competitors. as evidence that clients are able to successfully Comparison of an individual's performance to make out the stimulus materials does not rule with conventional norms, or norms based on out the possibility that their sensory deficits, regression scores derived from demographic rather than a higher level problem, has impaired variables (i.e., age, education, current or former their performance. occupation, etc.), can address the issue of The presence of sensory loss should also be whether there is evidence of acquired impair- borne in mind when attempting to evaluate if ment in a particular functional domain. The there is dispositional change resulting from a latter approach, presumably using multiple central organic process. For example, hearing regression equations, can then potentially in- loss can lead to withdrawal from previous social form the clinician as to whether such impair- activities because of frustration and the impa- ment is likely to be unusual for someone with tience of others. this particular combination of factors in their 136 Neuropsychological Assessment of the Elderly medical history. It should be noted, however, (1989) states in this latter context, ªthe examiner that this latter approach would be complex and is attempting to estimate whether the patient is a would require very large samples. passive receptor of disability or an active fighter struggling to achieve a better outcomeº (p. 66). The neuropsychologist has a large agenda to 7.07.3 THE NEUROPSYCHOLOGICAL cover in the interview and often will be under INTERVIEW time pressure; this necessitates a structured, systematic inquiry. However, most formal Conducting a neuropsychological interview neuropsychological tests also provide a struc- demands considerable empathy, tact, and ture for the client; the examiner sets out the intellectual effort. In many cases, the client will concrete aims and rules, and largely controls have multiple cognitive and physical disabilities the pace and order of the items administered and organically induced changes in mood and (see the section on assessment of executive personality; they will also be attempting to cope deficits for further discussion and exceptions to with the often massive interpersonal and this). It is, therefore, important that enough of economic upheaval arising from their illness the interview is minimally structured to or injury. Added to this is the fact that a determine the extent to which the client initiates neuropsychological assessment can be anxiety and organizes the discussion of topics. provoking because of potential threats to self- A detailed educational history is important in esteem or because of its medico-legal ramifica- building a picture of a client's premorbid tions; accordingly some clients can exhibit more abilities. The history should include years of concern at the prospect of such an assessment schooling (with a check on whether any of these than over the lengthy and sometimes painful were repeat years), the nature of any tertiary and bewildering physical investigations they education and any further study (evening may have to undergo. classes, day release, etc.), and formal qualifica- As in all clinical interviewing, time must be tions and grades achieved. The possibility that spent establishing rapport and clarifying the health, economic, social, or attitudinal factors nature and purpose of the investigation. Gen- may have prevented a client achieving their full eral, open-ended, and nonthreatening questions educational and occupational potential should should be employed, followed by a request for be carefully explored. the client to describe any problems they have The client should be asked to describe the been experiencing in their everyday life. The nature of their previous and/or current occupa- client's description of these everyday problems tion with a detailed breakdown of the duties constitutes a principal source for the generation and functions performed. The nature of their and refinement of clinical hypotheses which will work and responsibilities provides additional be tested in the course of the examination. Such clues to general premorbid level of functioning descriptions and follow-up questions are also but also an indication of specific premorbid crucial in establishing the degree of insight the cognitive skills that are likely to have been client has into the nature and severity of their strongly developed/highly practiced. The clin- deficits. Lack of insight is a major barrier to ician should inquire if there have been any effective intervention and a client's successful recent changes in living circumstances, and if adjustment. A client may exhibit a cheery relevant, the work environment (i.e., introduc- disregard in the face of severe deficits coupled tion of new technology, reorganization of with grossly unrealistic expectations concerning duties) as such changes can often be the catalyst a return to a former occupation or lifestyle; in which exposes problems in an individual who other cases there may be a disproportionate had previously been coping despite diminished concern with a relatively minor cognitive or cognitive resources. physical problem when other deficits have much Lezak (1995) sets out a number of funda- more serious implications. mental questions which must be addressed prior Often, the most useful clinical information to formal testing; these include: does the client from the interview is gained by asking clients understand the reason for referral and do they about their short-, medium-, and long-term have specific questions of their own they want goals and how they intend to achieve them. answered? Do they understand the uses to which Answers to such questions are relevant to the information gained from the examination assessing drive, mood, planning ability, and may be put and who will and will not have access level of insight. Inquiries about how they spend to it? (of particular importance in medico-legal a typical day can also be employed to address contexts); do they know how and when feed- these issues which have implications for the back will be provided? Finally, do they approach that should be adopted in any appreciate that the assessment will largely be rehabilitation/remediation attempts. As Brooks concerned with cognitive functioning (misper- Basic Psychometric Issues 137 ceptions abound) and are they aware of the 7.07.4.2 Converting Scores to a Common general nature of the tests to be employed? In Measurement Scale individuals with severe deficits the answers to these questions cannot be fully in the affirmative In constructing a neuropsychological profile and it is therefore important that their relatives of a client's strengths and weaknesses, most or guardians are briefed. clinicians use instruments drawn from diverse sources. These instruments will differ from each other in the measurement scale used to express 7.07.4 BASIC PSYCHOMETRIC ISSUES test scores; for some instruments no formal scaling will have been developed so that 7.07.4.1 The Rationale of Deficit Measurement clinicians will be working from the means and in Clinical Practice standard deviations (SDs) of the raw score from normative samples. The process of assimilating Attempting to detect and quantify cognitive the information from these tests is eased greatly deficits in the individual case is problematic if the scores are all converted to a common scale because of the wide variability in cognitive of measurement. abilities within the general population. Scores Converting all scores to percentiles has the on neuropsychological measures which are important advantage that percentiles are com- average or even above average can still represent prehended easily by other health workers. a significant impairment for an individual of However, because such a conversion involves high premorbid ability (and have serious an area transformation (i.e., the difference implications for return to a previous lifestyle between a percentile score of 10 and 20 does or occupation). Similarly, test scores which fall not reflect the same underlying raw score well below the mean do not necessarily reflect an difference as that between 40 and 50), they acquired impairment for an individual whose are not ideally suited to the rapid and accurate premorbid resources were modest. Because of assimilation of information from a client's this, normative comparison standards are of profile; percentiles are also inappropriate for limited utility in neuropsychological assessment use with many inferential statistical methods. Z and must be supplemented by individual scores do not suffer from these problems but comparison standards when assessing acquired have the disadvantage of including negative deficits (Crawford, 1992; Lezak, 1983; Walsh, values and decimal places which can cause 1991). Ideally, this individual comparison problems in communication. standard can be obtained from psychological One option is to convert all scores to have a test scores obtained in the premorbid period. mean of 100 and SD of 15 (McKinlay, 1992) as However, this is rarely a viable option; the tests commonly forming a part of the neuro- amount of routine psychological testing con- psychologist's armamentarium are already ex- ducted varies greatly between countries so that pressed on this scale, that is, IQs and factor many individuals may have had no prior formal score indices on the Wechsler Adult Intelligence testing. Even where such test results exist they Scale-Revised (WAIS-R; Wechsler, 1981), are often difficult or impossible to obtain, the memory indices from the Wechsler Memory content of the tests may have limited relevance, Scale-Revised (WMS-R; Wechsler, 1987), and or they may have been administered so long ago estimates of general premorbid ability such as that they are of questionable value. Because of the National Adult Reading Test (NART; these difficulties clinicians normally have to Nelson & Willison, 1991). The most common settle for an individual comparison standard alternative is to use T scores (mean 50; SD=10); which is based on a client's current perfor- the meaning of such scores are easy to mance. The explicit rationale here is that (i) communicate and are free of the conceptual cognitive ability measures are almost invariably baggage associated with deviation IQs. positively correlated, therefore performance on Regardless of which method is used, the one measure allows some level of prediction of clinician must be constantly aware that the performance on another, and (ii) some abilities validity of any inferences regarding relative will be preserved, or relatively so, following strengths and weaknesses is heavily dependent most neurological injuries or illnesses. Thus, the on the degree of equivalence of the normative areas in which a client has performed best are samples for the test results compared. Although used as the standards (i.e., estimates of the quality of normative data for neuropsycho- premorbid ability) against which to compare logical tests has improved markedly since the performance on other measures. Large discre- 1980s, there are still tests used in practice which pancies between measures are taken as indica- are standardized on small samples of conve- tors of the presence and severity of acquired nience, the representativeness of which are impairment (Lezak, 1991). largely unknown. Thus, discrepancies in an 138 Neuropsychological Assessment of the Elderly individual's profile may in some cases be more a reliability of a difference score (e.g., see Crocker reflection of differences between normative & Algina, 1986) reveals that the reliability of this samples than differences in the individual's priming score would be only 0.37. This relative level of functioning in the domains compares unfavorably with the reliability of covered by the tests. most explicit memory tests and raises the danger that the clinician may conclude that an individual has impaired explicit memory 7.07.4.3 Reliability coupled with preserved implicit memory when the pattern may simply be an artifact of Adequate reliability is a fundamental re- differences in reliability. quirement for any instrument used in neuropsychology regardless of purpose (Franzen, 1989). However, when the concern is with 7.07.4.4 Reliable vs. Abnormal Differences assessing the cognitive status of an individual its importance is magnified, particularly as the The distinction between the reliability and the demands of clinical practice are such that abnormality of differences between test scores is decisions, must be commonly made based on an important one in clinical neuropsychology. A information from single administrations of difference between scores normally would be each instrument. considered reliable if it exceeded the 95% Information on test reliability is used to confidence interval for the difference, that is, quantify the degree of confidence that can be a difference of this magnitude is unlikely to have placed in test scores, for example, when arisen from measurement error in the instru- comparing an individual's scores with appro- ments. Establishing if a difference is reliable is priate normative data or assessing whether only the first step in neuropsychological profile discrepancies between scores on different tests analysis. There is considerable intraindividual represent genuine differences in the functioning variability in cognitive abilities in the general of the underlying components of the cognitive elderly population such that reliable (i.e., system as opposed to simply reflecting measure- statistically significant) differences between ment error in the tests employed. In the latter tests of these different abilities are common. case, that is, where evidence for a differential In evaluating the probability that a discrepancy deficit is being evaluated, it is important to reflects acquired impairment, it is important to consider the extent to which the tests are consider the abnormality or rarity of the matched for reliability; an apparent deficit in difference, that is, what percentage of the function A with relative sparing of function B general (i.e., unimpaired) elderly population may simply reflect the fact that the measure of would be expected to exhibit a difference of this function B is less reliable. This point was well magnitude? made in a classic paper by Chapman and Base rate data, which permits the clinician to Chapman (1973) in which the performance of a assess the abnormality of test score discrepan- schizophrenic sample on two parallel reasoning cies, is available for some neuropsychological tests was examined. By manipulating the measures. When such data are not available, a number of test items the schizophrenic sample simple formula can be used to estimate the was made to appear to have a large differential abnormality of any discrepancy from the deficit on one or other of the tests. correlation between the two tests of interest Particular care should be taken in comparing (see Payne & Jones, 1957). It is also possible to test scores when one of the measures is not a assess the abnormality of the discrepancy simple score but a difference or ratio score. Such between a single test and a client's mean scores scores are used quite commonly in neuropsy- on a series of measures (Silverstein, 1984). chological assessment; for example, in the To highlight the distinction between the assessment of implicit memory functioning a reliability and abnormality of a difference take priming score may be derived from the the example of a discrepancy between the difference between completion of word frag- General Memory and Attention/Concentration ments (e.g., c±pe± / carpet) from a list that has indices of the WMS-R. A discrepancy of 17 been primed in an earlier study phase and an points would be necessary for a reliable unprimed list (performance on the unprimed list difference (p < 0.05). Based on the average essentially controls for individual differences in correlation between these two indices in the verbal ability). This priming score will have WMS-R standardization sample (r=0.51), poor reliability because the measurement error approximately 25% of the general population associated with the two lists is additive. For would be expected to exhibit a discrepancy of example, if both lists had reliabilities of 0.75 and this magnitude; to be abnormal (operationally an intercorrelation of 0.6, the formula for the defined for the present purpose as discrepancy Basic Psychometric Issues 139 which would occur in less than 5% of the provide a good example as they are widely used general population), a 29-point discrepancy in the treatment of various conditions and yet would be required. can have serious negative effects on cognition, The importance of evaluating the abnorm- particularly memory (Crawford, Besson, & ality of discrepancies through base rate data or Ebmeier, 1990). correlational techniques cannot be overstressed. In assessing the effectiveness of a rehabilita- Most clinical neuropsychologists have not had tion effort it is often possible to obtain multiple the opportunity to administer neuropsycholo- repeated measures of an individual's perfor- gical measures to significant numbers of mance before, during, and after intervention. A individuals drawn from the general elderly number of inferential statistical techniques can population. It is possible, therefore, to form a be used in this situation because there are distorted impression of the degree of intrasub- multiple data points for the different phases (see ject variability found in unimpaired individuals. Barlow & Hersen, 1984 for a general treatment The impression is that the degree of normal of single-case designs). However, in general variability may be underestimated leading to a clinical practice the neuropsychologist often danger of overinterference when working with must come to conclusions about change from clinical populations. For example, Matarazzo, only a single retesting. This situation will also Daniel, Prifitera, and Herman (1988) have arise in rehabilitation settings; although multi- reported that in the WAIS-R standardization ple measures may have been obtained on the sample, a sample presumed to be free of training task(s), the issue of the generalizability neurological or psychiatric disorder, the mean of any improvement is often addressed by difference between an individual's highest and comparing single before-and-after scores on lowest WAIS-R subtest score was 6.7. For this related, but separate tests. difference (i.e., the subtest range to be abnormal Monitoring change on the basis of a single it would have to exceed 11 Scaled score points. retesting is a formidable task except in cases As subtests have an SD of 3, it can be seen that a where the level of change has been dramatic. It is subtest range of around 3 SDs is not unusual in rendered more formidable by the fact that many individuals without acquired impairments. of the standard instruments used in clinical These considerations are just as relevant when neuropsychology (e.g., the WMS-R) do not profile analysis is carried out with more specific have parallel versions. The clinician must neuropsychological instruments. The WMS-R therefore differentiate changes resulting from and WAIS-R are used here as examples simply systematic practice effects and random mea- because of the availability and quality of the surement error from change reflecting genuine relevant data. improvement or deterioration. Among other complications are the fact that (i) the magnitude of practice effects vary with the nature of the 7.07.4.5 Monitoring Change task (e.g., the Performance subtests of the WAIS-R show larger practice effects than their There are many situations in which the Verbal counterparts), (ii) the length of time that neuropsychologist needs to measure potential has elapsed between test and retest will influence changes in cognitive functioning in the elderly. the magnitude of effects, and (iii) a diminution Common examples would be to determine of practice effects is to be expected in whether cognitive decline is occurring in an neurological populations given the high pre- individual in whom a degenerative neurological valence of memory and learning deficits, but the process is suspected, or to determine the extent expected diminution is difficult to estimate for of recovery of function following a stroke or individuals. traumatic brain injury. In both these cases, One approach to dealing with many of these neuropsychological assessment will provide considerable interpretive problems is to gather useful information to assist clients, relatives, information from test±retest studies on the and other health professionals to plan for the relevant neuropsychological tests. Provided future. Monitoring the cognitive effects of that such studies report the test±retest correla- surgical, pharmacological, or cognitive inter- tions, means, and SDs, regression equations can ventions in the individual case is also an be constructed to predict performance on retest important role for the neuropsychologist. from scores at initial testing. The predicted Although the aim here is most commonly to scores are then compared with the retest scores determine if there has been any improvement, actually obtained by the client to assess whether the possibility of detrimental effects can also be the observed gain or decline significantly an issue. For example, many drugs can exceeds that expected (see Knight & Shelton, potentially impair cognitive functioning, parti- 1983; McSweeny, Naugle, Chelune, & LuÈ ders, cularly in the elderly. Anticholinergic agents 1993). The utility of this approach is determined 140 Neuropsychological Assessment of the Elderly by the extent and nature of retest studies 1991). Further, because of the time taken to available for a particular test. For example, complete an assessment, many of the measures the test±retest scores on memory tasks for an may be administered by psychology assistants elderly client with suspected dementia could be rather than fully accredited clinicians. It has compared with estimated retest scores derived been argued that important clinical information from a healthy, elderly sample retested after a may therefore be missed or misinterpreted similar period to gauge how atypical any decline (Brooks, 1989). In the fixed, battery approach may be. For some questions test±retest data all clients and normative groups are adminis- from a clinical sample may be used. For tered the same tests, therefore services employ- example, a stroke patient's scores on measures ing this approach accumulate substantial data of attention or speed of processing could be on their measures. Such databases are tremen- compared with estimated retest scores from a dous clinical assets. However, the very existence stroke sample if the clinician suspects that the of this database, and the resources expended to extent of recovery is atypical. obtain it, may promote a reluctance to substitute existing tests with newer measures designed to reflect developments in neuropsychological knowledge. 7.07.5 APPROACHES TO ASSESSMENT Approaches to assessment can also be IN CLINICAL characterized by the emphasis placed on NEUROPSYCHOLOGY qualitative vs. quantitative evidence. The extreme quantitative pole of this dimension is Approaches to the assessment process can be characterized by a strict statistical/actuarial characterized as falling on a continuum between methodology in which comparison of a client's what has been referred to as the ªfixed, big test scores against various cut-offs is the batteryº approach and a flexible, hypothesis- principal focus. At the other extreme, tests are testing approach (Brooks, 1989; Walsh, 1991). used to reveal qualitative features of a client's In the former, a large comprehensive battery is behavior, the emphasis being on how a task is routinely administered to all clients. This approached rather than on any empirical approach is most common in the USA and is analysis of the test scores obtained. In the exemplified by the Halstead±Reitan battery service of this end there may be major deviations which consists of a large number of specific from standardized test instructions, thus pre- neuropsychological measures, for example, tests cluding statistical analysis in any case. Although of tactual performance, sensory extinction, there is no fundamental reason why this finger tapping, categorization, language func- dimension should not be orthogonal to the tioning, etc., which are often supplemented with fixed/flexible dimension, in practice they have a full-length WAIS or WAIS-R and personality tended to be correlated. The fixed, battery inventories (see Reitan, 1986). approach arose from researchers working in the In the latter approach, measures are selected actuarial tradition and the sheer number of to test clinical hypotheses derived from the measures administered almost demands the neuropsychological literature on a client's employment of actuarial indices to assist in known or suspected disorder and from infor- the assimilation of the information obtained. mation gained from the interview. The process A strict quantitative methodology could be is a dynamic one; the results of preliminary employed with the flexible hypothesis-testing testing are used to test or modify existing approach. Indeed, the term hypothesis-testing hypotheses and generate new ones. As a simple might be seen as implying this and indeed example, screening measures may detect pro- influential figures in the development of this blems with the organization of visual material approach devoted considerable attention to which are consistent with spatial and/or plan- quantification (e.g., Shapiro, 1973). However, ning deficits; follow-up measures can then be many clinical proponents of this approach have administered to evaluate these three competing tended to emphasize qualitative analysis that is, possibilities. hypotheses may be expressed and tested in Proponents of the flexible approach acknowl- qualitative as well as quantitative terms edge that there is a potential danger of failing to (Walsh, 1991). It should be stressed that very detect a client's difficulties in some cognitive few clinical neuropsychologists are at the domains if the clinician focuses too rapidly on extreme ends of this qualitative/quantitative testing inappropriate hypotheses (Miller, 1992). dimension; qualitative observations are verified However, they argue that the fixed, big battery with quantitative instruments whenever possi- approach may represent an inefficient use of ble whilst recognizing that much important resources and is simply not an option in some information is not easily amenable to such hard-pressed services (Brooks, 1989; Walsh, verification. Measures of Current Intellectual Ability 141

