REVIEW ARTICLE
VANZELER, Maria Luzinete Alves [1]
VANZELER, Maria Luzinete Alves. Neuropsychology and differential diagnosis in cognitive declines and demoralprocesses in the elderly. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 09, Vol. 02, pp. 30-54. September 2020. ISSN: 2448-0959, Access Link: https://www.nucleodoconhecimento.com.br/psychology/cognitive-declines, DOI: 10.32749/nucleodoconhecimento.com.br/psychology/cognitive-declines
SUMMARY
In order to review the literature on cognitive decline in aging, normal and pathological and the role of neuropsychological evaluation in the differential diagnosis of these declines, a search was conducted in specialized textbooks, neuropsychological evaluation manuals and indexed scientific articles (in capes, lilacs, pubmed, mediline and scielo and academic Google journals), the review was conducted in November and December 2019. The study gathered information about cognitive deficits in normal aging, mild cognitive impairment (CLC) and different types of dementia, such as: Alzheimer’s disease (AD); Frontotemporal dementia (FTD); Dementia with Lewy corpuscles (DCL); Vascular dementia (DV); Mixed dementia (AD/dv); dementias associated with other neurodegenerative disorders; infectious dementias and reversible dementias. The importance of neuropsychological evaluation was verified as a diagnostic tool, using resources such as: interviews, behavioral observations, batteries of screenings and specific tests (exclusive use of the psychologist). Neuropsychological evaluation characterizes dementia as a progressive deficit in cognitive function, with impaired memory from the initial phase, which impairs social and occupational activities. In addition, neuropsychological evaluation can identify situations in which there is the possibility of reversal, primary and sequelal conditions and also guide therapy and indicate prognosis.
Keywords: neuropsychological evaluation, cognitive functions, dementias, aging, elderly.
1. INTRODUCTION
The increase in life expectancy is undoubtedly an achievement of contemporary society. According to Burlá (2013) the population group that has grown the most in almost everyone is that of people aged 60 years or older. This growth is related to the reduction in mortality rates from infectious and chronic diseases in all age groups. In addition, the advancement of medical technology, greater access to health services and the improvement of living conditions in general, plays a fundamental role for population growth in this age group (BURLÁ, 2013; KALACHE et al., 1987).
The Brazilian Institute of Geography and Statistics (IBGE) (2010) has seen an increase in population aging in Brazil in recent decades. In the same period, the reduction of fertility, birth rate and mortality was also recorded, associated with improvements in basic sanitation, feeding and drug development (ZIMERMAN, 2000). According to IBGE (2010), by 2050 Brazil will have the fifth largest elderly population in the world. This increase in life expectancy brings with it an increase in the propensity to chronic-degenerative diseases, such as diabetes mellitus, hypertension, among others (CARAMELLI and BARBOSA, 2002). In addition, with aging, cognitive decline arises, which can occur in a natural and physiological way, or it can mean a pathological picture. This condition can be characterized as dementia, or present as mild cognitive impairment (CLC) whose magnitude does not interfere with activities of daily living (ADL), but individuals with CLC are more likely to develop dementia. Thus, CCL can be considered as an intermediate stage between normal aging and pathological aging (MALLMANN and DORING, 2017).
In an attempt to understand more and more the process of population aging, society has already inserted the theme in the formation of public policies. Psychology seeks to deal with this demand, using the health care of the elderly. In this context, neuropsychological evaluation plays a fundamental role, as it provides support for early diagnosis and promotes intervention measures that can delay cognitive degeneration (FRAGA, 2018).
Performing neuropsychological evaluation of the old, even if without cognitive complaints is a very important resource, since some neurodegenerative diseases exist well before the symptoms of functional or cognitive declines arise (BONDI et al., 2008; CARAMELLI and BEATO, 2008).
Rossini et al. (2007) e Yassuda et al. (2010) emphasize the importance of research as soon as possible, so that the elderly with some commitment can benefit from psychopharmacological and psychotherapeutic interventions. Damasceno (2006) emphasized neuropsychological evaluation as a fundamental procedure for knowledge of the cognitive profile of people in general, especially to differentiate the different types of dementias.
