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
Sl~N5IlI*~IlY
PD-
PO+
(SLN!:
A
7
(A
+
B)
(SPE):
i)
4
(C
+
D)
0
i
(A
+
0)
c
i
ic
+
D)
P(IPD+lf’U+)
DIAGNOSIS
SPCCIFICITY P(lPD-JPD-1
1
PD+
FALSE
E
NEGAlIVi
RATC
P(TPD-IPD+)
s T
FALSE
or POSlTIVi.
PREDICTIVE
P(PD*ITPD+) NEGATIVE
T:
(A
PREDICTIVE
P(PD-/TPD-) PO:
VALUE
or
(0
f
Dementia;
P(PD+):
FIGURE
(A
+
VALUE
or
Primary Test;
t
P(l’D+).
C))
P(PD+)
(PV-1:
P(PD-).
P(Tf’D-/PD-)
D))
P(PD-).
P(TPD-/PD..)
+
+:
Present;
Prevalence
I. Bayesian
for
-: PD;
Absent:
Predictive
-
SFt)
+
i’ ( PD
+
P(i’Dt).
F(lFD+~PD+) *
P(PD-1:
Derivations
5EN)
JFPR):
(1
or
iPV+):
(B
-
RAIC
P(TFD+/l’D-) POSITIVE
(iNR):
(1
P ( TFD+
P:
1 PI)+
)
I: for
for Sensitivity,
r ( 1 I’D+
1PC- 1
P:lPD-/PD+!
Probablllty;
Prcvalrnce
)
hiart>
that;
othrrs.
Specificity,
and
Values.
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
10, 1990
August
6, 1991