The Future of The Future of DementiaDementia

We Can Make a We Can Make a DifferenceDifference

Pairing Cognitive Pairing Cognitive Training With Specific Training With Specific

Neurocognitive Testing To Neurocognitive Testing To Improve Memory Improve Memory

FunctionFunction

Barbara C. Fisher, Barbara C. Fisher, Ph.D. CBSMPh.D. CBSM

Neuropsychologist/Board Certified Neuropsychologist/Board Certified Behavioral Sleep Medicine Behavioral Sleep Medicine

United Psychological United Psychological ServicesServices

www.unitedpsychologicalservwww.unitedpsychologicalservices.comices.comI have nothing to disclose

The Call to ActionThe Call to Action

Carol the Ph.D.: Came in for a dementia Carol the Ph.D.: Came in for a dementia seminar, signed up for an evaluation, did seminar, signed up for an evaluation, did therapy for a few sessions and therapy for a few sessions and disappeared. Would not allow us to inform disappeared. Would not allow us to inform her physician of the test results. She her physician of the test results. She returned a year later looking worse which returned a year later looking worse which was seen in the memory decline in the was seen in the memory decline in the testing. Again refused coordination with testing. Again refused coordination with PCP. She came back a year later in PCP. She came back a year later in winter coat on a 90 degree day in Julywinter coat on a 90 degree day in July

Forward in TimeForward in Time

That was almost eight years ago. That was almost eight years ago. Since that time we have coordinated Since that time we have coordinated with the PCP even placing with the PCP even placing psychologists in their offices. psychologists in their offices.

Dementia testing is primarily at the Dementia testing is primarily at the request of the PCPrequest of the PCP

But how does the PCP see the But how does the PCP see the problem? Usually report from family problem? Usually report from family and by then it is late.and by then it is late.

The New MandateThe New Mandate

Alzheimer’s International Meeting of Alzheimer’s International Meeting of 20132013

We need to catch people earlier in We need to catch people earlier in their 50’s and 60’s not in their 70’s their 50’s and 60’s not in their 70’s and 80’sand 80’s

Our outreach effort: Writing articles Our outreach effort: Writing articles (Wall Street Journal) seminars, local (Wall Street Journal) seminars, local papers, visiting the PCP’s papers, visiting the PCP’s

Adult Signs Suggesting Need Adult Signs Suggesting Need for Neuropsychological for Neuropsychological

EvaluationEvaluation Memory problems: Memory problems: Daily tasks, appointments, Daily tasks, appointments,

cooking, routine activities, conversations, loss of cooking, routine activities, conversations, loss of items (keys, glasses, credit cards, check book)items (keys, glasses, credit cards, check book)

Getting lost and disoriented in familiar places Getting lost and disoriented in familiar places

Unable to make decisions, stuck and obsessed Unable to make decisions, stuck and obsessed Emotional: Accusations, paranoid, moodyEmotional: Accusations, paranoid, moody Conversations not making senseConversations not making sense Old personality emerges, deepened Old personality emerges, deepened

depressiondepression Actions occur without rhyme and reasonActions occur without rhyme and reason

Memory QuestionsMemory Questions

1.1. Difficulty remembering things that Difficulty remembering things that someone recently told you?someone recently told you?

2.2. Do you forget places where you Do you forget places where you have been?have been?

3.3. Do you forget the things that you Do you forget the things that you need to do?need to do?

4.4. Do you forget where you have Do you forget where you have placed something just that day placed something just that day before or even an hour ago?before or even an hour ago?

5.5. Do you keep getting lost, even if it is Do you keep getting lost, even if it is the same route to the same place the same route to the same place that you have been going to for that you have been going to for years and years?years and years?

Memory QuestionsMemory Questions

6.6. Do you find yourself forgetting what Do you find yourself forgetting what you wanted to say?you wanted to say?

7.7. Do you just think about things, Do you just think about things, becoming upset, unable to take action becoming upset, unable to take action to change things?to change things?