Despite the benefits regarding the performance of the neuropsychological evaluation, it is still a little used practice, mainly in the case of healthy elderly or without cognitive complaints (FIGUEIREDO et al., 2009). This suggests the urgent need for further studies on aging and the role of neuropsychological assessment in this context. In this sense, the aim of this article is to conduct a descriptive study of cognitive decline in aging, emphasizing the differences between the normal process, mild cognitive impairment and demenciais, as well as describing the role of neuropsychological evaluation in the differential diagnosis of these states of life.
2. Method
A bibliographic survey was conducted on articles indexed in PUBMED, LILACS, MEDLINE, SCIELO and Google Scholar, as well as specialized textbooks and neuropsychological evaluation manuals.
The literature review was carried out in November and December 2019, when articles were selected, critically analyzed. The following descriptors were used to search the articles: Neuropsychological evaluation, dementia, cognitive functions, elderly, aging.
3. DEVELOPMENT
3.1 NEUROPSYCHOLOGY AND NEUROPSYCHOLOGICAL EVALUATION
Neuropsychology is the frontier area of several disciplines, thus having an interdisciplinary character, as it incorporates concepts and techniques of basic disciplines, such as: neuroanatomy, neurophysiology, neurochemistry and neuropharmacology, and application disciplines, such as: psychometrics, clinical and experimental psychology, psychopathology and cognitive psychology (RAMOS and HAMDAN, 2016).
The neuropsychological domain can be understood through three complementary strands:
a) in the first aspect, neuropsychology is understood as a clinical discipline in order to identify the profile of cognitive deficits of patients who have suffered brain injuries or are in the process of aging;
b) in the second aspect, it is a neuroscientific discipline, which establishes anatomical-clinical correlations, enabling a better understanding of elementary operations, dynamics and plasticity of cognitive functions;
c) and the third aspect is characterized as a cognitive discipline, because it considers the performance in tests and tasks obtained by subjects with brain lesions, and in the aging phase, formulates hypothesis tests based on cognitive theories based on studies conducted with healthy people (SIÉROFF, 2009).
In any of the three aspects, neuropsychological evaluation is an indispensable tool, since it is a method that includes several systematized procedures, in order to investigate and map mental and cognitive functions related to the functioning of the central nervous system (CNS) (MICHALICK-TRIGINELLI, 2018).
The neuropsychological evaluation analyzes the presence of behavioral alterations, resulting from neurological dysfunction or cognitive difficulty caused by developmental disorders, brain lesions or due to the aging process (COSTA et al., 2004).
For Cunha (2008) neuropsychological evaluation is a very complex type of psychological evaluation, as it requires a solid foundation of the professional in clinical psychology and familiarity with psychometrics as well as specialization and training in contexts where knowledge of the CNS and its pathologies is fundamental.
Mader-Joaquim (2018) states that neuropsychological evaluation consists of a detailed examination, which has the function of evaluating cognitive, linguistic, perceptual and psychomotor performance, aiming to relate this performance with the functional and structural conditions of the brain. For this, interview techniques, qualitative and quantitative examinations are used, and therefore a refined extension of clinical observation.
For neuropsychological evaluation, instruments are used that assess various cognitive domains. Second, Lopes and Argimon (2017) are included in the evaluation of intellectual skills (IQ), academic skills (aritmetics, reading, etc.), attention, mental flexibility, response inhibition, problem solving, reasoning, language comprehension, verbal fluency, verbal and verbal memory, spatial vision skills, speed and visual motor integration and cognitive processing speed.
To assess the different cognitive domains, the Neuropsychological Assessment includes several instruments common to various health professionals, such as interviews, observations and neuropsychological tasks. However, when neuropsychological assessment is performed by neuropsychologists with a background in psychology, the possibility of using psychological tests is added. Pursuant to § 1 of Art. 13 of Law No. 4,119/62, psychological tests are for the exclusive use of psychologists. The regulations on its use were published in CFP Resolution No. 002/2003. This resolution determines the standards under which tests are created, used and marketed (MICHALICK-TRIGINELLI, 2018).
