Office-based Cognitive Testing: Cases
Paul R. Solomon, PhD
Professor of Psychology /Neuroscience
Williams College
Visiting Professor of Neurology
Boston University School of Medicine
Clinical Director
Boston Center for Memory
Clinical Director
The Memory Clinic
DEMENTIA: A Comprehensive Update
Boston, June 7-10, 2017
Disclosure
(past 12 months)
 Grant Support: AstraZeneca, AVID, Axovant,
Biogen, Cambridge Cognition, Eli Lilly, Forum
Pharmaceuticals, Hoffman-LaRoche, Neuronetrix,
ONNIT Labs, TransTech Pharma
 Consulting:, Boehringer-Ingelheim, Eli Lilly,
General Electric, Neuronetrix, Novartis
 Royalties: Elsevier(Saunders), Psychological
Assessment Resources
Steps in Diagnosis / Differential
Diagnosis
 Decision that dementia is present
 Determination of cause of
dementia (differential diagnosis)
Steps in Diagnosis
Decision that
dementia is present
Determination of
cause of dementia
(differential diagnosis)
Cognitive
Eval.
Hx Cognitive
Complaints
Neuro
Exam
Lab
Eval
Cognitive
Profile
Imaging
Approaching Differential Diagnosis
 Up to 75% of cases will include AD
 Start with the hypothesis that AD is the cause in
full or in part
 Be aware of the signs/symptoms of other
common causes of dementia
 Cases
 Real cases
 Focus on most common causes of dementia
Other Common Causes
Of Cognitive Impairment
Dementias
FRONTAL
~5%
VASCULAR
AD
~ 15 - 25%
~ 75%
NONDEGEN
DEM
~ 5%
Medication
Side Effects
~5-10%
MCI
~3-22%
LEWY
BODY
~ 20%
Depression
•MDD ~3%
•Subsyndromal
~ 15-27%
Office Based Assessment
Procedures
 Neuropsychological Tests
 Informant Completed Questionnaires
Neuropsychological Tests
Advantages
Disadvantages
 Commonly used,
 Requires patient to
many choices
 Requires only
patient (not the
caregiver) to be
present
be present
 Requires patient to
be cooperative
 Requires staff time
to administer
Informant Questionnaires
Advantages
Disadvantages
 Does not require
 Requires caregiver
patient to be
present and /
cooperative
 Requires minimal
staff time to
administer
to be present
Neuropsychological Tests:
Montreal Cognitive Assessment
(MOCA)
Advantages
Disadvantages
 Test and Instructions freely
 Takes 10 minutes to administer
available on the web
(www.mocatest.org)
 Clear Instructions and scoring
 Translated into 30 + languages
 Covers multiple cognitive
domains (orientation, memory,
attention, language, executive
function, visuospatial function)
 Accuracy > MMSE for AD and
MCI
(Nasreddine et al. JAGS, 2005)
Montreal
Cognitive
Assessment
(MOCA)
MOCA + 5 ≅ MMSE
Informant Completed
Alzheimer’s Disease Caregiver
Questionnaire (ADCQ)
Advantages
 Test and Instructions freely
available on the web
(bostonmemory.com)
 18 item YES / NO
questionnaire
 Sensitivity > 90%,
Specificity > 85%
 Minimal staff time required
Disadvantages
 Requires presence of
caregiver
 Not validated for selfreport by patient
Solomon et al. International Psychogeriatrics, 2003
Domains Evaluated
MOCA
ADCQ
 Visuospatial /Executive
 Recent Memory
 Naming
 Executive Function
 Memory
 Language
 Attention
 Visuospatial
 Abstraction
 Mood & Behavior
 Delayed Recall
 Progression
 Cued Recall (optional)
 Abstraction
Case 1
Patient Profile
 88-years old
 Female
 19 years of education (2 bachelors, 1 masters
degree)
 Taught at the public school and college level
 Plays the organ
 Plays golf
Medical
Medical History
Current Medications
 Hypothyroidism
 Levoxyl
 Mild anemia
 multivitamin + iron
 Mild arthritis
 cortisone injection
Physical / Neurological
Exam
 Metamucil
 Unremarkable
 B6
Laboratory Results
 Within normal limits
 calcium
Imaging Studies
 CT scan w/o contrast
 Impression:
 Moderate cerebral atrophy
 No evidence of acute cortical infarction
or intracranial bleed
History of Cognitive Complaints
Onset: 3 years ago, insidious
Initial symptoms: deficits in recent memory
Progression: progressive - particularly in the last 1–2 years
Current Complaints:
 Memory
 Repeats questions multiple times within same conversation
 Rapidly forgets conversations
 Executive Function
 Bills now disorganized
 Can no longer organize medications
 Language
 Word finding difficulties
 Other aspects of cognition intact
Cognitive Assessment
 MMSE = 24
 Missed 3/3 delayed item recall
 Disoriented time, place
 MOCA =19
 Missed 5/5 delayed item recall
 Missed 4/5 with cues
 Trailmaking B impaired
 Verbal Fluency impaired (8 animals / 1 minute)
 Clock Drawing impaired (hands set incorrectly)
 Alzheimer’s Disease Caregiver Questionnaire (ADCQ) -
positive
 Endorsed forgetting conversations / repeating questions
 Endorsed deficits in executive function
 Problems have been Progressive
MOCA Cued Recall
Function
 ADLs intact
 IADLs mildly impaired
 Living independently
 Difficulty paying bills
 Difficulty managing medications
Impairment index = 15%
Differentials
 Alzheimer’s disease
 Mild Cognitive Impairment
Diagnosis
Alzheimer’s disease
- early stages
Diagnostic Criteria – Probable AD
Dementia Present
 Presence of significant cognitive decline documented
by knowledgeable informant and neuropsych. testing
 Interferes with independence in everyday activities
 Impairment is in a minimum of 2 domains
Probable AD Dementia
 Insidious onset (months / years)
 Clear cut worsening
 Initial deficits are in memory (amnestic) or other
cognitive area ( non-amnestic) such as language,
visuospatial, executive.
 No evidence for other dementing disorder
Why is this not MCI?
 The Concept of MCI due to AD was
introduced in the 2011 NIA-AA criteria
 DSM-5 refers to this as Minor Cognitive
Disorder due to AD
 Both NIA-AA and DSM-5:
 Assumes that AD pathology is present and patient will
eventually progress to clinical AD
 Recognizes that biomarkers will eventually be available
(e,g., amyloid and Tau PET, volumetric MRI) and will
add confidence to this diagnosis
MCI due to AD
AD
early stages
Differential Diagnoses
Mild Alzheimer’s
disease
Mild Cognitive
Impairment due to
AD
Cognitive complaints by Present
patient or family
Present
Cognitive deficits
Present, mild deficits
Dementia
Present
Present, very mild
deficits
Absent
Functional impairment
Present –
Absent –
Interferes with
Independence of
independence in everyday function–
activities
although patient may take
longer or experience
more difficulty
Case 2
Patient Profile
 71 year-old
 Female
 Living independently
 12 years education
 Retired Home Health Aide (1980s)
 Recent death of companion
Medical
Medical History





