Transcript Assess, Diagnosis, Early Intervention: Awareness for

Raymond H. Hamden, Ph.D.
Nicole El Marj, M.Sc.
* ****
Human Relations Institute & Clinics
ASSESSMENT
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Learn to increase clinical
accuracy in diagnosing
Alzheimer's disease
Sensitivity to early signs and
symptoms will be addressed
When to refer for
psychological assessment and
remediation
Lessen hesitation time to
diagnose and refer for
psychological treatment
To increase clinical accuracy
in diagnosing Alzheimer's
disease
REMEDIATION
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To better understand early
signs and symptoms
To recognize when to seek
psychological assessment and
remediation
To clarify progressive stages
of Alzheimer's disease (mild,
moderate, severe)
To enhance working memory
To retain reasoning and
communication skills
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Screening: Identify people at risk or with
asymptomatic or undiagnosed disease
– Formal evaluation is required
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Monitoring: People with diagnosed disease
– Follow progression and response to therapeutic intervention
Many clinicians use performance-based
measures to “screen”
when they are actually “monitoring”
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Psychologists are searching for tests that can identify
Alzheimer's disease even before symptoms appear.
To be effective, the medications currently available to
treat Alzheimer's have to be used early on.
But what's the best way to detect the disease before
it's too late?
Psychologists have identified several promising tests:
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Paired-associate learning test. In this test, people try to
remember related pairs of words and unrelated pairs. For most
people, it’s easier to remember the related word pairs. But people
destined to develop Alzheimer’s disease don’t do any better when
the words are related than when they’re not, according to findings
from the Longitudinal Aging Study (PDF, 140 KB).
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Perceptual identification task. People undergoing this
test read words aloud as they appear briefly on a computer screen.
Experimenters repeat some words to test for “priming,” a sense of
familiarity that should allow test-takers to read those words faster.
Priming doesn’t help people at high risk of developing
Alzheimer’s, the Amsterdam researchers found. That’s a sign that
these individuals aren’t learning as well as they should.
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Visual association test. In this test, people try to remember line
drawings that have been illogically paired with other objects. Poor performance
on this test suggests problems in episodic memory, according to the Amsterdam
researchers.
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Dichotic listening task. This test involves listening to information
through headphones, with one stream of information going to the left ear and a
different stream going to the right ear.
People with early dementia do a better job of remembering information
presented to the right ear, according to a Study from Washington University's
Alzheimer's Disease Research Center
(http://depts.washington.edu/adrcweb/files/9213/1162/5979/Alzheimers_Disease_Fact_Sheet.pdf).
The right ear is the default pathway for processing information. As dementia
progresses, the researchers say, people have a harder time overriding the
usual pathway and switching their attention to their left ear. As a result, the
test is a good early-warning sign for Alzheimer’s.
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Psychologists are also determining what tests aren’t
as effective at predicting Alzheimer’s disease.
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According to the Amsterdam researchers, for
instance, the commonly used Mini Mental Status
Exam is not as effective as other tests when it
comes to predicting who will get Alzheimer’s.
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Brief tests may be:
– insensitive to the early stages of dementia
– culturally biased
– heavily weighted towards memory
– limited to a single cognitive domain
– not validated in large samples
– too complex for office use
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Comparison with normative values may
– not detect very mild decline in high functioning individuals.
– falsely detect dementia in individuals with life-long poor
cognitive function
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Formal neuropsychological evaluations have less bias but
require extensive training and are lengthy
Report cognitive loss in comparison with
patient’s premorbid function
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Report interference with activities usually
performed by the individual
Consistent change reported by
observant/informant, even when patient’s
cognitive test performance is “normal”, can
detect earliest symptomatic stages of dementia
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Unbiased by race, culture, education or SES
Predictive of early dementia
Inexpensive as possible
High face validity
Reliable, Sensitive and Specific
Brief, without compromising thoroughness
Easy to administer and score
Socially acceptable
Culturally sensitive
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Forgetfulness, especially recent events
Confusion or losing track of things
Difficulty finding words
Difficulty finding your way or performing
familiar tasks
Poor or impaired judgment
Changes in mood or behavior
Needing help with simple daily tasks
Lack of interest in activities
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Clinical Interview
Family as Informants
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Mini Mental Status Examination
Wechsler Adult Intelligence Scale – IV
Wechsler Memory Scale
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Luria-Nebraska NeuroPsychological Battery
Halstead-Reitan NeuroPsychological Battery
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Alzheimer’s Disease Assessment Scale
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The ADAS is not a timed test and the subject's score does
not depend upon how rapidly the test is completed.
