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The Construct Validity and Clinical Utility of the Frank Jones Story as a Brief Screening Measure of Cognitive Dysfunction
The Construct Validity and Clinical Utility of the Frank Jones Story as a Brief Screening Measure of Cognitive Dysfunction KATHLEEN THERESE BECHTOLD, PH.D., MICHAEL DAVID HORNER, PH.D. LAWRENCE A. LABBATE, M.D., WHITNEY K. WINDHAM, B.A.
The use of quick and easily administered screening measures of cognitive functioning has become increasingly important in clinical settings. A number of brief screening instruments are available, but few have been thoroughly examined for their validity and clinical utility. The Frank Jones Story is a 2-minute screening procedure proposed to measure problem solving by asking patients to explain an absurd proposition. The authors used this screen to help them classify 155 patients as cognitively impaired or unimpaired based on a full neuropsychological evaluation. Overall, the total score on the Frank Jones Story was a good predictor of intact functioning for patients that were unimpaired but was poor at predicting cognitive dysfunction. However, various subscores of the test reflected differing patterns of sensitivity and specificity for cognitive impairment. These data suggest that the Frank Jones Story might have some utility for initial screening for cognitive dysfunction. (Psychosomatics 2001; 42:146–149)
C
linicians are regularly confronted with the need to assess patients’ mental status under severe time constraints. Cognitive deficits, particularly in the elderly, can be subtle during the early stages of some diseases, making it difficult to determine whether cognitive changes are the result of normal aging or the beginning of a disease process.1 However, appropriate diagnosis of some disorders is critical so that appropriate medical care can be administered quickly, possibly staving off decline in functioning and the need for institutionalized care.2 Because comprehensive cognitive assessment of each patient is not feasible, clinicians must often carry out an initial assessment of cognitive functions for determining
Received June 12, 2000; revised September 7, 2000; accepted November 27, 2000. From the Department of Psychology, Southern Illinois University at Carbondale, Carbondale, Illinois; Institute of Psychiatry, Medical University of South Carolina, Charleston, South Carolina; Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina; College of Charleston, Charleston, South Carolina. Address correspondence and reprint requests to Dr. Horner, Mental Health Service (116), Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401–5799; e-mail: [email protected]. Copyright 䉷 2001 The Academy of Psychosomatic Medicine.
146
treatment decisions and appropriate referral. Rapid and accurate screening tests for cognitive impairments permit clinicians to direct at-risk individuals toward a more complete neuropsychological evaluation.3 Largely because of this need for rapid screening of cognitive impairment, bedside mental status testing has increased in popularity as clinicians make preliminary decisions for treatment and referral for further evaluation of cognitive impairment. Several screening measures have been developed, such as the Mini-Mental Status Examination4 and the Clock Drawing Test.5 Overall, research suggests that these instruments are useful in identifying changes in mental status over time6–8 and are reliable and valid initial screening tools of dementia.8–10 However, even these measures can take too long to administer. Consequently, clinicians may rely on briefer screens of cognitive function that have not been thoroughly examined for their validity and clinical utility. One such brief screen, which was created by George Murray and popularized at the Massachusetts General Hospital, is the Frank Jones Story.11,12 This screen is used to examine a patient’s emotional and cognitive response to an absurd proposition. As posited by Murray,12 an intact limPsychosomatics 42:2, March-April 2001
Bechtold et al. bic system should govern an emotional response to the absurd proposition, and an intact neocortex should resolve the intellectual conundrum of the story. Although this test was developed as a test of limbic function specifically, the Frank Jones Story has largely been used in the inpatient consultation setting for the screening of patients with dementia and delirium. It has reportedly been useful in this regard, especially for patients with delirium who typically demonstrate the appropriate emotional reaction but are unable to articulate the absurdity.11,12 The purpose of the present study is to determine the construct validity and clinical utility of the Frank Jones Story by examining its ability to aid in distinguishing between cognitively impaired and unimpaired outpatients. We hypothesize that the Frank Jones Story will aid in accurately classifying individuals as impaired versus unimpaired.