7.07.6 SCREENING TESTS FOR MENTAL however, according to Spreen and Strauss STATUS (1991) the normative sample cannot be considered representative of the elderly population This section will briefly review screening tests as it contained a disproportionate number of for mental status. All these Scales include high socioeconomic status (SES), highly edu- questions covering basic orientation for time cated participants. and place but differ in the extent to which they As noted, the CAMDEX (Roth et al., 1986) address other competencies. Among the most includes a cognitive section (CAMCOG). This common Scales are the Mini Mental State Scale contains the items of the MMSE with the Examination (MMSE; Folstein, Folstein, & addition of some additional coverage of McHugh, 1975), the Mattis Dementia Rating perception, memory, and abstract thinking. A Scale (MDRS; Mattis, 1976), and the cognitive study (Huppert et al., submitted) has examined section (CAMCOG) of the Cambridge Mental the psychometric properties of the CAMCOG; Disorders of the Elderly Examination (CAM- the test±retest reliability of the Scale as a whole DEX; Roth et al., 1986). These instruments was very high (0.86), as was its internal produce a global score which summarizes a consistency (coefficients ranged from 0.82 to patient's cognitive competence. They are brief 0.89). A study carried out in a group of 222 and easy to administer and provide sufficient elderly people reported that CAMCOG scores information for epidemiological studies, or as are affected by age, sociocultural factors, and an index of severity of decline. They cannot be hearing and visual deficits (Blessed, Black, viewed as exhaustive diagnostic instruments. Butler, & Kay, 1991). The cognitive subScale The MMSE (Folstein et al., 1975) is probably of the Alzheimer's Disease Assessment Scale the most frequently used screening Scale and is (Rosen, Mohs, & Davis, 1984) is used increas- often used as part of a larger battery for a ingly widely in clinical trials in DAT because of comprehensive assessment of dementia. It is a its proven sensitivity to the effects of cholines- very brief and easily administered instrument terase inhibitors and other drugs (Schneider, and takes about 5±10 minutes in total. It tests 1996). It takes around an hour to administer orientation, information, and visuoconstructive and includes tests of word recall, orientation, abilities; total scores can range between 0 and naming, spoken language and comprehension, 30. In their original study, Folstein et al. and constructional praxis. reported a high test±retest reliability of 0.83 when retesting was conducted by a different examiner, and 0.89 when the same examiner was 7.07.7 MEASURES OF CURRENT used. High test±retest reliability, ranging from INTELLECTUAL ABILITY 0.8 to 0.95, has been confirmed by later studies 7.07.7.1 Use of the WAIS-R With the Elderly (Anthony, Le Resche, Niaz, Van Korff, & Folstein, 1982; Dick et al., 1984). An effect of The WAIS-R (Wechsler, 1981) continued to age on MMSE scores has been reported by be used widely in neuropsychological assess- several studies (Magni, Binetti, Bianchetti, ment of all individuals of all ages. Lezak Rozzini, & Trabucchi, 1996; Pi, Olive, & (1988a), for example, describes the Wechsler Esteban, 1994; Tombaugh & McIntyre, 1992). as, ªthe workhorse of neuropsychological Furthermore, caution is required when inter- assessmentº and identifies it as ªthe single most preting scores obtained from poorly educated utilized component of the neuropsychological individuals. Level of education has been shown repertoryº (p. 38). A number of points should be consistently to have an effect on MMSE score made about the use of the WAIS-R with the (Kittner et al., 1986; Kukull et al., 1994; elderly. First, as will be discussed later, many Uhlmann & Larson, 1991). clinicians base their analysis of WAIS-R A useful instrument for the evaluation of the performance on a client's subtest profile. It is mental status is the Mattis Dementia Rating important that age-graded Scaled scores are Scale (MDRS) (Mattis, 1976). This Scale can used in this process rather than the standard take about 30±45 minutes to administer, but Scaled scores which are not corrected for age since items are ordered in descending order of (Lezak, 1995). Failure to use these former scores difficulty passes on early items can shorten the can produce a totally misleading picture of time required because of discontinuation rules. individuals' strengths and weaknesses relative The MDRS tests orientation, attention, initia- to their peers; (see Crawford, 1992 p. 27). tion and perseveration, visuoconstructive abil- Second, as aging is associated with reduced ities, conceptualization, and memory. Split-half visual acuity, it is regrettable that the stimulus reliability for this Scale is high (0.90) (Gardner, materials for some of the subtests (most notably Oliver-Munoz, Fisher, & Empting, 1981). Picture Completion and Picture Arrangement) Norms are available (Montgomery, 1982); are unnecessarily small and the artwork poor. 142 Neuropsychological Assessment of the Elderly

