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REVIEW ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 29-35

Neuropsychological assessment of cognitively impaired Indian elderly: Challenges and implications


1 Department of Psychiatry, Career Medical College, Lucknow, India
2 Department of Geriatric Mental Health, KG Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication6-May-2016

Correspondence Address:
Nisha Mani Pandey
Department of Geriatric Mental Health, KG Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-9995.181912

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  Abstract 

Cognitive impairment in elderly is a challenging issue which needs proper attention, care and management. Neuropsychological assessments (NA) are those authentic measures that help not only in narrowing down the differential diagnosis of cognitive dysfunction, but also assist in choosing treatment modalities, evaluating the efficacy of an intervention and to assess outcome. NA may also define the patient's functional limitations or cognitive strengths. Therefore, appropriate application of NA can improve the quality of care and management of an elderly with cognitive impairment. NA has many applications as it provides full understanding about the individual and his environment. However, in India there are many challenging issues regarding Na, which are discussed in the present article.

Keywords: Challenging issues, cognition, cognitive impairment, neuropsychological assessment, strategies


How to cite this article:
Tiwari S, Pandey NM, Singh P, Tiwari SC. Neuropsychological assessment of cognitively impaired Indian elderly: Challenges and implications. J Geriatr Ment Health 2016;3:29-35

How to cite this URL:
Tiwari S, Pandey NM, Singh P, Tiwari SC. Neuropsychological assessment of cognitively impaired Indian elderly: Challenges and implications. J Geriatr Ment Health [serial online] 2016 [cited 2019 Sep 23];3:29-35. Available from: http://www.jgmh.org/text.asp?2016/3/1/29/181912


  Introduction Top


Cognition is the process by which information is organized and recognized. Alteration in cognition with age is well-documented and affects a broad range of functions including intelligence, attention, language, memory, orientation, executive function, speed, etc. [1],[2] Deterioration in cognitive abilities and functional losses are common in Elderly (individuals aged 60 years and above), [3] and cognitive deficit increases with age significantly. [1],[4],[5] Further, cognitive impairment negatively affects self-independence, wellbeing, and quality of life. Thus, effective management of an elderly with cognitive impairment requires a full understanding of baseline and functional cognitive status. This is not only about enquiring about the chief complaints and challenges faced by an elderly, but also about the strengths/weaknesses that one possesses and developing management strategies to modulate these skills to optimize daily functioning and overall quality of life. Neuropsychological assessment (NA) is an authentic method for evaluation, planning, and managing treatment.

NA is a meticulous measure for evaluating one's cognitive, psychological/emotional, and behavioral functioning in a comprehensive manner. It is a standardized and objective technique which measures functional processing of various parts of the brain, and can also provide evidence for different types of damage or disease which ultimately affects a person's behavioral and emotional state. NA assesses change over time in relation to the deterioration of progressive illness or improvements due to recovery or following various kinds of treatment. [6] NA requires the use of rigorously standardized tests and scales with sound psychometric properties that allow quantification of impairments. These assessments can help in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis.


  Role of Neuropsychological Assessments for Evaluating Cognitively Impaired Elderly Top


NA comprehensively assesses a range of cognitive domains including intelligence, learning, memory, receptive and expressive language, visuospatial reasoning, motor functioning, executive functioning, and psychopathology. [7],[8],[9] In general, NA tools incorporate both verbal and nonverbal items for assessment of various cognitive domains of the population in general and also for the elderly. Thus, it is a decisive technique for identifying cognitive decline associated with dementia and related disorders. [10],[11] Further, in addition to neurocognitive disorders like Alzheimer's Disease (AD) and other dementias, other neuropsychiatric conditions like schizophrenia, mood disorders, substance abuse, and sleep disorders are also associated with some degree of neurocognitive impairment. [12] Thus, usage and application of NA play a significant role in assessing functional status of the elderly.

