Before closing the chapter, we will examine two cases of some of the more common neuropsycho- logical syndromes to affect the elderly. The first is of a patient with probable Alzheimer’s disease, whereas the second is a case of probable vascular dementia. It is recognized that these two etiol- ogies can be largely overlapping, but the behavioral presentation of each can be quite different.
Further, these two cases allow the opportunity to examine some of the practical considerations derived from objective behavioral testing such as a neuropsychological assessment.
140 R. D. Jones
Case 1
Case 1 is of a right-handed 74-year-old woman who had previously worked as a healthcare worker.
She had 12 years of formal education. At the time of our final assessment in 2014, she had been seen three times previously. Prior examinations had shown progressive decline in cognition, par- ticularly in anterograde memory, but it was noted that virtually no domains of cognition had been unaffected. The clinical scenario and the diagnosis of the neurologist reflected a diagnosis of likely Alzheimer’s disease. At the time of our final examination, the patient denied any cognitive impair- ment, reflecting anosognosia. She had been living with one of her children, who reported that the patient had shown progressive cognitive decline. The children were managing her finances, adher- ence to medications, transportation needs, and other daily duties. Neuroimaging reportedly showed cerebral atrophy only.
At the time of our examination in 2014 it was noted that orientation was grossly impaired, as were multiple other domains including working memory, verbal memory, letter fluency, naming, and comprehension. Visual acuity was intact. Performance on the Trail Making Test requiring speed and visual shifting was defective. She endorsed symptoms consistent with mild depression.
Overall, these serial evaluations provided a quantitative index of the rate and nature of change associated with the underlying diagnosis of Alzheimer’s disease. In addition, as her cognitive impairments progressed, a number of interventions were instituted, including moving in with her children, alarms, and management of her daily activities. Subsequent clinical notes reflect that the patient ultimately entered assisted living with full-time supervision and care.
Case 1 evaluation
Evaluation Date 2007 2008 2013 2014
Orientation
Time -0 -0 -32 -22
Personal Information 4/4 4/4 4/4 2/4
Place 2/2 2/2 0/2 1/2
WAIS-IV Ssa Ssa
Similarities 5 6 - 2
Digit Span 7 6 3 1
Arithmetic 6 4 - -
Comprehension - - 4 6
Block Design 10 - 3 -
Coding 14 10 7 -
Picture Completion - - - 6
CVLT-II Raw Raw Raw Raw
Immediate Recall 6-5-6-6-4 1-3-4-4-4 - -
Short Delay Free Recall 4 0 - -
Long Delay Free Recall 1 1 - -
Long Delay Recognition Hits/False 9/10 15/20 - -
HVLT-R (Form 4)
Raw Raw Raw Raw
Immediate Recall - - - 1-2-2-5
Delayed Recall - - - 0
Retention (%) - - - 0
Recognition Discrimination Index - - - 4
Complex Figure Test Raw Raw Raw Raw
Copy 18.5 - - -
Recall 5 - - -
(Continued on p. 142) 141 Neuropsychological Assessment of Aging Individuals
(Continued)
BVRT Raw Raw Raw Raw
# Correct - - 0 -
# Errors - - 21 -
WMS-III Raw Raw Raw Raw
Logical Memory I - 8/75 1/75 -
Logical Memory II - 2/50 0/50 -
Logical Memory II- Delayed Recognition - 15/30 N/A -
Faces I 28/48 25/48 - -
Faces II 31/48 26/48 - -
Clock Drawing Rating Rating Rating Rating
3 3 4 4
COWA Raw Raw Raw Raw
19 11 5 -
Token Test (Form A) Raw Raw Raw Raw
- - 26/44 -
Boston Naming Test Raw Raw Raw Raw
- - 20/60 16/60
Complex Ideational Material Raw Raw Raw Raw
- - 7/12 4/12
Case 2
The second case is of a 54-year-old right-handed male construction foreman. He had 14 years of education, and the referral question noted that the patient had experienced sudden cognitive decline. The patient had been seen a total of three times previously, including in 2012 and 2013. Those assessments demonstrated impairments in executive functions and memory, in addition to processing speed. At the time of the most recent assessment he had begun to experience incontinence, slurred speech, gait changes, and poor balance. Underlying medical history included neuroimaging demonstrating multiple small strokes, hypertension, hyperlipidemia, and diabetes.
In our interview with the patient in 2014 he denied any cognitive decline in the past two years, although he noticed he had a mild memory deficit. His wife, on the contrary, reflected that he had been having greater difficulty in the past several months, with some equivocal improvement in the past several weeks. He had become withdrawn, sleeping more often, and was not completing pro- jects. He reportedly spent much of his day watching television. Although the patient described his mood as normal, his wife characterized him as frustrated and bored. He had been unable to return to work.
During the final examination the patient’s behavioral presentation was notable for markedly flat affect and prolonged staring. Speech had limited prosody, with occasional apparent word-finding difficulty and mild dysarthria. It was noted that he continued to drive, despite medical contrain- dications and instructions.
