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Chronic use of mind altering substances can lead to a wide variety of neuropsychological deficits, affecting the domains of attention, learning, memory, reasoning. Executive functions such as working memory, cognitive flexibility and inhibitory control may specifically be impaired. These deficits can impact engagement in effective psychosocial interventions. Mild to moderate cognitive dysfunction may not be picked up in routine clinical examination or through commonly used tests like the mini-mental state examination (MMSE). Detailed neuropsychological tests, although extremely valuable, are time and human-resource intensive and are not readily available to the clinician. This study attempted to devise a brief cognitive screen (BCS- AUD) for alcohol use disorders. Ninety subjects who fulfilled ICD-10 criteria for alcohol use disorders were assessed on the MMSE and selective tests from the NIMHANS neuropsychological battery. While 79 (87.78%) of patients had adequate scores on the MMSE (>25), cognitive deficits were noted with relatively high frequency on finger tapping (92.22-93.33%), auditory verbal learning test delayed recall AVLTDR (37-63%) and Tower of London 5 move subtest (42%). Statistically significant associations were found between MMSE and Digit symbol total time (0.05), Finger tapping right hand (0.01), Tower of London total number of problems solved with minimum moves (TNPSMM) (0.05), Verbal working memory two back hits (VM2BKHIT) (0.01), AVLTDR (0.01), and complex figure test-copy (0.01). Principal component analysis helped to identify three tests that merited inclusion in the BCS-AUD, namely Finger Tapping Test, Verbal Working Memory N Back Test and Auditory Verbal Test (AVLT). The utility of the BCS-AUD in identifying cognitive dysfunction in other substance use disorders needs to be examined. Patients rating positive on the cognitive screener would require in-depth evaluation, monitoring and remediation.
Neuropsychological tests are specifically designed tasks that are used to measure a psychological function known to be linked to a particular brain structure or pathway.[1] Tests are used for research into brain function and in a clinical setting for the diagnosis of deficits. They usually involve the systematic administration of clearly defined procedures in a formal environment. Neuropsychological tests are typically administered to a single person working with an examiner in a quiet office environment, free from distractions. As such, it can be argued that neuropsychological tests at times offer an estimate of a person's peak level of cognitive performance. Neuropsychological tests are a core component of the process of conducting neuropsychological assessment, along with personal, interpersonal and contextual factors.
Aims: To pilot a neuropsychological battery for diagnosing dementia and provide normative scores in an elderly Sri Lankan sample. Materials and Methods: Consecutive subjects over the age of 60 yrs were administered tests assessing the individual domains of language, verbal episodic memory, visual perceptuospatial skills and executive functions in the Sinhala language. Results: There were a total of 230 subjects in the final sample. The mean age of the entire sample was 69 years, mean education level was 12 years and the sample comprised 53% female. One -month test-retest reliability ranged from 0.71 to 0.85 for the various tests. Most tests were significantly influenced by age and education level but not gender. The exceptions to this were some language subtests (repetition, grammar comprehension and word picture matching) and two tests of executive functioning (maze completion and alternate target cancellation), which were uninfluenced by age. The subtests where ceiling performance was attained by almost all subjects were repetition, grammar comprehension and word picture matching from the language domain, dot position discrimination from the visuospatial domain and maze completion test from the executive function domain. Scores for various tests after stratifying subjects by age and educational level are given. Conclusions: The tests were well received and could provide a basis for cognitive profiling in similar settings elsewhere.
Such a neuropsychological battery can also been used with appropriate norms to diagnose cognitive impairment in patients with epilepsy, stroke and Parkinson's disease. In Sri Lanka as opposed to neighboring countries like
Cross-cultural norming of neuropsychological tests can involve either adapting existing tests to suit the local population or tests can be newly developed and tested for reliability and validity. We have chosen both the above methods to develop and norm a neuropsychological battery for dementia.
and had voluntarily offered to undergo the cognitive test battery. These subjects were relatives or spouses of patients attending the orthopedic or general medical outpatient departments. They were initially screened by a board certified doctor for neurological (stroke, epilepsy, head trauma or Parkinson's disease) or psychiatric disease (depression, psychosis or alcoholism) and visual or hearing impairment that might affect performance on the neuropsychological test battery. They were also administered the Concise Cognitive Test (CONCOG), a brief cognitive test, and only those scoring above 23/30 were included.161 Depression was screened for by the Patient Health Questionnaire-2 and any participant scoring > 3 out of 6 was excluded.171 We did not exclude subjects with the mere presence of vascular risk factors such as hypertension, diabetes or hypercholesterolemia as that would have resulted in the creation of a \"super normal\" sample. All subjects gave written informed consent and the study was approved by the ethics review board of the hospital.
A subset of 30 participants were administered the entire neuropsychological battery twice at 1 month interval and test-retest reliability was calculated. It ranged from 0.71 to 0.85 for the various tests. Inter-rater reliability was not calculated as all the tests were administered by only one of the authors (QJ).
In fact, the largest normative neuropsychological study so far, the 10-66 study across India, China and Latin America, also concluded that gender had negligible effects on test performance.[9] The strongest effect of age was on word list memory and this has also been the case with the 10-66 study. On the other hand, in the present study, education had a significant effect on semantic verbal fluency as well as memory. The study by Gureje et al. in Nigeria also showed a similar effect of education on the CERAD word list learning and recall test, which is similar to the 10-66 word list test adapted for this study.[14] However, in the Singaporean validation of the RBANS battery, executive function tests and tests of attention were affected to the greatest degree by age and education in addition to memory.[16] Our results are not in agreement with the above study probably because of the varying tests used for the assessment of executive skills and differing education levels.
There are a few limitations to this study. This was a relatively well-educated sample (mean years of education: 12 yrs) and we did not include rural elders in the test sample. This might significantly limit the applicability of this cognitive test battery to other areas of Sri Lanka and neighboring countries. Nevertheless, this sample is representative of the type of patients encountered at most private hospitals in urban areas. We also could not have tests for visual memory and praxis, which could have made the battery a comprehensive stand alone instrument. Deriving robust norms for most neuropsychological tests would mean repeat testing at yearly intervals and weeding out patients who subsequently develop mild cognitive impairment or dementia.[21] This was not however possible in the present study which was only cross-sectional.
To the best of our knowledge, this is the first normative study of a neuropsychological test battery in the elderly in Sri Lanka. It remains to be seen how this battery performs in similar settings within Sri Lanka and the neighboring countries.
14.Guruje O, Unverzargt FW, Osuntokun BO, Hendrie HC, Baiyewu O, Ogunniyi A, et al. The CERAD neuropsychological test battery: Norms from a Yoruba-speaking Nigerian sample. West Afr J Med 1995;14:29-33.
How to cite this article: Srinivasan S, Jaleel Q. Norms for a neuropsychological test battery to diagnose dementia in the elderly: A study from Sri Lanka. J Neurosci Rural Pract 2015;6:177-81. Source of Support: Nil. Conflict of Interest: None declared. 153554b96e
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