Geriatric Neuropsych

GERIATRIC NEUROPSYCHOLOGY
GERIATRIC
NEUROPSYCHOLOGY
Assessment and Intervention
edited by
DEBORAH K. ATTIX
KATHLEEN A. WELSH-BOHMER
THE GUILFORD PRESS

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Library of Congress Cataloging-in-Publication Data
Geriatric neuropsychology : assessment and intervention / edited by

Deborah K. Attix, Kathleen A. Welsh-Bohmer.
p. cm.
Includes bibliographical references and index.
ISBN 1-59385-226-6 (cloth)
1. Geriatric neuropsychiatry. 2. Cognition disorders in old age
—Diagnosis. 3. Neuropsychological tests. I. Attix, Deborah K.
II. Welsh-Bohmer, Kathleen A.
[DNLM: 1. Mental Disorders—diagnosis—Aged. 2. Mental Disorders
—therapy—Aged. 3. Behavioral Symptoms—Aged. 4. Neuropsycho-
logical Tests—Aged. WT 150 G36855 2005]
RC451.4.A5G4665 2006
618.97′68—dc22
2005017534
For Eva, Ted, Noah, and Maximus
—D. K. A.
For Patrick, Elise, and Nathan

—K. A. W.-B.
About the Editors
Deborah K. Attix, PhD, completed her postdoctoral fellowship in Clinical Neuro-

psychology at the Cleveland Clinic Foundation. She joined the Department of Psychiatry
and Behavioral Sciences (Division of Medical Psychology) and Department of Medicine
(Division of Neurology) at Duke in 1995 and is now an Assistant Clinical Professor there.
Dr. Attix worked with the Joseph and Kathleen Bryan Alzheimer’s Disease Research Cen-
ter and subsequently organized and became the Medical Director of the Clinical
Neuropsychology Service at Duke University Medical Center. Her clinical work focuses
on geriatric neuropsychological assessment and intervention. Dr. Attix is best known for
her intervention work involving cognitive training and compensation and for psycho-
therapeutic techniques targeting memory, function, and mood in dementia.
Kathleen A. Welsh-Bohmer, PhD, is a Professor within the Department of Psychiatry and

Behavioral Sciences (Division of Medical Psychology) at Duke University Medical Center
and holds a joint appointment in the Department of Medicine (Division of Neurology).
Dr. Welsh-Bohmer was recruited by Duke University Medical Center in 1987 to join the
newly formed Joseph and Kathleen Bryan Alzheimer’s Disease Research Center, and she
currently is the Director of that center. Dr. Welsh-Bohmer is best known for her work in
the clinical detection of early-stage Alzheimer’s disease (AD) and related dementias and
the relationship of these diseases to genetic and environmental factors. She has been a
leader in many multicenter collaborative studies of AD and currently leads the nationally
known Cache County Memory Study, a population-based epidemiological investigation
of mild cognitive impairment and AD. Dr. Welsh-Bohmer’s clinical work focuses on
neuropsychological assessment in neurodegenerative disorders, including AD and related
dementias.
vi
Contributors
Amarilis Acevedo, PhD, Department of Psychiatry and Behavioral Sciences, Miller

School of Medicine, University of Miami, Miami Beach, Florida
Deborah K. Attix, PhD, Department of Psychiatry and Behavioral Sciences,
(Medical Psychology) and Medicine (Neurology), Duke University Medical
Center, Durham, North Carolina
Ann Louise Barrick, PhD, Psychology Department, John Umstead Hospital, Butner,
North Carolina, and Department of Psychology, University of North Carolina–
Chapel Hill, Chapel Hill, North Carolina
Mark W. Bondi, PhD, Psychology Service, VA San Diego Health Care System, and
Department of Psychiatry, University of California–San Diego, San Diego,
California
Michelle S. Bourgeois, PhD, Regional Rehabilitation Center, College of
Communication, Florida State University, Tallahassee, Florida
Robyn M. Busch, PhD, Department of Psychiatry and Psychology, Cleveland Clinic
Foundation, Cleveland, Ohio
Cameron J. Camp, PhD, Myers Research Institute, Beachwood, Ohio
M. Allison Cato, PhD, VA RR&D Brain Rehabilitation Research Center, Malcolm
Randall Veterans Affairs Medical Center, and Department of Clinical and
Health Psychology, University of Florida, Gainesville, Florida
Gordon J. Chelune, PhD, The Mellen Center, Cleveland Clinic Foundation, Cleveland,
Ohio
Cory K. Chen, MA, Department of Psychology, University of North Carolina–
Chapel Hill, Chapel Hill, North Carolina
Linda Clare, PhD, School of Psychology, University of Wales, Bangor, Wales
Bruce A. Crosson, PhD, Department of Clinical and Health Psychology, University
of Florida, Gainesville, Florida
Joanne Green, PhD, Wesley Woods Health Center, Department of Neurology, Emory
University, Atlanta, Georgia
Kathleen Hayden, PhD, Joseph and Kathleen Bryan Alzheimer’s Disease Research
vii
viii Contributors
Center, Division of Neurology, Department of Medicine, Duke University Medical

Center, Durham, North Carolina
Katina R. Hebert, MS, Department of Psychology, University of Alabama, Tuscaloosa,
Alabama
Wes S. Houston, PhD, Department of Neurology, University of Iowa, Iowa City, Iowa
Nancy Johnson, PhD, Cognitive Neurology and Alzheimer’s Disease Center, Feinberg
School of Medicine, Northwestern University, Chicago, Illinois
David Loewenstein, PhD, Department of Psychiatry and Behavioral Sciences, Miller
School of Medicine, University of Miami, Miami Beach, Florida
Rebecca G. Logsdon, PhD, Northwest Aging Research Group, School of Nursing,
University of Washington, Seattle, Washington
Jennifer J. Manly, PhD, G. H. Sergievsky Center and Taub Institute for Research on
Alzheimer’s Disease and the Aging Brain, Department of Neurology, Columbia
University Medical Center, New York, New York
Daniel Marson, PhD, Department of Neurology and Alzheimer’s Disease Research
Center, University of Alabama–Birmingham, Birmingham, Alabama
Susan M. McCurry, PhD, Psychosocial and Community Health, University of
Washington, Seattle, Washington
Guy G. Potter, PhD, Department of Psychiatry and Behavioral Sciences, Duke
University Medical Center, Durham, North Carolina
Beth K. Rush, PhD, Department of Psychiatry and Psychology, Mayo Clinic and
Foundation, Jacksonville, Florida
Mary Sano, PhD, Department of Psychiatry, Mount Sinai School of Medicine, New
York, New York, and Bronx VA Medical Center, Bronx, New York
Glenn Smith, PhD, Department of Psychiatry and Psychology, Mayo Clinic and
Foundation, Rochester, Minnesota
Yana Suchy, PhD, Department of Psychology, University of Utah, Salt Lake City, Utah
Linda Teri, PhD, Psychosocial and Community Health, University of Washington,
Seattle, Washington
Cynthia K. Thompson, PhD, Communication Sciences and Disorders and Neurology,
Northwestern University, Chicago, Illinois
Lauren H. Warren, MA, Department of Psychology, University of North Carolina–
Chapel Hill
Kathleen A. Welsh-Bohmer, PhD, Department of Psychiatry, Joseph and Kathleen
Bryan Alzheimer’s Disease Research Center, Division of Neurology, Duke
University Medical Center, Durham, North Carolina
Preface
In the pages that follow, readers will find the essentials of geriatric neuropsychological as-
sessment and intervention. The first half of the volume focuses on assessment; presentation of
an assessment model is followed by chapters outlining common age-related conditions
and the special considerations critical to the neuropsychological evaluation process. The
second half of the volume focuses on intervention; presentation of an intervention model
is followed by approaches to cognitive training and compensation as well as psycho-
therapeutic techniques.
Our intent in this book is to provide a uniquely different text for the field of geriatric
neuropsychology, one that integrates not only assessment methods and issues of differen-
tial diagnosis but also emphasizes intervention and management approaches available to
neuropsychologists. Our contributors detail the current state of knowledge regarding the
neuropsychological, medical, pathological, and genetic aspects of the most common geri-
atric conditions. They also offer the latest intervention approaches involving the use of
nonpharmacological treatments with geriatric patients who have cognitive dysfunction
that is not expected to resolve. These interventions utilize modified techniques and thera-
peutic approaches designed to maximize use of residual capacities, enhance compensa-
tory functioning, and increase adjustment. These leaders in the field of geriatric dementia
present models for assessment and intervention, and also provide a thorough review of
geriatric central nervous system disorders, cognitive training, psychotherapy, and consid-
erations specific to this population.
In providing a synthesized approach to assessment and intervention, our intention is
to provide neuropsychologists with a practical reference source with which they are able
to (1) recognize common dementias in their diverse clinical manifestations, (2) identify
the diagnostic issues central to each, and (3) become familiar with how assessment ex-
tends beyond diagnostics to facilitate treatment planning. Likewise, we detail the use of
assessment data and neurobehavioral principles to maximize the likelihood of treatment
gains, and our contributors provide in-depth coverage of specific treatment approaches.
This text draws together practice techniques, theory, and evidence-based outcome data to
provide a conceptual framework for professionals involved in geriatric neuropsychologi-
cal assessment and intervention. We thank our contributors, who have helped us to
present and integrate these important aspects of practice.
DEBORAH K. ATTIX
ix
Acknowledgments
I would like to thank all the authors and editors involved with the creation of this book;
your careful work allowed the volume to exceed its original vision and I am grateful. I
also want to acknowledge my family, friends, mentors, colleagues, and patients. I espe-
cially want to thank Ted, who captures me with all of who he is, and my mother, who
gave me the world. I also want to acknowledge the powerful examples I have had in my
Uncle Laci and late Feri Bacsi, who always cheered me on, and the late Mel Stroupe,
whose lessons became a part of the fabric of who I am. Thanks also to Sally, who walks
with me and reads my whispers, and to Gordon Chelune, who taught me neuropsy-
chology with inspiration, cheer, and a horrible red pen. Thanks to “The Guys” and all the
patients who have given me the privilege of joining them on their journeys. Thanks also
to Warren Strittmatter, Ron Beauvais, and Joel Morgenlander—my cavalry—who gave
me the balance that brings me such joy. And most of all, thanks to my little one Noah,
who will always be my moon, stars, and life—your laugh sets me free—and to my new
Maximus, my cherished, thoughtful moose. We, too, will dance in the sunlight.
—D. K. A.
It is a privilege to be associated with this volume of collected works from so many nota-
ble and respected scholars in the field. I wish to thank Deborah Attix for the tremendous
opportunity she has given me to serve as a coeditor on this work. I would like to ac-
knowledge my loving family, Patrick, Elise, and Nathan, who show me daily the joy of
life reflected through their creative, youthful, and energetic lenses. I also wish to thank
my parents for their example in living and aging with love, grace, and wisdom. A special
note goes to my siblings, Karen, Greg, and Eric, and to the entire extended Welsh-Bohmer
family, who together give my life so much meaning and dimension. Finally, I thank my
many students, colleagues, patients, and their families, with whom I have had the plea-
sure to work over the years. You constantly remind me of the importance of human dis-
covery and why we do what we do in clinical neuropsychology.
—K. A. W.-B.
x
Contents
PART I. GERIATRIC NEUROPSYCHOLOGICAL ASSESSMENT 1
SECTION A. Assessment of Common Geriatric Conditions 3
1 An Integrated Model for Geriatric Neuropsychological Assessment 5

Guy G. Potter and Deborah K. Attix
2 Normal Aging and Mild Cognitive Impairment 27

Glenn Smith and Beth K. Rush
3 Neurodegenerative Dementias 56
Kathleen A. Welsh-Bohmer and Lauren H. Warren
4 Stable and Slowly Progressive Dementias 89

M. Allison Cato and Bruce A. Crosson
5 Potentially Reversible Cognitive Symptoms in Older Adults 103

Wes S. Houston and Mark W. Bondi
SECTION B. Specific Considerations 131
6 Using Norms in Neuropsychological Assessment of the Elderly 133

Robyn M. Busch, Gordon J. Chelune, and Yana Suchy
7 Functional Assessment 158

Daniel Marson and Katina R. Hebert
8 Cultural Issues 198

Jennifer J. Manly
9 Feedback 223
Joanne Green
xi
xii Contents
PART II. GERIATRIC NEUROPSYCHOLOGICAL INTERVENTION 237
SECTION A. Cognitive Training and Compensatory Techniques 239
10 An Integrated Model for Geriatric Neuropsychological Intervention 241

Deborah K. Attix
11 Training of Cognitive and Functionally Relevant Skills in Mild 261

Alzheimer’s Disease: An Integrated Approach
David Loewenstein and Amarilis Acevedo
12 Spaced Retrieval: A Model for Dissemination of a Cognitive Intervention 275

for Persons with Dementia
Cameron J. Camp
13 Multitechnique Program Approaches 293

Linda Clare
14 Language Interventions in Dementia 315

Cynthia K. Thompson and Nancy Johnson
15 External Aids 333

Michelle S. Bourgeois
SECTION B. Psychotherapeutic Interventions 347
16 Behavioral Treatment of Affective Disorders and Associated Symptoms 349

Rebecca G. Logsdon, Susan M. McCurry, and Linda Teri
17 Behavioral Treatment of Impaired Functioning and Behavioral Symptoms 367

Ann Louise Barrick
18 Group Psychotherapy Approaches for Dementia 394

Guy G. Potter, Deborah K. Attix, and Cory K. Chen
19 Pharmacological and Other Treatment Strategies for Alzheimer’s Disease 414

Kathleen Hayden and Mary Sano
Index 457
PART I
GERIATRIC
NEUROPSYCHOLOGICAL
ASSESSMENT
T he first part of the book is divided into two sections designed to introduce the reader to
geriatric neuropsychological assessment and special considerations in clinical interpreta-
tion. A conceptual model of the standard neuropsychological evaluation in geriatrics ini-
tiates Section A. The chapters that follow the assessment model review common geriatric
conditions ranging from normal aging to dementia. Each of the chapters in this section
outlines our current understanding of various clinical syndromes or diseases by describ-
ing their most typical neuropsychological presentation and underscoring the related
neuropathology, histopathology, and genetic etiology (when known). Section B delineates
topics of particular importance in the assessment of the geriatric population, including
normative and multicultural considerations, functional capacity and competency, and the
use of feedback.
1
Section A
Assessment of Common
Geriatric Conditions
Section A presents an assessment model and reviews geriatric conditions ranging from
normal aging to dementia.
Chapter 1 introduces the broad issues of neuropsychological assessment in elderly
groups: goals of the evaluation, commonly employed instruments, factors influencing test
performance, interpretation of findings, and the importance of supportive medical data.
Rather than present the assessment model as any definitive method of evaluation, we of-
fer it as an evolving dynamic model that is meant to be introductory and orienting for the
reader. This chapter sets the stage for the chapters that follow, in which more detailed dis-
cussion is given to specific diagnostic conditions, their etiology, and clinical management.
Chapter 2 takes us into the realm of neurocognitive impairment that exceeds normal
aging with a consideration of mild cognitive disorders, commonly referred to as mild cog-
nitive impairment (MCI), and conditions that presage Alzheimer’s disease and other
dementias. This chapter reviews the historical evolution of the definition of MCI and key
classification issues that affect our clinical and research conceptualizations of this condi-
tion.
Chapter 3 details the typical presentation of the three most commonly encountered
neurodegenerative conditions of aging that are invariably progressive: Alzheimer’s dis-
ease, frontotemporal dementia, Parkinson’s disease dementia, and diffuse Lewy body
dementia. A thorough consideration of these fundamental clinical conditions provides a
firm basis for recognizing the less commonly encountered progressive conditions.
Chapter 4 presents an analysis of geriatric conditions that are more variable in their
longitudinal course, with either slow progression or stability. The emphasis again is on
the most common illnesses affecting elders in this category: Parkinson’s disease, vascular
cognitive impairment and dementia, alcoholic dementia, and traumatic brain injury.
In Chapter 5 we consider conditions that have been regarded as either partially or to-
tally reversible with adequate, timely treatment. Specifically reviewed are the conditions
associated with normal-pressure hydrocephalus, hypothyroidism, vitamin B12 deficiency,
thiamine deficiency, sleep breathing disorders, and late-life depression. This latter topic
introduces the notion of pseudodementia and the dementia of depression, which is of
3
4 GERIATRIC NEUROPSYCHOLOGICAL ASSESSMENT
particular importance to elderly patient groups. We have stated elsewhere that evaluation
of mood is indispensable to any comprehensive evaluation, and that any evaluation that
does not carefully consider this dimension runs a high risk of inaccuracy. It is well under-
stood that depression alone can result in diminished cognition. In addition, it must also
be considered as a comorbid condition to other central nervous system disorders,
potentially—and in all probability—altering the overall constellation of findings. It is
well known that the prevalence of depression decreases across the lifespan among normal
community dwellers, although some believe that the prevalence of mild subclinical emo-
tional distress is notable among elders. It is extraordinarily important not to underesti-
mate the prevalence of dysthymia and major depression in samples of memory-disordered
elders, in whom prevalences rise sharply.
In offering a volume focused on both assessment and intervention, we intend to
emphasize the fact that specific factors related to cognitive compromise are treatable.
Depression and other sources of emotional unrest are perhaps the most common appro-
priate target of intervention. Improvement leading to adaptive, successful coping and
adjustment in the context of neurological change can have a perceptible, meaningful im-
pact on quality of life. In addition to the importance of considering mood for accurate
diagnosis, it is this potential for improvement in quality of life through identification and
treatment of a treatable factor that we would like to underscore.
Of course, an entire volume could be devoted to this topic, as well as almost any
other condition or disease reviewed in Section A. The reader is encouraged to consider
this when reviewing the common geriatric conditions, syndromes, and diseases that are
presented. We also appreciate the fact that we offer views based upon our current state of
knowledge—which is but a snapshot in a continuously evolving field of research and
practice. We look forward to the enhanced discernment in each area that will come with
time.
1
An Integrated Model for Geriatric

Neuropsychological Assessment
GUY G. POTTER
DEBORAH K. ATTIX
D eclining memory and cognitive losses are common with age (Blanchard-Fields & Hess,
1996; Craik & Salthouse, 1992). Because similar changes often present as the early signs
of progressive cognitive disorders such as Alzheimer’s disease (AD), distinguishing the rel-
atively benign changes of normal aging from the more adverse changes associated with
progressive cognitive disorders is a critical issue in the neuropsychological assessment of
older adults. Fortunately, the field of neuropsychology has made great strides in distin-
guishing “normal” and “abnormal” processes of cognitive aging and in characterizing
the numerous disease processes that can impair the cognitive functioning of older adults.
For instance, the prevailing diagnostic consensus for mild cognitive impairment (MCI) in-
cludes characterization based on neuropsychological performance (Winblad et al., 2004),
whereas the diagnosis of AD has long recognized the role of neuropsychological measures
in objectively assessing cognitive function (McKhann et al., 1984). The neuropsycholo-
gist’s ability to detect and diagnose age-related cognitive disorders depends not only on a
knowledge of psychometrics and brain–behavior relationships that is the bedrock of
neuropsychological training, but also on an ability to integrate data from other disci-
plines concerning the health and function of older adults, including epidemiology, cogni-
tive neuroscience, and geriatric medicine.
The purpose of this chapter is to present a model of geriatric neuropsychological as-
sessment that encompasses the range of information that may be involved in the detection
and diagnosis of age-related cognitive disorders. We present a framework for interpreting
neuropsychological findings in relation to our current knowledge of the presentation and
course of these disorders. We begin by considering the prevailing uses of neuro-
psychological assessment for older adults, followed by consideration of variables relevant
to the geriatric evaluation. The remainder of the chapter focuses on neuropsychological
interpretation, including consideration of factors related to an older individual’s presenta-
5
tion and performance, the role of a core neuropsychological knowledge base, and the use
of attendant data.
APPLICATIONS OF GERIATRIC NEUROPSYCHOLOGICAL ASSESSMENT
There are three major applications of neuropsychological testing in the clinical assess-
ment of older adults: diagnostics, estimation of functional status, and intervention plan-
ning.
Neuropsychological Assessment and Clinical Diagnosis

The most common application of geriatric neuropsychological assessment continues to be
differential diagnosis of cognitive disorders of aging. Consequently, this focus tends to
play the major role in the planning of most neuropsychological evaluations. Frequently,
neuropsychological assessment is requested in cases of suspected early dementia, where
the patient’s or family’s report of cognitive loss may be ambiguous or undetected in a cli-
nician’s interview. Because a neuropsychological evaluation provides characterization of
deficits based on objective data, it potentially avoids many sources of error inherent in
subjective observational methods (Davison, 1974; Lezak, Howieson, & Loring, 2004).
The neuropsychological evaluation can characterize the presence and severity of cognitive
compromise independent of structural imaging and other correlates of neuropathology,
and also provide domain-based profiles of impairment that can assist in the inclusion or
exclusion of diagnoses that appear viable based on other aspects of the clinical presenta-
tion. Because of its clinical utility, the neuropsychological examination is now recognized
as playing a central role in the medical evaluation of Alzheimer’s disease and other cogni-
tive disorders of aging (Cummings et al., 1996).
Neuropsychology and Estimation of Functional Status and Competency

Although diagnosis remains the primary referral issue for most geriatric neuropsy-
chological evaluations, neuropsychologists are frequently called upon to address how
cognitive impairments might affect a patient’s ability to function in his or her daily life.
Because most neuropsychological tests were developed to detect and differentiate brain
dysfunctions, rather than to provide ecological validity, prediction of functional out-
comes cannot typically be answered on the basis of test data alone. Until fairly recently
there have been few data on the predictive relationship between functional outcomes and
neuropsychological test performance, but an emerging body of research suggests that
neuropsychological test performance does predict function in activities of daily living,
such as medication management and bill paying (Cahn-Weiner, Boyle, & Malloy, 2002;
Diehl, Willis, & Schaie, 1995). Related outcomes such as health care utilization and need
for institutional care appear to be related to neuropsychological performance as well
(Rockwood, Stolee, & McDowell, 1996; Willis & Marsiske, 1991). Questions about fit-
ness to operate a motor vehicle are frequently raised in geriatric referrals, and it does ap-
pear that driving ability is adversely affected by neuropsychological deficits (Lesikar,
Gallo, Rebok, & Keyl, 2002) and dementia severity (Dubinsky, Stein, & Lyons, 2000).
Despite these informative findings, unresolved questions remain about (1) the degree
of shared variance between neuropsychological tests and functional outcomes, (2) the
An Integrated Model for Assessment 7
neurocognitive domains that are most predictive of functional ability, and (3) how these
associations generalize across different diagnostic populations (Farias, Harrell, Neumann,
& Houtz, 2003; McCue, Rogers, & Goldstein, 1990; Richardson, Nadler, & Malloy,
1995). McCue and colleagues (1990) have argued that neuropsychological tests have
greater utility in predicting performance for complex functional tasks than for simple ac-
tivities. Other researchers have found support for this assertion (Farias et al., 2003), but
also note that the strength of association for neuropsychological measures in general may
be greater for performance-based functional assessment than for informant report of
function. These researchers also note that a considerable amount of variance in functional
performance is not explained by neuropsychological performance. On the whole, current
research suggests that neuropsychological assessment and functional assessment measure
related but non-overlapping domains, indicating that neuropsychological data are com-
plementary to assessments of functional performance, rather than substitutes for them.
In some instances cognitive impairment becomes a legal as well as a clinical issue,
particularly when it applies to an individual’s competency to make medical and financial
decisions. In such cases a neuropsychologist may be called upon to provide information
relevant to a legal determination of competency. Competency, in this context, is a legal
term whose meaning is not under the purview of the clinician; however, the determina-
tion of whether or not a person is deemed to be legally competent can be influenced by a
neuropsychologist’s characterization of how an individual’s observed neurocognitive per-
formance may affect specific decision-making capacities. Although there is some support
for the use of neuropsychological tests in helping to characterize an individual’s decision-
making capacity, there is no consensus about which specific cognitive constructs or test
scores best predict competency (e.g., Marson, Cody, Ingram, & Harrell, 1995; Stanley,
Stanley, Guido, & Garvin, 1988; Tymchuk, Ouslander, Rahbar, & Fitten, 1988). One
consistent finding across studies is that although dementia patients may be like non-
cognitively impaired older adults in their ability to make reasonable choices, they differ
from their cohorts in their ability to provide a rationale for their decision and to appreci-
ate the consequence of one decision versus another (Marson, Ingram, Cody, & Harrell,
1995). Although a diagnosis such as dementia can be informative in characterizing decision-
making capacity, characterization based on diagnosis alone provides limited information
about specific questions of capacity; an individual’s functioning may be intact in an area
such as financial decision making but impaired in a different area such as medical deci-
sion making (Scogin & Perry, 1986). Neuropsychological testing holds promise as an ob-
jective counterpart to clinical impressions of decision-making capacity. Nevertheless, it
should be viewed as one facet of information in a comprehensive assessment. For further
discussion of this issue, see Marson and Hebert (Chapter 7, this volume).
Neuropsychological Assessment and Intervention Planning

In addition to functions of diagnosis and prognosis, clinical neuropsychologists have be-
come increasingly involved in intervention and treatment planning. Neuropsychological
evaluations often serve as a baseline reference of cognitive performance from which
changes in an individual’s performance may be tracked over time. It is desirable to track
cognitive changes in order to assess the efficacy of an intervention, whether it is
pharmacotherapy or psychotherapy. To track therapeutic progress, serial assessment of
neuropsychological function may be advised. Psychotherapeutic interventions may in-
clude traditional approaches to treatment, such as behavioral therapy (Teri, Logsdon,
Uomoto, & McCurry, 1997), or more focused cognitive rehabilitation methods (Prigatano,
1997). Most individuals with MCI can benefit from such interventions, and information
from their neuropsychological evaluations may suggest strategies to capitalize on cogni-
tive strengths and to accommodate weaknesses. Information from assessment may also
indicate whether mnemonic aids such as calendars, diaries, or alarms can be utilized ef-
fectively. An in-depth discussion of how neuropsychological data are utilized for interven-
tion planning appears in Attix (Chapter 10, this volume).
EXAMINATION FACTORS
Whether the purpose of neuropsychological evaluation with older adults is diagnosis,

functional estimation, intervention planning or (most likely) all three, several testing fac-
tors need to be considered when working with this population. Much as cognitive func-
tion can decline with age, decline in physical functions can present confounding variables
to test administration and interpretation. Clinicians often explore potential testing con-
founds at the beginning of a visit, which allows them to modify their approach as needed.
If neuropsychological data are collected by psychometricians, they should be trained to
identify potential confounds and to interact with the supervising neuropsychologist about
how to make appropriate modifications to testing (e.g., use of voice amplification device
to accommodate hearing impairment). In some cases, the clinician may face the prospect
of omitting a measure if the confound cannot be accommodated, such as the problem of
administering tests of visual memory to someone who is profoundly visually impaired. In
other cases, procedures can be modified so that the individual can complete a test, albeit
in a nonstandardized fashion. Such “testing of limits” can provide valuable diagnostic in-
formation even when the validity of normative interpretation is questionable. Consider
the case of an individual who cannot draw visual memory figures due to paresis or severe
tremor in his or her drawing hand. If that individual studies the figures visually for an
equivalent length of time and later performs flawlessly on forced-choice recognition of
those figures, the clinician at least has qualitative information about the individual’s abil-
ity to store visual information in memory. When testing of limits does occur, clinicians
must consider how any modifications to standard protocol may affect their interpretation
of norms based on standardized administration. With that caveat in mind, the following
section addresses several potential confounds that can occur in geriatric neuropsy-
chological assessment.
Vision
Vision problems are overrepresented among adults ages 65 and over, in that this group
makes up approximately 13% of the U.S. population but accounts for roughly 30% of
the visually impaired (Desai, Pratt, Lentzer, & Robinson, 2001). Vision is an important
issue to geriatrics as a whole because visual impairment is related to decreased functional
independence among older adults. For instance, impairments in visual acuity and contrast
sensitivity are significant predictors of functional impairments in such skills/actions as
reading, telephone dialing, and descending and ascending stairs (West et al., 2002). One
study of cognitive outcomes reported significant improvement on a dementia screening
measure following cataract surgery, even when items related specifically to visual func-
tion were excluded (Tamura et al., 2004).
As it relates to neuropsychological assessment, poor vision can be a confound to test

validity and interpretation. It may require specific test selection and modification of pro-
cedures. Among blind patients, for instance, an informal evaluation of naming ability can
be obtained by having an individual name common objects that are placed in his or her
hand (given that there is no additional deficit in tactile discrimination). Tactile stimuli can
also be substituted in some memory testing; for instance, the Fuld Object Memory Evalu-
ation (Fuld, 1977) utilizes touch in the identification of objects to be remembered. A
more common problem than outright blindness is impaired vision due to problems such
as macular degeneration or diabetic retinopathy. In many cases, the print and visual stim-
uli on neuropsychological tests are too small and complex to be perceived adequately by
individuals with poor vision. Some tests, such as the Wide Range Achievement Test–3
(WRAT-3; Wilkinson, 1993), provide versions of their materials in larger type. In other
cases, visual stimuli may be enlarged in a photocopier or placed under magnification.
When evaluating older patients, a pocket eye chart is often useful to help identify individ-
uals who may have difficulty perceiving print and other visual stimuli.
Hearing
Hearing loss is another common problem among older adults. One estimate from the
Centers for Disease Control and Prevention is that 37% of all hearing problems occur
in individuals over the age of 65 (Desai et al., 2001). Moreover, hearing loss may be
harder to detect than visual problems because older adults are found to be less likely to
get hearing evaluations and to wear hearing aids than they are to get consultation and
correction for poor vision. As is the case with poor vision, hearing deficits are associ-
ated with increased cognitive and functional difficulties. One study that investigated
hearing loss among nondemented individuals versus those with AD found it to be asso-
ciated with increased cognitive impairment among both groups, including a dose-
dependent relationship among those with AD (Uhlmann, Larson, Rees, Koepsell, &
Duckert, 1989). Moreover, concurrent visual and hearing deficits may be associated
with greater cognitive and functional impairment than each impairment alone (Lin et
al., 2004). In the context of a neuropsychological evaluation, examiners can address
the potential confound of minor hearing loss by speaking clearly, making eye contact,
and positioning themselves to face the ear with the best hearing. Hearing aids are typi-
cally helpful, as are systems that amplify sound via headphone. In cases of severe hear-
ing deficits, test instructions may have to be presented to the examinee in written form.
Administration of verbal memory tests is particularly challenging in the context of
hearing impairment, and it is useful to note that the word-list learning items from the
CERAD battery (Consortium to Establish a Registry for Alzheimer’s Disease; Morris et
al., 1989) appear in printed form, which can be read by the patient to minimize the
risk of information loss due to poor hearing.
Motor Function
Like vision and hearing deficits, impairments of upper extremity motor function are com-
mon among older adults but vary considerably in type and severity. Stroke is one condi-
tion that is more prevalent with age and which commonly produces dyscoordination,
paresis, or even paralysis of an extremity. Arthritis and peripheral neuropathy are condi-
tions with greater prevalence among older adults that can compromise speed and dexter-
ity. Motor impairment can make it difficult to administer the many neuropsychological
tests that rely on writing or drawing. Visual study, as mentioned previously, is a useful
“test of limits” for drawing-dependent visual memory tasks when there is a subsequent
visual recognition trial that can be used to assess recall. There are a few tests of
psychomotor processing that provide limited normative values for oral administration,
including the Symbol Digit Modalities Test (Smith, 1982) and the Trail Making Test
(Ricker & Axelrod, 1994).
Fatigue
Another factor to consider when assessing older adults is the reasonable length of the test
battery. Lengthy testing may produce fatigue effects that adversely affect performance
among older adults and individuals with cognitive disorders in general (Lezak et al.,
2004). Consequently, clinicians may need to modify testing into a shorter, more focused,
and less taxing session than is used with a younger population. Testing might also be
structured so that assessment of a specific neurocognitive domain does not occur all at
the same time, so as to minimize the differential effects of fatigue on functions assessed
later in the examination. The final consideration for limiting the length of an assessment
for older adults is evidence that suggests that most elders perform significantly better on
effortful cognitive tasks in the morning than they do in the afternoon (Hasher, Chung,
May, & Foong, 2002; May, Hasher, & Stoltzfus, 1993); hence, a test battery that can be
completed in the course of a morning has the advantage of assessing older adults at their
optimum time of day while also minimizing test fatigue.
Literacy
The rate of illiteracy among adults ages 65 and over has been estimated at 44%, with in-
creasing rates as a function of age (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993). Literacy
should be considered an important domain in geriatric neuropsychological assessment be-
cause higher literacy appears protective of memory decline (Manly, Touradji, Tang, &
Stern, 2003), whereas lower literacy is a risk factor for negative outcomes such as hospi-
talization and poor disease management (Baker, Parker, Williams, & Clark, 1998; Wil-
liams, Baker, Parker, & Nurss, 1998). It is well known that many neuropsychological
measures have strong education effects. Research by Manly and colleagues has high-
lighted the negative bias that low-literacy level can have on test interpretation (Manly et
al., 1999; Manly, Jacobs, Touradji, Small, & Stern, 2002). Our clinical experience sug-
gests that the prevalence of low literacy levels is greater among the populations of inpa-
tient hospital wards and state psychiatric hospitals that serve the underprivileged than
among the typical outpatient population of tertiary care clinics. It can be difficult to iden-
tify low literacy in an individual who is embarrassed or otherwise reluctant to acknowl-
edge this fact; for instance, an individual may refuse to take tests rather than reveal his or
her inability to read the stimuli. Low literacy is also problematic in that many
neuropsychological tests and test items are based on reading or providing written re-
sponses and thus are fundamentally compromised by an individual’s low literacy level.
The clinician needs to keep these factors in mind when deciding which tests will be the
most valid indicators of cognitive function for a patient with low reading ability. The
Reading subtest of the WRAT-3 (Wilkinson, 1993) may be useful for estimating the grade
reading level of examinees.
Rapport and Motivation

Rapport and motivation are important variables that can influence neuropsychological
assessment performance, and certain aspects of these variables are particularly relevant to
a geriatric population. The neuropsychological evaluation may be an older adult’s first
contact with a professional psychologist, and it may be viewed with trepidation if the
outcome of the assessment is perceived as potentially contributing to an unwanted diag-
nosis of cognitive impairment and possible major life changes. Moreover, some exam-
inees may arrive at their appointment reluctantly, at the urging of family members, rather
than of their own accord. For such individuals, additional attention may be needed to ed-
ucate them about the causes of cognitive impairment and the possibility of both positive
and negative outcomes of an evaluation. Reassuring reluctant patients that participation
in testing is voluntary while also explaining ways in which testing provides valuable in-
formation for their care can help them find ways to feel personally invested in the pro-
cess. The clinician may also need to “normalize” the testing experience for patients by in-
forming them that although they may find some tests to be difficult, this does not
necessarily mean that they have dementia; rather, easy and difficult items are part of the
normal testing experience. Taking the time to address patient concerns at the beginning of
the evaluation can place the process in an informative and potentially less threatening
context, which may optimize motivation while reducing test anxiety and other forms of
emotional distress that could adversely affect test performance. Any distress or signs of
poor motivation that do emerge should be addressed promptly with appropriate reassur-
ances, or if necessary, temporary or terminal discontinuation of testing. Continued assess-
ment of an agitated or unmotivated patient is likely to compromise test validity and inter-
pretation.
ASSESSMENT STRATEGIES
The clinician’s approach to selecting tests to administer in a neuropsychological evalua-

tion is typically guided by (1) the referral question, and (2) the utility of a test to answer
the referral question for an individual patient (i.e., the availability of appropriate norma-
tive data). Although a referral question often dictates attention to a particular cognitive
domain, such as extensive language assessment for an individual with suspected primary
progressive aphasia, test batteries are typically selected with comprehensiveness in mind.
Most clinicians would agree that a comprehensive neuropsychological evaluation should
include assessment in the domains of (1) orientation, (2) attention, (3) executive func-
tions, (4) memory, (5) expressive and receptive language, (6) visuospatial functions, (7)
motor skills, (8) emotional status and personality, (9) estimated premorbid function, and
(10) functional status.
Although the proliferation of new neuropsychological measures over the past decade
has made it easier for the clinician to select test instruments that are tailored to specific
populations and referral questions, shortcomings still remain in the assessment of older
adults. For instance, there are still few measures that effectively accommodate impair-
ments in vision, hearing, and motor functions. However, the most salient issue is the need
for tests with norms that correct for multiple demographic variables of age, education,
ethnicity, and gender. The application of normative standards in test interpretation is
based on the assumption that the individual who is being evaluated is similar in most re-
spects to the population that comprised the normative sample. That assumption is in-
valid, however, when an individual’s characteristics are not a good fit with the normative
population, which has historically occurred when an individual has a low level of educa-
tion, is a member of a minority ethnic group, or is older. Regarding education, for in-
stance, Pittman and colleagues found that neuropsychological tests can overdiagnose de-
mentia among individuals with low levels of formal schooling (Pittman et al., 1992).
Fortunately, the recent generation of neuropsychological instruments has been developed
with greater attention to validation on large, demographically representative samples. For
instance, the normative sample for the Wechsler Adult Intelligence Scale—3rd Edition
(WAIS-III, Wechsler, 1997a) and Wechsler Memory Scale—3rd Edition (WMS-III, Wechs-
ler, 1997b) was collected to broadly reflect the demographic representation of the U.S.
population. These tests also have a scoring supplement that corrects for specific demo-
graphic factors.
In addition, work by Heaton and colleagues (Heaton, Miller, Taylor, & Grant, 2004)
has resulted in a compilation of demographically corrected norms for neuropsychological
measures that provide norms for specific demographic subpopulations; these corrected
norms include combinations for age, education, African American versus European
American ethnicity, and sex. While the field of clinical neuropsychology continues to
make progress in the development of demographically representative norms, it is impor-
tant to note that even when norms are carefully collected to represent the general popula-
tion, the application of these norms to geographic and ethnic subpopulations can still be
misleading (Spreen & Strauss, 1998), particularly if members of that subpopulation do
not have English as their native language. Ultimately, it is incumbent on clinicians to be
well informed about the normative properties of the tests they use to assess older adults.
An informative discussion of criteria for evaluating normative properties appears in
Mitrushina, Boone, and D’Elia’s (1999) thorough collection and review of neuropsy-
chological test norms.
Another aspect of assessment that affects test selection is the overall approach to test
battery construction; that is, fixed versus flexible assessment batteries. Bearing in mind
that the nomenclature itself may be misleading, the “fixed battery” approach to
neuropsychological assessment is to administer the same collection of tests in the same
order to every patient, perhaps best exemplified by the Halstead–Reitan Neuropsy-
chological Battery (HRB). A “flexible battery,” in contrast, is composed of neuro-
psychological measures tailored to each individual’s specific referral question. One way
to summarize the two approaches is that the former collects the data before generating in-
terpretive hypotheses, whereas the latter often collects data guided by hypotheses.
Whereas a fixed battery approach, specifically the HRB, has a strong tradition in foren-
sics and the assessment of focal neurological conditions, there are disadvantages to this
approach for geriatric assessment; the time required to administer a large fixed battery is
fatiguing to many older adults, and many tests may not necessarily be suitable to the
functional levels of demented patients. In practice, many clinicians typically administer a
certain core collection of tests to all patients, while also selecting additional tests to ad-
dress specific referral issues. This approach retains one advantage that is often attributed
to the fixed battery approach, which is that consistent administration of tests across dif-
ferent diagnostic groups builds a sense of how different illness groups may perform on a
particular test. In addition, it also maintains the flexibility to add to these tests as circum-
stances dictate. Thus, a core of well selected, age-sensitive measures in a geriatric
neuropsychological assessment battery can improve diagnostic specificity without com-

promising the clinician’s flexibility.
One caveat to consider in test selection is that cognitive function among older adults
is heterogeneous; administering tests that are too hard or too easy for patients’ functional
levels can lead to both false negative and false positive errors in diagnosing impairment.
One example is the word-list learning task in the CERAD battery, which was developed
to assess AD and to be tolerable for individuals with mid- to late-stage impairments.
When administered to high-functioning individuals with mild or non-AD impairments,
however, this 10-item word list may produce a ceiling effect (see Welsh-Bohmer & Mohs,
1997). On the other hand, tests that generate floor effects due to a high level of difficulty
can be demoralizing, which may lead to diminished effort.
Some clinicians administer screening tests as either a core or starting point for their
assessments. These measures typically sample a few items from several cognitive domains
and range in administration time from 5 to 45 minutes. An example that is on the brief
end of the screening spectrum is the long- and oft-used Mini-Mental State Examination
(MMSE; Folstein, Folstein, & Fanjiang, 2001). The MMSE is pervasive in clinical re-
search studies involving cognition and is widely used by physicians to screen for cognitive
impairment. One drawback to using the MMSE as a global screen for cognitive impair-
ment is its poor sensitivity to right-hemisphere dysfunction and subtle cerebral dys-
functions (Naugle & Kawczak, 1989). Another drawback is adherence to the common
convention that an MMSE score below 25 is indicative of dementia. In fact, there are
significant effects of age, education, and lifetime principal occupation on the MMSE (An-
thony, LeResche, Niaz, Von Korff, & Folstein, 1982; Frisoni, Rozzini, Bianchetti, &
Trabucchi, 1993; Launer, Dinkgreve, Jonker, Hooijer, & Lindeboom, 1993), which can
result in overdiagnosis of impairment in older and lower-educated individuals and
underdiagnosis of impairment among individuals who are younger, more highly edu-
cated, and more mildly impaired. Although many neuropsychologists include the MMSE
in research batteries because of its brevity and status as a lingua franca for cognitive sta-
tus, its utility as a stand-alone measure of cognitive function is limited.
Several other screening batteries are more extensive in length and consequently dem-
onstrate higher levels of sensitivity and specificity for age-related cognitive impairments.
The Cognistat (formerly Neurobehavioral Cognitive Screening Examination; Kiernan,
Mueller, & Langston, 2001) and the Repeatable Battery for the Assessment of Neuro-
psychological Status (RBANS; Randolph, 1998) are examples of screening batteries used
in general neuropsychological assessment that have been validated as stand-alone assess-
ments in demented populations. Each of these batteries yields information about the pres-
ence and severity of cognitive deficits by sampling cognitive processes that tend to change
in the context of neurological dysfunction. The drawback to screening batteries is that
they can fail to detect subtle cognitive deficits or may lack the necessary comprehensive-
ness to inform differential diagnosis. One way to address the latter drawback is to admin-
ister additional tests in the domains that are positive for impairment on the screening
measure, thus making the instrument the “core” of a larger flexible assessment. A screen-
ing approach may also be used effectively in an inpatient setting where time constraints
preclude the administration of a comprehensive battery for all referrals, and where test
specificity may be a lesser priority. Although there is potential utility in measures that
broadly screen for cognitive dysfunction, appreciation of their limitations is an important
part of test selection and interpretation.
INTERPRETATION OF NEUROPSYCHOLOGICAL DATA
The interpretive process essentially defines the neuropsychological evaluation; it is the

process by which a standardized laboratory procedure becomes clinically relevant and
meaningful. Test interpretation is an inferential process that begins with the use of stan-
dardized normative information and extends consideration to information about onset
and course of illness, neurobehavioral signs and symptoms, medical history, family his-
tory, and other data that provide an important context for the test scores themselves. It is
this essential integration of test data with clinical knowledge that sets the neuro-
psychologist apart from a psychometrician or computer algorithm.
The following section details key aspects of integrated neuropsychological interpre-
tation. We consider how individual presentation and history provide context for
neuropsychological interpretation, and how clinical knowledge of neuropathological pro-
cesses can provide an organizational framework for relating individual profiles to
broader diagnostic entities. Although these aspects are recognized elements of most
neuropsychological evaluations, we consider them as they pertain to the assessment of ge-
riatric cognitive disorders.
Core Neuropsychological Knowledge Base

Functional Neuroanatomy
A comprehensive understanding of brain–behavior relationships is an intellectual corner-
stone in the specialty practice of clinical neuropsychology. Familiarity with the neuro-
behavioral manifestations of changes to central nervous system structures, pathways, and
systems allows for an informed generation of hypotheses regarding the etiology of a pa-
tient’s presenting condition. Also important is an understanding of how neuroanatomy is
related to specific neurological and psychiatric disorders. From this starting point, the
neuropsychologist can proceed to test interpretive hypotheses based on the relationship
between patient data and established clinical knowledge.
Diagnostic Criteria
Many geriatric cognitive disorders can be defined by diagnostic criteria that have been
developed to formally characterize the relationship between patient presentation and es-
tablished profiles of neurocognitive change. For instance, numerous diagnostic guidelines
have been developed to aid the diagnosis and differential diagnosis of dementia. One of
the most prevalent sets of diagnostic criteria for dementia was developed for the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
Psychiatric Association, 1994). These criteria require memory impairment in addition to
at least one of the following cognitive disorders: (1) aphasia, (2) apraxia, (3) agnosia, or
(4) executive dysfunction. These cognitive impairments must also (1) be associated with
impairments in social or occupational function, (2) reflect a decline from premorbid per-
formance, and (3) not be better explained by other conditions, including delirium and
psychiatric disorder. Additional criteria in the DSM-IV differentiate AD from vascular
and other dementias. Other diagnostic criteria have been developed in clinical re-
search to diagnose AD (National Institute of Neurological and Communicative Disor-
ders and Stroke–Alzheimer’s Disease Related Disorders Association [NINCDS-ADRDA];

McKhann et al., 1984) and vascular dementia (National Institute of Neurological Disor-
ders and Stroke and Association Internationale pour la Recherche et l’Enseignement en
Neurosciences [NINDS-AIREN]; Roman et al., 1993). The chapters that follow in Part I,
Section A, of this book outline many formalized diagnostic criteria, including those for
MCI, which is non-normal cognitive performance that does not produce the level of im-
pairment consistent with dementia (Winblad et al., 2004). In the absence of formalized or
widely accepted criteria, clinicians often look to key studies to guide their conceptualiza-
tion of typical presentations of disorders linked to specific etiologies.
Although diagnostic criteria are useful to guide clinical diagnosis, it is important to
bear in mind that their nature is to capture the typical profile of a condition. There is,
however, considerable interindividual heterogeneity in the aging process, in risk factors
for neuropsychological dysfunction, and in presentation of the cognitive disorders them-
selves. It is thus important to recognize that some presentations of a cognitive disorder
may be atypical or influenced by comorbid conditions and, as such, may not precisely fit
a specific nosology. Therefore, divergence from typical diagnostic criteria does not neces-
sarily rule out specific interpretive hypotheses; rather, they should be considered in light
of each patient’s specific presentation, including knowledge of the base rates and age dis-
tributions of typical and atypical presentations of the etiologies under consideration.
Neurobehavioral Presentations
Although neuropsychological testing is the primary source of interpretive information for
the neuropsychologist, knowledge of behavioral manifestations in specific cognitive dis-
orders is complementary to the interpretation process. Many geriatric cognitive disorders
have characteristic behavioral presentations, with the dementia syndrome of depression
as a common example. Frontal lobe dementias are often notable for disinhibited behavior
that typically accompanies the disorder (Liu et al., 2004). Depressed affect often accom-
panies Parkinson’s disease (Leentjens, 2004), whereas dementia with Lewy bodies often
produces visual hallucinations early in the course of the illness (Rampello et al., 2004).
Although some manifestations of abnormal behavior can be observed in the course
of an evaluation, deficits in patient insight or unwillingness to report behavioral symp-
toms often makes collateral reports an important source of these data. Instruments that
help quantify the presence and severity of neuropsychiatric problems in geriatric popula-
tions include the Geriatric Depression Scale (GDS; Yesavage et al., 1983), the Neuropsy-
chiatric Inventory (NPI; Cummings, 1997), and the Clinical Assessment Scales for the
Elderly (CASE; Reynolds, 2001). Beyond the diagnostic utility of the behavioral presenta-
tion, it is important to consider the role of behavior in treatment prognosis, given that be-
havioral disruption in dementia increases the likelihood of institutionalization and de-
creases quality of life for both patients and caregivers (Finkel, Costa e Silva, Cohen,
Miller, & Sartorius, 1996).
Characteristic and Pathognomonic Signs

Another important aspect of a geriatric neuropsychologist’s core knowledge should be
the ability to recognize presentations that are highly specific to a particular disorder. For
instance, the neuropsychological assessment of a patient following stroke may reveal a
constellation of dysgraphia, dyscalculia, right–left disorientation, and finger agnosia,

which represent the characteristic signs of Gerstmann’s syndrome (Benton, 1992). In a
patient who presents with Parkinsonian features, it may be useful to assess for the impair-
ment in downward gaze that characteristically appears in the early course of progressive
supranuclear palsy (Golbe, 2001). When neuropsychological findings of confusion, dis-
orientation, and memory impairment are accompanied by observation of an apractic gait
and a reported history of urinary incontinence, a diagnosis of normal-pressure hydro-
cephalus is a strong diagnostic possibility (Lezak et al., 2004). These examples illustrate
the importance of evaluating neuropsychological test results in the context of other as-
pects of the assessment process, such as behavioral observations and medical history. This
theme of integrative interpretation continues throughout the discussion that follows.
Patient Presentation and Performance

Integrative neuropsychological interpretation proceeds as the clinician applies his or her
base of clinical knowledge to the patient’s specific presentation. In addition to data from
neuropsychological testing, patient presentation and history are valuable to the interpre-
tive process. Other chapters in this text are devoted to the neuropsychological profiles of
specific cognitive disorders, and we refer the reader to these for more detailed informa-
tion. Here we address the more general interpretive aspects of patient presentation, which
include estimation of premorbid function, behavioral observations, and characterization
of normal versus abnormal performance. Following these considerations we consider as-
pects of clinical and medical history that are key to the interpretive process. Finally, we
discuss neuroimaging and genetic data that are supplemental to the neuropsychological
interpretive process.
Patient Data
Estimating Premorbid Function. One of the key criteria for diagnosing a cognitive
disorder is whether an individual’s observed performances differ from expected perfor-
mances based on evidence or estimates from prior healthy function. Without a valid esti-
mate of premorbid function, interpretation based on normative standards alone may still
underdiagnose impairment among individuals with high premorbid ability or over-
diagnose individuals with low premorbid function. Unfortunately, few older individuals
have neuropsychological test results or formal estimates of intellect from earlier in their
life, so premorbid abilities must be estimated based on (1) educational and academic
achievements, (2) demographic factors (Barona, Reynolds, & Chastain, 1984), (3) tests
of verbal intellect or reading that are typically resistant to early cognitive decline (e.g.,
Shipley Institute of Living Scale, Shipley, 1946; North American Adult Reading Test, Blair
& Spreen, 1989; WRAT-3, Wilkinson, 1993), or (4) combined demographic–performance
estimates (e.g., Oklahoma Premorbid Intelligence Estimate–3 [OPIE-3], Schoenberg,
Scott, Duff, & Adams, 2002). Each of these methods has utility in estimating premorbid
neurocognitive performance, but all require caution in their application to older adults.
Educational level or occupational background may not reliably predict intelligence in this
age cohort, because economic, geographic, and cultural barriers limited the educational
and occupational opportunities of many individuals. Further, education level does not
influence performance in all cognitive domains equally (Heaton, Ryan, Grant, &
Matthews, 1995). In addition, caution must be exercised when using estimates based on
performance in such areas as reading, because these estimates may not be stable in condi-
tions such as stroke or traumatic injury (e.g., Johnstone & Wilhelm, 1996). Thus the cli-
nician needs to be appropriately judicious in the use of these approaches in cases when
these estimates may be prone to over- or underestimation of premorbid function.
Behavioral Observations. One source of nontest data that is nonetheless critical to

neuropsychological interpretation is that of behavioral observations. Observations of be-
havior during testing and other patient contact provide important contextual information
for interpreting test performances. For instance, consistent evidence of word-finding defi-
cits and circumlocution during conversation may alert the clinician to the possibility of
primary progressive aphasia, whereas perseverative responses and echolalia might raise
consideration of frontal-lobe dementia. There are also many diagnostic behaviors that
contribute to poor test performance that would go unnoticed in the examination of test
scores alone. For instance, poorer performances that appear influenced by inattentive and
impulsive behavior might suggest frontal-lobe involvement, whereas poorer performances
due to inattention and slowed cognitive processing might suggest a subcortical etiology.
Observation of behaviors such as these during the course of testing can help the clinician
make determinations regarding test validity. Behavioral observation is also an important
way to assess emotional presentation and thought processes. Depressed affect, for in-
stance, is important to assess via observation because self-report of mood is not always
veridical. The presence of insight into cognitive deficits is a key behavioral observation,
for example, because depressed individuals typically overreport their cognitive difficul-
ties, whereas individuals with AD or frontal-lobe dementia tend to underreport (Breitner
& Welsh, 1995).
Characterizing Normal versus Abnormal Performance. Perhaps the most critical ele-
ment of neuropsychological interpretation are the data themselves. The objective, stan-
dardized information generated from a comprehensive neuropsychological evaluation is
the primary source of data in establishing the presence or absence of deficits, the degree
of compromise, the specific neurocognitive domains affected, and the overall constella-
tion of test results—all of which allow for inferences regarding neuroanatomical corre-
lates and diagnosis. An analysis of deviations from expected performances typically in-
volves both normative comparisons and consideration of the overall pattern of test
findings. The principal purpose of normative data is to compare an individual’s perfor-
mance to what is expected of his or her peer group (see Busch & Chelune, Chapter 6, this
volume). Given that many older adults experience slowing and other mild cognitive
changes as they age, it is particularly important in geriatric assessment to distinguish nor-
mal age-related decline from abnormal performances indicative of a cognitive disorder.
Thus a brief review of the neuropsychology of normal aging is provided for this purpose.
Normal aging of the nervous system is the most common explanation for relatively
mild changes in cognitive functioning occurring after the fifth decade (Albert & Heaton,
1988). The profile of change with normal aging is often characterized as a loss of “fluid”
abilities that are associated with problem solving and novel task performance (Horn,
1982). “Crystallized” abilities, by contrast, are those skills that have been well learned
over time and tend to be less susceptible to age effects. It is important to recognize, how-
ever, that there is a great deal of interindividual variability in the rate and profile of
change among normally functioning older adults. Research suggests that some individu-
als may carry more of a cognitive reserve against age-related decline than others (Stern,
2002), which may be related to number factors such as genetic inheritance, intellectual
engagement, and health status. Establishing normal and abnormal performances within a
given evaluation rests upon normative comparisons, but also considers the overall con-
stellation of test findings. In this manner, suspected changes in patient function are con-
sidered in the context of relevant individual factors, such as estimated premorbid ability
and key developments in clinical history. Nonetheless, even with adherence to these prac-
tices, there can be considerable ambiguity in a cross-sectional assessment of neuro-
psychological status. In these instances, longitudinal follow-up is often essential to docu-
ment whether there is a progression of deficits that typifies dementia or a pattern of
stability or improvement that may suggest normal aging.
Historical Data: Clinical Presentation and Medical History

Clinical Presentation. Understanding the history of a patient’s presenting symptoms
is important to the neuropsychological assessment process because it is a key source of in-
formation about the onset, course, and presentation of deficits. This information allows
the neuropsychologist to compare the patient’s presentation to those that typify specific
cognitive disorders. Important aspects of the clinical presentation include type of onset
along with the rate and course of neurocognitive and behavioral changes.
Onset. The etiologies of many geriatric cognitive impairments can often be segre-
gated by whether the onset of symptoms was gradual or sudden. As a general rule, the
impairments that characterize AD and associated progressive dementias tend to develop
over the course of months and years, and may even have a preclinical period extending
decades prior to diagnosis (Hulette et al., 1998; Snowdon et al., 1996). In the case of vas-
cular dementia, progression is often characterized as “stepwise,” in that overall progres-
sive decline is interspersed with periods of stable function, gradually reflecting the cumu-
lative effects of acute episodes of cerebrovascular insults (Roman et al., 1993). In contrast
to gradual or stepwise onset, sudden changes in cognitive function are often linked to
acute events, such as cerebrovascular accidents, metabolic dysregulations, or psychiatric
disturbances. In some cases, the etiology of an acute change can be corroborated by clini-
cal signs or laboratory results.
Rate and Course. Although it is important to establish a patient’s symptom onset, it

is equally important to understand the rate and manner in which subsequent changes in
function have occurred. Neurocognitive performance can decline slowly or rapidly, re-
main stable, or even demonstrate improvement. For instance, although most dementias
present a progression from mild to severe impairment that can be measured in years, a
patient who progresses from mild to severe dementia in the course of months may be sus-
pected of having an uncommon, rapidly progressive illness such as Creutzfeldt–Jakob dis-
ease (Brown, Cathala, Castaigne, & Gajdusek, 1986). As mentioned previously, cognitive
impairments that present suddenly and remain stable often suggest the occurrence of
cerebrovascular occlusion or hemorrhage. The “dementia of depression” syndrome is a
common etiology of acute cognitive decline among older adults, which potentially can re-
solve as depressive symptomatology remits (Alexopoulos, Meyers, Young, Mattis, &
Kukuma, 1993; McNeil, 1999). Metabolic dysregulation and medication effects often
contribute to cognitive impairment in older adults, but can resolve in response to medical
intervention. Attention to progressive, reversible, and stable presentations of neurocog-
nitive impairment may aid the neuropsychologist with intervention planning as well as
with differential diagnosis.
Relative Decline In addition to considering the general rate and course of cognitive
impairment, neuropsychological interpretation is also aided by consideration of how spe-
cific neurocognitive domains decline relative to each other. The classic presentation of
AD, for instance, is characterized by an early disproportionate decline in memory abili-
ties, whereas frontal-lobe dementias are characterized by an early disproportionate de-
cline in executive functions. True to their names, progressive movement disorders such as
Parkinson’s disease present with early motor abnormalities (Tröster, 1998), whereas early
impairment in speech production in the context of general neurocognitive preservation is
the hallmark of primary progressive aphasia (Mesulam, 2001). Non-neuropsychological
but associated features such as extrapyramidal symptoms (EPS) can also have diagnostic
and prognostic utility when they are prominent factors in the disease course. For in-
stance, individuals who present with early EPS are more likely to have neuropathological
signs of Parkinson’s disease and Lewy body disease, and their clinical course is associated
with greater cognitive decline and behavioral disturbances (Green, 2001).
Informant Reports. Ideally, the neuropsychologist’s primary tool for evaluating the
direction and rate of neurocognitive changes involves longitudinal neuropsychological
comparisons; however, longitudinal test data are not present nearly as often as the clini-
cian would like. In the absence of previous testing, the clinician can attempt to estimate
direction and rate of progression from patient and family report by comparing the magni-
tude of cognitive deficits observed in current testing relative to the reported course of cog-
nitive compromise.
Medical History
Information regarding past or current medical conditions and medications is important
to neuropsychological interpretation because these factors can cause cognitive impair-
ment in their own right as well as influence the presentation of an underlying dement-
ing process. Medical history is particularly important because many medical illnesses
become more prevalent with age, and increased medical burden is associated with de-
creased cognitive function. Primary hypothyroidism, for instance, is more common
with age and can result in neurocognitive decline that is potentially reversible with
treatment (Dugbartey, 1998). Postoperative cognitive dysfunction is also common
among older adults (Lewis, Maruff, & Silbert, 2004). Overmedication is a cause of
neurocognitive impairment that is more prevalent among older adults (Moore &
O’Keefe, 1999); thus it is important to obtain a list of current medications as part of
the medical history. Prior medical history can also be a significant aid to neuropsy-
chological interpretation. For instance, brain trauma in early life can change the orga-
nization of the brain in atypical ways (Bates et al., 1997; Cioni, Montanaro, Tosetti,
Canapicchi, & Ghelarducci, 2001), and head trauma in early adulthood may be a risk
factor for later dementia (Plassman et al., 2000). Finally, family medical history is sa-
lient to diagnostic interpretation because many late-life cognitive disorders have famil-
ial influences (Plassman & Breitner, 1996).
Attendant Data
The previous section discussed the integration of patient presentation with essential clini-
cal knowledge of disease characteristics as a method for interpreting neuropsychological
data. The following section briefly highlights additional data that are not deemed essen-
tial to the interpretation process, but which are certainly important to refining or sup-
porting the interpretation of neuropsychological data.
Neuroimaging
The neuroimaging of brain structures and functions has produced some revolutionary
advances in the study of brain–behavior relationships and can be very useful in neuro-
psychological diagnosis when used appropriately. Imaging can be used to confirm areas
of neuropathology that would be expected in a given disorder, such as evidence of
brain lesions in suspected vascular dementia. In conditions such as stroke, imaging data
can also support hypotheses about lesion localization derived from neuropsychological
testing. Imaging also has emerging prognostic capability; for instance, regional brain
metabolism on positron emission tomography (PET) imaging was found to predict later
development of a neurodegenerative disorder (Silverman et al., 2001). Structural imag-
ing such as computed tomography (CT) and magnetic resonance imaging (MRI) pro-
vide useful information about the location and volume of lesions in specific areas of
the brain, but do not provide information related to brain function per se. Although
functional imaging techniques such as PET, functional magnetic resonance imaging
(fMRI), and electroencaphalography (EEG) are useful in identifying relationships be-
tween brain functions and structure, there is still an incomplete understanding of how
these relationships relate to many specific neurological conditions, to the severity of
cognitive impairment, and to neuropsychological strengths and weaknesses of a specific
individual. Studies relating imaging findings to treatment intervention are currently lim-
ited as well.
Genetics
One of the most promising developments in medicine is the use of genes and other
biomarkers to diagnose and treat medical conditions. Information from genetic investiga-
tions has proven useful in the diagnosis of AD (Welsh-Bohmer, Gearing, Saunders, Roses,
& Mirra, 1997) and some familial frontotemporal dementias (e.g., Yamaoka et al.,
1996). Apolipoprotein E (apoE), in particular, has been studied for its relationship to AD
and cognitive decline (Saunders, Hulette, Welsh-Bohmer, et al., 1996; Small, Mazziotta,
Collins, et al., 1995; Welsh-Bohmer, et al., 1997). As promising as these developments
may be, it is important to note that understanding of the diagnostic and treatment impli-
cations of such information is complex. For instance, one study found that the inclusion
of apoE genotyping to the information available for diagnosing AD increased the specific-
ity of diagnosis from 55 to 84%, but decreased the sensitivity of the diagnosis from 93 to
61% (Mayeux et al., 1998). Unlike the deterministic genotyping for Huntington’s disease
and rare familial forms of AD, apoE and other biomarkers will likely provide only proba-
bilistic information about disease susceptibility—which raises ethical issues about disclos-
ing the results of this testing. Because the diagnostic utility of biomarker information is
not yet well validated and there is potential psychological harm in disclosure of this infor-
mation, its use is not currently recommended outside of specialized research centers oper-
ating within protocols that include genetic counseling (Hedera, 2001).
CONCLUSIONS
The previous section on neuropsychological interpretation reviewed key factors that

should be synthesized with test data to arrive at diagnostic and functional impressions
that are beneficial to both the patient and other treatment professionals involved in his or
her care. Whereas some of these factors are addressed in the neuropsychological assess-
ment itself, other factors require the clinician to remain abreast of findings regarding the
etiology and diagnosis of cognitive disorders that occur among older adults, and to apply
this knowledge to the patient’s profile with the same intellectual rigor that is applied to
psychometric data.
As the proportion of elderly in the United States and other developed Western na-
tions continues to increase, the practice of geriatric neuropsychology becomes increas-
ingly integral to the care of older adults. The utility and relevance of neuropsychological
assessment are enhanced by attention to the characteristics and needs of this population.
Because there is a high degree of heterogeneity in the aging process, the specificity of
neuropsychological assessments can be improved by consideration of all relevant sources
of information. It is important for clinicians to remain abreast of developments in related
areas such as cognitive neuroscience and neuroepidemiology, which can provide valuable
information concerning the detection and treatment of age-related cognitive disorders.
Evaluations are enriched when they occur in conjunction with other sources of informa-
tion, such as historical information, functional change measures, and behavioral observa-
tions. Although the ultimate goal of eliminating dementing conditions altogether remains
immensely challenging, research across disciplines has made considerable progress in ear-
lier and more reliable detection of AD and other dementias. Treating these conditions be-
fore symptoms become overt offers the greatest likelihood of preventing or minimizing
decline. One goal for the field of geriatric neuropsychology should be to assure that our
expertise in intervention and management of cognitive disorders keeps pace with our ex-
pertise in detection and diagnosis.
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2
Normal Aging and

Mild Cognitive Impairment
GLENN SMITH
BETH K. RUSH
D ating back to the writings of V. A. Kral (1958, 1962) and perhaps before, two forms of
cognitive change have been associated with aging. One form is proposed to involve typi-
cal, benign, and perhaps “developmental” changes in cognition associated with nonspe-
cific histopathological brain changes. The second is a malignant, atypical form that may
reflect specific brain histopathology. An extensive nomenclature has arisen out of at-
tempts to diagnose each form of cognitive aging. A number of these diagnoses are
depicted in Figure 2.1. This chapter discusses these two forms of cognitive aging. There is
a vast literature that seeks to describe the fundamental processes of cognitive aging. We
do not attempt to survey this entire literature in one chapter. We do, however, discuss the
implications of cognitive aging for geriatric neuropsychological assessment. We then pro-
ceed to discuss mild cognitive impairment and related concepts that have arisen out of at-
tempts to find prodromes for dementia. Finally, we discuss mild cognitive impairment as
one of several “risk factors” for dementia.
WHAT IS COGNITIVE AGING?
Studies of cognitive aging typically involve either cross-sectional (interindividual compar-

ison) or longitudinal (intraindividual comparison) design. Most cross-sectional studies of
cognitive aging compare the performance of older adults to the performance of younger
adults at a single point in time. This approach is favored for its practicality and its ability
to appreciate obvious dimensions of difference between age groups on a given cognitive
task. However, a major disadvantage to this approach is that between-group comparisons
do not take into account cohort effects (e.g., differential access to quality education) or
selective attrition (the tendency for lower scoring members of a cohort to drop out of
27
FIGURE 2.1. Proposed terms for benign and malignant cognitive aging.
studies more rapidly). Therefore, cross-sectional studies can provide evidence of cognitive
differences between older and younger adult cohorts but may provide misleading infor-
mation about patterns of functioning over time or rates of decline within individuals.
In contrast, longitudinal studies of cognitive aging are labor intensive with regard to
execution and time. Studies that can model single individuals’ cognitive change over de-
cades are few. Longitudinal studies compare levels of performance across serial evalua-
tions within individuals and therefore provide information about patterns of performance
over time. These studies yield a great deal of information about cognitive change over
time. Longitudinal studies advance our understanding of benign cognitive aging by allow-
ing us to examine individual differences in rates of cognitive change. Such investigations
lead to a greater understanding of the role that both biological (e.g., genes, metabolism,
physical health) and environmental (e.g., lifestyle, demography) factors play in determin-
ing the level of cognitive functioning across the lifespan.
Most researchers agree that cognitive change is a nearly inevitable part of advancing
age (e.g., Schaie, 1994). A few “optimally” aging people may avoid cognitive decline as
they age (Powell & Whitla, 1994). For most, however, childhood development that in-
volves increasing efficiency and abstraction ability, peaks in the middle of our second de-
cade, followed by a slow loss of cognitive efficiency that may accelerate during the fifth
decade. A hallmark of cognitive aging is a reduction in mental processing speed
(Salthouse, 1996) and an associated reduction in the amount of information that can be
processed at a single point in time. Multiple studies have demonstrated that limitations in
mental processing speed consequently result in age-related changes in performance across
many cognitive domains (e.g., Fisher, Duffy, & Katskiopoulos, 2000; Meyerson, Adams,
Hale, & Jenkins, 2003; Meyerson, Jenkins, Hale, & Sliwinski, 2000; Salthouse, 1996).
Indeed, changes in processing speed influence attention, language, memory, and executive
functions (e.g., Finkel & Pederson, 2000; Hertzog & Bleckley, 2001; Keys & White,
2000; Parkin & Java, 2000; Sliwinski & Buschke, 1997, 1999; Zimprich, 2002). For ex-
ample, studies of “normal” memory change reveal that, compared to younger adults,
Normal Aging and Mild Cognitive Impairment 29
healthy older adults are less efficient at encoding to-be-learned information and therefore
have greater difficulty recalling information following a delay period (e.g., Brebion,
Smith, & Ehrlich, 1997; Frieske & Park, 1999; Light, 1996; Park et al., 1996; Sliwinski
& Buschke, 1997). In this case, limitations in the extent of early processing limit the yield
of later processing. Indeed, changes in general cognitive speed with advancing age impact
performance across cognitive domains.
The cognitive changes that accompany advancing age result from several neuro-
physiological changes. The most recent research in this area suggests that benign aging in-
volves minor deposition of beta-amyloid peptide and neurofibrillary tangles, as well as a
loss of synapses, neurons, neurochemical input, and neuronal networks (Fillit et al.,
2002). Additionally, normal aging can result in mild cerebral atrophy, slight ventricular
enlargement, and mild hippocampal atrophy. However, actual gliosis or cell death is now
thought to be less common in benign aging than it is in malignant aging processes such as
dementia (West, Coleman, Flood, & Tronosco, 1994). Senescence-related neurophysi-
ological changes appear to reduce the efficiency and net productivity of the neural system
without dramatically altering its structural integrity. This characterization of benign
aging sharply contrasts with the more dramatic structural neurological compromise typi-
cally associated with malignant aging processes. Interestingly, the same quality and mag-
nitude of contrast are evident when the neurocognitive profiles of benign versus malig-
nant aging are compared.
In the differential diagnosis of benign versus malignant cognitive change, serial as-
sessment (e.g., a longitudinal approach) might be seen as ideal. This approach allows for
the appreciation of performance across time, establishing evidence either in favor of or
against “excess” cognitive decline over time. However, serial assessment, especially over
the time frame it takes for clinical manifestation of malignant aging to develop, is a lux-
ury. This type of data is rare in clinical situations. Most clinicians must rely on data from
a single neuropsychological evaluation in order to contribute to an individual’s diagnosis.
These clinicians must thus consider several factors that could imitate or mask a malignant
decline in cognitive functioning. These factors include the age, education, ethnicity, health
status, and motivation of the patient.
In summary, benign or “healthy” cognitive aging results in cognitive change. It is evi-
dence of deviation from benign changes that leads to the diagnostic consideration of a
malignant aging process. Decreased cognitive processing speed is the hallmark of cogni-
tive aging, impacting the efficiency of cognitive functioning across multiple domains.
Age-related changes in processing speed likely result from senescence-related neurophys-
iological changes that compromise the efficiency and net yield of the neurocognitive sys-
tem. Although serial assessments over time may aid in appreciating an individual’s pat-
tern of cognitive functioning over time, such assessments are not routinely available in
clinical practice. The clinician must thus consider a variety of demographic factors to de-
termine if a person might be deviating from expected, typical, or benign cognitive change.
This need for normative referents creates a need for appropriate normative data. For a
detailed discussion, see Busch and Chelune (Chapter 6, this volume).
NORMATIVE STUDIES OF AGING
The benign cognitive changes of aging can mask the presence of malignant cognitive
change. Specifically, normal age-related changes in performance on neuropsychological
tests reduce the specificity of these tests for pathological conditions. Test specificity is
very important clinically because tests with high specificity are used to rule in the pres-
ence of a condition (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Norma-
tive data based on age help to improve the specificity of neuropsychological tests (Smith,
Ivnik, & Lucas, in press). Historically, the utility of neuropsychological tests in detecting
malignant aging processes such as Alzheimer’s disease (AD) has been limited by a lack of
age-appropriate normative data. This point was made clear as early as 1984, when the
National Institute of Neurological and Communicative Disorders and Stroke (NINCDS)
met and combined with the Alzheimer’s Disease Related Disorders Association (ADRDA)
to establish standard diagnostic criteria for AD (McKhann et al., 1984). The incidence of
AD is highest over age 75 (Kokmen, Chandra, & Schoenberg, 1988), yet in 1984, 75 was
the upper age limit of the standardization samples for most neuropsychological tests.
Thus the NINCDS-ADRDA criticism was quite reasonable and valid. Since then, how-
ever, a number of investigators has helped to provide norms for older persons on a wide
variety of neuropsychological measures (cf. Mitrushina, Boone, & D’Elia, 1999).
Our own studies, named the Mayo Older Americans Normative Studies (MOANS;
Ivnik et al., 1992) and the Mayo Older African Americans Normative Studies (MOAANS;
Busch & Chelune, Chapter 6, this volume) are discussed in Chapter 6. Collectively we re-
fer to these studies as the MO(A)ANS. These normative works have provided age and
education norms for comparing clinical populations to normal populations for persons
up to 95 years of age for a variety of tests (see Table 2.1 for test listing, test author, and
MOA(A)NS publications). Many of our normative analyses have focused on the Mayo
Cognitive Factor Scores (MCFS) (Smith, Ivnik, Malec, Petersen, et al., 1992, 1994; Smith,
Ivnik, Malek, & Tangalos, 1993), which are confirmatory-factor-analysis-derived indices
based on coadministration of the Wechsler Adult Intelligence Test—Revised (WAIS-R),
Wechsler Memory Scale—Revised (WMS-R; Wechsler, 1987), and Auditory Verbal
Learning Test (AVLT; Rey, 1964).
The MOANS and MOAANS studies are longitudinal; in the course of repeat testing
at quasi-annual intervals we have found that MCES stabilities are comparable to long-
term stabilities of traditional Wechsler indices for comparable cognitive domains (Ivnik,
Smith, Malec, Petersen, & Tangalos, 1995). Our cross-sectional and longitudinal data
document that some cognitive domains are less stable and more susceptible to age-related
change (see Figure 2.2).
However, we also find it important to highlight the limitations of this group data for
making clinical inferences about individuals. For example, stability coefficients arising
from group data tell us little about how much change over time in an individual’s score is
normal versus abnormal. This information is indicated by the more clinically relevant
data on frequencies of difference scores for factors over time. Table 2.2 shows percentile
scores for intrafactor change scores from the MOANS cohort. This is the minimum de-
gree of change that most clinicians would require to be present at a 1-year interval to be
sure that the change is beyond normative bounds. Relatively small changes in Verbal
Comprehension, on the order of 10 points or greater, are statistically rare in normal pop-
ulations over the interval of 3–5 years. However, it requires changes of 25 standard score
points for us to suggest that a drop in Retention score is statistically abnormal (Ivnik et
al., 1995).
Of course, longitudinal data from which to consider the meaning of magnitudes of
change is a luxury in neuropsychological assessment. Often neuropsychologists must in-
TABLE 2.1. Tests with MOA(A)NS Norms