Until neuroimaging techniques were not invented/widely in use, NAs were generally applied to assess the extent of impairment of a particular skill. One of the fundamental uses of NA was to locate the functionally impaired areas of the brain due to brain injury or neurological illnesses. With the advent of neuroimaging techniques, the location of space-occupying lesions can now be accurately determined and thus, the focus of NA has now shifted to Measurement of cognition and behavior and also to determine the effects of any brain injury or neuropathological process. Besides its clinical and therapeutic uses, NAs also help in solving medicolegal issues of elderly. Thus, the relevance and role of NA for assessment of elderly mental health problems with special reference to diagnosing dementias and memory complaints or the identification and localization of the brain lesions are widely recognized and expanded. [13] A neuropsychological evaluation can help in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis. Further, in patients with documented neurologic disorders, information from a NA can define the patient's functional limitations or residual cognitive strengths, and its application and subsequent management of deficits can improve the quality of care of the elderly.

Differentiating between normal age-related cognitive decline and disease-associated cognitive impairment in clinical practice can be challenging. In such situations, the clinicians need to recognize the modest changes in thinking abilities of the older adults as these changes may be an early warnings of neurocognitive disorders. An objective assessment of cognitive functioning is also useful for differential diagnosis, assessing presence and progression of cognitive disorders, and providing information relevant to treatment and planning.


  Need of Neuropsychological Assessment for Evaluating Cognitively Impaired Elderly Top


In general, referral to neuropsychological services is often made by a neurologist or psychiatrist. A referral for NA to evaluate cognitive functioning of an elderly patient can be considered:

  • To confirm and determine cognitive impairment.
  • To get information about patient's strength and weaknesses related to emotional state and cognitive abilities.
  • To facilitate the diagnostic process and clarify the impact of a particular disease.
  • To differentiate between various diagnoses and to discriminate various etiologies of dementias and cognitive impairment.
  • To assess the progression of cognitive decline.
  • To measure the outcome of a particular therapy or an intervention.


In India, where the total population of elderly is 103 million (8.6% of total population) [14] around 3.7 million (3.6% of total population) [15] have one or the other cognitive disorder, NA related services are an important necessity.


  Clinical Indications and Process to be Adopted for Evaluating Cognitively Impaired Elderly Top


On the basis of clinical indications [Table 1], one may consider to apply the NA measures to evaluate particular problem/s.

Through NA, one can assess a variety of functions including neurocognitive, behavioral, and emotional functioning. For assessment of cognitive functioning, one needs to select, administer, and interpret the neuropsychological tests appropriately. Hence, NA is a three-tier process including:

  1. Appropriate selection of valid and reliable tools
  2. Skillful administration and
  3. Scientific interpretation.


A thorough neuropsychological examination includes a comprehensive battery of tests. Such measures may be reliably replicated by various examiners and also be repeated over time to assess the course and outcome of an illness. In elderly, these evaluations are done for confirming clinical diagnosis, supporting early diagnosis, understand severity of symptoms, making prognosis, planning therapeutic/management/rehabilitation strategies, monitoring changes, assessing improvements/outcome, providing certificates of ability/disability, and carrying out researches, etc. NA measures consist of various psychometric properties including consistency, reliability, validity, and norms. These measures consist of various vehicles to carry out the assessments including paper and pencil tests, verbal tasks, structured and unstructured interviews, and computerized and constructional tasks. The following steps need to be adopted for NA of an elderly.
Table 1: Clinical indications for neuropsychological assessment*


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  1. Identification of tool: First of all, one needs to identify the particular tool/test which is to be applied
  2. Screening: Through screening the neuropsychologist/assessor can provide objective evidence to discern probable presence or absence of a particular psychopathology
  3. Detailed assessment: Detailed assessment on a particular tool provides objective evidence to confirm the presence or absence of a psychopathology
  4. Scoring: Scoring on each and every item of the tool is an important task. One needs to be careful while scoring items of a particular tool
  5. Analysis and interpretations: For providing meaning to the obtained scores, analyses of the scores are done on the basis of the available manual and norms. Further, interpretations of the scores are done for making an impression/diagnosis.