The most obvious problem in using the 7.07.7.2 Analysis of Subtest Profiles WAIS-R with the elderly is that the original norms only cover those up to age 74 years. For Analysis of WAIS-R performance can be clients over this age two sets of independently based on the IQs, the subtests or scores derived collected norms are available (Ivnik et al., 1992; from factor analysis. Authorities on the Wechs- Ryan, Paolo, & Brungardt, 1990). The Mayo ler have divided opinions on the usefulness of norms were established on a sample of 512 the summary IQs. Matarazzo and Herman healthy individuals from Rochester and sur- (1985), for example, have suggested that the rounding areas in the US and covers up to age discrepancy between Verbal and Performance 97 years. However, many of the total subject IQs is the best validated Wechsler index of pool were under age 74 years and were used to cerebral dysfunction, whereas Lezak (1995) is examine the comparability of the MAYO dismissive of its importance. Many clinicians norms with the existing WAIS-R norms. Thus, primarily base their interpretation of the WAIS- the norms for those over age 74 years were R on the pattern of strengths and weaknesses in based on a subsample of 222. The sample was a client's subtest profile (e.g., Lezak 1995; relatively highly educated and had an under- Walsh, 1991). Lezak (1988b), for example, notes representation of ethnic minorities. Two fea- that IQs can obscure clinically important tures of these norms are potentially appealing. strengths and weaknesses and suggests that First the norms were established using the ªalthough the traditional scoring scheme for the method of overlapping midpoint age ranges Wechsler exemplifies the IQ problem, these tests described by Pauker (1988); this takes max- also show us a way out of the problem by imum advantage of the data available and, providing a profile of (subtest) scoresº (p. 359). because it permits more age bands to be formed, A starting position in conducting such a lessens the sometimes substantial apparent profile analysis is to assess whether any improvement in scores that can occur when observed subtest differences are reliable (i.e., an individual moves from one age band to the statistically significant) as opposed to simply next. As an aside, it is worth noting that, using reflecting measurement error. The only assis- the existing WAIS-R norms and any spread- tance for this process provided in the WAIS-R sheet package, it is possible to go one step manual appears in Table 13 (Wechsler, 1981). further and derive continuous norms for those This table provides the critical values required aged under 74 years (see Zachary & Gorsuch, for significance when comparing any subtest 1985). Second, age corrections are carried out at with any other. It is appropriate to use these the subtest level rather than when converting critical values if and only if the clinician has the sum of Scaled scores to IQs. This is the same made an a priori decision to examine the approach used for the Wechsler children's difference between only one pair of subtests Scales; why it was not adopted for the adult out of the 55 potential comparisons that could Scales remains a mystery. be made. However, in practice, clinicians will Ryan et al's. (1990) norms were established want to compare more than one pair; indeed, for two age groups, 75±79 (n=60) and 80 and when the client's history and behavior at above (n=70). Although this sample was interview provide insufficient grounds for somewhat smaller than the Mayo sample, it forming clinical hypotheses, such comparisons was recruited to be broadly representative of the will be post hoc. In effect, all possible compar- US elderly population in terms of those isons are made in this situation even though the demographic variables that were considered clinician will focus attention on the subtest to be most pertinent to cognitive tests. Paolo comparisons which yielded the largest discre- and Ryan (1995) discuss the pros and cons of pancies. both samples in detail. They also provided an The principal problem with Wechsler's ap- example subtest profile for a case aged 75 years proach is that it does not introduce any (i.e., just outside the standard WAIS-R norms) correction for the inflation of the Type I error and compared the results obtained by both sets rate that occurs when multiple comparisons are of elderly norms and by scoring the case as if he conducted (Crawford, 1992; Silverstein, 1982). were 74 years using the original norms. The Any attempt to overcome this problem inevi- original and Ryan norms showed much greater tably involves striking a balance between evidence of convergence; the Mayo norms controlling the Type I error rate while retaining indicated significant deficits on some Perfor- reasonable power to reject the null hypothesis of mance subtests which were not present in the no subtest differences. For example, an un- other two profiles. An additional advantage of satisfactory solution would be to produce a the Ryan norms is that base rate data on subtest modified table in which a Bonferroni correction scatter and other aspects of performance are was applied to derive new critical values available (e.g., Ryan & Paolo, 1992). reflecting the fact that 55 comparisons were Measures of Current Intellectual Ability 143 involved. Although such an approach would method to prepare a set of abnormality tables control for inflation of the Type I error rate, it for use with any of the nine WAIS-R short- would result in very low power to detect subtest forms referred to earlier. differences, that is, the Type II error rate (i.e., The above methods allow clinicians to test the rate of false negatives) would be unaccep- hypotheses based on clinical experience or the tably high. research literature on a client's known or Knight and Godfrey (1984) and Silverstein suspected neurological disorder. However, the (1982) independently suggested a method methods themselves make no a priori assump- which achieves a useful compromise between tions about the nature of an individual's subtest the need to minimize both Type I and Type II pattern. In contrast, there have also been errors; instead of potentially comparing all attempts in the past to identify fixed, specific subtests with each other, each subtest is subtest patterns for differential diagnostic compared with a client's mean subtest score. purposes. Most of these attempts naively aimed In the case of a full-length WAIS-R this reduces to identify ªorganicityº and hence were based the number of comparisons to 11 so that, when on a unitary concept of brain damage which is the Bonferroni correction is applied to maintain totally discredited. Not surprisingly, empirical the Type I error rate at the specified level, the studies of these profiles, such as Wechsler's loss of power to detect subtest differences is ªHold±Don't Holdº pattern, have been con- much less acute; 11 appears in the denominator sistently disappointing (e.g., Christensen & rather than 55. Both authors provided a table MacKinnon, 1992; Savage, Britton, Bolton, & which recorded the size of discrepancy between Hall, 1973). each subtest and an individual's mean subtest A more rational and interesting attempt to scores required for varying levels of statistical identify specific subtest patterns was conducted significance. This approach, when combined by Fuld (1984). This approach arose from with equivalent tables on the abnormality of any evidence implicating cholinergic dysfunction in subtest differences (see below), provides a rapid the cognitive deficits seen in dementia of the and straightforward means of analyzing a Alzheimer type (DAT) (e.g., Perry et al., 1978; client's profile of strengths and weaknesses see Crawford et al., 1990 for a review). Fuld and therefore provides information which can (1984) examined Drachman and Leavitt's be integrated usefully with other quantitative (1974) data on the effects of scopolamine on and qualitative information available to the the WAIS performance of healthy adults and clinician. reported that the age-graded subtest profile Crawford (1997) presented a modified table could be typified by the formula A > B; B > C, which corrects a minor error common to both of C 4 D, A > D where A is the mean of the original tables. Further tables are provided Information and Vocabulary, B of Similarities for use with any of nine short-forms of the and Digit Span, C of Digit Symbol and Block WAIS-R, including those specifically developed Design, and D is Object Assembly. Fuld for neuropsychological purposes (e.g., Rey- reported that around a half of patients with nolds, Willson, & Clark, 1983; Walsh, 1991) and DAT exhibited this profile, whereas it was those in which the selection of subtests was observed in less than 7% of controls and guided by their suitability for use with the patients with multi-infarct dementia (MID). elderly and other groups in which reduced visual These results provoked much interest (see acuity can be a problem (e.g., Britton & Savage, Massman & Bigler, 1993 for a review). 1966; Crawford, Allan, & Jack, 1992a). Subsequent studies have reported rates of If subtest differences are found to be reliable, occurrence in DAT ranging from a high of it is often appropriate to determine if they are 57% (Brinkman & Braun, 1984) to a low of 7% also abnormal, that is, to establish how rarely (Logsdon, Teri, Williams, Vitiello, & Prinz, differences of the magnitude observed in an 1989). Most subsequent data on the specificity individual's profile occur in the general of the profile indicated that it occurred with population (see Section 7.07.4.4). Many low frequency in the healthy elderly and in healthy individuals have reliable strengths neurological disorders other than DAT. How- and weaknesses in their subtest, thus reliable ever, reasonably high rates of occurrence have differences do not imply the presence of been reported in depression (16%) and schizo- acquired impairment. Silverstein (1984) pro- phrenia (15%). A particularly disappointing set vided a table to assess the abnormality of of results was reported in the previously subtest differences. As was the case for the mentioned study by Logsdon et al. (1989) in reliability of subtest differences, this table is which the 7% rate of occurrence in DAT was used to compare each subtest with an indivi- exactly equivalent to the rates in the healthy dual's mean subtest score. Crawford, Allan, elderly and depressed patients. Gfeller & McGeorge, and Kelly (1997) adopted the same Rankin (1991) have also reported that the 144 Neuropsychological Assessment of the Elderly profile was exhibited by 12% of cases of multi- Arithmetic, Digit Span, and often Digit Symbol infarct dementia, a figure which is little (Crawford et al., 1989a; Leckliter, Matarazzo, different from the rate found in their DAT & Silverstein; 1986). The arguments in favor of sample (15%). using factor scores when interpreting WAIS-R With knowledge on the extent of intraindi- performance are many and compelling. First, vidual variability in subtest scores (e.g., Matar- the IQs do not have optimal construct validity, azzo et al., 1988), it should not be surprising that the subtests were allocated to a Verbal and the profile has low sensitivity for DAT. For Performance Scale on intuitive grounds. Sec- example, it would not be uncommon for ond, the factor structure of the WAIS-R individuals to have premorbid Block Design appears to be very robust in that it is or Digit Symbol scores which were well over one consistently extracted from samples from SD higher than their average subtest score; countries outwith the USA. Most crucially, it similarly, it would not be uncommon for emerges when the WAIS-R scores of clinical individuals to have Information or Vocabulary samples are factor analyzed (e.g., Atkinson, scores which were substantially below their Cyr, Doxey, & Vigna, 1989). Third, the average subtest score. Thus, although these sets reliabilities of factor scores are much higher of subtests may be differentially affected by the than those of the individual subtests from onset of DAT, a massive effect would be which they are formed. Fourth, although required to reverse the premorbid pattern; authorities on the Wechsler have laid stress accordingly, these differential effects often on the analysis of subtest scatter, the WAIS-R would be obscured in the individual case. In could be viewed as primarily providing broad conclusion, the Fuld profile has little to indicators of current functioning against which recommend its use in clinical practice. However, more specific neuropsychological measures are it is still of some theoretical interest as compared. Again, the superior construct va- scopolamine-treated healthy subjects and lidity of the factorially derived composites DAT cases are apparently the only groups suggest they are better suited to provide these studied to date in which the profile is exhibited broad intraindividual comparison standards in their respective means. This provides some than the IQs. support for the cholinergic hypothesis in DAT. Crawford, Johnson, Mychalkiw, and Moore However, it should be noted that there has been (in press-a) have examined the clinical utility of no attempt to replicate the original report on the IQs, indices of subtest scatter, and factor scores effects of scopolamine. It would also be in discriminating between healthy (n=356) and important to demonstrate that the profile has head-injured samples (n=233). The scatter pharmacological specificity, that is, that a indices employed were the Profile Variability similar profile would not be observed following Index (McLean, Reynolds, & Kaufman, 1990), administration of a benzodiazepine or some which simply records the variance of an other centrally active agent. individual's subtest scores, and The Mahalano- bis Distance Index (Burgess, 1991); this latter index factors in the correlation between subtests 7.07.7.3 WAIS-R Factor Scores (therefore, a discrepancy involving a subtest which has a relatively low average correlation An alternative to the analysis of both IQs with the other subtests is given less weight than a and subtest discrepancies is to examine scores discrepancy involving a subtest with a high obtained from factor analysis of the WAIS-R correlation). Factor scores were significantly (Atkinson, 1991; Canavan, Dunn, & McMillan, better than both the IQ Scales and the scatter 1986; Crawford, Allan, Stephen, Parker, & indices at discriminating between healthy and Besson, 1989a; Kaufman, 1990). Although this impaired performance; the scatter indices suggestion has a long history (Maxwell, 1960), essentially performed at chance levels. The factor scores have not been employed widely in extent to which these findings will generalize clinical practice or research. Factor analyses of to neurological conditions more directly asso- the WAIS and WAIS-R commonly have ciated with the elderly (e.g., DAT, stroke, etc.) extracted three factors: a verbal (V) factor on remains to be determined. which Information, Vocabulary, Comprehen- The lack of a rapid method of factor scoring sion, and Similarities have high loadings; a the WAIS-R, combined with the absence of data perceptual±organization (PO) factor defined by with which to assess the reliability and abnorm- high loadings from Block Design and Object ality of discrepancies between factors, acted as Assembly (other Performance subtests have barriers to the effective use of factor scores in more modest loadings); and a third factor clinical practice. Both these limitations have termed attention/concentration (A/C) or simultaneously been rectified in a very useful freedom-from-distractibility consisting of paper by Atkinson (1991). Specific Methods for the Estimation of Premorbid Ability 145

7.07.8 SPECIFIC METHODS FOR THE resistant to the effects of many neurological ESTIMATION OF PREMORBID and psychiatric disorder, for example, depres- ABILITY sion, acute schizophrenia alcoholic dementia, closed head injury, and Parkinson's disease The National Adult Reading Test (NART) (Crawford, 1992; O'Caroll, 1995) and compares (Nelson & Willison, 1991) is the test most widely favorably with previously suggested alternative used to estimate premorbid ability. The NART measures of premorbid ability such as the is a single word, oral reading test consisting of Vocabulary subtest of the WAIS or WAIS-R 50 items. All the words are irregular, that is, they (e.g., Crawford et al., 1988). Mixed findings violate grapheme±phoneme correspondence have been found in samples with probable rules (e.g., chord). Because the words are DAT. O'Carroll, Baike, and Whittick (1987) irregular, intelligent guess work should not readministered the NART to a sample of provide the correct pronunciation, therefore the dementia cases after one year and found no test taps previous word knowledge; as the test change in performance despite a significant only requires the reading of single words, clients decline on measures of dementia severity. do not have to analyze a complex stimulus and it Crawford et al. (1988) found that the NART is argued that the test therefore makes minimal performance of DAT cases did not differ demands on current cognitive capacity (Nelson significantly from matched controls despite & O'Connell, 1978). Development of the NART the presence of severe deficits on other cognitive arose from the clinical observation that oral measures and the presence of marked morpho- reading is commonly preserved in dementia logical and blood flow abnormalities on brain (whereas reading for meaning is commonly imaging. Stebbins, Wilson, Gilley, Bernard, and impaired). However, the test is used to estimate Fox (1988), in contrast, found that NART premorbid ability in a wide range of conditions. performance was impaired significantly in DAT To qualify for use as a measure of premorbid cases classified as moderate or severe, although ability, a test must fulfill three criteria (Craw- impairment was not in evidence in mild cases. ford; 1992; O'Carroll, 1995). First, as with any Subsequent studies have continued to produce psychological test, it must possess adequate conflicting results in DAT (e.g., Patterson, reliability. The NART has high split-half Graham, & Hodges, 1994; Sharpe & O'Carroll, reliability/internal consistency, test±retest relia- 1991) but it is becoming increasingly clear that bility, and inter-rater reliability (Crawford, NART performance can be impaired substan- 1992). Second, it must have high criterion tially in many cases of moderate to severe validity. The NART is normally used to provide dementia. Any findings of impaired NART an estimate of general premorbid IQ against performance poses a threat to the validity of this which current performance on the WAIS-R is approach. However, the practical implications compared. Thus, to meet the second require- of impaired performance in cases of severe ment, the NART must be capable of predicting neurological disorder are not as serious as they a substantial proportion of IQ variance. There may appear; in such cases the presence of has been some confusion in the literature on deficits is unfortunately only too obvious, how to examine this aspect of putative measures thereby largely obviating the need for the of premorbid ability (e.g., Klesges, Wilkening, NART or a similar instrument to assist in its & Golden, 1981), so it is worth noting that it detection and quantification. must necessarily be studied using unimpaired Most research on the NART's ability to rather than clinical samples. In a clinical sample, estimate premorbid ability has used scores on NART performance and performance on the IQ tests as the criterion variable. Although this criterion (e.g., the WAIS-R) will commonly is in keeping with the notion of obtaining an become dissociated, indeed it is the presence of estimate of general level of premorbid function- such a dissociation (i.e., a large discrepancy ing, the NART also has the potential to provide between estimated premorbid ability and cur- estimates of premorbid functioning for other rent ability in favor of the former) that is used to WAIS-R indices and for more specific neurop- infer impairment. In most studies using the sychological tests. For example, Crawford, WAIS or WAIS-R as the criterion variable the Moore, and Cameron (1992c) built a regression NART predicted well over 50% of IQ variance. equation which can be used to estimate For example, in one study the NART predicted premorbid performance on the FAS verbal 66% of WAIS IQ variance in a sample of 151 fluency test (see Section 7.07.13). Similarly healthy subjects (Crawford, 1992). Crawford, Obonsawin, and Allan (in press-b) The final criterion for a putative measure of have provided an equation which uses NART premorbid ability is that test performance be and age to estimate premorbid scores on the resistant to neurological or psychiatric disorder. Paced Auditory Serial Addition Test (PASAT; NART performance appears to be largely Gronwall, 1977). 146 Neuropsychological Assessment of the Elderly