Test Author (year) MOA(A)NS norms papers
Wechsler Adult Intelligence Wechsler (1981) Ivnik et al. (1992); Lucas et al.
Scale—Revised (WAIS-R) (2005a); Pedraza et al. (2005)
Wechsler Memory Scale— Wechsler (1987) Ivnik et al. (1992); Lucas et al.
Revised (WMS-R) (2005b); Smith et al. (1997)
Auditory Verbal Learning Test Rey (1964) Ivnik et al. (1992); Harris et al.
(AVLT) (2002); Ferman et al. (2005)
Visual Spatial Learning Test Malec et al. (1992) Malec et al. (1992)
Boston Naming Test Kaplan, Goodglass, & Ivnik et al. (1996); Testa et al.
Weintraub (1978) (2004)
Controlled Oral Word Benton, Hamsher, Varney, & Ivnik et al. (1996)
Association Test Spreen (1983)
Stroop Neuropsychological Golden (1978) Ivnik et al. (1996)

Screening Test
Trail Making Test Spreen & Strauss (1991) Ivnik et al. (1996)
Judgement of Line Orientation Benton et al. (1983) Ivnik et al. (1996)

Test
Multilingual Aphasia Benton & Hamsher (1978) Ivnik et al. (1996)

Examination Token Test
Wide Range Achievement Test Jastak & Wilkinson (1984) Ivnik et al. (1996)
(U.S. modification) Nelson Grober & Sliwinski (1991) Smith, Bohac, Ivnik, & Malec
Adult Reading Test (1997)
Dementia Rating Scale Mattis (1988) Lucas et al. (1998a);

Rilling et al. (2005)
Category Fluency Test Lucas et al. (1998b);

Cerhan et al. (2002)
Free and Cued Selective Grober & Buschke (1987) Ivnik et al. (1997)
Reminding Test
terpret the cognitive data from assessment at a single point in time. In this context
neuropsychologists often assume that cognitive skills are highly intercorrelated and
roughly comparable. Thus discrepancies among cognitive skills at a given point in time
are assumed to be an indicator of decline in those areas that are out of line with other
cognitive functions (Lezak, 1995). In a second set of analyses reported by Ivnik et al.
(1995), intraindividual, interfactor variability across different MCFS cognitive domains
was examined. Table 2.3 depicts the frequency of cross-sectional interfactor discrepancy
scores in the MOANS population. Note that even with Verbal Comprehension to Percep-
tual Organizational comparisons, relatively small discrepancies in scores are necessary
before the discrepancy falls outside normal limits. In comparisons of Learning and Reten-
FIGURE 2.2. Mean Mayo Cognitive Factor scores on repeat testing at approximately annual inter-
vals.
tion to verbal comprehension, splits of 25 points or greater are necessary before clinicians
can reasonably assume that this variation is outside normal limits. These data extend to
the MCFS scores, with cautions previously presented in the literature (Matarazzo &
Prifitera, 1989; Ryan & Paolo, 1992) about interpreting discrepancies between cognitive
performances as indicative of some underlying neurological insult. Moderate levels of dis-
crepancy may simply represent normal individual differences in cognitive strengths and
weaknesses. It is important to develop test norms not only for performance at a single
time but also for discrepancies between coadministered measures and for performance
change over clinically relevant intervals.
Through these studies of typically aging individuals, we have been able to better un-
derstand normative patterns of performance on cognitive tests. Establishing these pat-
terns also elucidates patterns of abnormal performance. These studies have thus helped to
clarify the boundary zone between benign and malignant cognitive changes (see Figure
2.1). We now turn to a fuller explication of several of these concepts.
TABLE 2.2. Percentage of Normal People with MCFS Test–Retest “Change Scores” of
Different Magnitudes
Test–retest change scoresa
MCFS ≥5 ≥10 ≥15 ≥20 ≥25 ≥30
VC 30 7 2 <1 — —
PO 57 27 9 2 <1 —
AC 53 28 6 3 1 <1
LRN 64 35 13 6 2 1
RET 65 43 23 9 5 3
Note. MCFS, Mayo Cognitive Factor Scales; VC, Verbal Comprehension; PO, Perceptual Organization; AC, Attention/
Concentration; LRN, Learning; RET, Retention. From Ivnik, Smith, Malec, Petersen, and Tangalos (1995). Copyright
1995 by the American Psychological Association. Reprinted by permission.
a Change scores are the absolute values of Test 1–Test 2 difference scores.
TABLE 2.3. Percentage of Normal Older Persons with MCFS Difference Scores of
Varying Magnitudes
MCFS
difference Magnitude of the difference score
score dyad ≥5 ≥10 ≥15 ≥20 ≥25 ≥30
VC–PO 64 37 20 9 4 1
VC–AC 66 40 20 11 5 2
VC–LRN 70 45 28 18 10 6
VC–RET 70 49 32 18 9 3
PO–AC 71 53 25 14 6 3
PO–LRN 70 46 29 17 9 4
PO–RET 69 46 27 16 8 4
AC–RET 73 48 31 20 12 6
AC–LRN 75 53 33 20 10 4
LRN–RET 69 41 25 14 5 2
Note. MCFS, Mayo Cognitive Factor Scales; VC, Verbal Comprehension; PO, Perceptual Organization; AC, Attention/
Concentration; LRN, Learning; RET, Retention. From Ivnik, Smith, Malec, Petersen, and Tangalos (1995). Copyright
1995 by the American Psychological Association. Reprinted by permission.
BENIGN COGNITIVE CHANGE

Age-Associated Memory Impairment
In 1986 a National Institute of Mental Health work group proposed the diagnosis of age-
associated memory impairment (AAMI; Crook et al., 1986). This diagnosis was intended
to identify age-related changes in memory performance. As originally proposed, the con-
cept of AAMI was predicated on the comparison of older persons to young adult norms
on a variety of memory tests (Crook et al., 1986).
We criticized the method of establishing AAMI diagnoses because it did not recog-
nize that traditional memory measures in clinical neuropsychology have tremendous
heterogeneity in terms of their sensitivity to age effects (Smith et al., 1991). We sug-
gested that it would require greater specificity in which aspects of memory were as-
sessed in order for the concept to be applied reliably. Studies using the concept and
definition of AAMI continue. Many of these studies originate in Europe, and many
represent clinical trials aimed at mitigating age-related cognitive changes (cf. van
Dongen, van Rossum, Kessels, Sielhorst, & Knipschild, 2003). Ultimately, instead of
becoming more rigorously defined in DSM-IV, the AAMI concept evolved into a much
more loosely defined concept of age-related cognitive decline (ARCD; American Psychi-
atric Association, 1994).
Age-Related Cognitive Decline

The definition of ARCD is not linked to psychometric test performance but is specifically
tied to an intervention approach that focuses on memory that is normal in relation to age.
Individuals diagnosed with ARCD are sometimes described colloquially as “worried
well.” In other words, it applies best to the clinical situation in which an older person is
worried about his or her memory function, but there is no objective evidence of memory
impairment. In recent practice the term is sometimes used interchangeably with normal
aging (cf. Caccappolo-van Vliet et al., 2003).
MALIGNANT COGNITIVE CHANGE
There is now an extensive literature on early detection of Alzheimer’s-type dementia us-

ing neuropsychological instruments (Becker, Boller, Saxton, & McGonigle-Gibson, 1987;
Berg, 1992; Masur, Sliwinski, Lipton, Blau, & Crystal, 1994; Morris et al., 1991;
Petersen, Smith, Ivnik, Kokmen, & Tangalos, 1994; Robinson-Whelen & Storandt, 1992;
Storandt & Hill, 1989; Welsh, Butters, Hughes, Mohs, & Heyman, 1991). Most of these
studies however, have utilized a case–control methodology comparing normal controls to
persons who have previously established clinical diagnoses of dementia, albeit early in the
course of the disease. Moving beyond these studies, the question arises of just how
“early” can dementia be detected. For example, can the evolution of dementia be pre-
dicted in persons assessed while still considered to be clinically not demented?
Dementia researchers and clinicians have improved their ability to diagnose and
study “at risk” or malignant boundary conditions (see Figure 2.1). Again a variety of
terms and criteria have been promoted. Figure 2.3 presents the combined results of
MEDLINE and PsycINFO searches on isolated memory impairment, questionable de-
mentia, cognitive impairment not demented, AAMI, and mild cognitive impairment
(MCI) for the period 1985–2003. Clearly the concept of MCI (Petersen et al., 2001) has
gained wide acceptance. MCI receives the greatest attention here.
Late-Life Forgetfulness
Historically, late-life forgetfulness (LLF) as suggested by Blackford and LaRue (1989) as
modification to AAMI, was probably the forebear of MCI. LLF was defined as having
borderline to impaired memory function relative to age-matched peers but the absence of
dementia.
FIGURE 2.3. Frequency of studies of various boundary conditions as listed on MEDLINE and
PsycINFO.
Questionable Dementia/Possible Dementia Prodrome

Prior to the evolution of the MCI concept, it was very difficult to label the growing
numbers of elderly patients presenting to outpatient clinics when complaints included
cognitive impairment, but formal diagnostic criteria for dementia were not met. For
this reason, many groups began using a diagnostic category referred to as questionable
dementia (QD), with which patients were classified if they obtained a Clinical De-
mentia Rating (CDR; Morris, 1993) score of 0.5. Longitudinal follow-ups of these pa-
tients yielded mixed outcomes; some researchers found good prognosis in QD groups
(Reisberg, Ferris, Franssen, Kluger, & Borenstein, 1986; Youngjohn & Crook, 1993)
whereas others showed full conversion from QD to Alzheimer’s dementia (Hughes,
Berg, Danziger, Cohen, & Martin, 1982; Rubin et al., 1993; Storandt & Hill, 1989).
The heterogeneity of diagnostic outcomes emerging from the QD classification estab-
lished the feasibility of clinical research programs aimed at defining specific clinical
(and more specifically, cognitive) markers for improving diagnostic accuracy in AD and
dementia.
Welsh-Bohmer and colleagues (Welsh-Bohmer, Hulette, Schmechel, Burke, & Saunders,
2001) and others have proposed that preclinical AD is characterized by a continuum of
cognitive changes that is paralleled in course by a continuum of histopathological change
representative of disease. Neuropsychological studies from the Consortium to Establish a
Registry for Alzheimer’s Disease (CERAD) and other groups have identified very specific
cognitive markers for Alzheimer’s-type dementia prodromes. Unsurprisingly, recent mem-
ory measures (particularly those requiring delayed free recall) appear to be most sensitive
in identifying possible dementia prodromes (Welsh et al., 1991; Welsh, Butters, Hughes,
Mohs, & Heyman, 1992). Most recently, Welsh-Bohmer and colleagues (2001) proposed
that testing recent memory over multiple brief delays provides the greatest sensitivity in
detecting possible AD prodromes.
Aging-Associated Cognitive Decline

The International Psychogeriatric Association and the World Health Organization
criticized AAMI as a concept because it presumes that early malignant cognitive aging
surfaces exclusively within the learning and memory domain, and not in other cognitive
domains (Ritchie & Touchon, 2000). As an alternative to AAMI, the term “aging-associated
cognitive decline” (AACD) was introduced (Levy, 1994) and defined by (1) performance
on a standardized cognitive test that is at least one standard deviation below age-adjusted
norms in at least one of any of the following cognitive domains: learning and memory, at-
tention and cognitive speed, language, and visuoconstructional abilities; (2) exclusion of
any medical, psychiatric, or neurological disorder that could cause cognitive impairment;
and (3) normal activities of daily living and exclusion of dementia according to DSM-IV
criteria. AACD differs from AAMI because it is defined by age-adjusted normative data,
allows for cognitive impairment in cognitive domains other than memory, and allows for
mild cognitive impairment in multiple cognitive domains. Recent work by Pantel, Kratz,
Essig, and Schroder (2003) demonstrated that parahippocampal volumes in patients
meeting AACD criteria were intermediate between cognitively intact elderly individuals
and individuals meeting criteria for AD. As such, AACD criteria appear to be a feasible
approach for establishing diagnostic criteria for preclinical or potentially prodromal Alz-
heimer’s dementia.
Cognitive Impairment No Dementia

The Canadian Study of Health and Aging (CSHA) has utilized multicenter studies to
characterize the epidemiology of cognitive impairment among Canadians ages 65 and
older (Graham et al., 1997). A diagnostic concept known as “cognitive impairment no
dementia” (CIND) has emerged in these population studies to describe individuals with
demonstrated cognitive impairment (using a modified Mini-Mental State Examination
cutoff score) but no clinical evidence of dementia. The CIND classification is a heteroge-
neous diagnostic category that is nonspecific with regard to etiology of cognitive impair-
ment. CIND applies to individuals with delirium, chronic alcohol and drug use, depres-
sion, psychiatric illness, and mental retardation, although the most popular diagnostic
subcategory of CIND relates to circumscribed memory impairment. The prevalence of
CIND among the Canadian elderly is about twice that of all dementias combined (Gra-
ham et al., 1997). A recent longitudinal study revealed that despite etiological subcatego-
ries of CIND, individuals with CIND have higher rates of conversion to dementia, admis-
sion to facility care, and mortality than individuals without cognitive impairment
(Tuokko et al., 2003). MCI has been recognized as a subcategory of CIND (Fisk, Merry,
& Rockwood, 2003), but it remains unclear whether all etiological subcategories of
CIND represent malignant cognitive change (i.e., prodromal stages of dementia).

Flicker, Ferris, and Reisberg (1991) used the term mild cognitive impairment for a group
scoring 3 on the Reisberg Global Deterioration Scale (Reisberg, Ferris, de Leon, &
Crook, 1982). The score is based on clinician assessment/judgment and ranges from 1 (no
impairment) to 7 (a vegetative state due to dementia). A score of 2 on this scale represents
a subjective cognitive concern but no objective evidence of cognitive impairment. A score
of 3 reflects the earliest clear deficits identified only upon intensive interview conducted
by a trained clinician (Reisberg et al., 1982). These deficits are evident in the person who
gets lost in unfamiliar environments, performances poorly at work, shows name-finding
problems, loses objects of value, etc.
We (Petersen et al., 1995) adopted the term mild cognitive impairment (MCI) for
studies of a boundary condition. At the level of the individual who will develop dementia,
MCI was conceptualized as epoch in the longitudinal course of the disease, wherein cog-
nition is no longer normal relative to age expectations, but also wherein daily function is
not sufficiently disrupted to warrant the diagnosis of dementia. Figure 2.4 depicts this ep-
och. The initial clinical definition of MCI was proposed to include (1) the presence of a
memory complaint, (2) the performance of normal activities of daily living, (3) evidence
of normal global cognitive function, and (4) evidence of abnormal memory function com-
pared to the age and education norms described in the first section of this chapter. A CDR
(Morris, 1993) of 0.5 is used to corroborate the criteria. The ability to identify this group
has been enhanced substantially by the MOANS studies.
With regard to groups of people, MCI constitutes that level of cognitive function
wherein low-functioning normals and high-functioning dementia patients cannot be reli-
ably distinguished. Figure 2.5 depicts this overlap. This figure is a bit misleading because
it seems to suggest three different groups along the continuum of cognitive function.
However, our initial concept of MCI was not as a “condition” present in the patient but
as a state of uncertainty in the clinician. We conceived of all persons labeled as MCI as
FIGURE 2.4. Theoretical trajectory for an individual progressing to Alzheimer’s disease. From
Petersen (2000). Copyright 2000 by Elseiver. Reproduced by permission.
belonging in either a normal population, not destined to develop dementia, or from a

population that is developing dementia. Because we could not know from which group
that individual arose, we turned to the MCI label to reflect our uncertainty. As it turns
out, that state of uncertainty can be thought of as constituting a risk factor for the patient
with regard to subsequent development of dementia.
We have found that, on average, persons with MCI have intermediate degrees of
hippocampal atrophy impairment compared to controls and patients with AD (Jack et
al., 1999), and intermediate changes in regional cerebral metabolic patterns (Kantarci et
al., 2000). However, we note that these previously reported data represent mean values
FIGURE 2.5. Mild cognitive impairment at the overlap of distributions of low normal cognitive
function versus early dementia. Adapted from Petersen (1995). Copyright 1995 by Lippencott, Wil-
liams, & Wilkens. Adapted by permission.
TABLE 2.4. Comparison of Studies of Boundary Conditions
Condition Annual Sampling Sampling Memory Other Memory
Study of interest conversion rate method frame tests cognitive domains complaint
Petersen et al. Mild cognitive 12% Community Community Immediate and delayed Attention, language, Spontaneous
(1999) impairment internal medicine recall of unstructured visuospatial
practice verbal material
Goldman et al. CDR –0.5 a. 12% Advertisement Convenience None (only immediate None Spontaneous
(2001) a. DAT B. 7% solicited structured recall in
b. incipient DAT C. 4% volunteers other research)
c. Questionable
dementia
38
Ritchie et al. a. “MCI” a. 6.5% General Population Immediate and delayed Attention, language, Solicited
(2001) b. age-associated b. 28% practitioner recall of structured visuospatial
cognitive decline network verbal material
Albert et al. Questionable 6% Advertisement Convenience Immediate and delayed Attention, language, Not required
(2001) dementia solicited recall of structured and visuospatial, executive
volunteers unstructured verbal function
material
FIGURE 2.6. Survival time from MCI to dementia diagnosis by risk factor (a) by apoE status, (b) by
hippocampal volume, and for (c) overall MCI group. Peterson (2001). Copyright 2001 by Wiley.
Reproduced by permission.
and could reflect average measurements taken from patients developing dementia with
those of normals. We have also found that patients with MCI show similar apolipo-
protein E allelic frequencies to patients with AD (Petersen et al., 1995). Finally we have
found that these same neuroimaging and genetic variables help predict progression to de-
mentia. See Figure 2.6.
In following their group of patients with MCI, Flicker et al. (1991) found a conver-
sion rate to the full syndrome of dementia of approximately 72% over 2 years of follow-
up. Our conversion rate is about 12% per year over the initial 7 years of follow-up (see
Figure 2.6c). An age- and gender-matched group of normal controls had only a 5% rate
of developing cognitive impairment in the comparable interval (Petersen et al., 1995).
Other researchers have found progression to dementia rates ranging from 6 to 28%. A
summary of selected studies is provided in Table 2.4. A review of this literature reveals at
least four important dimensions along which studies of boundary conditions must be
compared in order to understand their discrepant findings: (1) the population sampled,
(2) the nature of memory complaint, (3) the types of memory assessment used, and (4)
the number and type of other cognitive domains assessed.
Population Sampled
It is important to distinguish MCI studies that use clinical samples from studies for which
MCI “patients” are culled from a population sample or a normal volunteer sample of
older adults. Our studies, and those of several others (e.g., Bowen et al., 1997; Tierney et
al., 1996), have used clinical samples. The fact that a clinical concern exists for these pa-
tients increases the likelihood that they are drawn for the predementia group shown in
Figure 2.5.
Other studies of boundary conditions have identified their cohorts by recruiting nor-
mal older adults (e.g., Albert, Moss, Tanzi, & Jones, 2001; Ritchie & Touchon, 2000).
These samples are composed of individuals who either served as controls in clinical trials
or longitudinal aging studies, or were selected as a community sample of older adults in
order to describe cognitive function in a group conceived to be representative of older
adults from the general U.S. population. MCI “patients” are often culled from these nor-
mal samples by using a psychometric cutoff based on their memory performance. Thus,
by definition, normal patients scoring at the lowest end of the memory score distributions
receive a diagnosis of MCI. Selection in this fashion necessarily increases the likelihood
that these MCI patients arise from the normal population rather than from a cognitively
impaired population, as depicted in Figure 2.5.
Nature of Memory Complaint

The Mayo criteria for MCI (Petersen et al., 1999) propose that a memory complaint must
be present. Differences in the nature of memory complaints across studies are a corollary
of differences in recruitment methods. In clinical samples, memory complaints are gener-
ally “spontaneous.” Complaints arise as a concern from some member of the health care
process (e.g., patient, family, provider). Such memory concerns, especially from family or
physicians, may have a better correspondence with objectively established cognitive dys-
function (cf. Carr, Gray, Baty, & Morris, 2000). In studies that recruit general or normal
samples, a memory complaint is typically established by administration of standardized
subjective ratings of memory function. Numerous studies have demonstrated that scores
on such instruments are more likely to be associated with mood or self-efficacy than with
actual cognitive dysfunction (Smith, Petersen, Ivnik, Malec, & Tangalos, 1996; Taylor,
Miller, & Tinklenberg, 1992)
Nature of Memory Assessment

Another key difference across studies of boundary conditions involves the manner in
which memory is assessed. The term memory impairment has been used to describe a
wide variety of cognitive impairments that may have different neural substrates. Most
studies have focused on episodic memory. However, even within the realm of episodic
memory, differences may exist in the extent to which impairments are associated with
risk for subsequent decline to dementia. It may be important to distinguish between en-
coding and retrieval phases of memory tasks. Encoding is typically assessed by aspects of
immediate recall, whereas retrieval is assessed by delayed recall. The encoding phase of
memory is sensitive to aging effects alone, but may be insensitive for detecting incipient
dementia relative to indices of delayed recall (Petersen, Smith, Kokmen, Ivnik, &
Tangalos, 1992; Petersen et al., 1994). For example, a recent study of nine people who
died and were observed to have healthy brains, compared to five people who were
nondemented at death but observed to have Alzheimer’s disease changes in the brain, re-
vealed no difference in the cognitive profiles between groups. However, all memory test
scores in this very small study focused on immediate recall (Goldman et al., 2001). Nu-
merous studies suggest that delayed recall measures appear to be most sensitive for early
discrimination of dementia (Bondi et al., 1994; Ivnik et al., 2000; Tierney et al., 1996).
Studies that focus on immediate recall (encoding) versus delayed recall (retrieval) in es-
tablishing the memory impairment criteria for MCI may engender very different samples.
Number and Type of Cognitive Domains Assessed

The number and type of non-memory-related cognitive domains assessed in studies of
MCI are important because MCI criteria typically stipulate “no dementia.” Commonly
accepted dementia criteria require impairment in at least two cognitive domains. Because
MCI patients have memory impairment, rigid statistical applications of dementia criteria
exclude from MCI samples any person with scores falling below some cutoff in any non-
memory-related domain. As the number of non-memory-related measures assessed in a
given individual increases, there is an increasing probability that at least one other cogni-
tive measure will fall below a given cutoff by chance alone. Because all cognitive domains
tend to be correlated to at least a moderate degree, excluding nondemented persons with
memory impairment from MCI samples because of low scores in other domains increases
the probability that the memory scores for those patients are spuriously low. A study by
Ritchie, Artero, and Touchon (2001) provides an example of this problem. In this study,
seven non-memory-related domains were assessed. Seventy-five percent of persons with a
(loosely defined) memory impairment (scores < –1 standard deviation below age norms)
also had at least one non-memory-related score fall below this cutoff. Of the remaining
25% of “MCI” patients, only 7% continued to have memory scores below their cutoff at
follow-up. By excluding persons with modestly low non-memory-related scores from
their sample, these investigators appeared to exclude persons with true memory impair-
ments.
The common finding that MCI patients show poor performance on sensitive mea-
sures in other cognitive domains as well as the relatively common presentation of persons
with isolated cognitive concerns in non-memory-related domains has led to an evolution
in the concept of mild cognitive impairment.
EVOLUTION OF THE MCI CONCEPT
Of course, not all dementia is Alzheimer’s disease, so the idea that MCI could include
only memory problems was quickly recognized to be a limitation of the concept (Petersen
et al., 2001). For example, we know that early in subcortical dementias such as Parkin-
son’s dementia, memory is spared but basic attention and processing speed are compro-
mised. This knowledge led to the recognition of the need to broaden the concept of MCI
to include presentations that are not amnestic or not exclusively amnestic in nature.
Petersen and colleagues (2001) proposed at least three subtypes of MCI. All forms of
MCI include basic criteria of (1) normal general cognitive functioning, (2) normal activi-
ties of daily living, and (3) no dementia. The three subtypes are suggested as follow:
1. Amnestic MCI (aMCI)

• Memory complaint
• Memory impaired for age
2. Single non-memory-domain MCI (sMCI)
• Impairment in one of the following cognitive domains:
• Attention/concentration
• Executive functioning
• Language functioning
• Visuospatial functioning
3. Multiple-domain MCI (mMCI)
• Two or more impaired domains, often including memory
Although this conceptualization of MCI is relatively new, preliminary studies argue

that multiple-domain MCI and single non-memory-domain MCI may be more common
than amnestic MCI (Lopez, Kuller, DeKosky, & Becker, 2002). Single and multi-domain
MCIs with an amnestic component progress at roughly equal rates to AD (Petersen et al.,
2004). Nonamnestic MCI is also a risk factor for AD but may give rise to non-AD
dementias, such as Lewy body dementia or frontotemporal dementia more commonly
than does amnestic MCI (Boeve, Ferman, Smith, et al., 2004, Ferman et al., 2005;
Petersen et al., 2002).
With regard to multiple-domain MCI, an astute observer will ask, “How can a per-
son have scores in the impaired range in two cognitive domains and not have dementia?”
Two fundamental principles of neuropsychology are relevant in this regard. First, a low
score is not necessarily equal an impairment. A certain percentage of the normal popula-
tion scores below clinical cutoffs on any measure. If the cutoff is liberally set at –1 stan-
dard deviation, as in the Ritchie study cited above, 16% of the general population will
fall below the cutoff. In persons with appropriate histories (e.g., low academic attain-
ment, low IQ), it is entirely possible for a score below this cutoff to be deemed clinically
normal for those individuals. Dementia criteria require a decline from a higher level of
cognitive function. The second fundamental issue is that low scores on tests do not neces-
sarily imply “significant impairment in social or occupational functioning” (American
Psychiatric Association, 1994). There are plenty of people who live normal day-to-day
lives who would “fail” the Wisconsin Card Sorting Test.
NOT ALL MCI IS EARLY DEMENTIA: A CAUTIONARY NOTE
If all aMCI and most mMCI patients converted to AD, than it might be unnecessary to
have a concept of MCI at all. Morris et al. (1991) and others have argued that MCI is
simply early AD and that clinicians need to be brave enough to say so. These investiga-
tors base this opinion, in part, on their neuropathological study of 10 patients who died
with questionable dementia. In all 10 cases there was sufficient neuropathological burden
to justify the CERAD (Gearing et al., 1995; Mirra et al., 1991) diagnosis of AD. How-
ever, the neuropathological substrate of MCI is not fully known. We (Jicha et al., in press)
studied 15 Mayo Alzheimer’s Disease Patient Registry cases who died while their clinical
classification was still aMCI. The brains were processed using standard neuropath-
ological techniques and classified according to Katchaturian (1985), CERAD (Mirra et
al., 1991), and the National Institute on Aging—Reagan (Hyman & Trojanowski, 1997)
neuropathological criteria. Eight of these cases did not meet any of the three neuro-
pathological criteria for AD, although their pathology suggested a transitional state of
evolving AD. In addition, there was a great deal of concomitant pathology, including
argyrophilic grain disease, hippocampal sclerosis, and vascular lesions. One of these 15
subjects had no identifiable neuropathology. These findings would argue that is not ap-
propriate to simply conclude that all MCI, including aMCI, is simply early AD. In addi-
FIGURE 2.7. (a) Incidence of dementia by age group and gender; (b) incidence of Alzheimer’s dis-
ease by age group and gender. Edland et al. (2002). Copyright 2002 by the American Medical Asso-
ciation. Reproduced by permission.
tion, these neuropathological findings suggest that MCI is not just a state of uncertainty
in the clinician, but that the clinical syndrome of MCI may reflect a transitional
neuropathological state in many but not all patients. If it is ultimately possible to arrest
the development of neuropathology at this point, it would be tantamount to preventing
dementia. As such, maintaining the concept of a boundary condition seems valuable.
Incidence of Dementia and Prevalence of MCI

The prevalence (number of cases at a given point in time) of MCI has not been well estab-
lished. In contrast, the annual incidence (number of new cases in a year) of dementia in
the over-65 population is well established at 1–2% (Edland, Rocca, Petersen, Cha, &
Kokmen, 2002). This incidence is strongly associated with age (see Figure 2.7). We also
believe that about 12% of MCI patients will progress to dementia per year (Figure 2.6c)
and that 7–10% of MCI patients will not show a progressive neuropathology at autopsy.
If we assume that all dementia patients will pass through the MCI state before displaying
dementia, then we can use the percentages above to estimate MCI prevalence. Estimated
prevalence of MCI that will progress to dementia would be 1–2% divided by 12% or
8.3–16.6%. Total prevalence would then be 8.3–16.6% divided by (roughly) 90%, which
results in an estimated prevalence of 9–18%.
A few studies have investigated the prevalence of MCI and MCI-like conditions
(Bennett et al., 2002; Larrieu et al., 2002; Lopez et al., 2002). The prevalence varies
widely from 3 to 54% mainly because of the different methods and criteria used. The
Cardiovascular Health Study (CHS) evaluated several definitions of MCI in their
nondemented cohort (ages 65 years and older) and provided useful prevalence figures
(Lopez et al., 2002). The CHS included amnestic and multiple-domain MCIs defined in a
very similar fashion to that above. They concluded that the prevalence of MCI among
nondemented individuals was 19%, and that it increased with increasing age. These re-
sults are strikingly similar to the estimate of MCI prevalence calculated above. In addi-
tion, they found a ratio of 2.5:1 for the prevalence of multiple-domain-type MCI (which
included memory impairment) compared to amnestic MCI (Lopez et al., 2002). The CHS
findings provide preliminary support for the idea that almost all dementia patients pass
through the MCI state, and possibly for the idea that MCI cohorts should include a pro-
portion of people that will not develop dementia.
OTHER RISK FACTORS FOR DEMENTIA
As we have noted, certain patterns of cognitive function, described as MCI, may signal
the presence of malignant brain changes. These syndromes identify increased risk for a
dementia process. Several other risk factors for dementia are known or postulated.
Age
Age is typically thought of as the least equivocal risk factor for dementia. However, at
least three studies (Breitner et al., 1999; Ritchie, Kildea, & Robine, 1992; Wernicke &
Reischies, 1994) have suggested that the prevalence of dementia and AD increases expo-
nentially up to age 80 or 85 years but then either remains stable or declines. A number of
prevalence studies do not support this hypothesis, either for dementia (Hofman et al.,
1991) or for AD (Rocca et al., 1991). Moreover, because prevalence reflects the combina-
tion of incidence and survival, prevalence can be a misleading statistic in terms of risk (as
explained below). We think of “risk” as more associated with the chance of “developing”
a disorder (incidence) as opposed to the chance of “having” a disorder (prevalence). Thus
information on age and incidence is desirable. Unfortunately, information on incidence of
dementia and AD past age 80 years is more limited. Incidence rates from three European
studies (Brayne et al., 1995; Fratiglioni et al., 1997; Letenneur, Commenges, Dartigues,
& Barberger-Gateau, 1994) and the Framingham study (Bachman et al., 1993) consis-
tently show a continuing increase in the incidence of AD at extreme ages. As shown in
Figure 2.7 above, there is a continuous increase in incidence with age (Edland et al.,
2002). Data from the Cache County, Utah study showed an increased incidence of de-
mentia and AD until ages 85–90, with a decline in incidence around age 93 for men and
age 97 for women (Miech et al., 2002). Finer-grained analyses suggested that an interac-
tion between age and the apolipoprotein E (apoE) genotype further influences AD
incidence; homozygous E4 carriers demonstrated accelerated onset of AD compared to
non-E4 carriers. Heterozygous E4 carriers also demonstrated accelerated onset of AD
compared to non-E4 carriers, although the acceleration effect was more modest than that
observed for homozygotes.
Gender
We noted above that prevalence data may be misleading when considering risk factors
because prevalence reflects the combination of incidence and survival. Thus a factor (such
as gender) will increase prevalence through its impact on survival rather than increasing
incidence (i.e., risk). The prevalence of AD appears higher in women than in men
(Breteler, Claus, van Duijn, Launer, & Hofman, 1992; Rocca et al., 1991). The Cache
County study showed that the prevalence of AD appears higher in women than men, spe-
cifically when women are positive for the E4 allele of apoE (Breitner et al., 1999). The
Framingham study did not show higher age-specific incidence rates in women; the sex
pattern was inconsistent over age (Bachman et al., 1993). As shown in Figure 2.7, Mayo
data reveal an inconsistent sex pattern over age and, in general, small differences in inci-
dence between men and women (Edland et al., 2002). On the other hand, Fratiglioni and
colleagues (1997) showed a consistently higher incidence of AD in women from Stock-
holm, Sweden. Data from the Cache County study showed that the incidence of AD after
age 90 is higher among women than men, despite the fact that the incidence of AD after
age 90 declines for both men and women (Miech et al., 2002).
Head Injury
Numerous population-based studies (Graves et al., 1990; Heyman et al., 1984; Mayeux,
Ottman, et al., 1993; Mayeuz et al., 1995; Mortimer, French, Hutton, & Schuman, 1985;
Van Duijn et al., 1992) and case-control studies (Fleminger, Oliver, Lovestone, Rabe-
Hesketh, & Giora, 2003; Mortimer et al., 1991; Van Duijn et al., 1994) have indicated
an association between history of traumatic brain injury (TBI) and risk of Alzheimer’s
disease or other dementias. Other case–control studies have failed to show an association
(Broe et al., 1990; Chandra, Kokmen, Schoenberg, & Beard, 1989; Ferini-Strambi,
Smirne, Garancini, Pinto, & Franceschi, 1990; Fratiglinoni, Ahlbom, Viitanen, &
Winblad, 1993 ). Longitudinal studies are also mixed (Katzman et al., 1989; Launer et
al., 1999; Schofield et al., 1997; Williams, Annegers, Kokmen, O’Brien, & Kurland,
1991). Several prospective studies of cognitive decline after TBI suggest the possibility of
long-term cognitive decline (Corkin, Rosen, Sullivan, & Clegg, 1989; Plassman et al.,
2000; Walker & Blumer, 1989).
The findings of several studies suggest that history of TBI may shorten time to onset
of AD in persons who were predisposed to develop the condition (Gedye, Beattie, Tuoko,
Horton, & Korsarek, 1989; Nemetz et al., 1998; Schofield et al., 1997). Nemetz and col-
leagues (1998) used the population-based resources of the Rochester Epidemiology Pro-
ject to examine whether persons with a history of TBI had reduced time to onset of AD
among persons at risk of developing AD. Although a similar proportion of persons with
TBI as without TBI developed AD, the observed time from TBI to AD was significantly
less than the expected time to onset of AD (median = 10 years vs. 18 years). Schofield and
colleagues (1997) suggested a time-dependent relationship between TBI and AD. Persons
with a history of TBI within the past 30 years were diagnosed with AD at a younger age
than those with remote history of TBI (greater than 30 years). The role of head injury as a
risk factor for dementia remains unclear.
Genetics
At the time of this writing, there are three genetic mutations that appear to have a caus-
ative link to AD. These genes are the APP gene on chromosome 21, the presenilin 1 gene
on Chromosome 14, and the presenilin 2 gene on chromosome 1. In addition, a few other
genes have been identified that cause related forms of dementia. For example, mutations
on chromosome 17 cause a form of frontotemporal dementia (Hutton, 2001; Hutton et
al., 1998). These genetic mutations occur in only a small number of families. Thus it is es-
timated that these genes explain less than 5% of all the AD present in the world today
(Bird, 1994). These gene mutations are called causative because whenever the genetic mu-
tation is present, and the carrier of the gene lives to the age of risk, he or she invariably
develops dementia. Moreover, members of the family who live through the age of risk
without developing dementia are not carriers. All of the AD causative gene mutations are
associated with early onset (AD occurring before the age of 65). The identification of
these genes is significant because it demonstrates that AD can have a genetic etiology. It is
possible that a portion of the common late-onset form of AD will have a genetic cause as
well.
In addition to genetic mutations that apparently cause AD, at least one genetic varia-
tion has been identified that increases AD susceptibility to AD: the apoE gene on chromo-
some 19 (Strittmatter et al., 1993). This gene has three common forms, labeled E2, E3,
and E4. People who possess the E4 genotype are at increased risk for developing AD.
However, unlike causative genes, some people with the E4 genotype do live through the
age of risk without developing AD. Moreover, over 45% of people with late-onset AD do
not carry the E4 genotype. Thus the E4 genotype is neither necessary nor sufficient for
development of AD. Still, inheriting one E4 gene increases risk for AD approximately 4
times, and inheriting two E4 genes increases risk on the order of 16 times. Identifying
such a significant increased risk for AD may justify intervention E4 carriers before signs
of dementia emerge.
Whether the apoE genotype directly influences cognitive function remains a source
of debate. Studies have shown that by the time of diagnosis there is a genotype effect on
persons with AD such that memory performance is more impaired in E4 carriers (Smith
et al., 1998). Several reports have also suggested that in persons who are older than 50
years (i.e., less than two decades from age of risk), E4 carriers perform more poorly on
memory and executive function tests. However, these differences may disappear when
persons who subsequently develop dementia are removed from the sample (Bondi,
Salmon, Galasko, Thomas, & Thal, 1999). Whether or not cognitive differences exist in
E4 carriers younger than 50 years of age is equivocal. Reiman et al. (1996) report deficits
on reduced cerebral glucose metabolism in the cingulate and prefrontal cortex in E4
homozygotes. Some researchers have postulated that differences may exist in genetic car-
riers that cannot be detected on crude neuropsychological measures alone. The concept is
that persons at risk muster equivalent performance but have to “work harder” to do so
(Bookheimer et al., 2000).
CONCLUSIONS
Cognitive aging typically involves a reduction of processing speed or “cognitive effi-

ciency.” Longitudinal cognitive aging studies and normative neuropsychological studies
with older persons have enhanced our ability to distinguish typical cognitive aging from
early signs of neurodegenerative diseases associated with aging.
Boundary concepts remain important to dementia research and clinical practice. One
such concept, MCI, appears associated with biomarkers of AD even before patients meet
AD criteria. MCI patients are at elevated risk for progressing to dementia. MCI samples
are probably comprised of patients with incipient dementia, persons with static neuro-
pathology, and normal older persons with poor cognitive function. The relative propor-
tion of each group in an MCI sample will be influenced by the sampling frame (clinical
vs. general or normal), the nature of the memory complaint (spontaneous vs. elicited), the
type of memory assessment used in selecting patients (e.g., immediate vs. delayed recall)
and the number, type, and interpretation of measures of non-memory-related domains.
These factors need to be considered when comparing outcomes from studies of boundary
conditions.
Using a boundary group conceptualization avoids the problem of knowing for sure
whether a person at the boundary between normal and dementia has a disease entity or
not. It enables an alternative to attempts to predict which individual normal people will
develop dementia. Instead, boundary conditions themselves can be diagnosed. These di-
agnoses acknowledge the overlapping distributions but still identify risk status. Iden-
tifying persons in this way would not preclude their involvement in intervention research.
In fact, being able to identify such persons may give impetus to early intervention re-
search. In DSM-IV (American Psychiatric Association, 1994) “mild neurocognitive disor-
der” (MND) is listed as a diagnosis for future consideration. This concept is congruent
with the idea of a boundary area or preclinical status. The DSM criteria for mild
neurocognitive disorder are similar but not identical to MCI. Regardless of whether the
CIND, MCI, MND, or other labels and criteria ultimately gain widest acceptance, there
is likely to be substantial research and clinical benefit to including a boundary condition
as a “legitimate” diagnosis in the next DSM.
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3
Neurodegenerative Dementias
LAUREN H. WARREN
Alzheimer’s disease (AD), Parkinson’s disease dementia (PD-D), Lewy body dementia
(LBD), and frontotemporal dementia (FTD) account for nearly 70% of the cases of de-
mentia occurring in late life (Breitner et al., 1999). These conditions are often contrasted
to one another and conceptualized as unique clinical entities. And yet, with the advances
in neuroepidemiology and genetics, it is becoming clear that these conditions may share a
number of common features and underlying etiological mechanisms (Mayeux, 2003). All
of the conditions are neurodegenerative in nature, with onset of symptoms occurring typ-
ically in mid- to late life. There are strong genetic underpinnings at least to some forms of
each of the disorders. AD, PD-D, LBD spectrum disorders, and FTD each has an appar-
ent inherited version as well as a more common sporadic form of disease. Finally, new ad-
vances in clinical genetics suggest that at least some of the basic biological mechanisms
governing disease onset and perhaps other features of symptom expression are shared
across the disorders (Li et al., 2002, 2003).
The goal of this chapter is to present a detailed overview of the clinical presentation
of these seemingly disparate neurodegenerative disorders. Central to the consideration is
AD, an illness that, alone or in combination with other neurological disorders, accounts
for nearly 50–75% of all late-life dementias. Other common neurodegenerative condi-
tions leading to dementia in late life are also discussed. The chapter is not inclusive of all
dementing disorders, but rather focuses attention on the major neurodegenerative condi-
tions of aging that can be clinically mistaken for AD. Specifically we contrast two disor-
ders whose clinical features overlap with AD: frontotemporal dementia and the PD spec-
trum of dementing disorders (PD-D and LBD). Within each section that follows we
discuss the prevalence of the condition, the typical clinical features, the associated
neuropsychological profile, and, when appropriate, the role of emerging biomarkers and
surrogate markers in diagnosing and tracking the disorder in question.
56
Neurodegenerative Dementias 57
ALZHEIMER’S DISEASE
AD is the most common cause for late-life dementia, currently affecting 4.5 million
Americans (Hebert, Scherr, Bienias, Bennett, & Evans, 2003) and accounting for nearly
50% of the prevalent cases of dementia in nearly all epidemiological and case-based se-
ries (Breitner et al., 1999). Vascular dementia (VaD), discussed by Cato and Crosson
(Chapter 4, this volume), is the second most common cause of dementia, but in isolation
likely only accounts for approximately 12–20% of the late-life dementias (Bowler, 2002;
Lobo et al., 2000; Rockwood et al., 2000). More commonly, VaD co-occurs with AD
(Graves et al., 1996; Knopman, Parisi, et al., 2003). Consequently, when these mixed de-
mentia etiologies (AD and VaD) are considered in calculating AD prevalence, the rates of
AD dementia occurrence approach nearly 75%. There is some variation in these relative
prevalence figures across countries, with AD being more prominent overall than VaD in
North American countries and Europe, and VaD tending to be more common in Asian
countries (Fratiglioni, De Ronchi, & Aguero-Torres, 1999), suggesting differences either
in environmental exposures or genetic factors that may account for differences in demen-
tia rates. It is possible that these relative distributions simply reflect methodological dif-
ferences in case ascertainment. However, more recent studies suggest that they are real
and that dietary and other environmental factors related to culture may be responsible,
because the rates vary by geographic location, with Asian Americans showing similar
rates to European Americans in the United States but different rates in mainland Japan
(Graves et al., 1996).
AD and related dementias of late life present enormous public health challenges.
With current survival trends and in the absence of preventive treatments, it is anticipated
that the disease will affect over 8 million individuals in the U.S. by midcentury
(Brookmeyer, 1998) and likely will exceed 13.2 million (Hebert et al., 2003). As such, the
United States faces a public health crisis of phenomenonal proportions, with current per-
sonal and societal expenditures related to long-term care of dementia patients generally
quoted at $80–100 billion annually (DeKosky & Orgogozo, 2001; Fillit & Hill, 2002).
However, some recent figures based on the state of California alone suggest that the $100
billion price tag for dementia care may be a gross underestimate (Fox, Kohatsu, Max, &
Arnsberger, 2001). Consequently, there is both a scientific and a public policy priority to
quickly develop effective treatments and preventive strategies for AD and related disor-
ders. In this context, a challenge for clinicians is the ability to reliably recognize the dis-
ease early in its expression to facilitate effective treatment implementation at a point in
the illness when it is likely to be most effective.
Illness Characterization
AD dementia has been well studied since its initial description nearly a century ago (Alz-
heimer, Stelzmann, Schnitzlein, & Murtagh, 1907/1995) and is now well understood
both in terms of its clinical presentation and symptom heterogeneity. Typically the disease
emerges in later years, after the age of 50, although in rare instances (under 2% of the
cases) it can present at earlier ages. Generally, causal factors for the earlier-than-expected
onset can be identified, such as a strong genetic predisposition for the illness, including
the rare autosomal dominant familial forms of the illness, or the confluence of risk fac-
tors leading to brain compromise (e.g., serious head trauma, Down syndrome). Through-
out the illness the disease is characterized by prominent memory impairment for recent
events (Welsh, Butters, Hughes, Mohs, & Hayman, 1991). This impairment is evident
even in the earliest symptomatic stages, including the prodromal stage of AD and in cases
of mild cognitive impairment (MCI; Petersen et al., 1999), a risk condition for AD
(Bowen et al., 1997; Flicker, Ferris, & Reisberg, 1991; Morris et al., 2001; Ritchie et al.,
2001). Ultimately, as the illness progresses there is a slow erosion of general cognition
(Welsh, Butters, Hughes, Mohs, & Hayman, 1992), resulting in increasing functional de-
pendence and eventually death (Tschanz et al., 2004).
The memory impairment of AD is not a singular problem, but it is highly character-
istic and distinguishable from other neurocognitive disorders of later life (Cummings &
Benson, 1992; Geldmacher & Whitehouse, 1997). The hallmark feature of forgetfulness
in everyday life is typically attributable to a disturbance in the consolidation of new infor-
mation into episodic memory stores (Hart, Kwentus, Taylor, & Harkins, 1987; Hart et
al., 1988). The neurocognitive problem parallels the underlying pathobiology in the
mediotemporal lobe (Braak & Braak, 1991), where input pathways from the entorhinal
cortex and hippocampus are fundamentally disturbed over the course of AD, leading to a
functional isolation of the structure from association areas in the neocortices (Hyman,
Van Hoesen, Damasio, & Barnes, 1984). As a consequence of this problem, rapid forget-
ting deficits are observed on formal testing, such as on list-learning procedures and simi-
lar tasks (Salmon et al., 2002; Welsh et al., 1991). Unlike normal aging (Nebes & Mad-
den, 1988) and in other neurocognitive disorders, such as VaD, performance of patients
with AD on memory tests benefits little by reminder cues (Looi & Sachdev, 1999;
Matsuda, Sito, & Sugishita, 1998; Tierney et al., 2001). Semantic memory, including past
knowledge of the world and events acquired over many experiences in life, tends to re-
main more patent until much later in the illness. However, subtle problems can be detected in
semantic knowledge at the middle stages of disease, for example, on tasks involving
knowledge of detailed information that was once known (Chertkow & Bub, 1990;
Hodges, Patterson, Qcbury, & Funnell, 1992). Working memory, a process of holding
and manipulating information in more transient short-term memory stores, is also affected
early in the illness (Becker, 1988), whereas immediate registration of information and basic
stimulus encoding tends to remain well preserved until late stages (Hart et al., 1988).
Episodic memory is by no means the only domain of cognition affected by AD. Ex-
pressive language difficulties are common and often manifest as anomia and a vacuous
speech quality, empty of word content (Bayles, Boone, Tomoeda, Slauson, & Kaszniak,
1989). Verbal flexibility becomes deficient, leading to selective disturbances on semantic
fluency procedures (Troster et al., 1998). Behavioral patterns emerge to compensate for
this problem in expression, typified by circumlocution (e.g., describing the object) during
the moderate stages of AD. Receptive speech, such as aural comprehension, is relatively
better preserved early in the disorder but is affected later as cognition continues to erode.
Essentially, the language disturbance of early- to middle-stage AD resembles a trans-
cortical sensory aphasia; by late stages it may be more akin to a frank Wernicke-type
aphasia (Cummings, Benson, Hill, & Reed, 1985; Hier, Hagenlocker, & Shindler, 1985;
Murdoch, Chenery, Wilks, & Boyle, 1987).
Rather classic visuospatial disturbances also occur in AD (Benke, 1993). Apraxia is
common in the middle stages of the disorder, often manifesting in everyday life as diffi-
culty in initiating and organizing previously known motor tasks (e.g., dressing, manipu-
lating hand tools). Other problems can occur in spatial navigation, judgment of distances,
and correct perception of objects (Damasio, Tranel, & Rizzo, 2000; Rizzo, Reinach,
McGhee, & Dawson, 1997; Rizzo, Anderson, Dawson, & Nawrot, 2000). Construc-
tional tasks, such as drawing tests or block assembly, are commonly used to assess
apraxia, whereas spatial perception is commonly assessed with any of a number of proce-
dures, such as the Judgement of Line Orientation test (Benton, Hamsher, Varney, &
Spreen, 1983). Spatial integration may be determined by using tests such as the Hooper
Visual Organization Test or other similar procedures (Lezak, 1995) that require the indi-
vidual to determine the likely identity of an object when presented with fragments or de-
constructed component parts, akin to puzzle pieces. Form perception can be determined
with visual matching procedures (e.g., Facial Recognition Test; Benton et al., 1983), and
spatial navigation can be measured with computerized tests or with simple paper-and-
pencil tests of maze completion (Lezak, 1995).
Intelligence, or what might be termed “higher-order conceptualization,” is uniformly
affected in the early to middle stages of AD. This problem can be assessed with tests of in-
telligence (Wechsler Adult Intelligence Scale or its revisions [WAIS-R, WAIS-III]; see
Wechsler, 1987, 1997), or by administering selected subtests from these batteries, such as
measures of abstraction (e.g., Similarities) or tests of reasoning and judgment (e.g., Com-
prehension). Related to intelligence is executive function, an ability to think flexibly and
creatively. Executive function is perhaps best conceptualized as a global “processing con-
trol function” that is imposed over the basic perceptual-, memory-, and language-based
functions of thought and behavior. Executive function involves the shifting, adjusting, or
withholding of behavioral responses in problem-solving situations. Discussed previously,
working memory, an ability to hold one idea in mind while attending to other new infor-
mation, may be considered a process that has both executive and memory demands (e.g.,
Baddeley, 1986). Executive functions are among the earliest cognitive domains affected
by AD. Though perhaps subtler than the prominent memory problems, difficulties in con-
ceptualizing, behavioral regulation, and/or novel problem solving can be detected using
tests such as the Trail Making Test, Wisconsin Card Sorting Test, or the Stroop
Neuropsychological Screening Test. Other control processes affected by AD include dif-
ferent aspects of attention and concentration. Both the ability to shift visual attention
when required and the capacity to divide attention across competing tasks are affected
early in the AD process (Baddeley, Baddeley, Bucks, & Wilcock, 2001; Greenwood,
Parasuraman, & Alexander, 1997; Parasuraman, Greenwood, & Sunderland, 2002), as
described below.
Neuropsychological Profile
Early-Stage AD Dementia
As discussed, memory disorder characterized by rapid forgetting is the typical early mani-
festation of AD. On formal neuropsychological testing, this difficulty is easily discerned
using formal memory tests in which delay intervals are imposed to assess retention under
cued and uncued procedures. Delayed memory is a particularly powerful discriminator
between early AD and normal aging. In one study, delayed word-list recall correctly dis-
tinguished 91% of subjects diagnosed as very-mild-stage AD (CDR 0.5, MMSE > 24)
from controls. Naming also is a significant early predictor when combined with delayed
memory, but does not increase the overall correct classification rate (Welsh et al., 1992).
In community-based samples the same finding holds, underscoring the importance of
memory assessment. However, other measures of expressive language and executive con-
trol also appear to be important. In one study (Cahn et al., 1995) immediate and delayed
recall on the Benton Visual Retention Test and delayed recall on the CERAD Word-List
Memory Test showed good sensitivity and specificity in distinguishing patients with AD
from controls. Equally important was performance on lexical fluency and executive func-
tion, measured through Trails B. Together, the combination of measures was particularly
powerful, leading to a correct classification of 98% of the cognitively normal individuals
and 82% of the AD-affected subjects in the sample. Other population-based studies also
underscore the relevance of impairment profiles. For example, Tschanz et al., 2000 ap-
plied strict cut-points for impairment (< 7% percentile on any test) and suggested that
neuropsychological algorithms of dementia may fare as well as more extensive clinical di-
agnostic procedures in correctly classifying individuals into broad categories (e.g., demen-
tia vs. not demented; Tschanz et al., 2000).
This same cognitive profile demonstrated in early AD (i.e., profound memory im-
pairment, executive disturbances, and difficulties in expressive language) is also charac-
teristic of the early preclinical phase of the disorder, albeit of a lesser magnitude overall.
Most of the studies that have demonstrated this effect include population-based investi-
gations or community-based samples that focus attention on large unselected groups and
then follow the cognitively normal individuals forward in time to prospectively determine
the cognitive changes that were predictive of early symptomatic disease, years before di-
agnosis. Using this approach, analyses from the Framingham study (Elias et al., 2000;
Linn et al., 1995) have shown distinctive differences in baseline test performances in the
subsample of individuals who later develop AD over a 5-year observation interval. Spe-
cific deficits were reported in baseline measures of delayed memory (Logical Memory II
from the Wechsler Memory Scale—Revised [WMS-R]), memory tests involving novel as-
sociations and retention (verbal paired associates, WMS-R) and on tests of abstraction
(WAIS-R Similarities subtests; Elias et al., 2000). Other approaches to determine early
preclinical cognitive changes have used smaller, more select samples that are at risk for
developing AD over a shorter interval than most unaffected individuals. These samples
included older unaffected family members in “AD-enriched” families—families in which
there is multigenerational evidence of AD transmission (Almkvist, Axelman, Basun,
Wahlund, & Lannfelt, 2002). Another enrichment procedure is to oversample older indi-
viduals who carry the AD risk-promoting gene, apolipoprotein E4 (Baxter, Caselli, John-
son, Reiman, & Osborne, 1996; Bondi, Salmon, Galasko, Thomas, & Thal, 1999;
Tierney et al., 1996). Using this latter approach, one study has demonstrated memory
deficits on the California Verbal Learning Test 1–2 years before an AD diagnosis could be
made (Bondi et al., 1994).
These prospective investigations have repeatedly provided evidence that there are de-
tectable and characteristic cognitive disorders that precede AD dementia onset (Elias et
al., 2000), an observation that bolsters the notion that there is a continuum of cognitive
change in AD that spans normal cognition to a transition zone, as noted, now referred to
as mild cognitive impairment (MCI; Reisberg, Ferris, de Leon, & Crook, 1988), before fi-
nally developing into fully manifest symptoms of AD dementia (see Figure 3.1). Although
not technically considered the prodrome to AD (Petersen et al., 1999), there is no clear
consensus on this point, with some arguing that when properly diagnosed so as to ex-
clude other possible explanations, MCI is, in point of fact, early-stage AD (Morris et al.,
2001). Additional longitudinal studies will be needed to fully resolve the issue. Regard-
less, it is clear that individuals with these so-called “borderzone disorders” such as MCI
are at 5–10 times increased risk of developing dementia when compared to cognitively
healthy individuals (Tuokko et al., 2003). In general, studies of MCI report conversion
FIGURE 3.1. Trajectory of cognitive change in AD.
rates of 12–15% per year to AD compared to a base rate of 1–2% in age-matched,

cognitively normal individuals (Petersen et al., 2001). More broadly defined syndromes
may have even higher rates of conversion to dementia outcomes (Ritchie & Touchon,
2001; Ritchie et al., 2001; Unverzagt et al., 2001). Cognitive impairment no dementia
(CIND), proposed by the Canadian Study of Health and Aging (CHSA; Ebly, Hogan, &
Parhad, 1995), is one of the more broadly defined transitional conditions. In contrast to
MCI, it is a broad heterogeneous category of conditions with more liberal exclusion crite-
ria; no assumptions are made regarding the role of age-associated disease comorbidities
such as depression, vascular disease, or medications (Graham et al., 1997). Aging-associ-
ated cognitive decline (AACD), proposed by the World Health Association (Levy, 1994),
has broad inclusion criteria for cognitive decline, permitting any domain to be affected
(akin to multiple-domain MCI). Both of these more broadly defined conditions have rates
of overall conversion to dementia approaching 20–29% in some studies (Ritchie et al.,
2001; Unverzagt et al., 2001). For further discussion of normal aging and mild cognitive
disorders, see Smith and Rush (Chapter 2, this volume).
Moderate Stages of AD
With progression of AD into the moderate to more severe stages of the illness, other
predictable aspects of cognitive decline begin to emerge that parallel the neuro-
pathological trajectory of the illness (Locascio, Growdon, & Corkin, 1995; Welsh et
al., 1992), resulting ultimately in global and pervasive cognitive impairments. By the
end stages of the illness, the dementia of AD can be virtually indistinguishable from
other similar neurodegenerative conditions, including VaD, PD-D, or FTD; however,
some distinctions are present even in moderate stages of illness (Binetti, Locascio,
Corkin, Vonsattel, & Growdon, 2000; Graham, Emery, & Hodges, 2004). Throughout
the moderate stages of AD, episodic memory remains profoundly affected, bottoming
out quickly on formal testing and providing little useful information when staging the
progression of illness. Likewise, reasoning ability and higher-order conceptualization as

might be assessed with tests of executive function or set shifting (e.g., Trail Making
Test, Part B), are profoundly affected and of little utility in tracking disease progression
or responsiveness to therapies.
Typically, deficits emerging in the moderate stages of illness include more pro-
nounced difficulties in expressive speech, language comprehension, and praxis (Welsh et
al., 1992). Errors in memory recognition performance, both for previous target items and
for correctly discerning foil items, are common at this stage of illness. Intrusional tenden-
cies are characteristic, which, with the other recognition memory difficulties, suggest that
the memory problem has progressed beyond consolidation deficits to more defective en-
coding and temporal tagging of events from past stored experiences. The temporal profile
of change can be very useful in distinguishing AD from other neurodegenerative condi-
tions (Storey, Slavin, & Kinsella, 2002). The unfolding of symptoms across a longitudinal
time frame provides a rich definition of the disease, and is characteristically different in
AD, PD-D, and frontotemporal disorders. As described later in the text, Pick’s disease and
FTD commonly present in the initial stages with profound personality disorders and/or
rather isolated language and semantic memory disorders; AD, by contrast, is character-
ized initially by memory disorders, and the personality changes similar to those of frontal-
lobe disorders emerge much later, usually at the moderate stages of the disease. Language
declines in the moderate stages of AD are likewise less precipitous than in frontal
dementias, suggesting a rather slow and gradual erosion of function over time in AD
(Binetti et al., 2000). When compared to dementias with motor-neuron involvement
(e.g., Lewy body dementia or PD-D), the disturbances in visuospatial processing are less
profound in AD and the memory problems more severe when the groups are adequately
matched for demographic variables, overall dementia severity, and stage of illness
(Aarsland, Andersen, Larsen, Lolk, & Kragh-Sorenson, 2003; Heyman et al., 1999).
There have been some attempts to quantify the average deterioration on neuro-
psychological measures for purposes of facilitating estimates of transitional probabilities
or conversion rates in untreated patients between stages of dementia, and for purposes of
determining effect sizes in pharmaceutical and other interventional studies (Morris et al.,
1993). For simple metrics such as the Mini-Mental State Examination (MMSE), there is
approximately a 10% change in score per year (e.g., 3 points on the MMSE per year) in
AD, although the relationship is curvilinear with dementia severity, and cognitive decline
in the moderate stage tends to be faster than in the early or late stage (Morris et al.,
1993). Modeling average change on other domains is a bit trickier than on global assess-
ment measures. Despite typical profiles of cognition in AD, there is tremendous variabil-
ity in disease progression across patients due to a host of intervening variables, such as
age, education, gender, premorbid abilities, area of brain affected by disease, presence
and absence of disease comorbidities, and other factors. More rapid decline has been sug-
gested in some AD variants, underscoring the potential influence of genes and gene–gene
and gene–environment interactions on disease expression and variability over time (Far-
rer et al., 1995).
Also affecting rate of change are neuropsychiatric symptoms that can lead to “excess
disability” both cognitively, on neuropsychological tests, and in functioning. Depressive
symptoms are common early in the illness (Lykestos et al., 2002) and may even precede
detection of cognitive impairment, perhaps reflecting the individual’s own awareness of
subtle deficits (Moore, Sandman, McGrady, & Kesslak, 2001). Later in the disorder, pa-
tients frequently develop significant behavioral disturbances, including agitation, halluci-
nations, and delusions (Steinberg et al., 2003). All of these problems, when untreated,
can lead to what appears to be a more pronounced loss in ability.
Neurobiology
AD is defined not only by its well-recognized neuropsychological manifestations but also
by its distinctive neuropathological features, first described by Alzheimer in 1907 (see
Alzheimer et al., 1995). These changes, easily visualized under the microscope, include
the amyloid plaque, an extracellular accumulation of a viscous transmembrane protein
(amyloid; 39-42 amino acid derivative) at the core of the plaque, surrounded by cellular
debris from dead and dying neurites, inflammatory markers, and glia. The second com-
mon neuropathological feature is the appearance of neurofibrillary tangles within neu-
rons. This intraneuronal abnormality consists of paired helical filaments resulting from
an abnormally hyperphosporylated microtubular protein, tau. The abnormal cross-
linking of these proteins results in a massively disturbed microtubular array, leading to a
contorted cytoskeletal structure, unable to support the normal intracellular transport of
proteins, and eventually, neuronal death.
Plaques and tangles are not unique to AD; each individual feature can be seen in
other neuronal disorders. Amyloid plaques occur in some prion diseases, in dementia
pugilistica, and in a vascular disorder termed amyloid angiopathy. Tangles in isolation
can be seen in FTD, progressive supranuclear palsy, corticobasal degeneration, and are
also seen in some elderly patients without dementia. It is the abundance of the pathology
and the characteristic distribution of the features that distinguish AD (Hyman et al.,
1984). The pathology is largely confined to the hippocampus and entorhinal areas of the
medial temporal lobe, but as the disease progresses, expands to include association areas
of the neocortex (Arnold et al., 1991; Braak & Braak, 1991).
Genetics
The causes that precipitate the neuropathological cascade of events in the brain, leading
ultimately to the cognitive demise of the patient with AD, are not entirely clear. However,
determining the triggers and events that regulate or contribute to AD onset is of critical
importance in effecting a treatment and in eventually eradicating the disease altogether.
There can be little dispute that genes play a pivotal role in both AD risk and pathogenesis
(see Pericak-Vance et al., 2000, for review). Three gene loci, on chromosomes 21, 14, and
1, have been identified as causal in the majority of early-onset AD cases: APP (Goate et
al., 1991), presenilin 2 (PS2; Levy-Lahad et al., 1995), and presenilin 1 (PS1; St.-George
Hyslop et al., 1992). These genes account for only 1–2% of all AD cases. Another gene,
apolipoprotein E (apoE), has also been identified as a genetic risk factor for AD. Unlike
the other genes, it is not causal for AD but rather influences disease susceptibility and
symptom onset (Corder et al., 1993; Saunders et al., 1993a, 1993b; Strittmatter et al.,
1993). ApoE is a common gene that regulates the transport of lipids and appears to play
a role in neuronal repair. Polymorphisms, or common variations, in this gene appear to
play a role in modifying AD risk and symptom onset. There are seven allele types (E1–E7)
of the apoE gene, although some forms vary by only a couple of amino acids; the three al-
lele types—E2, E3, and E4—are, for the most part, the only forms seen commonly, with
99% of the population having at least one copy of these three isoforms. The E4 genotype,
although relatively infrequent in the population (14% of European Americans), is associ-
ated with approximately 15–50% of the late-onset forms of AD (Evans et al., 1997;
Plassman & Breitner, 1996) in a dose-dependent fashion, so that the E4/E4 genotype is at
highest risk of AD, followed by E4/E3, and then E3/E3.
Several lines of evidence suggest that apoE does not account for all the genetic varia-
tion of AD (see Pericak-Vance et al., 2000 for review). Combined together, the various
genes identified only account for 55% of the genetic risk for the disease (see Plassman &
Steffens, 2004, for review). Continued study suggests that there are likely several more
“risk” genes operating in AD and that in all likelihood, there are complex interactions
among multiple genes from different causal pathways giving risk to AD. Using associa-
tion methods, a number of other genes has been suggested in late-onset AD. Early studies
using genetic linkage suggest that there is at least one gene on chromosome 12 associated
with late-onset AD (Pericak-Vance & Haines, 1998), a finding later confirmed with ex-
panded datasets and enhanced genetic models that control for potential gene–gene inter-
actions (Scott et al., 2000). Myriad other gene associations with AD has been reported,
although many of these findings have not been consistently replicated. Among the most
interesting and secure of the recent findings include reports of genetic loci of interest on
chromosome 10 (Bertram et al., 2000; Ertekin-Taner, et al., 2000; Myers, Holmans, Mar-
shall, Hardy, & Goate, 2000) and chromosome 9 (Pericak-Vance et al., 2000).
Diagnosis of AD Dementia
The clinical diagnosis of AD can be made with a high degree of accuracy (85% accuracy
or more at major medical centers) if the clinician is proficient in recognizing the disorder
and adheres to standard accepted clinical criteria (McKhann et al., 1984). These criteria,
summarized in Table 3.1, draw heavily on what is now understood about the clinical
symptomatology as specified through neuropsychological study. The syndrome of rapid
memory impairment, accompanied by other deficits in at least one area of cognition, is
required. The neurocognitive problem must be acquired in adulthood (not a longstand-
ing, static problem from development), represent a change from a previous level of func-
tion, and must be causing impairments in the individual’s ability to perform everyday
functions. Finally, other potential contributing medical or psychiatric conditions must be
excluded as the primary cause of the cognitive disorder.
Neurocognitive and Functional Assessment

The neuropsychological evaluation plays a central role in establishing the presence of the
required inclusionary features of AD dementia. The evaluation is not required in all cases
of dementia, when the syndrome is evident. A diagnosis will require more than
neuropsychological testing, however. To establish the presence of functional loss, inter-
view with a knowledgeable informant (e.g., spouse, adult child) may be needed to verify
this information, because a loss of insight is common in AD and may result in the affected
individual being unable to reliably report his or her functional abilities accurately. Com-
monly used for this purpose are interview tools developed for the Clinical Dementia Rat-
ing Scale, a metric with which to gauge the functional impairment in AD (Hughes, Berg,
Danziger, Cohen, & Martin, 1982). This scale rates patients across 6 different functional
domains (orientation, memory, language, home, social activities, personal care) and re-
sults in an overall cumulative score that can range from 0 (normal) to 0.5 (questionable
dementia) to 1.0 (mild dementia), 2.0 (moderate), 3.0 (severe), 4.0 (profound), and 5.0
TABLE 3.1. NINCDS–ADRDA Criteria for Alzheimer’s Disease