METHODS Participants were 155 VA Medical Center outpatients referred between 1996 and 1999 for neuropsychological evaluation of possible cognitive impairment. They ranged in age from 22 to 87 years (meanⳲstandard deviation (SD)⳱54.2Ⳳ15.4). The group was 92.9% male, 70.3% White, and 25.8% African American. Educational level ranged from no formal education to 18 years (meanⳲSD⳱11.6Ⳳ3.1). Current vocational status included 32.3% unemployed, 21.9% retired, 20% employed full-time, 10.3% on disability, 7.7% employed part-time, and 5.8% in school. Each patient was told the following proposition. “I have a friend, Frank Jones, whose feet are so big that he has to put his pants on by pulling them over his head.” The story was told with no emotional expression exhibited by the clinician. Patients were rated on whether they showed an emotional response to the proposition, such as a smile, laugh, or disdain. Patients were then asked, “Can he do it?” If patients correctly answered “No,” they were then asked to explain “Why not?” Each of these three responses was scored either one or zero, with one point awarded for showing an emotional response, answering “No” to “Can he do it?” and then providing a correct explanation for “Why not?” Thus, each participant’s total score ranged from 0 to 3. A comprehensive neuropsychological evaluation was also administered to assess cognitive functioning. The evaluation typically included standardized tests of attention, language, visuospatial skills, memory, executive functions, and mood. Based on this evaluation, diagnosis of the Psychosomatics 42:2, March-April 2001
presence of cognitive impairment was made. The cognitively impaired group included individuals who met criteria for any dementia diagnosis, amnestic disorder diagnosis, or cognitive disorder not otherwise specified. The unimpaired group included all individuals who did not meet criteria for diagnoses related to acquired cognitive impairment, including patients who were diagnosed with affective disorders, anxiety disorders, developmental learning disorders, attention deficit-hyperactivity disorder, and substance use disorders.
RESULTS All statistical analyses were two-tailed with an alpha level of P⬍0.05. Of the 155 participants who were neuropsychologically evaluated, 53 were found to meet criteria for a diagnosis of cognitive impairment, including 16 (10%) with cognitive disorder not otherwise specified, 8 (5%) with dementia of the alzheimer’s type, 14 (9%) with vascular dementia, and 15 (10%) with dementia not otherwise specified. Of the 102 participants in the unimpaired group, 12 (12%) had substance abuse disorders, 33 (32%) had mood disorders, 8 (8%) had anxiety disorders, 13 (13%) had learning disorders, and 36 (35%) had no diagnosis. Cognitively impaired patients were found to be older (age: impaired, meanⳲSD⳱65.1Ⳳ12.9; unimpaired, meanⳲSD⳱48.6Ⳳ13.5; t⳱7.3, P⬍0.001) and have fewer years of education (impaired, meanⳲSD⳱10.3Ⳳ3.7; unimpaired, mean education⳱12.2, SD⳱2.5; t⳱ⳮ3.8, P⬍0.001) than the unimpaired patients. To explore the relationship between the total score on the Frank Jones Story and age and education, Pearson correlations were performed. The results indicate that age (r⳱ⳮ0.21, P⬍0.01), but not years of education (r⳱0.16, NS) was significantly related to overall performance on the measure. Table 1 illustrates the relationship of cognitive impairment to performance on each of the three Frank Jones Story variables (Emotional reaction, Can he do it?, and Why not?). Emotional reaction was not able to contribute significantly to the classification of impaired versus unimpaired participants (v2⳱1.65, NS). A correct answer to Can he do it? correctly classified 91.2% of unimpaired participants but also classified 34.0% of the impaired participants as unimpaired, which demonstrated good specificity but poor sensitivity (v2⳱15.32, P⬍0.001). Conversely, response to Why not? correctly classified 81.1% of cognitively impaired patients; however, it also classified 53.9% of unimpaired patients as impaired (v2⳱11.12, P⬍0.01); 147
Brief Screening Measure of Cognitive Dysfunction thus, the Why not? question had good sensitivity but poor specificity. To determine whether the cognitively impaired and unimpaired participants could be correctly classified according to the total score on the Frank Jones Story, a discriminant function analysis was conducted. The results showed that one function made up of the total score on Frank Jones Story was extracted (Wilks’ k⳱0.90; v2⳱16.1, P⬍0.001), which accounted for 10% of the difference between the cognitively impaired and unimpaired groups (canonical⳱0.32). This function was 96.1% accurate at predicting membership in the unimpaired group (true negatives) and 18.9% accurate at predicting membership in the cognitively impaired group (true positives). Based on the total score, 69.7% of the participants were correctly classified as either impaired or unimpaired. The Frank Jones Story was found to be reasonably useful as a cognitive screen. Pearson correlations were conducted to determine if it was sensitive to particular cognitive domains. Scores on neuropsychological tests sensitive to attention and information-processing speed (Trail Making Test, Part A),13 expressive language (Controlled Oral Word Association),14 memory (California Verbal Learning Test, long-delay free recall),15 and executive functions (Wisconsin Card Sorting Test, percent perseverative errors)16 were correlated with the three scores of the Frank Jones Story. The results indicate that a correct response to the question of Can he do it? and Why not? were significantly correlated with better performance on a task of attention and information processing speed (r⳱ⳮ0.30, P⬍0.01; r⳱ⳮ0.22, P⬍0.05, respectively) and a task of expressive language (r⳱0.28, P⬍0.01; r⳱0.22, P⬍0.05, respectively). Performance on tests of memory (r⳱0.10, NS; r⳱0.10, NS) and executive functions (r⳱ⳮ0.12, NS; r⳱ⳮ0.02, NS, respectively) were not significantly related to these two Frank Jones Story responses. Only the test of memory was related to whether an emotional response occurred to the telling of the story (r⳱0.21, P⬍0.01).