Schlosser and Ivison (1989) derived a regres- graphic variables account for only 30±54% of sion equation which incorporated age and the variance (Barona, Reynolds, & Chastain, NART scores to estimate performance on the 1984; Crawford & Allan, 1997; Crawford et al., Wechsler Memory Scale (WMS). They reported 1989b; Wilson et al., 1978). This compares that the discrepancy between current WMS unfavorably with the NART and its variants performance and estimated premorbid perfor- (Crawford, 1992; O'Carroll, 1995). mance was a highly successful index for the detection and quantification of memory dysfunction in DAT. O'Carroll et al. (1994) 7.07.9 AGING AND MEMORY extended this work by comparing a group of 7.07.9.1 Introduction to Aging and Memory DAT patients, a group of depressed patients, and a group of healthy controls on the It is a well-established phenomenon that as discrepancy between NART-estimated premor- humans age, memory complaints increase. bid intellectual ability and current mnemonic These subjective complaints are reflected in ability as assessed using the various indices of objective measurements of memory test perfor- the WMS-R. While large mean differences were mance. For example, Davis and Bernstein demonstrated between groups, the degree of (1992) examined verbal memory performance, overlap between the DAT and depressed group as assessed by the Auditory Verbal Learning was large, leading them to conclude that none of Test (AVLT) in a sample of 474 healthy the NART/WMS-R discrepancy quotients were individuals ranging from those in their twenties significantly discriminating between depression to those in their eighties; a steady decrease in and DAT to be useful in clinical practice. performance was observed with increasing age A proposed modification to the NART is the in those over 30 years. Free recall performance Cambridge Contextual Reading Test (CCRT; often appears to be more detrimentally affected Beardsall & Huppert, 1994). As its name by the aging process than recognition, although suggests, the NART words are embedded in other memory processes do appear to be sentences to provide context for the examinee. sensitive to age effects, for example, priming Baddeley, Emslie, and Nimmo-Smith (1993) skill learning and classical conditioning (see proposed another alternative reading test which Binks, 1989 and Schonfield, 1980 for reviews). they termed the Spot The Word Test (STW). Shimamura (1994) proposed that age-related STW is a lexical decision task in which the effects on memory may be associated with examinee has to identify the legitimate words regional brain changes, that is, that problems of from a series word/pseudoword pairs (e.g., attention, working memory, word finding, and stamen/floxid). Both of these new tests have source memory may be related to aging effects in considerable potential as alternatives to the frontal lobe functioning, whereas problems with NART. However, their use is mainly limited to new learning may be related to medial temporal research applications as regression equations lobe dysfunction. Superimposed on these have yet to be developed to provide estimates of changes, Shimamura (1994) argued that general premorbid ability for individuals and there is changes in neuronal efficiency may pervade all insufficient evidence on their resistance to neural systems as a consequence of age (e.g., impairment. reduced blood flow, inability to prevent damage An entirely different approach to the estima- from oxidation, and poor metabolic uptake). It tion of premorbid ability uses demographic is proposed that these metabolic changes variables (e.g., years of education, occupational account for the pervasive finding of cognitive classification) as predictors. This has the slowing in older individuals. It can be imagined advantage that the estimates it provides are easily how these specific age-related memory entirely independent of current level of func- effects may act synergistically with nonspecific tioning (care should, however, be taken to assess slowing to result in impaired performance. whether prodromal difficulties could have led to Evidence has shown that differing brain regions a client's failing to achieve their educational or undergo differing degrees of neuronal loss with occupational potential). As evidence of im- age. Many areas, such as striate-cortex and paired NART performance in various clinical parietal cortex, do not lose an appreciable conditions accumulates, the demographic ap- number of neurons during life. However, proach may be a useful alternative method in 15±20% of the neurons in the neo-striatum cases where use of the NART would be and frontal cortex are lost between young inappropriate. However, the obvious disadvan- adulthood and old age (Squire, 1987). Similarly, tage of the demographic approach is its modest approximately 5% of hippocampal neurons are criterion validity. Where WAIS or WAIS-R lost per decade, so that at the age of 80 years; scores have been used as the criterion variable, approximately 20±30% of hippocampal pyr- regression equations based solely on demo- amidal cells will have been lost (Squire (1987). It Aging and Memory 147 is tempting, therefore, to link the neuronal cell raged over whether dementia (particularly of loss in frontal and hippocampal regions to the Alzheimer type) represents accelerated aging frontal and temporal memory systems which effects or whether it represents a quite separate Shimamura (1994) has implicated in the aging clinical entity (Huppert, 1994). In an important process. study, Huppert and Kopelman (1989) found that normal aging produces a mild acquisition deficit as well as a significant increase in 7.07.9.2 Age-associated Memory Impairment forgetting rate, and the rapid rate of forgetting in the elderly cannot be attributed simply to Crook et al. (1986) proposed the concept of differences in the initial level of acquisition. In a age-associated memory impairment (AAMI). comparison of normal aging with dementia, The following criteria were developed: normal aging produced a mild acquisition (i) at least 50 years of age; deficit and a slight increase in the rate of (ii) gradual onset of complaints of memory forgetting, whereas dementia superimposes a loss in everyday activities; severe acquisition defect but no further effect on (iii) memory test performance one standard forgetting rate (Huppert & Kopelman, 1989). In deviation below the mean of young adults on their study, Greene, Baddely, and Hodges standardized tests of recent memory with ade- (1996) employed the Doors and People test quate normative data; (Baddeley, Emslie, & Nimmo-Smith, 1994; see (iv) adequate intellectual function (e.g., below) in a comparison of early DAT patients Scaled score of at least nine on WAIS-R vs. elderly controls. They concluded that the vocabulary); episodic memory deficit in DAT is general in (v) absence of dementia (i.e., Mini-Mental nature and primarily reflects impaired learning Status Examination score of 24 or above); and rather than accelerated forgetting or disrupted (vi) exclusion criteria, delirium, neurological retrieval. Thus, memory functioning in demen- disorder, cerebrovascular pathology, head in- tia appears to be qualitatively different from jury, etc. that observed in ªnormalº aging. However, it is clear that a vast number of elderly people would meet these criteria, particularly the reference to scoring one standard 7.07.9.4 Commonly Used Memory Tests: deviation below memory test scores for young Implications for use with Elderly adults; indeed by definition over 16% of young Subjects adults would meet this criterion. This led to the proposed diagnostic category being severely In the following sections several commonly criticized (e.g., O'Brien & Levy, 1992). Partly used clinical memory measures will be outlined as a consequence of this type of criticism, briefly and evaluated, with a particular empha- AAMI was not included in the Diagnostic and sis on the appropriateness of their use with the Statistical Manual of Mental Disorders (4th ed., elderly. For further details, the interested reader DSM-IV) of the American Psychiatric Associa- is referred to Lezak (1995) and Spreen and tion. Some skeptics felt that the condition may Strauss (1991). Unfortunately, pressure of space have been invented in order to legitimize precludes coverage of all but a few of the most pharmaceutical treatment of this new disorder. widely used instruments. However, it is clear that aging is associated with significant impairment of memory functioning and more needs to be known about this 7.07.9.4.1 The Auditory Verbal Learning Test naturally occurring phenomenon rather than The auditory verbal learning test (AVLT; labeling it as a categorical disorder. Caine Rey, 1964) is one of the most widely used word (1992) has proposed that instead of the term learning tests in clinical research and practice. AAMI, age-related cognitive decline (ARCD) Five presentations of a 15-word list are given, should be discussed and researched and this has each followed by attempted recall. This is been included in DSM-IV (code 780.9). followed by a second 15-word list (list B), followed by recall of list A, and delayed recall 7.07.9.3 Does Memory Functioning in Dementia and recognition are also tested. A key feature of Represent Accelerated Aging? the AVLT (and its successor, the California Verbal Learning Test) is that it affords the In many studies, the finding that memory opportunity to measure rate of learning, as after a delay is poorer in the elderly than in opposed to recall of a single stimulus, or series young subjects has usually been attributed to an of stimuli. An equivalent form of AVLT has acquisition deficit rather than to faster rate of been provided by Crawford, Stewart, and forgetting. For many years, a controversy has Moore (1989c). Because of the rather abstract 148 Neuropsychological Assessment of the Elderly nature of the test, that is, 15 unconnected words includes new subtests such as figural memory, and repetition over five trials, this can be a visual paired associates, and visual memory rather stressful measure for an elderly individual span. As Mayes and Warburg (1990) comment, of failing cognitive abilities. The initial norma- ªthe revised WMS therefore appears (poten- tive data that was referred to widely was rather tially) to be considerably more satisfactory in a limited (Lezak, 1983). However, the situation number of respects than its older brotherÐ has improved, with excellent norms for the particularly in respect of normative data, elderly provided by Geffen, Moar, O'Hanlon, information of standardization, validity and Clark, and Geffen (1990), Ivnik et al. (1992), reliability, scoring criteria (especially logical and Tuokko and Woodward (1996). The memory), range of memory functions sampled normative data on this test has also been and provision for clinical interpretation of test reviewed by D'Elia, Boone, and Mitrushimo rests. This has been achieved at the cost of (1995). For a detailed review of the AVLT, see increased administration time, particularly if Peaker and Stewart (1989). the Delayed Recall is tested, abandonment of provision of an equivalent alternate form, and increased cost of the test.