Modest but clear declines were observed in orientation and visual spatial reasoning. His cogni- tive profile was felt to be otherwise broadly stable, with impairments in executive functions and deficits in memory and speed of processing. The profile was felt to be consistent with his known vascular disease, and not felt to be consistent with a primary progressive dementia such as Alzhei- mer’s disease.
As with the first case, practical recommendations were addressed, including reinforcing that he was at risk of errors while driving. The patient agreed to an on-the-road test by the Department of Motor Vehicles, which he subsequently did not pass. Further, his wife had begun to manage daily
142 R. D. Jones
activities including finances and medication adherence. Based on available research, the patient had begun a mild exercise program under the supervision of his physician, and was careful to adhere to medications related to cerebrovascular health.
Case 2 evaluation
Evaluation Date 10/24/2012 10/7/2013 6/20/2014
Orientation
Time -0 -0 -1
Personal Information 4/4 4/4 2/4
Place 2/2 2/2 2/2
WAIS-IV Ssa Ssa Ssa
Similarities - 7 -
Digit Span 10 10 8
Arithmetic 8 - -
Comprehension - - 5
Block Design 8 9 9
Matrix Reasoning 10 - 8
Symbol Search 5 - 5
Letter-Number Sequencing - - 6
Coding 3 4 4
Picture Completion - - 11
WRAT4 SS SS SS
Word Reading 97 - -
Rey AVLT Raw Raw Raw
Immediate Recall 5-5-4-7-8 5-5-5-6-6 3-5-5-7-8
Short Delay Recall 3 4 4
Long Delay Recall 1 1 2
Recognition (Hits/False) 5/3 7/9 6/5
Complex Figure Test (Rey-O) Raw Raw Raw
Copy 27 20 17.5
Recall 14 9 12.5
BVRT Raw Raw Raw
# Correct 4 - 3
# Errors 7 - 12
WMS-III Raw Raw Raw
Logical Memory I 34/75 - 35/75
Logical Memory II 16/50 - 15/50
Logical Memory II- Delayed Recognition 23/30 - 25/30
Clock Drawing Rating Rating Rating
- 2 3
COWA Raw Raw Raw
23 17 16
Boston Naming Test Raw Raw Raw
58/60 - -
Complex Ideational Material Raw Raw Raw
- - 10/12
Judgment of Line Orientation Raw Raw Raw
- - 22/30
Grooved Pegboard Test Raw Raw Raw
RH - 0 drop; 149 secs 0 drop; 122 secs
LH - 1 drop; 156 secs 1 drop; 145 secs
Trailmaking Test Raw Raw Raw
(Continued on p. 144) 143 Neuropsychological Assessment of Aging Individuals
(Continued)
Trails A 0 error; 57 secs 0 error; 63 secs 0 error; 51 secs Trails B 3 error; 324 secs 2 error; 315 secs 1 error; 241 secs
Stroop Raw Raw Raw
Word: - 60 -
Color: - 41 -
CW: - 12 -
Beck Depression Inventory Raw Raw Raw
13 16 -
Geriatric Depression Scale Raw Raw Raw
- - 12
These cases demonstrate not only the diagnostic value of neuropsychological assessment in the elderly, but also the use of such assessment in relation to management recommendations. Both conditions were progressive, and serial assessments provided the treating physician and caregivers and index of risk with respect to areas of responsibility. Ultimately, both patients and their families benefited by having direct feedback and objective findings to support increasing interventions in the areas of decision-making, driving/transportation, medical care, and other daily activities.
Summary
As an overview, neuropsychological assessment has become a staple of care for the elderly who experience cognitive changes. Over the past 70 years, the quality and accuracy of these assessments has improved, and have demonstrated value both in increasing diagnostic acumen, which is rele- vant to treatment, and also in addressing practical implications of cognitive decline in the elderly.
The field of neuropsychology itself has undergone dramatic transformation, with the advent of licensing and board certification, reflecting a greater level of sophistication within the field. Con- current with these advances in regulation, an overview of the history of neuropsychology reflects the confluence of“schools”of assessment, indicating greater agreement with respect to models of assessment and the values of tests. The nature of assessment itself is highly dynamic, and a neuro- psychological assessment today is very unlike what had been practiced 50 years ago. Drawing from this lesson, it can be anticipated that the nature and goals of neuropsychology are likely to change, and that assessments 50 years from today will significantly differ from what is provided by today’s practitioners.
Key Readings
Strauss, E., Sherman, E., & Spreen, O.A compendium of neuropsychological tests(3rd ed.). (New York: Oxford University Press, 2006).
Lezak, M., Howieson, D., Bigler, E., & Tranel, D.Neuropsychological assessment(5th ed.). (New York: Oxford University Press, 2012).
Heilman, M. K. M., & Valenstein, E.Clinical neuropsychology. (New York: Oxford University Press, 2010).