TABLE 1.
DISCUSSION The results provide some support for the Frank Jones Story as a screening test for cognitive impairment. Specifically, the results suggest that an incorrect response to Can he do it? is most likely indicative of cognitive impairment, whereas a correct response to Why not? is most likely associated with intact functioning. Interestingly, many unimpaired participants were unable to adequately explain the conundrum, and an emotional response to the story did not aid in classification, in contrast to Murray’s reports on patients with delirium.12 Discriminant function analysis showed that the total score on the Frank Jones Story could predict intact functioning for patients who were cognitively intact but was poor at predicting the presence of cognitive dysfunction in cognitively impaired patients. Overall, a correct performance on both questions of the Frank Jones Story was found to be associated with intact cognitive functioning, as determined by comprehensive neuropsychological evaluation. Given that this test could be useful as a screen of cognitive function, an understanding of the cognitive domains to which its three responses are sensitive could be helpful. Correlational analyses showed that the presence of an emotional response was related to better performance on a memory task, whereas correct responses to Can he do it? and Why not? were related to better performance on tasks of attention and expressive language. Based on these findings, there were some advantages of using the Frank Jones Story as an initial screen for cognitive impairment. It was a practical and easily administered screening instrument that took approximately 2 minutes to administer and to interpret. Additionally, these results indicated that performance on the test was not related to education level, suggesting that it can be useful with a wide variety of patients. Finally, the Frank Jones Story was shown to have a low false-positive rate (3.9%).
Number of patients obtaining each possible score on Emotional Reaction, “Can he do it,” and “Why not,” grouped by presence of cognitive impairment Emotional Reaction
Cognitively unimpaired Cognitively impaired Total
Why Not?
Yes
Total
Incorrect
Correct
Total
Incorrect
Correct
Total
30 21 51
72 32 104
102 53 155
9 18 27
93 35 128
102 53 155
55 43 98
47 10 57
102 53 155
v2⳱1.65, NS
148
Can He Do It?
No
v2⳱15.32, P⬍0.001
v2⳱11.12, P⬍0.01
Psychosomatics 42:2, March-April 2001
Bechtold et al. On the other hand, its relatively high false-negative rate suggested that patients with subtle cognitive disorders would frequently be overlooked using this procedure. For any test that is truly to function as a screen, false-negative errors can be more serious than false-positive errors because individuals who truly need further evaluation would be erroneously missed.7 Thus, like any screening instrument, the Frank Jones Story does not suffice for diagnostic purposes, but it might aid in making a decision about referral for further evaluation. The present findings are limited, because the results
have not been cross validated in another sample. Additionally, because the study sample was drawn from a VA population, the findings might not be generalizable to other populations. Nevertheless, the present findings suggest that the Frank Jones Story might be a useful addition to the available screenings for cognitive impairment. Although the story has typically been used for inpatient screenings, the results from our present study suggest that it is useful for outpatients as well. We anticipate that the validity for inpatients would be similar, although we did not test this hypothesis in our present study.