8.8. Do you forget names of people you Do you forget names of people you have known for years?have known for years?

9.9. Is it hard to learn new things?Is it hard to learn new things?10.10. Do you make the same mistakes? Over Do you make the same mistakes? Over

and over?and over?11.11. Do you continually ask for directions to Do you continually ask for directions to

be repeated?be repeated?

The Problem of Testing:The Problem of Testing:What test you use is what What test you use is what

you findyou find Findings depend upon the tests that you Findings depend upon the tests that you

useuse MEAMS versus the RBANSMEAMS versus the RBANS If too simplistic memory will appear intactIf too simplistic memory will appear intact Testing in the morning may be very Testing in the morning may be very

different from the later afternoondifferent from the later afternoon Different tests may yield different data Different tests may yield different data

that would be missed if reliant upon one that would be missed if reliant upon one measure.measure.

Testing for Donna, age 74; BA: Testing for Donna, age 74; BA: Global Systems Check vs. Global Systems Check vs.

Specific Assessment Specific Assessment First Testing:First Testing: Impaired memory, average and above Impaired memory, average and above

average scoring for language (reading average scoring for language (reading recognition) and attention (task of coding, recognition) and attention (task of coding, sequential and cognitive flexibility) average sequential and cognitive flexibility) average intelligence. intelligence.

Second Testing:Second Testing: RBANS, Doors and People, BVMT-R, Three RBANS, Doors and People, BVMT-R, Three

Word Three Shape: More severe picture: Word Three Shape: More severe picture: confusion, word retrieval, delayed recall, confusion, word retrieval, delayed recall, verbal memory worse, not retaining verbal memory worse, not retaining informationinformation

Neurocognitive Neurocognitive AssessmentAssessment

It is not uniformIt is not uniform Some are using broad brush: tests of Some are using broad brush: tests of

intelligence, attention, processing intelligence, attention, processing speed, memory, languagespeed, memory, language

Testing based upon decision tree for Testing based upon decision tree for the types of dementia: Lewy body, the types of dementia: Lewy body, Cardiovascular, Frontal, Cardiovascular, Frontal, FrontotemporalFrontotemporal

Assessment for Specific Assessment for Specific Types of DementiaTypes of Dementia

Cardiovascular: Memory (Retrieval, Cardiovascular: Memory (Retrieval, Recognition, Short term and delayed) Recognition, Short term and delayed) and Executive Reasoning (planning, and Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, word retrieval)sequencing, word retrieval)

Frontal: Executive Reasoning (planning, Frontal: Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, abstract reasoning and sequencing, abstract reasoning and problem solving, word retrieval, problem solving, word retrieval, aphasias)aphasias)

Assessment for Specific Assessment for Specific Types of DementiaTypes of Dementia

Lewy Body: Visual perceptual (visual Lewy Body: Visual perceptual (visual closure, figure ground, visual closure, figure ground, visual discrimination, visual sequential memory) discrimination, visual sequential memory) and Executive Reasoning (planning, and Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, abstract reasoning and sequencing, abstract reasoning and problem solving, word retrieval, aphasias)problem solving, word retrieval, aphasias)

Frontotemporal: Emotional Assessment Frontotemporal: Emotional Assessment (loss of sense of self) Memory (Retrieval, (loss of sense of self) Memory (Retrieval, Recognition, Short term and delayed) and Recognition, Short term and delayed) and Executive Reasoning (planning, Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, word retrieval)sequencing, word retrieval)

Examples of Memory Examples of Memory TestingTesting

Verbal Retrieval: Learning tasks; word lists, Verbal Retrieval: Learning tasks; word lists, stories, names of peoplestories, names of people

Verbal Recognition: Names, names and Verbal Recognition: Names, names and facesfaces

Visual Retrieval: Learning tasks; visual Visual Retrieval: Learning tasks; visual designsdesigns

Visual Recognition: Shapes, designs, Visual Recognition: Shapes, designs, picturespictures

Short term memoryShort term memory Sequential memorySequential memory Delayed recall and recognitionDelayed recall and recognition

Three Word Three Shape Three Word Three Shape TestTest

To Be PresentedTo Be Presented

Bedside hospital measure or in your Bedside hospital measure or in your office. office.

