Dementia: Update for the Practitioner

Neuropsychology of Mild Cognitive Impairment,
Alzheimer's Disease, Dementia with Lewy Bodies,
and Frontotemporal Dementia
Penne Sims, Ph.D.

Protocol of a Declining Patient


	Predicting Decline

Patient protocols are very useful models for understanding the kinds of cases and issues you are likely to face. The first one I will present is HW, whom I saw on two consecutive evaluations. HW is a 74-year-old German man with 18 years of education. German is his first and predominant language at home, but he does speak English, and he preferred to be tested in English.

Intellectual testing gives us two different IQ scores: verbal and nonverbal or visuospatial scores. HW scored an 86 on his verbal IQ, which is low average, while his performance IQ was 104, which is average. This is not a typical discrepancy, but I think in this case this was due to language bias.


Neuropsychological Profile of MCI to AD (HW)
	02/01/01	03/13/02
mMMS	47/57	37/57
VIQ	86 (lang.)	N/A
PIQ	104	N/A
SRT-LTS	1%ile	<1%ile
CLTR	5%ile	2%ile
Trial 6	5/12	4/12
Delay	2/12	0/12
Recog	8/12	4/12

The results of two evaluations of 74-year-old patient HW, taken approximately one year apart. HW was diagnosed with MCI progressing to Alzheimer's disease. Courtesy of Penne Sims, Ph.D.

We should notice first that his initial modified Mini Mental Status exam, mMMS, score was 47 out of 57, which translates to a Folstein MMSE of 25 out of 30. This is at the cusp of the cutoff for concern. A year later his mMMS declined 10 points, which translates to 19 out of 30 on the Folstein MMSE. This is a significant and dramatic decline. It is important to remember again that the MMSE is very heavily weighted on verbal items, and German is HW's predominant language, so there may be some language bias involved in his decline.

If we look at Selective Reminding Task (SRT), a word-list learning task, HW initially had difficulty learning any of the words. On the sixth of six trials he was only able to learn only 5 of 12 words. After a 15-minute delay he recalled only 2 words, but he recognized 8 of those 12 words. A year later there was very little change in these results, because his results were already near floor levels; there was a bit of a decline on delayed recall, and he did not benefit quite as well from recognition cues.

His visual memory was relatively intact when initially assessed. He scored above average on immediate recall of geometric figures (VRI), and within a thirty-minute delay (VRII), he was still in the low-average range but he still retained some of what he learned. A year later his immediate recall fell from above-average to average. The biggest change was in his delayed recall of visual information, which fell to the borderline range.

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