3.2 NEUROPSYCHOLOGICAL EVALUATION OF OLD PEOPLE
Neuropsychological evaluation in the old should be carried out with caution, especially when investigating diagnostic situations, as it requires professional expertise in understanding the limits between normal aging, the presence of CLC and the emergence of medical conditions, taking into account individual particularities (FRAGA, 2018). In this sense Gil and Busse (2009) state that:
Population aging has raised concerns for clinicians, among them, to understand what is behind memory lapses. The elderly often complain about forgetting the names of known people, commenting that the name of objects is on the tip of the tongue and do not come up, do not remember the names of places they have attended; these are common complaints within an increasingly numerous list. It is enough to know whether these difficulties represent cognitive decline associated with aging, whether complaints are part of the diagnosis of Mild Cognitive Impairment (CLC) or whether they actually represent a degenerative condition of the central nervous system. Progressive deficit of memory and at least one other superior cortical function (language, executive function, praxia and visual function) makes the diagnosis of dementia that is clinical, but which requires confirmation of cognitive impairment, by detailed neuropsychological evaluation, especially in the initial phases, according to the criteria of NINCDS-ADRDA.
NINCDS-ADRDA, are criteria for the diagnosis of Alzheimer’s disease, proposed in 1984 by the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) and the Alzheimer’s Disease and Related Disorders Association and are widely used internationally (MCKHANN, 1984). These criteria are determinant for the presence of cognitive deficit and/or suspected dementia syndromes to be confirmed by neuropsychological examinations, before determining a clinical diagnosis of possible Alzheimer’s. The criteria also establish that the definitive diagnosis can only be confirmed through a histopathological examination (microscopic analysis of brain tissue) and also indicate the cognitive domains that may be affected by Alzheimer’s disease (AD) (BLACKER, 1994).
3.3 TYPES OF COGNITIVE DECLINE IN AGING
3.3.1 DECLINE IN NATURAL AGEING
Aging is a phenomenon that affects all human beings. Since it is a dynamic, progressive, irreversible process linked to biological, psychological and social factors (BRITO and LITVOC, 2004).
Normal aging is usually associated with cognitive decline, but without significantly compromising ADLs. This decline is probably related to the reduction of the speed of information processing and changes in some specific cognitive abilities, especially memory, attention, and executive functions (PETERSEN et al., 2001). Decarli (2003) describes the prevalence of memory complaints in the elderly as very frequent ranging from 22% to 56%, and among cognitive alterations is probably the most frequent complaint in this population.
Aging causes changes in the speed of information processing, providing an increase in the time to process data from: reading, comprehension and memorization (AlMEIDA and BERGER, 2007). It is also common to note the difficulty in activities that require flexibility and mental speed during the processing of information in the individual in the aging process (DE SOUZA et al., 2010).
Clemente and Ribeiro-Filho (2008) briefly describe the main types of memory, and the parts that may be affected during aging are:
a) episodic memory (wrapped with memories of a small story, or what you ate the night before, or what you did on the last birthday);
b) semantic memory (related to knowing the color of a lion or distinguishing a fork and a spoon);
c) memory of procedures, (related to driving a car or playing football);
d) Working memory (involved with performing mathematical calculations).
According to De Vitta (2000 apud FECHINE and TROMPIERI, 2015) during the aging process, the CNS is the system that suffers the greatest impairment, as there is a reduction in the number of neurons, changes in nerve conduction velocity and reflex intensity, as well as restriction of motor responses, reaction power and coordination capacity.
Gallahue et al., (2013) report that, between 20 and 90 years of age, the cerebral cortex suffers loss of 10 to 20% of mass. In other parts of the brain can occur damage of up to 50%. Thus, in the normal process as the brain ages, biochemical activity, performed by neurotransmitters, neuropeptides and brain hormones, also decline.