RBANS: Repeatable RBANS: Repeatable Assessment of Assessment of

Neuropsychological StatusNeuropsychological Status Immediate Memory: List learning, short Immediate Memory: List learning, short

story story Delayed Memory: List learning recall and Delayed Memory: List learning recall and

recognition, short story, visual figure recallrecognition, short story, visual figure recall Visuospatial/Constructional: Copying visual Visuospatial/Constructional: Copying visual

figure, line judgmentfigure, line judgment Language: Naming, word retrievalLanguage: Naming, word retrieval Attention: Short term recall number Attention: Short term recall number

sequences, Coding sequences, Coding Total ScoreTotal Score

RBANS: Repeatable RBANS: Repeatable Assessment of Assessment of

Neuropsychological StatusNeuropsychological Status Examples to be presentedExamples to be presented

BVMT-R: Brief Visual BVMT-R: Brief Visual Memory Test-Revised Memory Test-Revised

Examples to be presentedExamples to be presented

Cognitive TrainingCognitive Training Specific and individualized based upon Specific and individualized based upon

the test resultsthe test results Targeting visual perceptual, memory Targeting visual perceptual, memory

processes, executive reasoning, languageprocesses, executive reasoning, language Tasks of short term recall, recognition, Tasks of short term recall, recognition,

verbal and visual memory, word retrieval verbal and visual memory, word retrieval Over 200 exercisesOver 200 exercises Re-testing every three months to change Re-testing every three months to change

program program

Carole, Age 79 years: H.S.: Pre and Carole, Age 79 years: H.S.: Pre and Post Testing Post Testing

How is her life different: Her daughter has noticed How is her life different: Her daughter has noticed changes in her overall functioning; she is taking trips changes in her overall functioning; she is taking trips with her daughter and more social in her interactions. with her daughter and more social in her interactions. She enjoys her therapy visits and looks forward to She enjoys her therapy visits and looks forward to them. them.

BVMT-R 6-2013 1-2014

Total Recall 22 (↓1st %tile) 49 (46th %tile)

Delayed Recall

27 (1st %tile) 43 (24th %tile)Doors/People 6-2013 1-2014

Total Recall 3 (↓1st %tile) 7 (10-25th %tile)

Forgetting Score

4 (1-5th %tile) 13 (75-90th %tile)BVMT-R 6-2013 1-2014

Total Recall 22 (↓1st %tile) 49 (46th %tile)

Delayed Recall

27 (1st %tile) 43 (24th %tile)

Carole: Age 79 years: Pre and Carole: Age 79 years: Pre and Post Testing Post Testing

Test Date

Immediate

Memory

Visuospat/

Construct

Language

Attention

Delayed Memory

Total Score

6-2013 81 (10th %)

102 (55th %)

92 (30th %)

79 (8th %)

64 (1st %)

79 (8th %)

1-2014 97 (42%)

105 (63rd %)

101 (53rd %)

94 (34th %)

107 (68th %)

100 (50th %)

Louise: Age 81 : BA degree: Pre and Louise: Age 81 : BA degree: Pre and Post Testing Post Testing

Three Word Three Shape:Three Word Three Shape: 12-2013: Initial recall: 1 word 12-2013: Initial recall: 1 word and 1 shape and 1 shape

Five learning trials, recalled 3 words and 1 shape on 5Five learning trials, recalled 3 words and 1 shape on 5 thth trial trial Delayed Recall: remembered 2 to 3 words and 1 or no shapes, Delayed Recall: remembered 2 to 3 words and 1 or no shapes,

recognized 3 words and 2 shapes recognized 3 words and 2 shapes

Three Word Three Shape:Three Word Three Shape: 4-2014: Initial recall: 2 words 4-2014: Initial recall: 2 words and 3 shapes and 3 shapes

Recall after one learning trial, recalled 3 words and 3 shapesRecall after one learning trial, recalled 3 words and 3 shapesDelayed recall: remembered 2 to 3 words and all 3 shapesDelayed recall: remembered 2 to 3 words and all 3 shapes

How is her life different?:How is her life different?: Increased activity in her social Increased activity in her social life, going on life, going on many vacations, driving to appointments. She is currently putting her house up for sale to move to Colorado to be closer to her family.  When first seen she only driving short distances by herself and more dependent upon her caregiver.

