When Is Memory Loss Alzheimer’s Disease?: The Neuropsychology of Dementia and Alzheimer’s Disease Mary K. Foster, Ph.D. Health Psychology Associates Premier Health Specialists

Our Practice Health Psychology Associates Health Psychology Associates Part of Premier Health Specialists Part of Premier Health Specialists Doctors: Doctors: –Mary Foster, Ph.D. –James Gilchrist, Ph.D. –Douglas Griffith, Psy.D. –Bruce Ladle, Ph.D. Office Number: Office Number:

What is neuropsychology? The scientific study of the relationship between the brain and behavior. The scientific study of the relationship between the brain and behavior. Clinical Neuropsychology Clinical Neuropsychology –A specialty within clinical psychology that explores a person’s cognitive abilities in the context of the whole person. Also offers research and teaching opportunities. Also offers research and teaching opportunities.

Neuropsychological Assessment Who needs a neuropsychological assessment? Who needs a neuropsychological assessment? –Individuals with a variety of medical, neurological, and neuropsychiatric conditions, such as: Mild cognitive impairment Mild cognitive impairment Dementia Dementia Traumatic brain injury Traumatic brain injury Stroke Stroke

Purpose of Neuropsychology (What We Can Offer) Describe cognitive and functional strengths & weaknesses Describe cognitive and functional strengths & weaknesses Aid in differential diagnosis Aid in differential diagnosis Identify affected brain regions and measure the functional impact Identify affected brain regions and measure the functional impact Provide prognostic information Provide prognostic information Supply a baseline for comparison Supply a baseline for comparison Offer information about appropriate treatment and compensatory or assistive strategies Offer information about appropriate treatment and compensatory or assistive strategies

Neuropsychological Assessment A broad assessment that integrates multiple tests of cognitive abilities (a neuropsychological battery) A broad assessment that integrates multiple tests of cognitive abilities (a neuropsychological battery) Primarily interested in the pattern of results: identifying deficits in performance relative to overall ability Primarily interested in the pattern of results: identifying deficits in performance relative to overall ability Use special tests with good normative data Use special tests with good normative data –Potentially able to describe age- and gender-related differences To be used when it will provide good information To be used when it will provide good information –Individual, In-Depth, Detailed –Results are only indicative of the current state May use behavioral or medical insurance (depending on plan) May use behavioral or medical insurance (depending on plan) –Our office manages pre-authorizations

Domains of a Neuropsychological Assessment Orientation, Concentration, Attention Orientation, Concentration, Attention Intellectual Assessment Intellectual Assessment Achievement/Ability Achievement/Ability Memory Memory Executive Function Executive Function Language Language Visuospatial Function Visuospatial Function Brief Psychiatric Assessment Brief Psychiatric Assessment

Neuropsychological Assessment is Broad Cognitive abilities are hierarchical Verbal Sensory → Attention → or → Memory → Executive Nonverbal If the results show a deficit in a higher function, you must test the lower functions to rule them out as a cause.

Memory Memory problems are the most common presenting compliant Memory problems are the most common presenting compliant Multiple elements to memory Multiple elements to memory –Working or short-term memory –Long-term memory –Memory for new learning –Verbal memory –Non-verbal memory

Memory assessment Generally requires at least 4 tests Generally requires at least 4 tests –Verbal and Non-verbal –Immediate and Delayed –Usually include a test of new learning (e.g., word list) Different deficits suggest different affected brain regions Different deficits suggest different affected brain regions

Psychiatric Assessment Psychiatric symptoms can effect test performance Psychiatric symptoms can effect test performance –Ex: Emotional distress, substance abuse, personality can negatively affect performance Important to distinguish between a neurological vs. a psychiatric disturbance Important to distinguish between a neurological vs. a psychiatric disturbance Typically assessed using an interview and/or self- report, paper-pencil, true-false or Likert questionnaires Typically assessed using an interview and/or self- report, paper-pencil, true-false or Likert questionnaires

Neuropsychological Assessment: Interpretation Integrate all the information to provide a full picture of the person Integrate all the information to provide a full picture of the person What is the person’s overall intellectual ability? What is the person’s overall intellectual ability? Does the person exhibit any deficits? Does the person exhibit any deficits? Do other factors (e.g., psychiatric symptoms) contribute to these deficits? Do other factors (e.g., psychiatric symptoms) contribute to these deficits? What can he or she do or not do? What can he or she do or not do?