3.3.2 MILD COGNITIVE IMPAIRMENT (CCL)
In the concept of CCL, memory, attention, language, executive functions and visuoconstructive skills are involved. In this case, in addition to cognition, other elements should be taken into account, such as the performance of the old person and the absence of a demencial framework (PETERSEN, 2009).
The CCL in the elderly refers to the condition in which there is cognitive loss compared to normal aging (in the same age group), but do not meet criteria that characterize dementia. However, this construct has undergone changes in its definition over time, and is currently characterized as a transition stage between normal cognitive aging and a demencial syndrome (ARETOULI et al., 2013; PETERSEN, 2014; VAN DER MUSSELE et al., 2014).
According to Petersen et al. (2014), the criterion for ClC takes into account the preservation of global cognitive performance, without functional impairment that makes it impossible to perform ADl and there is no dementia. However, more recent articles have been reviewing these criteria, based on observations of patients with CLC who have minimal functional deficits, especially in performing more complex tasks (FORLENZA et al., 2013).
In this context, the CCL is now seen as a clinical syndrome with differentiated profiles. Biological and genetic issues, predictors of progression and comorbidities are aggregated (PETERSEN et al, 2014).
Currently, two main subtypes of CCL are described, amnéstico and non-amnéstico. The amnestic subtype is characterized by memory decline, especially episodic, and may exist in isolation (single domain amnéstic CCL), or present minor cognitive deficits in other domains such as; language, executive functions, or visuospatial skills (multiple domain amnéstico CCL) (ZHENG et al, 2012). In the second subtype (non-amnestic), memory is preserved, with one or multiple domains compromised (FICHMAN, 2013).
3.3.3 NEUROPSYCHOLOGY OF DEMENTIA
Dementia is defined as a syndrome of cognitive-behavioral decline that is manifested by the impairment of at least two mental functions, such as memory, language and visuospatial ability, of sufficiently severe intensity to compromise the autonomy of the patient in performing the activities of daily living (DE SOUSA and TEIXEIRA, 2014).
The main causes of dementia are neurodegenerative diseases. Alzheimer’s disease (AD) is the most frequent cause reaching 60% of all dementias (LOGIUDICE, 2002). The least frequent neurodegenerative causes include Levy body dementias (DCL) and frontotemporal (FTD). In addition to neurodegenerative diseases there are non-degenerative dementias, which belong to vascular dementia (DV), responsible for about 25% of cases and other less common, known as secondary dementias that include infectious processes (HIV-associated neurosyphilis), metabolic processes (hypothyroidism and vitamin B12 deficiency), and structural (tumor, hematoma and normal pressure hydrocephalus) (DE SOUSA and TEIXEIRA, 2014). Finally, there are several medical conditions that are associated with the presence of adverse symptoms, some of them will be described below.
Alzheimer’s disease (AD) – AD is a disease of unknown etiology, except in rare family cases, whose early onset is related to specific genetic mutation (HEYMAN et al., 1984). It is characterized by a progressive cognitive, behavioral and functional difficulty, especially in old age (REITZ and MAYEUX, 2014) and corresponds to about 60% of dementia cases (GALLUCCI NETO et al., 2005). The typical form of AD usually arises from the age of 65, with an initial symptom characterized by progressive anterograde episodic memory deficit. These amnesiac symptoms are directly related to the involvement of medial temporal regions, especially the hippocampus and the entorrine cortex (DE SOUSA and TEIXEIRA, 2014). On the other hand, the evolution of cognitive and behavioral symptoms of AD is related to the advancement of neurological alterations, which at the histopathological level, begins to present neurofibrillary tangles and senile plaques in the brain that gradually lead to the loss of synapses and neuronal death, whose clinical manifestations appear in the form of cognitive changes (VALLS-PEDRET et al., 2010).
AD has slow and insidious evolution, progressively impairing neurocognitive functions such as; orientation, planning, memory, language and judgment (HERRERA-RIVERO et al., 2010).
