Diagnosis and Management of Dementing Disorders web series

Presenter's answers to questions asked during the session follow below.

1. Can the animal fluency screen be given in another language? Would it still be valid?

Animal Naming is likely to be useful as a brief initial screening test if given in a language other than English. This is because the process that it taps (retrieval from semantic memory) is affected in Alzheimer’s disease in general, and because animals are a familiar category in most societies. However, caution is needed with regard to cut-off scores for persons tested in languages other than English. In many languages, there are no published normative cut scores so far as I am aware. So, on a practical basis, I’d recommend using a more conservative cut-score (e.g., fewer than 12 items as a sign of possible impairment), especially if the person has fewer than 8 years of education. Also, studies indicate that bilingual persons may score a bit lower on the average on fluency tests than persons with only one language.

No screening test is sufficient to diagnose dementia. Their use is to help to identify individuals whose cognitive difficulties are significant enough to warrant a more thorough diagnostic assessment.

2. Please send the Cognistat and instructions to all the participants.

The Cognistat is a copyrighted test and is available for purchase at http://cognistat.com.

The Manual provides test instructions. I’d recommend using the cut-score adjustments for older adults that are discussed in the manual.

I’m happy to answer questions you might have if you begin using the Cognistat and run into any difficulties with scoring or interpretation. I can be reached at larue@wisc.edu or (608) 829-3308.

3. Are there adverse consequences to diagnosing Alzheimer’s disease early?

Not in the vast majority of cases. The diagnosis of any disease, whether it be Alzheimer’s disease, breast cancer or lung cancer, carries with it a certain amount of fear and uncertainty. This is particularly true for Alzheimer’s disease for which there is no cure. In a study from the University of Chicago, people were asked about whether they wanted to know if they had an Alzheimer’s disease diagnosis as early as possible. Ninety-two percent responded that they wanted to know about the diagnosis as early as possible. Respondents stated that they wanted to make necessary changes in wills, job situations, etc., while they were cognitively able to make independent decisions for themselves. The desire to make these decisions prior to significant AD disability was stronger than the fear of the ultimate outcome of the disease.

4. How would depression look on these screening tools?

Depression may reduce verbal fluency scores slightly and may also affect Cognistat scores to some extent (e.g., on digit repetition, initial learning of the list of four words, and delayed recall of the four word list). On delayed recall, a depressed person may have difficulty retrieving the words on their own, but is likely to benefit from category cues or multiple choice recognition. If a person with symptoms of both depression and mild dementia obtains a normal delayed recall score, I’d recommend looking carefully at what other evidence there is for dementia….this could be a depression-only situation.

Clinical history is more important for a differential diagnosis of depression vs. dementia than scores on cognitive tests. For a person with both types of symptoms, an important question is… Which came first? If depression preceded cognitive problems, this strengthens the case for depression as the primary illness. If cognitive problems preceded the depressive symptoms, the likelihood of dementia is increased. When in doubt, the advice is usually to treat depressive symptoms and see if cognition improves as depression remits. Be aware, though, that there have been a number of recent studies showing that depression itself may be a risk factor for dementia.

4. Are there education norms for the MMSE?

Yes, there are both age and education norms for the MMSE. The MMSE is now a copyrighted test and a manual, which gives suggested norms, is available for purchase from Psychological Assessment Resources (PAR), Inc.

Or, you might also want to check out the following article:
Crum RM et al. Population-based norms for the Mini Mental State Examination by age and educational level. JAMA 1993;269:2386-2391.

Click here for the Session 1 archive presentation.