What The Patient Receives: Feedback and Handout In-person feedback In-person feedback –Broad overview of the pattern of results –Review details of test results with examples as needed –Oral discussion of likely etiology/contributing factors –Review of personalized recommendations May be accompanied by handout which includes: May be accompanied by handout which includes: –Overview of results –Graphical representation of results –Personalized recommendations

What You Receive: The Neuropsychological Report Typically ~3-5 pages Typically ~3-5 pages Includes: Includes: –Brief History (Presenting Problem, Medical, Psychosocial) –Behavioral Observations –Measures Used –Summary of Test Results –Impressions of Profile and Potential Etiology –Recommendations –Graphical Representation of Performance

“Memory Problems” Depression versus Dementia

Spectrum of Cognitive Impairment in Older Adults Normal Aging → Mild Cognitive Impairment → Dementia Normal Aging → Mild Cognitive Impairment → Dementia Normal Aging: Potential changes in cognitive abilities that are commensurate with premorbid abilities for age Normal Aging: Potential changes in cognitive abilities that are commensurate with premorbid abilities for age Mild Cognitive Impairment (MCI): Changes in cognitive abilities that are greater than expected in normal aging, with generally intact instrument activities of daily living Mild Cognitive Impairment (MCI): Changes in cognitive abilities that are greater than expected in normal aging, with generally intact instrument activities of daily living Dementia: Changes in cognitive abilities that are greater than expected in normal aging, with impaired instrumental and/or basic activities of daily living Dementia: Changes in cognitive abilities that are greater than expected in normal aging, with impaired instrumental and/or basic activities of daily living –Commonly thought of as a decline in memory and at least one other domain

Dementia: Alzheimer’s Disease Alzheimer’s disease (AD): Most common etiology (~50% of dementia cases); typical onset is after 65 but earlier onset possible Alzheimer’s disease (AD): Most common etiology (~50% of dementia cases); typical onset is after 65 but earlier onset possible Insidious onset and gradual progression with early and prominent memory complaints (temporal gradient) and early loss of insight Insidious onset and gradual progression with early and prominent memory complaints (temporal gradient) and early loss of insight Memory “plus 1” Memory “plus 1” –Other difficulties may include: Aphasia/Language (e.g., word-finding difficulties, loss of semantic knowledge), Agnosia (perceptual or associative), Acalculia, Apraxia (e.g., ideomotor), Executive Dysfunction, Visuospatial Difficulties (perceptual and/or constructional)

Dementia: Alzheimer’s Disease Memory Profile: Shallow Learning Curve (Encoding), Rapid Forgetting (Consolidation/Recall), Not Notably Aided by Recognition Cues (Recognition) Memory Profile: Shallow Learning Curve (Encoding), Rapid Forgetting (Consolidation/Recall), Not Notably Aided by Recognition Cues (Recognition)

Dementia: Other Common Etiologies Vascular (VaD): 2 nd most common etiology; Vascular (VaD): 2 nd most common etiology; Approximately 10% of dementia cases due to “pure” VaD plus 15% of “mixed” etiologies; onset – –Hetergeneous presentation (location of infarct), commonly with stepwise progression Frontotemporal dementia (FTD) & Primary Progressive Aphasia (PPA): ~20% of presenile dementia; typical onset Frontotemporal dementia (FTD) & Primary Progressive Aphasia (PPA): ~20% of presenile dementia; typical onset –Insidious Onset and Gradual Course –2 Behavioral variants of FTD with early & prominent personality and behavioral changes: Disinhibited & Apathetic –3 language variants (PPA): Progressive-nonfluent variant, Semantic dementia, and Logopenic

Dementia: Other Common Etiologies Dementia with Lewy bodies (DLB): 2 nd or 3 rd most common, 12-17%; Onset Commonly Dementia with Lewy bodies (DLB): 2 nd or 3 rd most common, 12-17%; Onset Commonly –Fluctuations in arousal/cognition, visual hallucinations, parkinsonian symptoms –Cognitive changes may predate motor symptoms Posterior cortical atrophy (PCA): Possibly 3-5%; Typical onset between Posterior cortical atrophy (PCA): Possibly 3-5%; Typical onset between –Insidious onset and gradual course with initial visual complaints but relatively preserved memory and insight –Simultagnosia, constructional deficits, visual field deficits, environmental disorientation, or features of Gerstmann’s syndrome Other considerations: PD-PLUS, NPH, Systemic Other considerations: PD-PLUS, NPH, Systemic

