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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 42-45

Higher mental functioning in dementia: A status assessment


1 Department of Psychiatry, B. P. Koirala Institute of Health Sciences, Dharan, Nepal, India
2 Department of Geriatric Mental Health, KGMC, Lucknow, Uttar Pradesh, India

Date of Web Publication23-Jul-2015

Correspondence Address:
Dr. Rajesh Kumar
B P Koirala Institute of Health Sciences, Dharan, Nepal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-9995.161382

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  Abstract 

Background: Of the higher mental functions, certain deteriorate earlier than others. The relative deterioration of the different higher mental functions in dementia patients would be of interest to investigate.
Aim: We intended to study the status of higher mental functioning in dementia patients.
Materials and Methods: Household screening of a randomly selected ward, Musahebganj of urban Lucknow generated 1,216 elderly people aged >55 years. After taking the informed consent to participate in the study, all the subjects were screened using the Mini Mental Status Examination (MMSE) for cognitive disorders. Age and education specific cut-off criteria were used to find out MMSE positive subjects. MMSE positive subjects were assessed in detail using the Cambridge Examination for Mental disorder in the Elderly-Revised instrument.
Result: Fifty patients were diagnosed to have dementia as per the international classification of diseases-10 criteria. The study demonstrated that the higher mental functioning especially visual reasoning, ideational fluency, and memory are maximally affected in dementia patients.
Conclusions: The deterioration in higher functioning is usually seen in dementia. The mental functioning relates with each other and is interrelated, leading to overall deterioration.

Keywords: Cambridge examination for mental disorder in Elderly-Revised, dementia, Mini mental status examination


How to cite this article:
Kumar R, Koirala P, Tiwari SC. Higher mental functioning in dementia: A status assessment. J Geriatr Ment Health 2015;2:42-5

How to cite this URL:
Kumar R, Koirala P, Tiwari SC. Higher mental functioning in dementia: A status assessment. J Geriatr Ment Health [serial online] 2015 [cited 2019 Dec 15];2:42-5. Available from: http://www.jgmh.org/text.asp?2015/2/1/42/161382


  Introduction Top


Deterioration of higher mental functioning in dementia is characterized by a significant deficit in all cognitive domains though not all are affected to the same extent. The risk of dementia is known to increase significantly when cognitive impairment is present. [1],[2] The deficit in abstract thinking, visual reasoning, ideational fluency, perception, recognition are so evident and affect individual's ability to follow simple day to day tasks and commands accurately. Impairment in language is also present, such as repetition of words (echolalia), perseveration, and nonverbal activity.

It was reported that there is a greater degree of decrement in the new memory and lesser degree in recent and remote memory of dementia patients. Domains of higher mental functioning such as executive function, ideational fluency, praxis, visual reasoning, perception, language, and other cognitive decline slow down as the disease progress. [3]

There are certain higher mental functions, which deteriorate faster than others in dementia patients. Knowledge of this can help to prioritize target symptoms for their management and rehabilitation. The present study is an attempt to identify the status of higher mental functioning in dementia patients.


  Materials and Methods Top


Household screening of a randomly selected ward, Musahebganj of urban Lucknow generated 1,216 elderly people aged >55 years. After obtaining the informed consent to participate in the study, a semi-structured proforma of sociodemographic and personal history, socioeconomic status (SES) scale [4] were administered on all the subjects. All the subjects were screened using the Mini Mental Status Examination (MMSE) for cognitive disorders. Age and education specific cut-off criteria were used to find out MMSE positive subjects. [5] MMSE positive subjects were assessed in detail using Cambridge Examination for Mental disorder in the Elderly-Revised instrument (CAMDEX-R). [6] Deficits in higher mental functioning of dementia patients were tabulated on the domains of CAMDEX-R. That is "recognition, recent and remote memory, attention and concentration, language, recall, abstract thinking, ideational fluency, visual reasoning and perception."


  Tools Top


Following tools were administered to arrive at the study sample:

  1. Household screening form for identification of houses where individuals aged 55 years and above were permanently residing, proforma of sociodemographic, and personal history, SES scale. [4]
  2. Screening schedules for "in" individuals aged 55 years and above to identify dementia suspects:


Mini Mental Status Examination [7] : Following criteria were used for MMSE positivity [Table 1].
Table 1: Age and education specific cut-off criteria for the MMSE (Crum et al., 1993)

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Cambridge Mental Disorders of the Elderly Examination Revised [6] : The following cut-off scores were used for different domains of Higher Mental Functioning on CAMDEX-R [Table 2].
Table 2: The cut-off score were given in following table for severity

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  Results Top


The sample for this study consisted of 50 patients diagnosed with dementia. Distribution of the subjects is given in [Table 3] and [Table 4].
Table 3: SES, age, and sex wise distribution of dementia patient

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Table 4: Age and education wise distribution of dementia patient

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[Table 3] shows that out of total 50 diagnosed dementia patients maximum cases belongs to lower SES (48%) followed by middle (46%) and only 6% cases from upper SES.

More females (54%) were diagnosed with dementia than males (46%). Maximum cases (46%) belonged to 60-69 years of age group followed by 70-79 years of age group (32%) and >80 years (18%). In all the age groups, there were more females than males, except for the age group of 70-79 years.

