DSIDC Mini Symposium on Dementia

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DSIDC Mini Symposium on Dementia
How useful are Assessment Scales in diagnosing
and caring for people with dementia? Dr. Robert
Coen Mercers Institute for Research on
Ageing St. Jamess Hospital, Dublin 8
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• The focus in this presentation is not what
  scale and how
• The focus is on
• What can you learn from doing the scale at all
• To interpret correctly what a test or scale is
  telling us requires sophistication in using it
• In particular we need to be aware of a number of
  factors that can affect performance and ratings
• Dont take the numbers at face value

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• I intend looking at some typical examples of
  tests / scales used to evaluate
• Cognition
• Functional abilities
• Behavioural and Psychological Symptoms of
  Dementia (briefly, as youll be hearing more
  about that later in the day)
• Burden

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Basics

• Vision?
• Hearing?
• Age?
• Education?
• Gender?
• e.g. to get a brief global index of cognition you
  administer the MMSE
• Any of the above factors can affect performance

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Sensory processes

• Sensory processes decline with age, and this
  means that test stimuli must be designed to be
  appropriate for the elderly. Can test materials
  be clearly seen?
• The examiner needs to consult with the client to
  ensure that the instructions are heard and
  understood.
• Spectacles, hearing aids, hearing devices..

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Whats normal?

• many cognitive tests have limited if any norms
  for the elderly. When norms are available, they
  often extend only to the age of 75, but adults
  over the age of 85 are in the most rapidly
  growing segment of the population in many
  countries.
• Cut-off scores can be misleading. MMSE 23/30
  isnt necessarily dementia, MMSE 26/30 isnt
  necessarily normal

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Individual differences

• Individual differences increase dramatically with
  age, making a wider range in older adulthood of
  what is normal. Ceiling and floor effects are
  therefore more likely in older adult groups where
  the range of ability is so great.

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Test anxiety

• Test anxiety can be a problem when people feel
  that their mental capacities may be declining.
• They may be unused to being tested (many elderly
  people had a basic Primary level education).
• The person may be fearful as to what the tests
  are going to reveal, and their implications
• Sometimes excessive test anxiety rather than any
  age-or disease-related problem contributes to
  impaired test performance

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Lack of test anxiety!

• The person way be poorly disposed to bother on
  testing to start with
• Insight ?
• Who made the referral?
• Are the tests perceived as of any value by the
  testee?
• Effort and motivation have to considered
  regarding test performance

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Test fatigue

• Test fatigue can occur sooner in older people.
  Because of decreased stamina, shorter test
  batteries are recommended for older clients.
• Watch out for and check for fatigue

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Other factors affecting screening test performance

• Other factors such as depression, dysphasia,
  drugs (psychotropic, social), psychosocial
  stressors, pain, physical illness, and so on all
  need to be taken into account...

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Assessing cognition e.g. MMSE
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• What can we learn about a client by administering
  an MMSE?

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Mini-Mental State Examination (MMSE)

• Review Tombaugh McIntyre (1992)
• limited sensitivity to mild cognitive impairment
• relies heavily on language
• limited coverage of non-verbal cognition
• limited sensitivity to executive dysfunction
• Limited instructions on administration and
  interpretation
• Folstein et al (1975)
• Spencer Folstein (1985)
• The Mini-Mental State Examination, in
  Innovations in Clinical Practice A Source
  Book.
• Folstein et al 2001. Users Guide (of sorts..)

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MMSE orientation

• Temporal orientation
• Well, what date is it? Are you ever inaccurate
  about the date?
• Alternatively maybe the client has been
  rehearsing it for weeks.
• Spatial orientation
• Just because you cant recall the name of the
  hospital doesnt mean you dont know where you
  are.
• What floor are we on? 4th? 2nd? Did you use the
  lift or stairs?

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Scoring Serial 7s?

• .say keep going (as needed) until he or she
  has given you a total of five answers..
• Score 1 point for each correct answer. An answer
  is correct if it is exactly 7 less than the
  previous answer, regardless of whether that
  previous answer was correct.

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Scoring Serial 7s?

• ..93..73.7 from 100 is 93 and 86..am I wrong
  7 from 93mm..86..am I right or wrong.7 from
  97867 from 86 is 79 7 from 79 is 72. 7 from
  72 would be 67no 65.
• And the score is?

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Scoring World backwards? - Folstein

• There are at least 3 scoring systems.
• Folstein system the score is the number of
  letters in correct order.
• So how do you score
• D..L.O.D.O.R.LD I think Im wrong..

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• Dimensions of the MMSEJones Gallo 2000, Psych
  Med.
• n 8556, age 50-98.
• 5 factor solution
• Concentration (dlrow / Serial 7s)
• Language Praxis (naming, command, praxis)
• Orientation (temporal and spatial)
• Memory (delayed recall)
• Attention (registration)
• The factors correspond with original MMSE sections

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Lets look at Delayed recall?