Probable Alzheimer’s disease
1. Dementia established by clinical examination and documented by mental status testing.
Defined as
• Disturbance in intellectual function that significantly interferes with work or usual social
activities or relationships with others.
• Demonstrable impairment in memory.
2. Dementia confirmed by neuropsychological assessment.
3. Deficits in two or more areas of cognition (can include memory, abstract thinking, constructional
ability, language, and orientation).
4. Progression in symptoms over time.
5. No disturbances in consciousness (no delirium).
6. Late onset and not developmentally acquired; onset between ages 40–90.
7. Absence of other conditions that are capable of producing dementia.
Possible Alzheimer’s disease

1. Atypical onset, presentation or progression of dementia symptoms, and/or
2. Presence of another systemic or other brain disease capable of producing dementia but not
thought to be the cause in the case under consideration.
3. Meets criteria for dementia, as confirmed by clinical examination and neuropsychological testing.
4. Progressive decline in symptoms over time.
5. No disturbances in consciousness.
6. Absence of other identifiable causes.
Definite Alzheimer’s disease

1. Clinical criteria for probable Alzheimer’s disease are fulfilled.
2. Histopathological evidence of Alzheimer’s disease by biopsy or postmortem examination.
(terminal stage). An informant version of the scale has been developed (Dementia Severity
Rating Scale) and can be employed in clinical settings as a useful screening tool; infor-
mants then can be queried in more detail to clarify the nature, extent, and onset of re-
ported difficulties (Clark & Ewbank, 1996).
Interpreting neurocognitive test results and observed functional impairments re-
quires consideration of competing causes for the observed problems. Developmental his-
tory must be considered and weighed in the clinical decision making. Learning disabili-
ties, such as attention deficit disorder or dyslexia, may result in learning and memory
difficulties that can confound the interpretation of newly acquired problems. Further-
more, the clinician needs to consider other related modifying variables: Level of school-
ing, familiarity with cognitive testing, age, and cultural variables can all influence testing
performance and potentially lead to erroneous decisions regarding the presence and se-
verity of cognitive losses (Anthony, LeResche, Niaz, von Korff, & Folstein, 1982). To this
end, education level has been shown repeatedly to be directly related to cognitive perfor-
mance on neuropsychological measures and must be taken into account before interpret-
ing test performance (see Lezak, 1995, for review). In the absence of age and educational
allowances, false-positive errors for dementia diagnosis are more likely in the sample of
individuals that is older or has low formal education (8 years or less; Welsh et al., 1994).
Similarly, differences in cognitive performance are commonly reported on the neuro-
psychological measures that are used for clinical diagnosis in some minority groups; these
differences are related to levels of acculturation and educational experiences. As an exam-
ple, a number of studies contrasting neurocognitive performance of elderly African Amer-
ican samples and European American groups has shown differences even after educa-
tional correction (Manly et al., 1998; Welsh et al., 1995); these changes appear to be
related to cultural variables and educational inequities, because the group differences vir-
tually disappear when premorbid ability and quality of schooling are controlled (Manly,
Jacobs, Touradji, Small, & Stern, 2002, 2003).
Excluding Medical Comorbidities

A necessary part of the clinical diagnosis of AD is to rule out other medical explanations
for the cognitive loss. Perhaps the single most important component of the dementia eval-
uation is obtaining a thorough medical history, which allows the review of symptoms,
their evolution of time, and the presence or absence of other medical problems that coin-
cide with symptom onset or may potentially explain the problems described. A diagnosis
of AD can be made with a great degree of certainty based solely on the report of func-
tional and cognitive loss, described above. With a history of a slowly evolving, gradually
progressive cognitive decline, characterized by memory impairment and leading to func-
tional losses, a diagnosis of AD would be prime consideration. The absence of competing
causes for the loss would make the diagnosis an “almost certainty.” Studies investigating
the influence of different sources of information in the diagnosis suggest high prediction
of the AD diagnosis with medical history information and cognitive test scores (Steffens
et al., 1996).
However, it is recognized that phenocopies of AD do occur; that is, disorders with
virtually identical symptoms but other provoking etiologies. Some of these disorders are
treatable, such as VaD (see Table 3.2), whereas others are not and are due to neurological
disorders such as FTD, vascular disease, and other progressive dementias described later
in this chapter or in other parts of the text. Very similar patterns of neurocognitive
change (e.g., recent-onset memory loss, attentional disorders) can result from diverse
medical causes, including but not limited to thyroid disorders, perturbations in B12 or fo-
late levels, cardiovascular disease, stroke, and other neurological conditions. Some of
these disorders are reversible if treated early, before significant neurological injury has oc-
curred (Eastley, Wilcock, & Bucks, 2000; Goebels & Soyka, 2000; Lehmann, Regland,
Blennow, & Gottfries, 2003). A careful history and laboratory tests are needed to fully
rule out the potential contributions of these causes in the cognitive syndrome. Typically,
TABLE 3.2. Criteria for Vascular Dementia

1. Meets criteria for dementia, as described previously.
2. Presence of clinical syndrome of stroke with:
a. CT or MRI findings consistent with clinical focal deficits, or
b. In the absence of consistent CT or MRI findings, clinical syndrome cannot be explained by
any other cause.
3. Onset of dementia within 3 months of the onset of stroke, with evidence (by history or previous
evaluation) of intact function prior to stroke.
4. In the assessment of cognitive ability to evaluate the presence of criteria for dementia, both of
the following are required:
a. Memory impairment cannot be directly attributable to the focal deficit associated with the site
of lesion.
b. Two other cognitive deficits are required. One of these must be in a domain that is not
attributable to focal deficit associated with the site of the stroke lesion.
Note. Based on Tatemichi et al. (1994) criteria; essentially a revision of the Roman et al. (1993) criteria.
the laboratory studies order include a complete blood count, thyroid panel, serum levels
of B12, other vitamins, and homocysteine, as well as other blood studies of kidney, liver,
and endocrine function (Clark & Karlawish, 2003).
Psychiatric Factors
In the medical history and clinical examination, attention must also be directed to current
and past psychiatric health. Depression and other psychiatric factors can result in cogni-
tive disorders that are difficult to distinguish from dementia. Additionally, these problems
can co-occur with dementia and exacerbate the underlying memory disorders. Identifica-
tion and treatment of psychiatric comorbidities may reduce, or entirely reverse, the cogni-
tive and functional symptoms. For more detailed discussion of the cognitive effects of de-
pression, see Houston and Bondi (Chapter 5, this volume).
Diagnostic Procedures
Structural Imaging. The diagnostic evaluation of dementia includes structural imag-
ing of the brain, primarily to rule out space-occupying lesions (e.g., tumors), stroke, or
other types of neurological conditions that might be treated. Typically in the early stages
of AD, results of the computed tomography (CT) or magnetic resonance imaging (MRI)
are normal on visual inspection. However, quantification of regional changes and com-
parisons to either normative standards (for cross-sectional analysis) or to images ob-
tained from the affected individual over a previous 2-year interval or more reveal selec-
tive atrophy of the temporal lobe, hippocampus, and amygdala (Moore et al., 2001). This
technique shows purpose as an early, surrogate marker of AD but is considered experi-
mental at this point. Structural variability across individuals normally makes any routine
clinical assessment difficult and prone to error. As the disease progresses, diffuse cortical
atrophy and ventricular enlargement become prominent. There is cortical cell loss, with
typical sparing of the occipital cortices.
Functional Imaging. New imaging methods targeting brain neuropathology show

particularly encouraging diagnostic potential but are not yet a routinely accepted method
for AD diagnosis. Positron emission tomography (PET) studies using the radioligand
fluorodeoxyglucose have shown particular utility in the early AD stages or in atypical
presentations, serving to support diagnostic suspicions (e.g., Silverman et al., 2001). A
pattern of bilateral or asymmetric temporoparietal hypometabolism is seen in AD and is
detectable even in the early stages of the disorder, perhaps even before the symptoms are
clearly manifest (Reiman et al., 1999; Small et al., 2000). The imaging pattern has been
validated in autopsy-confirmed AD cases and is considered fairly prototypical of the dis-
order (Hoffman et al., 2000). However, the use of fluorodeoxyglucon positron emission
tomography (FDG-PET) studies or related methods (such as single photon emission to-
mography [SPECT]) remains controversial in diagnostic settings from both health eco-
nomic and basic clinical practice perspectives (Kulasingam et al., 2003). In the absence of
effective treatments for AD, the radiation exposure and the fact that care decisions will be
essentially unchanged by the results make the merit of pursing SPECT or PET imaging
low compared to the potential risks and costs.
Recently, selective markers that bind with high affinity to brain amyloid have been
used in conjunction with PET (Klunk et al., 2003). If such methods can be safely and
effectively used in patients with AD, they may permit a method for analyzing the in-life
amyloid burden in key brain areas of the medial temporal lobe affected by AD. The ad-
vantage of this approach would be in its ability to directly monitor any changes in the un-
derlying disease response to treatment over time. It may even allow a strategy for direct
treatment delivery, if therapeutic molecules could be attached to the ligands, permitting
targeted delivery to cells with high amyloid burden.
Genetics and Family History Information

When diagnosing AD and other neurodegenerative dementias, it is important to secure a
good family history of any related illnesses. Each of the disorders under consideration in
this chapter—AD, FTD, PD-D, and Lewy body dementia—carry some genetic risk. Fa-
milial forms and sporadic forms exist for each of the disorders; and even in sporadic
forms of illness, genetic predisposition may play a role in an individual’s risk of disease.
FRONTOTEMPORAL DEMENTIA
FTD, like AD, is a slowly progressive neurodegenerative condition with onset in middle
to late adulthood. Unlike AD, where severe memory problems dominate the clinical pic-
ture, FTD is generally characterized by prominent personality change and expressive lan-
guage problems. Memory complaints, although present, are more variable in nature and
are more commonly attributed to impaired attentional focus. The typical onset of symp-
toms in FTD occurs relatively early compared to AD, occurring primarily in the fifth or
sixth decade of life. The condition evolves over the course of 5–10 years and results in
significant social and occupational impairments and, ultimately, death. Impairments in
judgment, behavioral regulation, and diminished insight throughout the illness render the
condition particularly challenging to the family and other caregivers, who must accom-
modate for the affected individual in society. As FTD progresses, severe impairments oc-
cur in emotional and behavioral regulation, resulting in a spectrum of abnormal behav-
iors from disinhibition, perseveration, lability, to severe akinesia and mutism. Ultimately,
the disorder culminates in complete functional dependence and, ultimately, a vegetative
state, indistinguishable clinically from AD and other end-stage dementias. In the early
stages, however, because of its insidious onset, progressive nature, and similarity in some
of the clinical symptoms to those of AD (e.g., forgetfulness, language disorder), FTD can
be clinically confused with AD. Even so, on closer inspection an astute clinician can usu-
ally distinguish between the two disorders. It is now clear that FTDs are a unique clinical
entity, separable from AD in terms of underlying neuropathology, anatomical specificity
of damaged brain circuitry, genetic loci, and clinical presentation (see McKhann et al.,
2001, for review). These characteristics are reviewed in the following text.
Epidemiology
Population- and community-based studies of dementia in the United States and abroad
are shedding light on the public health significance of FTD in the context of aging and
other dementias. Historically, FTD was considered relatively rare, with Pick’s disease, a
form of frontal dementia, representing the prototype (see Rossor, 2001, for a historical
overview). The original six cases described by Arnold Pick were characterized by a rela-
tively circumscribed language impairment (amnesic aphasia), which progressed over time
and corresponded to temporal lobe atrophy at postmortem examination (Alzheimer et.
al., 1995). The neuropathological correlates of the illness were later described by Alzhei-
mer et al. (1995) and underscored the absence of senile plaques and the relative sparing
of the hippocampus—pathological features characterizing Alzheimer’s disease. Two
histopathological features were thought to be the gold standard for the condition—
argyrophilic inclusions and swollen achromatic cells—and were termed Pick bodies and
Pick cells, respectively. These histopathological features were certainly correlated with the
dementia but were only rarely observed, leading to the conclusion that the frontal demen-
tia, or Pick’s disease, was an infrequent condition. This perception of its relative preva-
lence has also been influenced by imperfect clinical recognition.
The importance of FTD as a much more common family of neurodegenerative disor-
ders is a more recent concept. Over the last 25 years a number of case series and epidemi-
ological reports have described patients with very similar clinical symptoms to Pick’s dis-
ease, who were lacking the classic lobar atrophy and histopathological signatures of the
condition on postmortem examination. These disorders have carried descriptive names,
characterizing the uniqueness in the cellular pathological features (e.g., frontal-lobe de-
mentia of the non-Alzheimer’s type; dementia lacking distinctive histopathology), or in
the unique clustering of clinical symptomatology (e.g., semantic dementia, primary pro-
gressive aphasia). It is now believed that rather than a rare phenomenon, the disorder
may be a fairly common cause of dementia in middle adulthood (ages 45–65). Neuro-
pathological series suggest that it accounts for nearly 10% of the dementia cases that
come to postmortem examination (Neary & Snowdon, 1996). Clinic-based series and ep-
idemiological studies place the prevalence as high as 20% in the general population
(Snowden, Neary, & Mann, 2002). The condition has been pathologically verified in in-
dividuals as young as 21 years of age (Snowden, Neary, & Mann, 2004), and although it
is unusual to find cases of the disorder in carefully examined populations over age 75
(Breitner et al., 1999), one study reports a prevalence as high as 3% in a Swedish popula-
tion over age 85 (Gislason, Sjogren, Larsson, & Skoog, 2003). Men and women appear
to be affected equally by the disorder, and there is some familial aggregation suggesting a
role of genetic factors.
Genetics
FTD is likely not a single disorder with a single cause but a family of conditions arising
from a complex interaction of genetic and environmental factors, resulting in a final com-
mon pathway of selective neurodegeneration confined initially to the frontal cortex and
its efferent connections. As noted previously, familial aggregation is common in FTD,
with evidence of genetic transmission across generations. A history of similar dementia is
present in approximately half the cases of FTD that come to clinical attention (McKhann
et al., 2001), and mutations in the tau gene on chromosome 17 has been verified in some
familial forms of the condition (see Spillantini & Goedert, 2001, for review). These tau
mutations account for only about 5–6% of the cases of FTD (Poorkaj et al., 2001). In all
likelihood other genes and environmental precipitants are important. Genetic linkages to
chromosome 3 (Brown et al., 1995) and chromosome 9 (Hosler et al., 2000) have been
reported, but the actual causal genes in these instances have not yet been identified. Mu-
tations in the presenilin gene, located on chromosome 14, have also been associated with
some familial forms of FTD (Raux et al., 2000) as well as some instances of autopsy-
confirmed Pick’s disease—the latter occurring without amyloid plaques (Dermaut et al.,
2004), suggesting that FTD and AD may share common biological causal pathways.
The neuropathology of FTD is heterogeneous but differs from AD by the absence of
amyloid plaques. Tangles, however, are common to both disorders. Neurofibrillary tan-
gles are a requisite pathology in AD dementia; they are also a common feature in FTD,
being found in almost half the cases (McKhann et al., 2001). At least three histopath-
ological subtypes have been described (Knopman, Boeve, & Petersen, 2003; Snowden et
al., 2002); a microvacuolar subtype accounts for approximately 60% of the cases. This
subtype is characterized by spongiform degeneration or “microvacuolation” of the super-
ficial neuropil and a loss of large cortical neurons in the frontal and temporal cortices.
Gliosis is generally absent, and the limbic system and striatum can be affected, but usu-
ally only to a minimal extent. A second type, the Pick body subtype, accounts for perhaps
as much as 23% of the cases and is characterized by the loss of cortical neurons, wide-
spread gliosis, swollen, chromatic, and distended neurons (Pick cells), along with tau and
ubiquitin positive inclusions in the surviving neuropil (Pick bodies). The limbic system
and striatum tend to be more heavily affected in this subtype, but typically the hippocam-
pus is spared, and spongiform changes in the cortex are absent. A third subtype, occur-
ring in 15% of the cases, has clinical features of both FTD and motor-neuron disease
during life and also has correspondingly neuropathological features of both disorders at
autopsy.
Diagnosis
Diagnostic criteria that aid the clinician in identifying the disorder in its various symptom
manifestations (Lund & Manchester Groups, 1994) are summarized in Table 3.3. Be-
cause the location of the pathology to frontal systems can be located to anterior, mesial,
or lateral sectors of the frontal cortex, the constellation of symptoms can vary tremen-
dously. Although histopathological subtypes are well described in FTD, the disorder is
now generally conceptualized as falling into one of two distinctive clinical subtypes: a be-
havioral subtype, often heralded by changes in personality and behavioral regulation; and
a language subtype, comprised of semantic dementia and/or progressive nonfluent apha-
sia (Hodges et al., 2004). Most clinical cases present with a combination of the behav-
ioral and language problems. Additionally, motor symptoms are common to both clinical
presentations (Hodges, 2001). The neurocognitive and behavioral features of each of the
subtypes are described in the following text.
Neuropsychological Presentation
Behavioral Subtype. The neuropsychological presentation of FTD varies by subtype,
but it almost certainly includes a combination of behavioral and neurocognitive features.
In the more common behavioral form of the disorder, the neurocognitive features may be
indefinite, particularly early on. It is not uncommon for affected individuals to test in the
normal range on conventional tests used in dementia evaluations, such as mental status
screening examinations (e.g., MMSE of 27 or higher) and tests of intelligence and recent
memory function, including delayed recall (Cherrier et al., 1997; Pachana, Boone, Miller,
Cummings, & Berman, 1996). However, deficits are easily discerned on tests of frontal
executive function (Pachana et al., 1996). These patients have difficulty on tasks such as
the Wisconsin Card Sorting Test or the Short Category Test, which involve behavioral
TABLE 3.3. Clinical Diagnostic Features of Frontotemporal Dementia

Core diagnostic features
1. Behavioral disorder that is insidious in onset, slowly progressive, and characterized by any of the
following early features:
a. Loss of personal awareness (e.g., neglect of personal hygiene or grooming)
b. Loss of social awareness (e.g., loss of social tact, misdemeanors etc)
c. Decreased insight into pathological changes in own behavior or mental state
d. Disinhibition early in course (e.g., unrestrained sexuality)
e. Mental inflexibility
f. Hyperorality
g. Sterotyped and perseverative behaviors
h. Utilization behavior (i.e., unrestrained exploration of objects in the environment)
2. Affective symptoms are common and include any of the following:
a. Depression, anxiety, sentimentality, suicidal and fixed ideation or delusions early in the
disorder
b. Hypochondriasis or bizarre somatic preoccupations early in the illness
c. Emotional indifference or lack of empathy, sympathy, apathy
d. Amimia (inertia, aspontaneity)
3. Speech disturbances characteristic of the disorder uniquely distinguish it from other common
dementias. Symptoms include:
a. Progressive reduction of speech (aspontaneity, economy of utterance)
b. Sterotyped speech (limited repertoire of words or themes)
c. Echolalia or perseveration
d. Late mutism
4. Frontal lobe signs and other physical signs:
a. Early primitive reflexes
b. Early incontinence
c. Late akinesia, rigidity, tremor
d. Low and labile blood pressure
5. Perceptual spatial disorders are absent; intact abilities to negotiate the environment.
6. Investigative findings include:
a. Normal EEG, despite clinically evident dementia
b. Brain imaging (structural or functional or both) that shows predominantly frontal or anterior
temporal lobe abnormalities.
c. Neuropsychology findings of profound failure on frontal lobe tests; absence of severe memory
impairments, aphasic disorder, or perceptual spatial disturbance
Supportive diagnostic features

1. Onset before age 65
2. Positive family history of similar disorder in first-degree relative (i.e., parent, sibling)
3. Bulbar palsy, muscular weakness, wasting, fasciculations (e.g., motor-neuron disease)
Exclusionary features
Abrupt onset with ictal events Head trauma related to the onset
Early severe amnesia Early spatial disorientation or other signs of agnosia
Early severe apraxia Logoclonic speech with rapid loss of train of thought
Myoclonus Corticobulbar and spinal deficits
Cerebellar ataxia Choreoathetosis
Early, severe pathological EEG Laboratory tests indicating brain inflammatory process
Brain imaging with either predominant postcentral structural
or functional defect or multifocal cerebral lesions (CT/MRI)
Relative diagnostic exclusions

1. Typical history of chronic alcoholism
2. Sustained hypertension
3. History of vascular disease
Note. Summarized from Brun et al. (1994).
regulation, flexibility, higher-order conceptualization, and multitasking. Additionally, ex-

pressive language may appear normal in casual conversation but is typically characterized
by difficulty in word generation, as can be discerned on tests of either confrontation nam-
ing or verbal fluency.
More notably in the behavioral form of FTD is the character change. Central to the
disorder is difficulty in behavioral regulation, which can lead to excessive irritability, vol-
atility, or emotional lability that is described by family members as uncharacteristic of the
patient’s normal baseline behavior. At the other extreme, some individuals display severe
apathy and behavioral inertia that can progress to mutism. Personality changes accompa-
nying the disorder include early signs of declining social judgment, impulsivity, dis-
inhibition of thought and action, and difficulty in maintaining personal boundaries (e.g.,
a normally reserved person starting inappropriate conversations with strangers). Unusual
behaviors, including components of the Kluver–Bucy syndrome such as hyperorality or
hypersexuality, are also noted in some cases. In diagnosing the disorder, it is absolutely
essential to obtain a thorough history of behavioral change, neurocognitive observations,
and psychiatric symptoms from a knowledgeable informant to complement the objective
neurocognitive testing and assessment of function. Patients themselves are often unable to
self-reflect on their own difficulties; and early on the neurocognitive profile may appear
relatively unremarkable, despite enormous changes in everyday functioning.
Language Subtype. The language subtype of FTD can be subdivided into two dis-
tinctive entities in which the symptom manifestations, at least in the early phases of the
illness, are almost entirely confined to the language domain. The symptom complex dif-
fers in the two language variants of FTD, and there is some indication that the differing
phenotypes may share different pathogenesis (Hodges et al., 2004). One form of language
disorder in FTD involves impaired language expression and is termed nonfluent “primary
progressive aphasia” (Mesulam, 2001), also discussed in Clare (Chapter 13, this volume;
Johnson, 2005). The less common form of language disorder in FTD involves selective
difficulty in understanding word meaning and has been designated as “semantic demen-
tia” (Hodges, 2001; Hodges & Miller, 2001).
The early manifestations in primary progressive aphasia (PPA) include rather iso-
lated and distressing difficulties in word retrieval leading to labored speech, articulation
problems, reduction in output, circumlocution, and anomia on formal assessment. Com-
prehension is generally intact at this stage of illness, as are many other aspects of
neurocognitive function, including general intelligence and visuospatial functioning. The
impairment is not usually accompanied by problems in new learning or memory; how-
ever, performance on verbally based memory tests may suggest deficiencies due to the
aphasic element. When memory problems are evident, they are less severe overall than
those of AD. When patients present with prominent language disorders and memory im-
pairments, the diagnosis of AD with prominent language disturbances may be more
appropriate (Knopman, Boeve, & Petersen 2003). As the condition of PPA progresses,
language decline becomes much more pronounced and generalized, resulting in compre-
hension impairments, severe reduction in verbal output, and eventually mutism. Other
aspects of cognition are almost invariable impaired at the later stages of the disorder,
making clinical differentiation from AD difficult in the absence of reliable historical in-
formation of symptom manifestation and progression.
Semantic dementia, by contrast, is characterized by fluent speech but substantial im-
pairments in word comprehension. Word-finding difficulty is common across the two
subtypes and can be elicited on clinical examination by tests of naming. Characteris-
tically, these patients have difficulty on semantic memory tests that assess their verbal and
nonverbal knowledge of object relations and categorical membership (Hodges et al.,
2004). In addition, there are often a number of behavioral or psychiatric features in
semantic dementia. Depending on the area of focal brain involvement, different neuro-
cognitive and behavioral features emerge. In left anterior temporal cases, language prob-
lems, as described, are accompanied commonly by depression. In many instances there
are also reported changes in dietary habits and development of food fads (Thompson,
Patterson, & Hodges, 2003). In cases where the neuronal degeneration is more lateralized
to the right temporal lobe, word finding is a common complaint, comprehension is gener-
ally unaffected, but there is often poor facial identification. This pattern is coupled with
behavioral changes that include bizarre affect and impaired social conduct; patients are
often described as rude, disinhibited, socially awkward, and lacking insight.
Attendant Data
Beyond neuropsychological testing, a diagnosis of FTD requires a complete medical his-
tory, similar to evaluation of any other neuropsychological disorder. Differential diagnos-
tic considerations in FTD include prior serious head injury, cerebrovascular events, brain
tumor, metastic illness, or other progressive neurodegenerative disorders, such as AD or
progressive supranuclear palsy. Because FTD shows a heritable component in nearly 50%
of the cases, a good family history of mid- to late-life neurological and psychiatric disor-
ders can be helpful and provide useful supportive information for the diagnosis. Genetic
testing for mutations in the tau gene is not commonly done in the clinical evaluation of
FTD and is generally only appropriate in instances where chromosome 17 FTD is sus-
pected by virtue of proven multigenerational evidence of FTD in the family kindred
(Knopman et al., 2001).
Perhaps the most useful attendant information to secure a diagnosis of FTD comes
from structural and functional neuroimaging studies. To exclude focal lesions in the fron-
tal and anterior temporal areas, MRI studies are generally preferred over CT for the eval-
uation of suspected FTD. Although these studies may be unremarkable initially in symp-
tom manifestation, the presence of focal atrophy confined either to the prefrontal cortex
or the anterior temporal areas provides confirmatory evidence of the FTD diagnosis.
Functional studies using either PET or SPECT also can provide direct evidence of focal
frontotemporal dysfunction. The metabolic patterns associated with FTD and AD are
very different, with hypometabolism confined largely to the frontal and temporoparietal
cortices in the respective disorders. This contrasting pattern allows the disorders to be re-
liably identified by a skilled neuroradiologist or other dementia specialist trained and
qualified to interpret neuroimaging scans using standard visual inspection methods
(Higdon et al., 2004).
DEMENTIA OF PARKINSON’S DISEASE AND LEWY BODY DEMENTIA
Parkinson’s disease (PD) has attendant changes in cognition that may evolve over time
into a full dementia syndrome in about a third of affected patients (Jacobs et al., 1995;
Janvin, Aarsland, Larsen, & Hugdahl, 2003). Current estimates place the rates of demen-
tia between 19 and 40% in PD patients, compared to elderly adults unaffected by the dis-
order (Aarsland et al., 2001, 2003; Marder, Tang, Cote, Stern, & Mayeux, 1995; Tison et
al., 1995). Risk factors for the development of dementia in PD include older age, late-
onset age of PD, family history of dementia, longer disease duration, greater motor symp-
tom severity, depression, hypertension, limited education, low socioeconomic status, and
confusion or psychosis associated with treatment with levodopa or related agents (Emre,
2003).
Lewy body disease is a spectrum of disorders, with onset in the 60s and 70s typically,
which overlaps substantially with both PD and AD (Ballard et al., 1999). The dementia
associated with cortical Lewy bodies is characterized by attentional disturbances,
parkinsonism, and cognitive impairment. As noted it is often referred to as Lewy body
dementia (LBD); other common terms include dementia with Parkinsonism, dementia
with Lewy bodies—DLB—or DLB with Parkinsonism. For this discussion we use the
term Lewy body dementia—LBD—to describe the clinical syndrome, because the pres-
ence of Lewy body neuropathology requires postmortem examination, and this informa-
tion is not always available in many clinical reports describing the neurocognitive charac-
teristics. The diagnostic criteria for the disorder are summarized in Table 3.4 and are
elaborated in the text that follows.
The prevalence of PD-D and LBD in the population over 60 is not completely under-
stood. Currently, the frequency of PD alone in the elderly is estimated at approximately
1% (Baldereschi et al., 2003; Strickland & Bertoni, 2004). Most studies estimate that the
PD-D spectrum disorders (PD-D and LBD combined) may account for nearly 15–22% of
the cases of late-onset dementias, making it roughly as common as VaD and about half as
common as AD (Campbell, Stephens, & Ballard, 2001; Lennox, 1998; Rahkonen et al.,
2003). Some studies suggest that the rates may be even higher if combinations of pathol-
ogy are considered. One community-based study, confirming the diagnosis with postmor-
tem examinations, suggests that Lewy body neuropathology is very common in normal
aging, with approximately 22.5% showing these changes on postmortem examination. In
the demented subgroup, LBD dementia accounted for nearly 41% of the cases (Wakisaka
et al., 2003).
Genetics
The etiological causes of PD-D and LBD are not at all understood but appear to be
multifactorial and more than likely involve a complex interplay of genetic factors with
environmental exposures, as is true in the related conditions of AD and PD more gener-
ally. The evidence for genetic causes is supported first by observations of genetic
heritability in both early and late onset PD (Marder et al., 2003; Payami, Zareparsi,
James, & Nutt, 2002; see also Cato & Crosson, Chapter 4, this volume). These studies
suggest that in some instances, PD follows patterns of genetic transmission and accounts
for approximately 10% of the cases (Dawson & Dawson, 2003). In these familial forms,
causal mutations have been identified in the gene “parkin” that codes for the protein al-
pha-synuclein, a known protein that aggregates within the Lewy bodies and the Lewy
neurites of PD and LBD. Genetic linkage has also been reported on chromosome 2, on
the short arm of chromosome 4, and at three different loci on chromosome 1 (see Gwinn-
Hardy, 2002; Dawson & Dawson, 2003 for reviews).
The role of environmental exposures and lifestyle factors in PD-D–LBD is even more
tenuous. In PD there is some support for environmental exposures playing a role in the
more common sporadic (nonfamilial) form of the disorder; whether this finding extends
to LBD remains to be seen. At least 20 different studies report smoking as a protective
factor in PD, suggesting a possible role of the cholinergic pathway and its demise in PD
(see Fratiglioni & Wang, 2000, for review). In addition, PD appears to be more common
TABLE 3.4. Clinical Diagnostic Features of Lewy Body Dementia

1. Central feature of LBD is a progressive dementia of sufficient magnitude to interfere with normal
social and occupational function. Prominent or persistent memory impairment may not occur in
early stages but is evident with progression. Deficits on tests of attention and frontal-subcortical
skills and visuospatial ability may be particularly prominent.
2. Probable and possible LBD: Two of the following core features are essential for the diagnosis of
probable LBD. One of the features is necessary for designation of possible LBD.
a. Fluctuating cognition with pronounced variations in attention and alertness
b. Recurrent visual hallucinations that are typically well formed and detailed
c. Spontaneous motor features of parkinsonism
3. Features supportive of the diagnosis
a. Repeated falls
b. Syncope
c. Transient loss of consciousness
d. Neuroleptic sensitivity
e. Systematized delusions
f. Hallucinations in other modalities
Note. Summarized from McKeith et al. (1996).
in men, leading some to posit that estrogen may be neuroprotective (Baldereschi et al.,
2003). Herbicide and pesticide exposure has been linked to an enhanced risk of the con-
dition (Seidler, et al., 1996), with some studies providing evidence of a genetic interaction
that serves to provoke symptoms (Hubble et al., 1998). It is not clear that exposure to
any of these agents plays a role in LBD.
The clinical similarity between PD-D–DLB and AD has suggested that these disor-
ders may be linked etiologically. However, evidence for the same genetic causes in AD
and PD spectrum conditions has not yet been definitely demonstrated. It is posited that if
the same genetic mechanisms underlie the conditions, then AD and PD disorders should
co-occur with high frequency within the same families. This co-occurrence has not been
found. In recent work examining the risk of AD in familial PD, no increased susceptibility
was found for AD when compared to control families (Levy et al., 2004). However, in
this study probands with PD-D were not included, which may have biased the findings
toward the null result. Other studies suggest that genes with overlapping susceptibility to
brain neurodegenerative conditions may act in concert with specific AD or PD etiological
factors, which then act to trigger one disorder or the other (Li et al., 2002, 2004).
Whatever the genetic or environmental triggers of PD, the ultimate etiological factor
underlying both PD-D and LBD appears to be the aggregation of cortical Lewy bodies and
not AD cortical changes. A series of investigations has examined the neuropathological
correlates of these dementias. And, although alpha-synuclein aggregates occur in PD,
LBD, and AD (Lippa, Schmidt, Lee, Trojanowski, 2001), the dementia associated with
PD and LBD appears to be more strongly related to cortical Lewy bodies than to the
plaques and tangles of AD (Hurtig et al., 2000; Mattila, Rinne, Helenius, Dickson, &
Roytta, 2000).
Diagnosis
The diagnosis of PD-D dementia or LBD rests, in large part, on the relative occurrence of
dementia with regard to extrapyramidal motor symptoms. A diagnosis of PD-D is made
when global cognitive and functional impairments emerge in patients who have already
been diagnosed and treated for PD. The diagnosis of LBD is made when the symptoms of
dementia either predate or follow the onset of parkinsonism within a 1-year time interval;
however, frequently, the dementia and motor symptoms coincide. Three key features de-
fine the LBD disorder: (1) arousal disturbances characterized by sleepiness, altered
arousal, and fluctuations in attention; (2) motor problems, which typically include gait
and balance problems, rigidity, and akinesia; and (3) a cognitive disorder, similar to AD,
with characteristic prominent memory impairments. As described later, the neuro-
cognitive profile is actually readily distinguishable from that typical of AD. Rapid eye
movement (REM) sleep disorders commonly precede LBD and are reportedly present in
nearly half of the cases (Boeve et al., 2003). Patients also typically experience fully
formed visual hallucinations early in the disorder; some researchers have suggested that
there may be intrusions of REM sleep into the wakefulness cycle (Knopman et al., 2003).
LBD tends to have a faster progression rate than AD and generally poorer prognosis with
shorter survival intervals (Olichney et al., 1998). However, with pharmacological inter-
ventions for management of the sleep disorder and neuropsychiatric disturbances, this sit-
uation may be changing.
Neuropsychological Profile of PD
The cognitive problems typically associated with the PD process are described in detail in
Chapter 4 of this volume. However, to fully understand the presentation of PD-D–LBD it
is important to be clear on the neurocognitive distinctions between PD and AD. We
briefly review key features of PD here, but refer the reader to Cato and Crosson (Chapter
4, this volume) for a more comprehensive discussion.
The disorder of PD is characterized by forgetfulness, a slowing in the thought pro-
cess, attentional problems, and difficulty in spontaneous word retrieval, particularly in
the absence of structural support or cuing (Janvin et al., 2003). These changes in cogni-
tion are not generally disabling, and patients frequently develop adaptive strategies to ac-
commodate for some of these problems. Qualitatively, PD patient examinations are dom-
inated by the extrapyramidal features associated with this disease; hypophonic speech is
common, along with bradykinesia, bradyphrenia, and poor graphic motor skills such as
micrographia (Hodges, 2001). Typically, this constellation of behaviors, along with the
cognitive profile of PD (described in Chapter 4), has been labeled by neuropsychologists
as “subcortical” in nature, and the disorder seen as distinguishable from AD by the ab-
sence of rapid forgetting (Noe et al., 2004). Although the cognitive problems are not
likely all based on the subcortical brain changes associated with PD, the “subcortical”
descriptor has been a useful construct with which clinician refer to the central processing
problem of PD and related conditions of the basal ganglia and nigrostriatal system, which
all share problems in retrieval mechanisms and flexible behavior and benefit from struc-
tural support strategies.
The key features of the neuropsychological profile of PD are mild executive and
attentional problems (Woods & Troster, 2003), which can be discerned on tests of sus-
tained attention and concentration, such as digit span or other simple span tasks. Mem-
ory impairment is also commonly reported in PD; however, when investigations carefully
control for age, education, and other confounding variables, PD patients generally have
less severe memory deficits than matched groups with AD (Heyman et al., 1999). In con-
trast to AD, recognition memory is either intact or generally less affected in PD when
compared to AD, and PD patients also benefit more from cues in paragraph recall tasks.
Verbal fluency is almost always impaired in PD, but naming is not. Visual constructional
abilities are characteristically affected by PD and not entirely due to the motor symptoms.
Some have suggested that an underlying fundamental defect in organizational ability and
executive function is responsible for the cognitive deficits described in speech, memory,
and visuoconstruction. In one study, in which executive function was controlled by
covarying the results of individual performance on the Wisconsin Card Sorting Test, the
deficiencies in learning, memory, visual perception, and visuoconstruction were no longer
significant in the PD-affected groups (Bondi, Salmon, Galasko, Thomas, & Thal, 1999).
Neuropsychological Profile of LBD

LBD can be difficult to distinguish from PD-D, but can be discerned from other condi-
tions such as AD and progressive supranuclear palsy (PSP) fairly readily (Aarsland et al.,
2003; Hamilton et al., 2004). LBD is characterized by the presence of marked deficits in
attention and executive function, visuospatial impairments, and constructional difficul-
ties early within the process (Connor et al., 1998; Galasko, Katzman, Salmon, & Hansen,
1996; Hansen et al., 1990; Salmon et al., 1996). Selective impairments often occur very
early in the disorder within attentional allocation and working memory (Ballard et al.,
1999; Emre, 2003). Patients with LBD have anterograde memory problems similar to
those of AD, although these deficits appear less severe in LBD (Hamilton et al., 2004;
Stern et al., 1998). Both AD and LBD show impaired acquisition scores on tests such as
the California Verbal Learning Test CVLT), the Logical Memory subtest of the Wechsler
Memory Scale, and the Buschke Selective Reminding Test, but delayed recall, savings
scores, and recognition performances are all comparatively better retained in the LBD
group. The memory problems of LBD are accompanied by better naming skills but
poorer executive and visuospatial functions in contrast to AD (Ballard et al., 1999;
Heyman et al., 1999). Qualitatively, when matched by stage these patients may appear
more apathetic than patients with AD, and they may show more distractibility and
greater tendencies toward perseveration, confabulations, and intrusions (Doubleday,
Snowden, Varma, & Neary, 2002). In the latter regard, although both groups make
intrusional errors, LBD patients show a propensity toward environmentally triggered er-
rors (e.g., upon seeing a trash can in the testing room, and LBD patient would be inclined
to volunteer trash can as a word on a memory test). The intrusions in AD tend to be more
semantically related to target stimuli or derive from previously administered tests.
Because of the overlap between the neurocognitive and behavioral features of LBD
with AD, the reliability of the diagnosis based on neuropsychological profile alone is im-
perfect. Clinical pathological studies have shown limits in both sensitivity and specificity
of the diagnosis, even when adhering to the published criteria, which include much more
than neuropsychological data (Holmes, Cairns, Lantos, & Mann, 1999; Mega et al.,
1996). Improving the diagnosis will require further understanding of the causal mecha-
nisms underlying each of the disorders: AD, PD, and LBD. Until that time, the clinical di-
agnosis at present can be enhanced by the clinician’s careful attention to the prominent
defining characteristics of the LBD disorder: the arousal and motor disturbances
(Knopman, Boeve, et al., 2003). Other neurodegenerative conditions that can mimic the
disorder need to be carefully considered in the differential diagnosis, including progres-
sive supranuclear palsy (PSP) and corticobasal degeneration (CBD). These conditions can
usually be distinguished clinically, based on the presentation of the motor findings. PSP
generally has ocular and brain stem abnormalities, along with Parkinsonsian signs, mild
subcortical cognitive profile, and balance problems (Litvan et al., 1996). CBD is often,
but not invariably, characterized by focal motor apraxia along with other similar
parkinsonism and cognitive features (Grimes, Lang, & Bergeron, 1999).
Attendant Data
The diagnosis of PD-D and LBD requires a careful consideration of current and past his-
tory variables regarding the relative onset of motor signs and dementia. The crux of the
differential diagnosis rests on the relative occurrence of dementia in the context of PD
symptoms. LBD diagnosis requires that the dementia did not occur within 1 year of PD
symptoms. Some have argued that this distinction is arbitrary and not supported on clini-
cal grounds (e.g., Ballard et al., 2002). It remains to be seen if the two disorders are in-
deed separate entities. At present, subtyping is useful in the event that the disorders show
different responsiveness to pharmacological treatments. Both disorders appear responsive
to cholinergic therapies, but differential responsiveness to levodopa therapy can distin-
guish PD from LBD. Presence of visual hallucinations, not associated with treatment, can
also help distinguish LBD from PD-D. In the future, the differential diagnosis of the con-
ditions from other dementias may be facilitated by consideration of biological markers,
neurological findings, laboratory, test results, and functional and structural imaging data.
No reliable diagnostic test for either PD-D or LBD is yet available.
Ultimately the firm diagnosis of PD, LBD, and AD rests on neuropathological verifi-
cation of these illnesses. The typical neuropathology of PD includes depigmentation of
the substantia nigra and locus coeruleus, along with neuronal loss in the nucleus basalis
of Meynert, the dorsal raphe nucleus, the dorsal motor nucleus of the vagus, and
thalamic nuclei. The remaining neurons within these areas show the characteristic pres-
ence of Lewy bodies—round eosinophilic inclusions that are composed of a halo of fibrils
surrounding a less defined core. These cellular inclusions are classic for the illness, along
with dystrophic neuritis (Lewy neuritis). LBD contrasts with PD in that the distribution
of Lewy bodies (intracytoplasmic eosinophilic inclusion bodies) in LBD is diffuse and
widespread across the cortex, nucleus basalis of Meynert, and substantia nigra. It should
be noted that there is considerable overlap in the neuropathology of these different
entities, however; most cases of LBD also show senile plaques and may also have neuro-
fibrillary tangles (Lennox, 1998). The overlap likely underscores shared etiological mech-
anisms. Coming to a further understanding of this continuum of pathological presenta-
tions and its correspondence to the unfolding of clinical features will be important in
ultimately identifying causal pathways.
CONCLUSIONS
AD and its prodrome, MCI, are easily detected and distinguished from other cognitive
disorders of late life through clinical methods, a cornerstone of which is detailed
neuropsychological testing (Grundman et al., 2004). There is overlap in the clinical fea-
tures of related dementias of late life, including PD-D, LBD, FTD, and vascular disorders
(not reviewed here). In part this clinical overlap reflects the overlap in the pathogenic fea-
tures that underlie the conditions, and the presence of mixed etiologies for the cognitive
disorders (Bird et al., 2003; Knopman et al., 2003). Distinguishing between disorders and
determining the relative contributions of various disease comorbidities is facilitated by
the advances in biotechnology, genetics, and functional imaging (Cacabelos, 2002;
Machulda et al., 2003). These methods already have produced useful biomarkers (such as
apoE) that assist in early and reliable AD detection. The advent of surrogate markers for
tracking disease course and responsiveness to therapy, in conjunction with effective
pharmacotherapies, may allow streamlined treatment of patients in the future in a way
that is tailored to their specific diagnosis (e.g., AD vs. LBD) and other variables related to
drug responsiveness (e.g., genotype). The field is exploding at present, with huge private
industry and government-supported investments in the pharmacogenetics, proteomics,
and metabolomics of dementia (Butterfield, Boyd-Kimball, & Castegna, 2003). Although
no “cures” for late-life dementias are immediately forthcoming, the potential for effective
treatment in the future is evident and appears not only strategically possible but encour-
aging.
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4
Stable and Slowly Progressive Dementias
M. ALLISON CATO
BRUCE A. CROSSON
In this chapter we review neurological, epidemiological, pathophysiological, and neuro-

psychological characteristics of a number of slowly progressive dementias. Many of the
dementias presented in this chapter share a frontosubcortical presentation in contrast to
that of the more “cortical” profile associated with Alzheimer’s disease (AD). Whereas the
dementias reviewed by Welsh-Bohmer and Warren (Chapter 3, this volume) are invari-
ably progressive, the dementias presented in this chapter often progress slowly, and in
some cases, are even stable in course. We do not cover all slowly progressive dementias,
however. The etiologies covered here (Parkinson’s disease, vascular, alcohol use, and head
trauma) were selected, in part, because of their relevance to the aging population.
Because the purpose of this discussion of dementias is to review information perti-
nent to geriatric neuropsychological assessment, a few introductory remarks regarding
current definitions of, and classifications among, slowly progressive dementias are war-
ranted. The neurocognitive profile associated with AD has greatly influenced conceptual-
ization of dementia as a construct (Looi & Sachdev, 1999). Historically speaking, the cor-
nerstone criterion for dementia was memory dysfunction. In frontosubcortical dementias,
perhaps more devastating than the memory impairment (which is primarily one of re-
trieval rather than encoding) are deficits in executive functions as well as debilitating
slowness in movement and thinking. Thus the following questions arise. Does the broad
term of dementia connote the same neuropsychological and functional disability in corti-
cal and frontosubcortical dementias? What level of cognitive impairment and what level
of functional decline are necessary and sufficient for a diagnosis of dementia? It is not
clear that a consensus has been reached, even among health care professionals, about this
boundary line for the dementias. We will return to this important issue at the conclusion
of the chapter. We now present Parkinson’s disease dementia, considered a prototype
among the fronto-subcortical dementias.
89
PARKINSON’S DISEASE DEMENTIA

Idiopathic Parkinson’s disease (PD) is a neurodegenerative disorder identified clinically by
a classic motor-symptom triad consisting of (1) a resting “pill-rolling” tremor that disap-
pears during intentional movement, (2) muscular rigidity, and (3) bradykinesia (slowness
of movement) (Jankovic, 1987). Cognitive slowing, or bradyphrenia, is another primary
feature of PD (Brown & Marsden, 1991). An obvious and sustained response to
levodopa or dopamine agonists is characteristic of PD. Other common clinical symptoms
related to muscular rigidity include gait disturbances (shuffling, short-stepped gait; di-
minished arm swing; turn en bloc); stooped posture (with flexion of hips, knees, elbows,
and neck); mask-like facial expression; hypophonia; and dysarthria. Muscular rigidity
can present in the form of a cogwheel (superimposed ratchety motion) or a plastic
(smooth increase in resistance) subtype. Other motor symptoms may include akinesia (a
difficulty initiating and paucity of movements), as well as a difficulty stopping move-
ments once in motion. Hypokinesia, or small movements, is observable in micrographia
(small, constricted handwriting). Postural instability secondary to loss of righting reflexes
and poor prosody (monotoned speech) are also commonly observed (Levy & Cummings,
2000). The clinical manifestations of PD can be highly variable. Two clinical subtypes,
the akinetic-rigid and the tremor-dominant, have been characterized in the literature and
have been associated with slightly different patterns of cell loss in the substantia nigra
(Jellinger, 2002).
Onset of the disease is typically asymmetrical with unilateral onset of tremor. Mean
age of onset occurs between 58 and 62 years of age (range 40–70 years), with peak onset
in the sixth decade (Duvoisin, 1984; Martilla, 1987). In terms of course, this disease
tends to follow a two-stage trajectory as dopamine levels are nearly depleted before mo-
tor symptoms become manifest. Thus a prodromal phase occurs during the two or more
decades prior to the obvious motor symptoms. During this prodromal phase, the degener-
ation of substantia nigra cells is slow and insidious. Following onset of clinical symp-
toms, this second stage can be further divided into early (1–5 years), middle (6–10 years),
and advanced (11–20+ years) stages. Cognitive decline is characteristically slow. Once
clinical symptoms become manifest, average time to death in PD if untreated is 8 years
(range 1–30 years). With medications, 50% of patients are alive 16 years after onset
(Levy & Cummings, 2000).
PD is observed in 150–200 out of every 100,000 individuals in the general popula-
tion (0.12–0.2%), and prevalence increases with age (Lezak, 1995). Parkinson’s disease
affects men more than women, but with no differences between sexes in age at disease
onset, duration, or severity. Estimates of prevalence of dementia in PD (PD-D) have var-
ied widely in the past, ranging from 4 to 93%, depending on the diagnostic criteria used
(Mindham et al., 1993; Woods & Tröster, 2003). Currently accepted prevalence of PD-D
is between 25 and 40% (Hughes, Daniel, Blankson, & Lees, 1993).
Attendant Data
The pathophysiological hallmark of PD is the progressive depigmentation and loss of
dopamine-containing neurons in the compact zone of the substantia nigra (SNpc) and
other brain stem nuclei, leading to a loss of dopaminergic input to the neostriatum (the
putamen, especially posterior portions, is more severely affected than the caudate) and
Stable and Slowly Progressive Dementias 91
neocortex (Levy & Cummings, 2000). Once dopamine levels drop below 30%, motor
symptoms become apparent (Lezak, 1995). Regarding the mechanism by which the loss
of dopamine leads to the clinical syndrome of PD, a number of theoretical explanations
have been offered (e.g., Mink, 1996; Penney & Young, 1986). Briefly, between the basal
ganglia and the thalamus, two normally dynamically balanced circuits, commonly re-
ferred to as the direct and indirect loops, decrease and increase (respectively) inhibitory
inputs to the thalamic nuclei. The thalamic nuclei, in turn, project to the neocortex. The
direct motor loop, via disinhibition of specific regions within the motor nuclei of the
thalamus (i.e., ventrolateral or VL nuclei), is thought to mediate desired motor programs,
whereas the indirect motor loop, via increased inhibition of specific regions within VL
nuclei of the thalamus, is thought to mediate the suppression of unwanted motor behav-
iors.
More recently, the role of direct corticosubthalamic connections in the initiation of
behavior has been explored (Nambu et al., 2000; Nambu, Tokuno, & Takada, 2002);
however, this route is not directly affected by PD because it bypasses the neostriatum
(caudate nucleus and putamen), where the loss of dopaminergic input has its impact. In
brief, the loss of dopaminergic input from the SNpc to the putamen results in a disruption
of the usual harmony between the two dynamic loops that pass through it, resulting in
unopposed inhibition of the thalamus. This inhibition of the thalamus leads to insuffi-
cient glutamatergic thalamocortical input and resultant parkinsonism. Presumably, the
loss of SNpc dopamine may affect other frontosubcortical loops (Alexander, Delong, &
Strick, 1986) in addition to the motor loop leading to other components of the disease,
such as bradyphrenia, executive dysfunction, and personality/mood changes.
It should be noted that the loss of dopamine in PD is not the sole pathophysiological
mechanism, and further, that PD is heterogeneous in its pathophysiology and resultant
clinical presentation. In frankly demented PD patients, pathophysiological mechanisms
include comorbid AD pathology, diffuse Lewy body disease, degeneration of other
subcortical projection nuclei (locus coeruleus, nucleus basalis of Meynert) or any combi-
nation of the above. Obviously, the dementia syndrome is not always the same in PD-D
patients, given the heterogeneity of the underlying neuropathology. In fact, approxi-
mately one third of all PD patients develop a dementia of the AD type or AD-D (Levy &
Cummings, 2000; Salmon, Heindel, & Hamilton, 2001). Whereas approximately 33% of
patients with PD have Alzheimer’s pathology, a greater number of patients with PD-D
have dementia that is not attributable to Alzheimer pathology. The prototypical neuro-
psychological profile of PD-D without AD differs from AD and is the focus of the next
section.
The frequency of depression in PD is high and is more common in patients diagnosed
with PD-D. Thirty to fifty percent of PD patients will develop symptoms of depression. Di-
agnosis of depression in PD is complicated by the fact that anergia, motor retardation, and
early awakening can occur in PD patients with or without depression. Anxiety disorders are
present in 30–40% of PD patients, with simple phobia the most common subtype, then
panic disorder, and then social phobia. These mood and anxiety disorders may be due to
neuronal cell loss in noradrenergic and serotonergic nuclei. Another hypothesized mecha-
nism is reduced dopaminergic stimulation of the orbitofrontal cortex, the primary source of
cortical input to brain stem serotonergic nuclei (Levy & Cummings, 2000).
Family history of PD or essential tremor and increasing age are two risk factors for
PD. Exposure to pesticides or heavy metals is another postulated risk factor. Conversely,
cigarette smoking and diets rich in vitamin E have been associated with reduced risk of
PD (Tanner & Goldman, 1996). Risk factors for dementia in PD include older age at on-
set, longer disease duration, and greater severity of motor symptoms (Glatt et al., 1996;
Marder, Tang, Cote, Stern, & Mayeux, 1995).
With the caveat that mild cognitive compromise is more common than dementia in PD,
deficits are typically observed in the broad domains of frontal or executive functions and
memory retrieval. In addition, bradykinesia (psychomotor slowing) and bradyphrenia
(slowed thinking), as evidenced by slowed psychomotor speed and reaction times, are the
most common aspects of cognitive dysfunction present even in nondemented PD patients
(PD-ND).
Executive Functions
Problems with self-directed generation (e.g., verbal/design fluency), maintenance of set
(e.g., Wisconsin Card Sorting Test [WCST]), slowness in set shifting (e.g., WCST; alter-
nating motor programs; serial hand sequences), concept formation (e.g., Matrices;
WCST, Category Test), and cognitive tracking and flexibility are often seen in PD (Duke
& Kaszniak, 2000). With regard to attentional functioning, there is evidence that the def-
icit in attention observed in PD patients differs from that of patients with frontal pathol-
ogy alone: Patients with frontal-lobe lesions may have relatively greater difficulty with
disengaging attention, whereas PD patients may show greater difficulty in maintaining
and reengaging a cognitive set (Partiot et al., 1996).
Memory
The typical memory profile in PD involves a deficit in short-term memory for novel,
supraspan information across verbal and visual domains. This deficit is observed in mini-
mal recall of units of information, but without the commission of intrusions during re-
call. Delayed recognition performances are better, indicative of some level of intact en-
coding and long-term storage. Semantic memory tends to remain intact (Brown &
Marsden, 1990; Dubois, Boller, Pillon, & Agid, 1991; Raskin, Borod, & Tweedy, 1990;
Taylor & Saint-Cyr, 1995).
Language
Language deficits may include reduced phrase length and output. Word- finding problems
are also common. Reduced word-list generation is often observed, the most common pat-
tern of findings reports better performance generating items from semantic categories
than words beginning with a specific letter. However, this pattern of better semantic than
lexical generation continues to be debated in the literature (Piatt, Fields, Paolo, Koller, &
Tröster, 1999). Presumably, an underlying retrieval deficit contributes to difficulties in
word generation.
Other Neurocognitive Deficits

Visuospatial deficits observed in patients with PD are shown to worsen with severity of
rigidity and bradykinesia. Some argue that underlying problems of motor and executive
dysfunction contribute to visuospatial deficits. This multifactorial view of visuospatial

deficits in PD has been discussed elsewhere (Lezak, 1995).
Variants
Variants of the pattern of neuropsychological deficits associated with PD have been re-
ported. For example, the scope of cognitive deficits in some PD patients includes such
“cortical” features as aphasia, amnesia, agnosia, and apraxia. In these cases, the presence
of cortical Lewy bodies, Alzheimer pathology, or both may contribute to a dementia with
mixed “cortical” and “subcortical” features (Levy & Cummings, 2000).
Course of Cognitive Decline

A limited number of studies has begun to disentangle the type and severity of cognitive
deficits in patients with clinical manifestations consistent with PD who do not have de-
mentia (PD-ND) versus those associated with PD-D. First, sustained and selective atten-
tion is intact in early stages (Duke & Kaszniak, 2000; Pillon, Dubois, Ploska, & Agid,
1991) but impaired in PD-D. Second, performance on tests of novel problem solving de-
clines as a function of disease progression (Duke & Kaszniak, 2000). Piatt et al. (1999)
found that whereas a PD-D group of patients performed more poorly on three verbal flu-
ency tasks (lexical, semantic, and action), compared to normal controls and a PD-ND
group, the disparity between the PD-ND and PD-D groups was largest for the measure of
action fluency. Thus impaired action fluency may be an especially sensitive indicator of
the conversion from PD-ND to PD-D. This finding is certainly of interest in light of the
action semantics literature that ascribes specificity of the frontal lobes in semantic pro-
cessing of action information (e.g., Damasio & Tranel, 1993; Hauk, Johnsrude, &
Pulvermüller, 2004; Pulvermüller, 2001). Finally, in a longitudinal study Woods and
Tröster (2003) found that patients with PD who were classified with PD-D the following
year performed consistently worse on some neurocognitive measures than patients who
retained a diagnosis of PD-ND the following year. The measures that discriminated be-
tween these two groups were Digits Backward from the Wechsler Memory Scale—Re-
vised; word-list learning (trials 1–5) and delayed recognition discriminability from the
California Verbal Learning Test; and perseverative errors on the Wisconsin Card Sorting
Test. These differences among PD patients with and without dementia suggest a gradual
decline of neurocognitive functioning predictive of the onset of dementia.
VASCULAR DEMENTIA
Until recently, the heterogeneity of pathology leading to vascular dementia (VaD) was less
well recognized, and VaD was thought to be caused by multiple large-vessel ischemic
damage. It is now recognized that different forms of VaD can arise from a variety of vas-
cular events involving large and/or small vessels and hemorrhagic or ischemic damage.
The magnitude and type of cognitive impairment that follows a neurovascular event gen-
erally are associated with the location and amount of affected tissue. Findings consistent
with focal brain lesion are often seen early in the course of VaD, such as mild motor or
sensory deficits, visual field cut, bulbar signs such as dysarthria and dysphagia, extra-
pyramidal signs such as rigidity and akinesia, or gait disorder (Roman et al., 1993). Man-
ifestation of neurological signs is, of course, dependent on location and extent of tissue
affected.
VaD can be further categorized by the extent of cortical versus subcortical involve-
ment. In cortical VaD, sensorimotor changes often occur, along with abrupt onset of cog-
nitive impairment, including aphasia if the language-dominant hemisphere is affected. In
subcortical VaD, pure motor hemiparesis may occur, along with bulbar signs and
dysarthria. Some small infarcts remain clinically “silent,” especially in the case of
subcortical white matter ischemic events. An accumulation of subcortical white matter
events can lead to dementia, referred to as subcortical ischemic vascular disease (SIVD).
SIVD follows from occlusion of the deep penetrating arteries and arterioles that feed the
basal ganglia, the thalamus, the internal capsule, and subcortical white matter. Overall, in
most cases of vascular origin, size of impacted tissue relates to severity of overall cogni-
tive impairment (Paul et al., 2000).
Typically, VaD is characterized by a relative abrupt onset (days to weeks), stepwise
deterioration (some recovery after worsening), and fluctuating course of cognitive func-
tions. Notably, this pattern can be seen with repeated lesions that affect cortical and
corticosubcortical brain structures, with large vessel multi-infarct VaD, and with water-
shed infarcts. In contrast, in patients with small-vessel dementia, such as SIVD, onset is
relatively insidious and the course is more slowly progressive (Chui et al., 1992; Leys,
Englund, & Erkinjuntti, 2002; Roman et al., 1993).
VaD is second only to AD in prevalence: from 10 to 50% of all dementia cases, de-
pending on geographic location, population, and criteria used (Leys et al., 2002). Among
the subtypes of VaD, SIVD may represent the most common form (Paul et al., 2001). In
the United States, the reported prevalence of VaD in people 65 years and older is 2.8%.
Generally, with increasing age the prevalence doubles every 5 years. Stroke patients have
increased risk of dementia: 1 year after stroke the probability of new-onset dementia is
5.4% in patients over 60 years and 10.4% in patients over 90 years (Leys et al., 2002).
Incidence rates of dementia among patients with cerebrovascular disease are complicated
by vastly different rates of sensitivity and specificity for the diagnosis of VaD among the
common diagnostic criteria used (Gold et al., 2002).
Several sources of diagnostic criteria are widely used to diagnose VaD, all developed
by consensus: the DSM-IV (American Psychiatric Association, 1994), the International
Classification of Diseases (ICD-10; World Health Organization, 1992), the State of Cali-
fornia Alzheimer’s Disease Diagnostic and Treatment Centers (ADDTC; Chui et al.,
1992), and the National Institute of Neurological and Communicative Disorders and
Stroke–Association Internationale pour la Recherche et l’Enseignement en Neurosciences
(NINCDS–AIREN) criteria (Roman et al., 1993). The literature abounds with articles on
the inconsistency in the diagnosis of VaD (e.g., Chui et al., 2000; Wetterling, Kanitz, &
Borgis, 1996). Contributing factors include different criteria for dementia among the ma-
jor classification systems, different conceptualizations of how to establish a vascular eti-
ology for dementia, and the heterogeneity of possible etiologies within VaD. Recently,
Gold et al. (2002) compared the sensitivity and specificity of these most commonly used
diagnostic criteria against the “gold standard” of neuropathological diagnosis with au-
topsy. Their findings indicated that the criteria are not interchangeable due to their differ-
ent emphases and levels of sensitivity and specificity. They found that the ADDTC criteria
for possible VaD are the most sensitive for detection (.70), whereas the DSM-IV and the
NINDS–AIREN criteria for possible VaD are more effective in excluding mixed demen-
tia. The NINDS–AIREN criteria are currently the most widely used in clinical drug trials
on VaD. In general, criteria for VaD must recognize the heterogeneity of the syndrome
and the variability in clinical course. Also important is the relationship between lesion
and cognition, as well as the temporal relationship between vascular event(s) and demen-
tia onset.
Attendant Data
Focal brain infarcts visible by computed tomography (CT) or magnetic resonance imag-
ing (MRI) are found in 70–100% of VaD cases (Leys et al., 2002). MRI, although more
costly, is the preferred imaging modality due to greater sensitivity. T1-weighted images
provide sharper anatomic resolution. However, T1-weighted images can underestimate
the extent of damage relative to T2-weighted, or FLAIR, images, which reveal changes in
water content, provide good visualization of white matter lesions and smaller infarcts,
and allow visualization of perilesional tissue. Single-photon emission computed tomogra-
phy (SPECT) and positron emission tomography (PET) can also be beneficial in charac-
terizing tissue affected by vascular events. For example, a patchy, multifocal reduction of
regional cerebral blood flow and metabolism is often seen in VaD. In addition, cortical
infarcts are visible by areas of absent blood flow, and diffuse white matter change can be
inferred with either generalized cortical reduction in blood flow or, in the case of
subcortical white matter changes at the level of the basal ganglia, reduced cortical blood
flow primarily to the frontal lobes (O’Brien & Barber, 2000). Finally, diffusion-weighted
MRI can reveal ischemia of recent onset and can differentiate chronic from acute infarcts
(Choi et al., 2000).
Most classification criteria require (ADDTC, NINDS–AIREN) or recommend (ICD-
10, DSM-IV) evidence of relevant cerebrovascular disease by brain imaging in order to
classify dementia etiology as vascular. Visible by structural neuroimaging are large-vessel
strokes, single strategically placed infarcts (e.g., in the angular gyrus, thalamus, basal
forebrain, posterior cerebral arteries (PCA), or anterior cerebral arteries (ACA) territo-
ries), multiple basal ganglia and white matter lacunes, and extensive periventricular white
matter lesions. Any of the latter observations (or combination of some of the latter) pro-
vides evidence that could be consistent with an etiological basis of VaD (Choi et al.,
2000). Risk factors for VaD include hyperlipidemia, hypertension, diabetes mellitus, car-
diac abnormality or disorder, carotid bruit, and hematocrit level over 45%. Psychiatric
comorbidity with VaD can include depression, anxiety, and emotional lability, among
other psychiatric symptoms. Depression, emotional lability, and psychomotor retardation
frequently accompany subcortical VaD (Leys et al., 2002).
Second only to AD, the movement to provide a diagnostic label for mild cognitive
changes below the threshold of dementia is underway for VaD (e.g., Bowler, 2000;
Bowler & Hachinski, 1995; Hachinski, 1994; Hachinski & Bowler, 1993; Meyer, Xu,
Thornby, Chowdhury, & Quach, 2002). In fact, in a recent Canadian study examining
epidemiology of vascular cognitive impairment, vascular cognitive impairment without
dementia (sometimes referred to as vascular CIND) was found to be the most prevalent
form compared to VaD and AD with a vascular component (Rockwood et al., 2000).
Some even argue that the term dementia never aptly describes the cognitive sequelae asso-
ciated with vascular changes in the brain (Bowler, 2000). A basis for this argument is that
the memory deficits associated with VaD are different qualitatively and quantitatively
from those that characterize AD. Because cerebrovascular disease does not preferentially
affect the mesial temporal lobe, as is the case with AD, encoding problems, a hallmark of
AD, are usually absent in VaD, as evidenced by normal delayed recognition dis-
criminability for verbal and nonverbal material (for review of cognitive impairments in
AD vs. VaD, see Looi & Sachdev, 1999). Although the VaD memory profile generally
conforms to a frontosubcortical pattern, the neuropsychological sequelae vary by size
and location of lesion. Thus a neurocognitive profile similar to AD can follow from vas-
cular etiology.
Much work has been done in describing the syndromes that accompany large-vessel
cortical strokes (such as aphasias, apraxias, and neglect). A growing but more recent lit-
erature is beginning to characterize the neuropsychological profile associated with SIVD.
The neuropsychological profile associated with SIVD has been likened to that of the
frontosubcortical dementia profile (for review, see Libon et al., 2001; see also Moser et
al., 2001; Yuspeh, Vanderploeg, Crowell, & Mullan, 2002). Overall, the pattern of cog-
nitive difficulties resulting from subcortical ischemic change includes memory impair-
ment (retrieval rather than encoding deficits), prominent psychomotor slowing, and exec-
utive deficits. This pattern of cognitive difficulties presumably arises in response to a
disruption of frontosubcortical circuits; and this pattern is quite similar to that of PD
(Paul et al., 2001).
ALCOHOLIC DEMENTIA
Alcoholic dementia refers to a profound and global cognitive decline following long-term
alcoholism. Alcoholic dementia bears many similarities to the Wernicke–Korsakoff syn-
drome. Briefly, the Wernicke–Korsakoff syndrome is a two-phase disease that begins with
Wernicke encephalopathy involving a triad of acute symptoms: global confusion, gait
ataxia, and ocular abnormalities. This encephalopathy results from thiamine deficiency
secondary to malnutrition associated with prolonged alcohol use (Victor, Adams, & Col-
lins, 1989). Subsequent to this encephalopathy, 84% of patients develop alcoholic
Korsakoff (AK) syndrome. The hallmarks of the AK syndrome include severe antero-
grade amnesia of declarative knowledge (Butters & Cermak, 1980) and a temporally
graded retrograde amnesia, with better recall for remote than for recent events (Squire &
Cohen, 1984). Another clinical feature is marked confabulation, exhibited often during
memory testing (Delis, 1989).
Prevalence rates of alcoholic dementia vary greatly due to difficulty with differentia-
tion between alcoholic dementia and individuals with the AK syndrome. Furthermore, it
has been demonstrated that continued abstinence after chronic alcohol abuse can lead to
at least a partial reversal of neuropsychological (e.g., Brandt, Butters, Ryan, & Bayog,
1983; Fabian & Parsons, 1983; Grant, Adams, & Reed, 1986) and even neuro-
pathological changes (e.g., Artmann, Gall, Hacker, & Herrlich, 1981; Carlen, Wortzman,
Holgate, Wilkinson, & Rankin, 1978). Many call into question the validity of an “alco-
holic dementia” classification. For example, the ICD-10 does not include a category for
alcoholic dementia. Many recent studies that examine alcohol abuse and the prevalence
of dementia have not included alcoholic dementia as one of the primary subtypes (e.g.,
Ruitenberg et al., 2002; Truelsen, Thudium, & Grønbæk, 2002), but rather report preva-
lence of AD, VaD, and “other dementia” as primary subtypes of dementias that occur in
chronic alcoholics.
Some studies do include a subtype of “cognitive impairment no dementia” (CIND)
secondary to chronic alcohol use (e.g., Thomas & Rockwood, 2001). One study that spe-
cifically examined the prevalence of alcoholic dementia reported rates of 7.6% of alco-
holic men and 14.3% of alcoholic women based on 1,000 alcoholic patients examined in
Melbourne, Australia (Wilkinson, Kornaczewski, Rankin, & Santamaria, 1971).
Attendant Data
Potential pathophysiological mechanisms for alcoholic dementia include a direct toxic
effect of ethanol (Mann et al., 2001) leading to cortical atrophy (especially reduced white
matter volume). Signs of cortical atrophy include ventricular enlargement and sulcal wid-
ening as well as atrophy of the cerebellum. Punctate hemorrhagic lesions at the level of
the diencephalon and brain stem may also be present (e.g., Jernigan et al., 1991; Kril,
Halliday, Svoboda, & Cartwright, 1997). Affected subcortical structures implicated in
the amnesia of the AK syndrome and of alcoholic dementia include the basal forebrain
nuclei, the mammillary bodies, and the dorsomedial nucleus of the thalamus (Salmon,
Butters, & Heindel, 1993).
Alcoholic dementia consists of an anterograde amnesia as severe as that associated with
the AK syndrome (Longmore & Knight, 1988). In addition to the memory deficit, in con-
trast to the AK syndrome, are more global neurocognitive deficits, including conceptual
and problem-solving impairments, and deficits of visuospatial abilities and visuo-
construction. Furthermore, blunted affect, apathy, inertia, impaired judgment, and
bradykinesia are associated with alcoholic dementia.
DEMENTIA DUE TO HEAD TRAUMA AND DEMENTIA PUGILISTICA
According to a consensus development panel on rehabilitation (National Institutes of