References
1. Evans DA, Funkenstein H, Albert M, et al: Prevalence of Alzheimer’s disease in a community population of older persons. JAMA 1989;262:2551–2556 2. Khachaturian Z: The five-five, ten-ten plan for Alzheimer’s disease. Neurobiol Aging 1992;13:197–198 3. Green RC, Green J, Harrison JM, et al: Screening for cognitive impairment in older individuals: Validation study of a computerbased test. Arch Neurol 1994; 51: 779–786 4. Folstein MF, Folstein SE, McHugh PR: “Mini-Mental state:” a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198 5. Tuokko H, Hadjistavropoulos T, Miller JA, et al: The Clock Test: Administration and Scoring Manual. Toronto, ON: Multi-Health Systems, 1995 6. Dick JR, Guilott RJ, Stewart A, et al: Mini-Mental State examination in neurological patients. J Neurol Neurosurg Psychia 1984; 47:496–499 7. Nelson A, Fogel BA, Faust D: Bedside cognitive screening instruments: a critical assessment. J Nerv Ment Dis 1986; 174:73– 83 8. Wolf-Klein GP, Silverstone FA, Levy AP, et al: Screening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc 1989; 37:730–734
Psychosomatics 42:2, March-April 2001
9. Shulman K, Shedletsky R, Silver I: The challenge of time: Clock drawing and cognitive function in the elderly. Int J Geriatr Psychiatry 1986; 1:135–140 10. Van Gorp WG, Marcotte TD, Sultzer D, et al: Screening for dementia, Comparison of three commonly used instruments. J Clin Exp Neuropsychol 1999; 21:29–38 11. Wise MG, Rundell JR: Concise Guide to Consultation Psychiatry. 2nd Edition. Washington, DC: American Psychiatric Press, 1994 12. Murray GB: Limbic music, in Massachusetts General Hospital Handbook of General Hospital Psychiatry, edited by Hackett, TP, Cassem, NH. Littleton, MA: PSG Publishing Co, 1987, pp116– 125 13. Army Individual Test Battery: Manual of Directions and Scoring. Washington, DC: War Department, Adjutant General’s Office, 1944 14. Spreen O, Benton AL: Neuropsensory Center Comprehensive Examination for Aphasia (NCCEA). Victoris: University of Victoria Neuropsychology Laboratory, 1969, 1977 15. Delis DC, Kramer JH, Kaplan E, et al: California Verbal Learning Test: Adult Version, San Antonio, TX: The Psychological Corporation, 1987 16. Heaton RK, Chelune GJ, Talley JL, et al: Wisconsin Card Sorting (WCST) Manual Revised and Expanded, Odessa, Fl: Psychological Assessment Resources, 1993
149
The use of quick and easily administered screening measures of cognitive functioning has become increasingly important in clinical settings. A number of brief screening instruments are available, but few have been thoroughly examined for their validity and clinical utility. The Frank Jones Story is a 2-minute screening procedure proposed to measure problem solving by asking patients to explain an absurd proposition. The authors used this screen to help them classify 155 patients as cognitively impaired or unimpaired based on a full neuropsychological evaluation. Overall, the total score on the Frank Jones Story was a good predictor of intact functioning for patients that were unimpaired but was poor at predicting cognitive dysfunction. However, various subscores of the test reflected differing patterns of sensitivity and specificity for cognitive impairment. These data suggest that the Frank Jones Story might have some utility for initial screening for cognitive dysfunction. (Psychosomatics 2001; 42:146–149)
C
linicians are regularly confronted with the need to assess patients’ mental status under severe time constraints. Cognitive deficits, particularly in the elderly, can be subtle during the early stages of some diseases, making it difficult to determine whether cognitive changes are the result of normal aging or the beginning of a disease process.1 However, appropriate diagnosis of some disorders is critical so that appropriate medical care can be administered quickly, possibly staving off decline in functioning and the need for institutionalized care.2 Because comprehensive cognitive assessment of each patient is not feasible, clinicians must often carry out an initial assessment of cognitive functions for determining
Received June 12, 2000; revised September 7, 2000; accepted November 27, 2000. From the Department of Psychology, Southern Illinois University at Carbondale, Carbondale, Illinois; Institute of Psychiatry, Medical University of South Carolina, Charleston, South Carolina; Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina; College of Charleston, Charleston, South Carolina. Address correspondence and reprint requests to Dr. Horner, Mental Health Service (116), Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401–5799; e-mail: [email protected]. Copyright 䉷 2001 The Academy of Psychosomatic Medicine.