According to Cruz and Hamdan (2008), with the progression of dementia, the subject loses the ability to manage ADl (work, study, leisure, social life), and in more advanced stages, loses the ability to take care of personal hygiene and food, requiring help from a caregiver. Symptom severity increases as different segments of the brain are gradually injured (HERRERA-RIVERO et al., 2010). In this context, AD has three stages:
a) in the first stage the predominant clinical data is memory loss for recent facts, with memory preservation for remote facts. The patient has difficulty storing and retrieving information learned a few minutes ago. Forget names, don’t remember where you kept personal effects, and repeat the same question over and over again. However, cognitive abilities such as languages and praxias are preserved;
b) in the moderate stage, the impairment reaches other cognitive domains such as (language, recent and remote memories, visual abilities, as well as visual praxias). At this stage, patients are lost inside their own homes and have difficulty dressing and performing personal hygiene, and it is necessary to help perform ADl;
c) in the severe stage, all cognitive functions are severely impaired, presents ecolalia, palilalia and mutism, sphincter incontinence, may present generalized stiffness, difficulty swallowing and bed restriction (DE SOUSA and TEIXEIRA, 2014).
According to Poulin and Zakzanis (2002), life studies are still insipid, lacking specific markers for laboratory and imaging research.
Other authors have verified the difficulty in relation to a definitive diagnosis of AD, and that it can only be done from the histopathological investigation of the post-mortem brain (BRAAK and BRAAK, 1991).
Frototemporal dementia (FTD) – Consists of a grouping of neurodegenerative syndromes, which successively compromise behavior and/or language. FTD progresses faster than other neurodegenerative diseases and is characterized by changes in movement and/or language, and progressive changes in behavior associated with damage to executive functions. The word frontotemporal is a consequence of the degeneration of the frontal and temporal cortex, in the presence of conservation of the posterior areas of the brain at the beginning of dementia. FTD is more frequently manifested, in the age group of 50 to 60 years (FERNANDEZ-MATARRUBIA et al., 2014; GHOSH and LIPPA, 2015). However, in a significant number of people the demonstration takes place after the age of 80 (DE SOUSA and TEIXEIRA, 2014).
Clinically, FTD, since its beginning is characterized by neuropsychiatric symptoms, linked to personality alteration and social conduct disorder. In this situation, behavioral symptoms such as impulsivity, disinhibition, affective indifference, apathy and loss of social rules are presented.
These symptoms are related to the three areas of the frontal lobe (orbital, medial and dorsal), and their interaction with parallel circuits between them, the base nuclei and the thalamus (TEIXEIRA and CARDOSO, 2004).
Orbital behavior would be associated with disinhibition, impulsivity, and antisocial and stereotyped behaviors. Stereotyped or ritualistic behaviors can take different forms, from simple motor and verbal stereotypes, such as frequently repeating gestures and words, to complex routines. Medial involvement (cingulate cortex) correlates with apathy, passivity and tendency to social isolation. According to the progression of the degenerative process to the convexity of the frontal lobe and consequent dorsolateral dysfunction, changes in executive functions appear (DE SOUSA and TEIXEIRA, 2014).
According to Le Ber et al. (2006), clinically, FTD is not homogeneous, and may present three differentiated behavioral patterns that are; the apathetic (inert) forms, the uninhibited form, and the mixta. The apathetic and uninhibited forms are particularly distinguishable in early stages, while in advanced stages it is common to overlap the forms.
Neuropsychological evaluation is a useful tool for the diagnosis of FTD, as it investigates behavioral and cognitive peculiarities that enable the achievement of differential diagnoses (VALVERDE et al., 2009). On the other hand, the recognition of frontal or temporal atrophy, through neuroimaging, is insufficient to define a FTD (NEARY et al., 2005).
Dementia with Lewy corpuscles (DCL) – is a neurodegenerative dementia, which presents fluctuating cognitive decline, combined with extrapyramidal symptoms and visual hallucinations. Mental state fluctuations present recurrent episodes of delirium (acute confusional state), with interference in the level of consciousness and attention, with no apparent cause and variable duration (DE SOUSA and TEIXEIRA, 2014; GALLUCCI NETO, 2005).