• How long is the delay? Versions of MMSE vary
• Some use DLROW only
• Some use Serial 7s only
• Some use DLROW only if Serial 7s refused
• Some use both.
• How valid is 3 word recall? Cullum et al (1993)
• Substantial variability in healthy elderly
• Significant proportion of normal subjects
  recalled zero or one word.
• Nonetheless, 0/3 recall on MMSE 27/30 warrants
  consideration..

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INTERPRETING MMSE SCORE The 23/24 cut off vs
norms for MMSE(Crum et al 1993, normative
sample, n18,056)

• Ed 5-8 yrs
• Age 65-69
• Mean MMSE 26/30 1.7

• Ed 5-8 yrs
• Age 85
• Mean MMSE 23/30 3.3

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Presumably everyone can copy pentagons...??

• Folstein et al (2001)
• Two 5-sided figures intersect to form 4-sided
  figure
• The two figures do not have to be perfect
  pentagons.
• The lines do not need to be perfectly straight.

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Samples

• Mild Alzheimers disease (n94)
• Consensus Mild AD
• NINCDS/ADRDA
• CDR 0.5 to 1
• MMSEdlrow gt 19/30
• MMSE 22.7 1.8
• (range 20/30 - 26/30)
• Female 70
• Age 74.64.1
• Education
• primary (64)

• Matched controls (n99)
• Healthy, community
• AGECAT screened
• MMSE / CDT
• Detailed history
• MMSE 27.8 1.8
• (range 22/30 - 30/30)
• Female 67
• Age 74.45.5
• Education
• primary (61)

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Results (Folstein scoring system)

• 50 (53) ADs failed.
• 45 (46) controls failed.
• Logistic regression
• Controls (n99)
• Education (F 2.89, p 0.09)
• Age (F 1.66, p 0.20)
• Gender (F 0.95, p 0.33)
• MMSE-pentagons (F 0.01, p 0.95)
• In stepwise backward regression no factors
  remained in model (education, p 0.13)

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MMSE and practice effects

• Galasko et al (1993)
• n39 patients with Alzheimers disease
• MMSE twice, one week apart
• Learning effect was evident
• Scores increased significantly by 1.12 0.47
• one point increase on average

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MMSE and fluctuation - score may vary due to
circumstances

• van Der Cammen et al (1989)
• Case 1, F/78, admitted with congestive cardiac
  failure
• After a week atrial fibrillation / heart failure
  under control.
• At that time MMSE 10/30. CT atrophy old L
  cerebellar infarct.
• week later MMSE 17/30 5 months later MMSE
  24/30
• Case 2, F/73, husband RIP, memory poor, OPD
  referral
• 3 days after husbands death MMSE 9/30
• 4 weeks later MMSE 18/30. Day 3 was misleading.
• Case 3, F/82, hypothyroidism, husband RIP, OPD
  referral over 12 months later, query depression?
• On admission MMSE 12/30 anxiety. Not
  depressed, but personality disorder and
  preoccupation with loneliness.
• Rehoused to residential home. Several months on
  MMSE 18/30.
• Two months later MMSE 14/30 recurrence of
  anxiety

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Functional abilities

• Instrumental acyivities of daily living (IADL)
• Activities of dialy living (ADL)
• e.g. physical self maintenance
• ADL is less problematic to observe and rate

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Functional abilities - ADL
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Rating functional abilities

• Core criterion for dementia
• typically IADL goes first

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• Lawton Brody IALD scale is a typical example

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Rating functional abilities

• Who does the rating - individual or reliable
  informant?
• If they disagree, who is more accurate?
• Issues
• carer stress?
• Informant bias
• Underestimating deficits (unconscious or
  conscious)
• Overestimating deficits (overprotective? could if
  let?)
• What about direct assessments of functioning?
• ?suitability of rating scale content - see IALD
  scale

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Behavioural and Psychological Symptoms of Dementia

• Behavioural
• Activity disturbances
• Aggression
• Eating / sleep
• Social
• Psychological
• Affect
• Apathy
• Delusions / hallucinations

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Behaviour disturbance -neuropsychiatric
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Behaviour disturbance general
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Carer burden

• Caregiving can be rewarding but it can also be
  highly stressful
• Depression
• Anxiety
• Burden

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Carer burden
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A model of caregiver burden(adapted from
Vitaliano et al. 1990)Stressors
declining cognition, behaviour, functioning,
general life events.....Vulnerability health,
age, living conditions, relationship.....Psycholo
gical resources expectations, attitudes, problem
focused coping.....Social resources formal
support from statutory bodies / voluntary
organisations. Informal support (family,
relatives, friends)
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• To recap
• To interpret correctly what a test or scale is
  telling us requires sophistication in using it
• In particular we need to be aware of a number of
  factors that can affect performance and ratings
• Dont take the numbers at face value