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My Patient Screened Positive for Cognitive Impairment. Now What?

A Primer on Neuropsychological Evaluation Sara L. Weisenbach,

Ph.D., ABPPBoard Certified Clinical

NeuropsychologistAssistant Professor

Department of Psychiatry,

VA Salt Lake City Healthcare System

Objectives

• Understand what a neuropsychological evaluation entails

• Introduce how neuropsychological evaluation can assist with differential diagnosis in older adults

• Discuss when to refer patients for neuropsychological evaluation

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What is Neuropsychology?

“An applied science concerned with the behavioral expression of brain dysfunction” (Lezak, 1995, p. 7)

Assists with:

• Diagnosis

• Patient care

• Rehabilitation and treatment evaluation

• Research

Lezak, M. (1995). Neuropsychological Assessment, 3rd ed. Oxford University Press: New York.

Basic Questions

• Why is the patient being referred?• What was the patient’s premorbid intellectual

functioning?• What is the patient’s current functioning in different

domains, and does this represent a decline from baseline?

• What is the patient’s pattern of cognitive performance?

• To what might cognitive impairments be related?• What strategies can assist the patient in managing

cognitive problems?

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Neuropsychological Evaluation: It’s more than just testing!

• Record review

• Clinical interview

• Behavioral observations

• Test administration– Generally covers all domains of cognitive functioning

• Test interpretation– Based upon normative data

• Report– Includes diagnosis and recommendations

• Feedback Session

Cognitive Domains

• General Intellectual Functioning

• Attention and Executive Functioning

• Memory

• Visuospatial Skills

• Language

• Upper Extremity Psychomotor Skills

• Emotional Functioning

• Effort/Test engagement

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Slide provided by David Darby, M.D.

Slide provided by David Darby, M.D.

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Why are People Referred?

• Cognitive complaint or observation of possible decline by caregiver/provider– Sustained injury– Medical diagnosis or treatment associated with cognitive impairment– Aging/question of dementia– Psychiatric illness– Question of ADHD/LD

• Question of function– Return to work– Return to play– Ability to manage finances/healthcare decisions

What It Can’t Do

• Predict trajectory of decline with strong sensitivity

• This requires serial assessment

• Make a diagnosis based upon tests results alone

• Provide follow-up rehabilitation care (in most cases)

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Case Example #1

• Referral Question: Please assess memory loss possibly complicated by depression.

• 76-year-old right-handed female, 12-years education, retired homemaker. Lives alone

• Approximately 1 year history of cognitive decline, per daughter Difficulty remembering dates, where she placed things Word-finding difficulty, problems remembering daily

events, repetitive statements Patient agrees, but attributes to life circumstances

• Independent in ADLs, requires help with managing finances and navigation while driving

• Eight-year history of depressive symptoms

Case Example: Medical History

• Diabetes

• Hypertension

• Hypercholesterolemia

• Arthritis

• Biological family history:

– Sister (deceased) with Parkinson’s disease and AD

– Brother with unspecified subtype of dementia

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Case Example: Medications

• Indapamide (diuretic)

• Amaryl (lowers blood glucose)

• MOBIC (for arthritis)

• Lisinopril (ACE inhibitor for hypertension)

• Atenolol (beta blocker)

• Zocor (for high cholesterol)

• Lexapro (SSRI)

Case Example: Corroborative Medical Results

• MRI of brain

– Small vessel ischemic changes in deep white matter bilaterally

• Normal B12, TSH, and Folate lab values

• Normal neurological exam

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Case Example: Behavioral Observations

• Ambulation slow and stiff but narrow-based• Speech normal in volume, rate, prosody; content

perseverative• Thought processes tangential • Memory difficulties apparent on informal

observation• Mood dysphoric• Alternately cooperative and resistant with testing• Test battery was altered due to patient’s difficulty

understanding some tasks• Effort appeared adequate

Case Example: Test Results: Screen & Verbal Abilities

Measure Score Norms

MMSE 17 WNL>23

AMNART 102 M=100, SD=15

WAIS-III VIQ 76 M=100, SD=15

WAIS-III

Information

6 M=10, SD=3

WAIS-III

Comprehension

6 M=10, SD=13

WAIS-III

Similarities

7 M=10, SD=13

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Case Example: Test Results: Attention & Executive Functioning

Measure Score Norms

WAIS-III WM Index 71 M=100, SD=15

WAIS-III Arithmetic 5 M=10, SD=3

WAIS-III Digit Span 6 M=10, SD=3

WAIS-III L-N Seq 5 M=10, SD=3

Trails A 62” 18th percentile

Trails B 215” (D/C) 2nd percentile

WCST-64

Categories

Persev. Errors

0

45

1st percentile

1st percentile

Case Example: Test Results: Memory

Measure Score Norms

HVLT-R

Total Recall (1-3)

Trial 4 (Delay)

Discrimination

14

0

6/12 hits; 7 FP

2nd percentile

1st percentile

1st percentile

WMS-III Log. Mem.

1st Recall

Delayed Recall

4 (6/50)

3 (1/50)

M=10, SD=3

M=10, SD=3

WMS-III Vis. Rep.

Immediate Recall

Delayed Recall

Recognition

3 (26/104)

6 (9/104)

7 (33/48)

M=10, SD=3

M=10, SD=3

M=10, SD=3

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Case Example: Results

Case Example: Test Results: Language

Measure Score Norms

MAE Visual Naming 38/60 5th percentile

MAE Tokens 34/44 1st percentile

COWA 33 56th percentile

Animal Naming 7 1st percentile

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Case Example: Test Results: Visuospatial Skills

Measure Score Norms

WMS-III VR Copy 8 M=10, SD=3

WAIS-III Block Design 7 M=10, SD=3

BVFD 27 WNL>23

Case Example: Test Results: Upper Extremity Motor Skills

Measure Score Norms

Simple Reaction Time 477 ms WNL<425

Tapping-Dom.

