Primary or depressive dementia: Psychometric assessment

Primary or depressive dementia: Psychometric assessment

Clinrroi Prycholo~ Ktwem, Vol. primed ,n rhc USA. 12, pp. 307-343, 027%7358/92 1992 Copyrig-hl All rlxhrs rewr\ed 0 $5.00 1992 Pergamon + .O...

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Clinrroi Prycholo~ Ktwem, Vol. primed

,n rhc USA.

12, pp. 307-343,

027%7358/92

1992 Copyrig-hl

All rlxhrs rewr\ed

0

$5.00

1992 Pergamon

+

.OO

Press Ltd.

PRIMARY OR DEPRESSIVE DEMENTIA: PSYCHOMETRIC ASSESSMENT Gabriel Addenbrooke’s

ABSTRACT.

In the wake

century Britain manage had

one’s patrimony

to be made

organic tion,

decline mental

Today,

(e.s.,

calculation,

psychometrically testing.

This

article first

A number

today

gave us most dementia

he noted, things,

condition 1986,

practice.

or

that

forgetful

p. 251).

emotional

‘The

term “pseudodementia”

past to describe

dementia”

Cambridge

are

in individual in single

and primary

case

demen-

that could prove useful in

live

in which

the

of Pergamon

attention

[thus]

observed

307

animals”

further

causing

depressives,

Mahendra,

are used instead

Cambridge

ignorant but

a

considered

memory

how

to fail to

to refer to a chronic

this term has often been used in the

in some

(e.g.,

severely

become

of old age” (Jackson,

by Carl Wernicke

Although

When

“they

of inferior

Galen

in this context

University,

life

1988), of Chronic

of what we regard

dementia.

is the calamity

last century

Symptoms

the first account primary

demen-

& Bernstein,

and

which

with

and depressive

Lasker,

On the Causes from

and

dementia”

primary

served in depression and Alzheimer’s disease respectively. Correspondence should be addressed to Gabriel desRosiers, brooke’s Hospital,

only a few

test validity

strategies

(Katzman,

in a condition

deterioration.

impairment

and “primary

assessment

comprehension.

though

of their efficiency

that determine

is perhaps

dotage

was introduced

the cognitive

comparisons

treatise

what

interfere

been raised about its connotations “depressive

his

its distinction

from

mental

immensely,

between

recently

of Aretaeus,

states

state mimicking

diagnosis

of themselves,

A contemporary

“strong

alternative

can lapse

is still “different

such

psychiatric

clearly

melancholies

to enable

to sauge orienta-

as memory and social

such

effect has grown

or

disorder),

specificity.

In

and

tests designed

simple

distinctions

depressive

used to dtff erentiate between depressive

attention

Aretaeus

affected, of all

diagnostic

in 13th-

to carry on independently,

others,

of the parameters

of differential

to clinical

came to offiate

(e.s.,

functionins

before describiq

as depressive

Diseases,

some currently

considerable

Regis

incapacitation

among

to the same

examines

the question

new

usins,

with enoup-h details

considered

has received

it is not

disease)

of measures

UK

duties and care, etc. In the process,

functional

more complex

newer tools to improve

Although tia’

discharge familial

of tests applied

documented

tia are then brieflr devising

and

the Prerogativa

reforms,

senescence,

degenerative

the number

assessment.

normal

Cambridge,

procedure to determine a person’s fitness

or business,

between

Hospital,

of Norman

as a legal certtfication

desRosiers

CB2 2QQ

1987).

objections

to refer to cognitive

Department UK.

have

Accordingly

also

the terms decline

of Psychiatry,

ob-

Adden-

308

G. desRosiers

register

actions

conception

or events

still very

sis was of crucial

attempts were

primary

mandates telling

apart

psychosis

those

an official

to time

and

wards

dementia

and

the limited

England elderly

place,

memory,

and reading

skills.

to determine

and

basic

Literally

hundreds

the help quite

of sophisticated

sensitive

reliably

(Eslinger,

cases,

results

dementia,

been

throughout

its course,

research

less published

arising

Parkinson’s

disease)

Poncet,

1989;

Huber,

1990;

addressing though that

issues

helpful

in single

ment

is bound

by

1983),

shown

consistently

depression man,

case

future

Kotsch,

rate Lasker,

& Bernstein,

is the question

is diagnosed

in some

patients

sometimes

ganic

process.

One (e.g.,

withdrawal)

presentation display

current guilt,

except

anxiety),

symptoms

from still

are who

in early

stages

will later may

neurological is to focus

vegetative

reasons

signs

(e.g.,

insomnia,

results,

can be devel-

1972;

assess-

Nunally must

&

also be

whether

this

1987;

confusion. major

Alzheimer’s and,

First,

disease.

In

in depression,

absence

of an orof certain

or behavioral

whether

it is Katz-

depression

the presence

versus

appetite),

to determine

& now

necessarily

individual

mark,

suggesting

are

clinically.

atypical

on the presence

in the two conditions

tests

syndrome,

develop

be quite

not

& Gershon, for

(King

studies

groups

lo-20%

(Siegel

As a prodromal

of patients focal

several

the

&

speculations

statistical

Ley,

between

(e.g.,

Ceccaldi,

are

new

1989;

differences

dementia

Because

for it to be useful versa

Psycho-

fueled

But

of

observed

has received

Donnet,

group

out how

statistically

In some

deficits

has again

basis.

to

the nature

or subcortical

questions,

(Cahan,

or vice

1989).

practice,

section.

to be

of standardized

to primary

general

around

found

psychometrically.

Some

to with

is deployed

about

Habib,

1989)

noncases

are

& Hill,

disease)

1988;

in pointing

hovers

There

approach

back-

attempt

neuropsychological

in a later

criteria

that

effort

in clinical

about

on a day-to-day

in symptoms.

15-20s

some

intrapsychic

clinical

responsiorientation

Increasingly,

theorizing

1986).

to differentiate

1988).

Storandt

it is related

with

today

combinations

Alzheimer’s

reviewed

dementia

of overlap

cases,

(e.g.,

significance

as organic

of with

as counting

measures

relationship

of interest

grappling

cases

royal

ones

to evaluate

for the cognitive

Weingartner,

are

today

the

and custodial

functions.

further

this

and how

assessment

to separate

1985;

& Marsden,

1988;

found

from

in use

using

& Freidenberg,

when

of misdiagnosis mistaken

surge

differentiation

a measure

stage

to spur

cortical

they

stricter

other

social

and

the question

such

of these

not a new concern

cognition

useful

of dementia

fashion,

a considerable

responsible

(Brown

& Steif,

demonstrably to enhance

there

impairs

these

latest

so-called

states

as today,

tests

are

more

to depict

though

Shuttleworth,

Sackeim

oped

The

and how best The

tests

Allen,

underpinnings

disorders

on how depression Caine,

& Van

from

of dis-

the occasional

as long

depression

on cognitive

at its earliest enough

attention.

in dementia

half

incompetency

currently,

and,

Benton,

in depression,

“organic”

competence,

clinical

gratifying

the neurological

from

out simple

techniques,

dementia

Damasio, have

and

differences

primary

days,

lived

nature,

incidence

IN ASSESSMENT

and organicity

statistical

to group

detect

tests

metric

of depression

legal

carried

difficulties

1979).

of experimental

the effects

in those

a

diagno-

considerable

the age-related

or

p. 371),

differential

of psychological

in a concrete

intellectual

(Neugebauer,

ISSUES

capture

as people

senescence

by the court

were

longevity

to address,

normal

In order

appointed

Yet,

began

with

Given

1969,

also,

of distress

the “functional”

practicality.

and dementia.

bilities,

he felt there

pathology.

differentiate

in medieval

cases

(Jackson,

For Galen

as a syndrome

brain

clinical

a state”

1986).

subtle

to conceptually

of restricted

such

(Caine,

depression

following

causing

during

today

as in certain

between

and depression

occurred

alive

importance

in discriminating eases

that

much

specific

(e.g., profiles

309

Primary or Depressive Dementia

could be reliably detected some of these points (e.g.,

1991).

(desRosiers, Benedict

& Nacoste,

Recent

reviews have recently

touched on

1990) and the following will focus on a

second reason for confusion bearing on the definition of dementia. Currently there are no antemortem markers of the conditions leading to primary dementia (PD), and our diagnostic definitions revolve around the notion of threshold of symptoms, signs, and constitutional features. A consensual definition of dementia might describe it as an acquired mental desintegration from premorbid levels manifest as cognitive and functional difficulties in personal, social, and professional activities, and which is due to an underlying disorder, organic, depressive, or otherwise (e.g., Lishman, 1988; OTA, 1988). Some ambiguities arise, however, when other descriptors of ‘normal’ cognitive attenuation,

such as benign

senescent

forgetfulness

or age-related

memory

impair-

ments, are considered (Baltes & Kliegl, 1986; Bamford & Caine, 1988). This predicament becomes particularly acute when instruments developed to assess cognitive impairment in the clinic are also used as first-stage tools to determine base rates. Cognitive measures can be sensitive to a host of confounding factors that do not necessarily herald dementia and, to a certain degree, this means that base rates (prevalence) figures will be contaminated depending

on the clinical

setting

surveyed

unless follow-ups

are carried

out to

confirm diagnoses. In general, however, there is agreement about rough estimates and, as detailed elsewhere (desRosiers, in press), five separate settings have been identilied in which clinical neuropsychologists are called upon to help differentiate PD from depressive dementia. Studies reporting prevalence rates for both dementia and clinical depression in the same survey were tabulated and used in the present article to provide estimates of base rates in later tables. Of note is that these surveys often did not distinguish between mild and severe cases of dementia. We know, however, that the former is substantially higher than the latter in the community at large, but much less so in nursing home settings (Parmelee, Katz, & Lawton, 1989), and the same relation may be true of clinical depression. Sharing responsibility for this lack of differentiation is the fact that until recently instruments devised to evaluate dementia severity using other than “test impairment” criteria have been few (e.g., Clinical Dementia Rating Scale) and are now only beginning to be applied routinely across diagnostic settings. As clinical psychologists are most apt to be consulted when cases are mild, and therefore ambiguous, reported estimates of this kind must be ad.justed accordingly. Kassirer and Kopelman (1989)

recently identified several stages where faulty decisions

can spell out diagnostic errors. Among others, failure to consider the prevalence of both a presumptive condition and of others of similar presentation as they occur in one’s working environment can create confusion when using standardized instruments. This is especially so for conditions where differential diagnosis is already difficult. For instance, to judge that cognitive aberration in an irritable 50-year-old patient presenting with mild focal signs signals the presence of primary dementia could be an example of what has been described as falling victim to representativeness or availability heuristics (Kahneman & Tversky, 1982). The probability of this patient’s clinical presentation being reflective of PD may be deemed high because of: 1) the degree to which the presenting picture resembles that of “classic” cases of PD, or 2) the ease with which similar cases are remembered from past experience. Foreknowledge that the base rate for such a case presenting, say, in a primary-care setting may be less than l%, together with the fact that the prevalence of other conditions with similar manifestations (e.g., depression) is highest in this age-group, can help redirect clinical thinking (Meehl & Rosen, 1955). In any case, when clinical features are not specific enough to warrant a definite diagnosis, the physician often requests additional information from speciaiized neurophysiologi-

310

G. desRosiers

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cal, biochemical, or neuropsychological testing (Somerfield, Weisman, Ury, Chase, & Folstein, 1991). Certain tests, such as the Wechsler Scales, provide extensive normative data that allow evaluation of results using Gaussian parametrics (e.g., t scores, predicted scores, ahnormality of difference scores, etc.). In other situations, however, the application of highly reliable

measures

that use cut-off criteria

(e.g.,

Benton

Visual

Retention

Test; Controlled Oral Word Association Test; Hooper Visual Organizati(~Il Test) may lead to more diagnostic errors than if allocating a decision purely on the basis of base rates alone. Unless a clinician has an instrument with 100% sensitivity and specificity (see below), specialized testing may not be of any benefit when base rates are extremely high or low. To help decide about a test’s potential in a particular setting, one can apply Bayesian derivations to compute conditional probabilities using both base rates and estimates of a test’s sensitivity and specificity (e.g., Ley, 1972, Willis, 1984). As detailed in Figure 1, sensitivity refers to the ability of an instrument to detect all positive cases for which testing is instigated. It is a measure of how “sensitive” the test is to cognitive disturbances and represents the likelihood of a positive test result in a person with the target condition (true positive rate). In a dementia clinic, for example, the sensitivity of a measure is determined by its ability to pick all patients who will eventually turn out to have primary dementia, A test’s specificity denotes its ability to exclude all negative cases for whom testing is not relevant. Its complement is often referred to as the false alarm rate. It represents the likelihood of a negative test result in a patient who does not have the targeted condition (true negative rate). In a dementia clinic, the specificity of a neuropsychological test would be gauged by its propensity, as a second-stage tool, to extricate all cases who, though positive during first-stage assessment, will later prove to be other than organically dementing. In current practice diagnosis is usually carried out in two steps. In first-stage assessment (e.g., screening), diagnostic hypotheses are narrowed down by ruling out normality. Highly sensitive tests are important in that when results are normal, they serve to increase the degree of confidence that a given individual Second-stage tools serve to pursue specific does not have the condition in question. suspicions (viz, is the abnormal result on the first-stage test the product of primary, instead of depressive, dementia?). Highly specific tests are vital when giving abnormal