MAS 12-2013 4-2014

Verbal Memory

75 (5th %tile) 87 (19th %tile)

Louise: Age 81: BA: Pre and Louise: Age 81: BA: Pre and Post Testing Post Testing

Test Date

Immediate

Memory

Visuospat/

Construct

Language

Attention

Delayed Memory

Total Score

12-2013 65 (1st %)

87 (19th %)

86 (18th %)

79 (8th %)

68 (2nd %)

71 (3rd %)

4-2014 106 (66th %)

105 (63rd %)

95 (37th %)

91 (27th %)

98 (45th %)

98 (45th %)

Review of the Research for Review of the Research for Cognitive Cognitive

Rehabilitation/TrainingRehabilitation/Training Cognitive Reserve vs. Reverse CausalityCognitive Reserve vs. Reverse Causality Current and early life engagement in Current and early life engagement in

cognitively stimulating activities was cognitively stimulating activities was shown to independently slow late life shown to independently slow late life decline. decline. (Wilson, Boyle, Barnes, et al., 2013)(Wilson, Boyle, Barnes, et al., 2013)

Cognitive activity slowed the rate of Cognitive activity slowed the rate of decline years before death: Cognitive decline years before death: Cognitive activity offers protection against decline activity offers protection against decline and may help preserve cognitive function and may help preserve cognitive function despite the presence of pathologydespite the presence of pathology

Review of the Research for Review of the Research for Cognitive Cognitive

Rehabilitation/TrainingRehabilitation/Training Consistent benefit of treatment of cognitive Consistent benefit of treatment of cognitive

function over and above medication effectsfunction over and above medication effects Specificity of the training appears to be a Specificity of the training appears to be a

primary variable for improved functioningprimary variable for improved functioning Effectiveness and durability of cognitive Effectiveness and durability of cognitive

training intervention improves functioning training intervention improves functioning even if limited in time and durationeven if limited in time and duration

Overall agreement that cognitive therapy Overall agreement that cognitive therapy (cognitive stimulation, cognitive training or (cognitive stimulation, cognitive training or rehabilitation) is an efficacious method to rehabilitation) is an efficacious method to address dementia with or without medicationaddress dementia with or without medication

Take Home MessageTake Home Message

There is treatment for dementia: The There is treatment for dementia: The diagnosis of dementia does not mean diagnosis of dementia does not mean that the disease course is fixed and that the disease course is fixed and untreatableuntreatable

Perhaps if this concept was propagated Perhaps if this concept was propagated as opposed to the latter, more people as opposed to the latter, more people would be willing to undergo early would be willing to undergo early evaluationevaluation

Early evaluation = Increased prognosis Early evaluation = Increased prognosis for changefor change

Take Home MessageTake Home Message Concept of focused treatment providing Concept of focused treatment providing

individualized activities based upon brain behavior individualized activities based upon brain behavior relationships addressing specific aspects of relationships addressing specific aspects of memory, executive reasoning, language and visual memory, executive reasoning, language and visual perceptual functioning. perceptual functioning.

Cognitive or brain enhancing activities address Cognitive or brain enhancing activities address memory (short and long term, retrieval and memory (short and long term, retrieval and recognition, visual and verbal) executive reasoning recognition, visual and verbal) executive reasoning processes (selective attention, integration, processes (selective attention, integration, perseveration, sequential analysis, cognitive perseveration, sequential analysis, cognitive flexibility) language (word retrieval) and visual flexibility) language (word retrieval) and visual perceptual. perceptual.

Cognitive training and medication are becoming Cognitive training and medication are becoming the gold standard.the gold standard.

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