Tapping-Non-Dom.

27.3

30

1st percentile

7th percentile

Grooved Pegs-Dom.

Grooved Pegs-Non-

Dom.

109”

125”

1st percentile

1st percentile

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Case Example: Test Results: Emotional Functioning

Measure Score Norms

Geriatric Depression

Scale

6 WNL<5

Hamilton Depression

Rating Scale

9 WNL<14

Zung Anxiety

Inventory

41 WNL<50

Conclusions & Recommendations

• Dementia with likely mixed Alzheimer’s disease/vascular etiology with comorbid mild depression

• Recommendations:– Assistance with iADLs, including medication

management and finances– Formal driving assessment– Continued monitoring for ability to live alone– Consideration of acetycholinesterase inhibitor– Caregiving resources from AA– Psychotherapy oriented toward people with comorbid

cognitive impairment and depression (e.g., ENGAGE)

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Dementia (AD) vs. Depression

Dementia (AD)

• Loss of insight

• Deficits in recall and learning

• Little benefit from serial presentation

• False positive errors

• Impairments in temporal orientation, praxis, gnosis

Depression without Dementia

• Extensive cognitive complaints

• Deficits in recall only

• Shallow encoding but benefit from serial presentation

• False negative errors

• Prominent executive functioning impairment (especially in late-onset depression)

Case Example

• 69 year-old female with 17 years of education, referred from Neurology for evaluation of depression versus dementia

– 6-year history of treatment resistant depression and anxiety

– Husband complains of difficulty with decision-making and planning

– Patient reported that it is difficult to get motivated to start new activities

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Case Example

• Medical History– Major Depressive disorder, recurrent, severe without psychotic

features with anxious features, carpal tunnel syndrome

• Social History– Resides with her husband, two grown children, independent for

instrumental activities of daily living (iADLs) and ADLs, retired librarian

• Biological family medical history– Depression (brother and sister), Alzheimer’s disease beginning

in 9th decade (uncle)

• Medications– Effexor XR, 150 mg q.a.m.; 75 mg. q.p.m.; Klonopin, .5 mg q.h.s.

p.r.n, B12

Test Results: Screen & Verbal Abilities

M=100, SD=15107WAIS-III VIQ

M=10, SD=138WAIS-III Comprehension

M=10, SD=1313WAIS-III Similarities

M=10, SD=313WAIS-III Information

M=100, SD=15118AMNART

WNL>2330MMSE

NormsScoreMeasure

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Test Results: Attention & Executive Functioning

M=100, SD=15

M=100, SD=15

85

85

WCST-64

Categories

Persev. Errors

M=100, SD=1576Trails B

M=100, SD=1593Trails A

M=100, SD=15

M=100, SD=15

WNL < 425 ms

76

134

370 ms

Gordon CPT

Omissions

Commissions

Reaction Time

M=10, SD=313WAIS-III L-N Seq

M=10, SD=310WAIS-III Digit Span

M=10, SD=313WAIS-III Arithmetic

M=100, SD=15111WAIS-III WM Index

NormsScoreMeasure

Test Results: Memory

M=10, SD=3

M=10, SD=3

10

13

WMS-III Vis. Rep.

Immediate Recall

Delayed Recall

M=10, SD=3

M=10, SD=3

8

10

WMS-III Log. Mem.

1st Recall

Delayed Recall

M=100, SD=15

M=100, SD=15

M=100, SD=15

88

90

100

Hopkins Verbal Learning Test-R

Total Recall (1-3)

Trial 4 (Delay)

Discrimination

NormsScoreMeasure

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Test Results: Language

M=100, SD=15109Animal Naming

M=100, SD=15105Controlled Oral Word Association

M=100, SD=15100MAE Visual Naming

NormsScoreMeasure

Test Results: Visualspatial Skills

WNL>2327Benton Visual Form Discrimination

M=10, SD=312WAIS-III Block Design

M=10, SD=36WMS-III Visual Reproduction Copy

NormsScoreMeasure

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Test Results: Upper Extremity Motor Skills

M=100, SD=15

M=100, SD=15

90

91

Grooved Pegs-Dom.

Grooved Pegs-Non-Dom.

M=100, SD=15

M=100, SD=15

95

96

Tapping-Dom.

Tapping-Non-Dom.

NormsScoreMeasure

Test Results: Emotional Functioning

WNL<1427Hamilton Depression Rating Scale

WNL<5041Zung Anxiety Inventory

WNL<510Geriatric Depression Scale (15-item)

NormsScoreMeasure

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Conclusions

Attentional and executive functioning decrements.

Mildly compromised verbal immediate recall, possibly mediated by attentional difficulties

Profile is inconsistent with dementia, but typical of late-onset depression

Longitudinal Assessment Models

Word List Delayed Recall test

4

5

6

7

8

9

10

Baseline 6 mths 12 mths 18 mths 24 mths

WL

DR

te

st

sc

ore

Controls

Cognitive Decline

Differentiation of MCI and controls was not possible on the first assessment, but became significant at the third and fourth testing times (Collie et al., 2001)

** **

Courtesy of Bruno Giordani, Ph.D.

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Tx

Screening Flow Chart

Tx

Test:

First Visit 2 Visit 3+ Other...Visit:

Depressed/Anxious?

yes

1 2

Laboratory TestsNeuroimagingNeuropsychology

Contd.Decline?

yes

3Baseline

Monitoring

4+

NewDecline?

yes

Contd.Impaired?

yes

Courtesy of Bruno Giordani, Ph.D.

Thank you! Questions?