º For elderly subjects, 7.07.9.4.2 The California Verbal Learning Test however, the Delayed Recall Test requires an attempt to reach a criterion on both verbal and In an attempt to expand upon the assessment visual paired associates. This can lead to of learning and retrieval strategies, the Califor- repeated experience of failure over six trials nia Verbal Learning Test (CVLT) evolved from which can provoke distress in elderly indivi- the AVLT and was developed to provide an duals. In addition, the scoring of the tapping instrument ªreflecting the multifactorial ways in forwards and backwards subtest leads to which examinees learn, or fail to learn, verbal considerable anxiety on the part of many material. The CVLT's assessment of learning psychologists as they find it an extremely strategies, processes, and errors is designed for difficult subtest to score. However, preliminary use in both clinical and research practiceº data on the inter-rater reliability of this subtest (Delis, Kramer, Kaplan, & Ober, 1987). A appears to be satisfactory (O'Carroll & variety of memory measures are obtainable Badenoch, 1994). from this measure including short- and long- The normative sample consists of 316 subjects term free recall and recognition, serial learning in six age groups, selected to be representative curves, learning strategy (i.e., semantic vs. serial of the US population in terms of race, clustering), etc. The CVLT also has the added geographic region, education, and IQ. Elwood advantage of presenting the stimuli in an (1991) points out that the normative sample everyday, relatively nonthreatening manner, of 316 ªseems hardly adequate for the standar- that is, learning two shopping lists. The dization sample, given the broad age range reliability data for the principal measures of its target population. In relative terms, appear to be adequate although some of the comparison between the WMS-R sample and scores which are derived from them have poor the 2000 subjects used for the WAIS-R is reliability. The normative database consists of strikingº (p. 185). It is important to note that 273 neurologically intact individuals, 104 males, the WMS-R standardization sample system- 169 females, with a mean age of 58.9 (15.4) atically excluded subjects in the age range of years. This mean age for controls is considerably 45±54 years using interpolated values in their higher than that normally employed for psy- place. chometric test development. However, the Given that the WMS-R is one of the most control subjects were recruited from several widely used memory tests, it would be expected research projects and the authors state ªin order that the normative sample would be represen- to make the best use of the data while giving due tative of the general population. However, regard to the varying number of cases at each Huppert (1994) has pointed out that examiners age and sex, smoothed age curves were fitted to were instructed to screen potential examinees the raw data using multiple regressionº (Delis for a list of several medical factors which may et al., 1987, p. 35). This curve-fitting procedure affect cognitive performance and has suggested for normative data has been criticized (see that, not only were these criteria poorly Elwood, 1991). specified, they almost certainly excluded a high percentage of normal nondemented older 7.07.9.4.3 The Wechsler Memory Scale-Revised individuals. As she states, ªthis has serious consequences for the use of these norms in The WMS-R (Wechsler, 1987) is generally assessing whether or not an individual's mem- considered to be a considerable improvement ory performance is below that expected for their on its predecessor, the WMS. The WMS-R age. The effect will be to over-estimate the Aging and Memory 149 number of elderly people with clinically sig- and estimated premorbid intellectual level. This nificant memory impairmentº (p. 315). A additional work renders the RBMT one of the further brief discussion of this issue can be best memory measures for use in an elderly found in Section 7.07.2. sample. Furthermore, the nonthreatening nature of the stimulus materials makes it more user- friendly for an elderly sample than many of its 7.07.9.4.4 The Rivermead Behavioural Memory competitors. A limitation of the RBMT is that it Test may be rather insensitive to mild impairments of memory. Following on from this, ceiling effects The Rivermead Behavioural Memory Test may be encountered in mildly impaired patients, (RBMT) was designed specifically to try to making any positive effects of intervention detect impairment of everyday memory func- difficult to demonstrate. tion by providing test items that resembled activities in everyday life, for example, remembering to deliver a message, remembering to 7.07.9.4.5 The Rey Complex Figure Test retrieve a personal belonging after an interval, etc. The RBMT has the advantage of having This test has been used widely (Rey, 1964), four matched parallel versions, thus allowing particularly because of the dearth of adequate for repeated assessment to determine the effects visuospatial memory tests. A complicated figure of disease progression and/or clinical interven- is presented and the subject is requested to copy tion. An additional important advantage of the it. The original and copy are then removed and RBMT is the careful work the authors have the subject is asked to draw the figure again undertaken in order to ensure the measure's from memory, after varying delay intervals. As validity. They assessed validity in three ways: (i) Mayes and Warburg (1990) point out there have by demonstrating a high correlation between been many variants on administration and the RBMT and other standard memory tests; scoring criteria; and the available norms, (ii) by demonstrating a high correlation between particularly for elderly samples, have been RBMT scores and subjective ratings of memory rather limited. Spreen and Strauss (1991), impairment; and (iii) most importantly, by however, provide normative data from the demonstrating a high correlation between age ranges 60±85 years. While this is a welcome RBMT score and observer ratings of memory addition, the numbers in each respective age lapses (Wilson, Cockburn, Baddeley, & Hiorns band are again limited. For example, in the 70+ 1989). Such a rigorous approach to demonstrat- age range, the sample size is n=10. This ing the ecological validity of a memory measure obviously makes clinical interpretation some- is both unusual and welcome. what difficult. In general, the RBMT is well tolerated by elderly individuals on account of its ªeveryday feelº and the fact that it consists of a number of 7.07.9.4.6 The Recognition Memory Test brief, relatively nonthreatening subtests. The The recognition memory test (RMT) is a initial normative data were provided from 118 widely used instrument, particularly in amnesia subjects aged 16±69 years. However, a supple- research (Warrington, 1984). It consists of two ment to the manual provides details of elderly subtests, recognition memory for 50 words and healthy subject's performance and is, therefore, recognition memories for 50 faces. Following a welcome addition to the clinical neuropsy- presentation of the words and faces, the testee is chologist's armamentarium for the assessment required to perform an immediate two-choice of memory in the elderly adult. Cockburn and recognition task and is generally considered to Smith (1989) recruited 119 people aged between be less stressful and anxiety provoking than 70 and 94 years, with a mean age of 80.5 years. many other memory measures. The normative In order to provide as random a sample as data consists of 310 control in-patients without possible, every fourth name of people born in or cerebral disease, aged 18±70 years. As Nelson before 1917 was taken separately from anyone (1990) points out in a review of the RMT, ªThis from the age/sex register of a five-doctor general test can only be used with subjects up to the age practice that covered both urban and rural of 70 because of the unknown effects of normal areas. Such a detailed attempt to recruit a truly aging on the test scores past this age.º ªnormativeº elderly sample is welcome. Furthermore, the authors determined that age and general intellectual ability were significant 7.07.9.4.7 The Doors and People Test correlates of Rivermead performance. Accord- ingly, they developed useful tables for determin- The Doors and People Test was devised in ing abnormal memory scores in relation to age order to provide comparable measures of visual 150 Neuropsychological Assessment of the Elderly and verbal memory that test both recall and batteries. This can be problematic as the norms recognition, that does not provide floor or for the elderly are limited. In addition there is a ceiling effects and includes both learning and need to derive individual comparison standards forgetting measures (Baddeley et al., 1994). The when assessing language function because of test comprises four sections: a doors test, where the large degree of variability in premorbid single doors have to be recognized against three competence (see Section 7.07.4.1). Therefore, competing distracters; a shapes test, where examiners should devote time in their initial diagrams have to be reproduced from memory; interview to inquire about factors such as a names test, which is a verbal recognition test; educational level, previous occupation, and and finally, the peoples test, where the subject is reading habits. required to learn an association between a series of photographs and names. Normative data from 238 subjects is provided, in five age bands 7.07.10.1 Naming (16±31, 32±47, 48±63, 64±79, 80±97). In fact, one of the stated aims was that doors and people Everybody has personal experience of look- should ªprovide an unstressful test that is ing for the name of an object, having a very acceptable to a wide range of subjects, extending strong feeling of exactly knowing what one from patients suffering from dementia or dense wants to say but being unable to recall the amnesia to healthy young normal subjectsº correct word. This phenomenon is often (Baddeley et al., p. 4). However, some elderly, referred to as ªtip of the tongue.º Word finding cognitively impaired subjects may find this test difficulty is the most common language symp- quite demanding. tom experienced by healthy people over 60 (Burke, Mackay, Worthley, & Wade, 1991). It is experienced occasionally by young people, but 7.07.10 ASSESSING LANGUAGE aging seems to exacerbate the problem. The DYSFUNCTION standard task for assessing word finding abilities is confrontation naming, in which In normal aging, deterioration of language subjects are required to name a given object, has been considered to be either very marginal or more commonly, to name objects depicted in or a consequence of deterioration of other line drawings. One of the most popular tests is cognitive functions. Although the majority of the Boston Naming Test (BNT) (Kaplan, elderly people do not develop any gross Goodglass, & Weintraub, 1983). The original language disturbance, close scrutiny suggests version of this test included 85 items (Kaplan, that some subtle changes are indeed present Goodglass, & Weintraub, 1978); however, the (Kemper, 1992). In contrast, language deficits shortened version produced in 1983 is used are a very pronounced aspect of cognitive more frequently. This test consists of 60 line deterioration in DAT. Aspects of language may drawings of objects of graded difficulty, ranging also be disrupted by other forms of cortical and from very common objects (e.g., a tree) to less subcortical dementias (e.g., fronto-temporal familiar objects such as an abacus. Although dementias, Huntington disease, Parkinson's the original normative data are scanty, several disease, vascular dementia, etc.). studies have provided supplementary norms; Given the frequency of occurrence of lan- these studies have been reviewed comprehen- guage disorders after degenerative neurological sively by D'Elia et al. (1995). Data collected diseases associated with old age, language from a large sample of 750 older adults (over the should be investigated in depth. In the following age of 55 years) showed that performance on sections, the most frequent language distur- the BNT was influenced by age which bances encountered either in normal aging or as accounted for more than 10% of the raw score a consequence of degenerative disorders will be variance (Ivnik, Malec, Smith, Tangalos, & reviewed briefly and suggestions made about Petersen, 1996). appropriate assessment procedures. The exam- A study carried out with patients showed that ination of language competence should include correlation between the two (long and short) assessment of verbal expression (naming, forms of the test and two 42-item forms vocabulary, discourse and verbal fluency, (obtained by dividing the original test into repetition, prosody), verbal academic skills two nonoverlapping forms) ranged from 0.96 to (reading, writing, spelling), and verbal compre- 0.92 (Huff, Collins, Corkin, & Rosen, 1986). A hension (syntax, idioms, and proverb inter- study (Mitrushina & Satz, 1995) carried out pretation). As yet there is no comprehensive with healthy elderly individuals has reported battery specifically designed for assessing that repeated testing with the BNT reveals a language abilities in the elderly, therefore high stability of scores over time, suggesting a clinicians often fall back on general aphasia lack of practice effects. Assessing Language Dysfunction 151