The dehuman characteristics of The DCL have a rapid start and present noticeable deficits in executive functions, problem solving, verbal fluency and audiovisual performance. They present symptoms of parkinsonism such as hypomimia, bradykinesia, stiffness and resting tremor. But neuroleptics can aggravate parkinsonism rather than improve. In this classification, patients with Parkinson’s disease who became dementia (GALVIN, 2003) are excluded.
The neuropsychological profile of patients with CLD associates cortical and subcortical deficits. According to Cahn-Weiner et al. (2003) the presence of attentional, visospatial and visoconstructive deficits are quite accentuated in THE. These authors performed the test of the design of the clock in order to discriminate CLD in relation to AD, and found that although the scores for spontaneous design were similar, in the copy of the drawing the performance of patients with AD tended to improve and patients with CLD tend to maintain spatial organization errors. However, episodic memory is often less compromised in THE, and in adid tests, DCL patients benefit from clues (DE SOUSA and TEIXEIRA, 2014).
The specific pathophysiology of this dementia is the presence of Lewy corpuscles, which are hyaline eosinophilic inclusions, present in the cerebral cortex and brainstem in general, and pathological events related to AD, such as senile plaques and to a lesser extent tangles of neurofibrils (GALVIN, 2003).
Vascular dementia (DV) – DV are responsible for about 25% of dementia cases, being considered the second leading cause of dementia (KALARIA et al., 2008). Its diagnosis depends on the causal relationship between dementia syndrome and cerebrovascular disease. Clinical heterogeneity in DV is noted, since cerebrovascular disease conditions vary widely, ranging from small vessel disease (lacunar lesions and white matter lesions), large vessel disease (focal cortical lesions, or multiple lesions of borderline vascular territories) to intracerebral hemorrhagic lesions (BOWLER, 2003; AURIACAMB et al., 2008).
When defining dementia, memory impairment is classically prioritized (due to cortical involvement, as in AA (APA, 2000). However, a large number of patients present primary impairment in other cognitive domains. Patients with DV are affected by cortico-subcortical dementia syndrome, presenting initial symptoms of deficits in multiple executive or focal functions (ROMÁN, 2002).
Mixed dementia – this nosological entity is known to present typical AD and DV events at the same time. Pathological studies have suggested that more than one third of patients with AD present concomitantly vascular lesions, and the same proportion of patients with DV present pathological changes characteristic of AD (KALARIA and BALLARD, 1999).
There is a type of mixed dementia in which the patient with clinical symptoms of AD presents abrupt worsening associated with clinical signs of stroke, which is described as pre-stroke dementia (Henon et al., 2001)
Dementias associated with other neurovegetative disorders – a) Huntington’s disease (HD), a condition in which memory is affected in all aspects, and later arises aphasia, apraxia, agnosia and overall cognitive dysfunction; b) Parkinson’s disease; c) Creutzfeldt-Jakob disease (CJD), is the prototype of disease caused by prions, being an infectious and always fatal disease (GALLUCCI NETO et al., 2005).
Infectious dementias and other causation agents – Alcoholism; Neurocysticercosis; Herpetic encephalitis; AIDS-dementia complex; Neurosyphilis; Wernicke-Korsakoff syndrome (GALLUCCI NETO et al., 2005).
Reversible dementias – reversible dementias occur more rarely. However, its diagnosis is very important, since adequate treatment can reverse cognitive decline. The best known are: a) Normal pressure hydrocephalus (NPH); (b) Pelagra (caused by nicotinic acid (niacin) deficiency); c) Vitamin B12 deficiency; d) Hypothyroidism and; e) Depression (GALLUCCI NETO et al., 2005).
3.4 NEUROPSYCHOLOGICAL ASSESSMENT PROCESS IN THE ELDERLY
Due to cognitive decline and greater susceptibility to neuropsychiatric disorders in the elderly, a comprehensive study is necessary, involving evaluations of parameters such as language, motor coordination, perception and sensory conditions, abstraction capacity, reasoning, attention, calculation and memory.