Primary or Depressive Dementia

311

FIGURE 2. Different Distribution of Cases (Above Horizontal) and Noncases (Below Horizontal) Showing the Effects of Three Separate Cut-Off Points on Sensitivity (.75 to .95) and Specificity (.90 to .70).

results in that they increase confidence that the condition suspected is actually present and that results are not due to confounding conditions like depressive illness. In summary, to help confirm the presence of a targeted condition, a test must be specific. To help exclude the presence of the condition, a test must be sensitive. The probability of a condition being present after test results are known (posttest probability) depends on these two parameters interacting with antecedent (pretest probability) rates. For a clinician, the urgent question is whether a given patient with a positive test score is, in fact, compromised by organic dementia (positive predictive value of a test) and whether those with normal scores are indeed free from it (negative predictive value). Tests are often developed and used in selective experimental populations with artificial ratios (Ritchie, 1988). What is needed is an estimate of their potential in realistic clinical field conditions. An index to gauge this quality is the predictive power of a test. It represents the integration of information about test performance with the clinician’s estimate of the likelihood of the condition in a particular setting before specialized testing is instigated. The power of a test represents the probability that a positive result is truly indicative of organicity (positive) and a negative result truly indicative of its absence (negative). The predictive power of a test takes account of varying base rates, and therefore provides a more realistic . . appreciation of an instrument’s worth if intending to use it in a different setting from that in which its sensitivity and specificity were originally reported. As psychometric tests are seldom if ever completely accurate, a trade-off between these parameters must take place. Figure 2 portrays normal (for illustration’s sake) distributions of scores on a fictive memory measure by patients with primary (curves above horizontal) and depressive (curve below horizontal) dementia sampled in ratios of 1 : 1 and 5 : 2. It can be seen that as sensitivity to early PD increases from 75% to 95%) specificity

G. desRo.riers

312

diminishes

from

apportion person and

90%

cases is referred

memory

others than

instrument

B),

predictive

validity

everyone

(this

would

be

positive

by point

23%

Test

B

So what

46%

(.69

-

on this test,

ence

more

regular are

does

emotional,

patients status

sensitive

ments

that

general,

primary-care

not

be so casual

performance, capacity testing this

recently utility

and In

the

guish

amongst

kind

whereas

reports

of primary 1990),

Block

reviewed

to reach

the

rates

(.23)

of cognitive

prevalence,

and economical

section

in that

briefly

strategies.

As general

literature

(desRosiers, will

from

other

due

to primary

that

such

a two-stage

(or

and already et al.,

of these

focus

1991).

popular

organics)

of some the

assessbut the

indeed

of the most

1989),

may

differential

is required

available,

dements

causes

second-stage

that

In

or confuse

to elicit

where are

in press).

not escape

(Somerfield

reviews

Delis,

(e.g.,

instru-

thought

some

primary

of mental benefit

sensitivity

strategy

the GP

measures sensitive

centers

direction

examines

from

of functions,

necessary

decline

or

in this context

Highly

that

it is now

more

concerns

can be of enormous

distinction

testing

their

of psychological

quick

elsewhere

it is not so much

to experi-

so make

Because

decline.

becomes

tend

when

range

some

dementia

however,

organized

to suspect

that

intelligence Hold)

Design

arguing

will

variWith

measures

before

going

measures

have

remain

on

their

Nelson

and

with

early

results

FUNCTIONS

on intellectual

McKenna

Thus,

to the second

expressive

Miller,

Alzheimer’s

in its course,

to organicity.

belonged

that

(e.g.,

patients

quite

by contrasting (Don’t

dementia

leading

a

organic

assessment.

them

or not

surfaced

we

session,

base

and

instead 1986).

to administer

specialized

depressives

in the

began

(Hold)

to deem

an

fails

over

negative

process,

a brief

who

Even

medical,

to apply

challenge

signs

low

useful

are being

in general

tant

the

the elderly

agent.

of cognitive

quick

stages,

to more

with

alternative

As clinicians

been

society

on a broad

agent

are

that

& Lantigua,

INTELLECTUAL

of decline

(.90)

having

by 46%

in Western

seek

of primary

mild

when

case

these

At this stage,

the following

for single

suited

intellectual

is the most

appeared

Gurland

features

use to tell apart

on to consider

(.49)

have In

patient’s

lower the

after

a patient

It is known

to be examined

and

referral

settings

in mind,

clinicians

for

groups may

all kinds

conditions

procedure

ous clinical

they

to detect

some

to determine For

that

PD.

of a

specific

while

might

But

of this

primary-care

inexpensive,

agent. and

are applied.

dementia.

their

the most

dementia

hence

tools

other

Toner,

are cardinal

the

ment

represent

for

with

(Barsa,

enough

there

time.

is much

(.69)

and

validity

but more

to have

our confidence

terms?

any

accustomed

are simple,

in searching

means

(.70)

strategy

of the

(.23),

predictive

(.75)

to

behavior

depression

positive

clinic

of confused

(.23),

increases

likelihood

increases

or cognitive,

grown

may

the

This

than

contact

attention

or internist

of PD)

in practical

illnesses

social,

have

to the

points

An elderly

dementia.

frequent

psychiatric,

.23).

because

PD

0 ne informal

(.92).

as cut-off

the following.

low specificity

validity

referred

his result

this mean

chronic

and

predictive

increases

clinic are

1, the

but

chosen

consider

0 n a less sensitive

(prevalence

on

that he has primary

(.95)

(.98).

somewhat

or C are

center

in Figure

sensitivity

positive

B,

to a dementia

given

included)

only

result

cut-off

drops

A,

example,

at this

validity

the

patient

right

condition

high

predictive

(Test

rates

formulae

A) with

its negative

internist

Base

the

criteria

As a concrete

by a medical

From

(Test

when

noncases.

problems.

(.54).

measure

to 70%

from

vocabulary

1977)

and

(1975)

disease

others tests

WAIS

(AD)

proposed deemed

1983).

Soon

showed

subtle

decline

to advance

patients

(Kluger

a diametrically

signs

to distin-

to be either

vocabulary

(Lezak,

in depressed

showed ways

resis-

was of the first after,

however,

in early

stages

& Goldberg, opposite

view.

Primary or Depressive Dementia

Because

AD patients

other conditions

in general

show no symptoms

affecting articulation

(Huff, Boller,

313

of disarthria, Lucchelli,

orofacial

Querriera,

apraxia,

or

Beyer, & Belle,

1987), Nelson surmised that a more fruitful strategy might be to compare WAIS vocabulary results with scores on another indirect measure of lexical knowledge based on a patient’s ability to pronounce words with irregular spelling (e.g., sidereal). The assumption is that accurate pronunciation indicates previous familiarity and usage of the word, hence a person’s premorbid intellectual functioning (Nelson, 1982). Though psychomotor retardation is sometimes noted in elderly depressed (Blazer, 1989), this mainly affects rate of speech rather than articulation per se (Miller, 1975). The validity and reliability of Nelson’s National Adult Reading Test (NART) has now been documented in different groups. In a community survey of elderly women, Brayne and Birdsall (1990) confirmed that the distribution of predicted IQ using NART was normal, a requisite if intending to use Nelson’s reported standard error of measurement as a way to evaluate abnormality

of differences

between estimated

(NART)

and obtained

(WAIS vocabulary) IQ scores. Comparing controls against patients with either AD, Korsakoffs syndrome, multi-infarct dementia, or closed head injury, Crawford, Parker, and Besson (1988) found WAIS vocabulary scores to be generally lower in the clinical groups only. Moreover, in none of these groups were NART-estimated IQ’s significantly different from those of controls, thus supporting its validity as a premorbid index of intelligence. The information gained this way is particularly welcome in order to adjust patients’ scores on other psychometric measures known to be affected by intelligence in general (e.g., Heaton, Grant, & Matthews, 1986; Russell, 1988). Following primary dements for at least a year after their first examination, O’Carroll, Baikie, and Whittick (1987) confirmed the robustness of NART when decline on a mental status scale paralwhile NART scores remained unchanged leled a comparable drop in vocabulary, throughout. Similarly, Brayne and Birdsall’s epidemiological survey determined that NART-predicted IQ did not differ whether AD subjects were diagnosed as mildly or moderately demented. Very few studies (e.g., Abas, Sahakian, & Levy, 1990) compared AD with depressed patients on NART and none tabulated individual results about its sensitivity and speciticity. Kopelman’s (1986) AD and depressive patients obtained similar NART scores, but a sharp drop from premorbid to current IQ estimates in the former (32 + 18) contrasted with a milder decline in the latter (4 f 7.5). No independent indication of the severity of AD patients’ dementia was provided, however. Crawford and associates (1987) contrasted NART scores in depressives and a control group and found no differences in estimated IQ. Controls, however, performed better on WAIS vocabulary and, as in Kopelman’s study, this suggests that some confusion might occur if attempting to distinguish between patients with primary or depressive dementia on an individual basis. A less taxing approach that could improve specificity might be to validate NART against a measure of receptive vocabulary or a multiple-choice test so as to reduce demands for effortful responding, an influential factor in depressives’ performance on cognitive measures (see below). In support of this is the preliminary report by O’Carroll et al. (1987) showing that AD patients do exhibit a significant decline over one year on the Mill Hill Vocabulary Scale-Synonyms (see also Binks & Davies, 1985), and another study by Taylor, Redfield, and Abrams (1981) reporting a significant difference between depressed and AD patients on the Peabody Picture Vocabulary Test. Another early proposal by Goldstein (1939) was that organicity induced a regressive process forcing a shift from abstract to concrete reasoning through a “dedifferentiation of brain functions.” To think abstractly was to be able to hold in mind simultaneously various aspects of an event, synthesize and organize them hierarchically, and shift from

314

G. desRosim

one to the other at will. Operationalized by using a sorting test, categorical and classificatory skills were shown to gradually deteriorate with dementia, a scenario akin to what Hughlings Jackson called a “dissolution of function” in which intellectual decline proceeds from higher to lower functions. Reviewing their research to date with the Colour Form Sorting Test (CFST), Spinnler and Della Sala (1988) stressed the sensitivity of assessing conceptual impairment in the early diagnosis of AD, while Tamkin and colleagues (1984), comparing perceptual and conceptual tests in the same patients, noted that, when a patient failed on CFST, additional measures of symbolic reasoning increased discrimination. Accuracy improved by adding perceptual tasks when shifting was not a problem. Consistent with this is the frequent observation that early AD patients may show predominantly either right or left hemisphere dysfunction (Becker, Huff, Nebes, Holland, & Boller, 1988; Capitani, Della Sala, & Spinnler, 1990; Haxby, Grady, Koss, Horwitz, Heston, & Shapiro, 1990) and McFie’s (1975) report that CFST is particularly efficient in detecting the latter only. CFST arranged

provides a quick means to evaluate abstract thinking in which tokens must be according to form and/or color and early reports using CFST in AD patients

commented on their considerable difficulties in shifting from color to form sorting, an observation supported by Abas et al.‘s (1990) recent findings where AD, but not depressed, patients were particularly poor at using shape, but not color, cues in discrimination learning. This progressive shift in AD towards a more color-oriented performance is congruent with recent neurophysiological studies showing that the shape and color of objects are separable features represented and accessed separately, regardless of whether and where attention is focused (Isenberg, Nissen, & Marchak, 1990) and that the processing of the latter draws on less complex cerebral organization than shape processing (Livingstone & Hubel, 1988). Color processing primarily involves the participation of posterior lingual and fusiform regions of the brain (Lueck, Zeki, Friston, Deiber, Cape, & Cunningham, 1989), regions thought not to be particularly (Henderson & Finch, 1989; Pearson & Powell, 1989).

affected

in early AD

Whereas Hall (1952, p. 261) reported a “far clearer differentiation [on CFST] between organic and depressive than any apparent patterns on the Wechsler [deterioration ratios],” Hopkins and Post (1955) failed to distinguish them statistically. One possible reason for this conflict is that the scoring ofCFST can be done either emphasising qualitative, quantitative, or both aspects of the test. Closer in time, Grewal and his associates (e.g., Grewal & Haward, 1984) began reporting on a series of studies using a set of standardized scoring criteria, As Table 1 shows, detection of dementia appeared excellent in one study but some 12% of depressives were still wrongly classified. In a later study with more carefully selected samples, Grewal (1988) found no overlap regardless of whether depression was diagnosed as mild, moderate or severe, and suggested misclassi~cation in the earlier study perhaps resulted from errors in the diagnostic “gold standard” (i.e., psychiatric diagnosis). It should be noted, however, that the utility of a “specific” test must be gauged with ambiguous cases as they occur in the clinic if the test is to be of any benefit, and that veriftcation of its accuracy can only be carried out as an empirical exercise through follow-ups. As an indication of its concurrent validity, Grewal also compared CFST with a similar test developed by Tien (1960). The Organic Integrity Test (OIT) consists of cards (e.g., purple radio, brown radio, brown luggage) to be sorted. As with CFST, it is assumed that sorting by form represents higher functioning. In Tien’s (1960) report, patients with involutional psychosis performed somewhat worse than neurotics but still better than dementing patients (Table 1). As with CFST, Grewal (1988) found OIT unrelated to degree of depression. Depressives have been found to perform better than organics on a Davis, & number of other conceptual tests, including Gorham’s Proverbs (Watson,

315

Primary or Depressive Dementia

Gasser, 1978), the Wisconsin Card Sorting Test (Hart, Kwentus, Taylor, & Harkins, 1987), and the Category Test (Watson et al., 1978). In summary, conceptual sorting tests are short, reliable, and easy to administer. In particular, CFST appears readily acceptable to patients, makes little verbal demands, and correlates minimally with sociodemographics (Villardita, Cultrera, Cupone, & Mejia, 1985). The few studies available suggest that it is a sensitive test, though less is clear about its specificity. One way to improve its accuracy might be to modify the test by adding a simple variation along a third separable dimension such as size or number (e.g., Kopelman, 1989). In this way, more room is created for depressive patients to distance themselves from those with primary dementia.