Health, 1999), approximately 70,000–90,000 individuals incur traumatic brain injury
(TBI) each year at a severity level resulting in long-term significant loss in physical and
mental functioning. The DSM-IV-TR criteria for dementia due to head trauma, which re-
quires the presence of memory impairment and/or other cognitive disturbances that cause
significant impairment in social or occupational functioning, can apply to many individu-
als who have had TBIs. On the other hand, many TBI patients eventually return to gain-
ful employment. Recently León-Carrión (2002) argued that dementia secondary to TBI
should be differentiated from moderate or severe TBI because the severity and functional
impact of the deficits may be rehabilitated in the latter cases. On the other hand, a longi-
tudinal study of long-term outcomes of individuals following severe TBI 10–20 years
postinjury (Hoofien, Gilboa, Vakil, & Donovick, 2001) revealed that the impact of this
level of injury is chronic. Among the most frequent long-term sequelae of severe trau-
matic brain injury are high rates of depression and other psychiatric symptoms,
psychomotor slowness, slowed processing speed, and loneliness/social withdrawal. Thus,
although it is still debated how often even severe TBI should be conceptualized as demen-
tia, most cases of severe TBI do sustain long-term sequelae that require ongoing treat-
ment and caregiver support.
Dementia due to head trauma is considered stable, or nonprogressive; the possibility
of a slowly progressive dementia due to repeated head injury is also recognized and re-
ferred to as dementia pugilistica (DP). DP, caused by repeated blows to the head, is most
frequently studied with regard to sports-related injuries; however, DP could conceivably
occur from other circumstances (e.g., chronic physical abuse). A recent review of findings
regarding DP in sports (Erlanger, Kutner, Barth, & Barnes, 1999) revealed that mild cog-
nitive deficits exist far more frequently than dementia following sports-related head inju-
ries. Risk factors for DP include level of exposure to head injuries (e.g., length of profes-
sional boxing career; amateur vs. professional) and number of concussions. Early
detection of DP is critical for better outcomes in this population. Clinical use of
neuropsychological data to advise professional boxers, for example, should be considered
because this group is at great risk for DP.
Historically, DP has been associated with a “Parkinsonian” pattern of decline, with
noted clinical observations of tremor in the head and/or upper extremities. Cognitive im-
pairments affect memory performances and result in reduced psychomotor speed,
dysarthria, and behavioral or personality changes. Underlying brain damage includes dif-
fuse axonal injuries, shearing, intra- and extracerebral hemorrhages, and edema. Neuro-
pathological characteristics associated with DP include cerebral atrophy, the presence of
neurofibrillary tangles in cortical and subcortical areas, reduced cholinergic activity in the
basal forebrain, and diffuse presence of beta-amyloid plaques. Presence of the apolipo-
protein E epsilon-4 allele has been identified as a potential genetic risk factor for develop-
ing DP during a career of boxing (Jordon et al., 1997). Conversely, Lye and Shores
(2000), in a review article, cite a great deal of convergent evidence that TBI increases risk
for AD.
CONCLUSIONS
This review of current information about the clinical and neuropsychological characteris-
tics of a number of stable and slowly progressive dementias highlights several future
directions in geriatric neuropsychological assessment. First, our current classification sys-
tem does not adequately take advantage of the sensitivity of neuropsychological assess-
ment measures. Neuropsychological assessment provides domain-specific (e.g., verbal
memory, visual memory, executive functions, language) information about relative
strengths and weaknesses in neurocognition. In addition, a neuropsychological assess-
ment provides information about the level of impairment within each domain. Although
neuropsychological assessments already provide both types of information, current classi-
fication systems do not adequately take into account level of neurocognitive impairment.
Level of deficit severity within and across cognitive domains should be systematically
considered to make an empirically valid determination about whether that level is more
consistent with dementia or a designation of MCI. Creating a modified classification sys-
tem in which severity designations are operationalized (e.g., in MCI, by standard devia-
tion from the average performance in a normative group) would be one giant step toward
more accurate identification of neurocognitive status and improved diagnostic accuracy
in geriatric populations. The work of broadening MCI to dementias other than Alzhei-
mer’s is already underway (e.g., Petersen, 2004).
Study and better characterization of the course of these slowly progressive dementias
would provide an excellent service to patients and clinicians. Development of diagnostic
labels to capture prodromal stages of neurocognitive decline in slowly progressive
dementias could lead to a variety of benefits to the patient, including early detection and
intervention. Furthermore, classification of cognitive deficits as mild in patients whose
deficits do not yet meet criteria for dementia will foster increased well-being and auton-
omy. Conversely, the diagnosis of, for example, MCI secondary to PD or SIVD would
alert the clinician to the possibility of future cognitive decline to a severity level that may
later merit a diagnosis of dementia.
An interest in improved classification of stages of neurocognitive decline will lead to
better characterization of the prodromal phase of each dementing illness, increasing our
accuracy in detection at ever earlier stages. Of great importance, earlier detection pro-
vides a greater window of opportunity for rehabilitative treatments, the focus of the sec-
ond half of this volume.
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5
Potentially Reversible Cognitive

Symptoms in Older Adults
WES S. HOUSTON
MARK W. BONDI
T he identification of “reversible” or “treatable” causes of dementia is a common part of

any clinical and/or medical investigation. As such, the practice of “ruling out” reversible
cognitive decline is routine in the various neuropsychological and neurology practica and/
or supervision settings. But how common are reversible dementias? To what extent do
they actually reverse? Which dementing disorders are most likely to reverse, given the ap-
propriate treatment? The primary focus of this chapter is to review the literature on vari-
ous medical conditions with neurological and cognitive consequences that are commonly
identified as being reversible or treatable.
For the past three to four decades researchers and clinicians alike have sought to
identify medical conditions that are potentially reversible causes of intellectual and gen-
eral cognitive decline (Freemon & Rudd, 1982; Ovsiew, 2003). Widely differing results
(ranging from less than 1% to approximately 30%) have emerged from the numerous
studies examining the frequency with which dementing conditions have been shown to be
treatable. For example, an early paper by Marsden and Harrison (1972) reported that, of
84 patients admitted to the hospital with a diagnosis of dementia, a treatable condition
was found in approximately 15% of patients. Another investigation by Freemon (1976)
found that approximately 30% of patients with progressive intellectual decline had po-
tentially reversible symptoms. This finding of a high prevalence in the treatability of de-
mentia was commonplace in the 1970s and 1980s (see also Smith, Kiloh, Ratnavale, &
Grant, 1976; Larson, Reifler, Featherstone, & English, 1984).
However, more recently—in the 1990s and 2000s—studies have generally reported a
dramatic decrease in the prevalence of reversible or treatable dementias. Most investiga-
tions on the topic have concluded that the rate of reversibility of dementia is very low,
ranging from less than 1% to about 4% (Burke, Sengoz, & Schwartz, 2000; Freter, Berg-
man, Gold, Chertkow, & Clarield, 1998; Walstra, Teunisse, van Gool, & van Crevel,
103
1997). These more recent studies tended to examine a sample of consecutive referrals to
memory disorder clinics, then retrospectively identify and treat those who had potentially
treatable conditions (e.g., vitamin B12 deficiency, depression, normal-pressure hydroceph-
alus) and judge, either clinically or with standardized tests, the level of improvement in
cognitive and functional status. As an example, Walstra, Teunisse, van Gool, and van
Crevel (1997) found that 45 of 176 demented patients referred to their clinic were viewed
as having potentially reversible conditions, but none had a complete remittance and only
one was determined to show substantial functional improvement (i.e., an individual who
had depression with epilepsy). Five other individuals were regarded as improved based on
clinical follow-up examination after treatment, but formal assessment did not confirm
this subjective improvement. Thus Walstra et al. (1997) found a reversibility rate of ap-
proximately 0.6%. This low rate among clinic-based samples does not appear to be an
unusual finding in the literature.
There are a number of potential reasons for the vastly different findings in dementia
reversibility rates over the past few decades. One reason is the broad heterogeneity in the
patient populations included in the literature. Of particular import may be the variability
in cognitive impairment, ranging from mild deficits to severe intellectual decline. Accord-
ingly, some studies have included only outpatients—with presumably milder disorders—
whereas others have examined only severely impaired hospitalized patients. The wide-
ranging level of impairment across studies leads to another related methodological difference:
the use of different diagnostic criteria for dementia. The term dementia has been applied
quite loosely across studies; some studies included individuals with depression and nutri-
tional deficiencies, whereas other investigations evaluated patients with primary progres-
sive dementias such as Alzheimer’s disease (AD). We should expect to find different rates
of treatment success when examining such heterogeneous patient groups. Important
methodological differences have also extended to the specific cognitive assessment instru-
ments utilized to evaluate patients’ cognitive status. Although some studies administered
only a brief general cognitive screening measure (e.g., the Mini-Mental State Examination
[MMSE]) to estimate gross functional status, others employed formal, comprehensive,
neuropsychological assessment batteries that are aimed at evaluating disparate cognitive
functions. It could be argued that broad-based, relatively easy measures might be insensi-
tive to changes following treatment, whereas very specific tests may have an increased
likelihood of identifying a cognitive change.
Other factors also may have led to the contrasting findings in the rates of reversibil-
ity of cognitive decline, such as the use of individual case studies versus well-controlled
clinical trials. Furthermore, there may be critical periods in the progression of some of the
medical conditions, such that once a threshold has been crossed all attempts at reversibil-
ity are futile. In addition, the rates of treatment likely depend on the specific disorder be-
ing treated. Thus different medical conditions should not be lumped together in studies.
Finally, as noted by Ovsiew (2003), perhaps the findings of abnormal laboratory tests are
incidental. That is, some individuals may have had AD as well as an inconsequentially
low vitamin deficiency or hypothyroidism. In such cases, treatment of the ancillary condi-
tion should have little effect on patients’ overall cognitive functioning.
Given the myriad factors that cloud our ability to identify the true rate of reversibil-
ity of various medical conditions, we limited the scope of this chapter in the following
two ways. First, because this volume is dedicated to the assessment and management of
geriatric disorders, we confined our discussion of disorders to those which older adults
are prone, despite the fact that many of the following conditions/diseases also occur in
Potentially Reversible Cognitive Symptoms 105
younger individuals (e.g., congenital hypothyroidism, normal-pressure hydrocephalus

from secondary causes, medication side effects). Second, because many of the conditions
discussed below do not frequently lead to dementia, as defined either by the National In-
stitute of Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease
Related Disorders Association (NINCDS–ADRDA) criteria (McKhann et al., 1984) or
DSM-IV criteria (American Psychiatric Association, 1994), rather than refer to the condi-
tions as reversible or treatable dementias, we prefer to discuss them in terms of potential
amelioration of the cognitive symptoms that are commonly associated with the particular
treatable conditions.
What follows is a review of the research on the neuropsychological effects of a vari-
ety of medical conditions often described as being reversible following proper treatment,
including normal-pressure hydrocephalus, hypothyroidism, vitamin deficiencies (B12 and
thiamine), depression, sleep-disordered breathing (obstructive sleep apnea), and medica-
tion effects. These are only a subset of the many conditions with potential cognitive con-
sequences in older adults; however, they represent some of the more commonly occurring
conditions as well as those that are discussed most frequently as being “reversible.”
NORMAL-PRESSURE HYDROCEPHALUS
Description and Prevalence
Normal-pressure hydrocephalus (NPH), first described by Hakim and Adams (1965), is
among the most commonly reported neurological syndromes to be referred to as a treat-
able or reversible form of cognitive decline. Although NPH has been observed in young
adults and even children, it most typically affects adults over age 60 (Vanneste, 2000).
However, it accounts for only a small fraction (less than 5%) of dementia cases, and the
majority of cases are a result of secondary known sources such as subarachnoid hemor-
rhage and head trauma (Heidebrink, 2003; Katzman, 1977). A review 914 cases of NPH
by Katzman (1977) found that only 34% were idiopathic.
Etiology
The specific cause of NPH remains unclear, although it is commonly believed that the
condition results from impaired cerebrospinal fluid (CSF) absorption at the arachnoid
villi (Miller & Adams, 1992). This explanation, however, has been challenged by the
finding that such stagnation in the villi would not lead to the pressure gradient between
the intra- and extraventricular spaces that is necessary to produce the ventricular dilata-
tion characteristically observed in NPH (Ekstedt & Fridén, 1984). A more recent expla-
nation for the pathophysiology of NPH refers to a “suprasylvian subarachnoid block”
that suggests impaired CSF flow within the subarachnoid space over the convexity and
medial hemisphere surface (Adams, Victor, & Ropper, 1997).
Cognition
The most common characteristic features of NPH include the triad of impaired (mag-
netic) gait, sphincter dysfunction, and mental deterioration. The gait disturbance, typi-
cally the first symptom to appear, can be quite variable, ranging from ataxic and wide-
based to difficulties in initiation of walking and shuffling with frequent falls (Vanneste,
2000). Urinary incontinence tends to occur only late in the course of NPH, but urinary
urgency is often present throughout the disorder (Corkill & Cadoux-Hudson, 1999).
The cognitive features of NPH are quite variable and can advance to meet the diag-
nostic criteria of dementia, but the course of mental decline is usually slowly progressive
over months to years, with more severe deficits being likely with a longer duration. Rela-
tively few studies have investigated cognitive patterns of functioning using a standardized
and quantitative method. Memory complaints appear common, although a review of the
literature suggests that a “subcortical” pattern of deficits is associated with NPH. That is,
NPH patients tend to show relatively mild inattentiveness and poor initiation, with
slowed mental processes as well as apathy and emotional indifference (Heidebrink,
2003). In addition, a number of studies have found evidence of deficits on measures typi-
cally associated with frontal-lobe functioning as well as relatively better recognition
memory compared with rather poor delayed recall (Caltagirone, Gainotti, & Masullo,
1982; Gustafson & Hagberg, 1978; Heidebrink, 2003; Iddon et al., 1999; Thomsen,
Borgeson, Bruhn, & Gjerris, 1986). In another study, Stambrook et al. (1988) noted more
severe dementia, with deficits occurring in most areas measured, including motor speed,
attention/concentration, immediate and delayed recall for verbal and visual material, and
visuomotor sequencing/set shifting.
Treatment
The typical method of managing NPH involves the periventricular shunt procedure, and
successful procedures have been documented (Bech-Azeddine et al., 2001; Sekhar,
Moody, & Guthkeich, 1982). However, numerous significant risks are associated with
shunting, including subarachnoid hemorrhage, infections (e.g., meningitis), aqueductal
stenosis, blocked shunts, and mechanical shunt failures. Thus physicians (and patients)
must strike a balance between monitoring the progression of the cognitive effects associ-
ated with NPH and risking complications from the surgical procedure. In general, good
candidates for shunting include those who show gait disturbance predating mental de-
cline, a brief history of cognitive decline, and substantial clinical improvement following
CSF taps. Factors that appear to be suggestive of poor clinical outcome following shunt-
ing include severe dementia, presence of dementia predating the gait disturbance, and sig-
nificant cerebral atrophy or white matter lesions (Heidebrink, 2003; Vanneste, 2000).
Assessing the actual reversibility of the cognitive impairment in NPH has been prob-
lematic, given that the surgical literature often does not utilize standardized neuro-
psychological tests (either preshunting or following the procedure). Often only physi-
cians’ ratings of change and/or quality of life indicators are employed (Stambrook et al.,
1988). However, in general the literature suggests that there is broad variability (ranging
from 30 to 80%) in the extent to which an individual will improve significantly, let alone
show complete recovery, following surgical treatment (Alexander & Geshwind, 1984;
Thomsen et al., 1986; Vanneste, 2000). It appears that some of the variability in
postshunting improvement rate is explained by the etiology of the NPH—with secondary
NPH patients having a better chance of significant cognitive improvement compared to
those with idiopathic NPH (Stambrook et al., 1988; Thomsen et al., 1986; Vanneste,
2000).
Klinge et al. (2002) examined the neuropsychological profiles of NPH patients
preshunting as well as at 1 week and 7 months following a shunting procedure. They
found that early outcome scores on measures of visual attention and visuomotor preci-
sion (i.e., line tracing) were most predictive of long-term improvement after shunting.
Nonresponsiveness to the shunt procedure was associated with no improvement (actu-
ally, a decline) in verbal (word-list) recall early after the surgery. In another neuro-
psychological study, Thomsen et al. (1986) measured a variety of cognitive abilities both
prior to and following shunting. An examination of pre–post cognitive functioning found
that 40% of the sample of 40 patients showed improved cognition, whereas 48% were
unchanged and 12% actually deteriorated.
To summarize, although the cognitive and behavioral pattern of NPH can be variable,
in general, the most common findings are gait disturbance, urinary urgency/incontinence,
and mental decline. Specific areas of cognitive decrement include retrieval, executive
skills, attention, and visuomotor sequencing abilities. With regard to other neuropsy-
chological skills, it is rare to see memory consolidation, language, and visuospatial defi-
cits. The rate of improvement also varies widely, but, not surprisingly, better outcome is
associated with a shorter duration of illness, milder cognitive deficits, prominence of gait
disturbance over cognitive decline, and less cortical atrophy on imaging studies.
HYPOTHYROIDISM
Although many of the endocrine disorders can have noteworthy effects on cognitive abili-
ties, hypothyroidism is one of the more commonly observed that leads to impaired cogni-
tion. Hypothyroidism can occur at any time during the lifespan; however, for this chapter,
we are interested in adult-onset hypothyroidism, particularly in older adults, in whom the
symptoms could possibly be mistaken for a progressive dementing disorder. In terms of
prevalence of this disorder, Luboshitzky, Oberman, Kaufman, Reichman, and Flatau
(1996) reported that hypothyroidism increases with age to around 14% in older adults.
Because of its prevalence, recent practice parameter recommendations suggest routine
screening for hypothyroidism in any dementia workup (Knopman et al., 2001).
Etiology
Thyroid-stimulating hormone (TSH) is secreted by the pituitary gland, which regulates
the thyroid gland. In response to levels of TSH the thyroid gland releases thyroxine (T4),
among other hormones. TSH and T4 operate as a negative feedback system such that in-
creases in T4, in response to secreted TSH, decreases pituitary secretion of TSH, and vice
versa. However, in hypothyroidism, malfunction of this system occurs for any number of
reasons. If blood levels of TSH are elevated but T4 is in the normal range, the condition is
referred to as subclinical hypothyroidism. If T4 is abnormally low, the condition is re-
ferred to as overt hypothyroidism or primary hypothyroidism caused by dysfunction of
the thyroid gland (Smith & Granger, 1992).
Cognition
Hypothyroidism is most well known for its associated features of depression, lethargy,
dry skin, and feeling cold (Dugbartey, 1998); however, it is the related cognitive symp-
toms that are of import here. Many clinical case reports and well-controlled experimental
studies have sought to elucidate the specific pattern of cognitive impairments that has
been linked to hypothyroidism. The variety of different causes and ranges of severity of
the disorder lead to wide variability in reported cognitive symptoms. Whereas most stud-
ies of this disorder have assessed limited cognitive domains, taken together, studies gener-
ally report deficits in memory, visuomotor processing, and visuospatial and visuocon-
structional skills (Dugbartey, 1998; Haggerty, Evans, & Prange, 1986; Mennemeier,
Garner, & Heilman, 1993; Osterweil et al., 1992; Whybrow, Prange, & Treadway,
1969). In contrast, neurocognitive skills such as sustained attention, language, and verbal
fluency as well as gross motor abilities have been consistently reported as being intact
(Mennemeier et al., 1993; Osterweil et al., 1992).
Some research on subclinical hypothyroidism suggests that cognitive deficits may
also be present in this milder form of the disorder. For example, Baldini et al. (1997)
found that control subjects outperformed subclinical patients on a measure of verbal
memory. Conversely, Luboshitzky et al. (1996) did not find evidence of cognitive deficits
(on the MMSE) in their sample of mild, untreated hypothyroidism patients. Still, it has
been pointed out that this variant of the disorder may show the same clinical picture as
overt or primary hypothyroidism (Morganti et al., 2002). Furthermore, a recent investi-
gation suggested that subclinical hypothyroidism in women may be associated with an in-
creased risk of future cognitive decline (Volpato et al., 2002).
Treatment
With regard to the reversibility of cognitive difficulties associated with hypothyroidism,
the literature appears to be quite mixed. Clarnette (1994) found only one case of revers-
ible dementia (followed for 3 months) due to the disorder. In his review of 32 studies,
only 18 of 2,781 cases of dementia were specifically documented as being due to
hypothyroidism. Five of the 18 cases were lost to follow-up, six cases showed improve-
ment or partial recovery, and six either did not improve or continued to deteriorate. In
contrast to these findings, a more recent study by Baldini et al. (1997) found that a sam-
ple of 19 subclinical hypothyroid women showed improvements in verbal story memory,
visual memory, and attention over controls following 3 months of thyroxine treatment.
In addition, Smith and Granger (1992) reported on two cases of hypothyroidism (one
subclinical) that demonstrated some improvement, though perhaps not to baseline levels,
on a gross cognitive screen.
Thus, although there are fairly consistent patterns of cognitive impairments in pa-
tients with overt hypothyroidism and, perhaps to a lesser degree, the subclinical variety of
this disorder, studies on the remediation of deficits are less clear. It appears that
subclinical hypothyroidism may be more likely to resolve with thyroxine treatment than
the overt form. This resolution may be due to the decreased severity of the subclinical dis-
order and the duration of thyroid malfunction. Complete recovery, however, appears to
be rare.
VITAMIN B12 DEFICIENCY

Vitamin B12 (also known as cobalamin) deficiency is one of the most common nutritional
disorders that occurs in older adults (Dharmarajan, Adiga, Pitchumoni, & Norkus, 2003;
Dharmarajan & Norkus, 2001). Levels of B12 appear to be reduced as a function of in-
creasing age (Robins Wahlin, Wahlin, Winblad, & Bäckman, 2001). Deficiency in B12 lev-
els occurs commonly in both community-dwelling older adults as well as those in nursing
homes or hospitals, with estimates of the prevalence of low serum B12 being 26% and
17%, respectively (Dharmarajan, Adiga, Pitchumoni, & Norkus, 2003). Because of its
relatively high prevalence, routine vitamin B12 screening has been recommended in de-
mentia evaluations (Knopman et al., 2001).
Etiology
The most common cause of vitamin B12 deficiency is food-B12 malabsorption, which ac-
counts for up to 50% of the cases (Dharmarajan, Adiga, Pitchumoni, et al., 2003). Other
causes include pernicious anemia, atrophic gastritis, exocrine pancreas insufficiency,
small intestinal bacterial overgrowth (SIBO), and malabsorption due to drug interactions
(Dharmarajan, Adiga, & Norkus, 2003; Robins Wahlin et al., 2001). Foods that are high
in vitamin B12 content include organ meats, dairy products, some seafood, meats, and egg
yolks. Because the U.S. recommended daily amount of B12 consumption is relatively
small, and the content in foods is far greater than daily recommendations, is it rare that
an individual will become deficient due to dietary restrictions (although strict vegetarians
are an exception), and it often takes years to develop significant B12 deficiency (Dharmar-
ajan, Adiga, Pitchumoni, et al., 2003).
Cognition
For several decades researchers and clinicians have examined the relationship between
cognitive impairment and low serum B12 levels. The findings of cognitive (and psychiat-
ric) disturbances, potentially leading to dementia, that are associated with low vitamin
B12 levels have been well documented in the nutrition research literature (Garry,
Goodwin, & Hunt, 1984; Goodwin, Goodwin, & Garry, 1983; Robins Wahlin et al.,
2001). The appearance of clinical manifestations of vitamin B12 deficiency tends not to
occur until the later stages of the disorder but can be wide ranging, including physical
complaints such as lethargy, fatigue, and weakness; hematological features such as
leukopenia and thromobocytopenia; and/or a variety of cognitive deficits. The believed
mechanism of the neurological and neuropsychological symptoms associated with defi-
cient vitamin B12 is demyelination and axonal degeneration, ultimately leading to cell
death (Babior & Bunn, 1998). The clinical and cognitive presentation can vary depending
on the extent of degeneration to the peripheral nervous system, the spinal cord, and/or
the cerebrum.
Well-controlled neuropsychological studies of the cognitive profiles of patients with
vitamin B12 deficiency have very rarely been investigated. Many of the reported findings
tend to be either case studies or they lack detailed descriptions of specific cognitive func-
tions. However, given that demyelination and axonal degeneration occur with vitamin
B12 deficiency, it is not surprising that numerous reports of the neuropsychological
sequelae associated with this disorder have described a “subcortical-type” pattern of defi-
cits. For example, several studies have suggested that the cognitive deficit profile includes
impairments in abstraction, problem solving, complex visual perceptual skills, memory,
letter fluency, constructional apraxia, psychomotor retardation, and apathy (Meadows,
Kaplan, & Bromfield, 1994; Riggs, Spiro, Tucker, & Rush, 1996; Robins Wahlin et al.,
2001; Saracaceanu, Tramoni, & Henry, 1997). Some studies have found more severe im-
pairment, including deficits in visual and verbal memory (recall and recognition), naming
and word finding, but these tend to be case studies (cf. Larner, Janssen, Cipolotti, &
Rossor, 1999).
It is noteworthy that some findings have noted that subclinically low levels of vitamin
B12 may also be associated with subtle cognitive deficits. That is, generally healthy individu-
als with no significant medical history but with serum B12 levels slightly above the estab-
lished cutoff for deficiency, have been shown to exhibit lower verbal memory and problem-
solving scores than individuals with optimal serum B12 levels (Goodwin et al., 1983;
Wahlin, Hill, Winblad, & Backman, 1996). In addition, a recent study by Bunce, Kivipelto,
and Wahlin (2004) demonstrated an intriguing gene–environment interaction between the
apolipoprotein E (apoE) epsilon-4 (ε4) allele (i.e., a susceptibility gene for AD) and low vita-
min B12 on episodic memory. Given that the apoE gene may play a general role in neural sup-
port and repair mechanisms, and that possession of the ε4 allele results in a poorer capacity
than does the ε2 or ε3 allele in this regard, the authors suggest that brain reserve may vary as
a function of the apoE genotype and that ε4 carriers may be particularly vulnerable to cogni-
tive impairment in the presence of an additional factor (i.e., low vitamin B12) that deleteri-
ously influences neuroanatomical structures and processes.
Treatment
The standard treatment regimen for individuals with low serum B12 is administration of
the deficient vitamin. Traditionally, treatment has been intramuscular administration in
doses from 100 to 1000 micrograms per day for up to 1 week. This is typically followed
by monthly to quarterly injections for the rest of the patient’s life (Dharmarajan, Adiga,
Pitchumoni, et al., 2003). Preparations of oral, intranasal, and sublingual administrations
are also available.
Although laboratory tests are likely to show rapid improvement following supple-
mentation, the pattern of recovery for neurological and cognitive functions is not quite as
clear. Neurological symptoms may recover rapidly and completely if treatment is begun
quickly and the disorder has not gone untreated for a long period. In general, studies of
the reversibility of cognitive impairments associated with deficient vitamin B12 have not
been positive. Clarfield (1988) found only one case of dementia (out of 3,000) that re-
versed completely with supplementation. Also, Hector and Burton (1988) reviewed stud-
ies between 1959 and 1986 and found only three cases of dementia that improved with
vitamin B12 administration. Meadows et al. (1994) presented a case report with mixed re-
sults. That is, the patient demonstrated improved memory performances, but abstraction
and visuomotor scanning/sequencing remained impaired. Finally, a review paper by Chiu
(1996) found that 14 studies (totaling 69 patients) reported in the literature (from 1966
to 1995) identified cases of cognitive impairment that were attributable to deficient B12
levels. Twenty-five of the patients were judged to have cognitive deficits severe enough to
be diagnosed with dementia. Of those 25, 10 patients demonstrated marked improve-
ment following treatment with vitamin B12.
In summary, there are numerous studies supportive of the notion that there are sig-
nificant cognitive effects associated with vitamin B12 deficiency, though individuals often
demonstrate a few scattered or isolated mild deficits rather than a global dementia. The
severity of deficits appears to be related to the duration of the disorder. It has been sug-
gested that the “window of opportunity” for treating and reversing complications due to
deficiency is brief, being only a few months before neurological symptoms become irre-
versible (Dharmarajan, Adiga, Pitchumoni, et al., 2003). Though some investigations,

primarily case studies, have reported improvement in cognitive functions following vita-
min B12 supplementation, most reviews of the literature suggest that complete recovery is
rare.
THIAMINE DEFICIENCY
Celik and Kaya (2004) describe vitamin B1 (or thiamine) as a coenzyme in carbohydrate
metabolism that has a role in the maintenance of osmotic gradients between cellular
membranes. Although inadequate oral thiamine intake still accounts for the majority of
cases of thiamine deficiency (TD) in people in underdeveloped countries, approximately
95% of cases seen in people living in developed countries are associated with alcohol use
(Thomson, 2000). Although rare, TD is also sometimes seen in people with cancer, AIDS,
eating disorders, excessive vomiting caused by chemotherapy, diarrheal disorders, or any
condition where there is poor oral intake (Celik & Kaya, 2004). There are also a rela-
tively high number of older adults with TD, in particular, those living in hospitals or insti-
tutions (Johnson, Bernard, & Funderburg, 2002).
Etiology
Common consequences of TD include the Wernicke–Korsakoff syndrome (WKS) as well
as maple syrup urinary disease, heart failure (wet beriberi), and peripheral neuropathy
(Johnson, Bernard, & Funderburg, 2002; O’Keeffe, Tormey, Glasgow, & Lavan, 1994).
TD often occurs in individuals who have consumed large quantities of alcohol for a pro-
longed period of time. This occurrence is due, in part, to the fact that some individuals
dependent on alcohol obtain much of their caloric intake from alcohol and are often mal-
nourished. However, according to Gastaldi, Casirola, Ferrari, and Rindi (1989), alcohol
itself may cause TD by inhibiting the intestinal absorption of thiamine. Ciccia and
Langlais (2000) suggest that, when TD interacts with alcohol, there is a synergistic effect.
The period of time needed to become deficient in thiamine is subject to individual differ-
ences but can occur quite quickly, leading to serious medical complications in as short a
time as 2–3 weeks (Ambrose, Bowden, & Whelan, 2001).
Cognition
Prolonged and heavy use of alcohol has been associated with a wide variety of cognitive
and neurological impairments (Ciccia &Langlais, 2000; see also Salmon, Butters, &
Heindel, 1993, for review). These can range from very subtle or no deficits to the severe
amnesia that accompanies WKS. Mild deficiencies in thiamine can cause a number of
cognitive symptoms, including perceptual–motor difficulties, visuospatial problems, de-
creased abstraction/problem solving, and learning and memory deficits (Parsons &
Nixon, 1993). When TD progresses to a more severe state, Wernicke’s encephalopathy
can occur, presenting as a clinical triad of confusion, ataxia, and nystagmus (Johnson et
al., 2002). Worsening of the neuropsychological profile to include both retrograde and
anterograde amnesia constitutes WKS (Ambrose et al., 2001; Johnson et al., 2002;
Kopelman, 1995).
Treatment
Treatment requires daily administration of thiamine hydrochloride in adequate doses for
repletion of brain thiamine levels (Ambrose et al., 2001; Thomson, 2000). The probabil-
ity of recovery from WKS is not high. Thiamine treatment of Wernicke’s encephalopathy
often results in a reduction of confusion in addition to improving the ataxia and eye
movement abnormalities, but not in all studies (Ambrose et al., 2001; Todd &
Butterworth, 1999, but see Johnson et al., 2002). The severe memory impairment associ-
ated with WKS does not show improvement in the majority of cases (Parsons & Nixon,
1993), and Victor, Adams, and Collins (1989) estimate that less than 25% of those pa-
tients who survive a Wernicke’s encephalopathy show a complete return to their
premorbid personality or intellectual state, especially if their medical history includes
long-term alcoholism. However, a recent study examined thiamine treatment on working
memory deficits in people with alcoholism without the clinical signs of WKS (Ambrose et
al., 2001) and found a dose-related (up to 200 mg) improvement in performance on a de-
layed alternation task in this sample of 107 detoxifying patients.
Thus there appears to be some evidence of neuropsychological improvement with
thiamine treatment in a small percentage of patients with thiamine deficiency and alco-
holism, although in those with WKS, prognosis for recovery is poor (Johnson et al.,
2002). Bowden (1990), however, suggested a more optimistic outlook: that patients with
WKS who completely abstain from alcohol use for a significant period of time show im-
provement in cognitive function.
Given the mixed results from the various investigators and research designs (Bowden,
1990; Martin, McCool, & Singleton, 1993), it is important to continue to investigate the
benefits of thiamine treatment on those detoxifying from ethanol as well as examining
the effects of long-term abstinence from chronic alcohol consumption as a way of allevi-
ating the deleterious effects of TD. An inexpensive and relatively harmless treatment, it is
wise to begin thiamine supplementation at the earliest signs (Morcos, Kerns, & Shapiro,
2004). Important considerations include the appropriate dosage, duration, and the
method of administration (Bowden, Bardenhagen, Ambrose, & Whelan, 1994).
DEPRESSION-RELATED COGNITIVE DYSFUNCTION

There are a number of terms that refer to the presence of potentially reversible cognitive
impairments associated with depression in older adults. Terms such as pseudodementia
(Kiloh, 1961) and dementia syndrome of depression (Folstein & McHugh, 1978) are
commonly used but may not be the most appropriate. The cognitive effects of depression
can be variable in scope and severity, often not meeting the specific criteria for dementia.
Thus the term selected for use here is depression-related cognitive dysfunction (Stoude-
mire, Hill, Gulley, & Morris, 1989), because it refers to depression and is general enough
to cover a range of deficit severity.
The prevalence of major depressive disorder in adults age 65 and older has been re-
ported to be approximately 2% (Myers et al., 1984). However, the rate jumps to about
20% if those with significant depressive symptoms, but not meeting the formal DSM-IV
criteria for major depression, are included (Blazer, Hughes, & George, 1987). Further
complicating the situation is the rather high comorbidity of depression in dementia. For
example, although major depression in AD is considered rare, dysphoric affect and de-
moralization are more common and thought to occur in as many as 50% of AD patients
(see Kaszniak & DiTraglia Christenson, 1994, for discussion). Given the high frequency
of depressive symptoms in older adults, there is a clear need to evaluate the potential cog-
nitive effects of this disorder.
Cognition
Interest in the neuropsychological features of late-life depression is a relatively new and
incompletely understood area of research. Although numerous studies have examined the
cognitive effects of depression in older adults, many have utilized only limited test batter-
ies (see Butters et al. 2000, for discussion). Still, when summarized, studies have shown a
relatively consistent pattern of cognitive deficits in visuospatial skills, executive function-
ing, and psychomotor speed (see Boone et al., 1995; Hart, Kwentus, Taylor, & Harkins,
1987; Lesser et al., 1996; Palmer, Boone, Lesser, & Wohl, 1996).
It has been argued that depressed individuals with significant cognitive deficits repre-
sent a heterogeneous group, with some patients being in the early stages of a dementia,
such as AD or a vascular dementia (Kaszniak & DiTraglia Christenson, 1994). In support
of this notion is a study by Paterniti, Verdier-Taillefer, Dufouil, and Alpérovitch (2002)
that found that the presence of cognitive deficits in depressed individuals predicted future
decline at follow-up approximately 4 years later. This finding has been reported previ-
ously in the literature as well (see Bassuk, Berkman, & Wypij, 1998; Chen et al., 1999;
Geerlings et al., 2000).
However, not all depressed patients have significant cognitive deficits. Often older
adults may show only mild neuropsychological deficits, but they continue to report mem-
ory and concentration difficulties. On cognitive tests, these milder cases tend to have
lower scores on more effortful tests, such as those that require a free recall compared
with recognition (see review by La Rue, 1992). Historically, subjective memory com-
plaints have been shown to be more highly associated with depression in late life than
with objective memory impairments (see discussion by Kaszniak & DiTraglia Christenson,
1994). However, most of these studies have been cross-sectional and few, if any, have spe-
cifically addressed whether subjective memory deterioration predicts future dementia. To-
ward that end, Wang et al. (2004) conducted a community-based longitudinal study of
over 1,800 older adults, investigating the temporal relationship between subjective mem-
ory decline and future dementia. In short, they found that subjective memory deteriora-
tion significantly predicted the development of dementia. They also demonstrated consis-
tencies with previous findings, such as cross-sectional associations between subjective
memory decline and depression as well as important modifying relationships. For exam-
ple, they showed that advancing age diminished the strength of prediction of future de-
mentia. They concluded by suggesting that subjective memory decline provides additional
information about future dementia at a time when objective cognitive impairment is not
observed.
The implications of this study highlight that, in addition to depression assessments,
evaluation of subjective memory decline in older adults may be an important additional
component to both screening as well as comprehensive cognitive assessments. Moreover,
there appears to be poorer utility of this information with increasing age, perhaps due to
increasing executive or self-monitoring deficits with advancing age or the possibility that
memory problems are more common among very old adults (> 80). Thus distinguishing
between subjective memory decline as an early indicator of dementia or a concomitant

aspect of normal aging is more difficult in those who are very old. Nevertheless, the find-
ings of Wang et al. (2004) provide important information on the prediction of future de-
mentia from subjective estimations of memory decline, aside from their overlap with de-
pression.
In addition, Kaszniak and DiTraglia Christenson (1994) offered a variety of qualita-
tive features in cognitive assessments that might be helpful in differentiating AD from de-
pression. Compared to patients with AD, one would expect depressed individuals to
show relatively intact recognition memory, fewer false-positive errors on recognition
memory testing, more “don’t know” errors, poorer effort in attempting to perform tasks,
more variability in performance on tasks of similar difficulty, buttressed performance
with semantic organization and prompting, and an intact awareness of impairment. Of
course, longitudinal assessment, with treatment of depression, affords the greatest degree
of precision in determining whether cognitive impairments abate.
Treatment
Regarding the ameliorative effects of antidepressant medication on the cognitive impair-
ments in older adults with depression, studies tend to be somewhat inconsistent. Butters
et al. (2000) found that those who demonstrated cognitive impairments showed improve-
ment in executive functions following remission of depressive symptoms. In contrast,
Dahabra et al. (1998) reported that cognitive impairments persisted after recovery from
depression, whereas Nebes et al. (2000) found that measures of processing speed and
working memory improved following remission, but no more than that observed in con-
trol participants with repeat testing.
These contradictory findings suggest that there are different subgroups of depressed
older patients that influence the extent to which these patients will demonstrate cognitive
improvement. The findings that (1) only a portion of depressed patients actually demon-
strates cognitive deficits and (2) that some depressed patients with cognitive impairments
are a greater risk for future decline support the subgroup hypothesis. Also supportive is
the finding by Taylor, Wagner, and Steffens (2002) who reported that more severely de-
pressed patients were less likely to show cognitive improvement following treatment.
Finally, there does seem to be a fairly consistent finding that, if cognitive improvement
occurs following remission of depressive symptoms, it tends not to improve to baseline
levels on retesting (Butters et al., 2000; Nebes et al., 2000).
SLEEP-DISORDERED BREATHING
The most common health condition associated with sleep-disordered breathing is the syn-
drome of obstructive sleep apnea (OSA; Adams, Strauss, Schluchter, & Redline 2000). This
breathing disorder is usually caused by repetitive upper airway obstruction; its primary
symptoms are loud snoring and breathing stoppage during sleep (Dealberto, Pajot, Courbon,
Alpérovitch, 1996; Shochat & Pillar, 2003). OSA occurs more commonly in men, increases
with age, and is strongly correlated with body mass index. Its prevalence in the general pop-
ulation is estimated to be between 2 and 5%, but it increases dramatically to more than 25%
for individuals over age 65 (Dealberto et al., 1996; Naegele et al., 1995).
Etiology
The obstruction of the upper airway in affected individuals may involve compromised
pharyngeal airway anatomy (e.g., macroglossia, hypertrophy of tonsils, increased uvula
size, or long soft palate), leading investigators to surmise that an anatomical abnormality
of the pharynx eventually causes the collapse of the upper airway during sleep. Other risk
factors include smoking, alcohol consumption, use of sedative medications, lying in the
supine position, sleep deprivation, and several medical conditions, including hypo-
thyroidism and acromegaly (Shochat & Pillar, 2003).
As a consequence of OSA, many patients experience daytime sleepiness, irritability,
impatience, and depressive symptoms. In addition, OSA has been associated with hyper-
tension, cardiovascular and pulmonary disease, and increased mortality. Finally, a signifi-
cant consequence of the disorder is cognitive impairment that may resemble dementia in
older adults (Bliwise, 2002; Shochat & Pillar, 2003).
Cognition
Specific cognitive deficits include executive dysfunction, psychomotor slowing, inatten-
tiveness and memory impairment (Bedard, Montplaisir, Richer, Rouleau, & Malo, 1991;
Bliwise, 2002; Kales, Caldwell, Cadieux, Vela-Bueno, Ruch, & Mayes, 1985; Naegele et
al., 1995; Naegele et al., 1998; Shochat & Pillar 2003). Although some researchers have
related these impairments to the transient but repeated hypoxemia that accompanies
OSA, others have suggested that the impairments have more to do with the sleep disrup-
tion and subsequent daytime sleepiness (Findley et al., 1986; Redline et al., 1997). This
controversy has led to the suggestion that cognitive impairments are due to multiple
causes in OSA. That is, perhaps the cognitive deficits associated with executive function-
ing and psychomotor slowing are related to the hypoxemia, whereas the memory and at-
tention difficulties may be due to decreased vigilance (Bedard et al., 1991). Regardless of
the specific causes of the cognitive impairments, Bliwise (2002) suggested that there is lit-
tle doubt that sleep apnea leads to a complex neurobehavioral syndrome in old age (i.e.,
motor slowing, memory impairment, apathy, and dysphoric mood) that resembles de-
mentia, if left untreated.
Treatment
Treatments of OSA include continuous positive airway pressure (CPAP), bilevel positive
airway pressure (BiPAP), the avoidance of lying in a supine position, weight loss, nasal re-
construction, pharyngeal reconstruction, and in some cases, tracheostomy. Medications
have been found to be largely unsuccessful due to tolerance effects and adverse effects.
CPAP is the treatment of choice due to its low risk and noninvasive nature (Bassetti &
Gugger, 2002; Schochat & Pillar 2003), although it must be worn indefinitely, and this
necessity could lead to compliance problems.
There is a growing interest in preventing or reversing the cognitive effects of OSA.
Bliwise (1996) suggests that preventing OSA by use of a CPAP or BiPAP may improve
cognitive function or mood, particularly if alertness improves. Naegele et al. (1998) re-
evaluated OSA patients after 4–6 months of CPAP treatment and found that their scores
on measures of visual memory and executive functions were significantly improved and
returned to normal. However, tests of attention and working memory remained impaired.
Bliwise (2002) also reported two cases in which treatment with a CPAP resulted in im-
proved immediate visual memory and psychomotor speed.
In summary, the functional level of OSA patients appears to deteriorate in direct
relationship to the severity and chronicity of their sleep apnea (Kales et al., 1985). Pre-
venting sleep apnea may lead to reversibility of symptoms in at least some cases of cogni-
tive decline, although more clinical trials are needed to test this hypothesis further.
MEDICATION EFFECTS
Neuropsychologists and other clinicians are often confronted with estimating the degree
to which an individual’s cognitive impairment is related to medication effects versus a de-
menting disease. Given that most drugs administered in sufficient dosages can cause cog-
nitive impairment, especially in susceptible individuals, careful interviewing regarding pa-
tients’ medication regimen and ability to manage their medications appropriately is
necessary to determine the likelihood that drugs may be causing cognitive alterations. In
addition, being informed about the typical side effect profiles of different classes of medi-
cations, as well as the specific drugs that are most likely to cause cognitive impairment, is
becoming increasingly important.
Over the past decade clinicians have increased their study of the effects of psycho-
tropic medication on cognitive functioning (Stein & Strickland, 1998). A comprehensive
examination of the effects of medications on cognition is beyond the scope of this chap-
ter; however, there are a number of detailed reviews on the topic to which the reader is re-
ferred (Amado-Boccara, Gougoulis, Poirier Littré, Galinowski, & Lôo, 1995; Gray, Lai,
& Larson, 1999; Muldoon, Waldstein, & Jennings, 1995; Stein & Strickland, 1998). In
this section, we briefly summarize the most common cognitive effects of some of the more
frequently prescribed classes of medication in older adults, including antidepressants, sed-
ative-hynotics/anxiolytics, antihypertensives, anticonvulants, and antihistamines. As is the
case with most of the other medical conditions described in this chapter, the cognitive
consequences associated with medication use are not typically so severe that they lead to
diagnoses of dementia per se. More often, the effects are characterized as leading to defi-
cits in attention, concentration, memory and/or psychomotor speed.
Antidepressants
The widespread use of antidepressants among older persons necessitates that clinicians
keep abreast of the potential cognitive deficits associated with these medications. Numer-
ous studies have examined the cognitive effects of the different classes of antidepressant
medications (tricyclic antidepressants, monoamine oxidase inhibitors [MAOIs], selective
serotonin reuptake inhibitors [SSRIs]). However, studies of the effects of these drugs are
confounded by a number of important issues, including the fact that many of the antide-
pressant medications are prescribed for medical conditions other than depression, including
chronic pain (tricyclics), Parkinson’s disease (MAOIs) and obsessive–compulsive symp-
toms (SSRIs), among others. Also, the effects appear to differ depending on the popula-
tion being studied (e.g., depressed individuals, healthy control groups, young adults,
older adults) and the methodology (e.g., single dose, short-term, long-term administra-
tion).
Despite these relevant variables, in general it appears that tricyclic antidepressants,
particularly amitriptyline, have been shown to have negative cognitive effects, including
slowed reaction time, slowed information processing, decreased attention, and lowered
verbal recall (but not recognition; Amado-Boccara et al., 1995; Branconnier, DeVitt,
Cole, & Spera, 1982; Sakulsripong, Curran, & Lader, 1991; & Stein & Strickland,
1998). Fewer studies have examined the cognitive profiles of SSRIs, and many of these
studies, often industry sponsored, utilitzed few neuropsychological tests; typically psycho-
motor speed and verbal memory are tested on relatively small sample sizes (Stein &
Strickland, 1998). The results have varied from mostly minimal cognitive effects to im-
proved effects on some tests such as perceptual function and reaction time (Kerr,
Fairweather, & Hindmarch, 1993). MAOIs also appear to be superior to tricyclic antide-
pressants regarding cognitive effects and may be comparable to the SSRIs (Stein & Strick-
land, 1998).
Sedatives/Hypnotics
Most sedative/hypnotic medications (e.g., benzodiazepines, barbiturates) have wide-rang-
ing cognitive effects. These medications are commonly used for anxiety reduction, as
sleep aids, to combat irritability and agitation, and for seizure control; by definition, they
cause sedation and drowsiness that can affect cognitive abilities in older adults.
Benzodiazepines are the most frequently prescribed antianxiety drugs in older adults
(Madhusoodanan & Bogunovic, 2004). Although tolerance to the effects of benzodiaze-
pines often develops after multiple doses, older adults may develop tolerance more slowly
than younger individuals and thus be at risk for continued cognitive impairment. In gen-
eral, studies have documented cognitive effects with both short-term and long-term use,
such as slowed psychomotor speed, impaired verbal and visual learning, and impaired
vigilance (Morrison & Katz, 1989; Nikaido, Ellinwood, Heatherly, & Gupta, 1990;
Pomara, Deptula, Medel, Block, & Greenblatt, 1989). Basic attentional skills do not ap-
pear to be significantly affected by benzodiazepines (Mac, Kumar, & Goodwin, 1985).
These drugs are also associated with increased risk of delirium in older adults (Gray et
al., 1999). Support for benzodiazepine-related cognitive effects was found in a study by
Larson, Kukull, Buchner, and Reifler (1987), which showed that cognition improved fol-
lowing the withdrawal of this class of drug.
Nonbenzodiazepine anxiolytic medications such as zolpidem and buspirone are
viewed as safer alternatives to benzodiazepines with regard to adverse neuropsychological
impairment (Barbee, Black, & Todorov, 1992; DeClerk & Bisserbe, 1997).
Antihypertensives
Hypertension is a common disorder in older adults, and it is a well-known risk factor for
cognitive impairment due to cerebrovascular disease. Concerns about the cognitive effects
of the medications used in the treatment of this condition, especially the beta-adrenergic
blockers, has led to many studies of cognitive functioning during and following with-
drawal of antihypertensive medications. Although it was initially thought that some beta-
blockers (e.g., propranolol) were more likely to cause cognitive impairment, reports from
multiple reviews of the literature have disputed this early claim (Dimsdale, Newton, &
Joist, 1989; Gray et al., 1999; Stein & Strickland, 1998). A number of studies have exam-
ined cognitive functioning with both relatively short-term (e.g., 16 weeks) and long-term
(e.g., 54 months) use (see Applegate et al., 1991; Prince, Bird, Blizard, & Mann, 1996;
Skinner et al., 1992). The cognitive abilities most commonly examined included aspects
of attention, memory, and psychomotor functioning.
In general, it appears that there are no consistent neuropsychological changes due to
taking antihypertensive medications, including diuretics, angiotension-converting enzyme
(ACE) inhibitors, beta-blockers, and calcium channel blockers, although less is known
about the effects of this latter class of drugs. Interestingly, psychomotor speed actually
improved in a few studies of treatment with ACE inhibitors (see Stein & Strickland,
1998).
Anticonvulsants
Assessment of the neuropsychological effects of anticonvulsants is confounded by the fact
that very few studies have examined older adults, and they often do not include healthy
volunteers. According to Bergey (2004), the incidence of new-onset seizure disorders is
higher in older adults, and anticonvulsants are increasingly being used in psychiatric pa-
tients (e.g., for bipolar disorder); thus evaluation of potential cognitive side effects from
antiepileptic drugs (AEDs) remains important. Basically, all AEDs are associated with
dose-related effects on cognition and/or delirium. However, when administered in thera-
peutic doses, most of the major AEDs have little or no significant cognitive effects
(Devinsky, 1995). One study of first-generation AEDs in older adults found that
valproate had relatively worse effects on attention than did phenytoin, although the over-
all cognitive effects over 1 year were similarly minimal (Craig & Tallis, 1994).
Overall, it appears that first-generation AEDs (e.g., valproate, phenytoin, carbama-
zepine, phenobarbital, primidone) have a greater side effect profile than the newer second-
generation AEDs (e.g., oxcarbazepine, topiramate, zonisamide, levetiracetam). Also,
monotherapy tends to result in fewer cognitive problems (Gray et al., 1999). Of the older
AEDs, phenobarbital appears to produce the greatest negative neuropsychological effects
on psychomotor skills, attention/concentration, and memory, but phenytoin also may
have significant dose-related cognitive effects on memory and motor speed (Stein &
Strickland, 1998). At any rate, there is wide variability in the tolerability of AEDs among
older adults.
Antihistamines
It appears that the older, sedating antihistamines have effects on psychomotor speed, at-
tention and, to a lesser degree, memory (Stein & Strickland, 1998). In older adults,
diphenhydramine has been shown to be associated with impairments in attention, vigi-
lance, reaction time, and short-term verbal memory (Katz et al., 1998; Kay et al., 1997).
The second-generation antihistamines (e.g., loratadine, astemizole) generally cause less
sedation and cognitive problems (Kay et al., 1997).
In conclusion, many medications that are frequently prescribed to older adults can
cause cognitive impairment, particularly tricyclic antidepressants, benzodiazepines, first-
generation anticonvulsants, and older, highly sedating antihistamines, among many oth-
ers. Certainly, there is evidence for dose-dependent cognitive effects for many medica-
tions. Older adults may also be particularly sensitive to the effects of medications, per-
haps due to factors such as decline in renal function and metabolic clearance differences.
As clinicians charged with assessing cognitive functioning, it is necessary that we remain
aware of potential medication side effects in older adults in order differentiate permanent
cognitive impairments from potentially reversible conditions.
CONCLUSIONS
This chapter reviewed literature relevant to some of the more commonly reported causes
of “reversible dementia.” There is significant variability in the findings, both across disor-
ders and within the literature specific to each condition, as highlighted in Table 5.1.
However, there are several general conclusions that can be drawn from the literature. A
summary of the general findings from the broad literature covered in this review follows.
1. Although a severe dementia can result from some of the above disorders,
most of them do not typically present as a global dementia. More commonly, we find a
few isolated deficits, many of which are often mild rather than severe.
2. When dementia does result, the modal pattern or profile of deficits is consis-
tent with a “subcortical” dementia syndrome with deficits in memory retrieval, executive
functions, and psychomotor and cognitive processing speed.
3. Differentiating between the representative cognitive symptoms associated
with these disorders and normal aging can be quite difficult. The symptoms of slowed
psychomotor speed, slowed mental processing, and retrieval problems, particularly when
they are mild in these disorders, are consistent with the typical profile of age-related cog-
nitive decline.
4. Complete reversal of the symptoms associated with the reviewed conditions
appears to be very rare. Even when improvement does occur, cognitive functioning usu-
ally does not return to premorbid levels. Patients are often left with residual deficits.
5. In general, a shorter duration of illness is desirable for a better prognosis.
Early treatment tends to lead to greater recovery. Also, the less the severity of the medical
condition, the more likely there will be cognitive improvement when treatment is pro-
vided.
6. For each of the conditions discussed in this review, the literature is fraught
with methodological limitations that constrain our ability to draw hard conclusions from
the data. Pertinent methodological issues include heterogeneous patient samples, lack of
follow-up data, few prospective investigations, limited comprehensiveness of neuro-
psychological assessments, limited standardization in assessment procedures, use of
varying criteria in diagnosing conditions, and a heavy reliance on case studies. These
limitations interfere with our ability to identify reliable percentages of patients who are
likely to improve with treatment or the degree to which they will improve with treatment.
Given that most of the above conditions do not commonly present as a “full-blown”
dementia syndrome but often result in scattered, isolated, and/or mild cognitive dysfunc-
tion, it may not be accurate to refer to the cognitive consequences from these conditions
as a “dementia.” Furthermore, the extent of cognitive recovery is dependent upon many
factors but does not typically result in a complete return to previous levels of functioning.
Thus the appropriateness of the term “reversible” could also be questioned. As such,
based on the findings in the literature, it seems that the comment by Byrne (1987) that the
term reversible dementia is a misnomer has merit.
The material presented in this chapter was provided as a starting point for those in-
TABLE 5.1. Summary of the General Findings Regarding Treatable Medical Conditions
Condition Prevalence Etiology Clinical features Cognitive profile Treatment Reversibility
Normal- • Most commonly • Unclear; perhaps • Impaired gait, mental • “Subcortical” pattern Periventrucular • Variable (30–80%)
pressure occurs over age 60 impaired CSF deterioration, and • Mild inattention shunt • Secondary NPH
hydrocephalus • Accounts for < 5% absorption at the sphincter dysfunction • Poor initiation • Gait disturbance prior to
of dementia cases arachnoid villi, or • Slow progression • Slowed mental processes mental decline
• Most cases are “suprasylvian • Recogniton > recall • Improvement following
secondary to subarachnoid block” CSF tap
another condition
(e.g., SAH, TBI)
Hypothyroidism • Increases with age • Malfunction in the • Depression Impaired Supplementation • Literature mixed
• Approximately 14% negative feedback • Lethargy • Memory of T4 • Symptoms associated
in older adults system between TSH • Dry skin • Visuomotor processing with subclinical versus
(Luboshitzky et al., from the pituitary • Feeling cold • Visuospatial/ primary (overt)
1996) gland and T4 from visuoconstruction hypothyroidism appear
the thyroid gland Commonly intact to be more amenable to
• Subclinical • Sustained attention improvement
hypothyroidism (high
120
• Language skills (including
TSH but normal T4) fluency)
• Primary • Gross motor abilities
hypothyroidism (T4
abnormally low)
Vitamin B12 • 26% in community- • B12 levels reduced • Fatigue • “Subcortical” pattern Prescription Lab tests show rapid
deficiency dwelling older with age • Weakness • Severity of symptoms (intramuscular) recovery of B12 levels
adults •Food-B12 • Loss of appetite related to duration of and OTC (oral) following supplementation
• 17% in hospitalized malabsorption (50% • Sore mouth/tongue disorder B12 supplements • Neurological symptoms
and/or nursing of cases) • Diarrhea • Typically a few may completely resolve
home patients •Pernicious anemia • Tingling of scattered deficits if treatment is begun
•Other causes: atropic hands/feet Common impairments quickly (“window of
gastritis, pancreas • Abstraction/problem opportunity” only a few
insufficiency, SIBO, solving months)
malabsorption due to • Complex visual • Otherwise, results of
drug interactions perceptual skills studies are not
• Results in • Visuoconstruction optimistic
demyelination and • Letter fluency • Complete recovery
axonal degeneration • Verbal memory appears to be rare
impairment
• Psychomotor slowing
Thiamine • Oral thiamine • Malnourishment, • Acute presentation of Mild deficiencies Daily Wernicke’s
deficiency intake deficiency is often due to high- thiamine deficiency • Perceptual–motor administration encephalopathy
common in caloric intake of • Gait and truncal difficulties of thiamine • Reduced confusion
underdeveloped alcohol ataxia • Visuospatial problems hydrochloride • Decreased ataxia
countries rather than food • Ophthalmic disorders • Learning and memory • Improved eye
• 95% of cases in • Alcohol may also (nystagmus, lateral • Abstraction/problem movements
developed countries inhibit the intestinal rectus palsy, solving Wernicke–Korsakoff
is associated with absorption of conjugate gaze Severe deficiencies syndrome
alcohol use thiamine palsy), progressing • Wernicke–Korsakoff • Prognosis is poor
• Deficiency can occur to ophthalmoplegia syndrome • Memory deficit stable
rather quickly, in as • Confusional state • Severe anterograde • Abstinence may help
little as 2–3 weeks • Tachycardia amnesia
• Retrograde amnesia
• Possibly confabulation
Depression- • MDD in those Likely multiple • Depression Variable findings, often • Antidepressant • Study results are
related cognitive 65+: 2% etiologies • Subjective no cognitive deficits medications inconsistent, possibly
dysfunction • Significant concentration and Most common deficits • Psychotherapy due to heterogeneous
depressive memory complaints cited subgroups of depressed
symptoms: 20% • Decreased energy, • Psychomotor speed patients
121
• Complication: fatigue • Executive functioning Possibly improvement in:
Dysphoria in AD • Appetite and sleep • Visuospatial skills • Executive functions
is about 50% problems • Processing speed
Other findings
• Intact memory • Working memory
recognition • If improvement does
• Few false-positive occur, it tends to fall
recognition errors short of baseline
• More “don’t know” abilities
responses
• Variability on tests of
similar cognitive abilities
(continued)
TABLE 5.1. (continued)
Condition Prevalence Etiology Clinical features Cognitive profile Treatment Reversibility
Sleep-disordered • Most common Repetitive upper airway • Loud snoring Unclear if deficits are due • CPAP/BiPAP • Some suggestion that
breathing associated health obstruction • Breathing stoppage to transient, repeated • Avoidance of preventing OSA can lead
condition: Risk factors during sleep hypoxemia or sleep lying in supine to improved cognitive
obstructive sleep • Smoking • Daytime sleepiness disruption and subsequent position symptoms
apnea • Weight gain • Irritability/impatience sleepiness, or perhaps • Weight loss • More studies are needed
• General population: • Alcohol/sedative • Depression both • Nasal/ • Appears to be some
2–5% consumption • Associated with high Impaired pharyngeal improvement in visual
• More than 25% in • Lying in supine blood pressure, • Psychomotor slowing reconstruction memory, psychomotor
those 65 and older position cardiovascular, and • Executive dysfunction • Tracheostomy speed, and executive
• More common in • Sleep deprivation pulmonary diseases • Inattentiveness functions
men • Hypothyroidism • Memory • Attention deficits may
• Correlated with • Acromegaly remain
body mass index
Note. NPH, normal-pressure hydrocephalus; SAH, subarachnoid hemorrhage; TBI, traumatic brain injury; CSF, cerebrospinal fluid; TSH, thyroid-stimulating hormone; SIBO, small intestinal
bacterial overgrowth’ MDD, major depressive disorder; CPAP, continuous positive airway pressure; BiPAP, bilevel positive airway pressure; OSA, obstructive sleep apnea.
122
terested in this topic, who are further referred to additional sources for more detail on
conditions discussed.
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Section B
Specific Considerations
Section B of the assessment portion of the text includes chapters that draw attention to
specific considerations that are essential in the assessment of elders. Indeed, the integrity
of our evaluations often rests upon the issues highlighted: the use of appropriate norma-
tive data, the application of our data instrumentation to functional concerns, and sensi-
tivity to multicultural issues.
Chapter 6 begins this section with a critical review of the current available norms for
tests commonly used in the neuropsychological evaluation of the elderly. Most impor-
tantly, this chapter highlights the appropriate conceptualization of data, given the source
of normative comparisons. Many of the insights of this chapter are aptly applied to the
interpretation of any neuropsychological data, regardless of the age of the patient. How-
ever, they are unmistakably critical in regard to elders, because norms in the higher age
ranges are often vulnerable in key methodological areas affecting the normative product.
This chapter also addresses the importance of normative methods when utilizing longitu-
dinal data, which is often central to establishing or confirming diagnosis, tracking pro-
gression or treatment outcomes, and staging symptom severity in elderly groups.
Chapter 7 offers a review of the role of neuropsychology in the assessment of every-
day functional abilities, with information about the relationship of our traditional tests to
meaningful life-event outcomes and the importance of newer instruments in enhancing
our skills in assessing these functional areas. Innovative perspectives regarding the con-
ceptualization and measurement of competencies and capacities are eloquently presented.
Chapter 8 discusses factors critical to the assessment of elders from minority cultural
backgrounds. The current prevalence rates for dementia in African Americans are pre-
sented with a discussion of the sociocultural factors contributing to the accuracy of case
identification and symptom measurement. Methodological factors and patient variables
that affect clinical evaluations and programs of research are reviewed, offering a concep-
tual context within which to evaluate and conduct relevant work.
Finally, we encourage our readers to carefully consider the importance of feedback,
as outlined in Chapter 9. This chapter presents the feedback session as the primary
method of communicating assessment results and recommendations. The opportunity for
the provision of education through this process is inherently understood. However, this
potentially pivotal meeting also offers an opportunity to introduce the concept of inter-
vention; often this is the only time when the option of such work is considered, given that
131
our field and allied health practitioners are only now becoming versed in such approaches
as favorable reports emerge.
Not surprisingly, given the nature of these special considerations, none of these chap-
ters offers definitive solutions in the areas they cover. Any such “solution” would likely
lack depth and would become quickly antiquated, given our continual efforts to expand
our understanding in these areas. Instead, these chapters present the reader with a much
more valuable conceptual framework within which to consider the relevant issues as we
move forward with our daily clinical and research efforts.
6
Using Norms in Neuropsychological

Assessment of the Elderly
ROBYN M. BUSCH
GORDON J. CHELUNE
YANA SUCHY
T he practice of clinical neuropsychology in the United States is heavily rooted in

psychometric assessment and the use of normative information (Davison, 1974). Despite
this emphasis, test users frequently focus on issues of interpretation, with little consider-
ation given to how norms are developed and how this factor affects the interpretive state-
ments that can be made about a patient’s test performance. This problem is especially
evident in neuropsychological evaluation of the elderly, where test development and age-
appropriate norms have been slow to emerge, despite growing interest in elder populations.
GENERAL CONSIDERATIONS
Assessment of older adults presents a unique set of considerations for the clinical neuropsy-
chologist. One of the first areas that must be considered is the life context of the aging indi-
vidual. The transition from middle to old age is accompanied by a number of “normal” life
changes. Not only are elders adjusting to new roles and social expectations as they enter re-
tirement, but they must also cope with the physical (e.g., reduced visual acuity, hearing loss,
motor slowing) and cognitive (e.g., cognitive slowing, memory difficulties, decline in execu-
tive skills) changes that accompany normal aging (Cullum, Butters, Troster, & Salmon,
1990; Erkinjuntti, Laaksonen, Sulkava, Syrjalainen, & Palo, 1986; Howieson, Holm, Kaye,
Oken, & Howieson, 1993; Van Gorp, Satz, & Mitrushina, 1990). In addition to the inevita-
ble changes associated with advancing age, elderly individuals are also at increased risk to
develop a host of medical conditions, including heart disease, cancer, stroke, chronic ob-
structive pulmonary disorders, pneumonia, influenza, diabetes, and arthritis, which may re-
quire multiple medical treatments and behavioral interventions. These health problems are
also often associated with depression (Koltai & Branch, 1999).
133
All of these age-related factors can adversely affect cognitive functioning and the
ability to perform activities of daily living (ADLs). The contribution of each of these fac-
tors to current cognitive functioning can be difficult to tease apart, and neuropsy-
chologists are frequently called upon for assistance in this regard. Neuropsychological
evaluation can be recommended for a variety of reasons, including assistance with diag-
nostic issues (e.g., differentiation between depression, dementia, and delirium; see Section
A of Part I of this volume), determination of competency or functional capacity (e.g., de-
cisional capacity, ADLs, driving, living alone, etc.; see Marson & Hebert, Chapter 7, this
volume), and/or assessment of change in cognitive functioning over time (e.g., to track
the course of a dementing process; see Albert & Moss, 1988).
Historically, there has been a paucity of neuropsychological tests specifically de-
signed to address the issues unique to older adults, as well as a lack of normative data for
the oldest old. Advances in test development and research over the last decade have
started to fill some of these gaps. There is a growing body of literature designed to assist
neuropsychologists with the assessment of this population (Albert & Moss, 1988; Koltai
& Welsh-Bohmer, 2000; Nussbaum, 1998; Tuokko & Hadjistavropoulos, 1998). This lit-
erature includes recommendations for the selection of appropriate testing instruments
and alterations in test administration protocols to control for factors unique to older
adults that may confound test results (e.g., large print to compensate for visual difficul-
ties). Many researchers also highlight issues related to specific referral questions and the
interpretation of test data for older adults. All of these recommendations are important in
assuring that the test user obtains accurate and reliable test results and gives important
consideration to issues unique to the population of older adults.
Selection of the appropriate normative data with which to compare a patient’s test
results is another very important, and often neglected, issue in neuropsychological assess-
ment of older adults. Although great efforts have been made in recent years to develop
normative data for elderly individuals (Ivnik, Malec, Tangalos, et al., 1992; Ivnik,
Tangalos, Petersen, Kokmen, & Kurland, 1992; Malec et al., 1992; Morris et al., 1989),
not many texts provide guidance on how to select the most suitable norms for a particu-
lar patient based on his or her unique history and presentation. Norms provide an objec-
tive reference or standard against which to compare an individual’s current test perfor-
mance and weigh heavily into the interpretations made about a patient’s cognitive
abilities or deficits. Therefore, selection of the appropriate normative comparison group
is one of the most important aspects of neuropsychological assessment, particularly as it
pertains to older adults.
This chapter provides a guide for evaluating the nature and adequacy of available
norms for use with elderly populations. We begin with a discussion of the nature and pur-
pose of normative data as well as a summary of how normative samples are obtained and
the various methods by which norms are developed. This overview is followed by a dis-
cussion of what constitutes a “representative” normative sample and the key factors one
should consider in selecting a normative comparison group. Finally, we identify specific
considerations for assessing cognitive change in elderly individuals over time.
THE NATURE AND PURPOSE OF NORMS
Norms describe the distribution of performances on a given test that can be considered
the standard for the group concerned. In addition, norms provide the context within
which the performances of an individual external to the reference group can be inter-
Using Norms in Neuropsychological Assessment 135
preted (Mitrushina, Boone, & D’Elia, 1999). Although not specific to the evaluation of
older adults, there are some fundamental issues about norms that need to be considered.
At a macro level, there are two very different ways in which test norms can be used to an-
swer clinically relevant questions, and they both influence, and are influenced by, the
composition of the normative standard. Neuropsychological assessments are used to an-
swer a wide range of questions about patients; these questions can be grouped into those
that are descriptive in nature and those that are diagnostic. Depending on the nature of
the question to be addressed, different normative standards are necessary.
As the following sections indicate, when used for descriptive purposes, norms allow
the test user to address a fundamental question: “How is this individual functioning rela-
tive to the reference population?” The emphasis is on determining where the individual’s
performance on a test falls among the range of performances observed in the reference
population. The reference standard is the general population within which the patient is
believed to be a member. A patient’s scores can be characterized as “below average,” “av-
erage,” “high average,” and so on.
In contrast, when used for diagnostic purposes, norms aid the test user in answering
the question, “Is the functioning of this patient impaired or not? That is, does my pa-
tient’s score deviate from premorbid expectations (i.e., the score that would have been
obtained in the absence of an intervening illness or injury)?” The reference standard is the
premorbid status of the individual, and the deviations of interest from this individual
comparison standard are typically unidirectional. Thus performances are characterized as
“normal” or “within normal limits” versus “mildly impaired,” “moderately impaired,”
etc. The key point here is that population-based descriptive norms cannot be directly used
to make diagnostic statements about normality versus abnormality unless the test user
employs a different normative approach that infers a discrepancy between the patient’s
observed performance and presumed premorbid functioning. Let us further consider the
distinction between the descriptive and the diagnostic use of norms.
Descriptive Use of Norms

