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Per la creazione di linee guida sulla valutazione cognitiva dell’anziano
Abstract
La valutazione cognitiva appare una componente fondamentale della valutazione geriatrica multidimensionale e definire delle linee guida su come debba essere condotta sembra un’importante sfida. In risposta a recenti riflessioni che auspicano il ricorso ad un approccio clinico-neuropsicologico e la necessità di abbracciare nuove impostazioni teoriche e nuovi modelli, vengono messi in evidenza i principali elementi di criticità della valutazione cognitiva dell’anziano per poi illustrare come il modello della riserva cognitiva, il modello biopsicosociale e la visione “incarnata” del rapporto mente-corpo, aprano a nuove prospettive. Sulla base del Sistema Nazionale per le Linee Guida, promosso dall’Istituto superiore di sanità (ISS) e dal Centro nazionale epidemiologia, sorveglianza e promozione della salute (CNESPS), si immagina un possibile sviluppo di linee guida della valutazione cognitiva dell’anziano, utile a definire quali strumenti utilizzare nei diversi contesti di valutazione (ad esempio, valutazione di screening presso il medico di base, valutazione cognitiva presso centri specialistici, valutazione per l’assegnazione di una tecnologia assistiva) e con le diverse tipologie di utenti (ad esempio, soggetti con afasia).
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In the late Eighties it was recognized that individuals differ in their ability to cope with physiological or pathological cognitive decline. Since then, the distinction between Brain Reserve and Cognitive Reserve was specified, the former involving the available neurological resources, whilst the latter concerned with the cognitive, functional ones. However, the measurement of cognitive reserve has not yet been standardized by recourse to a unique, well-defined procedure. The aim of the present paper is the description of such a standardized procedure, by means of a questionnaire (Cognitive Reserve Index, CRI) specifically aimed at measuring the Cognitive Reserve construct. Standardization data collected so far and the possible relevance of CRI in clinical practice is discussed.
Over the past decade, several studies have shed light on how the Ambient Assistive Technology (AAT) may increase the life expectancy of older adults experiencing cognitive decline who continue to live in their own homes, as well as improve their autonomy and independence, facilitate their daily activities, and monitor their health status. These technologies can also assist in facilitating social inclusion, helping families, and supporting healthcare organizations (Rashidi & Mihailidis, 2013). One of the most promising applications of AAT for the aging population is provided by assistive robots (Broadbent, Stafford, & MacDonald, 2009; Nejat, Yiyuan, & Nies, 2008). Both older adults with dementia and their caregivers can benefit considerably from the deployment of assistive robots in actual, real-life, contexts of use. However, we still have to fill the gap between the designs of the developers of new technologies and the needs of the users and their caregivers. For example, evaluating what a robot should do and look like, and how it should meet the user’s needs efficiently, and facilitating the work of the caregivers and health professionals so as to prevent technology non-use or abandonment, still remains a challenge, which even the most recent models of user evaluation have not completely solved.
In this chapter, we review the state of the art and possible future developments of AAT for people with dementia, while discussing the main research issues in this area, focusing particularly on assistive service robots for eldercare and assistance services. Current technology design approaches, user-experience evaluation techniques, and assistive technology assessment models are discussed.
The neuropsychological exam plays a central role in the assessment of elderly patients with cognitive complaints. It is particularly relevant to differentiate patients with mild dementia from those subjects with mild cognitive impairment. Formal education is a critical factor in neuropsychological performance; however, there are few studies that evaluated the psychometric properties, especially criterion related validity, neuropsychological tests for patients with low formal education. The present study aims to investigate the validity of an unstructured neuropsychological assessment protocol for this population and develop cutoff values for clinical use.
A protocol composed by the Rey-Auditory Verbal Learning Test, Frontal Assessment Battery, Category and Letter Fluency, Stick Design Test, Clock Drawing Test, Digit Span, Token Test and TN-LIN was administered to 274 older adults (96 normal aging, 85 mild cognitive impairment and 93 mild Alzheimer`s disease) with predominantly low formal education. Factor analysis showed a four factor structure related to Executive Functions, Language/Semantic Memory, Episodic Memory and Visuospatial Abilities, accounting for 65% of explained variance. Most of the tests showed a good sensitivity and specificity to differentiate the diagnostic groups. The neuropsychological protocol showed a significant ecological validity as 3 of the cognitive factors explained 31% of the variance on Instrumental Activities of Daily Living.
The study presents evidence of the construct, criteria and ecological validity for this protocol. The neuropsychological tests and the proposed cutoff values might be used for the clinical assessment of older adults with low formal education.
This is the protocol for a review and there is no abstract. The objectives are as follows:
To determine the diagnostic accuracy of the informant-based questionnaire IQCODE, in detection of all-cause (undifferentiated) dementia in adults presenting to secondary-care services.
Where data are available we will describe the following:
• The diagnostic accuracy of IQCODE at various prespecified thresholds. We recognise that various thresholds or cut-off scores have been used to define IQCODE screen positive states. We will describe the properties of IQCODE for the following cut-off scores (rounded where necessary): 3.6; 3.5; 3.4; 3.3. These thresholds have been chosen to represent the range of cut-offs that are commonly used in practice and research; we have been inclusive in our choice of cut-off to maximise available data for review.