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The cognitive items should be given so that the session
moves smoothly and quickly, but so that the subject does
not feel pressured to respond rapidly.
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The rating of the subject’s language ability (i.e., spoken
language, word finding and comprehension) will be based on
this introductory conversation as well as the subject’s speech
throughout the ADAS testing session.
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Words Recall Task
Commands
Constructional Praxia
ADAS Figures
Delayed Recall
Naming Tasks
Ideational Praxia
Orientation
Word Recognition
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Remembering Test
Instructions and
Comprehension
Word Finding Difficulty
and Spoken Language
Ability
Executive Function –
Mazes
Maze Task Stimuli
Number Cancellation
Number Cancellation
Stimuli
Feature
Score
Abrupt Onset
Stepwise Deterioration
Fluctuating Course
Nocturnal Confusion
Relative Preservation of Personality
Depression
Somatic Complaints
Emotional Incontinence
History of Hypertension
History of Strokes
Evidence of Atherosclerosis
Focal Neurological Symptoms
Focal Neurological Signs
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Socio-Psychological Benefits
Medical Benefits
Harms from Failure to Recognize
Lists and Accountings for the Harms
Harms that might occur to those with
Negative Screening Test Results
Costs and Harms of Dementia Screening
Raymond H. Hamden, Ph.D.
Nicole El Marj, M.Sc.
* ****
Human Relations Institute & Clinics
Diagnosis, treatment and follow-up of AD
patients from the earliest stage possible will
reduce healthcare costs
and
increase quality of life
Perceived control
Control
Anxiety
Performance
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Brain workout
- Puzzles
Physical exercise
The evidence suggests that it is possible to
produce short-term improvements in
cognitive function and/ or reduce cognitive
decline in people with dementia using nonpharmacological approaches.
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The ability to hold and manipulate
information
Crucial in transfer of information from shortterm to long-term memory and vice versa
 Cognitive Training
 Cognitive Rehabilitation
 Cognitive Stimulation
 Reality Orientation and
 Reminiscence Therapy
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Involves guided practice on a set of standard
tasks designed to reflect particular cognitive
functions such as memory, attention or
problem-solving.
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There are few reports of any long-term follow
up to assess maintenance of any gains
achieved.
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A more individualized approach
A biopsychosocial approach
Aims at fostering the development of
strategies for coping with memory problems
Involvement of family caregivers
The emphasis is on enhancing residual
cognitive skills and coping with deficits
For example, mnemonic strategies that aid in
memory
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Targets cognitive and social function,
through reality orientation, activities, games
and discussions, prioritizing informationprocessing rather than knowledge
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This method has been used primarily for
people with a moderate degree of Dementia
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For example, categorization
Generally included under the umbrella of
cognitive stimulation, aims to improve the
quality of life through presentation of
orientation and memory information.
Involves the discussion of past activities,
events and experiences with another
person or a group of people.
Clare, L., Wilson, B. A., Carter, G., & Hodges, J. R. (2003). Cognitive rehabilitation as a
component of early intervention in Alzheimer's disease: A single case study.
Aging & Mental Health, 7 (1), 15–21.
Clare, L. & Woods, R. T. (2004). Cognitive training and cognitive rehabilitation for
people with early-stage Alzheimer's disease: A review. Neuropsychological
Rehabilitation: An International Journal, 14 (4), 385–401.
Clare, L., Wilson, B. A., Carter, G., Roth, I., & Hodges, J. R. (2004).
Awareness in Early-Stage Alzheimer’s Disease: Relationship to Outcome of
Cognitive Rehabilitation. Journal of Clinical and Experimental Neuropsychology, 26
(2), 215–226.
Prince, M., Bryce, R., & Ferri, C. (2011). World Alzheimer Report 2011: The benefits of
early diagnosis and intervention. Alzheimer’s Disease International, 1–69.
Dekosky, S. (2003). Early intervention is key to successful management of Alzheimer
disease. Alzheimer Disease and Associated Disorders, 4, S99–104.
Raymond H. Hamden, Ph.D.
Nicole El Marj, M.Sc.
* ****
Human Relations Institute & Clinics