VERBAL FUNCTIONS In contrast to Goldstein’s position, Babcock (1930) posited the fundamental impairment in senile dementia was a loss in the “fluid” ability to learn, and this could be demonstrated on tests of new verbal learning, such as story recall, paired associate learning, word definitions, etc. Walton’s Modified Word Learning Test (MWLT) required patients to learn the meaning of a number of new words using alternative definitions with each trial (Walton & Black, 1957). Although initial results were encouraging (Table 1), later reports pointed to the dangers of misclassification if IQwas low (Bolton, Savage, & Roth, 1967). In addition, Teasdale and Beaumont (197 1) f ur th er noted wide fluctuations in depressed patients’ scores following diurnal variations

in mood. To palliate for this lack of specilic-

ity, Kendrick’s (1965) Synonym Learning Test (SLT) used only one definition (not synonym) for each word in every learning trial and required readministration of the test 6 weeks after initial exposure-the assumption being that the intervening treatment should alleviate depression and its noxious effects on effortful learning. But like its predecessor, SLT was also subject to artifacts caused by low IQ and the test was still thought too stressful for functional patients (Davies, Hamilton, Hendrickson, Levy, & Post, 1978; Irving, Robinson, & McAdam, 1970; Whitehead, 1973). Thus, whether the acquisition of word definitions required “rote” or “semantic” learning did not make any differences to depressives but, in both cases, success was dependent or less lengthy definitional sentences.

on expressive

performance

of more

In contrast to tests of “short-term” memory, others particularly target material stored in “long-term” repository: material that presumably was learned years before testing. The boundaries between short-term and long-term memory are by no means the same for each and every researcher but, according to some accounts (Mayes, 1988; Parkin, 1987; Squire, 1987), storage and retrieval of such long-term material is less dependent on limbic structures involved in short-term processing and more reliant on distant posterior cortical sites often compromised in AD. Beside testing for remote episodic memories (e.g., retrograde amnesia tests, see below), clinicians can examine long-term semantic knowledge in a number of ways, two of which probe word fluency and naming abilities and, according to Spinnler and Della Sala (1988), difficulties in word generation emerge earlier than naming deficits in AD. Since neuropsychological functions can seldom be boxed in discrete functional zones, the question as to whether the cognitive function tapped by word fluency is primarily one of language or one of semantic memory is perhaps academic (Miller, 1989), and the few studies that have looked at its factorial complexity were not extensive enough to settle this question (Becker, Huff, Nebes, Holland, & Boller, 1987; desRosiers & Kavanagh, 1987; Teng et al., 1989). Beginning with Thurstone’s original measure, a number of fluency tests are now available that gauge word enumeration according to rules either following a predesignated category (e.g.,

iu 2

Organics Depressed Organics Depressed Dementia Depressed Organics Depressed Organics Depressed Organics Depressed Dementia Affectives Dementia Depressed

MWLT

Organics Affectives Organics Controls Dementia Depressed Dementia Depressed Dementia Depression

SLT

IPAL Hard

SLT

SLT

SLT

Dementia Depressed

SLT

SLT

MWLT

MWLT

MWLT

MWLT

MWLT

MWLT

Diagnosis

Test

60-80 60-80

52’ 56*

878365-87 65-83 7777-

(9) (31) (25) (25) (13) (13) (19) (la) (18) (18)

69’ 69’ 40; 38’ 60’ 60’ 65-80 68-85 56-82 58-81

(26) 60-80 (52) 60-80

(35) (42) (29) (68)

(22) (16) (17) (7) (53) (30)

(46) (40) (27) (21) (42) (27)

(N)Age

Psychiatric Hospital Liaison Psychiatry Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital

Psychiatric Hospital

Psychiatric Hosptial Psychiatric Hospital Psychiatric Hospital Liaison Psychiatry Liaison Psychiatry Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital

* Setting

Cutoff 31+ 31+ 26+ 26+ 26+ 6 Trials 26+ 56-

57-

56-(1st) 40 - (2nd) 57565631+

PEV

.38

.38

.38

.35

.35

.38

.3a

.38

.38

.3a

.35

.38

.38

.38

.70

.74

.94

.54

.92

.72

1.0

1.0

.35

.62

1.0

.34

.60

.91

.a0

.a5

1.0

.96

.79

.a4

1.0

.60

.71

.71

.68

.77

1.0

1.0

1.0

1.0

pv+

.77

.86

1.0

1.0

1.0

1.0

Spe

.a1

.a8

.a2

.86

.a5

.94

Sen

.96

.55

.93

.a6

1.0

1.0

1.0

.a0

.a7

.93

.91

.92

.92

.96

PV-

Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis

Psychiatric Diagnosis

Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Consensus Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis

Criterion Depressives include both psychotics and neurotics Two-year Follow-up of the above study Dementia includes cases of cerebrovascular disease Depressives diagnosed as Psychotics Depressives diagnosed as dysthymics and psychotics Organics include cases of Focal lesions MWLT correlates - .47 with WAIS in both groups Low scores go with low WAIS. Single Administration Test-retest format of the patients in Kendrick (1965a) 19 depressives originally thought pseudodements 50% of controls diagnosed as depressed or anxious Only recovered cases of depression considered Low WAIS in depressives Single administration Depressives selected for their memory problems

Comment

TABLE 1. Validation Studies for Selected Neuropsychological Measures

& Post (1967)

(1965b)

Inglis (1959a)

Michaelson, Rose, & May (1967) Hemsi, Whitehead, & Post (1968) Lamer (1977)

Kendrick

Kendrick

Orme, Lee, & Smith (1964) Bolton, Savage, & Roth (1967) Kendrick (1965a)

Walton & Mather (1961)

Walton (1959b)

Walton (1959a)

Walton & Black (1957) Table 1 Walton (1958)

Reference

3

cu

Dementia Function& Dementia Depression Dementia Depression Dementia Depression Organics Function&

IPAL Hard IPAL Med IPAL Med” IPAL Med IPAL Med

KCTE

KCTE

DCT

DCT

DCT

Dementia D epressed Organics D epressed Dementia Depressed Organics Function& Dementia Depressed Dementia Depression

Dementia Depression Dementia Function&

IPAL Hard IPAL Hard

DCT

Dementia Function.& Organics Function&

IPAL Hard IPAL Hard

(26) (52) (9) (31) (13) (13) (14) (20) (28) (35) (25) (24)

(14) (20) (16) (16) (16) (16) (10) (10) (26) i:153)

(26) (52) (50) (51)

(30) (30) (9) (13)

60-80 60-80 69’ 69’ 60+ 60+ 60-70 60-70 55 + 55 + 78* 75’

60-70 60-70 56-75 42-74 56-75 42-74 73’ 72’ 65 + 65+

60-80 60-80 76’ 73.

65-89 64-84 69’ 69*

Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital Psychiatric Hosptial Hospital & Community Liaison Psychiatry

Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital Community Survey

Psychiatric Hospital Psychiatric Hospital

Psychiatric Hospital Psychiatric Hospital

.60

Trials to Criterion 23-

.38

64-(M) 42 - (F) 6470OLT (22 -) DCT (65/69) As above

.38

.38

.27

.35

.38

64-

.38

.15

.88

13-

.84

1.0

.71

.85

.89

.88

.61

.75

.38

.36

.67

5-

79-

.38

.81

.38

60-

.38

.78

17+

31+

.38

1.0

.38

31+

.38

.92

1.0

.70

.85

.84

.77

.90

1.0

.81

.81

.80

.61

.86

.77

.87

.84

.71

.90 .80

.78 .59

.85

.91

1.0

.93

.77

1.0

.91

.93

.80

.70

.52

1.0 2-year drop on Mental status Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Consensus Diagnosis

.67

.52

.92

Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis DSM3

.75

.51

.74

Psychiatric Diagnosis Psychiatric Diagnosis

Psychiatric Diagnosis Psychiatric Diagnosis

.88

.85

1.0

.78

.68

.83

format Depressives included 4 Schizo-affective cases DCT correlates with sleep threshold in depressives Majority of function& diagnosed as depressives Only 76% of original sample of depressives were retested Excluded equivocal and coexisting cases

Test-retest

Function& included manic-depressive cases Primary depression Medicated patients Alzheimer cases of 3 years duration Some depressives had low mental status No independent clinical diagnostic confirmation

Depressives include both reactives and endogenous 82 % of function& were depressed patients

Function& included cases of schizophrenia 58% of functionals diagnosed as affective disorders (1965b)

(1986)

Kopelman

(1979) Knight & Moroney (1985)

Kendrick

&

& Post (1967) Hemsi, Whitehead, Post (1968) Alexander (1971)

Kendrick

La Rue, d’Elia, Spar, Clark, & Jarvik (1986) Little, Hemsley, & Volans (1987) Table 3 Kendrick (1965b)

(1986)

Kopelman

Irving, Robinson, & McAdam (19701 Study 1 Alexander (1973)

Kendrick

Gird, Sanderson, & Inglis (1962) Newcombe & Steinberg (1964)

Organics Depressed Dementia Controls

AVLT

2

Dementia Controls

BNT

(15) 74* (15) 73*

(48) (23) -

.55

.55

.55

easy associates;

50-

T-Score 43-

21-

14-

14-

.38

.15

36-

Ability to shift 50-

2-

2 SD below controls 346-

.35

.38

.38

.38

‘: Includes

Dementia Clinic

Dementia Clinic

Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital Liaison Psychiatry Psychiatric Hospital Commurtity Survey Dementia Clinic

.55

.38

T-Score 45-

.55

Dementia Clinic

Psychiatric Hospital Dementia Clinic

Cutoff

Prev

Setting

associates;

66-86 66-86 65-85 65-85 65-85 65-85 -

67-94 66-87 43’ 43’

(83) -

(52) (33) (25) (25) (13) (1) (13) (14) (103)

(86) (86) (25) (41)

(83) -

(53) 18-60 (48) 18-60 (103) -

(48) (23) -

(N)Age

*: Mean age; Med: Mediate value; PREV: Prevalence.

Dementia Depression

FAS

FAS

SET

SET

OIT

cu OIT

CFST

CFST

Dementia Depressed Organics Function& Organics Function& Dementia Depressed Dementia Depression Dementia Depression Dementia Controls

Dementia Depression

AVLT

AVLT

Diagnosis

Test

SEN:

.80 .53

.73

.8f

.77

.77

.98

.92

.76

Sensitivity;

.87 1.0

.78

.86

1.0

1.0

1.0

.97

.61

.88

.87 .89

.88 .91 1.0

.83

.76 .80

SPe

SPE:

.88 1.0

.81

.88

1.0

1.0

1.0

.95

.54

.84

.90 .91

.60

.81 .84

pv+ Comment

II

at

predictive

value;

1. Spontaneous. 60 items 2. Including Cueing

Depressives confirmed l-year follow-up

All males. No specific diagnoses detailed Affective patients were not included in the sample No details given on the severity of dementia Tendency for low scores to go with low so&I class 34% of respondents were aged over 85 years Cm-off mark adjusted for education

New scoring criteria

Immediate recall. Organic5 included 70 % head iniuries 1. Immediate recall 2. Delayed recall

1. Immediate recall 2. Delayed recall

PV + : Positive

NINCDSADKDA

Consensus Diagnosis

Diagnosis

COMXlSUS

Psychiatric Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis Neurologic Diagnosis Psychiatric Diagnosis Psychiatric Diagnosis

Specificity;

.78 .64

.69

.79

.96

.88

.99

.95

.81

1.0

.85 .87

Psychiatric Diaenosis Consensus Diagnosis

.70 ”

Consensus Diagnosis

Criterion

.82 .82

PV-

1. Continued

.42

.86 .86

Sen

TABLE

PV -

: Negative

predictive

Caltagirone, Gainotti, Masullo, & Miceli (1979) Gainotti, Calragtronc, Diodato, CGGrappone (1982) Williams, Mack, & Henderson (1989)

Isaacs & Kennie (1973)

Isaacs & Kennie (1973)

Grewal & Haward

(1984)

& Kunce (1985) Tien (1960)

Tamkin

Gainotti, Cahagirone, Diodato, & Grappone (1982) Coughlan & Hollows (1984) Cahagirone, Carlesimo, Nocentini, & Vicari (1989) Grewal & Haward (1984)

Reference

319

Primary or Depressive Dementia

Isaacs & Kennie’s

(1973)

Benton & Hamsher’s

Set Test) or in a dictionary

[ 19781 Controlled

fashion using specified letters (e.g.,

Oral Word Association

Test).