Hypercholesterolemia
Left hip replacement
Status post
cholecystectomy
Arthritis in many joints
L5 diskectomy
Physical / Neurological
Exam
 Parkinsonism
 Rigidity
Current Medications
 Levoxyl
 multivitamine + iron
 cortisone injection
 Metamucil
 calcium
 B6
Laboratory Results
 Within normal limits
Imaging Studies
 CT scan w/o contrast
 Impression
 Generalized atrophy
 prominent in presylvian area
 Old white matter ischemic changes
 Old right basal ganglia lacunar infarct
History of Cognitive Complaints
Onset: 2-3 years
Initial symptoms: becoming lost in familiar setting
Progression: gradual
Current Complaints:
 Memory
 Mild deficits in recent memory
 Executive Function
 Difficulty managing checkbook
 Can no longer organize medications
 Attention

Fluctuating
Cognitive Assessment
 MMSE = 26
 Disoriented to place
 Could not copy complex figure
 MOCA = 22
 Missed 1/5 delayed item recall
 Missed 0/5 with cues
 Trailmaking B impaired
 Clock Drawing impaired, could not copy cube
 Impaired attention, digits forward
 Alzheimer’s Disease Caregiver Questionnaire (ADCQ) -
positive
 Endorsed visuospatial problems (e.g., becoming lost)
 Endorsed deficits in executive function
 Problems are progressive
Clock Drawing
(from MOCA)
Function
 ADLs and intact
 IADLs impaired
• Impairment Index = 46%
Differentials
 AD
 MCI
 Lewy Body Disease
Diagnosis
Dementia with Lewy Bodies (DLB)
Diagnostic Criteria
Central Features (essential)