146
treatment decisions and appropriate referral. Rapid and accurate screening tests for cognitive impairments permit clinicians to direct at-risk individuals toward a more complete neuropsychological evaluation.3 Largely because of this need for rapid screening of cognitive impairment, bedside mental status testing has increased in popularity as clinicians make preliminary decisions for treatment and referral for further evaluation of cognitive impairment. Several screening measures have been developed, such as the Mini-Mental Status Examination4 and the Clock Drawing Test.5 Overall, research suggests that these instruments are useful in identifying changes in mental status over time6–8 and are reliable and valid initial screening tools of dementia.8–10 However, even these measures can take too long to administer. Consequently, clinicians may rely on briefer screens of cognitive function that have not been thoroughly examined for their validity and clinical utility. One such brief screen, which was created by George Murray and popularized at the Massachusetts General Hospital, is the Frank Jones Story.11,12 This screen is used to examine a patient’s emotional and cognitive response to an absurd proposition. As posited by Murray,12 an intact limPsychosomatics 42:2, March-April 2001
Bechtold et al. bic system should govern an emotional response to the absurd proposition, and an intact neocortex should resolve the intellectual conundrum of the story. Although this test was developed as a test of limbic function specifically, the Frank Jones Story has largely been used in the inpatient consultation setting for the screening of patients with dementia and delirium. It has reportedly been useful in this regard, especially for patients with delirium who typically demonstrate the appropriate emotional reaction but are unable to articulate the absurdity.11,12 The purpose of the present study is to determine the construct validity and clinical utility of the Frank Jones Story by examining its ability to aid in distinguishing between cognitively impaired and unimpaired outpatients. We hypothesize that the Frank Jones Story will aid in accurately classifying individuals as impaired versus unimpaired.
METHODS Participants were 155 VA Medical Center outpatients referred between 1996 and 1999 for neuropsychological evaluation of possible cognitive impairment. They ranged in age from 22 to 87 years (meanⳲstandard deviation (SD)⳱54.2Ⳳ15.4). The group was 92.9% male, 70.3% White, and 25.8% African American. Educational level ranged from no formal education to 18 years (meanⳲSD⳱11.6Ⳳ3.1). Current vocational status included 32.3% unemployed, 21.9% retired, 20% employed full-time, 10.3% on disability, 7.7% employed part-time, and 5.8% in school. Each patient was told the following proposition. “I have a friend, Frank Jones, whose feet are so big that he has to put his pants on by pulling them over his head.” The story was told with no emotional expression exhibited by the clinician. Patients were rated on whether they showed an emotional response to the proposition, such as a smile, laugh, or disdain. Patients were then asked, “Can he do it?” If patients correctly answered “No,” they were then asked to explain “Why not?” Each of these three responses was scored either one or zero, with one point awarded for showing an emotional response, answering “No” to “Can he do it?” and then providing a correct explanation for “Why not?” Thus, each participant’s total score ranged from 0 to 3. A comprehensive neuropsychological evaluation was also administered to assess cognitive functioning. The evaluation typically included standardized tests of attention, language, visuospatial skills, memory, executive functions, and mood. Based on this evaluation, diagnosis of the Psychosomatics 42:2, March-April 2001
presence of cognitive impairment was made. The cognitively impaired group included individuals who met criteria for any dementia diagnosis, amnestic disorder diagnosis, or cognitive disorder not otherwise specified. The unimpaired group included all individuals who did not meet criteria for diagnoses related to acquired cognitive impairment, including patients who were diagnosed with affective disorders, anxiety disorders, developmental learning disorders, attention deficit-hyperactivity disorder, and substance use disorders.