Norms intended for descriptive purposes are inherently population-based and are
grounded in principles of central tendency (Mitrushina et al., 1999). They assume that
the construct measured by the test procedure is normally distributed and that all potential
test scores fall under a normal curve. This curve has basic psychometric properties; that
is, there is a true midpoint or population mean, with half of the normative sample falling
above and half below this mean, and the distribution of scores is characterized by the
standard deviation of the mean. Using such population-based descriptive norms, the test
user can determine where a given person is functioning within the reference group. This
norm-based position can be expressed as a percentile, z-score, standard score, or T-score,
and labels such as “borderline,” “low average,” “average,” “high average,” etc., can be
used to describe ranges of performance around the mean. Many tests commonly used in
the evaluation of older adults employ descriptive population-based norms. The norms for
the Wechsler tests (Psychological Corporation, 1997) are classic exemplars.
Although the foregoing material may appear quite elementary, the astute reader will
discern at least three key issues that are particularly relevant when evaluating elders.
First, norms for tests that are primarily used for descriptive purposes are designed to mea-
sure abilities that are presumed normally distributed in the reference group. That is, a
person’s cognitive ability, as reflected by his or her test performance, can be below the
average, average, or above the average. This is quite different from tests that are deficit-
oriented. For example, performances on popular mental status measures such as the De-
mentia Rating Scale (DRS; Mattis, 1988) or the Mini-Mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975) are not normally distributed and tend to be highly
skewed and prone to ceiling effects. Rather than invoking concepts related to central ten-
dency when describing performances on these measures, it is more appropriate to think
of test performances in terms of normality and use unidirectional descriptors such as
“normal,” “mildly impaired,” “moderately impaired,” and so on. It is easy to appreciate
this point when considering a construct such as mental status; that is, it makes sense to
speak of an elder as having a normal versus abnormal or “impaired” mental status rather
than describing the elder as having an above-average versus a below-average mental sta-
tus. However, this distinction is less apparent when considering performances on a mea-
sure such as the Boston Naming Test (BNT; Goodglass & Kaplan, 1983), especially when
large descriptive datasets have been published (Heaton, Miller, Taylor, & Grant, 2004;
Ivnik, Malec, Smith, Tangalos, & Petersen, 1996; Tombaugh & Hubley, 1997). Still, the
careful test user will note that naming ability, as assessed by the BNT, is not normally dis-
tributed, even among older adults, for whom test performance becomes more variable
around the mean with increasing age (Tombaugh & Hubley, 1997). Norms for tests such
as these are best considered for diagnostic rather than descriptive purposes.
Second, it should be apparent that population-based descriptive norms cannot, in
themselves, be used to identify abnormal or impaired performances without inferring a
discrepancy between the observed score and the estimated premorbid score. By defini-
tion, descriptive norms describe normally distributed test scores, and all potential test
scores fall under the normal curve. Because decrements in normal cognitive ability are
age-related, descriptive test norms are stratified by age to normalize the distribution of
scores within a given age group. Thus descriptive norms assume that a person’s posi-
tion within the reference group is invariant across the age span. A Wechsler Adult In-
telligence Scale–III (WAIS-III; Wechsler, 1997a) IQ of 75 is relatively rare, occurring in
only 5% of the standardization sample for a given age group, and can be described as
being in the “borderline” range. However, it is not necessarily “abnormal,” unless the
test user infers that this score deviates from a premorbid level as the result of an ab-
normal condition.
The final and most fundamentally important issue to consider when using descrip-
tive norms is the composition of the normative sample itself. Because descriptive norms
allow us to address questions about how our patient is performing relative to the norma-
tive sample, it is imperative to know what kind of individuals actually make up the refer-
ence group to which the patient is to be compared. For example, is our patient being
compared to a U.S. Census-matched sample of elders (Randolph, 1998; Psychological
Corporation, 1997) or those from a specific geographical area (Ivnik et al., 1996; Ivnik,
Malec, Smith, et al., 1992; Ivnik et al., 1990; Ivnik, Malec, Tangalos, et al., 1992; Ivnik,
Tangalos, et al., 1992; Lucas et al., 1998) or specific ethnic group (Friedman, Schinka,
Mortimer, & Borenstein Graves, 2002; Heaton et al., 2004)? Is the reference group
screened for neurological and psychiatric illnesses (Randolph, 1998; Psychological Cor-
poration, 1997), or does it include elders regardless of their physical and mental health
status (Crum, Anthony, Bassett, & Folstein, 1993) in an attempt to increase its represen-
tativeness? Our inferences about a patient’s level of performance are context-specific and
limit what we can say about the patient’s abilities. The nature and composition of the ref-
erence group is especially important in the case of norms for elder populations and is ad-
dressed in detail later in this chapter.
Diagnostic Use of Norms
Unlike descriptive norms that employ traditional psychometric methods and principles of
central tendency, diagnostic norms use individual comparison standards (Crawford,
Johnson, Mychalkiw, & Moore, 1997) and follow more of the medical, pathognomonic
sign approach (Davison, 1974), in which it is assumed that normal individuals will show
little variability in the performance of a task and that deviations are due to abnormal
conditions. For example, the presence of a visual field defect can be considered
pathognomonic of an abnormality in the visual system, because such defects do not oth-
erwise occur among individuals who are neurologically intact. Errorless or near errorless
performance on a measure of cognitive ability is the comparison standard against which
an individual is compared, with deviations from this expectation representing degrees of
abnormality. Many of our widely used neuropsychological tests are patterned after the
pathognomonic model and can be described as deficit-oriented rather than population-
based tests. Many global measures of cognitive functioning commonly used in the evalua-
tion of mental status with elders fall into this category (e.g., MMSE [Folstein et al.,
1975]; DRS [Mattis, 1988]; Telephone Interview for Cognitive Status [Brandt & Folstein,
2003]; and the Repeatable Battery for the Assessment of Neuropsychological Status
[RBANS; Randolph, 1998]).
The use of individual comparison standards (Crawford et al., 1997) is even funda-
mental to the common practice of pattern analysis in neuropsychological assessment
(Hawkins & Tulsky, 2003; Lezak, Howieson, & Loring, 2004). When analyzing patterns
of individual performance, the focus is not so much on the magnitude of either of the
scores being compared but on the use of one test score to establish expectations regarding
the other score. Since the seminal publication of the “Base rate data for the WAIS-R”
(Matarazzo & Herman, 1984), there has also been a growing appreciation that it is not
enough for the discrepancy between two scores to be statistically significant (reliable), but
the base rate of the difference must also be sufficiently rare to signify an abnormality or
impairment (Chelune, 2002b; Ivnik et al., 2001; Smith, 2002).
It should be clear that the use of diagnostic norms requires a different conceptual
framework and a different set of statistical concepts. We are not so much interested in
how much of an ability a patient has or where the patient falls within the reference group;
rather we seek to know whether a performance is more likely to be characteristic of the
reference group or one that is outside of it (i.e., abnormal; see Chelune, 2002b; Smith,
2002). The utility of diagnostic norms depends heavily on cutoff scores; test-operating
characteristics such as sensitivity, specificity, and positive and negative predictive power;
and statistics such odds ratios, likelihood ratios, and receiver-operating characteristics
(Ivnik et al., 2001; Ivnik et al., 2000).
Because many neuropsychological evaluations are diagnostic in nature, there has
been considerable interest in developing diagnostic norms for tests that are largely popu-
lation-based and primarily designed for descriptive purposes. The approach generally
takes one of two forms, both of which are based on a discrepancy model (Hawkins &
Tulsky, 2003). In some cases a predicted difference method is used in which performance
on one measure is used to predict the expected performance on a second measure, based
on the correlation between these tests in a population-based normative sample. The sig-
nificance of the difference between what is observed and what is expected is then inter-
preted in terms of the frequency of the discrepancy score in the normative sample. The
larger and less frequent a discrepancy between the observed and expected score, the
greater the likelihood that it is clinically meaningful. For example, predicted difference
tables have been provided for the Wechsler Memory Scale–III (WMS-III) for identifying
potentially meaningful memory deficits (Psychological Corporation, 1997). A patient’s
Full Scale IQ score (FSIQ) is used to predict an expected WMS-III performance, and the
discrepancy between the observed and expected memory scores can then be compared to
statistical tables to determine whether the discrepancy is statistically reliable and rela-
tively rare in the standardization sample. This method often mirrors what practitioners
do clinically; that is, they attempt to determine a patient’s premorbid level of functioning
and then look for test scores that appear to deviate from this expected level. This latter
approach is highly subjective and prone to potential errors, but it can be enhanced by us-
ing objective test measures that are assumed to be relatively unaffected by brain dysfunc-
tion. For example, oral reading tests such as the Wechsler Test of Adult Reading (WTAR;
Psychological Corporation, 2001) are often used to assist the clinician in estimating the
patient’s premorbid level of functioning.
The second and most widely used discrepancy approach for translating population-
based norms into those with potential diagnostic value involves the use of demographic
corrections to predict the individual comparison standard for the individual. Because it is
well established that age is inversely correlated with performance on many neuropsy-
chological measures, it is common to correct test performances for the effects of age so as
to avoid misclassifying elders as impaired. However, there is overwhelming evidence that
cognitive test performances in normal adults are also affected by other demographic fac-
tors such as education, sex, and ethnicity (Heaton, Taylor, & Manly, 2003). By adjusting
population-based test norms for demographic factors that are known to affect test perfor-
mance, we can increase the specificity or probability of the test to correctly classify a nor-
mal performance as “normal,” while conversely increasing the sensitivity or probability
of the test to correctly classify an abnormal performance as “abnormal” (Taylor &
Heaton, 2001).
By adjusting norms for relevant demographic factors, we essentially create a pre-
dicted standard against which the individual’s observed performance can be compared.
Deviations from this individual comparison standard can be normally distributed and
may be expressed by T-scores or scaled scores, but they should be interpreted in a unidi-
rectional manner when used diagnostically. Extensive diagnostic norms based on demo-
graphically adjusted individual comparison standards covering the elder age range have
been developed for both population-based tests (e.g., WAIS-III and WMS-III—Psychological
Corporation, 2002; California Verbal Learning Test—Delis, Kramer, Kaplan, & Ober,
2000; Hopkins Verbal Learning Test—Vanderploeg et al., 2000; MicroCog—Powell,
Kaplan, Whitla, Catlin, & Funkenstein, 1993) and deficit-oriented tests and test batteries
(e.g., DRS—Lucas et al., 1998; Schmidt et al., 1994; Wisconsin Card Sorting Test
[WCST]—Heaton, Chelune, Talley, Kay, & Curtiss, 1993; Mayo Older Americans Nor-
mative Studies [MOANS]—Ivnik et al., 1996; Ivnik, Malec, Smith, et al., 1992; Ivnik et
al., 1990; Ivnik, Malec, Tangalos, et al., 1992; Ivnik et al., 1997; Ivnik et al., 1991; Ivnik,
Tangalos, Petersen, et al., 1992; Lucas et al., 1998; Malec et al., 1992; Schmidt et al.,
1994; Expanded Halstead–Reitan Battery—Heaton et al., 2004).
APPROACHES TO NORMS DEVELOPMENT
A number of different procedures has been employed to develop normative data for use
with older populations. The most common approach to norms development is the strati-
fied normative procedure. Although tabled norms can be stratified by using any number
of descriptive variables of import, the most common form of stratification is on the basis
of age: The sample is simply divided into non-overlapping consecutive age bands, with
norms reported for each of the specified age ranges (e.g., 50–59, 60–69; Tombaugh &
Hubley, 1997). Variations of this method have attempted to increase the “representative-
ness” of norms by selecting samples of individuals that closely match the demographic
characteristics of the overall population to which they intend to generalize. For example,
the norms for the WAIS-III and the WMS-III (Wechsler, 1997b) were created using an
age-stratified sampling method in which adults in the sample were selected to match the
U.S. Census data on a number of identified demographic variables (i.e., age, sex, race/eth-
nicity, education level, and geographic location). Still other studies using a simple age-
stratification method have recognized the importance of comparing a patient with spe-
cific demographic characteristics that are underrepresented in the general population to a
specialized population-based normative sample concordant on those demographic fea-
tures. For example, specific age-stratified normative data for the tests in the Consortium
to Establish a Registry for Alzheimer’s Disease (CERAD; Morris et al., 1989) have been
collected for African Americans (Unverzagt et al., 1996), Indians (Ganguli et al., 1996),
and Koreans (Lee et al., 2004).
One of the major limitations of the age-stratification method is that it is often very
difficult to find equal numbers of participants within each age band, unless the study is
conducted in a prospective manner. Hence, the mean for each age block (e.g., 50–59, 60–
69) is unlikely to be truly reflective of the midpoint of that age band. As a result, the dis-
tribution of scores around these age means is not as equidistant as the age bands imply.
Therefore, it is quite possible that the patient one is attempting to evaluate is actually
closer in age to the mean of the adjacent category than to the mean of the age band
within which his or her age actually falls. It is also often the case with this procedure that
the data may not be normally distributed within each non-overlapping age category,
which could result in improper interpretations of a patient’s performance. In addition, if
adjustments must be made to account for significant modifying variables, such as age, ed-
ucation, or sex, the stratification method will require a diverse normative sample as well
as a large number of tables to cover all possible modifier subgroupings (Pauker, 1988).
In order to address some of the limitations inherent in the simple stratification
method, two alternate methods have been suggested: overlapping cell tables (Pauker,
1988) and continuous norming (Gorsuch, 1983; Roid, 1983; Zachary & Gorsuch, 1985).
The former method has been employed in normative studies published out of the
MOANS (Ivnik et al., 1996; Ivnik, Malec, Smith, et al., 1992; Ivnik, Malec, Tangalos, et
al., 1992; Ivnik et al., 1991; Ivnik, Tangalos, et al., 1992). In this method, first proposed
by Pauker (1988), overlapping cell norm tables are created at specified age midpoints.
Hence, cells that are adjacent to one another differ in midpoint means but overlap in
range, allowing any one particular subject to appear in one or more of the adjacent cells.
Although there are redundant cases within each age block, the group means are more sta-
ble, resulting in less abrupt mean shifts between age blocks. This technique maximizes the
amount of useful information that can be gleaned from a sample and is particularly ap-
propriate when sample sizes are relatively small (Pauker, 1988).
Continuous norming, the other alternative to simple stratification, involves a proce-
dure based on the use of polynomial regression-based models in which standard scores or
percentile ranks are predicted rather than calculated (Angoff & Robertson, 1987;
Zachary & Gorsuch, 1985). The norms for tests such as the WCST (Heaton et al., 1993),
those in the Expanded Halstead–Reitan Battery (Heaton et al., 2004), and the demo-
graphically corrected WAIS-III and WMS-III (Psychological Corporation, 2002) are

based on this procedure. Continuous norming first involves derivation of polynomial re-
gression (linear lines or nonlinear curves) equations that best fit the progression of means
and standard deviations across small age subgroups. Combined with estimates of the
mean, standard deviation, skewness, and kurtosis of the distribution of the test variable,
percentile scores and standard scores are then generated. Because the estimators are con-
tinuously based, there are no abrupt shifts between cells, as is often the case when simple
stratification methods are used. As Zachary and Gorsuch (1985) point out, this proce-
dure likely results in better estimates for each age level, because the descriptive statistics
from the entire normative group are used to calculate the normalized distributions within
each age band, whereas the stratification method only makes use of data in each individ-
ual cell in the stratification table. This procedure also helps to correct for irregularities
that may exist within individual age bands, especially when the sample size is small
within a given age band.
Regardless of the method employed, it is important to be mindful of how the norma-
tive sample was selected, how representative the normative data are with regard to a par-
ticular patient, and which approach was used to develop the normative data. Only then
can a test user make an informed decision about the usefulness and applicability of a par-
ticular set of norms for the individual patient being evaluated.
CHALLENGES IN NORMS DEVELOPMENT
Availability of high-quality norms is essential to high-quality clinical practice and re-

search. Although most clinicians and researchers are likely to endorse this statement, few
are likely to be aware of the scope of challenges faced by test developers. Table 6.1 sum-
marizes many of these challenges, which include problems with obtaining funding, the
conceptual conundrums of defining normative populations, and the difficulty of recruit-
ing participants.
Funding and the Origin of Normative Samples

As pointed out by Mitrushina et al. (1999), norms development has traditionally not
been viewed as particularly “scientific” due to the inherently descriptive nature of the
work; therefore, it has not been deemed worthy of research funding or academic support
(p. 5). Consequently, funding and resources available for norms development vary widely.
Psychological tests such as the WAIS-III and WMS-III, which have a broad-based market
or promise of considerable commercial value, are acquired and/or developed by publish-
ing companies that have considerable resources available for norms development. In con-
trast, most neuropsychological measures do not appeal to a large enough audience to af-
ford funding of large-scale, prospective norms development. Many normative studies in
neuropsychology rely on relatively small samples or on samples that do not match na-
tional Census data. For example, five out of eight published normative studies of phone-
mic fluency that employed age stratification or circumscribed age groups had fewer than
45 participants in at least some of their age groups (Axelrod & Henry, 1992; Boone,
Miller, Lesser, Hill, & D’Elia, 1990; Kozora & Cullum, 1995; Norris, Blankenship-
Reuter, Snow-Turek, & Finch, 1995; Yeudall, Fromm, Reddon, & Stefanyk, 1986), and
the remaining three normative studies had between 90 and 100 participants per group
(Gladsjo et al., 1999; Ruff, Light, & Parker, 1996; Selnes et al., 1991). In contrast, the
TABLE 6.1. Challenges to Norms Development

Challenges Issues to consider Effect on norms
Funding of normative • Normative studies not viewed as • Norms as byproduct of research
studies and origin of scientific enough to secure projects
normative samples research funding • Small samples
• Neuropsychological instruments • Local samples
not having broad enough market • Constricted samples (control
base to secure funding from groups for studies)
publishing companies
• Instruments in public domain not
attracting publishing companies
Defining the normative • For a single normative study, • Intranorm incompatibilities

standard participants of different ages are
sampled from different segments
of population
• Different instruments have • Intertest incompatibilities
different purposes and different
normative standards
• Screening for cognitive impairment • Mild cognitive impairment (MCI)
is often defined by absence of individuals included in normative
dementia (e.g., MMSE > 24) samples
Subject recruitment • Methods of recruitment • Unknown effects on sample

vary composition
• Difficulties recruiting elderly • Smaller cells at higher age brackets
participants
WAIS-III norms are comprised of a national sample of 2,450 adults, with 200 partici-
pants in each of 11 age bands from 16–79 years, 150 participants in the 80- to 84-year-
old band, and 100 in the 85- to 89-year-old age band (Wechsler, 1997a).
To complicate matters further, many neuropsychological tests first appear in the re-
search literature and are in the public domain. Because such measures do not initially at-
tract funding from publishing companies, norms for these tests are often the by-product
of research projects that are conducted for purposes other than norms development. As a
result, such norms are generally comprised of samples that come from local, rather than
national, populations. The Trail Making Test (TMT; Reitan & Wolfson, 1985) is a classic
example of these measures. In fact, all but two (Heaton, Grant, & Matthews, 1991;
Heaton, Ryan, Grant, & Matthews, 1996) of 16 TMT normative studies listed in the
Handbook of Normative Data for Neuropsychological Assessment (Mitrushina et al.,
1999) collected data from a single location.
In some cases normative samples for tests originally in the public domain later be-
come commercially available. For example, normative samples from different research
studies with the WCST (Heaton et al., 1993) and the Expanded Halstead–Reitan Battery
(Heaton et al., 2004) have been compiled by investigators and secondarily have been
made commercially available by publishing companies. Because the elders included in
these norms were recruited as controls to match specific parameters of patient groups in
these research projects, they represent a narrow segment of the general population of el-
ders. Although economical, this approach has several potentially serious limitations. For
example, some of the original research studies may have excluded individuals who were
above or below a certain educational level, or only examined those who came from a par-
ticular geographical region or particular socioeconomic group. As a result, the variability
of performance among these normative control groups is apt to be somewhat restricted,

compared to the population as a whole. Although this is not a problem if one is interested
only in a comparison of the experimental (or quasi-experimental) group and the control
group, it may lead to serious misinterpretations of results, should one use such a control
group as a reference for clinical decision making. Test users should therefore be cautious
when comparing an elder patient to these norms, and remember that norms are context
specific.
Defining the Normative Standard

The term norm implies something that is common, standard, and normal. This statement
begs the question, “Normal or standard for what?” There are potentially as many normal
populations as there are assessment questions. For example, the Graduate Record Exami-
nation (GRE; Educational Testing Service, 2004) is designed to aid in the selection of fu-
ture graduate students, and as such its norms were developed on a narrowly defined
group of graduate school applicants. On the other hand, the WAIS-III (Wechsler, 1997a)
is designed for placing individuals’ intellectual performance on the continuum that theo-
retically encompasses the entire U.S. population. As such, this instrument was normed on
a much broader and inclusive sample.
As can be seen from these illustrations, the intended assessment purposes and client/
patient characteristics provide the conceptual framework for the composition of compari-
son populations. This framework must then be operationalized by clearly stated and well-
defined inclusion and exclusion criteria. Inclusion criteria are typically generous and in-
clude points such as being of the appropriate age and able to comprehend instructions.
Greater emphasis is generally placed on exclusion criteria in normative studies of older
adults, and these typically include points such as evidence of recent cognitive decline, his-
tory of central nervous system illnesses or injury, history of medical illnesses or disorders
that are reported to have compromised cognition, and presence of psychiatric disorders,
substance abuse, psychoactive medications, and sensory or motor difficulties (Malec,
Ivnik, & Smith, 1993; Randolph, Tierney, Mohr, & Chase, 1998; Psychological Corpora-
tion, 1997). However, one population-based normative study of the MMSE, involving
the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Pro-
gram, included individuals regardless of their physical or mental health status (Crum et
al., 1993).
It is important to recognize that any given set of exclusion criteria may or may not be
successful at capturing the intended population of interest. Yet, once in place, exclusion
criteria define not only the composition of a given normative sample but also the specific
decisions that can be made about patients. Thus, defining the exclusion criteria may well
represent the single most important decision a test developer makes.
Issues that need to be considered when selecting specific exclusion criteria for nor-
mative studies with older adults include (1) intranorm incompatibilities, (2) intertest in-
compatibilities, and (3) inadvertent inclusion of individuals with incipient dementia or
mild cognitive impairment.
Intranorm Incompatibilities
Intranorm incompatibilities arise when a single set of norms spans a wide range of co-
horts ranging from young adults through older adults. When this happens, differential
exclusion rates within the normative sample may result simply due to the fact that older
adults often have a higher prevalence of many of the typical exclusion criteria. In particu-
lar, the elderly tend to experience declines in cognitive functioning, health status, sensory
acuity, motor control, and functional independence much more frequently than their
younger counterparts (Albert & Moss, 1988; Koltai & Chelune, 1996; Koltai & Welsh-
Bohmer, 2000; Nussbaum, 1995). Consider, for example, the WAIS-III and WMS-III ex-
clusion criterion of “seeing a doctor or other professional for memory problems” (Psy-
chological Corporation, 1997). Although the exact prevalence of voiced memory com-
plaints in a doctor’s office is not known, as many as 25% of those ages 65 and over do
complain of memory difficulties in other settings (Tobiansky, Blizard, Livingston, &
Mann, 1995). Thus, by combining exclusion criteria that have high prevalence among the
elderly, normative samples may end up recruiting individuals from only the highest ranks
of successfully aging older adults, especially when sampling those of the category of old-
est old.
Although selection of only the healthiest individuals for a normative comparison is
not a problem in itself, it becomes problematic when an application of the same exclusion
criteria results in the selection of much more normal or average individuals from the
younger groups. Thus, when norms are developed for a given test on truly normal 40-
year-olds but only superior 80-year-olds, the net result is that any average 40-year-old is
bound to exhibit a spurious normative decline by the age of 80.
Intertest Incompatibilities
Intertest incompatibilities arise when multiple tests designed for different purposes are
used in the same evaluation. Tests that are designed specifically for the elderly do not face
as large a problem with differential exclusion rates among cohorts as do those designed
for populations throughout the lifespan. However, because tests for older adults tend to
be designed for fairly specific purposes (e.g., screening for dementia, screening for mild
cognitive impairment, competency assessment, prediction of functional independence),
they often rely on somewhat disparate normative samples, causing comparisons between
standard scores from different tests to be problematic.
As an example, consider the potential intertest incompatibility between the CERAD
(Morris et al., 1989) battery and the Behavioral Dyscontrol Scale (BDS; Grigsby & Kaye,
1992). The CERAD battery was developed specifically for the purpose of identifying Alz-
heimer’s disease in individuals age 50 and over. As such, its norms were developed on a
group of healthy community-dwelling individuals who were deemed to be cognitively in-
tact, based on obtaining a score above 24 on either the MMSE (Folstein et al., 1975) or
the Short Blessed Test (Katzman et al., 1983). In contrast, the BDS was developed for the
purpose of predicting functional independence among elderly patients who may have suf-
fered a stroke or who may even be in the early stages of dementia. As such, norms for this
instrument were developed on a heterogeneous sample that included both inpatients and
outpatients; only individuals with severe sensory deficits or a history of psychosis were
excluded.
The reader should note that intertest incompatibilities between normative standards
can arise in any comprehensive evaluation, regardless of the age of the patient, and they
have important implications for interpretation. The problem may be particularly acute in
the evaluation of an elder, because each set of norms may define impairment quite differ-
ently. Consider, for example, a 55-year-old patient with early-onset dementia who may be
exhibiting mild cognitive deficit on the CERAD battery. If this patient’s deficit is not sub-
stantial enough to be reflected in the more permissive BDS norms, one might appropri-
ately conclude that the patient may still be safe to live independently. However, although
the results from each of the two tests have their own interpretive value, the two sets of
data cannot be compared side by side. In particular, it would be a mistake for a clinician
to suggest that the above-described patient has experienced a greater decline on the do-
mains assessed by the CERAD battery than on those assessed by the BDS.

Mild cognitive impairment (MCI) has received considerable attention in recent years (see
Smith & Rush, Chapter 2, this volume) as there has been a growing interest in the early de-
tection and prevention of cognitive decline (Brandt, 2001; Petersen et al., 1999). These ef-
forts foreshadow the need for the development of norms that are based on only the most
cognitively intact older adults. However, the definition of cognitively intact appears to be a
moving target. Whereas a number of older normative studies excluded individuals with
MMSE scores below 24 (Bolla-Wilson & Bleecker, 1986; Kozora & Cullum, 1995;
Mitrushina, Satz, Chervinsky, & D’Elia, 1991; Morris et al., 1989), 23 (Ardilla & Rosselli,
1989), or even 20 (Norris et al., 1995), none of these standards may be adequate for future
normative efforts. In particular, MCI patients, by definition, have MMSE scores above 23
(Petersen et al., 1999), and thus much higher standards need to be employed if such individ-
uals are to be excluded from normative samples. Of course, this also means that individuals
with MCI have traditionally been included in many older sets of norms.
Because the main interest in MCI is the identification of individuals with incipient
dementia (Petersen et al., 1999), one possible way of dealing with this issue is to exclude
anyone with either known physical (e.g., hypertension, diabetes, heart disease) or familial
(i.e., family histories of dementia) risk factors for various dementing processes. However,
such norms might exclude normal individuals who are characterized by levels of func-
tioning that are normally low rather than abnormally declining.
As a clever way of excluding individuals with incipient dementia from a normative
sample, Marcopulos, McLain, and Giuliano (1997) conducted a follow-up with a group
of elders who had participated in a normative study 4 years earlier. By reexamining the
normative data after removing those participants who had converted to dementia in the
course of the 4 years, these researchers were able to determine to what degree early de-
mentia participants skewed the norms. Interestingly, the results showed that these indi-
viduals did not appreciably affect the norms. Although studies such as this one lend cre-
dence to our current normative procedures, more work is needed.
Subject Recruitment
Various strategies have been used to attract and recruit participants, including random
telephone calls, advertising in the media, and approaching various community organiza-
tions (e.g., the WAIS-III/WMS-III; Psychological Corporation, 1997), as well as ap-
proaching relatives of patients (e.g., the CERAD battery; Morris et al., 1989). Any of
these methods may be associated with varying amounts of reimbursement for time and
effort and varying degrees of initiative required on the part of the participant (e.g., requir-
ing that participants travel to the place where testing takes place versus conducting test-
ing near or in participants’ homes).
Unfortunately, it is not fully known to what extent different methods of recruitment

affect the final composition of the normative sample. However, one might speculate that
relatives of patients may be particularly conscientious in their performance, if they believe
that the research in which they are participating will ultimately help their loved ones, for
example. On the other hand, participants who are primarily interested in a financial re-
ward may not be motivated to do more than simply put it the time. And finally, partici-
pants who do not receive any financial reward for participation (e.g., the MOANS pro-
ject; Malec et al., 1993) may represent the most prosocially motivated and intellectually
curious from among their cohort.
In addition to potential confounds introduced by different recruitment methods, sim-
ply finding elderly participants who are both free of all exclusion characteristics and will-
ing to participate represents a challenge. In fact, it is not uncommon for normative sam-
ples to shrink in size with increasing age bands. For example, the WAIS-III (Psychological
Corporation, 1997) normative samples for the two highest age groups (80–84 and 85–
89) were only 100 and 75, respectively, as compared to 200 per age group for younger
participants. As an even more dramatic illustration, the MOANS normative sample for
the TMT (Ivnik et al., 1996) drops from over 50 participants among the 56- to 79-year-
olds to only five in the 90- to 95-year age group.
Such decreases in sample size have detrimental effects on the validity of any norms,
but even more so when norms are developed for the elderly. In particular, as people grow
older, the random cumulative effects of education, life experience, illness, medications,
and neurological insults lead to a progressively greater normal variability in cognitive
functioning among individuals, with successfully aging older adults on the one end of the
normal distribution and those exhibiting MCI on the other. As a result, accurately captur-
ing the range of performances among the elderly necessarily requires larger normative
samples. It is unfortunate, then, that it is often the highest age ranges where normative
sample sizes drop off considerably.
USING TEST NORMS WISELY
Even when norms are thoughtfully constructed based on clearly defined populations,
clinicians still face challenges when applying normative data to specific patients. Some
of these challenges include (1) selecting from among many different sets of norms
available in the literature, (2) determining the construct validity of different measures
at different ages, (3) dealing with decreases in test discriminability with an increase in
age, and (4) understanding the complexities of interactions of various moderating fac-
tors.
Multiple Norms
Given the difficulties of funding norms development, selecting appropriate populations,
and recruiting representative participants, it is sometimes the case that norms published
in test manuals may not fully meet the needs of clinicians. To address this issue, supple-
mentary norms have been developed and made available for many tests that are particu-
larly popular among clinicians. Multiple sets of norms are especially common for mea-
sures that are in the public domain, such as the TMT (Reitan & Wolfson, 1985) or
measures that have multiple versions such as the Stroop (Dodrill, 1978; Golden, 1978;
Spreen & Strauss, 1991; Trenerry, Crosson, DeBoe, & Leber, 1989). Thus, for example,
16 normative studies for the TMT have been published between 1968 and 1996, together
spanning ages 15–91 and education from 5 to more than 16 years (Mitrushina et al.,
1999). Similarly, 21 Stroop norms have been developed between 1962 and 1997, together
spanning ages 15–94 and from 8 to more than 18 years (Mitrushina et al., 1999) of edu-
cation.
Because different sets of norms are best suited for different patient populations, test
users need to be thoughtful in selecting the norms that are both psychometrically sound
and most comparable to the characteristics of a given patient. Additionally, different
norms are organized in different formats. For example, whereas some studies use years of
education as a stratification variable (Heaton et al., 1991), others stratify participants ac-
cording to their FSIQ (Dodrill, 1978). This distinction may be important for patients for
whom FSIQ is known and who have been deprived of educational opportunities or have
educationally underachieved for other reasons. Finally, some normative studies may be
characterized by fairly narrow sampling procedures but may nevertheless be of interest
when assessing patients from special groups, such as gay and bisexual men (Miller et al.,
1990) or elderly depressed patients (Boone et al., 1995).
Construct Validity
As previously mentioned, many tests are developed specifically for use with the elderly.
Such tests tend to assess constructs that are relevant for, and have been validated with, el-
derly populations, such as functional independence or the presence of a particular type of
dementia. However, at other times test developers attempt to take a test that was origi-
nally developed for younger adults and make it applicable to elders by simply extending
upward the age range of the normative sample (Heaton et al., 1993; Psychological Cor-
poration, 1997), assuming that the construct being measured remains the same. For pedi-
atric neuropsychologists, this is akin to test developers assuming that norms for a test
originally developed for adults can simply be extended downward for children. When this
is attempted, even the best normative data will not address potential problems with the
validity of the constructs measured.
It is well recognized that qualitative aspects of cognition, and thus the constructs we
measure, change with age (Sattler, 2001). Evidence for such change can be gleaned from
results of factor analytic research, wherein different factor structures may be identified
with different age groups. For example, an examination of factor loadings reported in the
WAIS-III/WMS-III Technical Manual (Psychological Corporation, 1997) reveals that the
Picture Arrangement, Block Design, and Picture Completion subtests all load on the Per-
ceptual Organization factor for individuals under the age of 75 but on the Processing
Speed factor for individuals 75 and over. Direct statistical examination of longitudinal
and cross-sectional invariance in the factor structure of many tests has repeatedly demon-
strated that the factor structures of the youngest and the oldest groups tend to differ from
each other (Schaie, Maitland, Willis, & Intrieri, 1998), whereas a reasonably stable factor
structure is present in the middle age groups. Thus test users need to exercise care in how
they interpret poor performances on a variety of indices among very old adults, because
the construct for which the index is named may be somewhat different. Furthermore,
careful consideration also needs to be given to a variety of possible intervening variables
that may contribute to changes in constructs, such as peripheral motor and sensory prob-
lems or alteration in insight and motivation.
Discriminability and Floor Effects

Problems with limited discriminability due to floor effects tend to arise when norms for a
test developed for younger populations are simply extended upward for application to
the elderly. An example of this problem is the Logical Memory subtest of the WMS-III
(Wechsler, 1997c). An 85-year-old who only recalls one story detail after a delay receives
a scaled score of 5. However, another 85-year-old who, after a delay, does not recall hav-
ing heard any stories, let alone recalling specific details, also receives a scaled score of 5.
A naïve clinician may interpret both performances as being in the borderline range if he
or she relies on scaled scores alone, although in reality the latter case more likely repre-
sents a significant impairment of memory. An even more dramatic example of floor ef-
fects can be seen with the Verbal Paired Associates subtest of the WMS-III (Wechsler,
1997c). Here, an 85-year-old can recall anywhere between zero and two words to receive
a scaled score of 6, a score that falls in the low end of the low-average range.
To address this problem test users need to examine raw scores as well as carefully
consider behavioral observations and pathognomonic signs; in addition, they should sup-
plement their batteries with tasks that are more appropriate for elders. However, it
should be noted that reasonably interpretable scores can be achieved on Logical Memory
II of the WMS-III up to the age of 74, where recall of zero or one story detail results in
scaled scores of 1 and 2, respectively.
Interaction of Age with Other Moderator Variables

Another complication in casually using norms when evaluating older adults arises from
the fact that some exclusion criteria may interact with demographic factors. For example,
consider how dementia screening may interact with ethnicity at different age ranges (see
Manly, Chapter 8, this volume). At the younger age range, it is unlikely that many indi-
viduals would be found to be demented. With increasing age, some volunteers would be
screened out due to suspected dementia. However, the gap between the educational op-
portunities of the ethnic minority and the ethnic majority also increases with age, simply
as a function of changing historical and political milieu. In other words, ethnic differ-
ences in cognitive performance increase with age, resulting in an overexclusion of many
ethnic minority volunteers due to suspected dementia (Baker, 1996).
A similar situation arises when the MMSE cutting score of 24 is applied across the
board with the goal of screening out volunteers with cognitive difficulties. In particular,
the work of Crum and colleagues (1993) has shown that the combined effects of age and
education can account for as many as 11 points on this instrument. For example, individ-
uals with fewer than 4 years of formal education perform at 24 or below at all but two
age groups, and as such, would virtually always be screened out of normative studies. On
the other hand, individuals with 5–8 years of education perform above 26 at all but the
highest age bracket (i.e., > 84), possibly resulting in underrepresentation of this particular
age group in the normative sample. Because such interaction effects are not always fully
outlined in test manuals or studies reporting normative data for the elderly, test users
need to use their own judgment when considering the particular demographic character-
istics of their patients and how well or poorly these might be represented in a given nor-
mative sample.
As these challenges demonstrate, test users need to exercise careful judgment when
selecting norms for their patients. Not only is it important to consider whether a given set
of norms matches the characteristics of a patient, it is equally important to think carefully

about the purpose of the assessment and the questions one is attempting to answer. For
example, if the question concerns an 84-year-old patient’s ability to live independently,
then such a patient should best be compared to a sample of 84-year-old independent com-
munity-dwellers. On the other hand, if the question is whether or not the patient is suffer-
ing from dementia, the use of norms that are based on nondemented 84-year-olds, re-
gardless of their functional status, may be more appropriate.
SERIAL ASSESSMENT WITH THE ELDERLY
Evaluation of an elder’s cognitive status not only requires appropriate test procedures but
normative data that are also appropriate. As we have seen, there are many factors to con-
sider when applying normative information to older adults. There are additional issues to
consider when cognitive tests are used serially.
Neuropsychological tests are typically designed only to assess the current capacity or
state of the individual. Still, there are many situations in which neuropsychological proce-
dures are administered serially to monitor changes in cognitive status or function over
time. This is especially the case in relation to elders, for whom the accurate diagnosis of
dementia is better characterized by a pattern of test–retest change than cognitive perfor-
mance at any one point in time (Desmond, Moroney, Bagiella, Sano, & Stern, 1998;
Sawrie, Marson, Boothe, & Harrell, 1999). Cognitive rehabilitation programs for the el-
derly and clinical trials research aimed at identifying meaningful cognitive change after an
intervention or treatment also rely on serial assessments (Gonzalez-Torrecillas, Mendel-
wicz, & Lobo, 1995; Koltai & Chelune, 1996; Koltai & Welsh-Bohmer, 2000; Yesavage,
1985). Until recently, test users have simply attempted to deduce meaningful change by
comparing a patient’s current test scores against his or her baseline scores, often with
only superficial attention to factors such as practice effects, measurement error, or regres-
sion to the mean (Chelune, 2002a, 2002b; Lineweaver & Chelune, 2003). Fortunately,
pressures from the emerging evidence-based medicine movement (Sackett, Straus, Rich-
ardson, Rosenberg, & Haynes, 2000) have led to a growing body of empirical methods
for assessing reliable change; these methods can be used in both research and clinical
practice at the level of the individual (Chelune, 2002a; Maassen, 2000, 2004; Murkin,
2001; Timken, Heaton, Grant, & Dikmen, 1999).
Basic Considerations: Bias and Error

In the absence of a significant intervening event, a person’s test performance should be
the same at retest as it was at the time of original administration. However, tests do not
have perfect stability and reliability, and we must deal with their statistical counter-
parts—bias and error. Bias represents a systematic change in performance; for a cognitive
test given two or more times, the most common cause of change is a positive practice ef-
fect, in which performance is enhanced by previous exposure to the test materials. When
large practice effects are the norm, the absence of change may actually reflect a decrement
in performance (Chelune, 2002a). Simply lengthening the test–retest interval does not
necessarily eliminate the effects of practice because significant retest gains have been
noted among the elderly tested over even 1- to 2-year test–retest intervals (Ivnik et al.,
1999; Sawrie et al., 1999). As is discussed later in this section, normal aging itself is a
form of systematic bias that may interact with practice (Barrett, Chelune, Naugle, Tulsky,
& Ledbetter, 2000; Chelune et al., 1999; Lineweaver & Chelune, 2003). Failure to take
into account expected practice effects could lead to serious errors in interpretation. For
example, the absence of an expected test–retest change in an elder suspected of early de-
mentia could be seen as signifying stability and delay early intervention, when, in fact, the
elder’s cognitive function may have deteriorated from expected retest levels. Conversely,
the presence of an increase in test performance following a cognitive intervention might
be interpreted as a positive treatment outcome when, in fact, the change may be merely
the result of practice.
In addition to the systematic bias introduced by practice effects, cognitive tests them-
selves are imperfect tools and can introduce an element of error across serial administra-
tions. For our discussion here, we consider two sources of imprecision in measurement,
both of which are inversely related to a test’s reliability (Chelune, 2002a). The first is the
standard error measurement—that is, the distribution of random variations in a test score
around the true score. The second source of error is regression to the mean—that is, the
susceptibility of retest scores to regress toward the population mean. The more a baseline
score deviates from the population mean, the more it is likely to regress toward the mean
on retest as a function of the test’s reliability. Retest performances on measures with less
than what is typically considered good test–retest reliability (e.g., > .80) can vary widely
simply on the basis of error, possibly obscuring or exaggerating true change.
Solutions
Our ability to detect meaningful test–retest changes as the result of disease progression,
recovery of function, intervention, or treatment requires us to separate the effects of bias
and error on test performance from the effects of the variable of interest. Use of alternate
test forms has been suggested as an effective means for avoiding or minimizing practice
effects. Although well-constructed alternate forms may attenuate the effects of content-
specific practice effects for some measures (Benedict & Zgaljardic, 1998; Delis et al.,
2000), research still demonstrates significant practice gains (Franzen, Paul, & Iverson,
1996; Goldstein et al., 1990; Ruff et al., 1996) because alternate forms do not control for
procedural or skill-based learning (i.e., test-taking strategies) and other factors (e.g., fa-
miliarity with the testing context and examiner, performance anxiety) that contribute to
the overall practice effect. Furthermore, alternate forms do not address the issues of reli-
ability and error. Thus alternate forms do not necessarily remedy the psychometric chal-
lenges inherent in serial assessments, prompting the development of methods of reliable
change that better account for test–retest bias and error.
Reliable change methods are statistical procedures (Basso, Bornstein, & Lang, 1999;
Chelune, Naugle, Luders, Sedlak, & Awad, 1993; Dikman, Heaton, Grant, & Timken,
1999; Hermann et al., 1996; Iverson, 2001; Jacobson & Truax, 1991; McSweeny,
Naugle, Chelune, & Luders, 1993; Sawrie, Chelune, Naugle, & Luders, 1996) that at-
tempt to describe the spread or distribution of test–retest change scores that would be ex-
pected to occur in the absence of true change. It is beyond the scope of this chapter to de-
tail these methods here, but the interested reader can refer to Chelune (2002a) for a
detailed discussion on how to calculate many of these reliable change measures. In their
simplest form (Chelune et al., 1993; Iverson, 2001; Ivnik et al., 1999; Jacobson & Truax,
1991; Timken et al., 1999), reliable change indices focus on the observed or estimated
mean and standard deviation of the difference (change) scores between time 1 and time 2
rather than the actual obtained test scores. These approaches are univariate and can take
into account mean practice effects and measurement error, but not regression to the
mean, and can define the magnitude of change necessary to be considered sufficiently rare
so as to be meaningful (e.g., a change that would be expected to occur by chance in only
5% of a given test–retest population). In more complex models (Barrett et al., 2000;
Chelune et al., 1999; Hermann et al., 1996; Lineweaver & Chelune, 2003; McSweeny et
al., 1993; Sawrie et al., 1996; Sawrie et al., 1999), multivariate regression procedures are
used to create standardized regression-based norms for change that build into the regres-
sion equation (1) the effects of practice, measurement error, and regression to the mean;
(2) differences in baseline scores between subjects, and (3) demographic variables that
can differentially affect the magnitude of test–retest change.
Although the use of reliable change methods is increasingly being used in outcome
research (Hermann et al., 1996; Kneebone, Andrew, Baker, & Knight, 1998; Sawrie et al.,
1996; Timken et al., 1999), only a few studies have been explicitly conducted among el-
ders. Ivnik and colleagues (1999) present data and univariate reliable change index scores
for the Mayo Cognitive Factor Scale scores on a sample of elders that was tested three or
four times at 1- to 2-year intervals. These data clearly demonstrate statistically significant
retest gains among the elders from time 1 to time 2, with performances beginning to pla-
teau between times 2 and 3. Reliable change indices are also presented for defining the
upper and lower cutoff scores for deciding whether a cognitive factor has shown a reli-
able change over the test–retest interval. Sawrie and associates (1999) developed stan-
dardized regression-based norms for a small group of normal elders tested twice over a 1-
year interval on measures such as the DRS, subtests from the WAIS-R (Wechsler, 1981)
and WMS-R (Wechsler, 1987), and common language measures such as the BNT. The
multiple Rs for these equations were generally high (> .81), with sex and ethnicity enter-
ing, along with baseline scores, to predict expected retest scores.
Standardized regression-based norms have been also developed for the WAIS-III and
WMS-III (Barrett et al., 2000; Chelune et al., 1999; Lineweaver & Chelune, 2003), albeit
from standardization data covering the adult lifespan (ages 16–89) and with very short
test–retest intervals (2–12 weeks; Psychological Corporation, 1997). Whereas baseline
scores were the primary predictor of retest performance in all of the equations, age, edu-
cation, and sex also entered into many of the equations, suggesting that test–retest
changes in cognitive performance are moderated by demographic factors. It is important
for test users to note that age was an important predictor of test–retest change in many of
these equations, even though the Wechsler scores themselves are age-corrected at time 1
and time 2; that is, age appears to moderate the amount of score inflation that can be ex-
pected from repeated exposure to the Wechsler test materials. Examination of the beta
weights for age in these equations indicates that the magnitude of score inflation de-
creases with increasing age. Thus application of simple reliable change methods that treat
practice as a constant may be especially inappropriate in an aging population, where in-
creasing age may offset expected gains due to repeated exposures to the test material
(Chelune, 1998).
CONCLUSIONS
With the growing numbers of elders in the United States, neuropsychologists will un-
doubtedly be called upon increasingly to perform evaluations to answer diagnostic issues
and questions concerning functional capacity. In the last decade there has been an influx
of tests and normative data for use with even the oldest of the old. However, the accuracy
and utility of our evaluations will depend on the capacity of test users to skillfully inter-
pret their test results within the context of available normative information.
In this chapter we have not attempted to provide a survey of available tests for use
with elders or to provide an encyclopedic critique of available normative samples. Rather,
by presenting a discussion of the nature and purpose of norms, how norms are obtained
and developed, the nuances of defining the normative standard, and issues inherent in se-
rial assessment among the elderly, we have attempted to provide a conceptual guide for
evaluating the nature and adequacy of available norms for use with elder populations.
We may be limited to the tests and norms currently available, but we can nonetheless
practice in a more informed manner by better understanding and recognizing the nature
of our normative information.
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7
Functional Assessment
DANIEL MARSON
KATINA R. HEBERT
T he population of the United States is aging rapidly, with the old-old representing the
fastest growing segment of the population and those at greatest risk for poor health and
functional impairment (Angel & Frisco, 2001; Fitten, 1999; Fowles, 1991; Lichtenberg
& Nanna, 1994). One of the most salient and growing concerns in the field of gerontol-
ogy is the steep rise in prevalence rates of functional incapacity among older adults,
particularly those over the age of 85 (Wiener, Hanley, Clark, & Van Nostrand, 1990).
Functional capacity represents a wide range of everyday skills and abilities that are neces-
sary for independent living within the home and community. These skills include basic,
routine physical self-care activities as well as more cognitively complex behaviors such as
financial management skills, use of transportation, and medication management.
Although cognition informs both the development and exercise of simple and, in
particular, higher-order functional abilities, it also remains conceptually and analytically
distinct from them. Functional incapacity in the elderly may occur with or without corre-
sponding declines in cognition. Impaired sensory processes, acute or chronic medical ill-
ness, or any other physical limitation or injury affecting strength, balance, mobility, con-
centration, and endurance may adversely impact functional performance (Loewenstein &
Mogosky, 1999). However, for both physically and cognitively impaired older adults,
functional outcomes are critical to assessment of overall disability and to appropriate res-
idential placement decisions (Royall, Chiodo, & Polk, 2000). Therefore, it is important
that functional performance be defined, measured, and interpreted separately from cogni-
tive performance.
At the same time, a large proportion of functional decline in the elderly is intimately
linked to cognitive change. A major risk factor for functional decline in older adults is a
progressive neurodegenerative dementia such as Alzheimer’s disease (AD), whose inci-
dence increases dramatically with age (Angel & Frisco, 2001; Demers, Oremus, Perrault,
Champoux, & Wolfson, 2000; Marson & Briggs, 2001). Functional change is a key diag-
nostic requirement for dementia diagnosis as well as for determining conversion from
158
Functional Assessment 159
mild cognitive impairment (MCI) to dementia (Griffith et al., 2003). In order to assign a
diagnosis of AD, the Diagnostic and Statistical Manual of Mental Disorders—Fourth
Edition (DSM-IV) of the American Psychiatric Association (1994) requires that an indi-
vidual demonstrate a gradual decline in memory and cognition and also significant im-
pairments in social and occupational functioning. Likewise, the National Institute of
Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease Related Dis-
orders Association (NINCDS–ADRDA) criteria for AD-type dementia require evidence
of impaired functional abilities in addition to declines in memory and cognition
(McKhann et al., 1984).
In the case of patients with MCI, current clinical diagnostic criteria suggest that
functional capacity is essentially preserved at the outset of the condition (Petersen et al.,
1999). One must consider, however, whether the absence of functional decline as an MCI
criterion reflects a true preservation of functional abilities in the face of clinically signifi-
cant memory loss or a lack of objective measures or expertise to detect subtle prodromal
changes in functional performance. Moreover, it is increasingly clear that MCI is a dy-
namic transitional period during which cumulative cognitive and functional change oc-
curs. Whereas an individual at “entry” into MCI may have only focal memory impair-
ment and little or no impairment in instrumental activities of daily living, the same
individual at MCI “departure” (conversion to early AD) will have cognitive impairments
well beyond memory and also notable declines in IADLs (Griffith et al., 2003). Not sur-
prisingly, recent studies have found mild but salient functional deficits in financial capac-
ity and other higher-order IADLs among persons with MCI (Albert et al., 1999; Daly et
al., 2000; Griffith et al., 2003; Petersen et al., 1999; Tabert et al., 2002; Touchon &
Ritchie, 1999). Thus any diagnostic assessment of individuals with suspected dementia or
MCI needs to incorporate a meaningful assessment of functional capacity (Loewenstein
& Mogosky, 1999). Such assessments also have practical value in determining appropri-
ate living arrangements and planning both acute and long-term health care as well as esti-
mating life expectancy (Angel & Frisco, 2001; Loewenstein & Mogosky, 1999).
Despite its clear importance, the evaluation of functional status has been a largely
neglected aspect of geriatric neuropsychological assessment and of neuropsychology gen-
erally. For reasons of history and training, neuropsychologists have tended to focus al-
most entirely on cognitive and personality changes in normal and abnormal aging, with
far less attention paid to functional outcomes and to the interrelationships of cognitive
and functional changes. In our personal experience, few neuropsychologists routinely in-
clude measures of everyday function to complement the multitude of other cognitive and
personality tests employed as part of their test battery. The field’s emphasis here is slowly
beginning to change, as witnessed by the increasing number of functional assessment in-
struments available to neuropsychologists and the growing literature examining specific
kinds of functional change across a range of neurocognitive disorders (Marson, 2002). In
particular, over the past two decades functional assessment in the specific form of civil
competency/capacity assessment has emerged as a distinct field of clinical and forensic
practice and research and has engaged the attention of neuropsychologists as well as
those in other professional disciplines (Grisso, 2003; Marson, 2002; Marson & Briggs,
2001; Marson & Ingram, 1996).
The time is thus appropriate for a closer examination of the role of functional assess-
ment in geriatric neuropsychology. In this chapter we begin with a conceptual overview
of functional assessment in the elderly and address the fundamental domains of activities
of daily living (ADLs) and instrumental activities of daily living (IADLs). As part of this
overview we discuss different approaches to assessment of these functional abilities (i.e.,

self- and informant report, direct psychometric assessment). We then examine literature
related to cognition and everyday functioning in the elderly, organized into areas of cog-
nitive aging, MCI, and dementia. The remainder of the chapter focuses on four specific
functional capacities that geriatric neuropsychologists frequently encounter. These are
medical decision-making capacity, financial capacity, testamentary capacity (i.e., capacity
to make or change a will), and driving capacity. Here we review applicable conceptual
models, instrument development, empirical group studies, and relevant neuropsychologi-
cal predictor models. We then provide an overall summary of the chapter and indicate fu-
ture directions for research. The goal of the chapter is to increase the practitioner’s
knowledge and appreciation of the value of functional assessment in clinical neuropsy-
chological research and practice.
CONCEPTUAL OVERVIEW OF FUNCTIONAL ABILITIES IN DEMENTIA

Defining Functional Capacity
As our society ages and the incidence of degenerative dementias such as AD rises, clinical
assessment of functional capacity has become increasingly important (Marson, Dymek,
& Geyer, 2000). Functional capacity represents a range of everyday skills and abilities
that enable a person to live independently within the home and community (Loewenstein
& Mogosky, 1999). Functional abilities have traditionally been divided into two broad
classes: ADLs and IADLs (Angel & Frisco, 2001; Lawton & Brody, 1969; Loewenstein &
Mogosky, 1999). As discussed below, ADLs involve basic self-care skills such as dressing,
grooming, personal hygiene, and toileting, whereas IADLs involve more cognitively com-
plex activities such as managing finances, using transportation, doing laundry, making
health care decisions, and managing one’s medications (Wolinsky, Callahan, Fitzgerald,
& Johnson, 1993).
ADLs and IADLs exist on a functional continuum and primarily reflect a method of
categorization rather than independent constructs (Wolinsky & Tierney, 1998). At the
same time, as discussed further below, IADLs are distinguishable from ADLs by their de-
gree of cognitive complexity and their pattern of acquisition and loss (Loewenstein &
Mogosky, 1999; Reisberg et al., 1984; Reisberg, Ferris, & Franssen, 1985; Spector, Katz,
Murphy, & Fulton, 1978; Stern, Hesdorffer, Sano, & Mayeux, 1990). Acquisition of
functional abilities mirrors stages of cognitive development, with basic ADLs being ac-
quired before more complex IADLs (Katz & Akpom, 1976; Spector et al., 1978). Simi-
larly, recovery of basic ADLs precedes recovery of more complex IADLs (Katz, Downs,
Cash, & Gratz, 1970) in traumatic brain injury (Olver, Ponsford, & Curran, 1996;
Sohlberg & Mateer, 1989), whereas complex IADLs demonstrate an earlier and faster
rate of decline than ADLs in AD-type dementia (DeBettignies, Mahurin, & Pirozzolo,
1993; Reisberg et al., 1984; Reisberg et al., 1985; Stern et al., 1990; Willis, 1996). In the
following section we describe ADLs and IADLs in more detail and discuss the neurocog-
nitive basis associated with each of these functional domains.
Activities of Daily Living

ADLs comprise a limited set of basic, everyday physical self-care activities such as bath-
ing, grooming, dressing, eating, getting from the bed to a chair, using the toilet, and walk-
ing across the room (Loewenstein & Mogosky, 1999; Wiener et al., 1990). These activi-
ties rely on procedural memory skills and basic motor programming (Patterson et al.,
1992). As such, ADLs may be classified as automatic behaviors that require little con-
scious attention and can be performed simultaneously with other tasks (Jorm, 1986).
ADLs are acquired early in childhood and remain relatively intact until late life in
normal aging (Grigsby, Kaye, Baxter, Shetterly, & Hamman, 1998; Marsiske & Willis,
1995). They are also somewhat resilient to dementia, with declines emerging only in the
later stages of AD and related dementias (Cohen-Mansfield, Werner, & Reisberg, 1995;
Galasko et al., 1997; Reisberg et al., 1984). Patients with mild AD may perform equiva-
lently with age- and education-matched nondemented individuals on ADL measures
(Patterson et al., 1992; Vitaliano, Breen, Albert, Russo, & Prinz, 1984; Willis et al.,
1998). Frank impairment of ADLs, therefore, is thus very often a cardinal sign of proba-
ble dementia—as long as the source of the impairment is cognitive. Care must always be
exercised in interpreting ADL impairment in older adults, because impairment associated
with declines in physical abilities is not indicative of a dementia (Patterson et al., 1992).
The clinician must determine if poor performance on an ADL measure reflects cognitive
decline or a loss of physical ability unassociated with dementia (Patterson et al., 1992).
ADLs have proven to be an important index of disability in the elderly. Research has
found that impaired ADL functioning is associated with greater caregiver burden, higher
rates of institutionalization, and subsequent mortality (Goode, Haley, Roth, & Ford, 1998;
Wolinsky et al., 1993). Furthermore, an increasing number of private long-term care insur-
ance policies use ADL measures in determining qualification for benefits, and similar prac-
tices have been proposed for public insurance programs as well (Wiener et al., 1990).
Instrumental Activities of Daily Living

In addition to ADLs, individuals must acquire and use more complex skills in order to
function independently within home and community settings (Loewenstein & Mogosky,
1999). These skills include managing finances, managing medications, making medical
treatment decisions, and using transportation. Although IADLs and ADLs exist on the
same functional continuum, IADLs are conceptually and statistically distinct from ADLs,
and this distinction is directly related to the cognitive demands of these respective abilities
(Loewenstein & Mogosky, 1999; Spector et al., 1978). Put differently, whereas ADLs
consist of a limited set of basic, daily self-care activities that rely primarily on automatic
processing and procedural memory, IADLs comprise tasks that require controlled pro-
cessing and executive function as well as procedural memory (Patterson et al., 1992).
IADL skills are acquired in later stages of human development than ADLs (Spector
et al., 1978) and can be linked to frontal-lobe development (Bell-McGinty, Podell,
Franzen, Baird, & Williams, 2002; Cahn-Weiner, Malloy, Boyle, Marran, & Salloway,
2000; Chen, Sultzer, Hinkin, Mahler, & Cummings, 1998; Grigsby et al., 1998). In con-
trast to ADLs, impairments in complex IADLs are evident in the preclinical and early
stages of AD (Griffith et al., 2003; Patterson et al., 1992). This pattern of functional im-
pairment is consistent with the course of cognitive decline observed in AD, in which fluid
intelligence, executive functions, and controlled processing begin to decline at an earlier
and faster rate than crystallized intelligence and automatic processing (Willis, 1996).
Household Activities of Daily Living. IADLs may be further divided into the two
subsets of “household” ADLs and “advanced” IADLs (Lawton, 1990). Household ADLs
involve those skills that are specific to maintaining the home environment, such as shop-
ping for food and other necessities, preparing meals, engaging in light and heavy house-
work, and doing laundry. Household ADLs differ from other IADLs in that performance
ratings may more accurately reflect gender roles of specific age cohorts (Lawton, 1990;
Rubenstein, Schairer, Wieland, & Kane, 1984; Teunisse, 1995). For example, older adults
typically subscribed to traditional roles in which the husband rarely engaged in house-
hold ADLs, leaving these responsibilities to the wife. As such, measures of IADL perfor-
mance that incorporate household ADLs employ different norms for men than women
(Lawton & Brody, 1969; Rubenstein et al., 1984).
Advanced Independent Activities of Daily Living. Advanced IADLs differ from ba-
sic and household ADLs in that they engage higher-order cognitive abilities that require
greater levels of neuropsychological organization in addition to the routine motor move-
ments and scripts common to ADLs (Marson, 2001a; Wolinsky & Johnson, 1991).
Driving or using public transportation, managing finances, managing medications, and
making medical treatment decisions are examples. Recent research suggests that declines
in advanced IADLs are evident in preclinical and early dementia of the AD type
(Barberger-Gateau, Fabrigoule, Helmer, Rouch, & Dartigues, 1999; Griffith et al., 2003;
Marson, 2001a; Marson, Sawrie, et al., 2000). Declines in advanced IADLs differentially
predict the frequency of hospital contact, nursing home placement, and mortality
(Wolinsky & Johnson, 1991). An assessment of an individual’s ability to carry out ad-
vanced IADLs is an essential component of appropriate diagnostic judgments and opin-
ions concerning an individual’s ability to live independently.
Methods of Assessing ADL and IADL Functioning

As was previously mentioned, a diagnosis of dementia based upon both DSM-IV (Ameri-
can Psychiatric Association, 1994) and NINCDS–ADRDA (McKhann et al., 1984) crite-
ria is contingent upon impairments in functional ability in addition to changes in memory
and cognition. As such, reliable and valid measures of functional ability are essential to
proper diagnosis of dementia. Measures of functional assessment also provide informa-
tion relevant to symptom management in AD, the making of placement decisions, and the
determination of the level of assistance needed for patients with AD living in the commu-
nity (DeBettignies et al., 1993; Demers et al., 2000).
Numerous measures of ADL and IADL functioning have been designed. In fact,
more than 40 different measures have been described in the literature (Kluger & Ferris,
1991). These measures can be organized into three types: self-report and caregiver/infor-
mant report, performance-based functional assessments, and clinician rating measures
(Loewenstein & Mogosky, 1999). Specific descriptions of these measures and their ad-
vantages and limitations are available (Demers et al., 2000; Kluger & Ferris, 1991;
Loewenstein & Mogosky, 1999). In the following sections, we describe self-informant re-
port and direct assessment methods.
Self- and Informant Reports

Self- and informant reports are the most commonly used methods for assessing functional
abilities of older adults. These instruments involve the patient or (more typically) a care-
giver or other knowledgeable informant (i.e., proxy) to provide ratings of the patient’s
ability to perform basic self-care and complex instrumental activities at home and in the
community. Respondents are asked to indicate whether the individual with AD can per-
form a series of activities with or without the help of someone or the use of a special de-
vice (Angel & Frisco, 2001). The degree of functional disability is measured by both the
number of activities with which the individual needs assistance and the amount of help
needed to complete each activity (Angel & Frisco, 2001). Caregivers and proxy infor-
mants are believed to be in the best position to provide such ratings, because they observe
the functional behavior of patients within the home environment on a daily basis
(Loewenstein & Mogosky, 1999). Furthermore, in contrast to results of performance-
based measures of ADLs and IADLs, which may fluctuate as a function of patients’ moti-
vation, cognition, and behavior (DeBettignies et al., 1993), caregiver observations of pa-
tient functioning in an everyday environment across time are assumed to result in more
stable estimates of functional skills and limitations (Loewenstein & Mogosky, 1999).
On the other hand, self- and caregiver judgments of functional ability suffer a num-
ber of limitations (DeBettignies et al., 1993; Rubenstein et al., 1984; Wadley, Harrell, &
Marson, 2003; Wild & Cotrell, 2003). Research has shown that dementia patients, like
hospitalized elders, tend to consistently overestimate their functional abilities (Rubenstein
et al., 1984; Wadley et al., 2003; Wild & Cotrell, 2003). In addition, caregivers have been
found to significantly misestimate the everyday functioning of individuals with AD, re-
sulting in low to moderate correlations with performance-based functional assessment
measures (Angel & Frisco, 2001; Wadley et al., 2003; Wild & Cotrell, 2003). For in-
stance, Wadley and colleagues (2003) found that caregiver ratings of current financial
abilities demonstrated low levels of stability over a 1-month period. In addition,
DeBettignies and colleagues (1993) found that spousal caregivers of individuals with AD
overestimated functional impairment in comparison to spouses of individuals with multi-
ple infarcts and healthy older adult controls. Other studies have found that caregivers un-
derestimated functional impairments of individuals with AD, specifically related to driv-
ing and handling finances (Wadley et al., 2003; Wild & Cotrell, 2003). This pattern of
misestimation among caregivers has been linked not only to patient cognition but also to
fluctuations in caregivers’ mood, their perceived level of burden, and their use of denial as
an adaptive mechanism (DeBettignies et al., 1993; Ippen, Olin, & Schneider, 1999; Sager
et al., 1992). Despite these limitations, self- and caregiver/informant ratings are still com-
monly used because of their minimal cost and relative ease and brevity of administration
and scoring (Angel & Frisco, 2001; Loewenstein & Mogosky, 1999).
Performance-Based Assessments
In contrast to self- and informant rating scales, performance-based measures require that
individuals with AD actually perform a series of tasks relevant to everyday living, as ad-
ministered by a trained examiner (Angel & Frisco, 2001). Performance-based functional
assessment measures have several advantages over self- and informant ratings (Zimmer-
man & Magaziner, 1994). These measures gauge actual abilities equivalent to those per-
formed in the home environment in a way that is psychometrically objective, quantifi-
able, repeatable, and norm referenced. As such, the results of these measures are
generalizable across patients and assessment settings and provide objective information
to the clinician. Performance-based assessment also provides information regarding the
elements of specific functional tasks that can be highly relevant to the formulation of
tailored recommendations and treatment strategies. Finally, performance-based measures
are not affected by the reporter bias that is inherent to self- and proxy report measures.
Therefore, it is recommended that performance-based measures of ADL and IADL func-
tioning be used regularly to inform and augment self- and informant-based measures of
functional decline (Loewenstein & Mogosky, 1999; Wadley et al., 2003).
A criticism of performance-based functional assessment concerns possible limited
ecological validity in relation to the patient’s everyday environment (DeBettignies et al.,
1993; Loewenstein & Mogosky, 1999). In contrast to a laboratory setting, patients’
homes and community environments provide contextual cues that may assist individuals
with AD or MCI in successfully completing functional tasks (Loewenstein & Mogosky,
1999). In addition, home and community environments also present distractions and
competing demands that can interfere with patients’ abilities to perform everyday tasks.
As such, results of performance-based measures of ADLs and IADLs may either underes-
timate or overestimate the actual ability of individuals with AD to perform basic self-care
and more complex instrumental tasks in their home environments. Furthermore, these
measures, as opposed to self- and informant rating scales, are more difficult to adminis-
ter, require special equipment and training, and are both time consuming and costly
(Angel & Frisco, 2001; Sager et al., 1992). Lastly, some researchers have questioned the
degree to which performance-based assessments detect subtler functional deficits in MCI
and very mild AD (Loewenstein & Mogosky, 1999). However, this concern is likely due,
in part, to the insensitivity of some performance-based tasks to detect these subtle perfor-
mance deficits (Griffith et al., 2003; Loewenstein & Mogosky, 1999; Marson & Briggs,
2001). For example, functional impairments in MCI and very mild AD have been de-
tected using measures that assess more cognitively demanding tasks, such as financial ca-
pacity and driving (Griffith et al., 2003; Marson, Sawrie, et al., 2000; Wild & Cotrell,
2003).
Conceptualizing Independent Living Skills through a Functional

Disability Framework
Functional disability, as defined by the World Health Organization (1980), is any restric-
tion or inability to perform an activity in a manner consistent with the individual’s partic-
ular stage of sociobiological or cognitive development (Demers et al., 2000). Difficulty in
performing one or more physical self-care or independent daily living skills qualifies as
functional disability. The degree of functional disability is contingent upon the number of
activities that are impaired as well as the amount of help needed to complete the activity
(Angel & Frisco, 2001; Patterson et al., 1992). Individuals who require only verbal
prompting to initiate or complete a task are qualitatively different in terms of functional
disability than individuals who require actual physical guidance. Furthermore, an indi-
vidual’s level of previous experience with a task as well as his or her past available oppor-
tunities to perform a task are other factors that may be considered during the course of
functional assessments (Patterson et al., 1992). For example, should a male patient who
demonstrates difficulty in balancing a checkbook be assumed to be declining in financial
capacity when his wife has always been in charge of this task? However, although prior
experience and opportunity should be considered when determining dementia severity or
the rate of functional decline associated with AD, these factors are of little relevance
when the goal of the assessment is to identify specific functional performance deficits and
the level of assistance presently needed to support independent living (Patterson et al.,
1992).
Implications of Functional Incapacity for Older Adults

Functional impairment has significant implications for older adults. Research has found
that functionally impaired older adults are more likely to be placed in a nursing home
and have higher mortality rates than individuals who continue to function independently
(Angel & Frisco, 2001; Wiener et al., 1990). Using data collected from six national epide-
miological surveys, Wiener and colleagues (1990) compared estimates of functional abil-
ity in community-dwelling and institutionalized persons 65 years of age and older. Esti-
mates of disability in one or more activities of daily living ranged from 5.0 to 8.1% of
community-dwelling older adults and more than 90% for institutionalized elderly
(Wiener et al., 1990). Functionally impaired older adults reported greater need for assis-
tance, poorer health status, poorer health outcomes, and poorer quality of life than indi-
viduals who were able to perform tasks independently (Angel & Frisco, 2001).
Functional impairments and losses also have significant psychological consequences
for patients and families (DeBettignies et al., 1993; Marson & Hebert, 2005; Moye,
1996). Research shows that functional incapacity is associated with greater caregiver bur-
den (Goode et al., 1998; Haley et al., 1996). Functional changes affecting the capacity to
manage finances (“taking away the checkbook”) and to drive (“taking away the car
keys”) appear to have particularly notable psychological consequences because they im-
plicate core aspects of autonomy in our society. Decisions to limit or remove an individ-
ual patient’s autonomy in these areas thus require careful consideration by health care
professionals and families.
STUDIES OF COGNITION AND FUNCTION IN THE ELDERLY
In recent years a considerable body of research has examined the relationship between
cognitive abilities and ADL/IADL functional performance, with particular reference to
older adult populations. Performance on various standardized psychometric measures of
intelligence, attention, executive function, memory, and global cognitive functioning has
been found to be significantly correlated with functional capacities of basic self-care,
IADLs, and academic achievement as well as vocational attainment and performance
(Heaton & Pendleton, 1981; Matarazzo, 1972). Cognitive aging studies have addressed
the relationship of functional performance to verbal versus nonverbal abilities, fluid ver-
sus crystallized intelligence, and declarative versus procedural knowledge in normal aging
(Leckey & Beatty, 2002; Mortimer, Ebbitt, Jun, & Finch, 1992; Willis et al., 1998). More
recently, cognitive models have been developed for specific IADLs such as financial man-
agement, medical decision making, and testamentary capacity (Griffith et al., 2003;
Marson, Cody, Ingram, & Harrell, 1995; Marson, Ingram, Cody, & Harrell, 1995). De-
spite considerable research into the cognitive abilities associated with driving perfor-
mance, no neurocognitive model of driving capacity has yet been proposed. Below we
discuss representative studies in these areas, using the dementia continuum of cognitive
aging, MCI, and dementia as our organizing framework.
Studies of Functional Change in Cognitive Aging

Many cognitive abilities that decline with age are linked to complex tasks of daily living
(Bell-McGinty et al., 2002; Cahn-Weiner et al., 2000; Willis et al., 1998). Normative age-
related declines in fluid abilities such as abstract reasoning, working memory, spatial ori-
entation, and information-processing speed have been observed to begin as early as the
sixth decade of life, with the rate of cognitive decline increasing in the 70s and 80s
(Schaie, 1996). In contrast, crystallized abilities such as vocabulary demonstrate later on-
set and slower rate of decline relative to fluid abilities, among older adults (Diehl, Willis,
& Schaie, 1995; Willis, Jay, Diehl, & Marsiske, 1992).
A number of research studies has examined the association between cognitive and
functional decline in normal older adults (Barberger-Gateau et al., 1999; Mortimer et al.,
1992; Willis et al., 1992). In a longitudinal study of 102 community-dwelling older
adults conducted by Willis and colleagues (1992), performance on measures of fluid intel-
ligence, crystallized intelligence, and processing speed declined significantly over a 7-year
interval, as did performance on a measure of everyday task competence. Fluid reasoning
ability emerged as the strongest longitudinal predictor of everyday task competence (ac-
counting for 52% of the variance), as compared to crystallized intelligence (11%), pro-
cessing speed (6%), memory (less than 1%), age (5%), and education (6%). Interestingly,
only 38% of the study sample demonstrated significant longitudinal declines in everyday
task competence, and this percentage was equivalent to the proportion of individuals
who demonstrated significantly reduced fluid reasoning ability (37%). Based on these
findings, the authors concluded that changes in functional performance are not the direct
result of advancing age, per se, but instead are linked to a concurrent decline in those cog-
nitive abilities that underlie everyday task competence.
Studies of Functional Change in Mild Cognitive Impairment

It is well accepted that declines in functional as well as cognitive abilities are hallmark
features of dementing illnesses. What is less appreciated is that such functional changes
usually first emerge in MCI or the preclinical phase of dementia (Barberger-Gateau et al.,
1999; Griffith et al., 2003; Marson, Dymek, & Geyer, 2000; Willis, 1996). According to
currently accepted diagnostic criteria, individuals with MCI do not experience significant
changes in their ADLs (Petersen et al., 1999). This is a critical diagnostic aspect of MCI,
because once decline in ADLs is detected, the diagnostic impression under DSM-IV
(American Psychiatric Association, 1994) and NINCDS–ADRDA (McKhann et al.,
1984) criteria begins to shift from MCI to dementia. Thus under the “Mayo criteria,”
MCI individuals have been described in the literature as having “usually intact” ADLs
(Ritchie, Artero, & Touchon, 2001) or “only slightly abnormal” ADLs (Petersen et al.,
1999). These guidelines for functional change in MCI are vague and unsatisfactory as di-
agnostic criteria (Ritchie et al., 2001), and probably reflect our currently limited empiri-
cal knowledge concerning the types and extent of functional change that occur in MCI.
There is emerging evidence that individuals with MCI do experience changes in ev-
eryday function prior to dementia diagnosis (Daly et al., 2000; Morris, 2002; Ritchie et
al., 2001; Touchon & Ritchie, 1999). Barberger-Gateau and colleagues (1999) found that
baseline scores on a four-item IADL scale (telephone use, mode of transportation, medi-
cation management, and handling finances) predicted 3-year incident dementia in a sam-
ple of 1,582 community-dwelling older adults, even after adjusting for the Mini-Mental
State Examination (MMSE) score. Touchon and Ritchie (1999) found that 2 years prior
to AD diagnosis, individuals with MCI demonstrated subtle but salient declines in every-
day activities such as using the telephone, dental hygiene, and dressing (Touchon &
Ritchie, 1999). These changes were identified through interviews of subjects and family
member proxies. The behavioral changes did not involve dramatic failures but rather oc-
casional lapses, carelessness, task slowing, and the need for cuing (Touchon & Ritchie,
1999). Thus MCI individuals could still carry out the activities in question, but changes
in qualitative performance were observed. Other recent studies using informant report
have also indicated functional changes in MCI. Using a standardized clinical interview,
Albert and her group (1999) identified functional changes (in financial skills, driving,
hobbies, and personal care) that were associated with MCI and conversion to AD. More
recently, a study using ADL report forms found that informant report of functional
change in MCI subjects, and the discrepancy between MCI patient self-report and infor-
mant report, both predicted subsequent conversion to AD within a 2-year period (Tabert
et al., 2002). As discussed further in the section below on specific capacities, our own
group has used a direct assessment approach to show that amnestic MCI patients demon-
strate mild impairments in higher-order financial skills in comparison to older controls
(Griffith et al., 2003).
Studies of Functional Change in Alzheimer’s Disease and Related Dementias