Naming may also be assessed using the Object knowledge may be responsible for word-finding Naming Test (Newcombe, Oldfield, Ratcliff, & difficulties. Wingfield, 1971) or the Graded Naming Test The situation is more complicated when (Warrington, 1984). A detailed examination of trying to understand the severe word-finding naming should also include naming of actions difficulties that occur in DAT. Conflicting (verbs), body parts, and colors. Naming of explanations have been provided for this, and actions may be tested by means of formal action evidence in favor of an access or retrieval deficit naming tests (McCarthy & Warrington; 1986; (Kempler, 1988; Neils, Brennan, Cole, Boler, & Obler & Albert, 1978). As an alternative, the Gerdeman, 1988), or evidence of a structural Boston Diagnostic Aphasia Examination disruption (Hodges, Patterson, Graham, & (Goodglass & Kaplan, 1987) provides a com- Dawson, 1996; Kempler, Andersen, & Hender- prehensive examination of naming abilities. son, 1995; Nebes, Brady, & Huff, 1989) has been However, this test is time-consuming and is best reported. Further, in demented people, failure suited to highly experienced examiners; further- on confrontation naming could be due to visuo- more, there is limited normative data for the perceptual deficits that result in failure to healthy elderly. identify and recognize an object, as suggested Confrontation naming studies based on the either by the fact that performance improves BNT indicate that there is an increase in the when additional sensory cues are provided variability of scores among apparently healthy (Barker & Lawson, 1968) or by the fact that individuals in their 60s, thereby suggesting errors consist of naming objects which are impairment in a subset of this age group (Van visually rather than semantically related to the Gorp, Satz, Kiersch, & Henry, 1986). There is target. consistent evidence of a steep decline in the late 70s (Goodglass, 1980; Mitrushina & Satz, 1995). This decline is evident with both low- 7.07.10.2 Vocabulary frequency nouns and verbs but is more marked As discussed earlier, structural knowledge in the former (Obler, Albert, & Goodglass, about words does not change greatly in the 1981). Poor scores on confrontation naming can normal elderly population, and vocabulary arise because of a failure to give any response or scores do not typically decrease in the normal because of incorrect responses. Increases in the aged (Salthouse, 1988), rather they may number of errors on confrontation naming increase, albeit modestly. This evidence sup- tasks were observed in a couple of studies that ports the notion of a preserved structural compared the performance of over 80-year-old knowledge of words in the normal aged subjects with younger subjects (60- and 70-year- population. The most widely used instrument olds) (Albert, Heller, & Milberg, 1988; Borod, for the assessment of vocabulary ability is the Goodglass, & Kaplan, 1980). Obler and Albert Vocabulary subtest of the WAIS-R (Wechsler, (1985) analyzed the qualitative features of 1981) which consists of 35 items organized in errors made by the elderly and noted that they order of increasing difficulty. Performance on tend to be characterized by the use of this test is greatly influenced by education circumlocutions. (Malec, Ivnik, Smith, & Tangalos, 1992) and Naming can also be studied using verbal socio-cultural factors (Huttenlocher, Haight, & fluency tasks which require the generation of Bryk, 1991) rather than age. A test±retest words from semantic or phonemic cues. These reliability coefficient of 0.71 has been reported tasks are reviewed in Section 7.07.13.2. Two in a study of the healthy elderly (Snow, Tierney, hypotheses have been put forward to explain the Zorzitto, Fisher, & Reid, 1989). naming problems that occur with normal aging. One argues for a degradation in the structure of lexical knowledge, whilst the other argues for an 7.07.10.3 Discourse impairment in retrieval mechanisms (see Light, 1992 for a review). Experimental evidence The assembling of a meaningful and well- shows that semantic priming effects are virtually structured discourse requires lexical and syn- identical for young and healthy older adults tactic competence, including a knowledge of (Balota & Duchek, 1988; Burke, White, & Diaz, pragmatics (i.e., discourse structure and rules), 1987; Monti et al., 1996); further, in naming adequate sequencing skills, including the ability tasks, performance both of young and old to integrate concepts within and between subjects is enhanced more by phonological cues sentences, and adequate working memory than by semantic cues (Nicholas, Obler, Albert, capacity. Material from the clinical interview & Goodglass, 1985). These findings suggest that can be used to assess the quality of discourse and structural semantic knowledge of words is intact this can be supplemented by asking a patient to and that a deficit of retrieval or access to this describe a standard picture or relate a well- 152 Neuropsychological Assessment of the Elderly known story (e.g., Little Red Riding Hood). As education. Adjusted scores of 25±28 are re- a standard picture, the Cookie Theft Picture of garded as indicating mild comprehension pro- the Boston Diagnostic Aphasia Examination blems and 17±27 moderate problems; scores (Goodglass & Kaplan, 1983) may be used. The below this are classified as severe or very severe. examiner should assess whether the production This test is extremely sensitive to impairment of is assembled coherently, if elements are con- linguistic processes. De Renzi and Faglioni nected and sequenced in the appropriate order, (1978) reported a true positive classification rate whether an individual makes correct use of of 93% when assessed against results from an reference pronouns, and whether appropriate extensive aphasia examination; the true negative elements are produced. Performance should rate was 95%. also be evaluated in terms of the complexity of Test±retest reliability with aphasic patients is sentences, grammar and syntax, and richness of very high, ranging from 0.92 to 0.96 (Gallagher, vocabulary. 1979; Orgass, 1976). There are inconsistent Aging does not have macroscopic effects on reports about the effects of age and education discourse; some subtle deficits, however, may be on performance, some suggesting a moderate present in the use of pronouns in discourse, with increase in number of errors with aging (see older subjects using pronouns without specify- Lezak, 1995). ing their referent in spontaneous speech, a Memory and attention play an important role situation that especially involves memory in performance on comprehension tests. For (Pratt, Boyes, Robins, & Manchester, 1989). example, working memory load is high on the It has also been reported that deficits on later items of the Token Test. Therefore, results discourse production reflect changes in those obtained from measures of attention and macrolinguistic skills that require integration of memory must be integrated with the results linguistic and nonlinguistic cognitive processes from tests of comprehension when reaching a rather than language-specific cognitive pro- formulation regarding the nature of an indivi- cesses (Glosser & Deser, 1992). It was observed dual's difficulties. that elderly subjects did not differ from young subjects on microlinguistic aspects such as syntactic complexity, lexical production, and use of lexical cohesive ties; however, older 7.07.11 ASSESSING VISUOPERCEPTUAL individuals failed to refer coherently to the DYSFUNCTION general topic. Discourse production is impaired significantly in patients with DAT, even in the Visuoperceptual deficits represent a very very early stages, and is characterized by common finding in sufferers of degenerative incoherence and emptiness of speech; sponta- cortical illnesses. A comprehensive evaluation neous speech therefore remains fluent but of visuoperceptual abilities should include carries less information (Giles, Patterson, & assessment of color perception, visual recogni- Hodges, 1996; Ripich & Terrell, 1988). tion, visual organization, and visual interference. A first step in assessing visuoperceptual functions should be to test for the presence of unilateral neglect; this topic is covered in 7.07.10.4 Verbal Comprehension Section 7.07.12.1. Comprehension is usually well preserved in healthy elderly individuals, and apparent def- 7.07.11.1 Visual Recognition icits are often simply a reflection of poor auditory acuity (see Section 7.07.2). The most Evaluation of visual recognition abilities common test of verbal comprehension is the includes assessment of several aspects. It Token Test (De Renzi & Vignolo, 1962). The includes, first of all, assessment of perception original version of this test consists of 62 items of angulation. The most widely used test in this but a 36-item short-form (De Renzi & Faglioni, case is the Judgment of Line Orientation Test 1978) is more commonly used in clinical (Benton, Hannay, & Varney, 1975). This test practice. The materials consist of tokens which includes 30 pairs of angled lines to be matched differ in color, shape (squares and circles), and with the corresponding lines in a radially size (large and small). The examinee has to arranged 11-line display. An advantage of this follow verbal instructions which increase in test over many clinical tests used to assess complexity from simple commands (e.g., visuospatial functioning is that it imposes ªTouch a circle,º ªTouch the red circleº) to minimal demands on praxic, mnestic, or execu- commands such as ªBefore touching the yellow tive functions. The norms include correction circle, pick up the red square.º The test authors factors for age and education but are based on recommend that scores be adjusted for years of only 144 subjects. Age effects on this test have Assessment of Attention 153 been confirmed by Eslinger and Benton (1983); Rey-Osterreith Complex Figure (Osterreith, test±retest reliability over a one-year delay in an 1944) is the most widely used copying test elderly sample was modest (r=0.59) (Levin (for further details see Section 7.07.9.4.5). The et al., 1991). Block Design subtest of the WAIS-R may be The recognition of objects depicted under used for assessing two-dimensional construc- conventional and unusual views should be tional abilities. examined. Warrington and Taylor's (1973) Unusual Views Test can be used for the latter. Assessment of visual recognition also includes 7.07.11.4 Visual Interference testing of face recognition abilities. For this Visual interference may be evaluated by purpose the Benton Facial Recognition Test means of the Hidden Figures Test (BFRT) (Benton, Hamser, Varney, & Spreen, (Gottschaldt, 1928) which requires a subject 1983; Benton & Van Allen, 1968) may be to recognize a simpler figure, hidden in a more administered. The original version of this test complex one, by marking its outline. Normative includes 22 items; it is a matching task rather data up to the age of 79 years are provided in than a true recognition task since it requires Spreen and Strauss (1991). Another useful and matching a front-view photograph of a target well-known task for assessing visual interfer- face to a matrix of faces photographed either in ence is the Overlapping Figure Test (Poppel- front-view, three-quarter-view, or under differ- reuter, 1917). An effect of normal aging on ent lighting conditions. Norms are available up performance on this test has been reported in a to the age of 74 years. Some degree of age- recent study (Della Sala, Laiacona, Trivelli, & related decline in performance on this test has Spinnler, 1995) in which severely impaired been observed (Benton, Eslinger, & Damasio, performance was observed in a sample of 1981) and the norms have correction factors for patients with DAT. age and education. Further evidence of age- associated impairment at several stages of the face recognition process has been reported (Maylor, 1990). It should be noted that prosopagnosics can perform within normal 7.07.12 ASSESSMENT OF ATTENTION limits on the BFRT. However, they take an 7.07.12.1 Unilateral Neglect inordinate amount of time per trial as their performance is characterized by a piecemeal Unilateral cerebral lesions (especially right strategy in which each feature of the target face parietal lesions) often results in unilateral is compared with each feature of the faces in the neglect. Neglect labels a phenomenon that matrix (Ellis, 1992). involves lack of awareness of stimuli appearing on the side contralateral to the cerebral lesion. It is accepted widely that neglect is not a unitary 7.07.11.2 Visual Organization phenomenon and evidence of dissociations across modalities within the same patient and Making sense out of fragmented, incomplete, between patients have been reported (Halligan or ambiguous figures requires intact visual & Robertson, 1992). organization abilities. Those abilities may be Assessment of neglect should explore repre- tested using tasks such as the Street Completion sentational and motor abilities as well as Test (Street, 1931) or the Hooper Visual visuospatial abilities. Personal (relating to the Organization Test (HVOT) (Hooper, 1983). subjects body), peripersonal (within arms The HVOT requires examinees to name 30 length), and extrapersonal space should be fragmented objects. Test±retest reliability in an investigated. A dissociation between personal elderly sample was 0.68 (Levin et al., 1991) and peripersonal space and extrapersonal space has the original norms cover up to age 68 years. been illustrated by Halligan and Marshall Studies which have investigated this task in (1991) who described a case with severe neglect elderly subjects (55±92 years of age) indicate in the former spheres but who nevertheless that performance drops off significantly with failed to exhibit neglect for distant experimental age (Farver & Farver, 1982; Montgomery & stimuli and could aim successfully at areas on a Costa, 1973; Villardita, Cultrera, Cupone, & dart board which were to the left of the midline. Mejia, 1985). The most frequently administered test for assessing visuospatial exploration is the Albert 7.07.11.3 Visuoconstructional Ability Test (Albert, 1973) which consists of 40 lines drawn out at various angles on a sheet of paper; Visuoconstructional abilities are usually as- the subject's task is to cross out all of them. sessed by means of copying or free drawing. The Normal subjects usually perform flawlessly on 154 Neuropsychological Assessment of the Elderly this test. Neglect may also be assessed using the noted that neglect was considered to be present Bells Test (Gauthier, Dehaut, & Joanette, 1989) if the discrepancies between errors on left- vs. that includes 315 silhouettes of common objects, right-sided stimuli on visuospatial tasks ex- of which 35 are bells; the subject's task is to ceeded control values (these control values were search for the bells. Normative data (including simple difference scores). As there typically will data from subjects aged 50±89 years) are be a high number of errors on visuospatial tasks available for this test, and no more than three in DAT cases, and often they will exhibit bells are usually missed by normal elderly considerable intrasubject variability, these re- subjects. Test±retest reliability over a two-week sults may be an artifact of Freedman and period was reported as 0.69. Dexter's (1991) scoring methods. This alter- Line Bisection is also a widely used task for native explanation is strengthened by the fact assessing neglect; it requires a subject to divide that the number of cases classified as exhibiting horizontal lines at the center point. Performance right-sided neglect was exactly equivalent to the on this task can be highly variable, and it is number classified as exhibiting left-sided neglect advisable to acquire data from multiple trials. (right-sided neglect is relatively rare). When Patients with right hemisphere lesions show a looking at individual reports of cases of DAT right-deviation error of the bisection point, that displaying neglect, only three cases have been increases as a function of the length of the line reported (Ishiai, Okiyama, Koyama, & Seki, (Halligan & Marshall, 1989). 1996; Pentore & Venneri, (1994). Pentore and Representational neglect, that involves men- Venneri (1994) in their study reported two tal imagery, may be assessed by asking a patient patients with DAT of moderate severity who to describe a well-known scene from a particular manifested neglect in the later stages; one of perspective. A patient may fail to recall objects these patients manifested motor neglect in on the left but recall the same objects when addition to visuospatial neglect. Such limited asked to imagine the scene from the opposite evidence may lead to the conclusion that neglect perspective (Bisiach & Luzzatti, 1978). in DAT is actually rather rare. This would be in A comprehensive battery for testing visual accord with the fact that neglect is generally neglect has been assembled by Wilson, Cock- observed after unilateral lesions, while DAT, burn, and Halligan (1987). This battery is called although it may present some degree of the Behavioural Inattention Test (BIT) and asymmetry at onset, involves bilateral degen- includes conventional tests (star cancellation, eration (see Kirk & Kertesz, 1991, for further letter cancellation, figure copying, line crossing, discussion). line bisection, and representational drawing) and behavioral subtests (picture scanning, 7.07.12.2 The Anterior Attention System telephone dialing, menu reading, article reading, telling and setting the time, coin sorting, The anterior attention system is considered to address and sentence copying, map navigation, underlie performance on tasks of sustained, and card sorting). The test manual reports divided, and selective attention (Posner & impressively high coefficients for inter-rater Petersen, 1990). Such attentional problems are reliability (0.99), test±retest reliability (0.99) and common and debilitating features of many parallel form reliability (0.91). Among the six neurological and psychiatric disorders asso- conventional tests included in the battery, star ciated with aging (Crawford, McKinlay, & cancellation had substantially greater sensitivity Parker, 1992b; Lezak, 1995; Walsh, 1991). than the other tests (Halligan & Marshall, 1988) However, the assessment of attentional dys- (see Figure 1). function is a problematic area in clinical Although many studies have explored the neuropsychology as many potentially useful performance of normal subjects on some of the tasks used in experimental studies have not been tests commonly used to assess neglect, relatively translated into practical clinical instruments. little is known about the effect of normal aging Many existing tests do not reflect theoretical and dementia on these tasks. Neglect is seldom knowledge on attention and its fractionation found in DAT, despite the frequency of (Posner & Petersen, 1990) and, in many cases, visuoperceptual disorders in this condition; are poorly standardized (Lezak, 1995). An Huff et al. (1987) reported an incidence of 3% additional consideration is that tests such as based on 95 cases. A high incidence of neglect the PASAT, which have proved valuable in has been reported by one study of visuospatial work with younger clinical populations because ability in DAT (Freedman & Dexter, 1991). of their demonstrated sensitivity and predictive These authors concluded that neglect in DAT validity, are too demanding to be suitable for may not be an unusual phenomenon but could use with the majority of elderly clients. Because often be missed because of a failure to conduct a of space limitations, we will limit coverage to a detailed assessment. However, it should be single battery, the Test of Everyday Attention Assessment of Attention 155