Words retrieved in a categorical fluency test act as symbols for underlying concepts as personally defined by their unique attributes and associative referents. Recent evidence (Troster, Salmon, McCullough, & Butters, 1989) suggests that patients with primary dementia may be particularly impaired in bottom-up structures instantiating semantic categories. Few exemplars in any set can be retrieved but category labels themselves appear more accessible. These patients often are better at answering superordinate (e.g., is this a fruit or vegetable?) than subordinate (e.g., is it smaller or larger than?) questions (Chertkow & Bub, 1989). This suggests that changes in saliency of specific attributes perhaps causes disorganization in semantic information and its coherent retrieval. Some authors report that AD patients are impaired on formal tests of category fluency (Gordon & Carson, 1990; Kontiola, Laaksonen, Sulkava, & Erkinjuntti, 1990), while others working with milder cases report mixed findings (Dal1 Ora, Della Sala, & Spinnler, 1989) or entirely disagree (Fischer, Gatterer, Marterer, & Danielczyck, 1988). Reporting on a prospective longitudinal study of 143 AD and 146 control subjects matched for age, sex, and education, Bracco and coworkers (1990) noted that semantic fluency on the Set Test decreased at each stage of AD severity, but the difference between controls and mild cases was small due to wide variance in the latter. Recently, Hart (1988) encouraged clinicians to test the clinical utility of categorical fluency as a specific marker in the individual assessment of early AD. Robertson and Taylor (1985) found unipolar depressed men to retrieve fewer animal names than controls while both groups were comparable for expressive vocabulary. As the measure was timed, it could be argued that this decrement originated from their usual slowness in complex psychomotor performance, but Emery and Breslau (1989) reported the same pattern when an untimed task was used. Peselow and associates (1991) matched depressed patients and controls on WAIS vocabulary, age, and sex and found a significant difference at baseline that vanished once patients were successfully treated. Gruzelier, Seymour, Wilson, Jolley, and Hirsh (1988), on the other hand, found no impoverishment in 21 affective patients, 43% of whom were diagnosed as manics. It is plausible that the latter patients improved the average, as manics were also found to perform nearly as well as controls in Robertson and Taylor’s (1985) study. In this case, however, vocabulary (WAIS) was also better than in unipolars, though this difference may not have been maintained had a nonexpressive test been applied instead. Hart et al. (1987) directly compared 14 mildly dementing patients against 10 major depressives matched for age, education, and receptive vocabulary. While both groups produced fewer exemplars than healthy controls, depressives also bettered dements, albeit not significantly so. Likewise, DSMS-diagnosed elderly depressives, matched on several demographic variables, outperformed dementing patients (Emery & Breslau, 1989) on an untimed version, but mild, moderate, and severe cases were all mixed together. Overall, it appears depressives’ semantic fluency may be diminished but not to the same extent as that of people with early primary dementia. More extensive are the data on orthographic (dictionary style) fluency. Evidence that mild dementia impedes orthographic fluency is divided, with some reporting a significant attenuation on Thurstone’s measure (Huber et al., 1989; Storandt, Botwinick, Danzinger, Berg, & Hughes, 1984) and FAS (Hart, Smith, & Swash, 1988; Hodges, Salmon & Butters, 1990), while others do not (Caltagirone, Carlesimo, Nocentini, & Vicari, 1989; Hart et al., 1987; Haxby et al., 1990). On Benton and Hamsher’s (1978) latest parallel version (CFL & PRW), th e consensus is that some deficits are apparent even in the mildest cases (Becker et al., 1988; Eslinger et al., 1985; Rosen, 1983). Results for

G. desRio.rierr

320

depressives

are also equivocal.

in unipolar

patients

failed

to

support

this

1982;

Beatty,

Salvolini, though

inclusion

Robertson

While

compared

Robertson

to controls

finding

using

FAS

Wonderlich,

of bipolar

and Taylor’s

patients

(1985)

and Taylor

matched (Angeleri,

& Ternes,

in the latter

study

for example,

described

other

Signorino,

1990;

Gruzelier

somewhat

show

a reduction

vocabulary,

Provinciali,

Staton,

data,

(1985)

for WAIS

et al.,

obscures

manic

reports

Piana,

these

subjects

&

1988),

findings.

to equal

controls

on this task. The

inconsistency

study

by Wolfe

in the literature

and

as well as healthy fared cases

were should

and

current

clinical

depressives tween 1).

differences.

depressed

Finally,

deficient Hart

when

fluency

1985,

al. (1989) mands.

concluded

Huber

aphasia

et al., mixed

1989; severity

traced

by Hart

(1988)

though,

in some

and

(i.e.,

it’s a fruit),

spatial

cuts

Murdock, to the

patients, AD

(1988)

1 short

Severa normative

tools.

For example,

versions

information

58 moderately

Teng

dementing

correlations

are presented

that

domain

have

and associates

(1989)

their

over

(4 weeks) performance

five

deless

distinction

of this deficit

has been

discrimination, Even

when

their

semantic

lexeme

and this, in each

(1990)

reviews

of the latter, class

to tag them

as Fischer

patient.

found

later.

patients

et al.

Working

a high degree

As providing

another

angle,

with difficulties

form of the Boston for experimental are applied four

(l-week version

groups.

15.item

interval)

an and

restricted

to

Naming

Test

purposes,

and

as routine

clinical

“mini-forms” sessions.

are reported,

of

visuo-

Becker

patients

ofone

in favor

reflected

ad ministered

with other

1990;

that this consistency

devrised

separate

is one of the

From

any of them

stability

The

& Carson,

the correct

on a short

been

task

patients

a part.

6 months

argued

of AD

scores

et

items,

identify

1989),

information.

before

patients

play and

and associates

is required

and test-retest

comparing

of BNT

also

retested

a subgroup

&

and Calev

but in all cases

the balance

of dementia

the authors

had normal

1991)

the source

& Chcncry,

were

depressives

to require

study.

(Gordon

in semantic

to produce

Henderson

patients

group

see

Robertson

to increased

first

presented

et al.,

ob,jccts

degree

a loss of lexical

discovered

been

dementia

may

able

related

in part from

more

form

not bc

Smith,

when

the visuoconstructive (BNT).

may

have

in tipping

to recognize

did not help pcrformancc,

arising

colleagues

be

impaired

consistency

anomia

still

et al. (1988) due

1990;

more

(but

& Chase,

believe

Hart

Though

confusion

able

be

Gomez,

both

or a failure

concord

rules

(1989)

no be-

(Table

of category

et al.,

Litvan

studied.

agnosia

(1989)

are

1989;

may

were

found

distinguish

demonstrated

Williams,

visually

primary

1987;

comparing

below.

to name

in

et al.,

perceptual

they

& Bub,

with moderately response

Miller

dementia

suggest,

Becker a visual

casts,

primary

an inability difficulties

reliably

task in the second

is considered

directly

may

by the

of this

membership

patients

Chazan

is taken

demanding

tasks

of dementia

to either

with

(1988)

to be the more

Huff,

might

distinctions

see Beatty

Paradoxically, fluency

can

conclusively

and

patients

the bipolar

et al. (1987)

dementia

(but

performed

bipolar

scores,

when

instead

to a recent

of group

Hart

Mohr,

Nigal,

performance

(anomia),

been

Beck

argued,

scores

primary

condition

categorical

observed

variably

(Chertkow

poor

not

Litvan,

Calcv,

findings).

that

fluency

but

effects

Lastly,

orthographic

1990;

the latter

and effortful

commonly

with

while

whereas

automatic

Nominal most with

is,

it is considered

between

that

for opposite

That

effort,

has

under

(1985)

vocabulary,

verbal

posited

status, and

relative

performance.

patients

et al.,

mental

Hamilton

the

AD

findings)

and

their

(1988) is gauged

affected

depressives

for receptive

whether

Kontiola

for opposite

Taylor,

early

by reference

As Willner

on cognitive matched

et al.

1987;

be more

horn state.

illustrated

DSMS-diagnosed

IQ

to disentangle

In all,

and

Hart

et al.,

1991, may

status

and dements

significant

judging

in order

FAS.

for age,

in a depressed

be made

be further

using

matched

However,

actually

can

associates

controls

the poorest.

kind

her

to

Parallel

but no data

321

Primary or Depress& Dementia

Though

its merits

dence

for BNT

1990).

Whereas

using

BNT

sensitive

in tracking

as a sensitive Storandt

and

Some

(1990)

63%

of their

some

confounding.

study,

not

questions

about

from

the meaning

concepts,

Though

BNT

testing

suggests

For

example,

drop

versions

in specificity

that letter,

or body-part

Breslau

(1989),

decrements tients

with

and associates and

both

were

depressives

visual

controls

BNT’s in AD.

about The

specific

enough

as a second-stage

confirm

the little

evidence

corrects

for intellectual

only limited Whereas gauge Test tients

with

(see

certain

recent,

and

how learning (RAVLT), whose

ing scores

tering, Coughlan

five trials.

the California

semantic and

cuing, Hollows

is on this.

past over was

raised

perhaps

RAVLT

published

Verbal (1984)

repeated about

Learning

other

recommended

As an index and

BNT

studies

not

be

required

naming,

and Warrington

a patient

can

other

tests

Rey’s

Auditory

involvement

memory, (CVLT)

to

which (1983);

organics

list to examine

word

and

to

Learning

by recording

help

from

possible

Verbal

in Delis’s

can further of such

remember

it is also

primacy-recency

and,

Comparing use

cognitive

may

are

of but

is available.

as a 15.word

the

the differ-

that in the context

that

devised

parameters.

performed

patients,

of clinical

functional

Test

deintact

it is well on the way,

indicate

what with

recognition

Whereas

mislabeled.

by McKenna

exposure.

specifically

impaired

test of confrontation

properties tell

PD

replication

A similar

patients,

been

can also be used to investigate

interference, and

but

to

dementing

suggests

as a result

on depression

thought Pearlson

This

once

no pa-

the study.

depressives

than

and

dementing

follow-up.

impaired

have

Emery reported

Cognitively

at

is obvious

experience,

doubts

subjects,

found

number,

patients

from

on BNT.

in scores.

can

whereas

AD

a slight

and

meagre.

depressive

better

though

Battery,

controls,

healthy

reducing to mild

not color,

is rather Aphasia

scores,

instrument,

but

excluded

would

a clinician

for example,

proactive

data

has been

tests

are

responses,

performance

naming

Western

somewhat

to dementia

remote

and other

prompted

(1989),

patients’

depression

similar

cases,

and

Henderson

dementing

on its psychometric

progresses

performance

over

below),

adaptation,

levels,

information

immediate,

there

that raises

measures

sensitive

examined

individuals early

“age-impaired”

more

depressives

organically

available

(1989)

this

appeared

expressly

due to a wide variance

is divided

earlier,

appreciably

to healthy

performing

certain

signifi-

sample

if psychometric

Unfortunately,

hand,

susceptibility

control

while

or object the

were

achieved

while

case assessment,

evidence

worst.

to be

were created

Hill’s

as efficient and

about

compared the

and

As mentioned

itemized

from

or impaired

not

Moreover,

heterogeneity

scale

on the other intact

and healthy

naming,

evidence

phenotype”

was not significant

of single

action,

fared

judged

poorly.

ence

the

(1989),

cognitively

pressives more

severity

a “dementia

Mack, (1983)

depressives

patterns perhaps

statistically

their

senescent,”

responses

Rosen

The

reported

while

and McAnulty’s

which

spontaneous

be just

on form,

a 60-item

in elderly

both

may

by Williams,

naming.

using

of mixed

present

to record

spontaneous

was evident

.47)

it not to be

AD.

the former

tested

=

hypometabolism

in Storandt

attention

et al.,

(w’

found

activation

amongst

“benign

size

like

group.

particular

of early

was evident.

impairment

mild,”

effect

(1989)

(outliers)

the evi-

Kontiola

Duffy,

respectively,

Gorp

AD

parietal

left cerebral

Moreover,

mild

will require

a clinician

now

time.

for all short

allows

the

right

and

obvious,

(e.g.,

et al. (1990)

As in Albert,

difficulties,

group

of “very

which

to be used in the identification the evidence

right

cases.

a questionable

Haxby

showed

and Van

in mild

be distinguished

borderline

Satz,

attenuation

identified

these

are

a substantial

regions.

and linguistic

Mitrushina,

small)

they

could

study,

with visuospatial

(but

patients

time

is disputed

reported

in left parietal

electrophysiological

cant

(1989)

over

dementia

of mild AD patients,

the rest were hypometabolic correlated

deterioration

of mild

Hill

as a discriminator

at all.

cognitive

detector

palearneffects

(1989)

latest

evaluate

clus-

depressives,

lists in differential

322

G. desRosiers

diagnosis

and,

RAVLT

to that

were

A few studies data,

between

Caltagirone poorest

and ate

RAVLT

group not

found

identified

differ

prodromal that,

because

test

subjects basis

the

should

diagnostic

or are just

RAVLT,

Litvan

learning

curves

assessment

revealed

head

injury,

Given

AD

The

from

B).