Neuropsychological examination is essential in geriatric clinic. As described by Morais et al. (2010):
The neuropsychological examination presents numerous applications in geriatrics and aims to apply psychometrically validated and standardized tests for cognitive, functional and behavioral evaluation, identifying syndromes, medications, psychiatric disorders and cognitive deficits, as well as the impact on activities, work, social, family and leisure.
Cognitive assessment is fundamental both for the diagnosis and for the planning and execution of therapeutic measures as described in the text below.
The realization of cognitive assessment can be a useful instrument in the overall evaluation of the elderly patient, allowing the general practitioner, psychiatrist, neurologist or geriatrics to obtain information that supports both the etiological diagnosis of the picture in question, as well as the planning and execution of therapeutic and rehabilitation measures to be performed in each case. Unfortunately, this is not a routine practice in Brazil in health services in primary care, and even secondary, whether in psychiatry, neurology or geriatrics (AZAMBUJA, 2007).
The evaluation of cognitive screening is of fundamental importance in the evaluation of the mental health of the elderly population, since it presents greater vulnerability to the development of dementia, with a growing concern with the detection of problems that compromise its autonomy and functional capacity (AZAMBUJA, 2007; SCHLINDWEIN-ZANINI, 2010).
A neuropsychological evaluation of the elderly involves several steps, including (anamnesis, behavioral observation, general neuropsychological screening test, investigation of individual functionality, and specific assessment). In the next items will be described the sequence of neuropsychological evaluation in general.
3.4.1 ANAMNESE
Patient evaluation begins with anamnesis associated with behavioral observations. The anamnesis is oriented to obtain historical data and systematization of the reasons for the consultation and current symptoms (CARRETONI FILHO and PREBIANCHI, 2011).
3.4.2 NEUROPSYCHOLOGICAL TRACKING BATTERIES
After anamnesis it is recommended to perform neuropsychological screening batteries, since these are sequences of simple and fast tests in order to evaluate the behavioral and cognitive condition of the individual. Batteries are of fundamental importance to establish a basal cognitive profile, the evolution profile during and after treatments, as well as, help the differential diagnosis when there is cognitive impairment (SPREEN, 1998). Among these instruments, the CERAD battery (Consortium Estabilish of Alzheimer Disease) (MORRIS et al., 1993), which is widely used, because it evaluates memory (fixation, evocation and recognition), language (naming and verbal fluency), praxia (copying geometric drawings) and executive functions (testing of tracks).
The Mini Mental State Examination (ESME) is an important neuropsychological assessment instrument especially for the preliminary assessment of cognitive disorders of older people with more than 8 years of schooling (BERTOLUCCI et al., 2001).
The Mattis scale for dementia assessment (MDRS) (MATTIS, 1988) is composed of 36 items, distributed in five subscales that are: attention, initiation and persperation, construction, conceptualization and memory. The sum of the five subscales represents the degree of cognitive impairment and/or severity of the demencial condition (PORTO et al., 2003).
The test of the watch design is a quick feature (lasts on average 3 to 5 minutes) and reproduces the type of frontal and temporoparietal operation. Patients with normal MMSE scores may present severe functional limitations in the clock test, indicating that executive dysfunctions may precede memory disorders in dementia (ATALAIA-SILVA and LOURENCO, 2008).
The verbal fluency test (VF) is a complex cognitive task and very sensitive to all types of brain damage, pointing out, early, the processes of executive deterioration. The most used VF test is the semantic category (animals/minute), this is recommended by the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology (NITRINI et al., 2005).
