The Role of Neuropsychological Testing In Guiding Decision Making related to Dementia

By Scott Knight, Director and Konstantine K. Zakzanis, PhD., C. Psych.

“74-year-old driver plowed his SUV through a crowded intersection and into a group of people waiting for the bus in Montreal… killing two bystanders and sending pedestrians hurtling through the air ‘like bowling pins’… the driver struck eight pedestrians in all” (1)

“87-year-old man drove his car through a crossed street market in Santa Monica, California, killing 10 people…” (1)

 

News stories like these seem to be occurring more frequently, sparking renewed debate over whether North America’s aging population poses a public-health hazard on the roads. According to Transport Canada, seniors have a higher annual fatality rate than younger drivers and, measured by distance driven, old drivers are involved in accidents out of proportion to their numbers.

 

The debate over the reliability of aging motorists usually includes discussion about the diseases and other health issues that are often part of the aging process. In particular, dementia is cited as a growing concern. In your role as an insurance adjuster, understanding dementia and how you can assist clients who may be suffering from dementia is likely to become more pertinent.


Aging Population & Rising Incidence of Dementia


As the population continues to age, by 2011 the oldest Baby Boomers (those born in 1946) will reach 65 and the proportion of people aged 65 and over will start to increase rapidly. This shift in the population size of the elderly will have far-reaching effects, especially on our healthcare system.

 

A major issue facing us in the future is the incidence of dementia. More than fifty percent of the residents in nursing homes are affected by dementia. One in every 13 seniors over the age of 65 has Alzheimer's, the most common form of dementia. By age 85 one-third have some form of dementia and by age 95 more than half do.

 

In July 2004, the Canadian Psychiatric Association published a research paper in the Canadian Journal of Psychology called Driving and Dementia in Ontario: A Quantitative Assessment of the Problem.


The findings indicate that:


      • The number of senior drivers (i.e. those 65 years or older) will increase from just under 500,000 in 1986 to nearly 2,500,000 in 2028. As the number of seniors on the road rises, so too will the number of drivers with dementia.
      • By 2028, there will be nearly 100,000 drivers with dementia in Ontario.
      • Although not all drivers with dementia are necessarily dangerous, most of these drivers will continue to drive as the disease progresses, increasing the likelihood that the dementia will eventually affect their driving ability.
      • The Ministry of Transportation does not require any remedial driver testing until age 80. In addition, the testing does not screen for dementia deficits related to driving or screen any population exhibiting possible deficits under the age of 80.
      • Increasingly, the responsibility for identifying drivers with dementia is falling on the healthcare system; a role the system was not designed for and is not equipped to handle.

 

The findings also recommend that the risks associated with the dramatically increasing number of drivers with dementia demand a psychometrically sensitive and efficient screening procedure. An effective approach in guiding decision making related to dementia is the use of neuropsychological testing. An understanding of the progressive nature of dementia highlights the importance of early intervention through neuropsychological testing.


Understanding Dementia


Dementia is an acquired condition of intellectual impairment produced by brain dysfunction (e.g. Alzheimer’s). Its prevalence is rapidly increasing and adequate care for this growing population requires a well-informed approach to diagnosis and management.

 

Dementia can be defined as an acquired persistent impairment of intellectual function that affects at least three of the following areas of mental activity:


      • Language
      • Memory
      • Visuospatial skills
      • Emotion/Personality
      • Cognition (i.e. abstraction, calculation, judgment, executive function, etc.)

 

Depending on the type of dementia (e.g., Alzheimer’s, frontal lobe dementia, etc.), cognitive deficits in the early stages may vary, however, it is important to note that regardless of the specific type of deficit(s), they are progressive.

 

Although individuals with the early stages of dementia often continue with day-to-day activities, such as housekeeping, they do experience some functional loss that may put them at risk for harm. For example, an individual with Alzheimer’s will often have early signs of learning and memory loss confined to recent memory. Forgetting to turn off the stove or becoming lost can place the individual and those that surround him/her at risk. Similarly, although an individual in the early stages of dementia may continue to drive, he/she (and others on the road!) may be at risk as the vehicle’s operation requires several cognitive functions that may be inhibited by the individual’s neuropsychological impairment(s).

 

The Importance of Early Identification through Neuropsychological Testing


Early identification is the best way to prevent harm and reduce risk. In addition, literature suggests that pharmacological strategies (i.e. medications) can slow down the progression of dementia. Accordingly, early intervention also helps to ensure that the individual is brought to the attention of the appropriate healthcare practitioner as soon as possible so that he/she may immediately begin appropriate treatment.