Conventional tests

Star Letter Figure Line Line Rep Cancellation Cancellation Copying Crossing Bisection Drawing

No. of patients Detected 30 24 22 17 16 11 100 90 100% 80 70 80% 73% 60 % Detected 50 57% 40 53% 30 37% 20 10 0 10 20% 27% 20

30 43% 47% 40 % Missed 50 63% 60 70 80 90 100 Neglect sample = 30

Figure 1 The relative sensitivities of the six conventional screening tests of the Behavioral Inattention Test (reproduced from Halligan & Robertson, 1992).

(TEA) (Robertson, Ward, Ridgeway, & the floor indicator has failed (thus counting the Nimmo-Smith, 1994; Robertson, Ward, Ridge- tones is the only way to establish which floor the way, & Nimmo-Smith, 1996). elevator is on). A related subtest, designed to TEA is a welcome development as it attempts measure auditory selective attention, requires to overcome some of the aforementioned the examinee to ignore distracter tones which problems in the assessment of attentional are of a higher pitch. dysfunction. It consists of eight subtests, The TEA was normed on 154 healthy standardized to have means of 10 and SDs of participants aged 18±80 years. In addition to 3, which measure sustained, selective, and reflecting current thinking on the fractionation divided attention. For example, in the Map of attention, it is designed to be ecologically Search subtest, which was designed as a measure valid, that is, many of the subtests are designed of visual selective attention, the examinee has to to mimic everyday activities. Another advan- search for symbols (e.g., a knife and fork tage is that it has three parallel versions; this representing eating facilities) on a tourist map of avoids the interpretative problems encountered a city. The Elevator Counting subtest, which when attempting to measure change using the was designed to measure sustained attention, is same test materials. a tone counting task in which the examinee is Crawford, Somerville, and Robertson (1997) asked to imagine they are in an elevator in which have prepared tables which allow clinicians 156 Neuropsychological Assessment of the Elderly to examine a client's relative strengths and that Bondi, Kaszniak, Bayles, and Vance (1993) weaknesses on the TEA (in terms of the have demonstrated that deficits in other reliability and abnormality of subtests cognitive domains were no longer significant deviations from the subtest mean), thereby after partialing out performance on tests of supplementing the conventional normative executive function. comparison standards presented in the test It has also been proposed that normal aging is manual with individual comparison standards. associated with a selective decline in fronto- executive function (Dempster, 1992). Daigneault, Braun, and Whitaker (1992), for 7.07.13 ASSESSMENT OF EXECUTIVE example, note that ªThe currently dominant FUNCTIONS neuropsychological model of normal brain aging postulates that cognitive functions de- Executive deficits arising from damage to the pendent on the integrity of the prefrontal brain prefrontal cortex and related structures can regions are among the first to deteriorateº have a much more profound effect on a client's (p. 99). This frontal hypothesis stems from prospects for successful adjustment and inde- indications that age-related changes in the pendent living than the more circumscribed neuroanatomy and neurochemistry of the brain deficits arising from posterior cortical lesions. are more pronounced in the frontal lobes than in However, these problems have proven difficult other cortical areas (Fuster, 1989) and from to quantify and as such can be regarded as demonstrations of age-related deficits on neu- constituting the most problematic area in ropsychological tasks sensitive to frontal dys- neuropsychological assessment. For example, function (Daigneault & Braun; 1993; reviews of tests such as the Wisconsin Card Daigneault et al., 1992; Mittenberg, Seidenberg, Sorting Test (Grant & Berg, 1948; Heaton, O'Leary, & DiGiulio, 1989). However, there is 1981), which are aimed specifically at capturing only limited evidence that such deficits qualify the core cognitive problems (e.g., planning as differential deficits (i.e., that they signifi- deficits, underutilization of feedback, etc.), cantly exceed the deficits found in other indicate that existing indices are of limited cognitive domains). utility when used with individuals (Mountain & Snow, 1993; Reitan & Wolfson, 1994). Thus, considerable reliance must be placed on careful scrutiny of a client's approach to a range of 7.07.13.2 Verbal Fluency tasks to identify these cognitive difficulties. Verbal fluency tests, and in particular initial letter fluency, are widely used as tests of 7.07.13.1 Frontal Hypotheses executive dysfunction (Parker & Crawford; 1992; Walsh, 1991). Initial letter fluency, also Executive deficits are thought to underlie referred to as the Controlled Oral Word many of the behavioral disturbances seen in Association Test (COWAT) (Benton; 1969) or neurological disorders associated with increas- phonemic fluency, requires the generation of ing age. One of the more obvious examples is words from initial letters (normally F, A, and S Parkinson's disease (PD). Executive deficits or C, F, and L) under time constraints (normally would be expected in PD on pathophysiological 60 seconds per letter, although 90 seconds is also grounds as the basal ganglia, which are deprived used). Fluency tests are reliable, quick to of dopaminergic innervation because of degen- administer, and even patients with quite severe eration in the substantia nigra, have strong deficits can understand the task requirements. reciprocal connections with the frontal cortex. In an area replete with failures to replicate, In addition, the ventral tegmental area, which studies of initial letter fluency have been provides a direct dopaminergic innervation of remarkably consistent in demonstrating im- the prefrontal cortex, also deteriorates in PD paired fluency following left or bilateral damage (see Crawford, Besson & Ebmeier, 1990 for brief (Benton, 1968; Bornstein, 1986; Miceli, Calta- review). There is neuropsychological evidence girone, Gainotti, Masullo, & Silveri, 1981; which suggests that executive deficits are an Miller, 1984; Milner, 1964). In view of the early feature in PD and that these deficits above, fluency tests are among the most useful qualify as differential deficits in executive tests in the clinician's armamentarium. functioning (Lees & Smith, 1983). Indeed, it Performance on verbal fluency tasks reflects has been argued that fronto-executive dysfunc- the integrity of the semantic system (i.e., the tion provides a parsimonious explanation for all system responsible for storage of words and of the cognitive deficits observed in nondemen- their associations), the efficiency of retrieval ted Parkinson's cases (Della Sala, 1988). This is strategies, and the efficiency of self-monitoring an extreme position but it is interesting to note and inhibition of inappropriate responses. In an Assessment of Executive Functions 157 early influential paper, Perret (1974) reported (Walsh, 1991). Perseverative errors (repeating a significant deficits on initial letter fluency in word produced previously) and rule-break patients with focal frontal lesions whilst noting errors (e.g., producing a proper noun or a word that semantic or category fluency (i.e., generat- beginning with the wrong letter on initial-letter ing exemplars from categories such as animals, fluency trials) have been regarded as evidence of fruits, etc.) often failed to expose deficits disinhibition or a failure of self-monitoring (Newcombe, 1969). Perret (1974) and others (Crowe, 1992; Walsh, 1991). Crowe (1992) has have argued that the differential sensitivity of produced data to suggest that such errors tend initial letter fluency to frontal dysfunction stems to be associated with orbito-frontal damage, from the fact that in everyday life words are whereas impoverished but legitimate output is retrieved predominantly on the basis of their more indicative of damage to the lateral meaning. Thus, initial letter fluency is relatively convexity. novel and places greater demands on strategy Given the importance attached to such errors, generation and inhibition of semantic associ- there is surprisingly little normative data on ates. In contrast, semantic fluency places greater errors to assist clinicians interpret an individual demands on the integrity of the semantic client's performance. Kozora and Cullum's system. Hodges, Salmon, and Butters, (1990), (1995) study provided means and ranges for for example, is one of many studies in which perseverative and rule-break errors. Although there was evidence of a differential deficit in the mean and modal rates were low in all age semantic fluency vs. initial letter fluency in bands, a finding consistent with a COWAT DAT. This is consistent with other evidence normative study conducted by Ruff, Light, indicating that deterioration of the semantic Parker, and Levin (1996), the ranges are quite system is a marked feature of DAT (e.g., substantial (e.g., 0±15 in the 50±59 age group). It Grober, Buschke, Kawas, & Fuld, 1985). would be useful to know how many errors are Further support for this distinction comes required to exceed the 85th or 95th percentiles of from dual task studies of initial letter and the healthy population but there is no relevant semantic fluency in healthy participants. Mar- published data. tin, Wiggs, Lalonde, and Mack (1994) demon- There is a strong relationship between verbal strated that a secondary task involving motor fluency and general verbal ability in the general sequencing (designed to activate frontal cortex) population. For example, Miller (1984) reproduced a differential deficit in initial letter ported a correlation of 0.87 between initial letter fluency, whereas a secondary task involving fluency and Verbal IQ in a healthy sample semantic decisions regarding visual stimuli (N = 30). Crawford, Obonsawin, and Bremner (designed to activate posterior cortex) produced (1993) reported a lower but still substantial a differential deficit in semantic fluency. correlation of 0.64 between Wechsler Verbal IQ Some very useful normative data for the in a sample of 144 healthy participants. This elderly have been published. Ivnik et al., (1996) indicates that an individual's premorbid verbal present age- and education-based norms based ability must be considered as an important on 743 elderly participants using the COWAT factor when interpreting fluency performance in (i.e., the letters C, F, and L with 60 seconds per clinical populations. This was graphically trial). Particularly positive features of these data illustrated by Borkowski, Benton, and Spreen are the age range covered (55±97 years) and the (1967) who reported that the fluency perfor- fact that most participants were also adminis- mance of a ªbrain-damagedº sample of above tered other commonly used neuropsychological average verbal IQ was significantly higher than instruments. This latter feature makes the data the performance of healthy subjects of below useful when attempting to construct a profile of average verbal IQ. Crawford et al. (1992c) have a client's relative strengths and weaknesses as provided a NART-based regression equation raw scores are converted to a common Scale and which provides an estimate of a client's there is no worry that observed discrepancies premorbid fluency performance (see Section are artifacts of differences between normative 7.07.8 for details of the NART). This equation samples (see Section 7.07.4.2). Kozora and was derived from a healthy sample (N = 142) Cullum (1995) have published elderly norms for with an age range of 16±88 years. initial letter fluency (F, A, and S) and semantic fluency covering the age range 50±90 years. The semantic fluency test used was the supermarket 7.07.13.3 Nonverbal Fluency item list from the Mattis Dementia Rating Scale (Mattis, 1988). A number of attempts have been made to Errors on verbal fluency tasks have been develop methods of assessing nonverbal flu- afforded great significance in both the research ency. Jones-Gotman and Milner (1977) devel- literature and in advice offered to clinicians oped a task they termed Design Fluency which 158 Neuropsychological Assessment of the Elderly requires examinees to draw abstract (nonsense) healthy participants with an age range of 16±87 designs under a time constraint. This test can years. As was noted previously, many of the capture the lack of creativity and spontaneity formal neuropsychological tests can fail to and the perseverative tendencies which are often detect executive problems because they are striking clinical features of patients with frontal highly structured. Shallice and Burgess (1991) damage. The disadvantages of this test include note ªThe patient typically has a single explicit the lack of adequate normative data, the highly problem to tackle at any one time . . . the trials subjective nature of scoring, and the fact that it tend to be very short . . . task initiation is can be difficult to maximize cooperation, either strongly prompted by the examiner and what because clients fail to grasp the nature of the constitutes successful trial completion is clearly task or view it as odd and lacking in relevance. characterizedº (pp. 727±728). Although some of Ruff and colleagues (Ruff, 1988; Ruff, Light, the tests reviewed above clearly attempt to & Evans, 1987) have developed a figural fluency deviate from this formula, the BADS represents test (hereafter RFFT) which requires the the most ambitious and systematic attempt to examinee to join up a repeating sequence of date to capture the core elements of dysexecu- dots such that each design formed is unique. The tive syndromes. procedure removes subjectivity from scoring as The BADS subtests include the Rule Shifts each design is unequivocally unique, a perse- Cards Test in which a previously established veration, or (more rarely) an error. The RFFT response set (responding ªyesº to red cards, was normed on a sample of 358 healthy ªnoº to black) has to be inhibited in favor of individuals with an age range of 16±70 years. responding in terms of whether or not a card Group studies of clinical populations indicate matches the color of the card immediately that the RFFT is sensitive to anterior cerebral preceding it. The Action Program Test is a damage, particularly in the right hemisphere planning task in which the solution requires the (Lee et al., 1997; Ruff, Allen, Farrow, Niee- client to utilize various everyday materials (e.g., mann, & Wylie, 1994). For example, Lee et al. plastic, cork, and wire). The Modified Six found that 35% of designs produced by a group Elements Test (see Shallice & Burgess, 1991) with right frontal lesions were perseverations, a assesses scheduling and time management by figure which substantially exceeded the rate in requiring clients to tackle three different tasks right temporal (14%) and left frontal (17%) within the time limit; there are two versions of cases. each task and the rules prohibit tackling these Motor slowing is a common consequence of contiguously. cerebral damage and should be considered as a The inter-rater reliability of the BADS is factor when interpreting the number of legit- excellent; correlations between raters ranged imate designs produced on the RFFT. Ruff, from a low of 0.88 on one index from the Evans, and Marshall (1986) have reported that Modified Six Elements Test, to unity, or near significant RFFT deficits are observed in unity, on most of the other tasks. Test±retest neurological samples after controlling for motor reliability coefficients obtained from a small speed using a finger-tapping test. However, the subset of the standardization sample (retested appropriateness of finger-tapping as a control over a 6±12 month interval) ranged from modest measure could be questioned. Crawford, to poor but this, in part, reflects the effects of Wright, and Bate (1995) used a simple motor range restriction. task which required subjects to join repeated A useful supplement to the formal BADS pairs of dots; the motor demands of this task are subtests is the Dysexecutive Questionnaire very similar to the RFFT but it does not require (DEX). The DEX covers dispositional and the generation of designs. They reported that the cognitive changes and comes in two forms, one RFFT deficit in a head-injured sample did not for completion by the client, the other by a significantly exceed the deficit on the motor task. relative or carer. A provisional factor analysis indicates that the DEX measures three broad factors labeled as ªBehavior,º ªCognition,º and 7.07.13.4 Behavioral Assessment of the ªEmotion.º Large discrepancies between client Dysexecutive Syndrome and carer reports of change are common when working with clients who have executive A very useful battery for assessing executive problems. The DEX provides one means of problems has been developed (Wilson, Alder- quantifying this lack of insight; DEX results can man, Burgess, Emslie, & Evans, 1996; Wilson, also form a basis for discussion when counseling Evans, Emslie, Alderman, & Burgess, in press). clients and their families. The Behavioral Assessment of the Dysexecutive The DEX has been used to examine the Syndrome (BADS) battery consists of six relationship between carers' ratings of executive subtests and was normed on a sample of 216 problems and formal test scores. Multiple The Differential Diagnosis of Dementia vs. Depression 159 regression analyses found that BADS scores between dementia and depression. In order to were the only significant predictors of rated highlight the problems associated with this problems from among a set of measures which approach, in the following section the Delayed included traditional ªfrontalº tasks and mea- Word Recall test will be used as an example. sures of current and premorbid general in- In two studies by the consortium to establish tellectual ability. a registry for DAT (CERAD), the investigators reported that delayed verbal recall was a highly sensitive indicator of early DAT (Morris et al., 7.07.14 THE DIFFERENTIAL DIAGNOSIS 1989; Welsh, Butters, Hughes, Mohs, & Hey- OF DEMENTIA VS. DEPRESSION man, 1992). In DAT, there appears to be a rapid rate of forgetting within the first 5±10 minutes The differential diagnosis of dementia vs. following acquisition (Butters et al., 1988; Hart, depression has been described as ªprobably the Smith, & Swash, 1988) but a relatively normal knottiest problem of differential diagnosisº rate of forgetting thereafter (Corkin et al., 1984; (Lezak, 1995), yet is a common reason for Kopelman, 1985). Knopman and Ryberg (1989) elderly patient referral to clinical psychologists. suggested that elaborative encoding may pro- Depression is the functional disorder which can vide a substantial benefit in normal elderly most closely resemble the early stages of a individuals but not to patients with DAT. They dementing condition. It is vitally important for proposed that the optimum memory test an accurate differential diagnosis to be made procedure for the early diagnosis of DAT because as Woods and Britton (1985) point out, should involve: (i) a study phase in which ªDepression can be treated; dementia typically subjects were required to engage in elaborative leads to therapeutic despair.º Des Rosiers encoding; (ii) a filled delay interval; and (iii) a (1992) reviewed 18 studies and reported that, test phase which involved free recall. Accord- on average, 10% of cases initially diagnosed as ingly, Knopman and Ryberg (1989) developed organic dementia were later rediagnosed as the Delayed Word Recall test (DWR). Ten depression. In practice, the diagnosis of de- nouns are presented on cards, one at a time mentia vs. depression is made by drawing on (chimney, salt, harp, button, meadow, train, information from a wide variety of sources, that flower, finger, rug, book). For each word, the is, previous history, informant's account, phe- subject is asked to read out the word and try to nomenology, brain scan measures, blood bio- remember it and then to make up a sentence chemistry, etc. Problems emerge, however, using the word. When all 10 words have been when an individual presents with no well- presented, the complete procedure is repeated, documented history and no useful informant with subjects instructed to produce an alter- information. native sentence. Following a five minute filled Huppert (1994) has pointed out that in most delay, free recall for the 10 words in the list is studies where an early DAT group has been tested. Based on the delayed free recall cut-off compared with a control group, it is likely that score of less than or equal to 2 out of 10=DAT, the controls vary from the demented subjects in Knopman and Ryberg (1989) reported an ways which are rarely specified. For example, as overall predictive accuracy of 95% in a group the normal controls are usually community of DAT patients vs. elderly control subjects. volunteers, they are less likely to have mobility This is an extremely impressive degree of problems than sensory deficits and are more between-group separation. likely to be in good health. The patients usually In a follow-up study, Coen et al. (1996) have been referred to specialists which means compared a group of mildly demented DAT that dementia is sufficiently severe to have come patients with individually matched healthy to specialist attention, and second, that the controls and found that the DWR recall patients who see specialists may not be measure achieved 98% overall accuracy (i.e., representative of all demented subjects. As almost perfect between-group separation). In an Huppert (1994) states ªone implication of these extension to the original DWR, Coen et al. considerations is that observed differences are included a four-choice recognition memory test likely to be an exaggeration (if not a distortion) and, using a cut-off score of less than or equal to of the performance which would be seen in a 9 out of 10=DAT, greater than nine=controls, genuinely representative sampleº (p. 295). they reported that the recognition measure yielded a sensitivity of 98%, specificity of 95%, 7.07.14.1 Delayed Verbal Recall Impairment as and an overall accuracy of 96%. Taken an Indicator of Early DAT? together, the results of the Knopman and Ryberg (1989) and Coen et al. studies suggests Over the years there have been many attempts that the DWR is an extremely promising at using memory tests to help distinguish measure to aid in the early detection of DAT. 160 Neuropsychological Assessment of the Elderly