proactive list (trials

on the other explicitly

hand,

lists,

patients.

paired

on

steeper

learning

forgetting that

the

in controls

were

evident

loss

if using Pearlson showed

material

“lo-word”

that

a dementia

a mental

status

RAVLT

level

it is likely

et al. (1989)

at delayed

sequences

of a certain

and below,

recall, compared

of scores

such

trials,

on semantic 13 AD

scores

at first

and

from

noted

Wolfe

trial

to trial limbic

and

intake

significant ventricular

unlike

could with

but brain

(e.g.,

28 DSM3 were (VBR)

hedonic

in both

a in

suggested degree

suggested

of the

reviewed

in depressives tone).

depressives, 2 years

in

detected

evidence

promoted

reported

than

no differences

to a noted

other

and

to be unim-

(1987) but

in the organics,

not at follow-up ratio

be greater

had previously

From

associations

not been

of “span-length”-

patients

due

be further

connotations

has

Parkinson,

colleagues

was

of in

Depressives,

this

might

(1983)

be

learned

the next list.

depressives

perhaps

might

the learning

material

the learning

her

Mungas

patients

in neuropsychol-

after

depressed

to unipolar

which,

issue

Although,

during

organization.

compared Highly

closed curve.

and hippocampal

from

and depressives

clustering

capitalized

scale.

with

learning

by Dannenbaum,

(1990)

recall.

of subjective that

in

stringent

distinguishes

(i.e.,

recalling

study

in functionals across

syndrome

when

subjects

associates

RAVLT

curve

in recall

operations

on

immediate

minimal

consistency above

in healthy and

effects

the hypothesis

of RAVLT

to interference.

procedure

list intrusions

scores

this

a Brown-Peterson

debated

less interference

a recent

While

to patients

on

similar

ceiling

a flat

step to an

curves

A more

that what

to investigate

trial

be apparent subject

RAVLT,

Beatty

way

is impaired,

be more

with

using

suggests

AD

that

version,

the amygdala

a vigorously

One

on the sixth

1 to 5) should

might

investigated (1988),

1987).

interference

point

displayed

of improvement

contention

on the next

forgetting.

still remains

Parkin,

If it is consolidation

the previous

Inman

1988;

(1987)

lack

“at-risk”

learning

sequence.

showed

multiple-

the

scores

and controls

contrary

target

this

exaggerated

that,

their

Scale),

Examining

in

who surmised

in these

low memory

did

were

be identified

Rating

subjects

to first

Squire’s

hypothesis

Mayes,

to evaluate

is thought

is their

consolidation

ogy (e.g., List

others

AD

consolidation,

supports

can

an eight-word

they

from

samples

the control

instrument

(1989),

affected

in the testing

(1989)

in early-stage

memory

effects

used early

esti-

immedi-

of their

perhaps

to be

differences.

and colleagues

scores

with

with no primacy amnesics

to Bigler

as they

Again,

on Rey’s

be extracted

such

scores patients

Interestingly,

and Hill

that AD patients

operating

neuropathology

associated

whether

AD

premorbid

scale.

that

Dementia

of individual

already

scores

at-risk

Clinical

commented

however,

were

RAVLT

that

fields

the results

(slopes),

groups

(e.g.,

Their

could

such

and

status

possibility

patterns AD

mild

in a subsample

appeared

Since

follow-ups

et al. (1991)

the healthy

variate

on

normative

administered,

discriminators.

by Storandt

function

criteria through

the

elderly

against

compared

education,

acute

tests.

is painted

patients.

sex,

measure

raising

canonical

(1989)

on a mental

most

cognitive

psychological

be to establish

AD process

of the

picture

AD

age,

the

Contrasting

patients

of all the tests

range

patients,

one unimodal

same

as in the mild

of other

that, for

for

of AD on memory.

a sensitive

on other

of AD

A similar

only

results,

one

to be

norms

(1990).

and Parkinson

and colleagues

matched

was

RAVLT

those

stages.

AD

in the nonimpaired

as outliers

from

the effects

discovered

controls

age-specific

and associates

dementing

Mitrushina

performance

also

complete

to chart

et al. (1989)

on RAVLT.

and all scoring

authors

most

by Ivnik

mildly

“well-functioning”

mates,

the

published

used RAVLT

of impairment were

end,

recently

Finally,

17 of whom later

as gauged

between dements

initial and

the

323

Primary or Depressive Dementia

latter depressives. follow-up RAVLT

Trial by trial scores were not detailed, however, and neither were scores reported, which might have shed more light on state effects.

The importance of this point is underscored in a recent report by Kral and Emery (1989), in which 39 out of 44 patients originally diagnosed with depressive dementia subsequently recovered on the same mental status scale but, when followed-up for an average of 8 years, went on to develop AD. The practice of testing people’s ability to associate two given words began with Mary Calkins’ (1894) experiments, though the concept of free word association was known to clinicians of the time. It wasn’t until the middle of this century that the technique of paired associate learning (PAL) was applied to investigate memory disorders in dementia. Today researchers are agreed that it is “obviously valuable for the differentiation of organic dementia and nonorganic mental disorders, e.g., depression” (Johansen, Gustafson, & Risberg, 1985, p. 62). Two of the most popular versions of PAL are those of and numerous studies have been published applyInglis (IPAL) and Wechsler (WPAL), ing either test as a marker of cognitive functioning (Table 1). Because organic patients in his earlier studies appeared most impaired in their memory function, Inglis (1959) undertook to investigate IPAL’s specificity by comparing functional and organic samples on different parameters, such as retention vs. acquisition, easy vs. hard associates, etc. Expectedly, dementing patients had considerable difficulty learning new (hard) pairs (e.g., Sponge-Trumpet). Functionals were also impaired on this task, whereas there were no differences on old (easy) pairs (e.g., East-West). Interestingly, differentiated on mediate pairs involving semantic relations (e.g.,

the groups were well Cat-Milk). Consider-

able overlap between depressives and dements seems to be the rule when difficult associates are used exclusively (La Rue, D’Elia, Spar, Clark, & Jarvik, 1986). Mediate pairs, on the other hand, may fare better (Whitehead, 1973) while still closely reflecting levels of self-care, activities of daily living, mental status, and survival (Little, Hemsley, & Volans, 1987; McLaren, Barry, Gamsu, & McPherson, 1986). Recently, Kopelman (1986) discovered that people with Alzheimer’s disease are impaired even on very easy pairs. This suggests that with a number of less demanding items, easy and mediate associates could improve the chances of discrimination, particularly if the material selected to covary in such a way (e.g., inherent organization by semantic category) as foster deeper processing in depressed patients. Despite innumerable statistical reports using WPAL as a cognitive correlate, not single study could be found that provided enough information to be included in Table

is to a 1.

This may be traced to insufficient normative data on this test, though recently more extensive information was provided with 1,100 (age 20-79) patients hospitalized for other than neuropsychiatric conditions (desRosiers & Ivison, 1988). In brief, distribution of the data for each age band conformed to a normal curve, so that the norms provided proved robust enough to allow individual assessment using the aforementioned techniques. Test-retest reliabilities for form 1 (.82) and form 2 (.80) proved adequate, as did their intercorrelation (.75). Factor analyses revealed form 1 to comprise three factors clearly corresponding to easy (e.g., Up-Down), mediate (e.g., Rose-Flower), and hard (e.g., Obey-Inch) associates. An interesting observation was the tendency for scores on the easy and mediate items to be lower on form 2. Using semantic word norms, analyses of the verbal attributes commonly found to affect paired associate performance pointed at these pairs being rated as less pleasant in general. The point was made that this bias could possibly affect depressives, but in the opposite direction. Studies using both forms in depressed (Fromm & Schopflocher, 1984) and dementing (Margolis, Dunn, & Taylor, 1985) patients do not provide enough details to verify this suggestion. As in IPAL, studies reporting total WPAL scores show AD patients

to be quite im-

324

G. desRosiers

paired (Eslinger

et al., 1985; Litvan et al., 1991). While differences

are most marked on

hard items (Gordon & Carson, 1990; Huber et al., 1989), other studies note significant difficulties on easy associations as well (Becker et al., 1988; Rosen, 1983; Storandt & Hill, 1989). The evidence concerning depression is less consistent with some research reporting decrements (Stromgren, 1977), while others do not report decrements (Breslow, Kocsis, & Belkin, 1980; Fromm & Schopflocher, 1984; Williams, Little, States, & Blockman, 1987). Working with depressed AD subjects, Breen, Larson, Reifler, Vitaliano, and Lawrence (1984) failed to find any effects of depression on performance, as have Lopez, Boller, Becker, Miller, and Reynolds, (1990) with IPAL. Because neither study detailed results for easy and hard pairs separately, it is not clear to what extent floor effects were operating. In all, PAL appears suitable to discriminate elderly persons with and without dementia, but some misclassifications do occur when depression is suspected, particularly if decisions are based on results with hard associates. Better specificity might be achieved when easier pairs are also considered, since floor and ceiling effects are less of a risk (e.g., Hartman, 1991). Using pairs involving semantic relationships based on hedonic connotations (e.g., Old-Wise; Idle-Bored) could promote organized encoding and retrieval in depression (desRosiers & Robinson, in press; McDaniel, Einstein, & Lollis, 1988). Manipulations of this kind, as Weingartner (1986) summed up, appear to offer room for improving distinctions between depressives and dementing patients. The relationship between task demands and group membership is further examined below in the context of selectivity and automatic Nonverbal

vs. effortful processing.

Functions

In practically every visuoperceptual test, depressives are found to outperform dementing patients. Statistically significant differences have been recorded on the Benton Visual Retention Test (Crookes & McDonald, 1972), Memory for Designs (Johansen et al., 1985), Symbol Digits Modalities Test (Watson et al., 1978), Bender-Gestalt Visuomotor Test (Inglis, Shapiro, & Post, 1956), Purdue Pegboard Test (Taylor, Redfield, & Abrams, 1981), Complex Figure Test (King, 1981), Hooper Visual Organization Test (Taylor et al., 1981), WAIS Performance Scale (Mazzucchi, Capitoni, Poletti, Posteraro, Bocelli, & Campani, 1987) and Wechsler’s Visual Retention Test (Hart et al., 1987), but in every case not enough details such information is particularly are also known to fare worse than 1984; Kluger & Goldberg, 1990;

are available to be included in Table 1. The need for important in this kind of test, since depressed patients healthy subjects on all of them (Fromm & Schopflocher, Niederehe, 1986).

When enough details are available, such as in La Rue et al.‘s (1986) study using the Benton Visual Retention Test, a majority of elderly depressives cannot be reliably distinguished from AD patients. In a more recent study (Rossi, Stratta, Nistico, Sabatini, Di Michele, & Casacchia, 1990), their performance on the Complex Figure Test was quite poor despite their intact scores on a sensitive mental status scale. The consistency of these findings suggests that depressed patients experience disturbances in posterior nondominant regions known to subserve perceptual functions. An alternative account might draw on the fact that visuospatial tasks are much more dependent on synthetical processing than verbal tasks and so may be more difficult to execute because of their greater susceptibility to disruptions in attentional functions. This interpretation is consistent with evidence suggesting that right frontal mechanisms are particularly important in attentional processes during visuospatial tasks (Deutsch, Papanicolou, Bourbon, & Eisenberg, 1987; Heilman, Bowers, Valenstein, &Watson, 1986), and with neurophysiological findings suggesting right frontal disruptions in depression (Depue, 1988). If diffi-

Primary or Depressive Dementia

culties

in visuoperceptual

damage with

to posterior

depressives

Drawing CDT

been

recent

have

and

however,

AD

patients with

Shuttleworth

depressives

who

related

easy tests:

had

Copying

Test:

DCT).

on the basis

dementia.

Drawing

excitation network

mised

but,

should

of diagnosis.

whereas

weeks

Some al.,

in tandem with

have

with

cases.

In

Bernstein study

an

(1988)

with

27

details

mildly

dementing

early

Wright, on

found dements were

50 and

Morris,

Grenden,

‘It should

be noted

trend

results

either

and

Ballinger

and OLT,

but

healthy,

depressed,

and

differences depressives

to permit

all tend Heald,

that the formal

Levy,

procedure

for

but

(Abas

for KCTE

scores

DCT,

and

would

readministered

have using

6

100%

KCTE.

initial

Knight

is to evaluate

et

finding,

or

sensitivity severe

in all

Portalska

and

A replication though

Incidental

predictions

Fish,

(Davies

it on its own

elderly, on

1990;

not

was deemed

comparisons. 1988).

on

reported

all groups

& Philpot,

or less

et al.,

others

dementing

Kendrick’s

scores

more

remain

be

studies

the

can result OLT

less practical.

(1988)

confirmed

only is comproand

not

test

dementia

individual

to support

but the

from

that corti-

lead to low OLT

in depression 1973),

DCT

was organic

hypothalamic-

performance

should

somewhat

on DCT

23

provided

that

from

the

the latter

task

(KCTE)

suggested and

that

would

details

two relatively

Elderly

Kendrick

in OLT,

KCTE

Though

depression

DCT

system

Whitehead,

Findlay,

the

impaired

requirement

renders

DCT

significant

patients

Sahakian,

arousal

the above

for

predicted

improvement The

1986;

patients

article

enough

confirmed

SLT.’

it was

MPAT,

AD patients

and a sensorimotor

In depression,

excitation,

(87% scores,

of dementia

Using

to combine

system

In depression,

assessment

1 displays

27 dementing

of arousal, activating

dementia.