Depression: Core Features Onset typically in 20’s Onset typically in 20’s Lifetime prevalence of 5-9% of women, 2-3% of men Lifetime prevalence of 5-9% of women, 2-3% of men Risk factors include female gender, 1 st degree family history, dysthymia Risk factors include female gender, 1 st degree family history, dysthymia Common symptoms: Common symptoms: –Depressed Mood –Apathy or Anhedonia –Changes in appetite/weight –Insomnia/hypersomnia –Fatigue or loss of energy –Thoughts of suicide –Psychomotor agitation or retardation –Feelings of worthlessness or inappropriate guilt –Difficulty with attention or decision-making

Depression: Core Features Can have partial/full remission of mood symptoms but individuals are likely to have a recurrence Can have partial/full remission of mood symptoms but individuals are likely to have a recurrence There may be a positive correlation between severity of mood symptoms and severity of cognitive symptoms There may be a positive correlation between severity of mood symptoms and severity of cognitive symptoms –More severe mood symptoms may relate to greater cognitive symptoms Cognitive difficulties may remain after improved mood Cognitive difficulties may remain after improved mood

Depression: Cognitive Patterns May have stable or fluctuating course May have stable or fluctuating course Typically has insight into complaints/difficulties Typically has insight into complaints/difficulties Generally subcortical pattern; difficulties may include: Generally subcortical pattern; difficulties may include: –Attention/Working memory –Processing speed –Executive function –May have a retrieval deficit in memory –Can have word-finding difficulties May use less effort on challenging or “effortful” tasks May use less effort on challenging or “effortful” tasks Frequent “I don’t know” responses Frequent “I don’t know” responses Often benefit from additional time or memory cues Often benefit from additional time or memory cues

Depression: Cognitive Patterns May have a retrieval deficit (adequate encoding, difficulty with recall, better with recognition) May have a retrieval deficit (adequate encoding, difficulty with recall, better with recognition) Can be further exacerbated by nonrestorative sleep and/or chronic pain. Can be further exacerbated by nonrestorative sleep and/or chronic pain.

When To Refer: Common Presentations Typically between ages (though younger and older patients are seen) Typically between ages (though younger and older patients are seen) Patient OR their family/friend has concerns about memory or other cognitive abilities. Patient OR their family/friend has concerns about memory or other cognitive abilities. Sometimes expressed as the patient having difficulty completing everyday tasks. Sometimes expressed as the patient having difficulty completing everyday tasks. Potential question of differential diagnosis (dementia vs. depression) or staging of possible dementia (normal aging vs. MCI vs. dementia) Potential question of differential diagnosis (dementia vs. depression) or staging of possible dementia (normal aging vs. MCI vs. dementia)

Case Presentation: General Information Patient Information: Patient Information: 89 y/o, RHD, Caucasian female with 13 years of education 89 y/o, RHD, Caucasian female with 13 years of education –Retired Accountant –Presented with family complaints about her memory –Denied any cognitive concerns

Case Presentation: History Course Course Current Complaints & ADLs Current Complaints & ADLs Mood/Sleep Mood/Sleep Medical History Medical History Psychosocial History Psychosocial History Behavioral Observations Behavioral Observations

Case Presentation: Results

Case Presentation: Impressions & Recommendations Impressions Impressions Normal aging? MCI? Dementia? Normal aging? MCI? Dementia? Importance of collateral information Importance of collateral information Do cognitive profile and course fit? Do cognitive profile and course fit? Recommendations Recommendations

Presented by Mary Foster, Ph.D. Neuropsychologist Health Psychology Associates Premier Health Specialists Selected Further Resources: Loring, D.J. & Meador, K.J. (1995). Neuropsychology for neurologists. Retrieved from February 27 th, 2006 from American Academy of Neurology on NLD on the Web!: Bondi, M. W., Salmon, D. P., & Kaszniak, A. W. (2009). The neuropsychology of dementia. In I. Grant & K. M. Adams (Eds.), Neuropsychological assessment of neuropsychiatric disorders (3 rd ed., pp ). New York: Oxford University Press. McKhann, G., Knopman, D., Chertkow, H., Hyman, B., Jack, C. Kawas, C. et al. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging and the Alzheimer’s Associate workgroup. Alzheimer’s & Dementia, 7(3), Thank you.