  Challenges in Application of Neuropsychological Assessment in Evaluating Cognitively Impaired Elderly Top


Neuropsychological evaluation helps in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis. [11] It needs advanced assessment tools and specialized training to apply, analyze and interpret the results. There are several challenges in the application of NA:

  1. Accessibility of screening and assessment tools: One of the major challenges in applying the tools can be realized after having a quick view of the available significant NA tools for evaluating cognitive impairments of Indian elderly [Table 2]. Unfortunately many of these NA tools are copyrighted and available as paid access limiting their use and application.
  2. Cultural appropriateness: Culturally appropriate NA tools for assessment of cognitively impaired elderly are essential for maintaining and managing their mental health care needs. Unfortunately, most of the screening and assessment tools have been developed in Western countries and adopted for use in India. During the process of adaptation, the items of individual tools are translated into Hindi or other regional languages and applied after validation. This practice does not provide culturally appropriate tools as there are significant sociocultural differences between Indian and Western cultures. Thus, many of items of these tests become irrelevant and other culturally appropriate aspects are missed.
  3. Challenges of normative data: Cultural influences on NA are important factors to interpret the test performance. [3] Meaningful interpretation of any NA tool can only be done when culturally appropriate norms are available or known. For example - most of the tools related to activities of daily living/instrumental activities of daily living developed in Western countries have items assessing activities of daily living skills like cooking and familiarity with use of household appliances. This is unlikely to be adaptable to the standard cultural norms of the Indian elderly population. Further, most of the tools have been developed on the basis of majority members of the society, and, therefore, the developed norms correlate to the majority. In such a situation, the minority remains neglected, and often they get poorer scores than the norm. Clinically, however, this does not imply that the particular groups of individuals lack the assessed skill.
  4. Challenges of analysis and interpretation: The analysis and interpretation of any of the NA tools need to be carefully prepared considering the background of subject's age, education, sex, and socioeconomic status. These issues often affect test performance and the form of conclusion. An illiterate elderly who has never used any kind of paper or pencil may be unable to perform a simple task of drawing a circle or clock or square and, therefore, the analysis related to such items should be done considering the subject's limitations
  5. Challenges of skilled professionals: The literature reports that the overall numbers of clinical psychologists against the need are not up to the mark and neuropsychologists for the evaluation of elderly are negligible [15],[45]
  6. Other challenges: Lack of awareness, understanding, and knowledge regarding NAs make it more challenging for professionals to apply them. Also, as NP tools can be extensive and detailed, patient participation and appreciation of their utility in assessment and management of the conditions are essential for accurate reporting.
Table 2: Some significant NA tools for assessing cognitive impairment of Indian elderly

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  Suggestions and Strategies to Improve Neuropsychological ASSESSMENT Services for Evaluating Cognitively Impaired Elderly Top


NA has an important role in assessment and management of elderly patients with cognitive deficits, and several measures can be taken to improve the clinical use and availability of NA services. Following strategies may be adapted:

  1. Adaptation of available tools for Indian settings.
  2. Development of culturally validated and appropriate NA tools as per Indian context
  3. Plan, develop, and carry out multi-centric and multilingual research studies to derive normative data for various domains of cognition, emotion, and behavior, so that variations could be minimized
  4. Parameters for different sub-groups of elderly population should also be derived so that problems of elderly could be measured properly, and management could be done in a better manner
  5. Practical aspects need to be considered, that is, literacy level of the subject, socio-economic status, etc.
  6. There is an urgent need to improve the availability of trained professionals, and this requires enhancement of resources as well as increased availability of training for existing professionals
  7. To improve understanding of the need for such detailed NA testing, greater emphasis to be placed on education/awareness among patients and their relatives/caregivers.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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