& Haynes,

Table

accounts

basis,

of depression.

Marcus,

1978).

this

Tests

reticular dementia.

range

scale.

a

specific.

OLT)

for distinguishing

in overall

treat ment,

the initial

reports

the

in the second

With

a diagnosis

Hayslip,

On

disruption

following

rationale

level

in primary

“pseudodementia.” confirm

Cognitive

in primary

a certain

be affected

intact

Kendrick’s

first

status

of early

status

h as been

recorded

of the

are drawn.

discrimination

Test:

a

subjects.

21 depressive

mental

in the moderate

(1985)

and

91

their

the test was quite

Learning

by both

deteriorates

if below

irrespective

by Kendrick

on contemporary

classified

on a mental

suggest

task (Object

of a simple

mediated

limbic

as impaired

105 AD

conclusions

of

to be

detected

depressed

et al. (1989)

from

signs

the test for individual

Sunderland

at least before

to elicit (1986)

and

to standardize

properly

of

as the Clock

no depressives

Raskin

healthy

an excellent

errors

adopted

assembled cal

scored

memory

were

reported

reversal”

Judging

such

means

found

Comparing

(1989)

is needed

standard

strategy

a pictorial

on the test.

studies

cases

(1989)

the small

efforts

and controls,

associates

tasks

because

discrimination

(MPAT).

(1964)

between

arise

deficits,

as an informal

(97 % specificity).

in both milder

and Huber

are not tabled,

(Digit

her

Test

of “clock

on their

patients

perceptual

Friedman

in a test

specificity

and

easier

difference

AD

attentional

Anomalies

by

now reported

and 20 of the latter

and replication

One

though

96%

from

for decades

report

with AD patients

Wolf-Klein

sensitivity)

by using

significant,

Working

patients,

from

drawing,

studies

sensitivity

early

by early

than

Picture

by clinicians An

statistically

assessment. 77%

used

at clock but

rather

or the McGill

dysfunction.

small,

experienced

regions

be enhanced

(CDT)

has

impaired Two

might

Test

parietal

functions

cortical

325

not

reports

on

(Kopelman,

1989;

and Moroney

(1985)

performance

from the

pattern given by OLT and DCT in tandem. For analytical purposes, tests are detailed when reported as such in the literature. Classification

results on individual sub(0: depressed; 1: organic)

for the 6 weeks’ repeat

(0 -

1 -

0 = 0; 1 -

1 =

scores 1).

was as follows (test

-

retest

= score):

0 = 0; 0 -

1 = 1;

326

compared

G. desRosiers

healthy subjects with unambiguous

cases of depression

and primary dementia.

Whilst DCT was poorest in the latter group and did not differ in the first two, whether at initial or retest sessions, false positives were most reduced when OLT was readministered at 6-week follow-up. The comment was made that certain patterns on OLT and DCT occasionally occurred for which no classifications were specified in the manual. One comment on Knight and Moroney’s study is that the validity of KCTE should best be examined in patients for whom diagnosis is still ambiguous (desRosiers, Berrios, & Hodges, in preparation). Fish and collaborators as defined on a mental appreciably from those

(1986)

looked at depression

within a sample of organic

status scale. Means for nonorganic depressives of healthy elderly but were significantly better

elderly

did not differ than those of

organics. Importantly, attenuations for OLT (1st & 2nd testing) were particularly pronounced in the depressed organic group. As in nonorganic depressives, DCT scores were initially affected by depression but not at the second interview, supporting Kendrick’s contention that DCT should recover after treatment. Working with NART-matched early AD patients and memory-impaired depressives who, at an average follow-up of 2 years, were judged to have recovered with no signs of dementia. Abas and colleagues (1990) noted that depressives’ initial low scores on OLT had reached those of controls at retest. Consistent with Kendrick’s belief, the time depressed patients took to complete DGT was even slower than in AD subjects. However, depressives were still slow at follow-up, and more ominously, the significant correlation between VBR and slow times on DCT at initial testing was even increased at retest, prompting the authors to consider whether some of these patients will develop AD sometime later. As modifications of OLT were introduced in the latest version, further studies are required to confirm its validity. Alternate forms are presented for OLT with good reliability. DCT and OLT did not correlate significantly in healthy controls (.18) at initial testing, but did so in depressed (.30) and dements (.53). This would suggest that in the case of depressive dementia, some impairment seen on OLT will also be registered as lower DCT scores, though not as extensively as in primary dementia. A remark by Hart (1988) cautions that confrontation naming, probably involved in performing on OLT, may be impaired in primary dementia. Failure on OLT may not necessarily always reflect episodic memory deficits as such; but, since naming

may not be a problem

in depression,

discrimination

should not be

adversely affected.

Retention Some 50 years ago it was suggested that what distinguished patients with organic dementia was their inordinate forgetting of newly acquired information, whereas depressives, though also poor at learning, still managed to retain reasonably well the little they had registered (Zangwill, 1943). In a recent study using the Wechsler Memory Scale (WMS) in patients with lateralized posterior and anterior lesions, Chlopan, Hagen, and Russell (1990) witnessed the greatest loss from immediate scores when delayed Logical Memory (DLM) and delayed Visual Retention (DVR) scores were recorded in those with left and right posterior damage, respectively. Cognitively impaired depressives, if asked to immediately recall a short narrative, verbal paired associates, or nonverbal stimuli, may sometimes be indistinguishable from primary dementing patients (e.g., Kopelman, 1986). But, like patients with “subcortical” dementia (e.g., Huntington’s disease), depressives do not appear overly prone to forget when required to recall after a delay (Cronholm & Ottosson, 1961; Steif, Sackeim, Portnoy, Decina, & Malitz, 1986; Sternberg & Jarvik, 1976; Stromgren, 1977). Unlike depressives, even mild “cortical” AD patients tend to

Primary or Depressive Dementia

exhibit

an out-of-proportion

loss of material

327

on delayed recall measures

(Bracco,

Ama-

ducci, Pedone, Bino, Lazzaro, & Cavella, 1990; Caltagirone et al., 1989; Hodges et al., 1990). Frisk and Mimer (1990) recently determined the crucial role of left hippocampal structures in this process with verbal material; structures that are most prone to AD pathology in its earliest stage. Huppert and Kopelman (1989) found a normal rate of forgetting over long periods in Alzheimer’s disease. Accordingly, they felt memory deficits in AD are not due to inordinate forgetting,

but to difficulties

in acquisition.

Because

it is possible,

after a 5-minute

delay, to cue AD patients with stem fragments to levels equal to that of controls (Morris, Wheatley, & Britton, 1983), it perhaps is not wholly accurate to characterize their impairment as solely one of acquisition. Objections to their procedural strategy have also been voiced by a number of authors. According to Mayes (1988), item-to-test delay, that is, total time intervening between the learning of any item in a list and its testing, may be much longer for those needing extra exposure time to learn. The matching success suggests the patients were in fact forgetting less than the controls. The discrepancy is also obvious when young healthy subjects equated with older people go on to perform worse than their seniors on delayed recall (Becker, Boller, Saxton, & McGonigle-Gibson, 1987). Finally, other researchers failed to replicate Huppert and Kopelman’s findings altogether (Hart et al., 1987). Recording a 30-minute delayed recall on a truncated RAVLT, Litvan and associates (1991) noted a significantly poorer retention in mild AD patients (15%) compared to controls (69%) and patients with Parkinson’s disease (55%) matched for dementia severity. Knopman and Ryberg (1989) used a lo-word delayed recall task similar in format to AVLT to isolate 28 mildly dementing subjects from 55 elderly controls. With a cut-off criterion of three or more words recalled after a 5-minute delay, 98% of controls (specificity) and 89% of clinicals (sensitivity) were correctly classified, but no measure of forgetting was calculated. Brinkman and colleagues (1983) reported a 75 % retention on DLM and 77 % on DVR in controls against AD patients’ retention of 24% and 38%) respectively, but no mention was made of the severity of their dementia and depressed subjects were excluded. Becker et al. (1987), using a short narrative, found an 87% retention in healthy controls but only 45 % in PD patients when tested 30 minutes after initial intake. Interestingly, no such decrement was found with visuoperceptual tasks, suggesting that patients with left hemisphere vulnerability may have been predominant in that sample. For example, though equal to controls in their copying scores on Wechsler’s Visual Retention Test, Hodges et al. (1990) f ound a high loss on DVR in mild AD subjects, while similarly poor DVR results in Haxby et al.‘s (1990) comparable patients apparently were linked to right-hemisphere hypoactivation, a phenomenon also noted in Albert et al.‘s (1990) EEG study. In depression, Williams, Iacono, Remick, and Greenwood (1990) noted no difference between depressed and control subjects on DLM, but delayed recall was elicited after only 5 minutes. Beatty et al. (1990) reported a 90% retention in controls and 83% in depressives using a 30-minute delay on a RAVLT-like measure. Goulet-Fisher, Sweet, and Pfaelzer-Smith (1986) reported decrements on DVR, but not DLM. Though no measure of forgetting was reported, a rough computation of their results suggests that retention with DLM and DVR for controls (80 % + ) and depressives (75 % + ) appeared comparable. Few studies have explicitly compared forgetting in depressives and dementing patients. Using the Williams Delayed Recall Test, in which pictures of common objects serve as stimuli, Knight and Moroney (1985) se p arated depressed from AD patients after a lominute delay with 84% sensitivity and 98% specificity. Contrary to stimuli in Becker et al.‘s (1987) study, items in Williams’ test appear more readily labelled verbally. Also,

328

G. desRosiers

ambiguous

cases

had been

in patients

diagnosed

neither

=

(n

67).

small

(n

with

=

those

in elderly

Moreover, always

parallel

of Whitehead

(1973),

the same 8 out

Kopelman recall,

was used

cut-off

with

depressives

and out

mer,

during

scores

across

recent

analysis

appeared

ac h‘teved

topped

Mungas

(1983)

when

20%

items

independent

loss on AVLT

in these

delayed

recall

may

Though

there

are

who

question

.

of mitral

may

not

suggested

have

that,

performance

of 50%

reten-

et al. (1988),

using

or may

not

may

It must

be a misno-

be the same

as those

in comparing

equated

to a large

for

on this kind of measure

forgetting

initial

extent,

and

between

as the criterion.

measures

problems

been

16 %

specilic-

discrimination

was applied

scores

but only

but lower

7 out of 7 AD patients

a perfect

recall.

groups

this

reported

or “forgetting”

(MMPI), consistent

a criterion

classified

that

was quite

nonetheless

Dannenbaum

correctly

65) or

of self-report

(.94)

when

DLM =

beyond

43 % in dements

for both

(n

dementia

are

sensitivity

during

immediate

diagnostic

reached

both

on retention

results

good

examined

68),

on the basis

two groups.

and

=

degenerative

These

100%

these task,

“retention”

of

forgetting

learning

as remembered

retrieved

where (1986)

(1986)

(n

no effects

with

was diagnosed status.

but

and Russell

depressed

to exert

a serial

amnesics that

Gass 70),

clinical

to separate

of 9 depressives,

be pointed

=

size for those

depression

on immediate

on DLM

(n

reported

sample

not

depressed.

ity (.69) tion

was

However,

7).

may

left out.

as organics

Depression

due to organicity. which

deliberately

either

learning,

a

rates

of forgetting

(Bogartz,

1990).

Primary-Recency Miller

(1977)

recall that

items were range

findings

younger for

both

depression overall.

patients nature

not

It is not clear ambiguous

mechanism

present

for

score

been

for individual

instruments

like CVLT

tion of Gibson’s is that

dementia

so that

it is still

Newer

evidence

Eslinger, other primacy

findings

1989;

recent

that

Poitrenaud,

report

patients

whether

suggests (Bigler

would

readily

be carried

out.

primacy Moy,

et al.,

Girousse, 1989),

be less

can

Wolmark,

early-stage

AD

in pri-

studies,

in controls

is responsible

index

this

have yet

well-normalized

an investigation,

to severe

use

above,

techniques that

that will need

verifica-

to be considered

or not documented,

be expected

affected

poor

still be put to good

forgetting

to such

factor

Mungas

in later than

&

found

curve

found

As

Given

moderate

findings

may

the

and

transfer)

could

respect.

lend

One

was either

the same

retrieval,

(Harris

position

lower

a

Miller’s

et al. (1986)

(1981)

a

across

1985).

serial

to

is usually

materials

in that no formal

in this

item

examined,

it was

asked

for items

observed

O’Hara

dementia.

that

Unlike

measure

assessment

various

Gibson

the finding

assessment.

and AVLT

in the above unclear

save

when

& Cook,

were

groups,

storage,

but

an been

U-shaped

in primary

curve

is still a qualitative

should

normal

(e.g.,

since

using

depressives

in dementia,

kind of differential standardized

of the

has

In contrast,

the two

loss

decrement

of recalling

replicated

material

shape

increased a modest

Kendrick,

1981).

elderly

pictorial

split

cases

been

& Fox,

when

an only

that

Sands,

an essentially

the

what

but

probability

Comparing

and

alter

for the primacy-recency when

have

Wilson,

patients.

verbal

did

The Santiago,

demonstrated

depressed

showed

a phenomenon

(Wright,

of this

patients

(recency).

