Clinical neuropsychology is concerned with brain and behavior, and how illnesses and injury to the brain affect behavior and the major domains of cognition including attention, language, memory, visuospatial abilities and personality. Most referrals received from neurologists and neurosurgeons to aid in the diagnosis and to document the course of brain disorders. Neuropsychology may also assist in patient care, assisting physicians and healthcare workers in management and treatment. Neuropsychology also helpful in estimating a pt’s level of functioning, the abilitly for self care. Therefore, neuropsychology may be helpful in the setting where elderly or geriatric pts are seen, but also with patients who may be at risk for cognitive changes.
Why should you care about the neuropsychological functioning of the patients you see? Determining a pt’s ability to live alone safely to complete IADLs is important. Consider the impact of a memory impairment, language impairment or attentional impairment for patients with many illnesses. difficulty understanding and remembering instructions or recommendations difficulty managing multiple medications - correct medicine in the correct dosage at the correct time difficulty recalling important information to share with you or to ask you during an office visit, or difficulty verbalizing one’s concerns pt safety These can impact pt compliance and ultimately have a negative affect on their cognitive abilities, physical health and level of functioning. As I’ll discuss in a bit - this can have a circular effect.
I think probably the most prototypical “cognitive impairment” is that of dementia. The two most common types of dementia are Vascular dementia and dementia of the Alzheimer’s type. The two may differ with regard to what aspects of cognitive function are initially impacted. Memory impairment, the hallmark symptoms of AD, if often the initial symptom reproted by patients and family members. In contrast, attention, psychomotor abilities and executive functions are disproportionately impaired in VaD.
AD affects every area of behavior, with memory being the most obvious of the early symptoms. Principle distinguishing features of AD are memory deficits, the presence of other intellectual disturbances in the absence of neurologic signs. Memory - difficulty learning new information temporal orientation and knowledge of current events problematic (poor learning) better recall of older memories learning for simple motor and skills is preserved Visuoperceptual and visuoconstructional abilities are evident on figure copying and drawings (such as clock drawing) Language - impaired quality, quantity and meaningfulness of speech px with verbal comprehension disruption of semantic meaning basic organizing principles of language remain intact, syntax and lexical structure OK (nounds placed where nouns go) - empty speech, little meaning and tendency to use words lacking clear referents (thing, this, that) naming problems seen later in course of disease Executive functions remain alert in early stages demonstrate difficulty with more complex aspects of attention - shifting, selective, divided attn perseverations and intrusions in speech and writing Personality emotional and personality changes irritability and angry outbursts. Signs that herald AD - failing recent memory, depression and irritability, word finding problems. Disease begins insideously and decline is gradual.
Neurofillrillayr tangles and senile placques in the ctx, hippocampus and amygdaloid areas, as well as specific brain stem nuclei (NBM) Gross anatomic alterations - enlarged ventricals and thinning of cortical mantle. Neuronal loss in midfrontal and lower inferior parietal areas surrounding the temporal lobes -serves to disconnect Tl structures from rest of cerebral ctx, as well as disconnect prefrontal from parietal structures - which may account for the early compromise in attentional and spatial abilities.
Diagnosis of vascular dementia requires memory impairment and at least one other affected domain aphasia apraxia - inability to perform previously learned movements agnosia inattention Memory impairment is relatively less severe than in AD, also reduced output (verbally and non-verbally). Unlike the gradual and insideous onset of cortical dementia, vascuclar dementia has an acute onset. Infarcts cause a step-wise decline in cognitive function. VAD is inferred if dementia occurs within 3 months of a stroke Vascular dementia was an umbrella term used for conditions in which widespread cognitive impairment takes place as a result of repeated infarctions - usually at many different sites. Now refers more specifically to large-vessel disease - often occlusions of main branches of middle, anterior and posterior cerebral arteries
It has been suggested that VaD may not be a specific single disease, but may include a number of disease processes associated with a variety of neuroanaotmical changes resulting from vascular disease. These vascular changes may be related to large strokes an/or small vessel disease. Local cerebral blood flow is lowest in periventricular regions and deep white matter. Thus the deep white matter is most susceptible to ischemia when there is a systematic drop in blood pressure. The diagnostic criteria of VAD requires a memory impairment. Many patients demonstrate difficulties in other domains with relatively intact memory. Emphasis on memory impairment may not be best for subcortical syndromes This diagnostic criteria suggests that a number of individuals who are experiencing cognitive changes, but not a primary memory impairment, are undiagnosed. Research investigating cognitive changes in individuals AT RISK for developing VaD has reported changes in executive function abilities in seemingly healthy individuals. Specifically, those diagnosed with hypertension or diabetes were more likely to experience impairment on measures of executive functions (thought to assess the frontal lobes). These findings suggest that the identification of cognitive changes associated with vascular disease may be made prior to the patient’s or family report and prior to a cerebrovascular event. There may be a potential benefit of early identification of cognitive changes associated with vascular disease - as careful monitoring and medical compliance may assist in minimizing deficits as well as controlling the illnesses’ contribution to cognitive decline.