References
1 Hebb, D. O.Organization of behavior. (Wiley, 1949).
2 Strauss, E., Sherman, E., & Spreen, O.A compendium of neuropsychological tests(3rd ed.). (New York:
Oxford University Press, 2006).
144 R. D. Jones
3 Rizzo, M., Eslinger, P. J.,Principles and practice of behavioral neurology and neuropsychology. (W. B.
Saunders, 2004).
4 Lezak, M. D. IQ: RIP.Journal of clinical and experimental neuropsychology, 10, 351–361 (1988).
5 Kolb, B., & Whishaw, I. Q.Fundamentals of human neuropsychology. (Macmillan, 2015).
6 Heilman, M. K. M., & Valenstein, E. Clinical neuropsychology. (New York: Oxford University Press, 2010).
7 Grant, I., & Adams, K. M.Neuropsychological assessment of neuropsychiatric and neuromedical disorders.
(Oxford University Press, 2009).
8 Smith, G. E. et al. Mayo’s Older Americans Normative Studies (MOANS): Factor structure of a core battery.Psychological Assessment, 4, 382 (1992).
9 Reitan, R. M., & Wolfson, D.The Halstead–Reitan neuropsychological test battery: Theory and clinical interpretation: Vol. 4(Reitan Neuropsychology, 1985).
10 Ashendorf, L., Swenson, R., & Libon, D. J.The Boston process approach to neuropsychological assessment:
A practitioner’s guide. (Oxford University Press, 2013).
11 Freedman, M.Clock drawing: A neuropsychological analysis. (Oxford University Press, 1994).
12 Benton, A. Clinical neuropsychology: 1960–1990.Journal of Clinical and Experimental Neuropsychol- ogy, 14, 407–417 (1992).
13 Tranel, D.The Iowa-Benton school of neuropsychological assessment.Neuropsychological assessment of neu- ropsychiatric and neuromedical disorders, 66–83 (2009).
14 Lezak, M., Howieson, D., Bigler, E., & Tranel, D.Neuropsychological assessment(5th ed.) (New York, Oxford University Press, 2012).
145 Neuropsychological Assessment of Aging Individuals
8
Normal Aging
Brain Morphologic, Chemical and Physiologic Changes Detected with in vivo MRI
A. A. Capizzano, T. Moritani, M. Jacob, and David E. Warren
Key Points
• MRI is sensitive to multiple dimensions of the aging process in the brain.
• Key dimensions which change in aging are regional atrophy, vascular differences, increased water diffusion, reduced perfusion, and metabolic and functional changes.
• MRI evidence has shown that brain changes related to healthy aging are distinct from specific brain changes due to neurological diseases of age.
Introduction
Magnetic resonance imaging (MRI) is a medical imaging technique that is widely used in the assessment of structural and functional brain changes in aging. MRI scanners use strong magnetic fields and radio waves to form images of the body. The popularity of MR methods in aging research can be attributed to their ability to probe the brain noninvasively using several different contrast mechanisms that are sensitive to different properties of brain tissue (e.g., water content, diffusion environment in the brain, concentration of different metabolites, perfusion, and oxygenation of blood). MR exams involve minimal risk and the hardware is now widely available, which makes MRI an ideal tool in aging research and clinical practice.
Imaging older individuals with MRI is associated with unique challenges. Claustrophobia related to the MRI environment was actually found to be lower in subjects over 65 years of age and higher in middle-age (40–65-year-old) individuals, particularly women.1Technical concerns of imaging older patients include motion artifacts2and limitations of subject positioning (for instance from exagger- ated kyphosis) in the scanner. Subject sedation is frequently helpful to obtain a good quality study in these cases although sedatives may affect functional MRI data acquisition. Furthermore, ferromag- netic medical devices commonly prescribed to the elderly such as cardiac pacemakers, cochlear implants or neurostimulation devices constitute a contraindication for MRI. Other medical devices such as orthopedic instrumentation or vascular stents, albeit not a formal contraindication for MRI, are associated with image artifacts that may reduce the utility of MRI exam.
These challenges notwithstanding, this review focuses on age-related changes in the brains of healthy elderly subjects as measured with state-of-the-art MRI techniques. Specifically, the review
The Wiley Handbook on the Aging Mind and Brain, First Edition. Edited by Matthew Rizzo, Steven Anderson, and Bernd Fritzsch.
© 2018 John Wiley & Sons Ltd. Published 2018 by John Wiley & Sons Ltd.
covers changes in brain structure and volume (structural MRI), water diffusion (diffusion-weighted imaging: DWI and diffusion tensor imaging: DTI), biochemical composition of neural tissues (MR spectroscopy: MRS), neuronal activity (functional MRI: fMRI) and cerebral blood flow (perfusion MRI). Positron emission tomography (PET) imaging studies and findings in Alzheimer’s disease are reviewed in chapters 9 and 21 of this book, respectively.