Kaszniak,

had earlier

AD

in a list (primacy),

in the list,

dementing

1982;

discrepancy

(1983) macy

last

of species

with

that

early

of its position

Dowson, no

reported

presented

function wide

first

appearing

in very

in these

patients

& Piette,

1989)

patients

showed

mild

cases.

(Pepin

though,

&

in an-

no significant

effects.

Remote Memory There

is evidence

past “everyday

to suggest

or real world

that

AD

knowledge”

patients (Roth

have

difficulties

& Hopkins,

with

1953).

material

In pure

bearing amnesia

on (i.e.,

Primary or Depressive Dementia

329

not dementing) impairment progressively encroaches on episodic learning (anterograde amnesia), but leaves retrieval of old semantic material more intact, thus creating a temporal gradient (Squire, Haist & Shimamura, 1989). By contrast, remote memory in primary dementia may produce a flatter curve over the decades covered by the test. Assuming pathology in depression does not involve an extensive retrograde process, their “memory curve” should also reflect a temporal gradient. Remote memory is commonly assessed with instruments like the Public Events Test (e.g., Squire et al., 1989) or the Famous People Test (e.g., Huber et al., 1989), in which patients are asked to recall/recognize different items that were prominent at different periods in the past. As Lezak (1983) notes, the need to monitor long-term memory over extensive periods means that assessment tools must be constantly upgraded and so, psychometrically, existing measures are often less than optimally standardized. In addition to these instruments, others have also been developed to probe knowledge of facts about one’s personal past (e.g., former addresses) and are usually referred to as autobiographical memory tests. Like the former, these measures are also assumed general, there may be a tendency

to be sensitive to progressive anterograde amnesia. In for a primacy-recency curve in performance of healthy

subjects, most noticeable on free recall and least on recognition (Beatty, Salmon, Butters, Heindel, & Granholm, 1988; Squire et al., 1989). Wilson, Kaszniak, and Fox (1981) assembled several of these instruments to compare patients with Alzheimer’s disease and healthy controls. In the outcome, a flat curve indicated that AD patients’ knowledge of world facts was equally poor for the five preceding decades. In contrast, Moscovitch (1982) witnessed a relatively intact performance in mild dementia for all periods save the immediately preceding decade, when perhaps anterograde amnesia had already begun to operate. Later still, Sagar and associates (1988) found a mild gradient in recall with a sparing of the most remote content relative to recent material. Beatty et al. (1988), reported similar results using an updated version of the Famous People Test. Dall’ Ora et al. (1989) f ound a general decrement in autobiographical memories but failed to replicate the expected temporal gradient in AD subjects with remote memory tests. Similarly, Kopelman (1989) assessed both autobiographical and remote memory in healthy, Korsakoff and AD subjects. In both recall and recognition of news events, a negligible temporal gradient emerged in AD with relative preservation of distant memories. This pattern was also typical for autobiographical memories. Controls for their part tended to show a much steeper curve. Frith and collaborators (1983) a d ministered a personality name test to depressives before and after treatment. Pretreatment, there was a significant attenuation compared to controls, which that disappeared at 6-month follow-up. No details were recorded for separate decades. Calev, Ben-Tzvi et al. (1989), using both a remote events test and an autobiographical measure, found little retrograde impairment in depressed patients being treated with antidepressants. No details for separate decades were provided. Pitting depressives and dementing patients on free or cued recall and recognition, Niederehe (1986) replicated earlier results for AD subjects while elderly depressives were unaffected. Again, there was no attempt to analyse performance by decades. Beside general difficulties in constructing a valid test of remote memory (e.g., difficulty of items across periods, degree of public rehearsal), specific problems must also be addressed. For example, there is an assumption of equal exposure to information across individuals. Also, one may be uncertain as to whether the information retrieved was stored at the time an event occurred or later, so temporal gradients could be confounded. With autobiographical memories, the danger always exists that some confabulation could contaminate the results, particularly when no corroborating independent source can be secured. This could be practically impossible to achieve when early memories are involved. Kopelman (1987), for example,

330

G. desRosiers

reports that ‘provoked’ confabulation (in response to memory questions) was observed in 44% of his patients with Alzheimer’s disease but it is not clear how severely demented they were. There is some evidence that confabulation in early primary dementia may not be so prominent (Kawai, Miyamoto, & Miyamoto, 1989), but more information is needed on this point. Newer remote memory tests have begun to address these issues and it should be possible in the near future to validly compare groups.

performance

between the two

Given that a task’s intrinsic demands may largely determine effort deployed in performance (Earle, 1988; Mulder, 1986), retrieval by recognition has often been viewed as less taxing of resources than other procedures. Motivational factors play an important role in the disruption of attentional mechanisms in depression (‘Johnson & Magaro, 1987; Mayes, 1988). The prospect of enhancing group separation along this line is appealing because of the relative acceptability of recognition tasks to older people and the number of parameters that can be derived from one test (e.g., response style, sensitivity, selective processing). As an example of its utility, Storandt and Hill (1989) recently administered a recognition trial on Wechsler’s Associate Learning subtest following the usual cued recall procedure. Controls outperformed mild AD patients, matched on so~iodemographits, for recall of easy (w’ = .41) and hard (w’ = .47) associates, but discrimination virtually vanished on recognition of easy pairs (w” = .OS). Significantly, separation of the two groups was greater (w2 = .54) for recognition of hard pairs. Using the Benton Facial Recognition Test (BFRT), a measure with non-easily named stimuli, Haxby et al. (1990) could only distinguish moderately dementing patients from controfs, a limitation previously reported by Huff, Becker et al. (1987). Wilson, Kaszniak, Bacon, Fox, and Kelley (1982) found that BFRT had good sensitivity (.90) and excellent specificity (1 ,O> with matched controls and AD patients. As the test is particularly sensitive to right hemisphere dysfunction, this disparity between studies may reflect group heterogeneity. Depressives also displayed some problems on immediate facial recognition measures, but performed as well as matched controls on delayed testing prior to treatment (Steif et al., 1986). Raskin (1986) reported similar results for immediate performance, confirming that delayed performance offers greater chances of discrimination. Another measure that covers both facial (FRT) and verbal (VRT) recognition is the Warrington Recognition Memory Test (WRMT). B ecause sub~jects are asked to judge each test item for pleasantness during the presentation phase, encoding at deeper levels is encouraged and inattention alleviated. In their attempt to separate AD patients from controls on a number of tests, Gordon and Carson (1990) found both subtests of WRMT to be among the best discriminators, though their clinical sample was quite mixed with respect to dementia severity, Kopelman (1989) compared healthy elderly and AD subjects. Judged against Diesfeldt and Vink’s (1989) norms for the elderly (60-93 years), it appears patients, but not controls, obtained quite low scores on both subtests. Coughlan and Hollows (1984) reported on depressives and neurological patients (age 18-60 years) matched for estimated premorbid IQ. Some 9 1% of depressives were successful on VRT and 98% scored intact on FRT, suggesting WRMT’s potential as a second-stage tool. With unstandardized tools, primary dementia is generally found to affect accuracy though the evidence is less consistent for depression. Wilson et al. (1982) reported that sensitivity on a facial recognition task was significantly lowered in AD subjects compared to controls, but no systematic deviation in response criteria (0) was observed. Table 2 shows that for photographs (Hart, Smith, 8r Swash, 1985), meaningful pictorials (Hart et

(1973)

Huppert & Kopelman (1939)

Wolfe, Granholm, Buttess, Saunders, & Janowksy (1987) Snodgrass, Cotwin (1988) Tables 5 & 7

Watts, Morris, & MacLeod (1987)

Grober tyr Buschke (1987)

Niederehe & Camp (1985) Figure 1

Hart, Smith, & Swash (1985) Tables 2 & 3 ‘w 2

Miller (1977) Wallach, Riege, & Cohen (1980) Zuroff, Golassy, & Wid@s (1983) Table 2 Dunbar & Lishman (1384) Tables 2 & 3

Whitehead

Reference Tables & Figures

Procedure

Words Presented Individually; Z-Minute Delayed Test; Sum of 3 Payoff Conditions; 30-Minute Delayed Test* Exposure .5s (Controls), 7s (AD); ‘10 Minute (e 24 Hour) Delayed Test

Measure (No. &Targets)

Pictorial (40)

.74 .53

.71 .80 .61 “96

Verbal Silent (Total: Hgh Imagery (90) Low Imagery (90) Pictorial (50)*

180)

“94

AVLT (15)

.93 .80 .82

Naming (16)

.78 .86 .69

.89 .93 .94 .92

.86 .69 “56 .70 .81 59 .6G .58 “73 .65

Verbal Vocal (60) Verbal Silent (60)

Pictorial

Verbal Silent (Total: 24) High Imagery (12) Low Imagery (12)

Verbal Silent (36) Nonverbal (Total: 48) Easy to Label (24)* Hard to Label (24)e

Geometrical (56) Verbal Vocal (16) 8 Neutral 8 Emotional Verbal (Total: 40) Positive (20) Negative (20) Verbal Silent (Total: 36) Neutral (12) Positive (12) Negative (12)

.13* ,130

.23 .16 .30 .04

.02

.O& .14

.02

.09 .08 .li

.04 .12 .07 .18

.15 .23 .14 .12 .14 .Oi .30 .26 .28 .36

(HIT)

,92

.73 .65

.67 .73 .62

Age: 63-96.

.74 .57

.8&

.26 .35

.33

N = 40 (34% Dementing Age: 65 +

Patients)

IO Undergraduates in Verbal Task. 101 Undergraduates in Pictorial Task and 11 Dementia (Alzheimer) Age: 55-79.

N = 40 (50% DSM3 Depressed) Matched IQ.

N = 50 (25 Controls);

N = 57 (351% Depressives) Screened on BDI and Mental Status Scale; Age: 58-88,

12 Controls (Mean Age: 72) and 8 Dementing Patients (Mean Age: 69) Matched for Education; NART Scores Higher in Controls.

.Q5

.12

Age: 60f

20 per Group. Age: 65-F ; Psych. Diag. Young Adults (18-32 years) Elderly (58-72 years) 39 Undergraduate Women; 15 BDI Depressed; 33 Formerly Depressed Scored Like Current Depressives. N = 60 Matched For Sex, Age (X = 41) and IQ; 30 Depressives With Psychiatric Diagnosis.

N = 46 (26 Depressed);

N = 60 (60% Depressives Self-Report?) Matched On Verbal IQ & Education.

xi1

.27 ,28 .26 .3Q

.28

.08

Comment Demographics & Diagnosis

.I6 .08

.05 .05 .05

.14 23 .05 .27 .21 .26 .36

.76 .83 .7O .59 .51 .54 .73 .87 -79 .79 .79

.47

.09

.69

.95

A0

Dementia HIT FA

and False Alarms (FA)

.OO

Depression HIT FA

Identification

Controls HIT FA

Studies With Target

Verbal Silent ( 16)

2. Recent Recognition

Auditory & Visual Presentation Recurring Items Paradigm Auditory Presentation 2-Haur Delay Test Words presented for Attribute Rating; I-day Delayed Test; Mixed List (?) Words Presented Individually on Cards; Items not Controlled For Valence Intensity; SO-Minute Delayed Test Items presented individually on Cards in Recurring Item Paradigm; + Objects & Shapes; “Photographs & Histology Slides Wards Presented Individually; Immediate Testing; First Trial Results Only. Recognition of individual Words Words Presented Individually on Cards; 4-Minute Delayed Test Mean of 6 Consecutive Trials

TABLE

al.,

1985;

Snodgrass

sensitivity creased.

SO (Cutting, compared

elderly

recovery and spatial

tests.

on the pattern

observed,

caution

process

being

needed

must

that

to clarify

Dernenting

same

2).

verbal

recognition

In general, 1986).

Corwin

can also be verbally

such

cover

have

properly

sensitivity,

may

dementia.

From

familiarity

dramatic

sorncwhat

using

svvrral

hits

than

tyPes

contribute an

encoding

occurs.

controls,

to reliably

then

at testing

fruitful

false

that

who

alarms

increase

segregation

could

in healthy

to increase,

In summary,

bias, (1988)

on

than

depressive

suggest

contributes tend

measures more

and

in yes responses

hinge

though

test of information

response

people,

sub-

recognition

few of these

Corwin

Watts, expendi-

In depressives,

in primary

and

experience

words,

same.

list inspection

dcmcnting

items

thus increasing

attention

tended

very

performance

like mildly

study.

already

a less effortful is that

a general

the

low

irnagery

(1981)

f’alse alarms

However,

during

may

Simi-

nonverbal

1989),

to increase

overall.

Snodgrass

when

By and

over

whereas

(high-imagery)

roughly

observation contrast

such

If dcprcssives, more

stayed

allowing

structures

studies. Herdman

and Fox’s

& Rouse,

required

of controls

perspcctivc,

of semantic

Wilson,

also improves patients

indicts.