15, 422 people in MA died of heart disease in 2000 Stroke is #3 killer in MA
Typically, patients who complete neuropsychological or cognitive testing are referred because someone has noticed a problem. A family member, or a healthcare worker notices some changes in the patient’s memory, difficulty managing the check-book, personality changes. This calls in question - how long has the patient been experiencing problems and might it be possible to minimized the impact of cognitive changes if identified earlier? Recent study, surveyed physicians acknowledged the necessity of cognitive screening and identified difficulties of time management and test familiarity as barriers to performing routine cognitive screens. When physicians do screen, it is probably when the expect there might be a problem, something has suggested thereis an issue. And When they do screen or test they typically use…..
Much information can be obtained through observation and discussion with the patient. pt’s appearance - manner of dress, hygiene, etc pts language - fluent, word finding problems, articulation errors pts memory - can pt provide details and information regarding personal history test incidental and new learning - “can you tell me what’s been happening in the news lately” pts attention - can pt stay on topic, is pt able to interact with you visuospatial abilities - figure copy executive abilities - simple coin switch Observing and attending to pt’s behavior during interview provides a naturalistic and inoffensive manner of obtaining important information. Conversationally inquire about date, age of birth. Attending not only to the information provided by the patient, but the qualitative nature may be helpful in making an informal assessment. Given the high prevalence of hypertension, diabetes and heart disease, the number of patients at risk for developing VaD - or cognitive impairment associated with vascular disease is growing drastically.
We are currently investigating the usefulness of a Clock Drawing test in determining cognitive change. The CDT is an often used neuropsychological measure considered a test of executive functioning. A variety of versions exist and a recent review of its psychometric properties found high levels of inter-rater reliability , high levels of test-retest reliability and positive predictive value across the varied versions. Additionally, the CDT is correlated with other established cognitive tests (e.g. Blessed Dementia sclcae, Block design). Given the characteristics of the CDT, we thought it might prove useful as a screening tool in the medical setting. Let me explain how we are using the CDT at this time.
When you think about this complicated system - you can see that is almost like a cycle. If one has an cardiac illness like high blood pressure or hypertension, One is likely prescribed medication. If that
Executive Dysfunction in
Patients with Cerebrovascular
Laura Grande, Ph.D.
Geriatric Neuropsychology Laboratory,
New England GRECC
VA Boston Healthcare System
Harvard Medical School
August 23, 2006
• Behavioral expression of brain dysfunction
• Neuropsych exam:
– Assists in diagnosis
– Pt care (management & planning)
• Provides insight into level of functioning
• Not only elderly and geriatric pt’s
Neuropsychology and Medicine
• Ability for self-care and independence
• Understanding and remembering
instructions and recommendations
• Managing complex medical regimens
• Remembering and accurately verbalizing
concerns to physician
• Pt safety (driving)
• Dementia - prototypical
• Two most common forms:
– Vascular dementia (VaD)
– Dementia of the Alzheimer’s type (AD)
• Differ in initial cognitive changes
Domains of Cognition
Domains of Cognition
• Affects every area of behavior
• Learning and memory - problems with new
information, better recall for older memories
• Visuoperceptual - poor copying & constructional
• Language - speech, comprehension, semantic
problems, naming, empty speech
• Executive functions
• Personality - emotional changes, irritability, lack of
• Insidious onset, steady decline
Vascular (Multi-Infarct) Dementia
• Learning and memory - problems learning and
remembering new information, relatively better than
• Other cognitive deficits may include
– Language - aphasia
– Motor - apraxia
– Visuospatial - agnosia
– Executive functions - inattention
• Personality - later in course of disease
• Acute onset, step-wise decline
• Similar to subcortical dementias (PD, HD)
Vascular Dementia (VaD)
• VaD may not be a specific single disease.