There is a more substantial literature that has demonstrated functional impairments in
patients with AD and related dementias. This is a critical area of study because, as noted
above, functional change is integral to a dementia diagnosis.
Cognitive and functional change in dementia are closely linked but also probably
distinct processes. In a longitudinal study of 65 patients with probable AD (Mortimer et
al., 1992), rates of cognitive and functional decline over a 4-year period were moderately
correlated (r = .63, p < .001). However, only 40% of the variance in functional decline
was accounted for by cognitive decline, indicating that cognition and functional capacity
reflect distinct yet parallel features of the disease process. Furthermore, Mortimer and
colleagues (1992) found that cognitive and functional progression rates differ substan-
tially with regard to neuropsychological predictors. Lower baseline scores on verbal
neuropsychological tests of confrontation naming, learning and recall, fluency, abstrac-
tion, and immediate memory emerged as key predictors of faster cognitive decline. In
contrast, lower baseline scores on nonverbal neuropsychological measures of visuospatial
function and visual memory were found to predict faster rates of functional decline. The
different predictor models for functional and cognitive decline again suggested that they
are distinct constructs in dementia. The results of this study also supported the utility of
neuropsychological assessment in predicting functional performance.
Global Cognition and Functional Change in Dementia

Studies have explored the relationship between global cognitive functioning (using tests
such as the MMSE) and everyday functional performance in patients with AD. These
studies have found variable correlations across different measurement approaches: clini-
cian ratings, caregiver ratings, self-ratings, and direct assessments of functional perfor-
mance (Grigsby et al., 1998; Leckey & Beatty, 2002; Mortimer et al., 1992; Perry &
Hodges, 2000; Stern et al., 1990; Willis et al., 1998). For example, Mayeux, Stern, and
Spanton (1985) found that scores on the modified MMSE were moderately correlated
(r = .50, p < .05) with the Blessed Dementia Rating Scale (BDRS), a clinician rating of
functional aspects of dementia not assessed by neuropsychological measures. Although
the BDRS was later factor analyzed to control for items unrelated to ADL/IADL perfor-
mance, the MMSE remained moderately correlated with both BDRS cognitive/IADL
(r = –.44, p < .05) and BDRS basic self care (r = –.51, p < .05) items (Stern et al., 1990).
In a 4-year longitudinal study of 65 patients with probable AD (Mortimer et al.,
1992) that employed caregiver ratings, baseline MMSE scores were weakly correlated
with caregiver ratings of ADL/IADL performance at baseline (r = –.24) yet moderately
correlated with the rate of functional decline across time (r = .63). Willis and colleagues
(1998) also found a correlation of .24 between MMSE scores and caregiver ratings of IADL
performance in 65 patients with AD, but this association failed to reach significance.
Other studies have found a stronger association between MMSE scores and care-
giver ratings of ADL/IADL performance (Leckey & Beatty, 2002; Perry & Hodges,
2000). In a study of 24 patients with AD conducted by Perry and Hodges (2000),
MMSE scores were strongly correlated (r = –.73) with overall scores on a 25-item care-
giver rating scale of functional abilities. However, items assessing memory as well as
attention and executive abilities were incorporated within the functional assessment
scale, possibly inflating the degree of association between caregiver ratings and global
cognitive function.
In a study using the Dementia Rating Scale (DRS), Lichtenberg and Nanna (1994)
found that DRS total scores were the only significant predictor of both ADLs (r = .27,
p < .05) and ambulation (r = .27, p < .05) in a sample of 60 older adults admitted to an
inpatient rehabilitation program, accounting for 8% and 16% of the variance, respec-
tively. Age, education, ethnicity, medical condition, length of hospital stay, and depres-
sion were unrelated to ADL performance and ambulation.
Level of dementia severity within a sample may also influence the degree of associa-
tion between global cognitive functioning and caregiver-rated functional performance
(Leckey & Beatty, 2002). Although moderate correlations were found between MMSE
scores and caregiver ratings of ADL (r = .51, p < .05) and IADL (r = .69, p < .001) perfor-
mance, the correlation between MMSE scores and IADL performance decreased to .29
(p < .05) when individuals with severe AD were excluded from analyses.
With respect to patients with AD self-ratings, MMSE scores were not found to con-
tribute significantly to the prediction of ADL and IADL performance (Grigsby et al.,
1998; Willis et al., 1998). This finding probably reflects the anosognosia characteristic of
AD, which appears to be particularly notable in the area of everyday functioning. Re-
search has consistently shown that patients with AD overestimate their functional and
cognitive abilities to a substantial degree (Loewenstein et al., 2001; Teri, 1997; Wadley et
al., 2003; Wild & Cotrell, 2003). A recent study by Wadley indicated substantial overes-
timation of financial skills in a sample of 20 patients with AD, relative to caregiver rat-
ings and a direct-assessment criterion (Wadley et al., 2003).
On the other hand, direct assessments of functional performance have yielded rela-
tively consistent moderate associations with global cognitive functioning (Burns, Morti-
mer, & Merchak, 1994; Grigsby et al., 1998; Willis et al., 1998). In a study of 77 patients
with mild to moderate AD and 15 normal elderly controls, MMSE scores were moder-
ately correlated (r = .67, p < .001) with overall performance of six daily living tasks, in-
cluding dressing, shopping, making toast, using the telephone, washing, and following a
map (Burns et al., 1994). A moderate association (r = .55, p < .05) was also observed be-
tween MMSE scores and the performance of 65 patients with AD on a direct measure of
everyday problem solving involving printed materials such as medication labels and
phone bills (Willis et al., 1998). In a study of treatment-consent capacity in patients with
mild to moderate AD, using a direct assessment vignette methodology, the MMSE
achieved a moderate univariate association with three out of five treatment-consent abili-
ties (i.e., capacity to appreciate the consequences of a treatment choice, r = .49, p = .008;
to provide rational reasons for a treatment choice, r = .55, p = .002; and to understand
treatment situation and choices, r = .62, p < .001), but failed to emerge in any of the final
multivariate models (Marson, Chatterjee, Ingram, & Harrell, 1996; Marson, Cody,
Ingram, & Harrell, 1995).
Thus, across a variety of assessment modalities, global cognitive functioning is sig-
nificantly related to everyday functional performance in patients with dementia. At the
same time, global cognitive functioning is certainly not a proxy for functional change in
dementia, because it accounts for only a limited portion of variance. The actual power of
global cognitive measures to predict functional impairment is even more limited. Al-
though the MMSE has been found to account for up to 48% of the variance in IADL
performance, the amount of variance accounted is reduced dramatically (to 9%) when
analyses are restricted to individuals with mild to moderate dementia (Leckey & Beatty,
2002). As such, MMSE scores, by themselves, are inadequate clinically for predicting
functional impairment in patients with AD.
Specific Neuropsychological Predictors of Functional Capacity in Dementia

Studies have also examined the relationship of specific neuropsychological abilities to
everyday functioning in patients with dementia. In contrast to global mental status mea-
sures, neuropsychological measures hold the promise of revealing specific cognitive abili-
ties and even the neurocognitive substrates that subserve everyday functional abilities.
Viewed broadly, measures of executive function have demonstrated the most consistent
relationships to functional declines in older adult populations (Marson & Harrell, 1999;
Royall, Cordes, & Polk, 1997). Executive functions involve those cognitive skills neces-
sary for regulating purposeful, goal-directed behavior, including such abilities as plan-
ning, sequencing, self-monitoring, and mental flexibility (Lezak, 1995; Royall et al.,
2000; Sbordone, 2000). Executive functions have been closely linked to frontal-lobe
function and integrity (Cummings, 1993; Malloy & Richardson, 1994), which declines as
a result of both cognitive aging (Cahn-Weiner et al., 2000; Fisk & Warr, 1996; Grigsby et
al., 1998; Salthouse & Miles, 2002; West, 1996) and dementias such as AD and Parkin-
son’s disease dementia (Marson & Harrell, 1999; Schaie, 1996). Several studies have ex-
plored the contribution of executive functioning to everyday task performance (Grigsby
et al., 1998; Loewenstein et al., 1992; Marson & Harrell, 1999; Norton, Malloy, &
Salloway, 2001; Willis et al., 1998). In a sample of 1,158 community-dwelling older
adults (Grigsby et al., 1998), a measure requiring attention and set shifting as well as ini-
tiation and inhibition of motor responses (Behavioral Dyscontrol Scale/BDS) was found
to be significantly correlated with subjects’ ability to handle money (r = .53, p < .001) and
manage medications (r = .36, p < .001), as measured by the Structured Assessment of In-
dependent Living Skills (SAILS). Furthermore, performance on the BDS accounted for
more variance in functional performance than did general mental status as measured by
the MMSE.
Cahn-Weiner and colleagues (2000) compared neuropsychological test scores and
IADL performance in a sample of 27 community-dwelling older adults. An executive
function composite score was formulated based upon performance on the Wisconsin
Card Sorting Test, the Trail Making Test (TMT) Parts A & B, the Controlled Oral Word
Association Test (i.e., word fluency), and Stroop test. Executive dysfunction was found to
predict everyday task performance more than other cognitive measures, including mem-
ory (Hopkins Verbal Learning Test—Revised and Brief Visuospatial Memory Test—Re-
vised), language (Boston Naming Test), visuospatial skills (Judgement of Line Orientation
Test), and psychomotor speed (Grooved Pegboard Test). Furthermore, the greatest pro-
portion of variance in IADL performance was accounted for by executive functioning.
Similarly, Willis and colleagues (1998) found moderate to strong correlations (.39–.70)
between scores on measures of executive functioning (TMT; Word Fluency; Wechsler
Adult Intelligence Scale—Revised/WAIS-R Digit Symbol and Block Design subtests) and
performance on a direct assessment measure of everyday problem solving (Everyday
Problem-Solving for the Cognitively Challenged Elderly/EPCCE). Moreover, both execu-
tive functioning and global cognitive functioning accounted for unique variance in
EPCCE scores, with executive measures significantly increasing the amount of variance in
EPCCE scores explained by global cognitive functioning alone (from R2 = .59 to R2 = .69,
p < .001). In a sample of 22 patients with AD and 18 older adult controls (Leckey &
Beatty, 2002), scores on a measure of verbal abstraction (Shipley Institute of Living
Scale—Abstraction; SILS-A) were moderately correlated with caregiver ratings of both
ADL (r = .50, p < .05) and IADL (r = .57, p < .01) performance, whereas tests of semantic
knowledge (15-item Boston Naming Test and SILS-Vocabulary) were unrelated (Leckey
& Beatty, 2002).
Performance on the executive function based Initiation/Perseveration (I/P) subscale of
the DRS has been linked with everyday functioning (Lichtenberg & Nanna, 1994; Nadler,
Richardson, Malloy, Marran, & Hostetler-Brinson, 1993; Norton et al., 2001). Nadler and
colleagues (1993) examined the association between subscales of the DRS and subject per-
formance on tasks involving self-care, safety, money management, cooking, medication ad-
ministration, and community utilization. The DRS total score (R2 = .27 to .49, p < .01) ac-
counted for a significant amount of variance in performance for each task, with the
exception of cooking. Both the I/P and Memory subscales of the DRS emerged as significant
univariate predictors of everyday task performance, with the I/P subscale the most strongly
correlated with five of the six performance tasks (r = .50 to .68, p < .002). These findings
were consistent with those of Norton et al. (2001), who found that the I/P subscale ac-
counted for 19 out of 22% of the variance in caregiver-rated IADL performance explained
by the DRS. Thus existing research supports a consistent relationship of moderate strength
between measures of executive function and everyday task performance.
A very interesting line of research has also suggested that visuospatial abilities may
have special links to functional decline in older adults. Perry and Hodges (2000) com-
pared neuropsychological and functional performance of 24 patients with early AD and
found that caregiver ADL/IADL ratings were strongly associated with semantic memory
(r = .58, p < .01) as well as global cognitive function (r = .73, p < .001), and visuospatial
function (r = .74, p < .001). However, only visuospatial function emerged as a significant
predictor of functional abilities, based upon multiple regression analyses. Furthermore,
performance on measures of episodic memory and attention was found to be unrelated to
functional performance. These results (Perry & Hodges, 2000) are consistent with those
of Mortimer and colleagues (1992), who found that visuospatial function and visual
memory, rather than confrontation naming, verbal recall, verbal abstraction, and imme-
diate memory, predicted rates of functional decline over a 4-year period. The findings are
also consistent with the work of Royall and his group (Royall, 1998; Royall, Chiodo, &
Polk, 2000), who have found that a simple clock copy task with executive aspects (CLOX
2) has been associated with IADL impairment in the elderly. According to Royall, it is
possible that right-hemisphere changes associated with aging and cerebrovascular disease
foreshadow frontal-system changes that underlie diminishing task performance in older
adults (Royall, 2003).
Conclusions and Implications

Research suggests that changes in functional performance occur with normal aging and
are likely the result of declines in cognitive abilities that underlie everyday task perfor-
mance (Willis et al., 1992). Likewise, cognitive and functional decline in MCI and AD
represent related but also distinct features of the disease course (Mortimer et al., 1992).
Intact cognition is thus a necessary but not sufficient condition for successful perfor-
mance of everyday tasks in normal and abnormal aging (Willis et al., 1992). Global men-
tal status measures, particularly neuropsychological measures of executive function, have
been found to account for a significant portion of the variance in ADL and IADL func-
tion. In addition, deficits in higher-order cognitive abilities have been found to corre-
spond with difficulty in performing complex tasks of everyday living even in the preclini-
cal stages of dementia (Griffith et al., 2003). As the disease progresses, more general
measures of global cognitive function emerge as significant predictors of diminished abil-
ity for basic self-care (Grigsby et al., 1998). Cognitive variables have been found to be
more strongly associated with everyday living skills, as measured by direct functional as-
sessment than caregiver or clinician rating scales of functional performance (Grigsby et
al., 1998; Leckey & Beatty, 2002; Mortimer et al., 1992). In this regard, Willis and col-
leagues also found that functional assessment measures that require everyday problem
solving of written materials (e.g., medication labels, bus schedules) are more strongly cor-
related with neuropsychological measures than those assessing performance of proce-
dural tasks (e.g., using the telephone, counting money; Leckey & Beatty, 2002; Willis et
al., 1998; Willis et al., 1992). Therefore, although cognitive test scores are strongly re-
lated to everyday living skills, the degree to which neuropsychological assessment can
predict functional performance is contingent upon the population studied and the mea-
sures employed.
Finally, although cognitive test scores are clearly related to everyday living skills, de-
cisions to limit autonomy in individuals with dementia should not be based solely, or
even primarily, on mental status screens or neuropsychological test performance. Clini-
cians should rely primarily on capacity-specific information, using diagnostic and
neuropsychological data as supporting evidence, in rendering clinical judgments regard-
ing a patient’s capacity or limitations in everyday living (Chelune & Moehle, 1986;
Marson, 2001a; Marson & Briggs, 2001).
COMPETENCY AND CAPACITY: ASSESSING CONTEXT-SPECIFIC

FUNCTIONAL ABILITIES IN OLDER ADULTS
Capacity Assessment in Clinical Neuropsychology Practice
Clinical neuropsychology is a relatively young specialty within the field of psychology
that focuses on the study of brain–behavior relationships. The traditional role of
neuropsychology has been threefold: (1) detecting the presence of brain lesions, (2) local-
izing lesions within the brain, and (3) lateralizing lesions to the right or left hemispheres
of the brain (Groth-Marnat, 2000). Although these initial diagnostic and descriptive func-
tions of neuropsychology continue to be useful, emphasis has steadily expanded to include is-
sues of functional impairment following brain injury (Chelune & Moehle, 1986; Lemsky,
2000). In addition to assessing cognitive and personality change related to brain injury,
neuropsychologists are increasingly called upon to assess important everyday functional
abilities such as financial management skills, medical decision-making capacity, medica-
tion management abilities, capacity to drive, and overall capacity to live independently
(Marson, 2002; Marson & Briggs, 2001; Marson, Ingram, Cody, & Harrell, 1995).
In particular, the increasing incidence of competency assessment issues in older adult
patients has both expanded and complicated the practice of clinical neuropsychology
(Marson, 2002). Neuropsychologists must not only assess cognitive and personality defi-
cits, but they are also increasingly called upon to make judgments of specific medical–
legal capacities. The contemporary geriatric neuropsycholoigst must be able to evaluate
everyday functional changes in older adults that are frequently of paramount importance
to the individual patient, his or her family, the treatment team, and the legal system. The
degree to which neuropsychology as a field can successfully address these evolving clini-
cal demands will be based upon its ability to develop conceptual models, assessment in-
struments, and clinical expertise relevant to capacity assessment and issues of everyday
living (Chelune & Moehle, 1986; Marson, 2002; Marson et al., 1996).
In this final section we focus on four specific functional capacities relevant to
community-dwelling older adults and frequently encountered by geriatric neuropsy-
chologists: medical decision-making capacity, financial capacity, testamentary capacity
(i.e., capacity to make or change a will), and driving capacity. We review conceptual mod-
els, instrument development, empirical group studies, and relevant neuropsychological
predictor models for each of these capacities.
Medical Decision-Making Capacity

Background
The capacity to consent to medical treatment (hereafter referred to as “MDC,” or medi-
cal decision-making capacity) is a fundamental aspect of personal autonomy, because it
concerns intimate decisions regarding the care of a person’s body and mind (Marson &
Briggs, 2001; Marson & Hebert, 2005). Consent capacity refers to a patient’s cognitive
and emotional ability to accept a proposed treatment, to refuse treatment, or to select
among treatment alternatives (Grisso, 1986; Tepper & Elwork, 1984). In the United
States, consent capacity is the cornerstone of the medical–legal doctrine of informed con-
sent, which requires that a valid consent to treatment be informed, voluntary, and compe-
tent (Kapp, 1992; Marson, Ingram, et al., 1995). From a functional standpoint, consent
capacity may be viewed as an “advanced activity of daily life” (Wolinsky & Johnson,
1991) and an important component of health and independent living skills in both youn-
ger and older adults.
As a competency, MDC is distinctive for several reasons: (1) it arises in a medical
and not a legal setting; (2) it generally involves a physician, psychologist, or other health
care professional, and not a legal professional, as decision maker; and (3) the judgments
are rarely subject to judicial review (Grisso, 1986). As discussed above, clinicians do not
decide competency in a formal legal sense. However, their decisions can have the same ef-
fect as a courtroom determination insofar as the patient loses decision-making power
(Appelbaum & Gutheil, 1991).
Conceptual Model
From a conceptual standpoint, MDC has been understood to consist of four different
consent abilities or standards (Appelbaum & Grisso, 1988; Grisso & Appelbaum, 1995;
Roth, Meisel, & Lidz, 1977). These abilities, with their underlying definitions, are:
(S1) The capacity to “evidence” a treatment choice (this standard focuses on the
presence or absence of a decision, and not on the quality of the decision (Roth et
al., 1977).
(S2) The capacity to make the “reasonable” treatment choice (when the alternative is
unreasonable; Roth et al., 1977; Tepper & Elwork, 1984), which we reference as
(S2). (S2) is not an accepted clinical standard for judging consent capacity be-
cause of concerns about arbitrariness in determining what constitutes a “reason-
able choice” (Tepper & Elwork, 1984). However, it is used as an experimental
variable to better understand subjects’ treatment preferences (Marson, Earnst,
Jamil, Bartolucci, & Harrell, 2000; Marson, Ingram, et al., 1995).
(S3) The capacity to “appreciate” emotionally and cognitively the personal conse-
quences of a treatment choice (this standard emphasizes the patient’s awareness
of the consequences of a treatment decision: its emotional impact, rational re-
quirements, and future consequences (Roth et al., 1977).
(S4) The capacity to reason about a treatment choice, or make a treatment choice
based on “rational” reasons (this standard tests the capacity to use logical pro-
cesses to compare risks/benefits of treatment options and weigh this information
to reach a decision (Appelbaum & Grisso, 1988).
(S5) The capacity to make a treatment choice based on an “understanding” of the
treatment situation and alternatives (this standard requires memory for words,
phrases, ideas, and sequences of information as well as comprehension of the fun-
damental meaning of the treatment-related information (Appelbaum & Grisso,
1988).
These standards represent different thresholds for evaluating MDC (Marson, Schmitt,
Ingram, & Harrell, 1994). For example, the first standard (evidencing a choice) requires
nothing more than a subject’s communication of a treatment choice to establish compe-
tency. In contrast, the fourth standard (reasoning) bases competency on a subject’s capac-
ity to supply rational reasoning for the treatment choice. These standards can be readily
applied to other competencies to consent, such as capacity to consent to research partici-
pation and to decisional capacity, in general.
Instruments for Assessing MDC

Over the past decade several investigators have developed instruments for the assessment
of decisional capacity in different patient populations (Grisso & Appelbaum, 1995;
Grisso, Appelbaum, Mulvey, & Fletcher, 1995; Janofsky, McCarthy, & Folstein, 1992;
Marson, Ingram, et al., 1995). In 1991 our research group used the above conceptual
model to develop a psychometric instrument called the Capacity to Consent to Treatment
Instrument (CCTI). The CCTI consists of two specialized clinical vignettes (Vignette A:
neoplasm; Vignette B: cardiac) that tested MDC using the consent abilities detailed above
(Marson, Ingram, et al., 1995). Each vignette presents a hypothetical medical problem
and symptoms and two treatment alternatives with associated risks and benefits. The ad-
ministration format approximates an informed consent dialogue and requires the subject
to consider two different treatment options with associated risks and benefits. Vignettes
are administered by having subjects simultaneously read and listen to an oral presenta-
tion of the vignette information. Subjects then answer standardized questions designed to
test consent capacity under the four standards set forth above (and also [S2]). The CCTI
has a detailed and well-operationalized scoring system for each vignette standard.
Empirical Studies of MDC in Dementia Populations

Study of MDC in AD. The CCTI has been used to investigate empirically the loss of
competency in patients with AD (n = 29) and older controls (n = 15) (Marson, Cody, et
al., 1995; Marson, Ingram, et al., 1995). Using the MMSE scores (Folstein, Folstein, &
McHugh, 1975), AD subjects were divided into groups of mild dementia (MMSE ≥ 20;
n = 15) and moderate dementia (MMSE ≥ 10 and < 20; n = 14). Performance on the five
standards was compared across groups. As shown in Table 7.1, the CCTI discriminated
the performance of the normal control, mild AD, and moderate AD subgroups on three
of the five standards. Whereas the three groups performed equivalently on minimal stan-
dards requiring merely a treatment choice (S1) or the reasonable treatment choice (S2),
patients with mild AD performed significantly below controls on more difficult standards
requiring rational reasons (S4) and understanding treatment information (S5). Patients
with moderate AD performed significantly below controls on appreciation of conse-
quences (S3), rational reasons (S4), and understanding treatment (S5), and significantly
below patients with mild AD on S4 and S5 (Marson, Ingram, et al., 1995).
Neuropsychological Models of Consent Capacity in Patients with AD. In addition

to providing a standardized basis for evaluating competency performance and outcome,
instruments such as the CCTI provide a psychometric criterion for investigating neuro-
cognitive changes associated with loss of consent capacity in neurocognitive disorders
such as AD. We used the CCTI and a neuropsychological test battery sensitive to demen-
tia in the above subject sample to identify, using the four standards, cognitive predictors
of declining competency performance in patients with AD (Marson et al., 1996; Marson,
TABLE 7.1. Performance on CCTI Legal Standards by Diagnostic Group

LS1 [LS2] LS3 LS4 LS5
n 0–4 0–1 0–10 0–12 0–70
a b,c b,d
Older controls 15 4.0 (0.0) .93 8.7 (1.2) 10.3 (3.8) 58.3 (6.6)
Mild AD 15 3.9 (0.4) 1.00 7.1 (2.0) 6.1 e (3.4) 27.3 e (9.6)
Moderate AD 14 3.6 (0.9) .79 5.9 (2.7) 2.3 (2.4) 17.9 (10.6)
Note. No group differences emerged on [LS2], χ2 = 4.2, p = .12. Adapted from “Assessing the competency of Alzhei-
mer’s disease patients under different legal standards: A prototype instrument” by Marson, Ingram, Cody, and Harrell
(1995). Copyright 1995 by the American Medical Association. Adapted by permission.
a Normal mean differs significantly from moderate AD mean, p < .001.
b Normal means differ significantly from moderate AD mean, p < .0001.
c Normal mean differ significantly from mild AD mean, p < .01.
d Normal means differ significantly from mild AD mena, p < .0001.
e Mild AD mean differs significantly from moderate AD mean, p < .01.
Cody, et al., 1995). Table 7.2 presents stepwise multiple regression results for the com-
bined AD group for these standards.
Findings from these psychometric studies suggest that multiple cognitive functions
are associated with loss of consent capacity in patients with AD, as measured by the
CCTI standards (Marson et al., 1996; Marson, Cody, et al., 1995; Marson & Hebert,
2005). Deficits in conceptualization, semantic memory, and probably verbal recall appear
to be associated with the significantly impaired capacity of patients with mild or moder-
ate AD to understand a treatment situation and its choices (S5). Deficits in simple execu-
tive dysfunction (word fluency) appear linked to the impaired capacity of patients with
mild or moderate AD to provide rational reasons for a treatment choice (S4), and to the
impaired capacity of patients with moderate AD to identify the consequences of a treat-
ment choice (S3). Finally, receptive aphasia and semantic memory loss (severe dysnomia)
may be associated with the impaired ability of patients with advanced AD to evidence a
simple treatment choice (S1). The results offer insight into the relationship between dif-
ferent legal thresholds of competency and the progressive cognitive changes characteristic
of AD, and represent an initial step toward a neurological model of competency in de-
mentia (Marson et al., 1996; Marson, Cody, et al., 1995).
Financial Capacity
Background
In this section we discuss a second and very different civil competency: capacity to man-
age financial affairs (financial capacity). Financial capacity comprises a broad range of
conceptual, pragmatic, and judgment abilities that are critical to the independent func-
tioning of adults in our society (Marson & Briggs, 2001; Marson & Hebert, 2005;
Marson, Sawrie, et al., 2000). As such, it differs in many respects from medical decision-
making capacity. Whereas MDC is almost exclusively a verbally mediated capacity, finan-
cial capacity comprises a complex set of abilities, ranging from basic skills of identifying
and counting coins/currency, to conducting cash transactions, to managing a checkbook
and bank statement, to higher-level abilities of making investment decisions. Such abili-
ties can vary enormously across individuals, depending on socioeconomic status, occupa-
tional attainment, and overall financial experience (Marson, 2001b; Marson & Briggs,
2001; Marson et al., 2000).
Loss of financial capacity (FC) has critical economic and household consequences
for dementia patients and their families as well as important implications for health care
TABLE 7.2. Multivariate Cognitive Predictors of Competency Performance in the AD Group

LS1 LS3 LS4 LS5
R2 p R2 p R2 p R2 p
SAC .44 .0001 CFL 58 .0001 DRS IP .36 .0008 DRS CON .70 .0001
BNT .11 .001
Note. n = 29 for the Ad group. No measures achieved univariate or multivariate significance for the control group.
LS1, evidencing a choice; LS3, appreciation of situation and consequences; LS4, rational reasoning; LS5, understanding
of treatment information; BNT, Boston Naming Test; CFL, Controlled Oral Word Association Test/Fluency subscale;
DRS CON, Dementia Rating Scale Conceptualization subscale; DRS IP, Dementia Rating Scale Initiation/Perseveration
subscale; SAC, Simple Auditory Comprehension Screen. Adapted from Marson, Chatterjee, Ingram, and Harrell
(1996). Copyright 1996 by the American Academy of Neurology. Adapted by permission.
and legal professionals (Marson, 2001b; Marson & Briggs, 2001; Marson & Hebert,
2005; Marson, Sawrie, et al., 2000). Patients with AD often have difficulties paying their
bills and carrying out basic financial tasks (Overman & Stoudemire, 1988). They are
continually at risk for making decisions that endanger assets needed for their own long-
term care or intended for testamentary distribution to family members.
Second, as discussed above, there are also important psychological consequences to
FC loss. Like driving and basic mobility, FC reflects a core aspect of individual autonomy
in older adults (Kane & Kane, 1981; Lawton, 1982; Marson, 1997). Much like loss of
the car keys, loss of control over one’s own funds represents a significant challenge to the
self-concept of older adults and can lead to depression and other significant psychological
consequences (Moye, 1996).
Loss of FC has important implications for health care and legal professionals as well
(Marson, 2001b; Marson & Briggs, 2001; Marson, Sawrie, et al., 2000). FC assessments
have diagnostic utility in that such evidence of impaired functional ability is required for
a diagnosis of dementia (DMS-IV; American Psychiatric Association, 1994). Recent re-
search has demonstrated that impairments in higher-order financial skills and judgments
are often early functional changes demonstrated by AD patients (Marson, Sawrie, et al.,
2000) and also patients with MCI (Griffith et al., 2003). Diminished or impaired mental
capacities place an individual at increased risk of financial exploitation, an all-too-common
form of elder abuse (Nerenberg, 1996). Frequent media accounts of older adults victim-
ized in consumer fraud and other scams provide further evidence of growing public con-
cern regarding their financial vulnerability (“Woman out $5,300 in two cons,” Birming-
ham News, 1996; Walton, 2002). Furthermore, family members, professionals, and third
parties may covertly exercise undue influence over the way in which older adults manage
their assets (Marson, Huthwaite, & Hebert, 2004; Spar & Garb, 1992). Loss of financial
capacity can also trigger important legal issues of guardianship and conservatorship
(Grisso, 1986; Marson, Sawrie, et al., 2000). A disproportionately high number of older
adults is subject to conservatorship proceedings each year due to high incidence of
dementias and other mental and medical illnesses affecting financial competency in this
vulnerable population (Grisso, 1986). These legal proceedings involve considerable time,
expense, and stress for families (Marson & Briggs, 2001).
Conceptual Model of Financial Capacity

Despite the clear relationship of FC to everyday living and independence, the conceptual
basis of the construct has been largely unexplored. Here we present a conceptual model
of FC in older adults (Griffith et al., 2003; Marson, Sawrie, et al., 2000; Marson &
Zebley, 2001). This model has been the basis for instrument development and ongoing
studies of FC in adults with AD and other clinical populations.
FC represents a broad continuum of activities and specific skills (Marson &
Hebert, 2005). Accordingly, it may be best conceptualized as a series of domains of ac-
tivity, each of which has specific clinical relevance to independence (Marson & Briggs,
2001; Marson, Sawrie, et al., 2000). Illustrative domains include basic monetary skills,
cash transactions, checkbook management, and bank statement management. This do-
main-based approach is clinically oriented and consistent with the presumed multi-
dimensionality of FC and its variability across individuals. It is also consistent with the
legal doctrine of limited financial competency adopted within most state legal jurisdic-
tions, which recognizes that an individual may be competent to carry out some finan-
cial activities but not others (Grisso, 1986; Marson & Briggs, 2001; Marson, Sawrie,
et al., 2000).
In addition to domains of activity, the model identifies specific financial abilities or
tasks (Marson, 2001b; Marson, Sawrie, et al., 2000). Tasks reflect more basic financial
skills that comprise domain level capacities. For example, the domain of “financial
conceptual knowledge” might draw upon specific abilities, such as an understanding of
basic concepts (e.g., a loan or savings) and the pragmatic application of such concepts
in everyday life (e.g., selecting interest rates, identifying a medical deductible, making
simple tax computations). The domain of financial judgment might consist of tasks re-
lated to detection/awareness of financial fraud or of making informed investment
choices. Tasks represent abilities that constitute broader, clinically relevant domains of
financial activity. Tasks are defined as simple or complex, depending on the level of
cognitive resources they appear to require (Marson, 2001b; Marson, Sawrie, et al.,
2000).
The model also includes FC at the global level (Griffith et al., 2003; Marson &
Zebley, 2001). Competency assessment involves an overall categorical judgment or classi-
fication made by a clinician or legal professional. Thus the conceptual model of FC cur-
rently has three levels (Griffith et al., 2003): (1) specific financial abilities or tasks, each
of which is relevant to a particular domain of financial activity; (2) general domains of fi-
nancial activity, which are clinically relevant to the independent functioning of commu-
nity-dwelling older adults; and (3) overall financial capacity, which reflects a global mea-
sure of capacity based on the summation of domain- and task-level performance. A
current version of the conceptual model, presented in Table 7.3, comprises 9 domains, 18
tasks, and 2 global levels (Griffith et al., 2003).
Instrument for Direct Assessment of Financial Capacity

The Financial Capacity Instrument (FCI) is a psychometric instrument designed to assess
performance of older adults at the task, domain, and global levels of the conceptual
model. The original FCI (FCI-6) assessed 6 domains and 14 tasks (Marson, Sawrie, et al.,
2000). As presented above, the current version (FCI-9) assesses 9 domains, 18 tasks, and
2 global levels. The FCI has previously demonstrated good internal, test–retest, and
interrater reliabilities (Earnst et al., 2001).
Empirical Studies of Financial Capacity in Dementia Populations

Study of Financial Capacity in AD. In an initial study a sample of 23 older con-
trols and 53 AD patients with AD (30 with mild dementia, 23 with moderate dementia)
were administered the FCI-6 (Marson, Sawrie, et al., 2000). As shown in Table 7.4, we
found that patients with mild AD performed equivalently with control subjects on
Domain 1 (basic monetary skills), but significantly below controls on the other five do-
mains. Patients with moderate AD performed significantly below controls and patients
with mild AD on all domains. On the FCI tasks, patients with mild AD performed
equivalently with controls on simple tasks such as naming coins/currency, counting
coins/currency, understanding parts of a checkbook, and detecting risk of mail fraud.
However, patients with mild AD performed significantly below controls on more com-
TABLE 7.3. Revised Conceptual Model of Financial Capacity

Task
Task description difficulty
Domain 1. Basic monetary skills
Task 1a. Naming coins/currency Identify specific coins and currency Simple
Task 1b. Coin/currency relationships Indicate relative monetary values of coins/ Simple
currency
Task 1c. Counting coins/currency Accurately count groups of coins and currency Simple
Domain 2. Financial conceptual knowledge

Task 2a. Define financial concepts Define a variety of simple financial concepts Complex
Task 2b. Apply financial concepts Demonstrate practical application/computation Complex
using concepts
Domain 3. Cash transactions

Task 3a. One-item grocery purchase Enter into simulated one-item transaction; Simple
verify change
Task 3b. Three-item grocery purchase Enter into simulated three-item transaction; Complex
verify change
Task 3c. Change/vending machine Obtain change for vending machine use; Complex
verify change
Task 3d. Tipping Understand tipping convention; calculate/ Complex
identify tips
Domain 4. Checkbook management

Task 4a. Understand checkbook Identify and explain parts of check and Simple
check register
Task 4b. Use checkbook/register Enter into simulated transaction; pay by check Complex
Domain 5. Bank statement management

Task 5a. Understand bank statement Identify and explain parts of a bank Complex
statement
Task 5b. Use bank statement Identify specific transactions on bank Complex
statement
Domain 6. Financial judgment

Task 6a. Detect mail fraud risk Detect and explain risks in mail fraud Simple
solicitation
Task 6c. Detect telephone fraud risk Detect and explain risks in telephone fraud Simple
solicitation
Domain 7. Bill payment

Task 7a. Understand bills Explain meaning and purpose of bills Simple
Task 7b. Prioritize bills Identify overdue utility bill Simple
Task 7c. Prepare bills for mailing Prepare simulated bills, checks, envelopes Complex
for mailing
Domain 8. Knowledge of assets/estate Indicate/verify asset ownership, estate Simple

arrangements
Domain 9. Investment decision making Understand options; determine returns; make Complex
decisions
Global 1. Sum of domains 1–7 Overall functioning across tasks and domains Complex
Global 2. Sum of domains 1–8 Overall functioning across tasks and domains Complex
Note. From Griffith et al. (2003). Copyright 2003 by the American Academy of Neurology. Reprinted by permission.
TABLE 7.4. FCI-6 Domain and Task Performance by Group

Score Controls Mild AD Moderate AD
range (n = 23) (n = 30) (n = 20)
Domain 1. Basic monetary skills 0–79 77.9a (1.9) 75.5c (3.5) 57.9 (16.3)
Task 1a. Naming coins/currency 0–30 30.0a (0.0) 30.0c (0.0) 26.7 (4.7)
Task 1b. Coin/currency relationships 0–37 36.0a (1.8) 34.0c (3.0) 22.7 (9.2)
Task 1c. Counting coins/currency 0–12 11.9a (0.3) 11.5c (0.8) 8.6 (3.8)
Domain 2. Financial concepts 0–41 35.5a, b (2.7) 29.6c (5.4) 19.1 (6.3)
Task 2a. Defining concepts 0–16 13.0a, b (1.9) 9.7c (2.9) 7.1 (2.7)
Task 2b. Applying concepts 0–25 22.5a, b (1.4) 19.9c (3.6) 12.0 (4.6)
Domain 3. Cash transactions 0–48 46.2a, b (2.7) 38.6c (8.5) 22.2 (10.1)
Task 3a. One-item purchase 0–16 15.3a (2.5) 14.4c (3.2) 8.6 (4.9)
Task 3b. Three-item purchase 0–16 15.2a, b (1.3) 10.7c (5.0) 4.6 (3.3)
Task 3c. Change/vending machine 0–16 15.7a, b (0.6) 13.6c (2.8) 9.0 (4.1)
Domain 4. Checkbook/register 0–62 60.2a, b (2.1) 50.7c (8.0) 33.3 (16.1)

a 27.9c
Task 4a. Understanding checkbook 0–32 30.7 (1.5) (3.1) 20.6 (7.6)
Task 4b. Using checkbook 0–30 29.5a, b (1.5) 22.8c (6.1) 12.2 (9.1)
Domain 5. Bank statement 0–40 37.4a, b (2.2) 28.6c (7.6) 14.9 (7.2)
Task 5a. Understanding bank statement 0–22 19.7a, b (2.1) 15.0c (4.1) 8.0 (3.6)
Task 5b. Using bank statement 0–18 17.7a, b (0.9) 13.6c (4.3) 6.9 (4.1)
Domain 6. Financial judgment 0–37 30.0a, b (3.0) 20.8c (5.4) 10.7 (5.1)
a 7.8c
Task 6a. Detecting fraud risk 0–10 8.6 (2.0) (2.2) 6.9 (2.8)
Task 6b. Investment decision 0–27 21.4a, b (2.1) 13.0c (4.4) 5.3 (3.5)
Note. From Marson, Sawrie, et al. (2001). Copyright 2000 by the American Medical Association. Reprinted by permis-
sion.
a Normal control mean differs from moderate AD mean using LSD post hoc test, p < .01.
b Normal control mean differs from mild AD mean, p < .01.
c Mild AD mean differs from moderate AD mean, p < .01.
plex tasks such as defining and applying financial concepts, obtaining change for vend-
ing machine use, using a checkbook, understanding and using a bank statement, and
making an investment decision. Patients with moderate AD performed significantly be-
low controls and patients with mild AD on all tasks (Marson & Briggs, 2001; Marson,
Sawrie, et al., 2000).
The findings from this initial study represented the first empirical effort to investi-
gate loss of financial capacity in patients with AD (Marson & Briggs, 2001; Marson &
Hebert, 2005). The findings suggest that there is significant impairment of financial ca-
pacity early in AD. Patients with mild AD appear to experience deficits in complex fi-
nancial abilities (tasks) and some level of impairment in almost all financial activities
(domains). Patients with moderate AD appear to experience loss of both simple and
complex financial abilities and severe impairment across all financial activities. Based
on these initial findings, we proposed two preliminary clinical guidelines for assessment
of financial capacity in patients with mild and moderate AD (Marson, Sawrie, et al.,
2000):
(1) Mild AD patients are at significant risk for impairment in most financial activities,
in particular complex activities like checkbook and bank statement management. Areas of
preserved autonomous financial activity should be carefully evaluated and monitored.
(2) Moderate AD patients are at great risk for loss of all financial activities. Al-
though each AD patient must be considered individually, it is likely that most moderate
AD patients will be unable to manage their financial affairs. (p. 883)
Study of Financial Capacity in MCI. In a subsequent study our group also examined
FC in patients with MCI (Griffith et al., 2003). As reflected in Table 7.5, the FCI-9 was
administered to groups of older controls, patients with amnestic MCI, and patients with
mild AD (Griffith et al., 2003). The groups were well-matched on demographic variables
of education, gender, race, and socioeconomic status (Griffith et al., 2003). Controls per-
formed significantly better than subjects with mild AD on all domains, with the exception
of Domain 8 (knowledge of assets/estate). Controls performed significantly better than
the MCI group on Domains 2 (financial concepts), 4 (checkbook management), 5 (bank
statement management), 6 (financial judgment), and 7 (bill payment). In turn, the MCI
group performed significantly better than patients with mild AD on Domains 1 (basic
monetary skills), 2, 3 (cash transactions), 4, 5, 7, and 9 (investment decision making).
There were no domains on which the MCI group performed better than controls.
Controls performed significantly better than the mild AD group on most tasks, with
the exception of simple tasks of basic monetary skills, cash transactions, and telephone
fraud (Griffith et al., 2003). Controls performed significantly better than the MCI group
on tasks of applying financial concepts, understanding and using a bank statement, un-
derstanding bills, and preparing bills for mailing. The MCI group, in turn, demonstrated
significantly higher scores than the AD group on tasks of understanding and applying fi-
nancial concepts, using a vending machine, understanding and using a checkbook, under-
standing and using a bank statement, prioritizing bills, and preparing bills for mailing.
There were no tasks on which the MCI group performed better than controls.
For overall FC (Domains 1–7), control participants performed significantly better
than MCI and AD participants, and MCI participants performed significantly better than
AD participants. On an experimental measure of overall FC that included knowledge of
assets and estate arrangements (Domains 1–8), smaller samples of control and MCI sub-
jects performed significantly better than patients with AD (p < .001) but did not differ
significantly from each other.
This study represents one of the first published reports of direct assessment evidence
for higher order functional decline and capacity loss in MCI (Griffith et al., 2003). We
found that patients with amnestic MCI demonstrated significant, albeit mild, declines on
some (but not all) financial abilities compared to age, education, gender, and racially
matched normal controls. MCI patients showed a decline in overall FC (Domains 1–7) of
1.74 standard deviation units compared to control subjects. These results strongly sug-
gested that decline in financial abilities is an aspect of functional change in MCI (Griffith
et al., 2003).
Testamentary Capacity
Background
In this section we discuss conceptual and clinical aspects of a third civil competency: ca-
pacity to make a will (testamentary capacity). The right of testation, or the freedom to
TABLE 7.5. Comparisons of Group Performance on the Financial Capacity Instrument

Controls MCI patients AD patients
Score (n = 21) (n = 21) (n =22) p (two- Post hoc
range Mean (SD) Mean (SD) Mean (SD) tailed) p < .05
Domain 1. Basic monetary skills 0–48 45.2 (3.5) 44.3 (3.7) 41.0 (6.3) .011 CM>A
Naming coins/currency 0–8 7.9 (0.3) 7.8 (0.4) 7.6 (0.7) .050 C>A
Coins/currency relationships 0–28 24.9 (3.4) 24.8 (3.5) 22.0 (5.5) .044 ––––
Counting coins/money 0–12 12.0 (0.2) 11.7 (0.5) 11.5 (1.2) .119 ––––
Domain 2. Financial concepts 0–40 36.9 (3.2) 33.1 (4.7) 27.6 (7.5) .001 C>M>A
Understanding concepts 0–15 13.8 (1.2) 12.9 (1.8) 11.2 (2.6) .001 CM>A
Applying concepts 0–25 23.1 (2.4) 20.2 (3.6) 16.4 (5.3) .001 C>M>A
Domain 3. Cash transactions 0–30 27.0 (3.4) 24.8 (3.6) 20.6 (5.9) .001 CM>A
One-item transaction 0–6 6.0 (0.0) 5.8 (0.6) 5.5 (1.1) .044 C>A
Multi-item transaction 0–7 6.1 (1.9) 5.7 (1.8) 4.5 (2.4) .037 C>A
Vending machine 0–9 8.6 (0.9) 8.0 (1.4) 5.6 (1.9) .001 CM>A
Tipping 0–8 6.3 (1.7) 5.4 (1.5) 5.1 (2.1) .068 ––––
Domain 4. Checkbook management 0–54 53.2 (1.5) 50.6 (2.9) 42.9 (8.0) .001 CM>A
Understanding checkbook 0–24 23.5 (0.8) 22.8 (1.5) 21.2 (2.5) .001 CM>A
Using checkbook 0–30 29.6 (1.4) 27.9 (2.2) 21.7 (6.0) .001 CM>A
Domain 5. Bank statement 0–38 35.2 (2.7) 29.9 (5.6) 23.3 (8.3) .001 C>M>A
management
Understanding bank statement 0–18 16.2 (1.6) 13.4 (2.7) 10.6 (3.9) .001 C>M>A
Using bank statement 0–20 19.1 (1.5) 16.5 (4.0) 12.7 (4.9) .001 C>M>A
Domain 6. Financial judgment 0–26 25.6 (1.2) 23.2 (3.7) 23.5 (3.5) .029 C>MA
Mail fraud 0–8 8.0 (0.0) 7.3 (1.3) 7.1 (1.6) .045 C>A
Telephone fraud 0–18 17.6 (1.2) 15.9 (3.0) 16.4 (2.3) .051 ––––
Domain 7. Bill payment 0–46 43.7 (3.3) 38.4 (6.2) 28.3 (9.6) .001 C>M>A
Understanding bills 0–6 5.9 (0.4) 5.1 (1.2) 4.7 (1.6) .006 C>MA
Identifying/prioritizing bills 0–13 12.6 (0.6) 12.3 (1.1) 10.9 (1.7) .001 CM>A
Preparing bills for mailing 0–27 25.1 (3.3) 20.4 (6.1) 12.7 (8.4) .001 C>M>A
Domain 8. Assets and estate 0–20 18.1 (1.6) 17.4 (2.6) 16.2 (2.8) .068 ––––
arrangementsa
Domain 9. Investment decision 0–17 13.9 (2.9) 12.4 (2.3) 9.2 (3.5) .001 CM>A
makingb
FCI total score (Domains 1–7) 0–282 266.8 (13.2) 243.8 (21.7) 207.2 (38.0) .001 C>M>A
FCI total score (Domains 1–8)a 0–302 282.1 (14.1) 264.0 (17.8) 223.8 (39.9) .001 CM>A
Note. C > A, control mean is greater than AD mean; C > M > A, control mean is greater than MCI mean and AD mean, and
MCI mean is greater than AD mean; C > MA, control mean is greater than MCI and AD means; CM > A, control and MCI
means are greater than AD mean. Adapted from Griffith et al. (2003). Copyright 2003 by the American Academy of Neurol-
ogy. Adapted by permission.
a Control = 15, MCI = 13, AD = 21.
b Control = 21, MCI = 19, AD = 18.
choose how one’s property and other possessions will be disposed of following death, is a
fundamental right under Anglo-American law (Frolik, 2001; Marson et al., 2004). A key
requirement of the law of testation is that the person making the will (the testator) have
testamentary capacity or competency (TC; Black’s Law Dictionary, 1968). A will is in-
valid and void, in effect, if TC is lacking at the time that the will is executed (Perr, 1981).
The legal requirement of TC exists across all state jurisdictions (Marson et al.,
2004). In order to make a valid will, the law across all state jurisdictions also requires
that the testator be free from undue influence by another individual who may profit from
a new will or a legal amendment of an existing will (i.e., a codicil) (Spar, Hankin, &
Stodden, 1995). An otherwise validly executed will may be voided by the court when evi-
dence suggests that the volition of the testator was, in effect, displaced by an individual
exercising undue influence over him or her.
The current legal requirements for TC in the United States vary to some degree from
state to state, but in many states four specific criteria or elements are recognized as law
(Marson et al., 2004). A testator must:
1. Understand the nature of the testamentary act;

2. Understand and recollect the nature and situation of his or her property;
3. Have knowledge of the persons who are the natural objects of his or her bounty;
and
4. Know the manner in which the disposition of the property is to occur.
These criteria have been detailed elsewhere (Marson et al., 2004; Spar & Garb, 1992;
Walsh et al., 1997) and are described briefly in a later section.
In addition to the four legal elements of TC described above, many states require
that the testator be free of delusions and hallucinations (Marson et al., 2004). However,
in order for a will to be invalidated, the psychotic symptoms must cause the person to de-
vise his or her property in such a way that he or she would not have done in the absence
of the symptoms (California Probate Code). In other words, to be invalidated, the will
must be the product of “insane” delusion (In re Estate of Raney, 1990).
Individuals with dementia do not lack testamentary capacity on the basis of their di-
agnosis alone (Becker & LeBlang, n.d.; Houts, 1985; Marson et al., 1994; Walsh et al.,
1997). Although testamentary capacity may be relatively intact in the early stages of AD,
as the disease course progresses, these individuals may exhibit persistent difficulty with
memory for their property and potential heirs, diminished abstract reasoning ability in
forming a plan for distribution of belongings after death, and a reliance on others for care
and decision making, thereby increasing their susceptibility to undue influence (Becker &
LeBlang, n.d.; Walsh et al., 1997). Marson (2001b) found that individuals with mild to
moderate AD were impaired in their personal knowledge of assets and estate when com-
pared with controls (p = .001), suggesting that cognitive decline associated with AD may
hinder execution of a valid will.
Conceptual Model of Testamentary Capacity

There is currently an absence of cognitive or neuropsychological models of testamentary
capacity that mental health professionals can draw upon (Marson et al., 2004). The ab-
sence of a sound scientific and theoretical base, in turn, adversely affects clinicians’ con-
ceptual knowledge and related capacity assessment practice patterns. Given the preva-
lence and importance of inheritance by will, testamentary capacity warrants much more
research attention than it has received to date. Our capacity research group has begun
work in this area and offers the following preliminary thoughts concerning the cognitive
components for each of the four legal elements of testamentary capacity. These are out-
lined below:
Cognitive Functions Related to the Element of Understanding the Nature of a Will.

This element requires a testator to understand the purposes and consequences of a will
and to express these verbally or in some other adequate form to an attorney or judge.
Possible cognitive functions involved may include semantic memory regarding terms such
as death, property, and inheritance; verbal abstraction and comprehension abilities; and
sufficient language abilities to express the testator’s understanding. Recognition items
may assist a testator with expressive language problems (Marson et al., 2004). A reply of
“yes” or “no” to an attorney’s queries regarding the nature of a will is unlikely to be sat-
isfactory in this regard, because such responses do not clearly support the testator’s inde-
pendent understanding of the element. Similarly, a testator’s signature on a legal docu-
ment, by itself, does not demonstrate understanding, because a signature is an automatic
procedural behavior not dependent upon higher-level cognition (Greiffenstein, 1996).
Cognitive Functions Related to Understanding the Nature and Extent of Property.

The second legal element of TC requires that the testator understand the nature and ex-
tent of his or her property to be disposed (Marson et al., 2004). As reported earlier, some
states differ in their interpretation of this requirement (Walsh, Brown, Kaye, & Grigsby,
1997). Possible cognitive functions involved here would include semantic memory con-
cerning assets and ownership; historical and short-term memory enabling recall of long-
term and more recently acquired assets and property; and comprehension of the value at-
tached to different assets and property. If the testator has recently purchased new posses-
sions prior to his or her execution of a will, then impairment in short-term memory (the
hallmark sign of early AD) can significantly impact his or her recall of these items. Testa-
tors also must be able to form working estimates of value for key pieces of property that
reasonably approximate their true value; it is likely that executive function abilities play a
role here.
Cognitive Functions Related to Knowing the Objects of One’s Bounty. This legal el-
ement requires that the testator be cognizant of those individuals who represent his or her
natural heirs, or other heirs who can place a reasonable claim on the estate (Marson et
al., 2004). Historical and short-term episodic personal memory of these individuals and
the nature of their relationships with the testator, would appear to be prominent cogni-
tive abilities associated with this element. As dementias such as AD progress, testators
may be increasingly unable to recall family members and acquaintances, leading ulti-
mately to failure to recognize these individuals in photographs or even when present in
person.
Cognitive Functions Related to a Plan for Distribution of Assets. This final legal ele-
ment of TC requires that the testator be able to express a basic plan for distributing his or
her assets to intended heirs (Marson et al., 2004). Insofar as this element integrates the
first three elements in a supraordinate fashion, the proposed cognitive basis for this ele-
ment arguably represents an integration of the cognitive abilities underlying the other
three elements. Accordingly, higher-order executive function abilities are implied, because
the testator must demonstrate a projective understanding of how future dispositions of
specific property to specific heirs will occur.
The preliminary cognitive psychological model of TC proposed above represents a

first step toward model building in this area. Such a model would require empirical verifi-
cation in an older adult sample through use of a relevant TC instrument and neuropsy-
chological test measures.
In summary, research in TC is in its infancy. Considerable work must be done in
areas of theory and model building, instrument development and validation, clinical edu-
cation, and targeted empirical studies. Such work will be of vital importance to the baby
boomers and succeeding generations of the 21st century. The successful resolution of
legal disputes concerning inheritance and property disposition among our elderly popula-
tion will be a sentinel forensic issue over the next several decades, as our society contin-
ues to age and to grapple with the overwhelming reality of widespread dementing ill-
nesses. Neuropsychological assessment can make crucial contributions to this process
through informed and sophisticated understanding and assessment of capacity function-
ing and loss.
Driving
Background
In this final section we describe driving capacity, a fourth civil competency of importance
to older adults in our society. We review the research on the impact of AD and related
dementias on driving performance and examine neuropsychological studies of driving ca-
pacity in AD. We note the absence of conceptual models of driving capacity in aging
adults and provide some indications for further work in this area. Finally, we offer basic
recommendations regarding the assessment of driving competence in individuals with AD
and discuss implications for public policy.
Driving is an advanced IADL that, like FC, is integral to the independence of
community-dwelling older adults. Driving is a distinct capacity insofar as it comprises a
set of overlearned and automatic motor, visuospatial, and procedural skills with simulta-
neous, intermittent demands on controlled processing abilities, including higher-order at-
tention, judgment, and decision-making skills. As discussed below, it is probably the least
verbally mediated of the four specific capacities presented here, and accordingly, it may
be the least amenable to neuropsychological modeling.
The capacity of older adults to drive is a clinical and public policy issue of substan-
tial and growing importance. Older adults represent the fastest growing segment of the
driving population (Duchek, Hunt, Ball, Buckles, & Morris, 1997). In the United States
the number of older drivers is projected to increase from 13 million in 1994 to 30 million
by 2020 (Eberhard, 1994). Research suggests that older adults, particularly those over
the age of 85, are at higher risk of automobile accidents than any other age group
(Dubinsky, Stein, & Lyons, 2000). This finding is particularly concerning because in-
creased risk associated with driving persists even in light of self-limiting behavior typical
among older adult drivers, such as driving fewer miles and avoiding driving at night or in
bad weather (Dubinsky et al., 2000; Fitten, 2003; Lundberg et al., 1997). Elderly drivers
over the age of 65 are one to three times more likely to be injured in a motor vehicle acci-
dent than drivers between the ages of 25 and 64 years, and they have more fatal crashes
per mile driven than any other age group except teenage males (Fitten, 2003; Grabowski,
Campbell, & Morrisey, 2004; Levy, Wernick, & Howard, 1995; Lundberg et al., 1997;
Lyman, Ferguson, Braver, & Williams, 2002). Furthermore, nearly one-third of all deaths
occurring at intersections involve older adults, and 50% of these elders died while at-
tempting left turns (Fitten, 2003).
Studies of Driving Capacity in Patients with AD

Medical conditions that compromise driving can occur at any age, but they are more
likely to occur with advancing age (Dobbs, Carr, & Morris, 2002). In particular, AD and
related dementias represent a direct challenge to driving capacity. Individuals with AD
typically demonstrate progressive deficits in memory, executive functioning, visuospatial
ability, and judgment that over time severely impair their ability to operate a motor
vehicle (Adler, Rottunda, Bauer, & Kuskowski, 2000; Dubinsky et al., 2000). Studies of
driving in AD have examined issues such as the prevalence of automobile accidents or
“near-accidents” relative to other groups of drivers, causes of and factors contributing to
automobile accidents, and the reliability and validity of neuropsychological tests or simu-
lator performance in predicting driving aptitude (Drachman, Swearer, & group, 1993;
Fitten et al., 1995; Hunt et al., 1997; Rizzo, Reinach, McGehee, & Dawson, 1997).
Patients with AD as a group drive more poorly and have a higher crash risk than
their normal older peers (Ball, 2003; Dubinsky et al., 2000; Friedland et al., 1988;
Lundberg et al., 1997). Dubinsky et al. (2000) conducted a systematic review of the liter-
ature to develop practice parameters for neurologists specific to driving and AD. Individ-
uals with AD were found to demonstrate significantly poorer driving performance than
controls for both on-the-road and simulator assessments as well as higher error rates on a
simple traffic sign recognition task. Only one study failed to find increased risk of motor
vehicle accidents and violations among individuals with AD relative to cognitively intact
older drivers (Trobe, Waller, Cook-Flannagan, Teshima, & Bieliauskas, 1996). Friedland
and colleagues (1988) found that a sample of AD drivers was 4.7 times more likely than
the control group to have had at least one crash in the past 5 years, and these accidents
were associated with errors related to maneuvering intersections, obeying traffic lights,
and making lane changes. Moreover, individuals with AD are more likely than cognitively
intact older drivers to experience disorientation in familiar as well as unfamiliar areas
and a decrease in both comprehension of traffic signs and general driving performance
relative to other groups of drivers (Carr, LaBarge, Dunnigan, & Storandt, 1998;
Dubinsky et al., 2000; Rizzo et al., 1997). Increased risk in the AD group persists even
though patients with AD reported driving less at night, on freeways, and in unfamiliar
places (Adler et al., 2000). In fact, research has shown that individuals with AD report
driving one-fourth as many kilometers as age-matched controls (Dubinsky et al., 2000;
Trobe et al., 1996).
Some studies suggest that drivers in the early stages of AD have no more crashes
than matched controls or drivers of all ages (Drachman et al., 1993; Trobe et al., 1996).
Trobe and colleagues (1996) compared Michigan’s driving records from 1986 to 1993 for
143 individuals with AD and 715 controls matched for age, sex, and county of residence.
Crash rates were nearly identical between the two groups, with 77 to 78% of subjects in
both groups having no crashes, 17 to 20% having one crash, and 3 to 5% having more
than one crash. Several limitations of this study which may have resulted in equivalent
crash and violation rates for AD drivers and controls include (1) the absence of cognitive
status testing for control subjects who were presumed to be not demented, thereby poten-
tially inflating cognitive deficits in the control group; (2) failure to include minor colli-
sions that may not be reported to the police; and (3) confounding of reduced driving ex-
posure among subjects with AD relative to controls.
As is true with other higher functional abilities such as FC (Wadley et al., 2003), pa-
tients with AD as a group appear to demonstrate anosognosia and denial with respect to
their driving deficits. Research has found that AD drivers are no more likely than
cognitively intact older adults to have discussed or made plans for driving cessation
(Adler et al., 2000; Hebert, Martin-Cook, Svetlik, & Weiner, 2002). In fact, Adler and
colleagues (Adler et al., 2000; Adler, Rottunda, & Kuskowski, 1999) found that 59 to
63% of AD drivers in each sample (n = 54 and 75) felt that their memory problems
would not cause them to stop driving. Furthermore, 43% of collaterals (i.e., spouse or
other individuals familiar with the subject’s driving habits) believed that subjects with AD
would be able to continue driving throughout the disease course (Adler et al., 1999). Ad-
ditional research has shown that individuals with AD continue to drive after onset and di-
agnosis of dementia (Hebert et al., 2002; Lundberg et al., 1997). Thus the lack of aware-
ness of impaired abilities among older drivers with dementia and their family members
raise clear issues for public policymakers as they seek to protect both individual rights
and public safety.
Neuropsychological Models of Driving Capacity in AD

A number of studies has examined the utility of neuropsychological test performance in
predicting performance or at-risk behaviors in older adult drivers. Overall the results of
these studies have been mixed.
Some studies have found reasonably high correlations between neuropsychological
test performance and driving competency (Duchek et al., 1997; Lundberg et al., 1997).
Measures of visual search and selective attention, visuospatial perception and construc-
tion, and executive function have been found to be highly correlated with driving status
(i.e., drivers vs. nondrivers) and performance (Daigneault, Joly, & Frigon, 2002; Duchek
et al., 1997; Ott et al., 2003; Rizzo, McGehee, Dawson, & Anderson, 2001; Rizzo et al.,
1997). Rizzo and colleagues (1997) examined the effect of AD on driver collision avoidance
using a driving simulator and found that performance on the Rey–Osterrieth Complex
Figure Test (copy trial), WAIS-R Block Design, and TMT Part B were highly correlated
with driving performance in drivers with AD. However, only the Rey–Osterrieth Com-
plex Figure Test emerged as a significant predictor of driving performance. In a study
comparing drivers with very mild (n = 12) and mild AD (n = 13) and healthy elderly con-
trols (n = 13), Hunt, Morris, Edwards, and Wilson (1993) found that measures of general
cognition (Short Blessed Test and Clinical Dementia Rating Scale), verbal and visual
memory (Wechsler Memory Scale/WMS Logical Memory and Benton Visual Retention
Test), visuoperceptual ability (Benton Visual Retention Test Copy), visual scanning and
information processing (TMT Part A and WAIS Digit Symbol Coding), and language
(Boston Naming Test) were significantly correlated with driving outcome. Daigneault and
colleagues (2002) found that older adult male drivers with a history of motor vehicle ac-
cidents (MVAs) demonstrated poorer executive function as measured by the Color Trails
Test, Wisconsin Card Sorting Test, Stroop Color–Word Test, and the Tower of London
test than those with no history of MVAs. Although subject groups differed significantly in
terms of performance speed, the number of errors and perseverative responses emerged as
the best predictors of at-risk driving.
Whereas visual acuity has been found to be only weakly related to crash involve-
ment, visual information processing and higher-order attentional skills as measured by
the Useful Field of View (UFOV) play a critical role in driving performance errors and
MVAs among older adult drivers (Ball, 2003; Rizzo et al., 2001; Rizzo et al., 1997). The
UFOV is a computerized assessment comprised of three subtests designed to assess speed
of visual information processing, divided attention, and selective attention. Loss of visual
field as assessed by the UFOV has been found to be relevant to improper backing up or
stopping and loss of control, as well as failure to merge, yield right of way, and notice
other drivers at intersections (Rizzo et al., 1997). Research has shown that drivers with
AD have greater loss in useful field of vision than older adult controls (Ball, 2003; Rizzo
et al., 1997). The UFOV has been found to predict vehicle crashes better than
neuropsychological test scores (Ball, 2003; Rizzo et al., 1997).
Several studies have found that neuropsychological tests do not help in identifying
at-risk drivers or predicting future adverse driving events (Friedland et al., 1988; O’Neill
et al., 1992; Trobe et al., 1996). For instance, Trobe and colleagues (1996) found that AD
drivers with one or more MVAs following diagnosis did not differ significantly from AD
drivers with no MVAs in terms of neuropsychological test performance. However, only
five out of the 46 dementia patients had experienced an MVA, and the small sample sizes
may have contributed to lack of significant findings. One study found that individuals
with AD having greater crash rates demonstrate better performance on measures of mem-
ory (WMS-R Memory Quotient) as well as verbal and nonverbal intelligence (WAIS-R
VIQ and PIQ) (Trobe et al., 1996). It is possible that these individuals lack awareness of
their neurocognitive deficits and consider themselves competent to drive, thereby failing
to self-impose limits on their driving and increasing their risk of crashes and violations
(Trobe et al., 1996).
In summary, although neuropsychological test performance correlates with driving
performance, the utility of these instruments in predicting driving competency of individ-
ual patients remains questionable (Dobbs et al., 2002; Friedland et al., 1988; Lundberg et
al., 1997; O’Neill et al., 1992). As noted, some studies have found little or no difference
in neuropsychological performance among those individuals who are at higher risk for
MVA versus those who are not (Friedland et al., 1988). Furthermore, neuropsychological
tests have not correlated sufficiently with the outcome of driving tests or future crash in-
volvement to be considered reliable and valid predictors of driving competency for indi-
viduals with AD. As noted above, driving as a capacity probably involves nonverbal,
procedural, judgment, and operational skills that are not easily measured by traditional
neuropsychological assessment measures (Rizzo et al., 1997).
Need for Conceptual Models of Driving Capacity