RESULTS All statistical analyses were two-tailed with an alpha level of P⬍0.05. Of the 155 participants who were neuropsychologically evaluated, 53 were found to meet criteria for a diagnosis of cognitive impairment, including 16 (10%) with cognitive disorder not otherwise specified, 8 (5%) with dementia of the alzheimer’s type, 14 (9%) with vascular dementia, and 15 (10%) with dementia not otherwise specified. Of the 102 participants in the unimpaired group, 12 (12%) had substance abuse disorders, 33 (32%) had mood disorders, 8 (8%) had anxiety disorders, 13 (13%) had learning disorders, and 36 (35%) had no diagnosis. Cognitively impaired patients were found to be older (age: impaired, meanⳲSD⳱65.1Ⳳ12.9; unimpaired, meanⳲSD⳱48.6Ⳳ13.5; t⳱7.3, P⬍0.001) and have fewer years of education (impaired, meanⳲSD⳱10.3Ⳳ3.7; unimpaired, mean education⳱12.2, SD⳱2.5; t⳱ⳮ3.8, P⬍0.001) than the unimpaired patients. To explore the relationship between the total score on the Frank Jones Story and age and education, Pearson correlations were performed. The results indicate that age (r⳱ⳮ0.21, P⬍0.01), but not years of education (r⳱0.16, NS) was significantly related to overall performance on the measure. Table 1 illustrates the relationship of cognitive impairment to performance on each of the three Frank Jones Story variables (Emotional reaction, Can he do it?, and Why not?). Emotional reaction was not able to contribute significantly to the classification of impaired versus unimpaired participants (v2⳱1.65, NS). A correct answer to Can he do it? correctly classified 91.2% of unimpaired participants but also classified 34.0% of the impaired participants as unimpaired, which demonstrated good specificity but poor sensitivity (v2⳱15.32, P⬍0.001). Conversely, response to Why not? correctly classified 81.1% of cognitively impaired patients; however, it also classified 53.9% of unimpaired patients as impaired (v2⳱11.12, P⬍0.01); 147
Brief Screening Measure of Cognitive Dysfunction thus, the Why not? question had good sensitivity but poor specificity. To determine whether the cognitively impaired and unimpaired participants could be correctly classified according to the total score on the Frank Jones Story, a discriminant function analysis was conducted. The results showed that one function made up of the total score on Frank Jones Story was extracted (Wilks’ k⳱0.90; v2⳱16.1, P⬍0.001), which accounted for 10% of the difference between the cognitively impaired and unimpaired groups (canonical⳱0.32). This function was 96.1% accurate at predicting membership in the unimpaired group (true negatives) and 18.9% accurate at predicting membership in the cognitively impaired group (true positives). Based on the total score, 69.7% of the participants were correctly classified as either impaired or unimpaired. The Frank Jones Story was found to be reasonably useful as a cognitive screen. Pearson correlations were conducted to determine if it was sensitive to particular cognitive domains. Scores on neuropsychological tests sensitive to attention and information-processing speed (Trail Making Test, Part A),13 expressive language (Controlled Oral Word Association),14 memory (California Verbal Learning Test, long-delay free recall),15 and executive functions (Wisconsin Card Sorting Test, percent perseverative errors)16 were correlated with the three scores of the Frank Jones Story. The results indicate that a correct response to the question of Can he do it? and Why not? were significantly correlated with better performance on a task of attention and information processing speed (r⳱ⳮ0.30, P⬍0.01; r⳱ⳮ0.22, P⬍0.05, respectively) and a task of expressive language (r⳱0.28, P⬍0.01; r⳱0.22, P⬍0.05, respectively). Performance on tests of memory (r⳱0.10, NS; r⳱0.10, NS) and executive functions (r⳱ⳮ0.12, NS; r⳱ⳮ0.02, NS, respectively) were not significantly related to these two Frank Jones Story responses. Only the test of memory was related to whether an emotional response occurred to the telling of the story (r⳱0.21, P⬍0.01).
TABLE 1.
DISCUSSION The results provide some support for the Frank Jones Story as a screening test for cognitive impairment. Specifically, the results suggest that an incorrect response to Can he do it? is most likely indicative of cognitive impairment, whereas a correct response to Why not? is most likely associated with intact functioning. Interestingly, many unimpaired participants were unable to adequately explain the conundrum, and an emotional response to the story did not aid in classification, in contrast to Murray’s reports on patients with delirium.12 Discriminant function analysis showed that the total score on the Frank Jones Story could predict intact functioning for patients who were cognitively intact but was poor at predicting the presence of cognitive dysfunction in cognitively impaired patients. Overall, a correct performance on both questions of the Frank Jones Story was found to be associated with intact cognitive functioning, as determined by comprehensive neuropsychological evaluation. Given that this test could be useful as a screen of cognitive function, an understanding of the cognitive domains to which its three responses are sensitive could be helpful. Correlational analyses showed that the presence of an emotional response was related to better performance on a memory task, whereas correct responses to Can he do it? and Why not? were related to better performance on tasks of attention and expressive language. Based on these findings, there were some advantages of using the Frank Jones Story as an initial screen for cognitive impairment. It was a practical and easily administered screening instrument that took approximately 2 minutes to administer and to interpret. Additionally, these results indicated that performance on the test was not related to education level, suggesting that it can be useful with a wide variety of patients. Finally, the Frank Jones Story was shown to have a low false-positive rate (3.9%).