Dementia Present
 Impaired executive function, attention, and
visuospatial ability often prominent
 Memory impairment may or may not be
prominent initially
Diagnostic Criteria
Core Features (2 for probable, 1 for possible LBD)
 Fluctuating cognition with pronounced
variation in attention and alertness
 Recurrent visual hallucinations, well formed and
detailed
-- Often or people or animals
-- Often initially present around sleep/wakefulness
transitions
 Spontaneous features of parkinsonism
Differential Diagnoses
Cognitive deficits
Alzheimer’s disease
Dementia with
Lewy Bodies
Multiple cognitive areas
with memory disorder
prominent
Visual hallucinations,
sleep disturbance later in
disease or not at all
Functional impairment
Present
More prominent deficits
in visuospatial, executive,
and attentional function
Visual hallucinations,
sleep disturbance often
present early in the
disease
Present
Dementia
Present
Present
Motor Symptoms
None until late stages
Parkinsonian symptoms
often present early in
disease
Behavioral Symptoms
Case 3
Patient Profile
 67 year-old male
 Retired truck driver with 12 years of education
 Premorbid IQ in average range
Medical
Medical History
Current Medications
 Hypercholestremia
 Simvastatin
 Hypertension
 Lisinopril
 Enlarged prostate (not
 Metroprolol
thought to be cancer)
 ASA 325
Physical / Neurological
Exam
 Procardia
 Unremarkable
Laboratory Results
 Within normal limits
 donepezil (10 mg)
Imaging Studies
 MRI
 scattered T2 hyperintensities
 some atrophy
 PET
 Hypometabolism in frontal lobes
Insert MRI scan
History of Cognitive Complaints
Onset: 6 years ago, insidious
Initial symptoms: behavioral
Progression: progressive - particularly in the last 2-3years
Current Complaints:
 Memory
 Recent memory deficits, especially in past year
 Executive Function
 Difficulty with financial decisions – wife now manages finances
 Difficulty organizing meals (no longer cooks) and household
projects
 Language
 Word finding difficulties
 Other aspects of cognition intact
Cognitive Assessment
 MMSE = 25
 Missed 2/3 delayed item recall
 Difficulty with WORLD backwards
 MOCA = 21
 Missed 3/5 delayed item recall
 Missed 0/5 with cues
 Trailmaking B impaired
 Verbal Fluency impaired (6 animals / 1 minute)
 Alzheimer’s Disease Caregiver Questionnaire
(ADCQ) - positive
 Endorsed forgetting conversations
 Endorsed deficits in executive function
 Problems are progressive
Function
 ADLs mildly impaired
 Needs reminders
 IADLs impaired
 Inappropriate in social settings
 Difficulty managing finances
 Difficulty planning and organizing household
tasks
Impairment index = 49%
Mood and Behavior
 Disinhibition
 Embarrassing comments in social situations
 De Novo high sex drive
 Made socially inappropriate comments toward
female examiner
 Paranoia
 misplaces items and feels others have stolen
these items
 Feels people on TV are speaking to him
 Wants to eat when anyone else is eating
Differentials
 Alzheimer’s disease
 Frontotemporal dementia
 Psychiatric disorder
Diagnosis
Frontotemporal dementia
Frontotemporal Dementia
Core Diagnostic Features (all must be present)



Insidious onset and gradual progression
Early decline in social interpersonal conduct
Early impairment in regulation of personal
conduct
 Early emotional blunting
 Early loss of insight
Frontotemporal Dementia
Supportive diagnostic features:
Behavioral variant







Decline in personal hygiene and grooming
Mental rigidity and inflexibility
Distractibility and impersistence
Hyperorality and dietary changes
Perseverance and stereotyped behavior
Utilization behavior
Physical signs: primitive reflex, incontinence,
akinesia, rigidity, tremor, low/labile blood pressure
Differential Diagnoses
Alzheimer’s disease
Frontotemporal
Dementia
Behavioral Variant
Age of Onset
Typically > 65
Typically < 65
Cognitive Deficits
Multiple cognitive
areas with memory
disorder prominent
None early, executive
dysfunction later in
disease
Behavioral
Symptoms
None early in disease, Socially inappropriate
apathy, agitation, and behavior early in
others as disease
disease
progresses
Differential Diagnosis
Alzheimer’s Disease
Functional Impairment Absent
Lack of Progression
Consider
MCI
Dementia Absent
Parkinsonism Present
Visual Hallucinations Early in Disease
REM Sleep Disorder
Fluctuating Attention
Age < 65
Behavioral Disorders Early in Disease
Spatial Abilities Preserved
Memory Abilities Variable
Imaging Evidence of Vascular Disease
Lack of Progression
Consider
Lewy
Body
Disease
Consider
Frontotemporal
Dementia
Consider
Vasc
Dem
Office-based Cognitive Testing: Cases
Paul R. Solomon, PhD
Professor of Psychology /Neuroscience
Williams College
Visiting Professor of Neurology
Boston University School of Medicine
Clinical Director
Boston Center for Memory
Clinical Director
The Memory Clinic
DEMENTIA: A Comprehensive Update
Boston, June 7-10, 2017