98
Other psychological testing methods The following list shows some tests which are widely used in the Czech Republic. For a deeper understanding and an overview of other tests and methods, you can use a range of data available on the internet or in the literature (e.g., Strauss, Sherman & Spreen, A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary; Lezak Neuropsychological Assessment).
The Mini-Mental State Examination (MMSE) MMSE is the example of a simple and rapid test for screening cognitive functions. It is used in patients with suspected dementia. The test is mainly applied among senior citizens with a moderate to severe cognitive deficit. On the other hand, the test is not sensitive to the populations with mild cognitive disability. If all answers are correct, the score equals 30. A score above 27 points indicates that cognition is not noticeably impaired. Dementia starts at a score of 23 points. A severe cognitive impairment is given by a score of 17 to 0 points. A low score does not simply mean that the patient is demented, but it should stimulate more detailed psychological examinations. MMSE is also routinely applied by psychiatrists, neurologists or geriatricians. In the Czech Republic, certain MMSE scores are required by health insurance companies for the financial reimbursement of medication (e.g., donepezil, rivastigmine or galantamine at 20–13 points, memantine at 17–6 points). The test contains simple questions focused on orientation, calculation, short-term memory, attention, understanding and use of the language, implementation of simple instructions and simple visual motor skills (e.g., what is the date today, in which city are we, in which facility, on which floor, what is 100 minus 7, etc.). The disadvantage of MMSE is its low sensitivity to the combined effect of old age and a low education.
The Clock Drawing Test (CDT) This test is often used together with MMSE. The simple demand on the patient is to draw a clock face and hands which show a specified time, e.g., 4:20. The test affects a range of cognitive functions including design and executive skills (planning), visual motor coordination, the long-term spatial memory and attention. The evaluation is usually related to the correctness of the individual parts of hours (circle, digits, hands – the length and setting). Definite signs of cognitive impairment are missing digits or hands, repeating digits, an increased number of hands or the wrong time. A patient with a visual failure (neglect) has a specific image of the clock. The part of the clock which is located on the opposite side of a brain injury or tumor is missing. In some cases, the patient tries to compensate for the missed digits by placing the image on the other side of the clock. The CDT may be difficult for patients with a tremor in the upper extremities. In these cases, the interpretation of the test may not be valid. For clinical use, a qualitative scoring is applied (normal version – abnormal version – inability to perform).
Ukázka elektronické knihy, UID: KOS226179
6. Laboratory and Auxiliary Examination Methods in Psychiatry
99
Addenbrooke’s Cognitive Examination (ACE) With an increasing knowledge of cognitive deficits of varying etiology in which the symptoms often overlap, the need to develop a more specific test showed up. Such a test should be relatively fast, but more complex than the MMSE and should enable basic differential diagnostics. As compared to MMSE, ACE added tasks aimed at verbal formation and fluency of thinking. ACE also expanded the memory items related to learning and recall, and investigates the language and visuomotor skills in more detail. The ratio of “verbal production” and “language abilities” to “orientation” and “delayed recall from memory” (the VLOM ratio) is designed to distinguish Alzheimer dementia (< 2.2) from frontotemporal dementia (> 3.2). The malfunction in the “counting dots” and “identifying letters” items can be a symptom of right-sided lesions of the CNS. The overall ACE evaluation is performed on a scale from 0 to 100 points. The lower limit of a normal performance is 88 points (sensitivity 0.94, specificity 0.89) or 82 points (sensitivity 0.84, specificity1.0). The effect of the patient’s age is negligible, but education may affect the outcome. Because ACE is more time-consuming than MMSE, ACE is not suitable for patients with a severe cognitive deficit.
The Montreal Cognitive Assessment (MoCA) This test was created for the purpose of a rapid screening for mild cognitive impairment (MCI). As compared to MMSE, MoCA contains items measuring executive functions, better captures the design capability and is more difficult in its visuospatial and audiospatial skills. MoCA is more swift as opposed to ACE, but lacks the differentiation potential of ACE. The evaluation is done on a scale of 0–30 with a cut–off score of 26 points (sensitivity 0.9, specificity 0.87). MoCA is suitable in research and clinical assessment in psychiatry and neurology. For visually handicapped patients, a MoCA version is available (MoCA-BLIND).
The MATRICS Consensus Cognitive Battery (MCCB) Because research data on cognitive deficit in schizophrenia grew, the initiative Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) was established in 2004. The goal was to stimulate the research of cognition enhancing medication. The unified neuropsychological MCCB was one of the outcomes of this activity. The test takes less than 90 minutes. The MCCB has a high reliability and validity, is easy to administer and tolerated well by patients. The MCCB cognitive domains and their examination are described in Table 6.8.
The Auditory Verbal Learning Tasks (AVLTs) The group of tests used to investigate the auditory memory and the ability to instill, hold and recall a learned word list is called memory tests of learning. The tests vary by the words used, number of words and repetition (e.g., the California Verbal Learning Test; CVLT), or the presence of semantic clusters (the Hopkins Verbal Learning Test; HVLT). The version derived from Rey’s methodology (Rey Auditory Verbal Learning
Ukázka elektronické knihy, UID: KOS226179
100 Table 6.8. Cognitive domains measured by MCCB Cognitive Domain
Method of examination
Speed of processing
Brief Assessment of Cognition in Schizophrenia (BACS): Symbol-Coding; Categorical fluence: Naming animals; Trail Making Test: Part A
Attention/Vigilance
Continuous Performance Test – Identical Pairs (CPT-IP)*
Working memory nonverbal verbal
Wechsler Memory Scale – III (WMS-III): Spatial scale Arrangement of letters and numbers
Verbal learning
Hopkins Verbal Learning Test – Revised (HVLT-R)
Visual learning
Brief visuospatial Memory Test – Revised (BVMT-R)
Reasoning and problem solving
Neuropsychological Assessment Battery (NAB): Mazes
Social cognition
Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT): Managing Emotions
* The test is not the same as the test for sustained attention (CPT-II)
Test; RAVLT) is used in the Czech Republic. The patient has 5 attempts to learn a list of 15 words. After that, he or she should repeat as many words from a read interfering list as possible, and then recall the words from the first list again. After 20–30 minutes, the patient is requested to recall the words from the first list again. Finally, a list of 50 words is read to the patient. Some words are from the first list, the other ones from the list of interference, and other words are just phonetically or semantically similar. The challenge is to correctly identify the words from the first list. The test measures the immediate and total capacity of auditory memory, the learning ability, the tolerance of interference and the ability of the short-term and delayed recall. A flat learning curve together with a small number of recalled words are the sign of a deficit of imprinting of new information. A fluctuating performance suggests difficulties with attention. The inability to recall an item after some time is a symptom of disorders of retention of information. Confabulation, a decreased endurance to interference and phonetic or semantic shifts of the words reflect a reduced self-monitoring ability in the patient. AVLTs are useful in a wide variety of memory disorders. The disadvantages of the test include a small but significant effect of repetition. If the test is performed repeatedly in the same patient, it is necessary to use an alternate version with different sets of words. The relationship of the test results with the patient’s education or intelligence has not yet been fully established.
The Rey Complex Figure Test (RCFT) The patient’s role in the test is to draw a complex two-dimensional object according to a pattern. Without knowing beforehand, the patient is asked to draw this object again by heart after 3–5 minutes. After 25–30 minutes, another drawing of the same
Ukázka elektronické knihy, UID: KOS226179