• Accuracy of IQCODE for diagnosis of the commonest specific dementia subtype - Alzheimer’s dementia.
• Effects of heterogeneity (see below) on the reported diagnostic accuracy of IQCODE. Potential sources of heterogeneity that we will explore include: age of cohort; case mix of cohort; reason for hospital consultation (dichotomised as 'memory' or 'non-memory' services); technical features of IQCODE; method of dementia diagnosis.
There are three general aims of clinical neuropsychological assessment: (1) to document strengths and weaknesses in cognition and related behaviors; (2) to interpret outcomes diagnostically; and (3) to make recommendations for treatment and management of problem behaviors. In diagnostic interpretation, contributions of suspected brain impairment must be integrated with a variety of nonorganic factors (e. g., decreased motivation, psychiatric disturbance, educational limitations) to explain performance deficits, and with elderly patients, special attention must be given to the possibility that these deficits are age-consistent.
The notions of ecological validity and everyday cognition emerged predominantly from three sources in psychology. These were the study of practical intelligence in cognitive psychology (Sternberg, 1977; Neisser, 1982), the study of everyday cognition in gerontology (Acker, 1986; Poon, 1986; West, 1985) and the prediction of everyday functioning in neuropsychological rehabilitation settings (Chelune & Moehle, 1986; Hart & Hayden, 1986). Movements in all of these areas were at least partially motivated by a reaction to the general psychometric, trait-oriented theories of intelligence and the arcane style of intellectual and neuropsychological tests which had developed largely since the second world war. The following is a very brief history of these movements, a review of the current ideas subsumed under the term ecological validity and a future program of test development which will presumably combine these new ideas with the best from the past.
Background:
The IQCODE (Informant Questionnaire for Cognitive Decline in the Elderly) is a commonly used questionnaire based tool that uses collateral information to assess for cognitive decline and dementia. Brief tools that can be used for dementia "screening" or "triage" may have particular utility in primary care / general practice healthcare settings but only if they have suitable test accuracy.A synthesis of the available data regarding IQCODE accuracy in a primary care setting should help inform cognitive assessment strategies for clinical practice; research and policy.
Objectives:
We sought to describe the accuracy of IQCODE (the index test) against a clinical diagnosis of dementia (the reference standard). In this review we focus on those studies conducted in a primary care (general practice) setting.
Search methods:
A search was performed in the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS (Ovid SP), ISI Web of Science and Conference Proceedings (ISI Web of Knowledge), CINHAL (EBSCOhost) and LILACs (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (York University); HTA Database (Health Technology Assessments Database via The Cochrane Library) and ARIF (Birmingham University). We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardized database subject headings such as MeSH terms (in MEDLINE) and other standardized headings (controlled vocabulary) in other databases, as appropriate.
Selection criteria:
We selected those studies performed in primary care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the "primary care" setting, we included those healthcare settings where unselected patients, present for initial, non-specialist assessment of memory or non-memory related symptoms; often with a view to onward referral for more definitive assessment.
Data collection and analysis:
We screened all titles generated by electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. Quality assessment (risk of bias and applicability) was determined using the QUADAS-2 tool. Reporting quality was determined using the STARDdem extension to the STARD tool.
Main results:
From 71 papers describing IQCODE test accuracy, we included 1 paper, representing data from 230 individuals (n=16 [7%] with dementia). The paper described those patients consulting a primary care service who self-identified as Japanese-American. Dementia diagnosis was made using Benson & Cummings criteria and the IQCODE was recorded as part of a longer interview with the informant.IQCODE accuracy was assessed at various test thresholds, with a "trade-off" between sensitivity and specificity across these cutpoints. At an IQCODE threshold of 3.2 sensitivity: 100%, specificity: 76%; for IQCODE 3.7 sensitivity: 75%, specificity: 98%.Applying the QUADAS-2 assessments, the study was at high risk of bias in all categories. In particular degree of blinding was unclear and not all participants were included in the final analysis.
Authors' conclusions:
It is not possible to give definitive guidance on the test accuracy of IQCODE for the diagnosis of dementia in a primary care setting based on the single study identified. We are surprised by the lack of research using the IQCODE in primary care as this is, arguably, the most appropriate setting for targeted case finding of those with undiagnosed dementia in order to maximise opportunities to intervene and provide support for the individual and their carers.
Cognitive reserve (CR) is a concept meant to account for the frequent discrepancy between an individual's measured level of brain pathology and her expected cognitive performance. It is particularly important within the context of aging and dementia, but has wider applicability to all forms of brain damage. As such, it has intimate links to related compensatory and neuroprotective concepts, as well as to the related notion of brain reserve. In this article, we introduce the concept of cognitive reserve and explicate its potential cognitive and neural implementation. We conclude that cognitive reserve is compatible and complementary with many related concepts, but that each much draw sharper conceptual boundaries in order to truly explain preserved cognitive function in the face of aging or brain damage.