• VaD associated with neuroanatomical
changes resulting from vascular disease.
• DSM-IV criteria - mandatory memory
• Cognitive impairment observed in those at
risk for VaD (Brady et al 1999; Pugh et al in prep).
Bowler, Steenhuis & Hachinski (1999); Schmidtke & Hill (2002)
Memory vs. Executive Function
• “Memory” problems - Elderly
– Most commonly reported cognitive problem
– Pts concerned about Alzheimer’s disease
– Many problems labeled as memory
• Executive dysfunction in those at risk for VaD
– Hypertension (Brady et al 2001), diabetes (Pugh et al 2004)
– Problems detected prior to pt/family report
• Associated with frontal lobe functions.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Heart Dis & Stroke, 42%
Suicides, homicies, 2%
Kidney Disease, 3%
Liver Disease, 1%
Respiratory Disease, 6%
Pneumonia & Influ., 4%
Major Causes of Death in MA - 2001
American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Tex.: American Heart Association;
Early identification and Screening
• Evaluation occurs after problems are noticed.
• Cognitive testing for all patients?
– Unnecessary, time consuming, expensive
• Screening in the primary care clinics?
– Physicians reported need for screening (Hogervorst et al, 2001)
– Time is biggest obstacle
– Test familiarity
• Could cognitive decline be minimized by early
• Obtain useful information through
observation and discussion
– Pt’s use of language
– Pt’s memory for own personal history, and new
– Pt’s ability to attend and stay on topic
• Naturalistic environment
Clock Drawing Test as a Screener
• Considered measure of executive functioning.
• Good psychometric properties across versions and
• Highly correlated with other cognitive measures.
• Quick administration ( 2 minutes).≈
• Useful as a screening tool in the medical setting?
Please read and do the following carefully:
• In the blue box on the next page:
• Draw a picture of a clock
• Put in all the numbers
• Set the time to ten after eleven.
Hand this sheet back and go to the next page
• Working Memory
– Correct square
– Resembles clock
– Includes all numbers
– Correct time indicated
(in any manner)
• Four WM points
• Planning & Organization
– Appropriate size
– Numbers in correct order
– Numbers evenly spaced
– Hands of different length
• Four PO points
Total Score = WM subscale + PO subscale
Is the CIB a predictor?
• Does CIB predict performance on
standardized cognitive measures?
– Stepwise linear regression
• CIB total, age & education entered into model
Prediction of performance
• Executive Function Measures
– Trail Making A
54.6 + CIB (-2.211) + Educ (-1.39) + Age (.345)
– Trail Making B
199.98 + CIB (-14.75) + Educ (-7) + Age (.237)
– NOT a significant predictor of fluency
• Memory Measures
10.64 + Educ (.341) + CIB (.273) + Age (-.137)
3.09 + CIB (.279) + Educ (.256) + Age (-.175)
54.25 + CIB (.194)
– NOT a significant predictor of recognition
Cycle of Problems
Not following Dr.’s plan
Illnesses not well-controlled
White matter changes
Disrupted frontal lobe messages
planning & problem
following Dr.’s plan
Procedures for Registering
and Getting CE credit
• VA people go to https://vaww.ees.aac.va.gov
• Non-VA go to https://www.ees-learning.net
• First-time users will need to “click for first time users”;
others should enter username and password
• On “Librix homepage” click on “Available courses” and
enter keyword “geriatric”
• Click on “Geriatric Audioconference Series: Executive
• Click on “Sign me in” and follow procedures
For Further Information:
• Vascular Dementia and CIB
– Laura Grande, PhD
• New England GRECC
– Kathy Horvath, PhD RN
• Geriatric Audioconference Series
– Ken Shay, DDS, MS
• Evaluation and CE Credit
– Instructions in “Brochure”
• Thursday, September 28, 3 pm eastern:
“Sleep disorders in older people”
(Sepulveda and Madison GRECCs)