 

Dementia is identified by neuropsychological testing that evaluates/tests disturbances in the various areas of mental activity. Neuropsychological testing is a specialized sub-discipline of psychology that focuses on the relationship between brain and behavior by way of formal standardized paper and pencil measures.


Research has shown that neuropsychological testing is capable of identifying dementia syndromes in their earliest stages and is more sensitive and accordingly, more effective than neuro-imaging instrumentation such as magnetic resonance imaging (MRI) or Computerized Tomography Scan (CT Scan).

 

A Clinical Neuropsychologist performs neuropsychological testing. This type of professional is a Psychologist with a designate in neuropsychology so he/she has a Ph.D., as well as research and clinical experience in neuropsychology and is licensed by the College of Psychologists of Ontario.

 

The assessment time required ranges from 1-2 days, depending on case complexity, client limitations, etc. The testing process consists of an:


      • Extensive diagnostic interview with client.
      • Interview with family/friend (i.e. someone who knew the client prior to the date of injury). This allows the Neuropsychologist to obtain perceptions of the changes in the client post injury.
      • Administration of the neuropsychological tests.

Specific tests vary depending on age, nature of the clinical problem, language and cultural factors, education/abilities, and the specific questions being posed. Test batteries typically include:


      • General Intellect
      • Academic Achievement (reading, spelling, arithmetic)
      • Language Functions (fluency, naming, repetition, comprehension, reading, writing)
      • Sensory Perceptual Functions (auditory, visual, tactile)
      • Visuospatial/Constructional Abilities (drawing, copying, building)
      • Orientation, Attention & Concentration Skills
      • Learning and Memory (verbal and visual)
      • Executive Functions (e.g., problem-solving, planning, organization, reasoning, judgement)
      • Self-awareness, initiation
      • Motor Performance
      • Personality and Psychosocial Functioning
      • Tests of effort level to assess validity of test results

When to Use Neuropsychological Testing


Due to its ability to provide more detailed and comprehensive information about cognitive capabilities, consider using neuropsychological testing for clients who:


      • Are suspected of having sustained a head injury (i.e., force applied to head/brain, any period of loss of consciousness, any loss of memory for events before/after accident, any alteration in mental state at time of accident, focal neurological deficits) and/or is reporting cognitive deficits resulting in functional decline.
      • Have sustained moderate to severe head injuries. They are likely to require repeated neuropsychological evaluations over the first two or so years post injury.
      • Have sustained a mild traumatic brain injury and continue to experience difficulties for an extended period of time and neuroradiological examination is negative (e.g., CT, MRI).
      • Identifies symptom magnification with regards to cognitive complaints.

       

      The Neuropsychological Report should contain the following information:


      • Document Review
      • Thorough and accurate biographical information on client
      • Credentials of assessor
      • Summary of face-to-face interview with client
      • Behavioural observations (e.g., level of insight, orientation, affect, presentation)
      • List of tests administered
      • Administration of validity tests and comment on validity of test profile
      • Results of testing
      • Summary (areas of strength and weakness)
      • Diagnosis/Deficits/Disability/Impairment
      • Relationship to accident injury
      • Prognosis
      • Recommendations
      • Responses to your questions

Neuropsychological Testing is the most effective approach for your Clients who may be suffering from Dementia.


All studies to date concur that dementia is a major problem among the elderly and will be an even larger public health concern as the size of the elderly population increases. Early identification using neuropsychological testing is warranted due to its sensitivity and specificity of impairment to real world behavior. It is the most effective way to provide the individual, family/caregiver(s), treating healthcare professionals and insurer with valuable information to guide decision making throughout the progressive course of dementia. Additional information about this topic is available through The Centre for Acquired Brain Injury at the University of Toronto being established by Dr. Zakzanis and SLR Assessments & Diagnostics at 1(866).440.4447. You can also access Sibley & Associates' Resource Library and educational seminars by contacting Angela Veri, Director of Customer Relations at 1.800.363.8900 (Ext 356).

      Sources:
      1. Accident raises aging concerns, Globe & Mail, Saturday, November 13, 2004

      • www.statisticscanada.ca/

      • www.cpa-apc.org/Publications/Archives/CJP/2004/july/july2004.asp