3.4.3 FUNCTIONALITY RESEARCH TOOLS
In this category are several instruments used to evaluate the functionality of the elderly in relation to functional independence, and ADl. The instruments aim to measure performance in basic activities (feeding, bathing, clothing, personal hygiene, intestinal eliminations, bladder eliminations, use of the toilet, bed-chair passage, ambulation and stairs) among the tests are: a) Barthel index which is a widely used instrument in the world for the evaluation of functional independence and evaluates ADL (MINOSSO et al., 2010); b) Katz index, also called the Basic Activities index of daily living (ABDV) was developed by Sidney Katz, and to this day is one of the most used instruments in national and international gerontology studies (DUARTE et al., 2007); c) Kenny’s self-care index, is an instrument for evaluating instrumental activities of daily living, his tasks are grouped into six categories: locomotion, transfers, basic activities, clothing, personal hygiene and food (RIBEIRO, 2017); d) broad geriatric assessment (GAA); it is a multidimensional, systematic diagnostic process, whose objective is to determine the fragility of the elderly in relation to medical, psychosocial and functional problems, and to plan a comprehensive and long-term treatment and follow-up (RIBEIRO, 2017); e) brief functional evaluation of the elderly (AFB): it is an instrument to investigate evidence of loss of functionality that implies losses in the performance of daily activities (RIBEIRO, 2017).
3.4.4 SPECIFIC NEUROPSYCHOLOGICAL INSTRUMENTS
Anamnesis was performed, and initial behavioral observations are followed by testing through general batteries of screening and investigation on the functionality of the elderly and at the end the general profile of the individual is obtained. From this profile, one can expand the investigation using the tests that are necessary for clarifications and differential diagnoses. Here will be described some of the most commonly used tests:
a) Abbreviated Weschsler Intelligence Scale (WASI), for providing traditional scores of Verbal IQ, Execution IQ and Total IQ and evaluating cognitive aspects, such as: verbal knowledge, visual information processing, spatial and nonverbal reasoning, fluid and crystallized intelligence in various contexts (TRENTINI et al., 2014);
b) Psychological battery for attention assessment (BPA), which aims to assess the general capacity of care, as well as to carry out an individualized evaluation of the specific types of care (Concentrated, Divided and Alternating Care) (RUEDA, 2013);
c) Rey auditory-verbal learning test (RAVLT) this test aims to evaluate episodic declarative memory using the repetition of a list of words. It is a test is more appropriate for patients with mental disorders and neurological diseases in particular neurocognitive disorders (dementia and CCL). (DE PAULA and MALLOY-DINIZ, 2018);
d) Rey’s complex figures – this instrument can be used for the purpose of investigating visual memory, visual-spatial ability and certain functions of planning and execution of actions (DIAS, 2014).
In addition to these many other tests can be chosen for evaluation, depending on what was detected in the initial evaluation.
4. CONCLUSION
With the population increasingly aging, the neuropsychological evaluation of adults and the elderly, assumes a fundamental role, because the earlier the identification of alterations in the cognitive system (memory, language, perception and executive functions) and their relationships (from simple behaviors to those of greater complexity that require a lot of the brain), but soon therapeutic interventions will be made. It is possible to interfere in the quality of life of patients with deficits, delay clinical evolution and even reverse dementias considered reversible, reducing the dramaticity of damage during clinical evolution.
Neuropsychological evaluation allows early identification of cognitive disorders, their quantification and differentiation, follow-up during evolution, and qualifies therapeutic interventions.
For greater safety, the analysis should always take into account the patient’s schooling, premorbid states, use of medications or other substances that work in the CNS. In addition, one should consider the data obtained in the anamnesis, the impression in the observations of the behavior, as well as the data obtained in the tracking batteries and in the evaluation tests referring to the limitations of the patient. All this information will guide the choices of the appropriate tests and will give more security to the differential diagnosis of CCL, types of dementia, or even indicate whether the result obtained makes a natural decline.
In the end, natural cognitive decline, CLC, and the various types of dementia were described, as well as the importance of neuropsychological evaluation as a differential diagnostic tool in cognitive deficits, according to the proposed objectives. Given the importance of neuropsychological evaluation, it is suggested that further studies be conducted in this area, in order to seek new techniques, which increase the possibility of achieving more accurate results, and more objective responses, with positive consequences for patients.
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[1] PhD in Pathology experiences and compared – USP-SP.
Sent: June, 2020.
Approved: September, 2020.