One

testing,

of hits and false alarms,

at presentation,

of material

in recognition

imagery

hits and

that

computational

standardized.

mechanisms

new words

than

pro-

more

of retrieval.

when

word

even

of high

concrete

on with

on ease

AD

sensitivity

as both

lower

different

activation

and

each but

sub.jects

somewhat

patients.

recognition

Vaughan,

even

attenuation

frequency

sub,jccts

that

appears

with AD

in Kaszniak,

Anderson,

a slight varies

in de-

the superiority

high-frequency

by voicing

was more

processing

patients

1982).

1985)

dementing

in depression

in terms

obscrvcd

considerably,

was

inappropriate

is

tend

& DeVitt,

CGRyrnes,

than

variations

positives

no impairment

the pattern

contrast

of word

of detecting

Using

(1987)

encoding

been

it is

research Raaijmakers,

false

describe

better

task during

in healthy

measure

to fare

confirmed

both

(Mou,

difficulties.

can

still

organic

Alternatively,

Spera,

report

others

to procedural

influence

accuracy

and MacLcod

measures

was

Further

stages,

Targum,

although

cautiousness

(1988)

labcllcd

with

found 1987),

drawn

still

while

the largest

sub.jccts

recognition

sensitivity

significant

of some

(Abbenhuis,

Cole,

studies

1990),

are

et al.,

did not play a role with demcnting

the situation

1989).

items

Weingartner,

on a secondary

in healthy

diminished

from

indistinguish-

impairment

state.

in the mildest

some

et al.,

a substantial

and

words

during

and

recognition

was a sizable

& Emery,

(Rranconnicr,

subjects,

has been

found

Snodgrass

ture

were

cognitive

in a subclinical

even

sub,jects

providing

performing

jects

for age

pattern

not be differentiated

As there

on verbal

and,

Interestingly,

attention

simultaneously

Morris,

(1990)

psychiatric

all matched

controls

in-

of healthy

when

out the possibility

(Kral

still

Silberman,

(Hart

the aged,

naming

ruling

patients

impaired

depressives

tasks

among

chances

test.

against

1990),

(Reatty

nounced

the

could and

residual

those

and colleagues

on forced-choice

depressives

are

not significantly

follow-up

controls

1977),

alarms

than

Abas

depressives which

were

usually

1985;

age (Niederehe,

subtle

and

recognition

of these

to healthy

dclay

(Table

Conversely,

tasks,

on

patients

are

& Erwin,

a X-minute

imagery

to he lower

at 2-year

patients

recovery,

tests

to nonclinical

(Calev

(1989)

and

& Lewis,

false

this point.

compared

Dobbs

and

in some

the

relative

Recently,

both

On

& van Woerdcn,

to be elevated

larly,

On

but

but often

study,

also examined

still be exercised

patients

Raaijmakers,

pression

VHR

present

possible

AD

were

(Miller

sensitivity, tend

treatment

but not the spatial,

between

lower

if anything,

Early

abilities testing.

shapes

to controls

I n a well-documented

before

at initial

able

correlation

alarms,

1977).

recognition

patients

geometric

compared

a somewhat

complete.

of prcmorbid

AD

after

false

depressives

was judged

estimates

When

and

& Lewis,

and

dementia

also display

1979),

(Miller

1988),

in primary

Depressives

controls

also

& Corwin,

is lower

to both

to show

comparing

that

to affect old

fewer

response

styles

instead.

ation,

Though

no report

possible

certain

directly

cut-off

points

standardized

contrasting on these

instruments

depression

current

that

varies

ence

effects

strategy occur

differentially often

when

conversely

in performance From

“negative

is thought

occurrence

while,

demand

1989;

for efficient

Weingartner,

1986),

(Dall’Ora

et al.,

accurately

judge

frequency

Sweeney,

1989;

Roy-Byrne,

patients

with primary

1986). isons

This confirm

(Downcs, derland, (e.g.,

suggests 1988;

dementia

Milner,

appear

sensitivity

Grafman, Petrides,

quite

Weingartner, experimental & Smith,

1985)

could

with

resources.

of

and

certain Though

thought

automati-

frequency

of

and elaboration

& Zacks,

1979).

that

1985;

Depressed

require

Watts

further

& Cooper,

difficulties

in mild

AD

depressed

patients

can

material

(Golinkoff

and pictorial Thompson,

& Post,

1986),

in this respect

Mellow, use both

(Weingartner, compar-

the two groups

Thompsen-Putnam, verbal

& Sun-

and nonverbal

standardized

&

whereas

in mild AD and direct in differentiating

b e readily

effort-

operation

suggest

processes

that

states,

the same

disadvantaged

Lawlor, tasks

most

the processing

tagging

& Erwin,

of this approach

controlled

requirements,

lists

in

attention

in organismic

organization,

reports

Bierer,

of automatic

that the tasks

on concerted

cognitive

Hasher

deficits information

concurrent

on verbal

verbal

memory

of commonly

evidenced

with

that

colour

(Calev

several

Weingartner,

a deregulation

Existing

1989;

studies hand,

measure

a proper

In general,

more,

decrements

of occurrence

the statistical

1990).

other

On the other

Though

once

requiring

resources.

generation,

& Rickard,

different

1973).

that channel

of the

examples

and retrieval

but

on tasks

meaning,

imagery

across

this split

commented

of’attentional

word

are

primary

to be debated,

of perturbations

(effortful)

criteria,

tone

dependent

terminology,

inordinate

encoding

1989).

Because is deficient

include

(Ellis

show

(1986)

were those

others

theoretical

processing

proposed functions

up attentional

less,

of events

for example,

structuring

tying

(1979)

Caine

(1967)

less controversially,

effortful

patients,

1990).

effects

in preparation).

in attentional

to lie on a continuum

strict

aspects

and Zacks

dementia

Beck’s

confidence

congru-

is processed

a review),

Wechsler,

continue

material

Mood

congruence for

in affective

& Hodges,

information.

mood

1988;

diagnostic

Berrios,

performance

demanding

satisfying

encoded

congruence

& Hardin,

schemata”

(automatic)

not always cally

for mood

with depressive

cognitive

to suggest

valence,

1988,

differences

to increase

in press).

strong

& Brosgolc,

Hasher

in

While

& Salovey,

to blur

of a disruption

because,

for such evalu-

is to incorporate

of its connotational

Cohen

(desRosiers,

of presented

of information tasks

instead

that depressives’

processing

state. (Singer

1989;

(Hertel

for manipulation ful

affective

patients

still serve

because

in patients

it is possible

by virtue

perspective,

occur

processing

affected

material,

responsible

could

another

during

& Robinson,

appears

standardized

depression

and sensitivity

& Kaszniak,

mechanisms

has been

of bias (desRosiers

to one’s

in depressed

(Allender

the exact

some

allow

is available

ISSUES

tone

to hedonic

according

reported

dementia tasks

in the investigation

according

easily

dementia

indices.

OTHER One

could

and mild

material

to allow

single

case

assessment. Lastly,

clinicians

often

misgivings

about

organically

dementing.

memory

appears

learning

rather

their more than

types

of complaints,

ives,

AD

patients

remark

memory

on a substantial who

When

analysed

related

to their

to retention O’Connor did

often

not

in detail, ability

as such and

appear

turn

number out

depressives’

to manage

(Squire

depressed

poor

appreciation

attentional

f ound

associates

(1990)

concerned

expressing

been

& Zouzounis,

any

more

of people

to have

that,

about

skills

1988).

serious instead

necessary

Comparing

in contrast

of

of their for both

to depress-

attention/concentration

difiiculties and

than

controls

ob.jectivca

alrraciy Mirscn.

and this

c:in

Evans

‘I’he

memory

data

indcpcndcnt

nature

suggest

dcprtsscd

and

B~ause

between

(Rabbitt

Gupta, AD

their

;I c,ross-lalidatiori

replications

relationship

obscure

M&lone,

96%).

without

of the

remains

bv

(spcciticity:

unrcliablr

exact still

rcportcd

(1990)

approach

bc quite

until

of

prcliminarl

using

wart’.

indices

Humphrry, patirnts

lYYO),

but

Oppenheimer,

arc

,jackknife

sampl?,

subjective

ct Abson, well

discriminated

discriminant

conclusions

procedure

must

bc

guarded

zirc’ published.

CONCLUSIONS RccausV tion,

dcmcntia,

it may

one

irrcspcctivr

br

in which

argu&

results

origins.

Qualitative

staging.

It was

dcmcnting for

diagnostic

to

global

functioning

mcr’s

disease. of

F rrris.

than

severity

Another reports

tendency

revicwrd

diagnoses, status. of

this

signs

of major

r‘vcn

if not

patirnts

though or

studirs

it is still

of psychometric

strategy

at

diagnosis. profiles

this Only

bc truly

appropriate Other essentials evaluating also

diagnostic

time in

is still such

like

more

consider

be

depend

in this

group patients

rcspvct

casts

srlcctcd

are

with

a recorded

that

years

is a risk should

designed

to help

all

in

cases

will

any

zrttcmpt

to

for thv

task

of single

case

diagnosis in AD,

relation

idcntif’y

our to

of AD

(desRosicrs, a prodromal

and

validity

and

follow-up

sprcific

asscssmcnt

history

in fixture context

a

showeci

number

included in

parallel,

either

psychiatric

factor

be

rcpresenta-

In

a considerable

preceding

patient’s

to validate

in fact who

Most

equivocal

each

needed

patients

those last

art’

dcmcnting

apparent

stud&. with

to conlirm

assessment.

patients

arc

it may that

the

to

best

confirm

ncuropsychological the development

of

tools. pertinent

reliability,

individual

to

casts

infornlativc

psychometric points

if they

from

samples

day-to-clay

depression

these

case,

tests

in or

whethrr

any

of the

in the

bctwcc.n (Rrisberg,

manner,

adcquatc

demarcations

primary

depression

unclear In

none

difficulties

It is now

of Alzhei-

satisfactory this

follow-up

clear

intcrvicw,

a patient’s

course

pt~rl’ormancc

casts their

for Icngthy

\vhcn

prrsumcd

assessnicnt

correlations

is less than

from

need

is that

time.

In

7’0

scales.

rliminatcd

at thr

clinical

lit~raturr thcsc

the

are

1986).

relevant.

to t’valuate

scales,

results

with clinic

ncuropsychological

ol‘altcrnativc

propose

some

patients

most

throughout

c-dude ambiguous

danger

at that

coincidental.

the

of the

avoided

etc.),

in

to a dementia of

on the basis

biomedical

on

is justifiable

dcprcssion

deprrsscd

becomes

for

of dcmcntia moderately

obvious

01’ n~urol)sy’t”)logi~~ll

date,

diagnostic

also

cxpcrirncc

1991)

must

the

not

indepcndcntly

& Kuttingcr,

ratrd to

because

post

of stud&

I’o

brcn

practice

who

or

patterns

oftrn

wcrr

population

that

of diagnostic

product

diffcrrntiating refcrrrd

manifestations

suggest

the

patterns

which,

dysl’unc-

is a quantitative

regardless

rcllect

to bc those

to clinical

specifically

constructs, those

majority

sign,

has

above

presumably While

theoretical tivc

not

this

appcarrd

de12ron,

factors. arc

likely

prrsonality,

qualitative

as “pscuclodcmrnts”

many

of drclinv

psychometric

Sinaiko,

of impairment

behavior, results

and

to examine

IIIOK

ofcognitivr

asscssmcnt

indeed

targeting

recently li\ing,

on the basis

perhaps

that

srvcrity

l’rcliminary

Korcnstein,

on other

rvscarch

in relation

drclinr

article

arc

dctcrminc

of daily

scvrrity groups

participants

1attc.r

instruments

activities

possible

in this

As the

is recognized

of ncuropsychological

bctwcrn

healthy

workup,

performance,

role

to vvaluatc

out

and

a mean

“stagrs”

used

pointed

dcmcntia.

provide

(c,g..

art’

the

dii’fvrcnces

patients

minilnal

ofctiology,

that

to

temporal results,

be considered. of the conditions

the

It can

the

tests

stability, role br

suspected.

themselves and

of other

argued

that

alternate

contributing poor

As in mental

were form factors

score

due

status

scales,

also

raised.

correlations like to such

Apart

from

necessary

for

sociodemographics factors

it is still moot

will

not

whether,

be

335

Primary or Depressive Dementia

say, limited

education

is of itself a risk factor

in the diagnosis

of primary

dementia,

perhaps as related to occupational exposures, life-style hazards, etc. All the evidence is not in on this point, and whether the incidence of dementia is in fact yoked to differences in educational achievements might be best addressed through clinico-pathological surveys. As for those with depressive dementia, no data are available to examine this question. Until more research comes to hand, sociodemographic influence on neuropsychological performance should be taken in consideration but, to date, only a limited number of tests were standardized adequately enough to provide such adjustments. Overall, neuropsychological performance is an essential aspect of clinical assessment toward the diagnosis of primary dementia. When the question of differential diagnosis arises, however, it has been the thesis of this review that many instruments used for this purpose might perform best if applied as second-stage assessment tools to weed out false positives rather than as first-stage instruments to detect true positives (Newman, Shrout, & Bland, 1990). In that respect, most tests were found to show less than perfect specificity when depressive dementia was the alternative suggest this may be improved.

diagnosis

though

recent

developments

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Received Accepted

May

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August

6, 1991