Research on driving has focused on identifying cognitive risk factors of poor driving per-
formance and developing clinical guidelines and tips for assessing driving ability
(Dubinsky et al., 2000; Lundberg et al., 1997). Unfortunately, the results of these studies
have not yet translated into unifying conceptual cognitive or neuropsychological models
of driving. Given the importance of driving to everyday functioning and its direct impact
on public safety, there is considerable need for sound, scientifically based models of driv-
ing capacity that can advance clinical practice and scientific research in this area.
Directions for future research here would include identifying the constituent compo-
nents of driving capacity. The existing neuropsychological research is instructive here.
Visuospatial skills, attention, judgment, and memory have been found to decline with dis-
ease progression, and these cognitive skills are directly relevant to driving safety. As de-
scribed by Lundberg and colleagues (1997):
Visuospatial skills are needed for a multitude of tasks such as appropriate positioning of the
vehicle, estimating distances, and interpreting a traffic situation and predicting its evolu-
tion. Selective, divided and sustained attention are necessary to detect potential hazards, to
deal with competing stimuli at intersections, and to maintain optimal vigilance during long
trips. Judgment merits special consideration in this context, because it applies not only to
the driving task but also to the awareness of deficits, making compensatory behavior possi-
ble. (p. 32)
In conjunction with declines in visuospatial abilities, memory deficits may pose difficul-
ties for drivers in retaining information after glancing in the rearview mirror or getting
lost, both of which can lead to driving errors and violations (Lundberg et al., 1997).
Thus a proposed working model of driving capacity would, at a minimum, include
procedural motor skills (e.g., reaction times), visuospatial skills, attentional abilities such
as those measured by the UFOV, semantic knowledge of signs and the rules of the road,
and decision-making skills such as risk estimation and judgment abilities, particularly
those called upon in novel situations. However, it is likely that not all of the variables of
interest will be linked to traditional neuropsychological variables. The task ahead is to
develop and test a truly comprehensive operational model in samples of cognitively nor-
mal and abnormal older drivers and determine how well it accounts for impairment and
crash risk.
Summary
Overall, research supports the finding that the neurocognitive decline associated with AD
results in impaired driving performance over time. Increased crash rate, significant im-
pairment in driving ability, and significant deficits in visual processing have been associ-
ated with drivers who have AD, and these impairments may be evident even in the early
stages of the disease process (Dubinsky et al., 2000; Duchek et al., 1997). However, sig-
nificantly, the negative impact of dementia on driving performance is poorly understood
by patients and their caregivers. As such, many individuals with AD continue driving for
many months following diagnosis, thereby posing challenges to public safety as the dis-
ease course progresses (Adler et al., 2000; Hebert et al., 2002). Matters are further com-
plicated in that some patients with mild AD retain good driving skills, suggesting that ba-
sic skills involved in driving are automatized and reflective of procedural knowledge,
which is relatively spared in early AD (Duchek et al., 1997; Lundberg et al., 1997; Trobe
et al., 1996). Although data on crash rates during the first few years after symptom onset
and diagnosis of AD do not suggest a significant problem, the precise point in time at
which risk becomes unacceptable remains to be determined (Lundberg et al., 1997). Un-
fortunately, tests of mental status, neuropsychological measures, and rating scales of
functional performance administered within a clinical setting are limited in their ability to
predict driving performance (Johansson & Lundberg, 1997; Trobe et al., 1996). As with
other capacities, direct assessment of driving capacity, via simulator or on-the-road test-
ing, remains the gold standard. However, although driving simulators are valid measures
of driving aptitude, they are more costly, less accessible, and more difficult to administer
than mental status tests, neuropsychological assessments, or state road tests (Dubinsky et
al., 2000; Odenheimer, 1993).
The issue of driving capacity among older adults will become increasingly prominent
over the next several decades, as our aging society struggles to balance the individual rights
of our older adult population with the demands of public safety. Current needs at the pres-
ent time include conceptual models of driving capacity, better assessment tools to identify
individuals at high risk for crashes and violations, and the creation of alternatives to driving
which are both appropriate and acceptable to high-risk older drivers (Adler et al., 2000).
CHAPTER SUMMARY
The assessment of everyday functioning in older adults is an integral part of gerontology

and geriatric medicine. It is thus surprising that, until recently, evaluation of functional
status has been a largely neglected aspect of geriatric neuropsychological assessment. For
reasons of history and training, our field has focused primarily on cognitive and personal-
ity changes in normal and abnormal aging, with less attention paid to functional out-
comes and the interrelationships of cognitive and functional change. The present chapter
reflects how the field’s emphasis is beginning to change and broaden in this regard. We
have provided a conceptual overview of ADLs and IADLs, described two prevailing as-
sessment approaches of self-informant report and direct assessment, and summarized lit-
erature linking cognitive and functional change in aging and dementia. In the second half
of the chapter we focused in detail on four specific functional capacities that geriatric
neuropsychologists frequently encounter (medical decision-making capacity, FC, testa-
mentary capacity, and driving), describing applicable conceptual models, assessment in-
struments, and empirical studies.
The increasing interest of neuropsychology in functional change and capacity assess-
ment is encouraging from both clinical and research standpoints. Neuropsychology as a
discipline is perhaps uniquely positioned to explore the relationships between the aging
brain, cognition, and everyday functioning. Utilizing functional brain imaging tech-
niques, its own cognitive testing armamentarium, and increasingly sophisticated func-
tional assessment methods, neuropsychology can elucidate the linkages between brain
diseases/lesions, associated neurocognitive and neuropsychiatric changes, and the changes
in everyday functioning and adaptation they occasion. This knowledge, in turn, can be
translated into useful clinical knowledge to guide issues of diagnosis, placement, and in-
tervention in community settings. In our view, the exploration and understanding of this
continuum of brain–cognition–function represents one of the exciting scientific chal-
lenges for geriatric neuropsychology in the 21st century.
ACKNOWLEDGMENTS
Supported in part by an Alzheimer’s Disease Research Center grant (NIH, NIA 1P50 AG16582)
(Lindy Harrell, Principal Investigator) from the National Institute on Aging; a grant from the Na-
tional Institute of Mental Health (NIH, NIMH 1 R01 MH55427); and the Alzheimer’s Disease Co-
operative Study (NIH, NIA AG 10483-12) (Leon Thal, Principal Investigator).
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8
Cultural Issues
JENNIFER J. MANLY
During the next few decades, there will be significant changes in the ethnic and racial
landscape among the elderly in the United States. These changes suggest that ethnic mi-
nority populations will bear an increased share of the economic and social burden associ-
ated with diseases that predominantly affect the elderly, such as Alzheimer’s disease (AD)
and other progressive dementias. The U.S. Census Bureau estimates that the proportion
of elders who are white and non-Hispanic will decline from 87% (in 1990) to 67% in
2050. By 2010, the population of Hispanic elders is expected to double from that in 1990
and will be 11 times greater by 2050. Of the 80.1 million elderly projected for 2050, 8.4
million (10.4%) will be black, as compared to 8% of elders in 1990.
The growth in diversity of elders in the United States presents a unique opportunity
for neuropsychologists to study the role of race, culture, and ethnicity in recognition, di-
agnosis, and treatment of age-related cognitive impairment and dementia. Scientists who
believe that genetic risk factors differ by race hope that comparison of different ethnic/ra-
cial groups residing in the same environment may help to uncover genetic factors respon-
sible for AD. At the same time, cross-cultural dementia research may provide an opportu-
nity to identify different prevalence rates of AD among elderly within the same ethnic
group (Osuntokun et al., 1992). For example, a comparative examination of Koreans liv-
ing in Korea versus those living in Russia and Scandinavia will likely reveal genetically
similar people who have been exposed to dramatically different environmental and cul-
tural forces. This research could enhance the search for risk factors because these envi-
ronmental and cultural forces may affect risk for dementia. Although both approaches
are potentially fruitful, cross-cultural research on dementia must contend with the fact
that assessments of both cognitive impairment and daily functioning are susceptible to
culturally dependent definitions and are quantified by measures that are sensitive to cul-
tural and educational backgrounds.
For illustrative purposes, two case examples are presented below that will be familiar
198
Cultural Issues 199
to clinicians practicing in a memory disorders clinic that serves ethnically diverse patients
and their families. These vignettes are provided as examples of the dilemmas that
neuropsychologists face when evaluating patients from ethnic minorities.
Patient 1 is an 83-year-old retired factory worker with 6 years of schooling. Her hus-
band passed away 3 years ago, and she now lives alone. Her oldest daughter, who visits
infrequently but keeps in touch by phone, has arranged for an evaluation after noticing
that she had to repeat conversations on several occasions during the last few months. The
patient denies any decline in her ability to carry out day-to-day activities, including fi-
nances, shopping, navigating around the city and her neighborhood, and keeping up with
friends. Patient 1 reports that although she thinks her memory is not as good as it used to
be, she does not think that it is interfering with her daily functioning. Born and raised in
Cuba, she identifies herself as Hispanic. She attended a one-room rural school in Cuba
and worked on a farm on the days she did not attend school. She immigrated to New
York City in her late 20s. Although she speaks English “pretty well,” she is much more
comfortable speaking Spanish, which she uses in her home and with her family and
friends. Her score on a translated Folstein Mini-Mental State Examination, which was
administered by a bilingual graduate student, was 23/30. She stated the incorrect date
(but correctly reported the day of the week, month, year, and season), remembered two of
three words after the delay, could not spell world backward, made an error on the phrase
repetition, omitted a word and misspelled a word on her sentence, and failed the inter-
secting pentagons copy.
Patient 2 is a 67-year-old lawyer with 19 years of schooling. He is married and lives
with his wife. He presents with complaints of memory difficulty over the past year. He
states that he is relying more on his wife and secretary to keep track of his appointments,
and that he cannot be relied on to remember a short list of groceries in the store. He
stated that he has also noticed difficulty learning how to operate a new spreadsheet pro-
gram on his computer. He reports no problems taking care of other daily activities. His
wife and son corroborate that he has had increasing forgetfulness for appointments, but
both suggest that he may be a bit depressed since deciding to reduce his busy work sched-
ule and move toward full retirement. Patient 2 identifies himself as African American. He
received his elementary and high school education in the integrated public schools of
Brooklyn, New York. After attending the City College of New York, he worked in his fa-
ther’s construction business for a few years, then enrolled in the University of Minnesota
Law School. He was a senior partner in a thriving practice in New York City for several
decades. He is now semiretired, does mostly consulting, and sits on several boards for
nonprofit organizations. His score on the Folstein Mini-Mental State Exam was 29/30; he
could not recall one of the three words after a delay.
Although Patient 1’s daily functioning is not impaired, it is concerning that her
daughter has noticed a change in her memory over time. The cognitive screening test re-
veals a low score, but this performance may be within normal expectations given her age
and educational and occupational background. Scores on more sensitive neuropsy-
chological tests will probably also be relatively low, possibly in the impaired range in re-
lation to published norms. Similar to most neuropsychologists in the United States, this
neuropsychologist is not likely to speak Spanish and is most comfortable assessing
English-speaking patients with English-language tests (Echemendia, Harris, Congett,
Diaz, & Puente, 1997). Should the patient be tested in English? If not, the clinician will
struggle to find a Spanish language battery that is normed for Caribbean Hispanic elders
(rather than Mexican American elders) and also corrected for years of education, which
is clearly a factor in this case. The clinician may not have access to a fully trained
psychometrist who is able to administer the battery in Spanish.
Patient 2 also presents a dilemma, but for different reasons. He has cognitive com-
plaints that may be related to mood, as suggested by his family, or could be early signs of
a degenerative process. Heaton, Miller, and colleagues (Heaton, Miller, Taylor, & Grant,
2004) have recently published norms for African Americans, but it is unclear why these
would provide a more appropriate comparison for this patient than norms established for
well-educated European Americans, since Patient 2 was educated in mostly European
American schools and worked alongside mostly European Americans throughout his ca-
reer. The screening test suggests that sensitive tests of cognitive ability will be needed to
detect a cognitive deficit (if there is one), and that the clinician’s expectations for perfor-
mance will have to be adjusted, given this individual’s educational and occupational
background.
Practical solutions for these common dilemmas are conspicuously inaccessible, de-
spite the growth of the field of neuropsychology in clinical settings and research domains.
In the absence of a substantial scientific body of literature that provides clear guidelines,
this chapter presents a discussion of cultural and educational factors that should be con-
sidered systematically when assessing cognitive function among elders from ethnic minor-
ities. In fact, I argue that acculturation, quality of education, literacy, and racial socializa-
tion are more meaningful and useful background variables to help adjust expectations for
neuropsychological test scores and improve specificity of cognitive tests, regardless of
race/ethnicity (Table 8.1). The chapter begins with a review of what we know about the
rates of AD and dementia within African Americans, Hispanics, Asian/Pacific Islanders,
and Native American living in the United States. I then explore the recognition of cogni-
tive impairment in individuals from these populations, including issues of cultural bias in
neuropsychological measurement of cognitive functioning and differences in presentation
of cognitively impaired elders across ethnic and cultural groups. Within this discussion, I
TABLE 8.1. Background Factors That Influence Neuropsychological

Test Performance
I. Culture
A. Language
1. Bilingualism
2. Orthography–phonology consistency
3. Articulatory time
B. Acculturation
1. Years in the United States
2. Level of exposure to mainstream culture
II. Education
A. Years of school
B. Quality of education
1. Segregation level
2. Teacher–student ratio
3. Per-pupil expenditures
4. Length of school year
C. Literacy level
III. Racial socialization
A. Stereotype threat
B. Perceived racism
Cultural Issues 201
use examples from my own work to highlight the issues and make recommendations for
future research.
RATES OF AD AND DEMENTIA ACROSS ETHNIC GROUPS
Most U.S.-based studies have focused on comparing rates of dementia or AD among Afri-
can Americans and Hispanics to rates among European Americans. These studies found
higher rates of cognitive impairment, dementia, and AD among ethnic minorities than
among European Americans (Prineas et al., 1995). For example, large longitudinal com-
munity studies in Northern Manhattan in New York City (Tang et al., 2001) and India-
napolis (Hendrie et al., 1995; Hendrie et al., 2001) reported higher rates of prevalent and
incident dementia and AD among African Americans as compared to European Ameri-
cans, but the Duke Established Populations for Epidemiological Studies of the Elderly
(EPESE) project found no differences in frequency of dementia between African Ameri-
cans and European Americans (Fillenbaum et al., 1998). These studies used National In-
stitute of Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease
and Related Disorders Associations (NINCDS–ADRDA) criteria, full neurological exami-
nations, and administered extensive neuropsychological batteries; the differences in rates
occurred even after correcting for differences in years of education. In addition, the rate
of dementia on admission to nursing homes is higher among African American residents
than among European American residents (Weintraub et al., 2000); however, findings
from studies of long-term outcomes for African American elders with dementia are not
consistent. Mortality associated with dementia was found to be higher among African
Americans than non-Hispanic European Americans, especially among African American
males (Lanska, 1998). However, there were no statistically significant differences in sur-
vival from time of entry into the CERAD study of European American and African Amer-
icans, after accounting for the effects of age, gender, and severity of dementia (Heyman,
Peterson, Fillenbaum, & Pieper, 1996).
The role of immigration and changes in environmental risk factors was examined in
several epidemiological studies of elders with Japanese ancestry. The age-standardized
prevalence of dementia (using DSM-III criteria) among elderly Japanese American men
living in Hawaii (White et al., 1996) was higher than Japanese men living in Japan, which
was similar to European populations. The authors suggested that environmental or cul-
tural exposures associated with migration from Japan to Hawaii influenced the develop-
ment of AD in these Japanese Americans. Similar results were reported in a study of
1,985 Japanese American participants in the Kame project in King County, Washington
(Graves et al., 1996). A cross-sectional study of dementia prevalence using the Alzhei-
mer’s Disease Diagnostic and Treatment Centers in California found that, as compared to
European Americans, Asian Americans had a greater proportion of vascular dementia
and lower proportion of AD (Yeo, Gallagher-Thompson, & Lieberman, 1996), similar to
studies of Asians in Asia.
It appears that Native Americans have a lower rate of AD than European Americans,
but equivalent rates of overall cognitive impairment or dementia. Hendrie et al. (1993)
examined 192 Cree living on two reserves in Manitoba, Canada, ages 65 and over, and
an age-stratified sample of 241 English-speaking European Canadians living in Winnipeg.
Using the Community Screening Interview for Dementia (CSI-D) to screen for cognitive
impairment, the authors found a significant difference between the age-adjusted preva-
lence of AD among the Cree Indians (0.5%) as compared to the European Canadians
(3.5%), despite the two groups having an equivalent age-adjusted prevalence of dementia
(4.2% in each population).
An interesting study of Cherokee Indians living in northeastern Oklahoma (Rosen-
berg et al., 1996) used NINCDS–ADRDA criteria to identify 26 people, with AD, ages 65
years and older, and then assessed an equal number of normal controls. The investigators
found that as the genetic degree of Cherokee ancestry increased, the frequency of AD de-
creased. That is, independent of apoE4 allele status, elders with more than 50% genetic
Cherokee ancestry were less likely to be in the AD group than the control group. Genetic
degree of ancestry for each participant was calculated using genealogical records pro-
vided by the Cherokee Nation Tribal Registration Department. A limitation of this study
is its case-control design; however, this study represents a more advanced method of ex-
amining the relationship of race/ethnicity to disease because the degree of ethnic ancestry
was assessed (albeit not though formal genetic analysis), as opposed to classifying indi-
viduals into racial groups based on self-report or investigator observation.
Autopsy Confirmation of AD Pathology

Although the exact etiology cannot be definitively determined before an autopsy, there are
research criteria for AD and vascular dementia that have been shown to predict the specific
pathological determination upon autopsy with up to 90% accuracy. However, the support-
ing research has involved European American subjects almost exclusively. The research
studies cited above showing ethnic differences in rates of AD and dementia use clinical crite-
ria only; they would be greatly enhanced by studies in which autopsies were performed to
obtain brain tissue for neuropathological investigation of individuals who were evaluated
during life. However, African Americans and other ethnic minorities are less likely to con-
sent to autopsy (Bonner, Darkwa, & Gorelick, 2000; Fillenbaum et al., 1996; Harrell,
Callaway, & Powers, 1993). Therefore, there are few published studies comparing the rates
of neuropathologically defined AD among different ethnic groups in the United States. The
few studies with ethnically diverse samples have found either no racial differences in fre-
quency of AD pathology among those autopsied (Miller, Hicks, D’Amato, & Landis, 1984),
or that AD lesions were more prevalent among European Americans than among African
Americans (de la Monte, Hutchins, & Moore, 1989). Small sample size is a problem for
each of these studies, and because there is a much lower rate of consent for autopsy among
African Americans, there may be a selection bias.
One study avoided selection bias by performing a survey of all autopsies on individu-
als ages 40–70 in the Maryland Chief Medical Examiner’s office for an 8-year time period
(Sandberg, Stewart, Smialek, & Troncoso, 2001). All died of “non-natural” causes,
mostly accidents and homicides. The researchers assessed the prevalence of senile plaques
(SPs) and neurofibrillary tangles (NFTs) in three brain areas: the hippocampus, ento-
rhinal cortex, and inferior temporal cortex. In their sample of 138 individuals, 42% were
African American and 61% were younger than age 65. NFTs were more common after
age 54 and were found mostly in the hippocampus and entorhinal cortex. SPs were less
frequent overall but were found mostly in people 75 years and older in the entorhinal
cortex and inferior temporal cortex. Prevalence of neuritic plaques was consistently lower
in African Americans than in European Americans. Although the authors confirmed that
prevalence of mixed SPs and NFTs was strongly correlated with age, there was no evi-
dence that these pathological changes had any differences in frequency by race.
Cultural Issues 203
Imaging Evidence
Brain imaging studies that use both structural and functional methods might provide an
alternative line of evidence concerning AD pathology, which could support the epidemio-
logical findings of ethnic discrepancies in the disease. However, there are very few studies
of structural or functional brain imaging using diverse groups of elders. Studies of Afri-
can American elders with clinical diagnoses of AD have shown that magnetic resonance
imaging (MRI) measurements of hippocampal volume (Sencakova et al., 2001) and quali-
tative computed tomography (CT) and MRI findings (Charletta, Gorelick, Dollear,
Freels, & Harris, 1995) were similar to those reported in other imaging studies of primar-
ily European American patients. One study using MRI and single-photon emission com-
puted tomography (SPECT) showed no major ethnic differences in degree of white matter
hyperintensities, ventricle-to-brain ratio, and uptake among 3,301 nondemented community-
dwelling elders without a history of stroke or transient ischemic attack (Longstreth et al.,
2000). Other research has found a higher prevalence of white matter lesions among
nondemented African American elders—a predictable finding, given that cardiovascular
risk factors (e.g., hypertension, diabetes) are more common among African Americans
(Liao et al., 1997; Lesser et al., 1996).
INTRUMENTATION ISSUES IN DETECTION OF DEMENTIA ACROSS CULTURES

Ethnic Differences and Cognitive Testing
One possible explanation for higher rates of AD and dementia among African Americans
and Hispanics is that the neuropsychological tests used to assess cognitive function have
not been properly validated for use among ethnic minorities in the United States. Lack of
such validation may account for the fact that, based on neuropsychological test perfor-
mance, ethnic minorities are judged to be cognitively impaired more often than non-His-
panic European American persons. This section reviews studies within and outside the
United States that have compared the cognitive test performance of different ethnic
groups and (2) describes constructs that might facilitate more sophisticated investigations
of ethnic differences in the future.
Use of the standard cutoff of 23 on the Mini-Mental State Examination (MMSE)
leads to overdiagnosis of dementia among African Americans, even after controlling for
years of education (Bohnstedt, Fox, & Kohatsu, 1994). Racial, ethnic, and cultural differ-
ences have been found on MMSE performance and other screening measures before
(Mast, Fitzgerald, Steinberg, MacNeill, & Lichtenberg, 2001; Unverzagt, Hall, Torke, &
Rediger, 1996) and after adjusting for education (Escobar et al., 1986; Fillenbaum,
Hughes, Heyman, George, & Blazer, 1988; Kuller et al., 1998; Salmon et al., 1989;
Teresi, Albert, Holmes, & Mayeux, 1999; Welsh et al., 1995).
Difficulties in interpreting cognitive scores among ethnic minority elders are not lim-
ited to brief screening instruments; several studies have indicated that ethnic or cultural
factors have a substantial effect on neuropsychological batteries (Adams, Boake, &
Crain, 1982; Overall & Levin, 1978). Even when ethnic groups are matched on socioeco-
nomic variables, discrepancies in neuropsychological test performance have remained
(Jacobs et al., 1997; Kaufman, McLean, & Reynolds, 1988; Manly et al., 1998b;
Reynolds, Chastain, Kaufman, & McLean, 1987). Roberts and Hamsher found that neu-
rologically intact European Americans obtained significantly higher scores on a measure
of visual naming ability than did neurologically intact African Americans, even after cor-
recting for education level (Roberts & Hamsher, 1984). Several other studies also re-
ported ethnic differences in performance on tests of visual confrontation naming
(Carlson, Brandt, Carson, & Kawas, 1998; Ross, Lichtenberg, & Christensen, 1995;
Welsh et al., 1995).
Ethnicity-related differences have been reported on measures of nonverbal abilities
as well (Bernard, 1989; Brown et al., 1991; Campbell et al., 1996; Heverly, Isaac, &
Hynd, 1986; Miller, Bing, Selnes, Wesch, & Becker, 1993). Jacobs et al. (1997) found that
Spanish-speaking elders scored significantly lower than age- and education-matched Eng-
lish-speaking elders on a measure of nonverbal abstraction (i.e., the Identities and Odd-
ities subtest from Mattis’s Dementia Rating Scale); multiple choice matching and recogni-
tion formats of the Benton Visual Retention Test; and measures of category fluency and
comprehension. In another study, healthy Spanish-speaking Mexicans and Mexican
Americans who lived near a U.S.–Mexico border (n = 200) were compared with residents
of Madrid, Spain (n = 218). After accounting for education, borderland residents ob-
tained significantly lower scores on measures of recognition discriminability for stories
and figures, learned fewer details from a story over five trials, and made more
perseverative responses on the Wisconsin Card Sorting Task (Artiola i Fortuny, Heaton,
& Hermosillo, 1998). There were some interactions between years of education and
place of birth, suggesting that among those with high levels of education, borderland and
Spanish participants performed similarly on several measures.
Several studies have reported significant differences in performance on neuropsy-
chological test batteries designed to detect dementia among African American and Euro-
pean American elders, despite correcting for years of education, age, occupational attain-
ment, and history of medical conditions such as hypertension and diabetes (Fillenbaum,
Heyman, Huber, Ganguli, & Unverzagt, 2001; Manly et al., 1998b; Unverzagt et al.,
1996). In contrast, a number of studies has failed to find discrepancies in test perfor-
mance between racial, ethnic, or cultural groups after participants were matched on years
of education (Carlson et al., 1998; Ford, Haley, Thrower, West, & Harrell, 1996), after
statistically adjusting for education (Loewenstein, Ardila, Rosselli, & Hayden, 1992;
Marcopulos, McLain, & Giuliano, 1997; Mungas, Marshall, Weldon, Haan, & Reed,
1996), or after cut-scores were adjusted for those with low education (Murden, McRae,
Kaner, & Bucknam, 1991). However, the statistical power to detect a significant differ-
ence in some of these studies was severely limited by small sample sizes of non-white par-
ticipants. For example, there were no significant ethnic differences among a small number
of blacks (n = 11) and whites (n = 32) with AD on measures of naming, picture vocabu-
lary, verbal abstraction, verbal list learning, and pragmatic language use after controlling
for MMSE score and years of education (Ripich, Carpenter, & Ziol, 1997). Another
study found that among 18 black and 114 white participants who met NINCDS–
ADRDA criteria for AD, there were no significant differences by race on decline in
MMSE score over an average 2.5-year period, whereas left-handedness, more years of ed-
ucation, and family history of dementia were associated with more rapid decline
(Rasmusson, Carson, Brookmeyer, Kawas, & Brandt, 1996).
Taken together, most previous studies of ethnic group differences in performance on
the MMSE and neuropsychological tests have shown that discrepancies between scores of
different ethnic groups persist, despite equating groups on other demographics such as
age, education, gender, and socioeconomic background. These discrepancies cause atten-
uated specificity of verbal and nonverbal neuropsychological tests, such that cognitively
Cultural Issues 205
normal ethnic minorities are more likely than whites to be misdiagnosed as impaired
(Ford-Booker et al., 1993; Klusman, Moulton, Hornbostle, Picano, & Beattie, 1991;
Stern et al., 1992; Manly et al., 1998b; Welsh et al., 1995). These findings indicate that
not all tasks are functionally equivalent (Helms, 1992; Ratcliff et al., 1998). In other
words, although performance on a cognitive test may not reflect the same underlying
construct across all racial and ethnic groups, many neuropsychologists assume that test
scores provide valid indicators of ability regardless of cultural background (Nell, 2000).
Although establishing separate test norms for ethnic minorities may help with mis-
diagnosis (Miller, Heaton, Kirson, & Grant, 1997), there is variability of educational and
cultural experiences within ethnicity that may decrease the accuracy of these norms. Sep-
arate norms do not address the variability related to culture, race, and education that un-
derlies ethnic group differences on cognitive test performance. It is therefore possible that
separate ethnic group norms will create more problems than they solve, lead to increased
misunderstanding of racial and ethnic group differences, and become unwieldy to the ev-
eryday practitioner. Instead, direct measurement of more meaningful and predictive vari-
ables that underlie test performance across cultural groups may serve to increase accuracy
of cognitive assessment and the validity of all instruments used to diagnose dementia. In
the following sections I review the relationship of cognitive test performance to some of
the variables that differ within and between racial and ethnic groups.
Acculturation
Most previous research on ethnicity has classified participants on the basis of physical
appearance or self-identified racial/ethnic classification, rather than measuring the cul-
tural variables that accompany ethnic group membership. However, as suggested by
Helms (1992), specification of the experiential, attitudinal, or behavioral variables that
distinguish those belonging to different ethnic groups and that also vary among indi-
viduals within an ethnic group, may allow investigators to understand better the under-
lying reasons for the relationship between ethnic background and cognitive test perfor-
mance.
Level of acculturation is one way in which social scientists have operationalized
within-group cultural variability. Acculturation is defined as the level at which an individ-
ual participates in the values, language, and practices of his or her own ethnic community
versus those of the dominant culture (Landrine & Klonoff, 1996; Padilla, 1980). Previous
studies have identified ideologies, beliefs, expectations, and attitudes as important com-
ponents of acculturation, as well as cognitive and behavioral characteristics such as lan-
guage and customs (Berry, 1976; Moyerman & Forman, 1992; Negy & Woods, 1992;
Padilla, 1980).
Few studies have examined the relationship of cognitive test performance to within-
group ethnic or cultural factors independent of those associated with socioeconomic
status. Arnold et al. (Arnold, Montgomery, Castaneda, & Longoria, 1994) found a rela-
tionship between Hispanic acculturation and performance on selected tests of the
Halstead–Reitan Neuropsycholgical Battery among college students. Artiola et al. (1998)
reported that among Mexican and Mexican American residents of a U.S. border region,
percentage of life in which individuals lived in the United States was significantly and
negatively related to number of words generated on a Spanish oral fluency measure, espe-
cially among those with fewer than 8 years of education. In addition, those who spent a
larger percentage of their life in the United States made more perseverative errors on the
Wisconsin Card Sorting Test, and bilingualism accounted for a significant amount of
variance in performance on a Spanish verbal learning test.
Three studies have explored the relationship of African American acculturation (as
measured by the African American Acculturation Scale (Landrine & Klonoff, 1994,
1995) to cognitive test performance. Manly, Miller, et al. (1998) found that among
neurologically intact African Americans between the ages of 20 and 65, those who
were less acculturated (more traditional) obtained lower scores on measures of general
information and naming than more acculturated African Americans. Among elderly
residents of northern Manhattan (Manly et al., 1998a), acculturation accounted for a
significant amount of variance in several neuropsychological measures assessing verbal
and nonverbal abilities, after accounting for age, education, and gender. Among elderly
African Americans living in Jacksonville, Florida, acculturation accounted for a signifi-
cant amount of variance in Verbal IQ (as measured by the Wechsler Adult Intelligence
Scale), Boston Naming Test, and delayed recall of stories from the Wechsler Memory
Scale—Revised (Lucas, 1998).
Taken together, investigations of acculturation level suggest that there are cultural
differences within elders of the same ethnicity that relate to neuropsychological measures
of verbal and nonverbal skills, and that accounting for acculturation may improve the ac-
curacy of certain neuropsychological tests. Although previous research has focused on
ethnic minority elders in the United States, it is likely that within-group cultural differ-
ences are also significant factors in the test performance of American elders who identify
themselves as white or Caucasian, as well as ethnic groups outside the United States.
Years of Education, Quality of Education, and Literacy

Extreme differences in educational level are often found between ethnic minorities and
European Americans. Illiteracy rates in the United States are highest among people ages
65 and over, but are especially elevated among elders from ethnic minorities (Kirsch,
Jungeblut, Jenkins, & Kolstad, 1993). Cross-cultural researchers are therefore challenged
to find measures that are sensitive to cognitive impairment across these broad educational
backgrounds (Ratcliff et al., 1998). Although it is common for investigators to use
covariance, matching procedures, or education-corrected norms in order to “equate” eth-
nic groups on years of education before interpreting neuropsychological test perfor-
mance, as discussed above, these techniques ignore ethnic discrepancies in quality of edu-
cation. Therefore, disparate school experiences could explain why many ethnic minorities
obtain lower scores on cognitive measures, even after controlling for years of education.
Table 8.2 provides examples of expenditures in selected states for African American and
European American schools.
Therefore, even if an investigator “adjusts” for years of school, we cannot assume
that the effect of educational experience has been removed from an analysis of ethnic and
racial group differences in cognitive test performance. Along with several other authors
(Kaufman, Cooper, & McGee, 1997; Loewenstein, Arguelles, Arguelles, & Linn-Fuentes,
1994; Whitfield & Baker-Thomas, 1999), I argue that due to the disparities in quality of
education, matching on quantity of formal education does not necessarily mean that the
quality of education received by each racial group is comparable. The variable “years of
education” systematically differs between African Americans and European Americans
(Margo, 1985, 1990; Smith, 1984; Smith & Welch, 1977; Welch, 1973, 1966) and is also
related to cognitive test performance. If this variable is not commensurate between racial
Cultural Issues 207
TABLE 8.2. Per-Pupil Expenditures by State in 1935

State Black White Ratio
Alabama 17.50 53.18 .33
Florida 17.71 39.80 .45
Maryland 80.63 102.84 .78
Mississippi 13.36 58.61 .23
North Carolina 32.92 51.43 .64
South Carolina 18.62 67.74 .28
Virginia 33.05 63.81 .52
New York 110.97
Pennsylvania 75.74
Note. Data from Blose and Caliver (1938).
groups, residual confounding will occur and spurious racial differences will be inter-
preted, despite matching groups on years of education.
Presence of poor literacy skills among elders is also a particularly relevant issue for
neuropsychologists attempting to accurately detect dementia using cognitive measures.
Reading level is a very powerful predictor of cognitive test performance, independent of
years of education, age, or ethnicity (Ardila, Rosselli, & Rosas, 1989; Lecours et al.,
1987; Manly et al., 1999; Matute, Leal, Zaraboso, Robles, & Cedillo, 1997; Reis,
Guerreiro, & Castro-Caldas, 1994; Rosselli, Ardila, & Rosas, 1990; Scribner & Cole,
1981; Weiss, Reed, Kligman, & Abayd, 1995). Table 8.3 presents results from one study
that suggest that performance on many verbal and nonverbal cognitive measures is more
dependent on literacy or reading skills than years of education.
Our group recently reported a study that sought to determine if discrepancies in quality
of education could explain differences in cognitive test scores between African American
and European American elders matched on years of education (Manly, Jacobs, Touradji,
Small, & Stern, 2002). A comprehensive neuropsychological battery was administered to a
sample of nondemented African American and non-Hispanic European American partici-
pants in an epidemiological study of normal aging and dementia in the Northern Man-
hattan community. The Reading Recognition subtest from the Wide Range Achievement
Test—Version 3 (WRAT-3) was used as an estimate of quality of education. African Ameri-
can elders obtained significantly lower scores than European Americans on measures of
word-list learning and memory, figure memory, abstract reasoning, fluency, and visuo-
spatial skill, even though the groups were matched on years of education. However, after
adjusting the cognitive test scores for WRAT-3 performance, the overall effect of race was
greatly reduced, and racial differences on all tests (except category fluency and a drawing
measure) became nonsignificant. Reading score also attenuated the effect of race after ac-
counting for an estimate of test-wiseness. Test-wiseness is defined as the ability to use the
format and characteristics of a test to achieve a high score (Scruggs & Lifson, 1985), and the
use of deduction and item cues to answer questions (Borrello & Thompson, 1985). This
finding suggests that “years of education” is an inadequate measure of the educational ex-
perience among multicultural elders, and that adjusting for quality of education may im-
prove the specificity of certain neuropsychological measures across racial groups.
These findings suggest that the full extent of discrepancies in educational experience
between African Americans and European Americans is not captured by a simple “high-
TABLE 8.3. Proportion of Variance (R2) in Neuropsychological Test Scores Accounted

for by Demographics, Acculturation, and Reading Level
Years of WRAT-3
Test Sex Age education Acculturation reading
Learning/memory
SRT total recall .001 .119 .166 .025 .189
SRT delayed recall .001 .070 .091 .011a .105
BVRT recognition memory .004 .059 .156 .029 .211
Orientation
MMSE Orientation .004 .012a .020 .002a .033
Abstract reasoning
WAIS-R Similarities Raw .005 .062 .319 .060 .386
DRS Identities and Oddities .005 .045 .077 .003a .088
Language
Boston Naming .002 .025 .148 .048 .316
Letter fluency .002 .046 .216 .030 .401
Category fluency .000 .070 .184 .028 .184
BDAE repetition .004 .010b .057 .028 .095
BDAE Comprehension .003 .012a .096 .017 .137
Visuospatial ability
Rosen Drawing .001 .036 .071 .039 .116
BVRT matching .001 .058 .139 .038 .156
Note. R2 is the proportion of variance in the neuropsychological test score that is accounted for by the
independent variable in a simple linear regression. All values shown had a p value less than .01 except
that none of the R2 values for the effect of sex was significant below the .01 level; and those values fol-
lowed by a did not reach significance. SRT, Selective Reminding Test; BVRT, Benton Visual Retention
Test; MMSE, Mini-Mental Status Examination; WAIS-R, Wechsler Adult Intelligence Scale—Revised;
DRS, Dementia Rating Scale; BDAE, Boston Diagnostic Aphasia Examination. From Manly, Byrd,
Touradji, and Stern (2004). Copyright 2004 by. Reprinted by permission.
est grade attained” variable, and thus residual confounding may explain findings of “per-
sistent” race effects after matching groups on years of education. Nevertheless, despite
the clear improvement in specificity that is provided by adjusting cognitive test scores for
differences in educational experience across ethnic groups, some researchers caution
against controlling for educational variables in studies of dementia, because low educa-
tion may itself be a risk factor for disease.
The relationship of educational experience to performance on neuropsychological
tests among normal elders across ethnic groups is a clear and consistent finding. How-
ever, because education has been found to be a risk factor for diagnosis of dementia
(Kawas & Katzman, 1999), there is remaining controversy about whether norms that
correct for years of school will reduce the sensitivity of cognitive tests. A higher preva-
lence of AD and dementia among elders with low levels of education has been found in
Brazil (Caramelli et al., 1997), China (Hill et al., 1993; Zhang et al., 1990), Finland
(Sulkava et al., 1985), France (Dartigues et al., 1991), Italy (Bonaiuto et al., 1990;
Prencipe et al., 1996), Israel (Bowirrat, Treves, Friedland, & Korczyn, 2001; Korczyn,
Kahana, & Galper, 1991), the Netherlands (Ott et al., 1995), Sweden (Fratiglioni et al.,
Cultural Issues 209
1991; Gatz et al., 2001), and the United States (Callahan et al., 1996; Gurland et al.,
1995; Mortel, Meyer, Herod, & Thornby, 1995). Higher incidence of dementia has been
demonstrated in several studies (Evans et al., 1993; Letenneur, Commenges, Dartigues, &
Barberger-Gateau, 1994; Stern et al., 1994; White et al., 1994). Cognitive decline appears
to be faster (Stern, Albert, Tang, & Tsai, 1999; Teri, McCurry, Edland, Kukull, &
Larson, 1995; Unverzagt, Hui, Farlow, Hall, & Hendrie, 1998) and associated with in-
creased risk of mortality (Stern, Tang, Denaro, & Mayeux, 1995) among highly educated
minorities with AD, which suggests that the level of brain pathology is greater by the time
well-educated individuals show the signs of dementia.
The studies reviewed in the previous section focus on the relationship of schooling
and literacy to dementia or AD, specifically. But there is also evidence for a role of educa-
tion in age-related cognitive decline. Several studies of normal aging have reported more
rapid cognitive and functional decline among individuals with lower educational attain-
ment (Albert et al., 1995; Butler, Ashford, & Snowdon, 1996; Chodosh, Reuben, Albert,
& Seeman, 2002; Christensen et al., 1997; Farmer, Kittner, Rae, Bartko, & Regier, 1995;
Finley, Ardila, & Roselli, 1991; Snowdon, Ostwald, & Kane, 1989). These studies sug-
gest that the same education-related factors that delay the onset of dementia also allow
individuals to cope more effectively with changes encountered in normal aging.
Cognitive reserve has been suggested as the mechanism for the link between low edu-
cation and higher risk of dementia and cognitive decline observed in these studies
(Mortimer, 1988; Satz et al., 1993; Stern, 2002). Reserve, or the brain’s ability to tolerate
the effects of dementia pathology, may result from native ability or from the effects of
lifetime experience. Years of education may serve as a proxy for reserve, whether it re-
sults from ability or experience. In passive models of reserve (Stern, 2002), education
would be a proxy for the brain’s capacity (synaptic density or complexity) to tolerate
either gradual or sudden insult. In active models, years of education would be an indica-
tor of the brain’s ability to compensate for pathology through more efficient use of exist-
ing cognitive networks or recruitment of alternate networks.
This paradox serves to illuminate the difficulty in comparing cultural groups with
disparate backgrounds. However, there are cases in which the relationship between edu-
cation and risk for cognitive impairment or dementia is weakened or absent. Two large
international studies of incident dementia found that illiteracy or low levels of education
did not increase the risk of AD among elders in India (Chandra et al., 2001) and West Af-
rica (Hall et al., 1998; Hendrie, 2001). In fact, these studies had the lowest prevalence
and incidence rates of dementia observed to date, despite the fact that a large proportion
of the populations lacked formal schooling or literacy training. Reserve is measured by
proxy variables (e.g., years of education, occupational level, or IQ measures), but there
are a number of ways in which cultural, racial, and economic factors may affect the pre-
dictive power of these proxies. First, it is possible that race- and income-based limits on
educational opportunity weaken the relationship between years of education and native
ability, leading to underestimates of the relationship between education and cognitive de-
cline. Minorities with strong intellectual abilities may not achieve high levels of academic
or occupational status because their opportunities are limited by societal forces (e.g., rac-
ism, poverty) unrelated to their native intellect or drive to succeed. Although such indi-
viduals may be powerful or influential in their community, their abilities may not be re-
flected in years of schooling or traditional indicators of occupational status. Alternatively,
rather than a reflection of innate ability, years of education could be an indicator of life-
time experiences that change the brain during childhood or adult life and thus create a re-
serve against disease pathology. However, use of years of education to represent a direct
effect of experience on the brain or cognition is also problematic when employed among
ethnic minorities and immigrants, due to the increased discordance between years of edu-
cation and quality of education among these groups.
It is possible that literacy could be a more sensitive proxy for reserve than years of
education because it more accurately reflects the quality of the educational experience
provided to elders from ethnic minorities. In addition, literacy could be a more accurate
reflection of native ability because it does not assume that all individuals get the same
amount of learning from a certain grade level; the fact that some excel more than others
or seek learning outside of school would be reflected in measurements of literacy.
I and my colleagues designed a study to explore the relationship of literacy level to
change in memory ability over time among an ethnically diverse sample of English-speaking
nondemented elders (Manly, Touradji, Tang, & Stern, 2003). Specifically, we wanted to
determine if literacy was a stronger predictor of memory decline (and thus a more sensi-
tive indicator of reserve) than years of education or racial/ethnic classification, although
each of these variables was expected to influence baseline scores. We focused our analyses
on immediate and delayed recall measures from a verbal word-list learning task, because
these measures are sensitive to age-related memory decline and the earliest signs of AD.
Among 136 participants, we found that elders with both high and low levels of literacy
declined in immediate and delayed memory over time; however, the decline was more
rapid among low-literacy elders (see Figure 8.1). This finding suggests that high literacy
skills do not provide complete preservation of memory skills but rather a slowing of age-
related decline. All participants had normal overall cognition and were functioning nor-
mally in daily activities; thus the decline in memory scores was not associated with the
onset of a dementia disorder. There were no interactions between time and either years of
education or ethnicity, suggesting that in this diverse population of normal elders, literacy
was the most sensitive predictor of memory decline. Unlike many prior studies that exam-
ined the relationship of education to dementia or normal aging, we did not find that low
education (less than 12 years) was a risk factor for cognitive decline. This finding may be
FIGURE 8.1. Change in Selective Reminding Test delayed recall score over time. From Manly,
Touradji, Tang, and Stern (2003). Copyright 2003 by Taylor & Francis Publishers. Reprinted by
permission.
Cultural Issues 211
related to the fact that we required that participants remain nondemented at each visit;
future research that allows for significant decline in function and cognition after the base-
line visit may more closely mirror the findings of previous studies.
Racial Socialization
Level of comfort and confidence during the testing session may also vary among partici-
pants from ethnic minorities. The concept of stereotype threat has been described as a
factor that may attenuate the performance of participants from racial minorities on cog-
nitive tests. Stereotype threat refers to the experience of diverting attention from the task
at hand to the concern that one’s performance will confirm a negative stereotype about
one’s group. Steele and his colleagues (Steele, 1997; Steele & Aronson, 1995) demon-
strated that when a test consisting of difficult verbal Graduate Record Examination
(GRE) items was described as measuring intellectual ability, black undergraduates at
Stanford University performed worse than SAT-score-matched white undergraduates.
However, when the same test was described as a “laboratory problem-solving task” or a
“challenging test” that was unrelated to intellectual ability, the scores of black students
matched those of white students. Researchers have also reported that when gender differ-
ences in math ability were invoked, stereotype threat undermined performance of women
on math tests (Spencer, Steele, & Quinn, 1999) and white males (when comparisons to
Asians were invoked; Aronson et al., 1999). The role of stereotype threat in neuropsy-
chological test performance of blacks and Hispanics has not been investigated to date. In
addition, it is likely that the salience of negative stereotypes differs among racial minori-
ties and therefore that stereotype threat will likely affect some test takers more than
others. Investigation of the experiential, social, and cultural variables that affect vulnera-
bility to stereotype threat should be examined.
Linguistic Issues
Translation of English-Language Tests
Clinicians and researchers sometimes erroneously assume that instruments are equivalent
across populations as long as the test is administered in the native language of the indi-
vidual. However, literal translation may not produce items with comparable word fre-
quency and/or salience in each culture, resulting in different difficulty levels (Loewenstein
et al., 1994; Sano et al., 1997; Teng, 1996). In addition, idiosyncrasies of different lan-
guages may introduce problems in equating certain tests. For example, when asked to
name as many animals as possible in a minute, Hispanics produce fewer exemplars than
do Vietnamese. This discrepancy can be explained by the fact that most animal names in
Spanish are multisyllabic, whereas most animal names in Vietnamese are monosyllabic
(Kempler, Teng, Dick, Taussig, & Davis, 1998).
Translators of cognitive measures must use extreme caution and proper methods to
adapt measures into another language. Artiola i Fortuny and Mullaney describe several
examples of Spanish versions of tests that include syntactic, lexical, and spelling errors
(Artiola i Fortuny & Mullaney, 1997). These authors also suggest that investigators con-
sult only those who possess native fluency and in-depth knowledge of the culture before
attempting to translate a measure. The accuracy of translated and adapted instruments
should be checked following established guidelines (Artiola i Fortuny & Mullaney, 1997;
Brislin, 1970, 1980; Loewenstein et al., 1994; van de Vijver & Hambleton, 1996). Re-
searchers and clinicians must also develop standards to determine in which language bi-
lingual individuals should be assessed (Ponton et al., 1996).
Translation of measures is not simply a linguistic issue; measures must be culturally
equivalent as well. That is, it must be determined whether the use of a particular test for-
mat to assess the cognitive skill of interest is equally valid within every culture in which
the test will be administered (Teng, 1996; Teng et al., 1994).
Norms
Investigators must be aware that the published norms for tests administered in English
are not necessarily valid when the tests are administered in another language. Further,
they should not assume that test norms can be applied to distinct populations simply be-
cause they share a language. For example, there is evidence that several instruments de-
veloped in Spanish-speaking countries may not be functionally or linguistically equivalent
when used among Spanish speakers in the United States (Artiola i Fortuny et al., 1998).
Similarly, tests and norms developed among a particular group of immigrants to the
United States (e.g., Cuban Americans) may not be valid among other groups in the United
States who share a language (e.g., Dominicans or Puerto-Ricans; Loewenstein et al.,
1994).
Use of Interpreters
Misinterpretation is a serious threat to the reliability and validity of testing. Family mem-
bers are often used as translators, even though they are not likely to be objective. And
even translators who are reasonably fluent in both languages may not be familiar with
many of the terms used in neuropsychological testing (Ardila, Rosselli, & Puente, 1994;
LaCalle, 1987). Increasing the linguistic diversity of testers and improving the availability
of objective translators are thus worthwhile goals for investigators; when these accuracy
measures are not feasible, the possibility of misinterpretation must be taken into consid-
eration when interpreting results.
CONCLUSIONS
Issues
Racial and ethnic diversity is increasing among people ages 65 years and older in the
United States. The share of the economic and social burden associated with AD and
other dementias borne by African Americans will increase accordingly. Neuropsy-
chologists are fundamentally unprepared for this growth in cultural, racial, and linguis-
tic diversity, because neuropsychological tests have poor specificity among minority
populations and cannot reliably differentiate subtle impairment associated with the
early stages of dementia from the effects of normal aging. Misdiagnosis of dementia is
thus more likely among cognitively normal ethnic minorities as compared to non-
Hispanic whites.
The most prevalent attempt to address these issues has been to develop separate
norms by race. Although this is a reasonable first step toward reducing misdiagnosis
among culturally and linguistically different groups, separate norms have many disadvan-
tages. The use of these norms depends on racial classifications that change over time and
Cultural Issues 213
on geographical region, and is invalid for the growing number of individuals who self-
identifies within multiple categories. Racial norms also lump together people who vary
enormously in linguistic, geographic, economic, and educational experiences and level of
exposure to European American culture.
A growing number or researchers has taken another approach to improving the spec-
ificity and utility of cognitive tests among elders from ethnic minorities. This work has
identified aspects of cultural and educational experience that could be explicitly mea-
sured, related these variables to test performance both cross-sectionally and longitudi-
nally, and included cultural experience, literacy, English fluency, and quality of education.
Regardless of ethnicity, these factors may explain significant variance in test scores and
thus should guide adjustment of expectations of performance before interpreting scores,
just as age, years of education, and gender are now routinely taken into account. This
work promises to expand our knowledge about the role of culture in affecting cognition
and the aging brain.
Recommendations
Before administration of cognitive tests begins, a valid assessment of elders from ethnic
minorities depends on the ability of neuropsychologists, psychometrists, and translators
to reflect true understanding of cultural variations in interaction style and allow for suffi-
cient time for thorough explanations of procedures and expanded inquiry regarding func-
tional status. Even if these procedures and knowledge are in place, interpretation of
neuropsychological test scores remains difficult, especially in cases of MCI or “question-
able dementia,” due to the poor specificity of our measures when used with individuals
from minorities. Considering the relative lack of published research on this topic, any
practical recommendations must be cautious and preliminary. Based on the work re-
viewed in this chapter, I advise the following:
• Do not assume to know an elder’s race/ethnicity, because this is a self-identified

classification. Ask patients/participants to self-identify their ethnicity, as well as to
choose race and ethnicity in a manner consistent with the U.S. Census.
• Evaluate cultural experience by asking about the neighborhood characteristics of
where patients/participants grew up and where they currently live.
• Evaluate educational experience by inquiring not only about highest grade
achieved, but also obtain details about where primary, secondary, and post-
secondary schooling took place, the segregation level of the school, whether it was
a one-room school or had a low student–teacher ratio, and whether it was a rural
or suburban/urban school.
• Become familiar with the number of years of compulsory education in the area
where the elder was educated. For example, in Mexico, the length of compulsory
education was raised from 6 to 9 years in 1992, but this requirement is enforced
differentially throughout the country.
• Assess reading level using the WRAT-3 for English speakers and the Word Accen
tuation Test (Del Ser, Gonzalez-Montalvo, Martinez-Espinosa, Delgado-Villapalos,
& Bermejo, 1997) for Spanish speakers.
• Among bilinguals or multilinguals, assess proficiency in each language.
• If you are using measures translated into another language, use published mea-
sures with large normative samples of individuals who are culturally similar to the
patient/participant. For example, published norms for Mexican elders living in
Mexico may not be appropriate for an elderly second-generation Mexican Ameri-

can.
• Testing of non-English and non-native English speakers presents an ethical chal-
lenge for many English-speaking clinicians (Harris & Cullum, 2002). Although
there are many complex considerations regarding this issue, it is clear that
neuropsychologists should not use an interpreter (trained or untrained) to simply
translate items and administer them to the patient/participant.
• Cautiously use the best available norms from the appropriate population.
Future Research Directions

The clear course for researchers is to measure and validate variables for which race/eth-
nicity serves as a proxy and determine the relationship of these variables with cognitive
function. Some of these variables, such as quality of education, appear to have reliable
and clinically significant relationships to test score across ethnic groups. However, it is
possible that other variables will have a minimal effect on cognitive test performance or
will be more meaningful in one cultural group but not others. Nevertheless, future studies
can be designed to further our knowledge of the influence of cultural variables on test
performance, as well as risk for cognitive decline over time, if they successfully address
the following issues:
• Recruitment of large numbers of nondemented ethnic minority elders into longitu-

dinal research studies is a difficult task, with which neuropsychologists have had
spotty success, at best. Nevertheless, responsible and comprehensive examination
of the relationships discussed in this chapter is impossible without achieving this
goal.
• Research on the effect of region of birth and current residence on cognitive func-
tion among ethnic minorities is badly needed but will require large multisite co-
horts. This is true not only of elders born in the United States, but also for immi-
grant groups. For example, it is of practical and theoretical interest to characterize
any differences that may exist among Spanish speakers by nationality.
• Although biological and genetic factors may play a role in ethnic differences in
cognitive test performance, these variables must be measured rather than assumed.
Furthermore, the critical period during which chronic diseases such as diabetes
and hypertension have an effect on cognitive function in aging and risk for demen-
tia may occur in midlife; therefore, studies of the relationship of cardiovascular
disease and cognitive aging must be longitudinal and enroll ethnically diverse peo-
ple in their fourth and fifth decades of life.
• Finally, the role of race and racism on neuropsychological test performance of el-
ders from ethnic minorities should not be ignored or underestimated. The
operationalization of racism for the purposes of research on cognitive function
among elders is an area that is ripe for exploration.
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9
Feedback
JOANNE GREEN
T his chapter describes a critical phase in neuropsychological evaluation: the provision of

feedback concerning the findings and implications of the testing. Guidelines of the Ameri-
can Psychological Association assert that individuals taking tests have a right to receive
prompt and comprehensible feedback describing their test results (American Psychologi-
cal Association, 1998), and part of the psychologist’s responsibility is to ensure that such
feedback is provided. Conducting a successful feedback session requires considerable ex-
pertise and skill, combining understanding of neuropsychological assessment with clinical
skills derived from psychotherapeutic techniques. The quality of this feedback and the
manner in which it is provided can be critical in determining the extent to which the out-
comes of the assessment phase are translated into effective treatment plans.
The chapter begins by describing objectives and purposes for providing feedback,
then describes common stages in the feedback process and offers guidelines for transvers-
ing these stages. Finally, therapeutic issues important to the feedback process are dis-
cussed.
PURPOSES FOR PROVIDING FEEDBACK
Providing feedback concerning the outcomes of a neuropsychological evaluation is often

challenging, particularly when the patient is an older adult. The usual complexities of in-
teracting with a patient are complicated by the special issues that face older adults, possi-
bly including the onset of a devastating illness, the loss of independence, and the involve-
ment of other family members in their care. While dealing with these issues, a number of
important goals must be accomplished, usually in a limited amount of time.
Specific objectives of the feedback follow:
1. To specify the patient’s neuropsychological strengths and weaknesses.

2. To explain how these strengths and weaknesses contribute to the memory, cogni-
tive, personality, and other behavioral changes that have been observed.
223
3. To describe possible explanations for the changes, particularly in terms of neuro-

logical, medical, psychiatric, or other disorders that might be contributing to the
changes.
4. To identify any follow-up evaluations necessary for better identifying underlying
disorders.
5. To discuss treatments likely to be effective for these disorders.
6. To determine whether treatments such as cognitive training or therapeutic sup-
port are needed to contribute to the patient’s health, independence, safety, and
comfort.
7. To identify those psychological issues affecting both the patient and involved fam-
ily members or friends that may emerge from, or be exacerbated by, the patient’s
illness, and to begin planning interventions for addressing these.
Accomplishing these objectives requires not only understanding of neuropsychologi-

cal assessment but also application of therapeutic skills that facilitate the patient and
family’s ability to process the information being presented during the session. A success-
ful feedback session is dynamic, interactive, and often emotionally charged, particularly
in the case of older patients who may feel threatened by anticipated changes in their life-
style or level of independence. The neuropsychologist may find it necessary to manage
not only the emotional responses of the patient and others, but also his or her own reac-
tions to the issues facing them.
Despite these challenges, the extent to which feedback is provided to the patient and
the quality of that feedback are critical in determining the usefulness of the overall evalu-
ation. A successful feedback session can motivate both the patient and involved family
members and friends to develop a new, more productive perspective for managing the dif-
ficulties they have been facing. After being presented with possible reasons for behavioral
changes as well as treatment alternatives, the patient and family frequently feel empow-
ered to develop more productive strategies for managing what was previously a distress-
ing and confusing situation. The feedback session can also be critical in helping the pa-
tient feel better about him- or herself. Patients experiencing change in memory and
cognition are vulnerable to negative self-concepts, such as feeling “stupid,” “crazy,” or
“lazy.” Naming and explaining the patient’s experiences during the feedback session can
have major therapeutic benefits in helping the patient to reorganize his or her self-concept
(Finn & Tonsager, 1992). The session can help reframe a negative self-concept by clarify-
ing that behavioral and mood changes are related to a definable and treatable disorder,
not to undesirable personality traits.
STAGES IN PROVIDING FEEDBACK

Deciding How to Provide Feedback
During the clinical interview at the beginning of the assessment, alternative approaches to
providing feedback are discussed with the patient. One issue of particular importance
with older patients is specifying who will receive feedback. To avoid compromising prin-
ciples of confidentiality, it is usually advisable for the neuropsychologist to suggest that
both the patient and members of his or her support system be informed of the test find-
ings. This permission is particularly important in the case of patients who are suspected
of having significant neuropsychological dysfunction and who do not have a legal guard-
Feedback 225
ian. In most cases, patients will agree to sign a consent form allowing their test results to
be shared with specified family members, friends, or professionals involved in their care.
Ideally, the neuropsychologist provides the feedback during a follow-up session oc-
curring several weeks after the assessment report has been completed. Because the
neuropsychologist fully understands the assessment, this approach increases the likeli-
hood that the findings and their implications are presented in a comprehensible frame-
work, and that follow-up services and treatment alternatives are pursued.
Ideally, both the patient and significant persons in his or her support system attend
the feedback session, which typically includes family members and perhaps close friends
or companions. The presence of involved family members or friends is particularly im-
portant for patients with significant neuropsychological dysfunction who may have diffi-
culty remembering the content of the session. It is advisable that the feedback session in-
clude all individuals who are significantly involved in supporting the patient. If the major
members of the patient’s support system are present, then the neuropsychologist can help
resolve any differences of opinion, address individual questions, and facilitate the interac-
tion between patient and his or her support system. From a practical point of view, meet-
ing simultaneously with the patient and his or her support system may avoid the need for
additional meetings and phone conversations with individuals who did not attend the
feedback session.
In reality, however, in-person feedback sessions with the neuropsychologist some-
times do not occur, or occur in only a highly abbreviated fashion. There are several rea-
sons for this unfortunate reality. A major factor is the current health care environment,
which does not necessarily support the provision of feedback by the psychologist who
performed the assessment. Managed health care and other organizations often either do
not allow reimbursement for feedback sessions or provide very limited reimbursement,
encouraging the psychologist to perform only brief sessions that may not allow sufficient
time for the outcomes of the assessment to be fully explained and processed.
In addition, some professionals and consumers of neuropsychological services incor-
rectly view neuropsychological assessment as a “procedure” similar to a medical proce-
dure such as a blood test or an electroencephalogram. This perception implies that the
findings consist of test scores that can be interpreted simply as “normal” or “abnormal”
and grossly oversimplifies the outcomes of the evaluation and their potential implications
for helping the patient. One aspect of the psychologist’s responsibility during the feed-
back session is to educate others concerning the richness of both qualitative and quantita-
tive data gathered during the evaluation and their relevance to a multitude of issues that
may affect the patient.
Direct feedback from the neuropsychologist may be impractical if the patient is in
frail health, lives at some distance from the psychologist’s office, cannot afford additional
costs, or wants to minimize appointments because he or she has to depend on a working
adult child or friend for transportation. In these cases, several alternatives are common
and practical. One possibility is that feedback be provided by another professional (most
typically, an internist, neurologist, or psychiatrist) who is experienced with neurobe-
havioral disorders and is involved with the patient’s ongoing care and treatment. Feed-
back by another professional can be highly effective when that professional is committed
to the continued care of the patient and when the neuropsychological evaluation is pre-
sented within the context of other diagnostic tests (e.g., blood or other laboratory tests,
brain imaging). An advantage to this approach is that the physician is able to prescribe
any other necessary medical treatments.
If the patient chooses to receive feedback from another professional, it is particularly

important that the neuropsychologist clearly communicate the neuropsychological find-
ings. Ideally, that clinician should have a copy of the final report. The neuropsychologist
may also want to speak directly with the clinician to stress issues that may affect the feed-
back session, such as the patient’s or family’s awareness of the patient’s deficits, and psy-
chological issues (e.g., defensiveness, a history of difficult family dynamics) that may af-
fect the involved individuals’ abilities to pursue treatment recommendations. If feedback
is provided by another professional, the patient can be encouraged to contact the neuro-
psychologist later if he or she would like additional information concerning the
neuropsychological findings.
To avoid additional appointments or costs, patients often request telephone feed-
back. This is generally a less desirable alternative because it limits the interaction between
the patient and the neuropsychologist and reduces the opportunity for the neuro-
psychologist to monitor patient and family reactions, possibly decreasing the likelihood
that recommended outcomes of the evaluation will be pursued. In some cases, however,
telephone feedback may be the only practical alternative. In these cases, it is recom-
mended that feedback be provided during a scheduled conference call that includes both
the patient and an involved family member or friend. This format is particularly impor-
tant for patients experiencing significant neuropsychological dysfunction. Both the time
and the duration of the conference call can be established in advance, similar to formaliz-
ing these variables for an in-person feedback session. To the extent that this is possible,
recommended practices for conducting in-person feedback sessions can be followed. Be-
cause the facial and bodily reactions cannot be observed, it is important to query those
involved frequently by asking questions such as, “How does what we’ve just discussed
seem to you?” “To make sure that we’re communicating, can you summarize what I’ve
just tried to explain?” “How are you feeling right now?”
It is not uncommon for patients or family members to request that they be mailed a
copy of the report. Although they are legally entitled to the report, this practice may not
be in the patient’s best interests for a number of reasons. Patients are vulnerable to ad-
verse emotional reactions if they misinterpret the technical language of the report or the
test findings. Without the encouragement of the neuropsychologist, they may be less mo-
tivated to pursue follow-up evaluations and the treatment recommendations described in
the report.
In most cases, patients can be persuaded that it is best for them to receive feedback
from a person qualified to interpret the report. However, if they insist on receiving writ-
ten findings of the evaluation, then it is often acceptable to prepare a letter summarizing
the results and recommendations of the evaluation, rather than sending the full evalua-
tion report. The neuropsychologist can talk with the patient briefly by phone after the let-
ter has been received to answer any questions that may have arisen.
Preparing the Assessment Report

The assessment report is the basis for feedback to the patient. It becomes part of the pa-
tient’s medical records and may be reviewed by a variety of professionals helping the pa-
tient, including physicians, therapists, and possibly attorneys. Thus it is critical that the
report be clear, well organized, readable, and relevant to the referral question and the is-
sues facing the patient. Because the report may be read by the patient or his or her family
members, it is important to use nonjudgmental and constructive language, particularly in
Feedback 227
descriptions of the patient’s behavior and the neuropsychologist’s overall impression of

him or her.
The evaluation report is organized in sections that have been described elsewhere
(Green, 2000). These sections generally include the following:
1. The referral and background information section summarizes the major purposes
for the evaluation; the symptoms of concern; relevant medical history, particularly con-
cerning conditions that might be related to the symptoms (e.g., uncontrolled hyperten-
sion, previous history of stroke); the patient’s educational and occupational history; and
the patient’s current support system.
2. The behavioral observations section describes the patient’s behavior during the
clinical interview and test administration, including descriptions of his or her awareness
of cognitive change, level of effort during testing, emotional tone and range, ability to un-
derstand instructions and generate verbal responses, and ability to establish and maintain
task sets.
3. The tests administered section lists the tests administered during the assessment.
4. The section on test results reports the quantitative findings from each test, orga-
nized by neuropsychological domains, such as general intellectual function, attention, ex-
ecutive functions, motor behavior, language, visuospatial and visuoconstructive abilities,
memory, and affect/personality.
5. The section on impressions and recommendations forms an important basis for
the feedback session, both in terms of content and organization. This section restates the
purpose of the evaluation, followed by a summary of findings relevant to accomplishing
that purpose. This includes a summary of the patient’s neuropsychological profile, outlin-
ing neuropsychological strengths and weaknesses in specific domains as well in specific
abilities with a domain. Conclusions relevant to the referral question are indicated. Diag-
nostic issues are addressed, and recommendations for follow-up evaluations and treat-
ments are suggested. An opinion regarding the adequacy of the patient’s current level of
support and the need for additional support can be offered. The impression of the pa-
tient’s competence for performing important functions such as cooking, driving, and
managing finances might be suggested.
Focusing the Feedback Session

During the neuropsychological evaluation, a wealth of data concerning the patient’s
neuropsychological, emotional, and everyday functioning has been gathered and ana-
lyzed. Although this information is summarized in the neuropsychological assessment re-
port, it is usually more than can be discussed and understood during the feedback session.
Therefore, the neuropsychologist must make some decisions concerning which informa-
tion will be presented when the patient and family return for feedback.
One important guideline for making this choice is to begin the feedback session by
asking the patient and family to summarize, once again, what they hoped to learn from
the evaluation, particularly the kind of help they are seeking. Addressing their issues and
questions during the session will help ensure that the feedback is useful and directed to-
ward helping the patient and family make future plans. In addition to helping the neuro-
psychologist determine which feedback will be provided, this initial questioning draws
the patient/family into the session and encourages a more interactive process.
It is also important to present any information that might affect the patient’s safety,
general health, or ability to continue at his or her present level of independence. For
example, if the patient is still driving but the test findings indicate that he or she has sig-
nificant deficits in attention or visuospatial abilities, then it is important that these find-
ings be discussed. If the patient has exhibited evidence of poor judgment, then his or her
ability to make financial decisions may be questionable. If the patient has a complex med-
ication regimen but also has impaired memory, then his or her ability to manage this
medication regimen is probably poor, and plans for organizing the medications might be
discussed.
Describing Neuropsychological Strengths and Weaknesses and Reasons

for Change
A major purpose of most neuropsychological evaluations is to quantify the nature of
strengths and weaknesses in attention, executive function, language abilities, visuospatial
abilities, and memory. During the feedback session, the neuropsychologist clarifies the
relative integrity of different neuropsychological domains, mentioning not only relative
weaknesses but also relative strengths. It is sometimes a good idea to describe how the
conclusions were reached in general terms by comparing the patient’s actual test perfor-
mance to normative data and to expectations concerning his or her characteristic level of
functioning. Although some individuals will not totally understand this information, de-
scription of the principles adds credibility to the findings and extends patient and family
understanding of the neuropsychologist’s expertise.
It is a good idea to begin on a positive note by describing the patient’s strengths
before discussing weaknesses. The relationship of these strengths and weaknesses to the
patient’s behavioral changes is described. For example, if the family has been confused
about why the patient repeats questions or manages his or her medication regimen unreli-
ably, these behaviors may be explained if the patient has significant memory dysfunction.
The irresponsible use of money and other unwise behaviors may be explained in terms of
a deficit in executive function. It is common for families to become concerned when the
patient exhibits decreased activity, such as a lack of interest in previously enjoyable hob-
bies. It is often important to clarify to what extent this change might reflect a deficit in
executive function (e.g., inability to initiate behavior) or the onset of depression.
When describing dysfunction within a neuropsychological domain, it may be impor-
tant to clarify the nature and severity of the dysfunction, particularly if this information
has practical implications for improving the patient’s functioning and comfort level. It is
usually not sufficient to simply say that “memory” or “visuospatial function” is “im-
paired.” Additional description often has implications for understanding the patient’s be-
havior and for possible compensatory aides. For example, elucidation of the difference
between long- and short-term memory can help explain why the patient can remember
distant personal history but not recent conversations or the current date. It is often im-
portant to explain whether memory dysfunction primarily reflects a deficit in the initial
acquisition of new information in memory, in the ability to retain (store) acquired infor-
mation for longer time intervals, or in the finding (retrieval) of information that is stored
in memory. In the first and last cases, characteristic of “subcortical disorders” such as
Parkinson’s disease, the use of structure, cuing, and repetition at the time of memory ac-
quisition may facilitate both initial registration and retrieval. In the second case, more
typical of “cortical” disorders such as Alzheimer’s disease (AD), these aides may have less
benefit.
Feedback 229
When a storage deficit is prominent, description of the severity of this deficit may be
helpful. The functioning of patients with a milder storage deficit may be improved if they
can remember to record important information in a single small notebook that they carry
with them at all times in the same location, for example, in a pant pocket or a handbag.
These aides may be less effective for patients with a more severe storage deficit; they may
want to ask for help from family members in remembering important information such
as when to pay bills or take medications.
Most patient/families also want to gain some idea about the likely cause of the
behavioral change. The psychologist can provide some feedback concerning the possible
diagnoses, the relative certainty of the different alternatives, and additional information
that would be useful in finalizing the diagnosis. For example, when family members are
told that the patient’s memory dysfunction may reflect AD, they may want to know how
this disease is definitively diagnosed and that additional memory decline, in the absence
of other illness, increases the likelihood that the patient has the disease. The patient/family
may request reading materials or support services related to the disease. The neuro-
psychologist should be prepared to provide these resources.
In many cases, however, it is advisable that neuropsychologists take a conservative
and cautious approach when discussing diagnostic and prognostic issues (Gass & Brown,
1992), particularly when medical or neurological disorders may be involved. It is impor-
tant not to overstate the conclusiveness of the findings and to indicate clearly that these
findings only suggest possible disorders or conditions that may contribute to cognitive
dysfunction but do not provide a definitive diagnosis. It is often appropriate for the
neuropsychologist to advise the family to seek consultation with a neurologist, psychia-
trist, or other physician. These clinicians are often well qualified to make informed and
more definitive statements about diagnostic and prognostic issues because of their exper-
tise in interpreting a variety of other tests, including the findings of brain imaging, elec-
troencephalography, and blood tests.
Discussing Treatment Alternatives, Patient Care, and Follow-Up Services

After the nature of and possible reasons for, neuropsychological change have been dis-
cussed, the implications of the findings for patient care, follow-up evaluations, and treat-
ment alternatives are addressed. One important issue is the implication of the neuropsy-
chological findings for the quality of the patient’s everyday functioning and for his or her
competence to continue assuming positions of responsibility. It is important to recognize
that the neuropsychological test findings have limited value for directly predicting the
quality of everyday functioning (Dunn, Searight, Grisso, Margolis, & Gibbons 1990;
Heaton & Pendleton, 1981); other instruments have been specifically designed to assess
both activities of daily living and instrumental activities of daily living (see Marson &
Hebert, Chapter 7, this volume; Fillenbaum & Smyer, 1981; Katz, Ford, Moskowitz,
Jackson, & Jaffee, 1963; Lawton, 1971; Lawton, Moss, Fulcomer, & Kleban 1982;
Loewenstein et al., 1981). However, if the patient has significant neuropsychological dys-
function, the neuropsychologist can begin a discussion about the patient’s competence for
assuming specific responsibilities. These responsibilities may include driving a car, man-
aging financial assets, controlling a firearm, following a medication regimen, maintaining
adequate nutrition and personal hygiene, caring for grandchildren, and using a stove. Er-
rors in handling such responsibilities may have grave implications not only for the com-
fort and health of the patient, but also for the safety of others.
Because they care about the patient and want to plan for his or her future well-being,
it is not uncommon for family members to suggest relieving the patient of all responsibili-
ties. This is often an overreaction, except in the case of a patient who has been deter-
mined to have severe and global dementia. The neuropsychologist may play an important
role in helping the patient and family determine how a balance can be maintained be-
tween allowing the patient to remain independent as long as possible and preventing him
or her from endangering self or others.
In most cases, the patient’s competence to handle each responsibility should be con-
sidered separately, with the exception of patients who are determined to be severely and
globally demented. Most patients are able to continue to handle some responsibilities but
are better relieved of others. The neuropsychological test findings may help the neuro-
psychologist infer the types of responsibilities in which errors are likely and those which
the patient can continue to perform adequately. For example, a patient with an amnestic
syndrome is likely to have difficulty performing responsibilities dependent upon consider-
ation of new information, such as the management of investments. However, this patient
may still be competent to handle responsibilities dependent upon overlearned skills, such
as driving on limited and familiar routes. Consideration of the patient’s recent function-
ing may be helpful. A history of previous mistakes within a specific area of responsibility
is often predictive that future errors are likely to occur, particularly for patients diagnosed
with dementia. So, for example, if an amnestic patient has already caused minor automo-
bile accidents or has become lost while driving, it is probably unwise for him or her to
continue driving (see Marson & Hebert, Chapter 7, this volume).
In some cases, a formal competency evaluation may be necessary, particularly if
there is disagreement between the patient and his or her family concerning his or her
competence. Competency evaluations are often needed to evaluate continued ability to
manage financial and legal affairs or to drive. Issues related to the evaluation of compe-
tence, including the need to determine the type of competence to be assessed, the nature
of state regulations, and the use of evaluation instruments specific to different aspects of
competence have been described elsewhere (Grisso, 1994; Marson & Hebert, Chapter 7,
this volume).
Decisions concerning the continued competence to drive are often particularly com-
plex and emotional. Patients who can no longer drive may also become unable to inde-
pendently perform important activities such as grocery shopping, attending doctor’s ap-
pointments, and participating in social activities. These changes may represent a major
blow to patients’ self-esteem and sense of efficacy. On the other hand, unsafe use of a car
can easily cause serious injury or even death.
Although older individuals with cognitive dysfunction or dementia are at increased
risk for driving poorly and having accidents (Friedland et al., 1988; Hunt et al., 1997;
Lucas-Blaustein, Filipp, Dungan, & Tune, 1988), a diagnosis of dementia does not neces-
sarily imply that the patient should stop all driving. Some patients with very mild or mild
dementia can continue to drive safely (Kapust & Weintraub, 1992; Hunt, Morris, Ed-
wards, & Wilson, 1993; Hunt et al., 1997; Trobe, Waller, Cook-Flannagan, Teshima, &
Bieliauskas, 1996), particularly if they reduce the extent of their driving and confine
themselves to familiar, low-traffic routes. However, as cognitive dysfunction or dementia
severity increases, the patient is at increased risk for poor driving performance and acci-
dents (Hunt et al., 1993; Hunt et al., 1997; Stutts, Stewart, & Martell, 1998; Tuokko,
Hadjistavropoulos, Miller, Horton, & Beattie, 1995). An international consensus confer-
Feedback 231
ence has recommended that patients with moderate to severe dementia not be allowed to
drive (Johansson & Lundberg, 1997).
Variables that may be useful in evaluating the patient’s driving safety include the re-
cent driving history, certain neuropsychological findings, and the presence of a movement
disorder (Logsdon, Teri, & Larson, 1992). A recent history of driving accidents or near-
accidents, episodes of getting lost while driving, or poor judgment may be predictive of
unsafe driving in the future. Patients with deficits in attention (particularly visual atten-
tion), in visuospatial and visuoconstructive abilities, or in mental speed are at increased
risk for accidents (Fox, Bowden, Bashford, & Smith, 1997; Logsdon et al., 1992; Hunt et
al., 1993; Lundberg, Hakamies-Blomqvist, Almkvist, & Johansson, 1998; Owsley, Ball,
Sloane, Roenker, & Bruni, 1991; Parasuraman & Nestor, 1991, 1993). Patients with
movement disorders such as Huntington’s or Parkinson’s disease are also more likely to
drive poorly (Heikkila, Turkka, Korpelainen, Kallanranta, & Summala, 1998; Rebok,
Bylsma, Keyl, Brandt, & Folstein, 1995). In some cases, the administration of a formal
driving test, available in some medical centers, may be useful in clarifying the patient’s
continued ability to drive. Even when it is determined that it is likely to be safe for the pa-
tient to continue to drive, it is important that his or her driving be monitored carefully
and that reassessment occur on a regular basis, particularly if there is evidence of in-
creased cognitive dysfunction.
Another major decision that may be addressed during the feedback session involves
the patient’s continued ability to remain in his or her current living environment. The pa-
tient’s response to considering a change is sometimes surprising. On the one hand, some
patients who have been living in their own home may already be feeling overwhelmed by
this responsibility. They may be relieved by the prospect of moving into an environment
that provides more support, such as a retirement community, assisted living facility, or
personal care home. However, some patients find it emotionally traumatic to consider
moving into an unfamiliar setting. For some, this possibility heightens their awareness
that they are approaching the last phase of their life and is perceived as involving difficult
choices between many treasured possessions and abandoning rooms filled with happy
memories to live in a smaller, unfamiliar space. The anticipation of learning the spatial
organization and routines of a new environment may cause considerable anxiety for a pa-
tient with even mild dementia. The manner in which the patient has reacted to change in
the past may be predictive of how well he or she will adjust to a new living environment.
Individuals who have always been flexible and made friends easily are more likely to
adapt well to future change.
If it is determined that the patient needs additional support and structure but would
prefer not to move, approaches to strengthening his or her support system can be consid-
ered. If the support system consists of several individuals, they may benefit from counsel-
ing to help determine how different responsibilities will be distributed. For example, if
the patient is no longer able to drive, a schedule for taking him or her to the grocery store
or providing groceries can be devised. Other social services, such as senior day care or
services that provide food (e.g., Meals on Wheels), can also be discussed, and a referral to
a social worker familiar with the community’s social service resources may be helpful.
Ways of restructuring the patient’s environment to help maintain his or her independence
can be considered. For example, a patient may be able to continue following even a
complex medication regimen if someone else organizes the medications and places them
in labeled pill boxes that clearly indicate what should be taken and when. A patient may
be able to keep better track of his or her own appointments and social engagements if
someone else records these on a large calendar displayed in a prominent location, for ex-
ample, on the refrigerator door. A patient who has caused fires while cooking may be
able to continue cooking if he or she can remember to always use a loud timer or to rely
on the microwave oven. Alternately, as noted, community resources for providing meals
can be considered. For patients requiring considerable care at home, health insurance
coverage can be considered. For example, some insurance plans provide in-home nursing
care to assist with activities such as dressing and bathing.
In some cases, the patient is advised to seek further medical evaluations, and the
neuropsychologist can provide advice on questions that might be addressed. Although the
neuropsychologist is not qualified to provide medical treatments, he or she can play an
important role in educating the family about what treatments are available. Because most
neuropsychologists currently do not have prescriptions privileges, the psychologist must
stress that he or she is only providing general information and that it is important for the
patient to discuss these issues in greater detail with a physician.
For example, if vascular disease may be playing a role in the patient’s cognitive dys-
function and the patient has not undergone brain imaging, then the patient/family might
be encouraged to ask their physician whether such a procedure might be helpful. If the
patient has not been eating adequately, then the patient/family might be advised to ask
the physician whether blood tests have indicated that the patient has a vitamin B12 or
other nutritional deficiency. For patients likely to have AD, the availability of medica-
tions (e.g., donepezil, galantamine, rivastigmine, vitamin E therapy) can be discussed in
general terms. For patients likely to be depressed, discussing possible treatments can be a
critical first step in determining whether the patient follows through in seeking treatment.
Many patients are reluctant to seek treatment for depression, or even admit that they are
depressed. If the patient is able to begin discussion of possible treatments with a psychol-
ogist that he or she has learned to trust, this rapport increases the likelihood that the pa-
tient will follow through on the treatment recommendations.
The neuropsychologist can also provide advice about psychological treatment pro-
grams that may be helpful, such as cognitive training or behavior management. Although
the neuropsychologist may be specialized in assessment, he or she should be prepared to dis-
cuss treatment programs available in his or her region; the more knowledgeable the
neuropsychologist is about the goals and advantages of specific programs, the greater the
likelihood that further treatment will be pursued. For example, for patients having rela-
tively mild or focal deficits, without generalized neuropsychological dysfunction, cognitive
training may help develop relatively preserved abilities. A behavior management program
may be helpful in encouraging agitated or aggressive patients to reduce the frequency of
these behaviors. These approaches are described in greater detail in Part II of this book.
THERAPEUTIC ISSUES IN PROVIDING FEEDBACK