[Table 4] shows age and education wise distribution of dementia patients. Of total 50 dementia patients' maximum subjects (74%) were illiterate followed by educated up to tenth level (12%), up to college (8%), and up to eighth level (6%). All the illiterates of the age range 55-59 years of the age group were demented and all the subjects educated up to college level belongs the age range of 60-69 years of age.

[Table 5] shows the level of cognitive impairment on the domains of higher mental functioning in the patient of dementia. Maximum number of elderly were found to be mildly impaired in the areas: "Attention and concentration" and "recall" (56%), followed by "recognition" (54%), "language" (50%), "perception" (48%), "recent and remote memory" (40%), "abstract thinking" (36%), "ideational fluency" (26%), and "visual reasoning" (18%).
Table 5 : show the severity of function in different domains in dementia

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The moderate level of impairment in higher mental functioning was found to be maximum in the area of "ideational fluency" (40%), followed by "recent and remote memory" (38%), "abstract thinking" (34%), "recall" (28%), "perception" (22%), "attention and concentration" (20%), "language" (18%), "recognition" (14%), and "visual reasoning" (12%) in elderly.

Severe impairment was seen "visual reasoning" (70%), other areas with severe impairment were "ideational fluency" (34%) followed by "recognition", "language" (both 32%), "abstract thinking," and "perception" (both 30%) and attention and concentration.


  Discussion Top


The study demonstrates that the higher mental functioning especially visual reasoning was maximally affected in dementia patients. It may because of the visual problem (cataracts) among the elderly. Nirmalan et al., [8] reported about 20% of adults over age 40 have signs of developing cataract. Therefore, adequate precaution should be taken to administer visual reasoning items.

Another major finding indicates "attention and concentration" and "recall" were mildly impaired to a similar extent. Alzheimer's disease studies also indicate that impairment in attention and executive functions at the earliest phase of the disease are common. [9],[10]

Mild level of impairment was found in recognition and language. Other finding also suggests that the maximum mild level of impairment is found in "perception." Studies also suggest that the executive function, perception, and language capacities become impaired as the patient progress, into the dementia phase of the disease. [10] The maximum level of impairment in mild level on "recent and remote memory." Regarding memory, Sacuiu et al., [11] found that mild memory disturbance is a first symptom of dementia, while a more global pattern of low cognitive performance emerges closer to clinical diagnosis.

Minimum impairment was found in "recall", "recent and remote memory," and "attention and concentration." The area of Ideational fluency was minimally affected. The dementia patients were similarly affected in severe level on the domains of abstract thinking, perception, recognition, and language.

There have been no studies of the natural history of the cognitive decline in dementia, and little is known about the range, rate or extent of cognitive deterioration in the stage of the disease. The present study is a novel attempt to study the nature of decline in different domains of higher mental functioning among urban dementia patients. The findings suggest for more elaborate and systematic studies in the area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Chen P, Ratcliff G, Belle SH, Cauley JA, DeKosky ST, Ganguli M. Cognitive tests that best discriminate between presymptomatic AD and those who remain nondemented. Neurology 2000;55:1847-53.  Back to cited text no. 1
    
2.
Guarch J, Marcos T, Salamero M, Blesa R. Neuropsychological markers of dementia in patients with memory complaints. Int J Geriatr Psychiatry 2004;19:352-8.  Back to cited text no. 2
    
3.
Katzman R, Terry R, DeTeresa R, Brown T, Davies P, Fuld P, et al. Clinical, pathological, and neurochemical changes in dementia: A subgroup with preserved mental status and numerous neocortical plaques. Ann Neurol 1988;23:138-44.  Back to cited text no. 3
    
4.
Tiwari SC, Kumar A, Kumar A. Development & standardization of a scale to measure socio-economic status in urban & rural communities in India. Indian J Med Res 2005;122:309-14.  Back to cited text no. 4
    
5.
Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:2386-91.  Back to cited text no. 5
    
6.
Roth M, Tym E, Mountjoy CQ, Huppert FA, Hendrie H, Verma S, et al. CAMDEX. A standardised instrument for the diagnosis of mental disorder in the elderly with special reference to the early detection of dementia. Br J Psychiatry 1986;149:698-709.  Back to cited text no. 6
[PUBMED]    
7.
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.  Back to cited text no. 7
[PUBMED]    
8.
Nirmalan PK, Robin AL, Katz J, Tielsch JM, Thulasiraj RD, Krishnadas R, et al. Risk factors for age related cataract in a rural population of southern India: The Aravind Comprehensive Eye Study. Br J Ophthalmol 2004;88:989-94.  Back to cited text no. 8
    
9.
Parasuraman R, Haxby JV. Attention and brain function in Alzheimer′s disease: A review. Neuropsychology 1993;7:242-72.  Back to cited text no. 9
    
10.
Perry RJ, Hodges JR. Attention and executive deficits in Alzheimer′s disease. A critical review. Brain 1999;122 (Pt 3):383-404.  Back to cited text no. 10
    
11.
Sacuiu S, Gustafson D, Johansson B, Thorvaldsson V, Berg S, Sjögren M, et al. The pattern of cognitive symptoms predicts time to dementia onset. Alzheimers Dement 2009;5:199-206.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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