Number of patients obtaining each possible score on Emotional Reaction, “Can he do it,” and “Why not,” grouped by presence of cognitive impairment Emotional Reaction
Cognitively unimpaired Cognitively impaired Total
Why Not?
Yes
Total
Incorrect
Correct
Total
Incorrect
Correct
Total
30 21 51
72 32 104
102 53 155
9 18 27
93 35 128
102 53 155
55 43 98
47 10 57
102 53 155
v2⳱1.65, NS
148
Can He Do It?
No
v2⳱15.32, P⬍0.001
v2⳱11.12, P⬍0.01
Psychosomatics 42:2, March-April 2001
Bechtold et al. On the other hand, its relatively high false-negative rate suggested that patients with subtle cognitive disorders would frequently be overlooked using this procedure. For any test that is truly to function as a screen, false-negative errors can be more serious than false-positive errors because individuals who truly need further evaluation would be erroneously missed.7 Thus, like any screening instrument, the Frank Jones Story does not suffice for diagnostic purposes, but it might aid in making a decision about referral for further evaluation. The present findings are limited, because the results
have not been cross validated in another sample. Additionally, because the study sample was drawn from a VA population, the findings might not be generalizable to other populations. Nevertheless, the present findings suggest that the Frank Jones Story might be a useful addition to the available screenings for cognitive impairment. Although the story has typically been used for inpatient screenings, the results from our present study suggest that it is useful for outpatients as well. We anticipate that the validity for inpatients would be similar, although we did not test this hypothesis in our present study.
References
1. Evans DA, Funkenstein H, Albert M, et al: Prevalence of Alzheimer’s disease in a community population of older persons. JAMA 1989;262:2551–2556 2. Khachaturian Z: The five-five, ten-ten plan for Alzheimer’s disease. Neurobiol Aging 1992;13:197–198 3. Green RC, Green J, Harrison JM, et al: Screening for cognitive impairment in older individuals: Validation study of a computerbased test. Arch Neurol 1994; 51: 779–786 4. Folstein MF, Folstein SE, McHugh PR: “Mini-Mental state:” a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198 5. Tuokko H, Hadjistavropoulos T, Miller JA, et al: The Clock Test: Administration and Scoring Manual. Toronto, ON: Multi-Health Systems, 1995 6. Dick JR, Guilott RJ, Stewart A, et al: Mini-Mental State examination in neurological patients. J Neurol Neurosurg Psychia 1984; 47:496–499 7. Nelson A, Fogel BA, Faust D: Bedside cognitive screening instruments: a critical assessment. J Nerv Ment Dis 1986; 174:73– 83 8. Wolf-Klein GP, Silverstone FA, Levy AP, et al: Screening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc 1989; 37:730–734
Psychosomatics 42:2, March-April 2001
9. Shulman K, Shedletsky R, Silver I: The challenge of time: Clock drawing and cognitive function in the elderly. Int J Geriatr Psychiatry 1986; 1:135–140 10. Van Gorp WG, Marcotte TD, Sultzer D, et al: Screening for dementia, Comparison of three commonly used instruments. J Clin Exp Neuropsychol 1999; 21:29–38 11. Wise MG, Rundell JR: Concise Guide to Consultation Psychiatry. 2nd Edition. Washington, DC: American Psychiatric Press, 1994 12. Murray GB: Limbic music, in Massachusetts General Hospital Handbook of General Hospital Psychiatry, edited by Hackett, TP, Cassem, NH. Littleton, MA: PSG Publishing Co, 1987, pp116– 125 13. Army Individual Test Battery: Manual of Directions and Scoring. Washington, DC: War Department, Adjutant General’s Office, 1944 14. Spreen O, Benton AL: Neuropsensory Center Comprehensive Examination for Aphasia (NCCEA). Victoris: University of Victoria Neuropsychology Laboratory, 1969, 1977 15. Delis DC, Kramer JH, Kaplan E, et al: California Verbal Learning Test: Adult Version, San Antonio, TX: The Psychological Corporation, 1987 16. Heaton RK, Chelune GJ, Talley JL, et al: Wisconsin Card Sorting (WCST) Manual Revised and Expanded, Odessa, Fl: Psychological Assessment Resources, 1993
149