However, for any neuropsychological test index This study highlights the degree of cognitive to have clinical utility, the method must be impairment which often presents in elderly shown clearly to identify patients suffering from depressed patients which can masquerade as DAT without producing false-positives from an ªpseudo-dementiaº (Robbins, Joyce, & Saha- elderly depressed comparison group. Unfortu- kian, 1992). nately, too many studies have appeared which have focused on the simple comparison between 7.07.14.2 Kendrick Cognitive Tests for the DAT and very healthy controls, and this Elderly criticism can be leveled at the Knopman and Ryberg (1989) and Coen et al. studies. The Kendrick Cognitive Tests for the Elderly O'Carroll, Conway, Ryman, and Prentice (KCTE) comprise two components, a pictorial (1997) attempted to test the utility of the DWR memory task (the Object Learning Test or OLT) in separating patients with DAT from patients and the Digit Copying Test (DCT). The with major depression. Fifty patients with DAT principle underlying the use of the KCTE in were compared with 50 patients who fulfilled differential diagnosis lies in the expected pattern DSM-IV criteria for a major depressive episode. of visual memory and psychomotor speed in While there were highly significant differences depression vs. dementia. According to Ken- in mean free recall and recognition scores, the drick, Gibson, and Moyes (1979), both DCT between-group overlap was large (e.g., see and OLT should be affected in primary Figure 2 for free recall resultsÐvery similar dementia and not in depression. An innovation results were obtained for recognition). Put of the Kendrick test is the requirement that the simply, if the recommended cut-off point for measures be readministered six weeks following free recall of 2 or less out of 10=DAT is the initial assessment. desRosiers (1992) de- adopted, 44% depressed patients would be scribes this requirement as somewhat less than misclassified as suffering from DAT. Using the practical. However, in our opinion, repeat less than 10 recommended cut-off score for neuropsychological assessment in cases where recognition score, 48% of depressed patients diagnosis is in doubt represents good clinical would be misclassified as suffering from DAT. practice.

40 DAT

DEP 30

20 Number of subjects

s 0 012345678910 Number of words recalled Figure 2 DWR Recall results. Using <3 recommended cut-offs, only 2 (4%) DAT (Alzheimer) sujects would be misclassified, but 22 (44%) DEP (Depressed) would be classed as DAT (reproduced from O'Carroll et al., 1997). The Differential Diagnosis of Dementia vs. Depression 161

One of the strongest claims regarding the depressed patient groups. It is interesting to KCTE is that ªit has been found possible to note that the recognition measure was more discriminate absolutely between dementias and discriminating than free recall, selective remind- non-dementing subjectsº (Kendrick et al., 1979, ing, or serial learning, all presumably more p. 329). The literature on the Kendrick test is ªeffortfulº than a recognition task. well reviewed by desRosiers (1992). Some Lachner et al. (1994) point out that the reports have confirmed the utility of the KCTE labeling of some cognitive tasks as effortful vs. in differentiating a depressed sample from a automatic is often ambiguous, and propose demented sample. However, as is usually the sensibly that ªIn future research, the tasks case in studies of this sort, the samples consist of cognitive capacity requirements should be very well-defined groups where differential examined empirically to avoid inconsistencies diagnosis is not a problem (Knight & by subjectively estimating capacity demandsº Moroney, 1985). As desRosiers (1992) cautions, (Lachner et al., p. 10). A particular advantage the validity of the KCTE should best be of the Lachner et al. study is their comparison examined in patients for whom diagnosis is still of severely depressed psychiatric inpatients with ambiguous. A further point to consider when a demented patient sample where 60% were still considering the theoretical foundation of the capable of independently running their house- KCTE is the assumption that in depression, hold, as it is this type of comparison of mildly psychomotor speed, and mnemonic function demented and severely depressed patients that is are not as detrimentally affected as in early of particular clinical interest with regard to the DAT. However, in depressive pseudodementia, problem of differential diagnosis. it is precisely because both domains are seriously impaired that diagnostic difficulties arise. 7.07.14.4 Is Poor Memory Test Performance in Elderly Depressed Patients an Artifact of Poor Motivation? 7.07.14.3 Effortful vs. Automatic Processing In commenting on the relatively poor per- and Memory formance of many depressed patients with standard neuropsychological measures, many Weingartner, Cohen, Bunney, Ebert, and writers have attributed this impairment to the Kaye (1982) proposed that tasks that are nonspecific effects of motivational deficits. Few normally accomplished automatically and re- studies have tested this hypothesis experimen- quire little cognitive capacity are particularly tally. One notable exception is the study of useful in distinguishing progressive dementia Richards and Ruff (1989), who randomly patients from depressed patients. Weingartner assigned two groups of subjects, depressed (1984, 1986) reported that depressed patients and nondepressed, to either motivation or experienced difficulty on memory tasks that nonmotivation conditions (motivation involved require elaborate or effortful organization and encouragement, a monitory incentive and processing of material to be remembered, but performance feedback). Richards and Ruff that they do not show problems in memory (1989) reported that motivation (as measured tasks on which ªautomaticº memory encoding by improvement on a simple card-sorting task) is presumed to be involved. In contrast, it is was enhanced for the subjects in the motivation postulated that demented patients have diffi- condition. Crucially, motivation did not sig- culty with both automatic and effortful proces- nificantly affect neuropsychological test perfor- sing. In line with this proposal, Weingartner, mance and the authors concluded that although Cohen, Murphy, Martello, and Gerdt (1981) depressed patients may be less motivated, this reported that depressed patients demonstrate reduced motivation does not fully account for impairments on delayed free recall (effortful) the observed cognitive impairments in depres- with no impairment on recognition memory sion. (relatively automatic), whereas demented patients perform poorly in both conditions. However, Lachner, Satzger and Engel (1994) 7.07.14.5 Future Directions have provided evidence which challenges the Weingartner model. They compared three The literature indicates that demented sub- groups (demented, depressed, and healthy jects are impaired at any task which requires the subjects) who were in their 70s on five verbal conscious recollection of newly learned materi- recall and two recognition memory tasks. They al. However, much work has been carried out found that both delayed recall and recognition attempting to evaluate whether specific aspects after long delay were the measures which best of memory functioning are disproportionately discriminated between the demented and the impaired in early DAT. Divided attention tasks 162 Neuropsychological Assessment of the Elderly are particularly sensitive to DAT, that is, tasks propose seeing the patient on more than one day where subjects are required to divide their and, if in doubt, readministering at least a attention during learning (e.g., performing a portion of the measures on a second testing digit span test while keeping a stylus on a target session (this would be in accord with the on a pursuit rotor task). This would appear to be protocol of the Kendrick Cognitive Tests for a particular deficit in ªworking memory,º that the Elderly). Sweet et al. conclude ªIn the event is, the ability to hold information in a short-term that a diagnostic conclusion regarding brain store or carrying out the other processing dysfunction in the depressed patient appears operations (Baddeley & Wilson, 1986). Addi- unclear, despite all your best efforts, recom- tionally, prospective memory tasks appear to be mend a re-evaluation of the depressed patient particularly impaired in early DAT. Huppert after a period of pharmacological or psy- and Beardsall (1993) administered a variety of chotherapeutic interventionº (p. 41). This is a memory tasks and found that even patients with recommendation that is fully endorsed. Neu- minimal dementia were disproportionately im- ropsychological measures should be used in paired on prospective memory tasks (e.g., conjunction with information derived from a remembering to ask for a belonging back at variety of sources (e.g., relatives and clinical the end of the Rivermead Behavioural Memory history). Developments in neuroimaging preci- Test). In the search for particularly dementia- sion suggest that an in vivo maker for DAT may sensitive screening tasks, a combination of become available (Jobst et al., 1994). divided attention and prospective memory tasks Given the potentially catastrophic outcome of may well be worthy of further investigation. misclassifying a treatable, depressed patient as having DAT, it has to be concluded that the available evidence indicates that no single 7.07.14.6 Recommendations and Conclusions neuropsychological measure can be recom- for the Differential Diagnosis of mended for use in the individual case to Dementia vs. Depression confidently separate early DAT from major depression in an elderly population. However, Sweet, Newman, and Bell (1992) made several neuropsychological measures may offer useful useful recommendations to facilitate the differ- information that can be integrated with data ential diagnosis of depressed patients from gathered from a variety of sources. In particular, demented patients. First, they recommend accurate objective quantification of change over administering neuropsychological measures time is one of the key areas where detailed that assess domains which the literature indicate assessment of cognitive functioning can provide are particularly discriminating, notably psycho- important diagnostic information. Further- motor retardation, recognition vs. recall, and more, changes in neuropsychological status easy vs. difficult paired associated learning. can offer a useful measure of treatment response Second, they recommend utilization of mea- in both dementia and depression. sures of affective status (e.g., the Beck Depres- sion Inventory or the Geriatric Depression Rating Scale). They also propose seeking collateral information through interviewing 7.07.15 REFERENCES the spouse or significant other. Third, when evidence of depression is found, customary Albert, M. L. (1973). A simple test of visual neglect. cognitive ªcut-offº scores may be misleading Neurology, 23, 658±664. Albert, M. S., Heller, H. S., & Milberg, W. (1988). Changes and they propose using more stringent criteria in naming ability with age. Psychology and Aging, 3, (e.g., an additional standard deviation away 173±178. from normal performance). Fourth, with de- Anthony, J. C., Le Resche, L., Niaz, U., Von Korff, M. 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