Therapy Skills Important in Neuropsychological Feedback
The neuropsychologist’s clinical skills in interacting with patients and their support sys-
tem are critical to the success of the feedback session. It is important that the session be
interactive, such that all participants feel comfortable asking questions, voicing their con-
cerns, and responding to the neuropsychologist’s comments. Maintaining rapport with
the patient as well as developing rapport with others attending the session are fundamen-
Feedback 233
tal. As during the clinical interview and testing, it is important to maintain an alliance
with the patient. However, the neuropsychologist’s rapport with members of patients’
support systems becomes especially critical for patients determined to have significant de-
mentia. For each patient’s best interests to be served, the patient and members of the sup-
port system must trust and have confidence in the neuropsychologist.
Careful listening and checking ensure that the information is being understood and
accepted. In many cases, the language of neuropsychological reports will not be well un-
derstood by nonprofessionals. The neuropsychologist should be alert to verbal and non-
verbal signs indicating that the feedback is being understood, and may even want to
check this understanding by asking questions such as, “To make sure that I’ve communi-
cated these results clearly to you, would you like to summarize your understanding of
what’s been described?”
It is important to be sensitive to the kind and amount of information the patient and
family are ready to hear and to their reaction to this information. If they have been que-
ried at the beginning of the feedback session concerning their purposes for seeking evalu-
ation and their questions, then their answers can often provide excellent guidance about
the kind of feedback that will be most helpful to them. For example, in many cases, they
may be prepared to hear circumscribed information, such as a description of the
neuropsychological weaknesses that may help explain unusual behaviors, but are not pre-
pared to hear details of how a dementing illness is likely to progress over time, such that
the patient ultimately becomes both mentally and physically incompetent. When the diag-
nosis is AD, some families prefer to obtain detailed information about the effectiveness
(or limited effectiveness) of current medication treatments, whereas others prefer to know
only that these treatments may help the patient. It is critical that the feedback not be pre-
sented in a manner that leaves the family and patient feeling hopeless, overwhelmed, and
powerless.
As Knight has discussed, the success of the feedback session may be affected by the
psychologist’s personal characteristics and concerns (Knight, 1994, 1996). Some neuro-
psychologists find it difficult to provide feedback because of concerns that they are per-
ceived as the bearer of bad news. Furthermore, although the evaluation may determine
that a significant decline has occurred, the neuropsychologist may anticipate that the
family expected to receive a more definitive diagnosis for these changes than can, in fact,
be provided. The inability to provide a definitive diagnosis may make some neuro-
psychologists vulnerable to feeling less competent. Such feelings may make it more diffi-
cult to plan and lead an effective feedback session.
The neuropsychologist’s success in leading a feedback session may also be affected by
his or her personal reactions to the patient’s condition. Delivery of feedback to a patient may
heighten the neuropsychologist’s concerns about what the future holds for someone he or
she personally cares about, such as an aging parent or other relative. For older neuro-
psychologists, the feedback session may exacerbate personal issues about age-related
changes in physical and psychological abilities and their own need for support in the future.
Neuropsychologists who have such reactions may become aware of their own un-
constructive emotional response during the feedback session and may find it necessary to
expend considerable internal resources trying to manage their personal feelings. It then
becomes more difficult to maintain the professional perspective necessary to attend to the
patient and family’s reactions and needs. Therefore, it is important for neuropsy-
chologists to be aware of their personal feelings and reactions throughout the evaluation
process and to seek any necessary supervision or counseling.
Addressing Interpersonal and Family System Issues
Although neuropsychological evaluation focuses on the evaluation and treatment of an

individual patient, family system and interpersonal issues often emerge during the feed-
back session. The patient usually functions as a member of an interpersonal system that
may include a spouse, adult children, close friends, or a companion. The qualities of the
interactions between the persons attending the feedback session, as well as the historical
roles of each, may be important factors in determining the dynamics and outcome of the
session. Knight provides an excellent discussion of how family system issues may impact
the feedback session (Knight, 1994, 1996).
Decline in the neuropsychological functioning of an elder member of the family may
have implications for the roles and responsibilities of each member of the family system.
If an elderly parent who develops dementia has played a major role in nurturing and
counseling the rest of the family, perceptions of his or her decreased ability to perform
this role may cause a shift in the roles of other family members. Those who have been
emotionally dependent upon the patient may experience a psychological crisis and re-
quire treatment themselves. In some cases, the family overreacts to the patient’s illness
and begins to make sudden, drastic changes in family roles, when this may not yet be nec-
essary or appropriate. During the feedback session, it is important that the psychologist
reinforce the family’s perception of the patient as a family member with an illness, who
can still assume important roles and responsibilities within the family.
If the patient needs support and structure, the process of deciding how these will be
provided may highlight the nature of interactions between other family members. Discus-
sion of how these responsibilities will be handled may revive longstanding or unspoken
conflicts. Alliances and tensions between sibling pairs may be exacerbated. When neces-
sary, family counseling may be suggested.
In many cases, the major responsibility for supporting the patient appears to fall on a
single individual, often a spouse or an adult daughter. The patient’s primary caregiver
may become depressed or overwhelmed when confronted with knowledge of the patient’s
illness, and the psychologist may offer to meet with the caregiver separately to discuss his
or her needs. Brief self-report instruments such as the Zarit Burden Inventory (Zarit,
Reever, & Back-Peterson, 1980; Zarit, Tood, & Zarit, 1986) or the Brief Symptom Inven-
tory (Derogatis & Spencer, 1982) may be helpful in assessing the nature and severity of
caregiver distress. In their concern for caring for a family member, some caregivers ne-
glect their own well-being, failing to maintain adequate levels of sleep, nutrition, and so-
cial activity. They may fail to appreciate that they may be better able to offer support for
a longer period of time if they also continue caring for themselves.
A primary caregiver may benefit from an opportunity to talk frankly about his or her
feelings concerning the patient’s illness, to discuss better approaches for coping with these
feelings, and to consider additional sources of support for the patient. If the primary care-
giver is a spouse, the extent to which adult children can provide some support can be
discussed. It is sometimes the case that the patient’s spouse has not revealed the need for
additional support to adult children because of the fear of burdening them, when, in fact,
the children are very willing to provide some help. Some caregivers benefit from support
groups that allow them to share their emotional responses with other caregivers and to
work together to develop strategies for dealing with common issues and problems. It
should be noted, however, that support groups are not necessarily helpful to all care-
givers. For caregivers of patients with mild to moderate cognitive dysfunction, support
Feedback 235
group discussions of the problems associated with more severe disease may be depressing
rather than supportive.
In summary, providing feedback on neuropsychological evaluation is an important
and complex phase of helping older patients. Successful feedback requires that the
neuropsychologist apply a variety of skills and knowledge, including expertise in princi-
ples of assessment, more general therapeutic skills important for interacting with patients
and their families, and information about resources available to facilitate the patient’s
care in the future. If the feedback is accepted and understood, this can be an important
transition to effective treatment for the patient in the future.
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PART II
GERIATRIC
NEUROPSYCHOLOGICAL
INTERVENTION
In contrast to the focus on assessment in the first part of this volume, Part II focuses on
intervention, beginning with a model outlined in Chapter 10 to assist the process of eval-
uation, case conceptualization, and treatment planning. As with our assessment model,
this intervention model is not presented as definitive or static, but rather as a dynamic
beginning effort to redress the current gap of literature in this area. Section A outlines
specific cognitive training interventions; Section B then presents approaches most appro-
priately classified as psychotherapeutic interventions.
We use the word intervention, in contrast to rehabilitation, because our elderly pa-
tients with significant cognitive compromise or dementia cannot be expected to make the
magnitude and nature of gains seen with younger populations who experience a marked
recovery of function after acute injury. The exception here is with elders suffering from
recent stroke, who often do show remarkable gains. It is with elders who are well beyond
acute recovery or who are in the early stages of a degenerative condition that intervention
focuses upon compensation and coping in the manner that we address here. Indeed, there
are also those who will not benefit from treatment, and ethical practice requires us to be
forthcoming regarding these limits. However, we systematically consider each case, be-
cause successful identification of targets and treatments to reduce excess disability can of-
ten be found, even in the context of irreversible or progressive cognitive decline.
The chapters that follow clearly reveal that intervention can lead to improved man-
agement of memory deficits, functional status, and mood. As an extension of these gains,
quality of life and health care outcomes may also improve. Indeed, over the past decade it
has been exciting to watch as reports emerge detailing how treatment leads to less depres-
sion even among dementia patients, that systematic training can result in reliable calendar
use among patients with Alzheimer’s disease, that targeted training skills can lead to func-
tional gains. Our own work has shown that training leads to better perceived memory
functioning, with adequate insight. Some of these studies are reviewed in the chapters
that follow.
237
238 GERIATRIC NEUROPSYCHOLOGICAL INTERVENTION
The focus of Part II is unique to this text and is worth some emphasis in the intro-
duction. We hope to underscore the important emerging truth: A neuropsychologist is not
simply a diagnostician, as may have been true in the past. The neuropsychologist is also a
therapist ideally trained to provide effective neurocognitive interventions to enhance indi-
vidual patient outcomes through increased coping capacities in relation to losses. The in-
tervention approach itself often involves systematic application of a specific technique,
program, or therapy, as outlined in the chapters that follow. These interventions are in-
formed by a clear understanding of the neurocognitive deficits present in each individual
case, which allows delineation of target behaviors and facilitates the appropriate design
of methodology with which to teach compensation. It is not the biological disease process
that is the target of intervention. Indeed, test scores on our traditional measures often do
not capture the gains. Additionally, the goal of intervention is rarely to fix or ameliorate a
problem. Rather, it is the practical functional and emotional outcomes that are addressed
through compensatory, training, and psychotherapeutic techniques.
It is our observation that many neuropsychologists do not feel that they have the
skills necessary to do this kind of work. Perhaps others in related fields also underesti-
mate their abilities in this arena. Some may attribute reluctance to practice in this area to
lack of experience with intervention in this particular population—and indeed, those
without adequate exposure will need to ensure appropriate training as they begin their
work. However, our experience suggests that reluctance to practice is fueled by more ba-
sic concerns, such as a sense of inadequacy and powerlessness. This perspective often
stems from lack of exposure to work that nets favorable outcomes, coupled with thera-
peutic nihilism—the belief that this particular population cannot benefit from interven-
tion. With the promising outcomes that are reviewed in these sections, it becomes clear
that the heretofore pervasive bias against treatment in this population was indeed prema-
ture and without merit. However, this evidence does little to empower the individual cli-
nician with a sense of command and capacity. We would like to challenge this
disempowerment and ask each clinician to carefully consider relevant skills he or she in-
deed possesses. What neuropsychologist is without training in behavioral principles and
therapy? What clinician does not understand loss and grief? And we are inspired to chal-
lenge even further: Are not neuropsychologists in a uniquely qualified position to engage
in this work, given that their expertise spans both the behavioral correlates to neuroana-
tomical compromise and the therapeutic arena? It is our belief, and perhaps bias, that
many clinical neuropsychologists and related professionals are indeed qualified and quite
skilled in intervention and that application of their intervention abilities awaits only their
awareness and enthusiasm.
Section A
Cognitive Training and

Compensatory Techniques
T he chapters in Section A focus on specialized cognitive training and compensatory tech-

niques.
Chapter 10 leads this section with a discussion of the intervention model. This model
outlines the process of evaluation, case conceptualization, and treatment planning in a
preliminary manner. Accordingly, cognitive training and compensatory techniques are
considered as well as psychotherapeutic interventions, as discussed in Section B.
The remaining chapters in Section A focus on specialized cognitive training and com-
pensatory techniques. As noted in this text, the primary targets of intervention tend to be
either cognitive (e.g., memory, language) or functional in nature, but often involve a com-
bination. As can be easily observed, many different techniques or combinations of tech-
niques can address the same problem. Often, it is desirable to address behavior with a
multimethod approach, because different patients have different strengths and prefer-
ences and are thus differentially able to use some techniques but not others. Indeed, pa-
tients should be informed about what is and is not known about each approach, and
forewarned that multiple approaches may be needed to determine the best method for
them. The reader is referred to the intervention model for consideration of factors that
may affect intervention target and technique selection.
Chapter 11 describes a very specific program of cognitive and functional interven-
tions. Importantly, this work emphasizes the need to target functional skills, which could
improve qualify of life and possibly even delay disability. This chapter also presents fol-
low-up data for what might be considered one of the most rigorous examples of interven-
tion outcomes research.
Chapter 12 describes another approach: the increasingly applied and researched
technique of spaced retrieval. This chapter outlines the strategy and provides examples of
successful application of the method and efficacy data. There is also a discussion of issues
relevant to the dissemination of the intervention, which applies to any effort to broadly
deliver these relatively new approaches to the clinical care arena.
Chapter 13 provides a description of methods that employ multiple techniques. This
multimethod approach is not only common in practice but is often clinically desirable.
239
Although this approach may lead to challenges in terms of researching effective compo-
nents, it represents the first step in demonstrating clinical efficacy, and it is anticipated
that additional study of program components will follow. The reader is encouraged to
consider the many individual techniques that can be applied. Many are modified associa-
tive techniques that originated in traditional rehabilitation settings.
Chapter 14 addresses approaches for dealing with language deficits that are often
applied with elders who have suffered stroke or have progressive aphasias. This work fo-
cuses on an area of functioning, language, that is often untreated in post-acute geriatric
populations. Language impairments post obvious implications for social autonomy and
function and are often quite distressing to patients when they occur. The neuropsy-
chologist can assist by teaching strategies that compensate for acquired deficits; he or she
is also in a position to provide comprehensive psychological care, incorporating targeted
behavioral and adaptive coping strategies, a point highlighted later in the book.
Chapter 15 discusses the use of external auxiliary aids to facilitate function. The im-
portance of establishing strong external methods of compensation for an impaired and
possibly progressively declining cognitive function cannot be sufficiently underscored.
The topics discussed here complement the other chapters dealing with specific psycholog-
ical or behavioral compensatory strategies.
10
An Integrated Model for Geriatric

Neuropsychological Intervention
DEBORAH K. ATTIX
T he notion that dementia and other cognitive disorders is not treatable is a myth. The
landscape of geriatric neuropsychological care services is unquestionably evolving, with
treatment being a rapidly growing area of practice complementing traditional assessment.
Reports demonstrating clinical efficacy of various intervention techniques are emerging
and systematically dissolving previous biases against intervention with patients who have
dementia. This promising work encourages the clinician to move beyond diagnosis in or-
der to maximize functioning, coping, and quality of life, even in the context of debilitat-
ing dementia conditions (Koltai & Branch, 1998, 1999; Zarit & Zarit, 1998).
The neuropsychological interventions discussed in this text involve patient popula-
tions with progressive conditions or dementias that are stable, with any expected neuro-
anatomical recovery already complete. Therefore, it is not the underlying neuropathology
that is targeted for modification, but rather coping, adjustment, and the use of compensa-
tory strategies and residual abilities (Koltai & Branch, 1998, 1999; Sohlberg & Mateer,
1989c).
In the chapters that follow, common intervention techniques are presented along
with the associated research and anecdotal evidence supporting their utility. It seems ob-
vious that these clinical approaches are best applied within an informed framework. It is
well known among those working in any rehabilitation or intervention capacity that
maximal benefit is contingent upon the development and execution of a carefully consid-
ered treatment plan. This chapter outlines one model that can be used to facilitate such
planning. It is an approach used to conceptualize geriatric neuropsychological interven-
tion services, built upon the clinical and research efforts within this emerging field. In this
model data acquired or reviewed during the intervention evaluation are utilized to formu-
late the treatment plan.
241
INTERVENTION PLANNING: IDENTIFICATION OF

INTERVENTION TARGETS AND STRATEGY SELECTION
The initial intervention evaluation is the primary source of clinical data from which the
treatment plan evolves, as variables relevant to the identification of treatment targets and
methods are examined. Maximal benefit from neuropsychological intervention is achieved
with careful, thorough planning. In this section variables relevant to the identification of
treatment goals and methods, and the process of matching these in relation to the charac-
teristics of each patient are described. The intervention evaluation is the context in which
these variables are reviewed, which facilitates creation of the treatment plan. These vari-
ables include:
• Goals
• Motivation
• Neuropsychological evaluation
• Insight
• Affective status
• Unique patient and environmental factors
• Current compensatory methods and activities
These variables should be systematically reviewed and incorporated into the treat-
ment plan. This step of the intervention process identifies the most feasible treatment tar-
gets and approaches by integrating neuropsychological data and identified intrapsychic or
interpersonal concerns with a theoretical understanding of the neuroanatomical correlates
of behavior and the appropriate psychotherapeutic approaches (Pramuka & McCue, 2000;
Sohlberg & Mateer, 1989a).
Goals
Intervention planning begins with elucidation of the major complaints driving the need for
treatment, because these give rise to treatment goals. Whereas some patients and families
enter the treatment process with well-defined goals, others look to the provider for assis-
tance in identifying targets. Regardless of the degree of goal identification that the patient
and family bring to the initial meeting, the end point is to identify valued outcomes that are
also amenable to treatment. The questions directly relevant to this factor include:
• What are the functional complaints of the patient? That is, what would he or she
like to change?
• What are the patient’s functional deficits from the perspective of the family? That
is, what would they like to change?
• From the patient’s perspective, what cognitive deficits are associated with the
functional deficits?
• From the family’s perspective, what cognitive deficits are associated with the pa-
tient’s functional deficits?
• Does the patient report any affective distress?
• What is the patient’s affective status from the perspective of the family?
• Is the affective distress in response to cognitive and functional failures (see below)?
• Is the affective distress of sufficient magnitude to contribute to the cognitive and
functional deficits (see below)?
An Integrated Model for Intervention 243
• Is there any discrepancy between patient and family reports of functional, cogni-
tive, or affective status? If so, what accounts for the divergence?
• What cognitive and affective deficits are likely related to the functional com-
plaints, given the neuropsychological data (see below)?
• Is there any discrepancy between patient and family reports? What would be ex-
pected, given the neuropsychological data (see below)? If there is a discrepancy,
what accounts for it?
Typically, patients referred for intervention are beyond the acute stages of injury. In
these instances few skill gains would be expected through natural history of recovery, and
some patients may even be expected to decline over time. Therefore, goals should be
structured within the context of an explicit understanding that cognitive deficits will be
managed and compensated for rather than cured or “rehabilitated.”
Although the patient and family will readily identify areas of functional disability, the
clinician needs to understand the antecedents to such difficulties in order to best intervene.
This understanding includes identifying sources of “functional dysfunction” from the per-
spective of both the patient and family members (Pramuka & McCue, 2000). For instance,
is the patient not doing things listed on the “to-do list” because he or she forgets to check the
list (memory disorder), does not follow the structure of the list (executive dysfunction), or
lacks interest (apathetic depressive disorder)? Even if the target of intervention is the same,
the strategy would vary considerably depending on the source of the problem.
To this end, the clinician should identify the presence of any cognitive dysfunction
and affective distress that may be contributing to functional deficits. In addition, it is use-
ful to know both patient and informant perspectives on the patient’s cognitive and affec-
tive status. When patient and informant reports diverge, it is helpful to identify the source
of discrepancy, because this information can also be helpful in planning (e.g., the patient
may have anosognosia which can influence outcome or it may reflect caregiver burden).
In addition, other sources of information, such as the neuropsychological evaluation,
should be utilized to enhance the identification and quantification of cognitive and affec-
tive dysfunction.
Motivation
The patient’s motivation to actively participate in the therapeutic process should be con-
sidered (Koltai & Branch, 1999). The state of being motivated involves feeling compelled,
usually from a need or desire, to act. The questions directly relevant to this factor include:
• Is the patient sufficiently motivated to actively participate in treatment? Spe-

cifically, is he or she willing to attend sessions? Is he or she willing to participate in
practice assignments that require effortful processing?
• If there is a lack of motivation, is it due to central nervous system dysfunction, re-
sulting in poor initiation/apathy or emotional distress? Are personality factors op-
erating, or is there another reason for poor motivation?
It is erroneous to assume that a patient will be inclined to expend the necessary effort
to learn and practice new techniques or to use compensatory strategies just because he or
she agrees that improving function is desirable. Similar to understanding the source of
functional disability when establishing goals, it is useful to identify the source of dimin-
ished or absent motivation that may be a barrier to treatment. Central nervous system
(CNS) dysfunction, particularly that involving frontal systems, can result in apathy and
impaired initiation of behavior that can be mistaken as a lack of motivation. Depression
can also significantly impair interest and energy levels. Finally, personality factors may
preclude adequate motivation to participate in treatment.
Because inadequate participation in the treatment process will likely preclude gains,
less-than-optimal levels of motivation should be addressed prior to the initiation of the
treatment plan. Of course, attention to personality and affective factors that influence
motivation may result in a change that would allow for adequate participation. In con-
trast, CNS dysfunction that results in an inability to actively participate, despite the de-
sire to do so, must be treated quite differently. In such instances the treatment plan would
have to utilize approaches requiring minimal-to-no patient effort (e.g., spaced retrieval,
behavioral conditioning). Thus lack of motivation does not completely preclude the pos-
sibility of benefit but, instead, significantly modifies the treatment approach.
Neuropsychological Evaluation
One of the most valuable sources of information for intervention planning is the neuropsy-
chological evaluation, because it provides standardized, objective data to assist in both goal
identification and strategy selection. The questions directly relevant to this factor include:
• What is the patient’s general level of cognitive functioning?

• What diagnosis is supported by the data? What does this diagnosis suggest about
the likely neuroanatomical structures and systems currently affected? What does it
suggest about the likely cognitive deficits, behavioral changes, and emotional reac-
tions of the patient? What does it suggest about likely progression and the
neurobehavioral changes that will evolve over time?
• What type of and how severe a memory disorder is present? Is it characterized pri-
marily by inadequate storage or poor retrieval?
• What types of executive deficits are present? Are the following processes affected:
initiation, working memory, speed of processing, cognitive flexibility, sequential
processing?
• Is there a processing advantage by modality (e.g., verbal over nonverbal)?
• Are expressive or receptive language skills affected? Visuospatial skills?
• What does the neuropsychological data suggest in terms of modification of technique?
Are specific techniques unlikely to be acquired or utilized effectively? What modifica-
tions to techniques might prove beneficial, given the patients’ cognitive presentation?
• Considering the data, are the identified goals realistic?
• Given the constellation of findings, which techniques might result in the greatest
gains relevant to the identified goals?
General Level of Cognitive Functioning

General information about the stage of cognitive compromise—that is, mild, moderate, se-
vere, profound—will set the tone for further exploration of the possibilities and limits of in-
tervention. If an individual exhibits a moderate dementia, for instance, it is likely that both
memory and executive deficits are present, whereas someone with a mild level of cognitive
dysfunction may be suffering from an isolated memory deficit. Although hypotheses about in-
tervention can be drawn from general stage information, more precise types of data should
guide the inclusion or exclusion of specific types of techniques in the intervention plan.
Diagnosis
The importance of the diagnosis is two-fold. First, knowledge of the diagnosis allows for in-
vestigation of hypotheses related to the cognitive, emotional, and behavioral sequelae that
typically attend various illnesses (Koltai & Branch, 1999). This appreciation of the
neurobehavioral sequelae that characterize the presentation and course of neurological ill-
nesses and syndromes guides the intervention process. For example, a patient in the early-
to-middle stages of Alzheimer’s disease (AD) will likely exhibit memory deficits (with con-
stricted acquisition and rapid forgetting), executive compromises, and mild word-finding
problems. A reactive depression and some mild changes in insight may also be present, be-
cause these deficits are common in early AD (Koltai & Welsh-Bohmer, 2000). In contrast, a
patient with a history of a progressive language disorder (e.g., primary progressive aphasia)
will likely demonstrate a moderate-to-severe aphasia syndrome, and depending on the stage
of the illness, may demonstrate other cognitive deficits related to the compromise of frontal
systems. Insight is likely to be spared in the early-to-middle stages of this illness. The inter-
vention goals for these two patients would be very different, as would the patients’ abilities
to capitalize on strategies with varying levels of complexity.
Second, knowledge of the diagnosis allows the clinician to incorporate prognosis and
likely patterns of future cognitive, affective, and behavioral changes into the intervention
plan (Koltai & Branch, 1999). In both logical and ethical practice, strategies should be se-
lected that would serve the patient well in the future.
The clinician uses the obtained neuropsychological data to generate or revise hypotheses
about cognitive strengths and weaknesses to further refine the treatment approach. The
constellation of findings from testing allows for specific planning. Because the concerns
of the patient and family often reflect the deficits observed on testing, these data allow for
anticipation of the types of complaints and goals the patient and family may bring to the
session. Ideally, the clinician is versed in how neuropsychological test performance relates
to everyday functional capacities (e.g., driving, medication management, financial deci-
sion making; Pramuka & McCue, 2000). However, when complaints diverge significantly
from test findings, the source of the discrepancy should be identified.
The neuropsychological profile not only contributes to appropriate goal selection
but also includes and excludes the use of specific techniques. In the most obvious sense,
strategies should be selected that allow the patient to use relative strengths to compensate
for relative weaknesses. Beyond this principle, the potential influence of each compro-
mised neurocognitive domain on each technique being considered should be reviewed.
For instance, the clinician will want to determine the nature of the memory deficit: Is it
characterized primarily by a storage or retrieval deficit? Obviously, techniques aimed at
effortful processing, which increase the chance of storage, would be appropriate for the
former (e.g., association techniques: story method, visual association methods), whereas
search strategies would be most relevant for the latter. The clinician will also want to con-
sider if there is a verbal over nonverbal processing advantage, or if there are any isolated
but significant deficits that should be considered. If there is executive compromise, the
clinician will want to understand in what way it may impact the initiation and implemen-
tation of various approaches. Feedback involving a review of results often benefits the pa-
tient and family and better prepares them for an intervention program that will be more
relevant and feasible, given the data (see Green, Chapter 9, this volume).
Technique Modification
Specific cognitive deficits preclude the use of certain strategies. For instance, the method
of loci, a mnemonic frequently used with normal elders that involves visually associating
target items along a fixed visual route, has been found to be too complex for many
cognitively impaired patients (Yesavage, Sheikh, Friedman, & Tanke, 1990; Hill, Yesavage,
Sheikh, et al., 1989). Many times, however, specific approaches remain feasible, but only
if they are adequately modified (Koltai & Branch, 1999). For instance, a very effective
strategy to improve face–name pair learning and the length of retention duration with el-
ders (Hill, Evankovich, Sheikh, & Yesavage, 1987; Wilson, 1987; Yesavage et al., 1990)
is likely to have more benefit if modified when used with patients who have early demen-
tia. The strategy typically involves first identifying a distinctive facial feature, then creat-
ing a visual association image with the name (e.g., turtle for the name “Tuttle”), and
finally connecting the visual association image with a prominent facial feature. However,
many dementia patients have difficulty executing the specific steps of this technique (Hill
et al., 1987). An effective modification involves repetition of the name, creation of a vi-
sual association image based on the name, and visualization of the person with this image
(e.g., a visualization of Mr. Tuttle interacting with the turtle).
In some instances only minor modifications will be necessary. For instance, the level
of executive dysfunction may suggest that training in the use of a calendar is best ap-
proached in a series of simple, concrete steps, such as first mastering information extrac-
tion before the patient attempts to make systematic entries. Strategy modification may in-
volve choosing one alternative over another based on ability, simplifying or eliminating
more complex steps that are not essential to improve performance, or altering the timing
of the introduction of strategy sections, as needed.
A critical element of intervention planning evolves during the intervention evaluation
through consideration of goals in light of the neuropsychological data. Each goal should
be considered in light of the test results. Specifically, the feasibility of targeting each goal
should be considered and then, given the profile, the best strategy for targeting each
should be identified.
Insight
Anosognosia, or the lack of awareness of deficits, is an indispensable patient variable to
consider during the intervention evaluation. Although neuroanatomical theories have, for
the most part, replaced motivational theories of “denial” in the dementia population
(McGlynn & Schacter, 1989), motivated denial remains a potential psychodynamic con-
struct that can influence intervention outcome and should be considered during the evalu-
ation. More often than not, however, the patient with dementia suffers from an organi-
cally based inability to appraise accurately his or her skills. The questions directly
relevant to this factor include:
• Is the patient aware of his or her cognitive deficits? Specifically, are both the pres-
ence and magnitude of deficit appreciated?
• Does the level of insight reflect other deficits in judgment or reasoning?
• Does the level of insight affect the patient’s goals or motivation?
Among patients with dementia, severity of disease is more predictive of anosognosia

than dementia duration or diagnosis (Anderson & Tranel, 1989; McDaniel, Edland,
Heyman, & CERAD clinical investigators, 1995; Migliorelli et al., 1995b; Sevush &
Leve, 1993; Starkstein et al., 1997). Neuroimaging studies implicate the integrity of fron-
tal-lobe structures in anosognosia (Reed, Jagust, & Coulter, 1993; Starkstein et al.,
1995). Clinical observations also associate frontal dysfunction with lack of insight into
diminished abilities or inappropriate behavior (e.g., Neary, 1990; see McGlynn &
Schacter, 1989; Stuss, 1991). The ability of densely amnesic patients to assess their abili-
ties accurately also suggests that “poor memory for memory failures” does not account
for anosognosia (McGlynn & Schacter, 1989). Interestingly, AD subjects with poor in-
sight into their own abilities retain the ability to predict their relatives’ performance accu-
rately, suggesting a monitoring defect restricted to the self (McGlynn & Kaszniak, 1991;
McGlynn & Schacter, 1989). Alternatively, patients may be impaired in updating knowl-
edge about the self as well as others, but because the informants have not changed, pre-
dictions about them remain more accurate (McGlynn & Kaszniak, 1991).
Additional evidence for the potential modifying effect of anosognosia on treatment
outcome became apparent to investigators at our center in a preliminary investigation of
a memory and coping program implemented with patients who had mild-to-moderate de-
mentia and who were experiencing difficulty adjusting to their cognitive losses (Koltai,
Welsh-Bohmer, & Schmechel, 2001). All participants with insight reported less memory
failures after treatment. In contrast, subjects without insight or in the control group re-
ported changes in memory failures with similar frequency. The difference between gains
among those with and without insight was statistically significant (p = .029), suggesting
that insight may well be an important variable that moderates actual treatment gain and/
or the perception of gain. In contrast, according to informants, there was a perceived ben-
efit among the treatment group relative to controls, independent of insight status, which
approached significance (p = .065). Clare, Wilson, Carter, Roth, and Hodges (2004) rep-
licated these findings in a recent prospective study.
These investigations highlight the need for research to further delineate the influ-
ences of anosognosia and other potential outcome-modifying variables, such as baseline
cognition and affective status. Further study to clarify the degree of perceived versus
actual gain by insight status is needed and could have profound effects on selection of po-
tential candidates for treatment. If anosognosia truly hinders treatment gain, as suggested
by the perception of participants in this study, such services may be inappropriate for this
subgroup. However, the greater gain perceived by treatment subject informants relative
to control group informants, regardless of insight status, suggests that perhaps partici-
pants do benefit from treatment, although those with anosognosia may not be able to ap-
preciate such gain, just as they do not appreciate the magnitude of deficits prior to treat-
ment. Unawareness of deficit or its functional consequences logically does not promote
the use of compensation (Crossen, 2000). If this is indeed the case, ethical practice would
require a clear delineation of expected versus perceived gains within this context.
It is reasonable to hypothesize that the benefit of intervention among anosognostic
patients may be hindered by decreased motivation resulting from a lack of appreciation
for the need for effortful processing. There may also be a decreased ability to acquire in-
tervention techniques due to the executive dysfunction frequently associated with this
condition.
Because poor insight can significantly influence treatment outcome, the patient’s de-
gree of awareness should be considered carefully during the intervention evaluation. To
the extent that is possible, the clinician should determine the degree of retained insight.
An effort to differentiate between observations “echoed” by the patient from those that
reflect a true appreciation of the presence and magnitude of deficits should be made.
Finally, this information can be considered in the context of the patient’s ability to accu-
rately judge and reason, and how these abilities (or their absence) may also affect motiva-
tion and goals.
Affective Status
No intervention evaluation is complete without a thorough assessment of the patient’s af-
fective status. Evaluation ideally involves structured interviews or questionnaires and ob-
servations of behavior. Patient interviews should be supplemented by informant reports,
but with awareness of how caregivers’ distress can affect their perceptions of their loved
ones. Careful consideration of affective status is essential because it is both a target of
treatment and a potential modifier of outcome. The questions directly relevant to this fac-
tor include:
• What is the patient’s affective status from the perspective of the patient, family,
and from the data?
• What is the magnitude of emotional distress?
• What characterizes the emotional distress (e.g., depressive symptoms, anxiety
symptoms, irritability)?
• How does the emotional distress affect the patient’s functioning?
• Does the patient have an affective disorder that warrants treatment?
• Is the emotional distress in response to cognitive demands and cognitive failures,
or independent of them? Can the onset of emotional distress be tied to any clear
event?
• Is there any history of an affective disorder?
Chapter 5 reviews cognitive dysfunction related to depression in detail. Because

emotional distress can affect function and aggregate in a manner that undermines treat-
ment progress, depression and its effects on behavior warrant some discussion here.
Depression and other emotional disorders can be considered sources of “excess
disability,” or treatable factors that can account for greater than warranted functional
incapacity (Brody, Kleban, Lawton, & Silverman, 1971) and should be identified and
targeted through intervention. Estimates of the prevalence of depression among elderly per-
sons with dementia underscore the need for directed attention to this domain of function-
ing. One study of dementia patients found that 27% had minor depression and 25% had
major depression (Ballard, Bannister, Solis, Oyebode, & Wilcock, 1996). Another study fo-
cusing on affective disorders among patients with AD revealed that 28% had dysthymia and
another 23% met criteria for major depression (Migliorelli et al., 1995a). These prevalence
figures far exceed those of depressed elderly patients without dementia (Myers, 1984). Not
surprisingly, dysthymia typically starts after the onset of AD and is more prevalent in the
early stages, whereas major depression typically has an earlier onset and similar prevalence
across stages (Migliorelli et al., 1995a). Obviously some variance exists across typical affec-
tive symptoms encountered by disease severity and diagnosis. However, it is clear that emo-
tional distress occurs frequently across dementia subtypes and at various times, and is thus a
pivotal variable to consider during evaluation for intervention.
Another feature of depression beyond the obvious impact of emotional distress on
quality of life is its potential to affect cognition. This cognitive effect can be observed in
cases of “pseudodementia,” the dementia syndrome of depression (Alexopoulos, Meyers,
Young, Mattis, & Kakuma, 1993, Barry & Muskowitz, 1988; Clarfield, 1988; Emery &
Oxman, 1992; Nussbaum, 1994) in which cognitive sequelae are related to depression
rather than a comorbid dementia. Also, some studies suggest additionally compromised
cognition in cases of dementia when depression is comorbidly present. Further, although
controversy exists as to the degree of discernible additional influence on cognition or
functional status, some studies have found depression to contribute unique variance to
cognitive performance among normal elders, patients with Parkinson’s disease, and pa-
tients with AD (e.g., Lichtenberg, Ross, Millis, & Manning, 1995; Rovner, Broadhead,
Spencer, Carson, & Folstein, 1989; Troster et al., 1995). Even among patients without
marked affective disorders, reports of less efficient processing skills during periods of
emotional distress are common.
Importantly, depression can also impair functional skills, both alone and in conjunc-
tion with cognitive impairment. Among behavior problems of patients with dementia in
special care units, those related to emotional distress have been shown to be second only
to problems related to memory impairment (Wagner, Teri, Orr-Rainey, 1995). Fitz and
Teri (1994) remark that while both depression and cognitive status have been related to
performance of basic activities of daily living (ADLS) and instrumental activities of daily
living (IADLs) in patients with AD, the influence of depression on IADL performance
may be contingent on the severity of cognitive dysfunction. In addition, the influence of
depression on utilization of health care services has been well documented, even in the
absence of dementia. Elderly depressed outpatients (1) are more likely to rate their health
as fair or poor, (2) have more emergency room and outpatient visits, and (3) higher out-
patient charges than nondepressed patients (Callahan, Hui, Nienaber, Musick, & Tierney,
1994). Koenig, Shelp, Goli, Cohen, and Blazer (1989) found significant health care utili-
zation differences between older medically ill patients with and without major depres-
sion, with depressed patients having longer index inpatient stays, higher in-hospital mor-
tality, and excess resource utilization after discharge.
Whereas the relationship between the domains of affect, cognition, and function
awaits further clarification, it is evident that successful treatment of depression, even in
the context of a neurodegenerative illness, may reduce cognitive and functional compro-
mises and, in turn, affect health care utilization. The use of residual capacities and the
need for formal care may also be impacted, given these interactive, multicausal domains
(Koltai & Branch, 1998, 1999).
Finally, intervention efforts that targeting cognitive variables may be unsuccessful if
attempted in the context of emotional distress. As noted above, emotional distress fre-
quently leads to excess cognitive disability; many symptoms of affective disorders (e.g.,
apathy, anhedonia, irritability) tend to work against participation in cognitive techniques
that require motivation and effort. Therefore, it is important to gain a thorough under-
standing of the emotional factors operating within the patient by differentiating emo-
tional and personality changes that are a result of disease-based neurological changes
from those that are reactive or premorbid, because treatment approaches differ as well
(Crossen, 2000; Pramuka & McCue, 2000). Although there are rare exceptions, affective
distress should always be targeted first in order to maximize the likelihood of benefit
from other intervention efforts. Doing so will minimize or eliminate inefficiency intro-
duced by the emotional distress and increase the patient’s resources, which then can be
applied during any cognitive-based intervention. In my experience, the only exception to
this general approach occurs when patients refuse treatment of psychological distress and
insist on focusing only on memory and processing skills. In such cases, the patient’s re-
fusal to consent to treatment of affective distress is, of course, honored, but with clear de-
lineation of the limit to treatment progress in all areas, including the preferred treatment
target. By honoring this decision, tension is minimized and an effective rapport is built
that eventually allows for this area of functioning to be formally addressed.
In summary, it is apparent that appreciation of the patient’s affective status is essen-
tial to consider both as a target of treatment and a potential modifier of outcome. There-
fore, a thorough assessment of affective functioning should be incorporated into the in-
tervention evaluation. In addition, it is important to understand not only the patient’s
overall affective status but also the antecedents and consequences of emotional distress
for the patient. Finally, an understanding of the patient’s history of depression can be use-
ful in conceptualizing his or her current affective functioning, and may also provide his-
torical data useful to the selection of treatment alternatives.
Unique Patient and Environmental Factors

One must be vigilant for factors unique to the patient or his or her situation that could
influence the outcome of intervention. The questions directly relevant to this factor
include:
• Are there unique factors about this patient that should be considered in the selec-
tion of treatment goals or methods?
• Who are the members of the household? How willing are they to be involved in
treatment?
• Is the structure of the physical environment conducive to functioning? Is it condu-
cive to the application of intervention techniques?
Although hard to anticipate at times, these factors are critical to identify and consider.
For instance, if it becomes apparent that a patient has significant obsessive–compulsive
tendencies, then caution must be exercised when teaching detailed structured techniques
that risk being overused.
Likewise, there may be social or environmental factors operating that are likely to
influence outcome. For instance, if the primary caregiver will not participate in treatment,
the strategies will be limited to those that the patient can execute independently. Thus the
patient’s support and care system should be clearly identified, including the willingness of
caregivers to be directly or indirectly involved in intervention efforts, and the patient’s
physical/environmental surroundings (Pramuka & McCue, 2000; Zarit & Zarit, 1998).
Current Compensatory Methods and Activities

The evaluation should consider what the patient is already doing to address cognitive and
emotional dysfunction. Often, patients and families have initiated compensatory rou-
tines, many of which are quite effective (Pramuka & McCue, 2000). The questions di-
rectly relevant to this factor include:
• How does the patient and family presently keep track of important information?
To what extent is this system working?
• Are there any other routine changes that have been made in an effort to compen-
sate for the patient’s cognitive losses?
• How does the patient spend his or her time? Is the patient sufficiently active?
• Do routines involve participation in rewarding and meaningful activities?
It is critical for the clinician to be aware of current efforts in order to avoid disman-
tling systems that are working or interfering with these by introducing competing rou-
tines. Sometimes only slight modifications to an established system will yield a markedly
different outcome. For instance, the patient may require training in when to check an ex-
ternal aid such as an appointment calendar, because use is inconsistent but well enough
established that abandonment of the aid would be illogical. Therefore, before the clini-
cian dismantles current efforts, he or she should carefully consider each feature of the
current compensatory scheme. Furthermore, careful review of such systems often pro-
vides insight into the capabilities of the patient to construct, initiate, and maintain com-
pensatory strategies, either independently or with assistance.
Likewise, the clinician should be aware of the patient’s activity level in order to make an
informed assessment of whether alterations need to be made in this area. Inactivity breeds de-
pression. Participation in rewarding, meaningful activities promotes emotional well-being.
CREATION OF THE TREATMENT PLAN
The information gathered during the intervention evaluation outlined above provides the
essentials that contribute to the treatment plan. From this data a treatment plan evolves.
Once the plan is established, it should be considered with the patient and family. The plan
should specify the following:
• Targets of treatment, with rationale clarified, if needed

• Methods of treatment
• Estimated length of treatment
• Methods of outcome evaluation
• Ultimate goals of treatment
Once treatment goals have been formulated, any discrepancies between the patient/
his or her family and therapist perspectives should be directly reconciled. Such goal dis-
crepancies arise frequently, both while treatment is planned and once it is initiated. Real-
ism and education ideally guide discussion of goals and goal discrepancies. Treatment can
proceed when the patient has provided consent, as appropriate.
Various models for intervention in geriatric dementia and neuropsychology have
been described (e.g., Camp et al., 1993; Camp, 2001; Gross & Schutz, 1986; Lynch, per-
sonal communication, 2005; Zarit & Zarit, 1998). Whereas some of these focus on
specific populations or techniques, others emphasize the identification of appropriate
intervention approaches, given the patient’s presentation. Examples of technique modifi-
cations for the geriatric dementia population can also be found, though sparingly. The
following guide to using the information gathered during the intervention evaluation is
not meant to be definitive, but rather to provide a general outline of how a clinician
might proceed. Each clinician will capitalize on his or her background and expertise in
creating a tailored approach to planning.
The information gathered during the evaluation provides the fundamental elements
of the treatment plan, which will then be refined. One model for conducting this phase of
the process is outlined in Figures 10.1 and 10.2. First, the clinician ascertains whether or
not there is affective distress present that will interfere with cognitive management ef-
forts. If so, the most effective means of treatment for this emotional distress should be
identified. Guidelines for planning psychotherapeutic interventions are outlined in Figure
10.1. If no affective distress is present, planning can proceed to cognitive management, as
outlined in Figure 10.2. Although intervention often encompasses treatment of cognitive,
affective, and functional elements, we have found it useful to consider these domains in-
dependently during the planning phase.
Is there affective distress that affects quality of life or NO Proceed to cognitive

functioning, or that will interfere with cognitive management management planning
YES
Consider referral for pharmacological treatment in addition to

psychotherapeutic intervention. Consider:
NO
• Behavioral therapy
Does the patient have insight and express motivation to • Caregiver education
address emotional distress?
YES
Consider the following
treatment options
YES Consider:
1. Is the presentation of symptoms primarily behavioral? • Behavioral therapy
• Caregiver education
NO
2. Does the patient clearly express grief over losses in Consider:

cognition or function? YES • Dynamic/existential/grief
approaches
NO
Consider:
• Cognitive-behavioral
3. Does the presentation instead focus on thought patterns
YES therapy
(e.g., self-deprecatory ruminations) and feelings, and do
• Dynamic/existential/grief
the data suggest that the patient has relatively isolated
approaches
cognitive deficits that allow for complex information
processing?
FIGURE 10.1. Psychotherapeutic interventions.

NO
Does the patient appear motivated to address
memory and functional problems and have
insight into his or her cognitive deficits?
Consider:
• Spaced retrieval (caregiver
initiated)
YES • Environmental modifications
Consider:
Does the patient have cognitive deficits that YES • Spaced retrieval (caregiver
preclude the use of strategies requiring effortful initiated)
processing? • Environmental modifications
• Training in the use of external aids
• Practical/functional methods
NO
Consider:
• Spaced retrieval (caregiver or
Does the patient have cognitive deficits that are patient initiated)
YES
mild enough to allow for strategies requiring • Environmental modifications
effort and practice, or deficits that allow for • Caregiver education
capitalization of domain strengths to compensate • Training in the use of external aids
• Practical/functional methods
• Face–name recall technique
• Verbal elaboration: story method
• Overt/covert repetition
• Retrieval search techniques
• Other modified cognitive strategies
FIGURE 10.2. Cognitive management.
The chapters that follow outline many of these techniques, allowing for a more de-
tailed appreciation of these methods. The examples of intervention approaches discussed
here have all been shown to be effective in specific samples. It is such evidence-based ef-
forts that will carry the intervention field forward to allow for beneficial, cost-effective,
ethical services.
Once a carefully designed intervention plan has been initiated, the clinician will need
to monitor treatment progress and should be prepared to make modifications to maintain
optimal gains. The clinician should be cautioned not to rely solely or extensively on tradi-
tional objective tests of cognition, because many of these preclude the use of the tech-
niques taught in intervention (Sohlberg & Mateer, 1989b). Neuropsychological measures
should thus be supplemented with ratings of perceived gains that capture patient and
family perceptions of treatment benefits and limitations. These are often well captured by
measures of subjective well-being in the targeted area (e.g., everyday memory function-
ing) and measures of quality of life. In addition, it is ideal to include performance-based
tasks that capture the targeted behavior and allow for strategy implementation, but these
require psychometric validation to yield optimal data.
In the next section brief case examples outline the presentation and treatment plan of three
patients. Patients with similar goals, levels of functioning, or diagnoses may require signifi-
cantly different intervention approaches to maximize benefit while promoting an appropri-
ate level of independence and autonomy. These examples are meant to be illustrative only.
CASE EXAMPLES
Case 1. Mrs. H, Mild Cognitive Impairment/Possible Early AD
Mrs. H was in her mid-60s when she was referred for intervention to develop compensatory
and information-processing strategies to facilitate memory functioning and coping patterns.
Goals and Motivation

The patient was highly motivated to learn ways to minimize the impact of her memory
disorder on her everyday functioning. Although she acknowledged mild anxiety and de-
creased self-confidence, she expressed a clear desire initially to focus on memory skills.
She understood that intervention would not correct the memory disorder but that it could
help her to manage the ensuing changes.
Neuropsychological Profile and Insight

Comprehensive neuropsychological evaluation revealed a marked verbal and nonverbal
memory disorder, characterized by constricted learning and impaired recall. Performance
improved on recognition memory testing, suggesting primarily a retrieval memory deficit
at that time. In addition, the patient was mildly inefficient, although not impaired, on
nonverbal timed sequencing tasks. The course of the illness was described as progressive,
and no explanatory structural abnormality (e.g., vascular lesion) was revealed. The
patient’s presentation was consistent with the descriptive diagnosis of mild cognitive
impairment, and longitudinal follow-up was anticipated to rule out the presence of a
neurodegenerative illness. The patient was aware of her cognitive status and demon-
strated insight into both the presence and magnitude of deficits.
Affective Status
As noted, mild emotional distress, characterized by anxiety and diminished confidence,
was apparent during the initial evaluation. However, the patient expressed a desire to fo-
cus on the management of her memory difficulties and thus attention to these affective
factors was initially deferred.
Unique Factors and Current Compensatory Methods and Activities

No consistent methods of addressing cognitive and functional deficits were being used,
although the patient did keep inconsistent notes.
Intervention
The primary initial targets of intervention involved the patient’s memory dysfunction.
As treatment continued, her awareness of how cognitive and affective arenas influence
one another increased, and she was more receptive to addressing her mood and coping
style. Intervention thus evolved to address those aspects of functioning that the patient
was able, willing, and motivated to address. Intervention focused on the following:
1. Education. Because the patient was high functioning and interested in under-
standing the nature of her memory disorder, intervention included an educational compo-
nent addressing models of normal and abnormal memory functioning, as well as how
passive versus active processing affects outcome.
2. Learning and memory. Although the patient’s memory deficit was significant, her
cognitive deficits did not impair her ability to initiate and practice complex techniques.
Many different management and processing techniques were introduced, including spaced
retrieval, the regular use of external aids, retrieval methods, verbal elaboration, repetition
to facilitate concentration, conscious review of conversations, and a face–name recall tech-
nique.
3. Affective functioning. As the patient worked on various memory techniques, im-
proving rapport and awareness of the influence of emotional factors on her processing
led to a willingness to address this domain. Because the patient had minimal executive
deficits and clearly articulated deprecatory thoughts, a cognitive-behavioral approach
was chosen to address the patient’s distress. Although not typically used in the geriatric
dementia population, the cognitive-behavioral seemed suited to this patient, who sponta-
neously articulated judgments and perceptions. Little additional effort was needed to link
her automatic thoughts with their negative emotional outcomes. The patient responded
favorably to these efforts.
Case 2. Mr. C, Vasculitis

Mr. C was in his mid-50s and suffered marked neuropsychological deficits after having
vasculitis, an inflammatory vascular disorder. He was referred for intervention approxi-
mately 1 year after the acute phase of the illness. Despite improvements, he had marked
residual cognitive deficits.

The patient was no longer able to work in his previous farming occupation, nor could
he drive or participate in complex independent activities. However, in general, he was
able to participate in basic ADLs, maintain religious and social activities, and play an
active role in his family. He was motivated to improve his functioning, and his initial
goals of addressing memory, confidence, and independence in specific skills were rea-
sonable.

The patient’s functional deficits were driven by a dense amnesia, milder complex process-
ing deficits, and mildly decreased awareness of both his deficits and his environment.
Neuropsychological evaluation corroborated a profound memory deficit and milder
executive compromises. Insight was clinically judged to be mildly compromised. Spe-
cifically, although the patient was aware of diminished skill levels, he did not always
appreciate how these impairments manifested in everyday functioning, because he under-
estimated the magnitude of deficits and the frequency of memory failures.
Affective Status
Mr. C was concerned about his performance in many areas and exhibited diminished
confidence, in response to which he was becoming increasingly withdrawn and demon-
strating limited independence.
Current Compensatory Methods/Activities and Unique Factors

Interestingly, several compensatory methods and activities were in place, because the pa-
tient’s wife realized early during the course of his recovery that cognitive stimulation and
external aids were important. The patient recorded his activities and important informa-
tion in a daily memory book that she had constructed for him, which, while detailed, was
straightforward and effective. In addition, the patient participated in a number of “activi-
ties,” or games/puzzles, to ensure cognitive “stimulation” in an effort to promote recov-
ery. For the most part, the patient enjoyed these activities. No unique factors relevant to
intervention were notable.
Intervention
The initial treatment targets included memory functioning, confidence and independence,
with later work related to awareness.
1. Memory functioning. Intervention first targeted memory skills. The patient made
significant gains using a combination of regular calendar use (which was systematically
trained; see the following point), spaced retrieval, and retrieval search techniques.
2. External aids and compensatory exercises. Modification of established compen-
satory activities was appropriate during the course of intervention at two time points.
First, education about our current understanding (and its limits) of the utility of
cognitively stimulating activities was provided. This information gave the patient and his
wife a context within which to choose how much to emphasize participation in games/
puzzles in hopes of enhancing functioning through cognitive stimulation. They were dis-
couraged from using in frustrating activities of any kind, given that these were more
likely to undermine confidence than provide any tangible gains. They modified their regi-
men accordingly. Second, as the patient continued to improve, it became evident that the
level of detail and structure involved in his memory book was not necessary the way it
had been during the more acute stages of his illness. We therefore progressed this system
toward the use of a regular appointment calendar. This was done by systematically col-
lapsing the established categories of entry, to the point that entries could be made in a
regular calendar in a few relevant domains (e.g., health-related tasks, social/recreational
activities, appointments).
3. Awareness. The focus of intervention then evolved to identification of methods
that would assist the patient in compensating for his reduced awareness. An example of a
practical intervention in this area involved a disruptive functional issue: The patient could
not track whether or not he had taken a shower each day, so he would have to rely on his
wife to either cue him to do so or to inform him that he had taken one already when he
asked (repeatedly, of course). This problem was resolved in the following simple manner:
Spaced retrieval (see Camp, Chapter 12, this volume) was used to teach the patient to
take a towel out of the drawer and put it on the bathroom counter first thing every morn-
ing before starting any other activity. With systematic repetition, this became an estab-
lished part of his routine. Later, when curious about whether or not he had showered, he
needed only to look at the counter—if the towel was there, he had not yet showered; if it
was not there, it had been used, indicating that he had showered. He no longer needed to
(repeatedly) ask his wife for assistance with this aspect of self-care. This simple solution
took 10 minutes of a session to introduce and review and approximately 10 morning
spaced-retrieval sessions (with the patient being cued by his wife) to establish this pattern
as an independent behavior.
4. Emotional functioning. Throughout treatment, the patient was encouraged to
identify and participate in meaningful and rewarding projects (see Logsdon, McCurry, &
Teri, Chapter 16, this volume) to address the overlapping areas of affect, confidence, and
independence.
Case 3. Mrs. L, Disconnection Syndrome

Mrs. L suffered from a vascular disconnection syndrome in her early 60s that had left her
with elements of aphasia. She was referred for intervention services with a specific func-
tional complaint.

The primary functional complaint of this patient and her husband was that she could no lon-
ger shop to prepare meals. She was completely capable of cooking—of planning and execut-
ing the process—with the exception of the shopping, which she had previously done daily for
each evening meal. She was highly motivated to identify and participate in a solution.

Specifically, she was anomic (could not name pictures or objects); she could not name
specific objects when she was trying to express something that she desired. She therefore
could not ask for specific items at the store. She also could not comprehend written lan-
guage and therefore could not follow a shopping list. Insight was intact.
Affective Status
Although Mrs. L was frustrated by her language deficits, she remained relatively
euthymic and free from excessive emotional distress.
Current Compensatory Methods/Activities and Unique Factors

There was no compensatory strategy in place and no relevant unique factors.
Intervention
Treatment targeted the patient’s specific functional complaint. Because Mrs. L could not
comprehend written language, she could not effectively use a prepared shopping list. She
likewise could not tell anyone what ingredients she needed due to her anomia, so even her
husband could be of little assistance. And although she could visually recognize (but not
name) the desired items, canvassing an entire store (e.g., “Do I need this? Do I need this?
Do I need this?”) would be unwieldy. This problem was targeted and resolved in the fol-
lowing simple manner: A pocket-sized picture photo album displaying the most common
grocery items Mrs. L used was constructed. Prior to shopping, she would mark the items
she wanted with stickies and then take the album with her as her shopping list. In con-
trast to written words, she could visually recognize pictures, and could thus match the
picture with the store item for purchase.
SUMMARY
This chapter outlined a model to guide intervention planning for individuals with demen-
tia and other geriatric cognitive disorders. It reviewed fundamental aspects of treatment
planning based on the best current approaches reported in the research literature. Those
working in intervention anticipate and welcome continued efforts in this arena, so that
treatment approaches and planning methods become more refined as new research helps
to further define this promising area of practice. The chapters that follow highlight effica-
cious and promising outcomes in specific areas of clinical intervention. Rigorously
defined research needs to continue to ensure that these services remain available in the
context of evidence-based practice.
The vignettes presented in this chapter illustrate intervention planning and the yield
of practical functional interventions at the individual level. The reader is encouraged to
consider the meaning of these simple practical gains in terms of patient well-being, auton-
omy, and quality of life. Regardless of the targets and techniques employed, this work in-
deed reflects how people try to find and use the degrees of freedom they have within the
constraints of their illness.
So what, then, is intervention? One answer is that it is the work that occurs at the in-
tersection of biology and existentialism. It is here that people try to find, and move them-
selves within, the context of their experience. Although treatment progress sometimes
centers on simple, practical solutions to specific complaints, it is more common that pa-
tients are debilitated and depressed by their functional deficits, and in these cases inter-
vention encompasses much more. In these cases intervention often involves a restructur-
ing of the patient’s responsibilities, expectations, and sense of self, largely to yield a
transformation in role identity that is adaptive in the behavioral context of the illness.
Many patients emphasize the favorable impact of intervention on quality of life,
functional outcomes, and sense of well-being, dignity, and purpose. The potential reduc-
tion of costs and disability should also not be overlooked. The chapters that follow illus-
trate these outcomes. At present, there are few treatment options for our rapidly aging
population of elders with cognitive compromise. Until prevention and cure of geriatric
cognitive disorders becomes a reality, it remains our obligation to continue devoting ef-
fort to both clinical and research-based intervention. We enthusiastically look ahead as
this promising area continues to be defined.
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11
Training of Cognitive and Functionally

Relevant Skills in Mild Alzheimer’s Disease
An Integrated Approach
DAVID LOEWENSTEIN
AMARILIS ACEVEDO
Cognitive rehabilitation has been employed as an effective means of improving memory

and other cognitive functions in patients who have suffered traumatic brain injury or
stroke (Prigatano, 1997; Salazar et al., 2000; Wilson, 1999). In the cognitively normal
older adult, training in the use of several memory techniques, including imagery, organi-
zation, and the method of loci, has been accompanied by memory improvement (see
Backman, 1996). However, most of these techniques, including organizational instruc-
tions (Diesfeldt, 1984), semantic orienting tasks (Corkin, 1982), as well as visual imagery
and verbal mediation (Butters et al., 1983), have been shown to be relatively ineffective
when used with individuals with Alzheimer’s disease (AD). The lack of efficacy of these
techniques in AD may be due to their reliance on episodic memory, which is vulnerable to
early impairment in the disease process. Episodic memory greatly depends on brain struc-
tures (e.g., the hippocampus) that are compromised in patients with AD (see Braak &
Braak, 1995; Eslinger & Damasio, 1986; Fox, Warrington, & Freebourough, 1996). In
contrast, techniques such as spaced retrieval, dual cognitive support, and procedural mo-
tor learning, which do not seem to rely on episodic memory and the implicated brain
structures, have been shown to improve cognition and/or function in patients with AD.
In this chapter we provide an overview of techniques that have demonstrated effi-
cacy in enhancing cognitive and/or functional performance among patients diagnosed
with AD. We then present data from a recently developed cognitive and functional reha-
bilitation paradigm that indicate efficacy in improving both cognitive and functional
skills of patients with mild AD. Finally, the limitations of previous empirical research, the
conceptual differentiation between cognitive and functional skills training, the impor-
261
tance of developing targeted interventions to address specific outcomes, and potential di-
rections for future interventions are discussed.
BRIEF REVIEW OF THE LITERATURE
First described by Landauer and Bjork in 1978, the expanding rehearsal method or
spaced retrieval technique (SRT) was one of the earliest interventions that had direct ap-
plicability to patients with AD. This approach, which is more fully described in Chapter
12, involves the incorporation of progressive increases in time intervals (in which other
activities prevent rehearsal) between the presentation of the to-be-remembered informa-
tion and its recall. In the event that a retrieval error occurs, the patient receives corrective
feedback, and the interval between stimulus presentation and recall is decreased to the
previous interval in which recall was correct. In contrast to other memory strategies such
as visual imagery, which requires effortful and elaborative processing that most brain-
impaired individuals are unable to achieve spontaneously, SRT seems to require little cog-
nitive effort, to be effective when used with patients who have AD (Bird & Kinsella,
1996; Camp & Stevens, 1990; Clare, Wilson, Carter, Roth, & Hodges, 2002; Davis,
Massman, & Doody, 2001), and to be spontaneously used by patients (Schacter, Rich, &
Stampp, 1985). It has been postulated that SRT works via a priming mechanism (Camp,
Bird, & Cherry, 2000) by engaging implicit rather than explicit memory processes, by
tapping procedural systems, and by decreasing reliance on semantic or declarative mem-
ory systems (Eslinger & Damasio, 1986). This last component is important, because both
procedural and implicit memory systems have been shown to remain relatively preserved
in AD (Backman, 1992).
Dual cognitive support, the provision of extensive support at both the encoding and
retrieval stages of learning and memory, has also been shown to facilitate memory in pa-
tients with AD (Backman, 1992). Support at encoding is sometimes achieved (1) by increas-
ing item richness (Davis & Mumford, 1984), (2) by anchoring the to-be-remembered infor-
mation to personal life material (De Vreese, Neri, Fioravanti, Belloi, & Zanetta, 2001),
(3) by providing guidance to engage in self-generated semantic encoding (Lipinska,
Backman, Mantyla, & Vitanen, 1994), (4) by activating event-relevant prior knowledge
(Johnson & Smith, 1998), or (5) by utilizing to-be-remembered stimuli that allow a
higher degree of organization (Herlitz & Vitanen, 1991). The use of material that is emo-
tionally laden (Moayeri, Cahil, Jin, & Potkin, 2000) or that is encoded in a multimodal
fashion (Lipinska & Backman, 1997) has also been found to result in better recall in pa-
tients with AD. Support at retrieval may be accomplished by providing appropriate recall
cues that are compatible with the approach used during the encoding stage (Bird &
Kinsella, 1996).
Activation of procedural memory and motor learning has also been shown to facili-
tate memory in patients with AD. Supportive evidence for the efficacy of procedural
memory in improving memory in AD stems from the finding that in the mild to moderate
stages of dementia, patients tend to recall their self-selected movements better than move-
ments selected by the experimenter (Dick, Kean, & Sands, 1988). In addition, patients
who have AD with varying severities of dementia recall command sentences better when
they perform the requested action (e.g., lift a cup, put on a glove) than when they read
but do not perform the command (Karlsson et al., 1989). Procedural motor learning in
patients with AD has been shown on (1) mirror tracing tasks (Gabrieli, Corkin, Mickel,
Training of Skills in Mild Alzheimer’s Disease 263
& Growdon, 1993), (2) rotary pursuit motor tasks (Eslinger & Damasio, 1986), (3) fin-
ger maze tasks (Kuzis et al., 1999), and (4) in learning-to-dance tasks (Rosler et al.,
2002). The effectiveness of procedural memory and motor learning in AD likely reflects
the relative sparing of the basal ganglia and sensory motor cortex in patients in the early
stages of the illness (Backman, 1999; Haxby, Grady, & Koss, 1990; Loewenstein, Barker,
et al., 1989). These brain structures are involved in the selection, initiation, sequencing,
and modulation of motor activity (Adams, Victor, & Ropper, 1997; Kandel, Schwartz, &
Jessel, 2000).
In addition to the aforementioned techniques, individual (see Squires, Hunkin, &
Parkin, 1997) and meta-analytic studies (see Kessels & de Haan, 2003) have shown the
effectiveness of errorless learning (i.e., the reduction of errors during learning) in improv-
ing memory in amnestic patients. Errorless learning used alone or in combination with
SRT has been shown to improve the ability of patients with AD to use memory resources
to improve orientation to time (Clare et al., 2000) and to learn face–name associations
(Clare et al., 2000; Clare et al., 2002; Clare, Wilson, Carter, & Hodges, 2003). (See
Clare, Chapter 13, this volume, for a more in-depth discussion of errorless learning ap-
proaches.)
These studies demonstrate improvement in memory in patients with AD after the uti-
lization of specific training techniques. Other studies have demonstrated functional im-
provement in this population following participation in functional training programs.
Zanetti, Magni, Binetti, Bianchetti, and Trabucchi (1994) trained patients with mild AD
during a 3-week program on basic activities of daily living (ADLs) and instrumental ac-
tivities of daily living (IADLs; e.g., writing a check, preparing coffee). At the end of the
program, patients were faster at completing not only the trained tasks but also untrained
tasks, suggesting transfer of skill learning. On the other hand, performance on cognitive
tasks for which subjects were not trained (i.e., memory) did not improve. Zanetti,
Rozzini, Bianchetti, and Trabucchi (1997) also studied the time it took to perform 20
ADLs in a group of untreated cognitively normal older adults versus a group of patients
with AD who participated in procedural memory training sessions for 3 weeks. Half of
the patients with AD were trained on 10 of the ADL outcome measures, and the other
half were trained on the alternate 10 ADL tasks. Results showed that not only were
trained patients with AD from 3.6 to 1.9 standard deviations faster than normal older
adults in the completion of the tasks, but that they improved in the untrained tasks as
well, completing them faster than the control group at postintervention. Consistent with
other studies, however, no change in performance was noted on neuropsychological mea-
sures tapping cognitive abilities for which the subjects were not trained.
In a more recent study, Lekeu, Wojtasik, Van der Linden, and Salmon (2002) suc-
cessfully employed an errorless learning paradigm to teach patients with AD to use a mo-
bile telephone. Farina and colleagues (2002) described an intensive 5-week program with
22 AD inpatients who participated in individual sessions, twice a day, 3 days a week. The
investigators compared the efficacy of a procedural memory training intervention that
was based on practicing ADLs (e.g., identifying currency, sending a letter) to a residual
cognitive function intervention that was based on activities aimed to stimulate cognitive
processes (e.g., looking for specific words in an array, recalling digits, naming pictures).
Results indicated significant postintervention improvement in performance of patients in
both groups on the Functional Living Skills Assessment, a measure that directly measures
performance on everyday functional tasks. They also found a slight improvement in the
procedural memory training group on two neuropsychological measures. Unfortunately,
all gains tended to regress to pretraining levels at 3 months postintervention. These re-
searchers suggested that training ADLs with a strong procedural memory component
may be more effective than stimulating “residual” cognitive functions in patients with
AD. More importantly, the above results suggest that functional training can generalize
to untrained tasks and to real-world functioning in patients who have AD.
LIMITATIONS OF PREVIOUS RESEARCH
Although spaced retrieval, dual cognitive support, and activation of procedural and mo-
tor memory have been found to enhance memory in AD patients, these procedures have
often been utilized in isolation. Over the last several years, our laboratory has been en-
gaged in developing an integrated cognitive and functional training program specifically
developed for patients with mild and very mild AD. The conceptual underpinnings of the
paradigm that has been developed are as follows:
1. Memory and functional skills in mildly and very mildly impaired patients with
AD can be improved by the integrated utilization of SRT, dual cognitive support,
and procedural motor activation, all of which have been suggested to rely on
brain processes and systems (i.e., implicit memory, basal ganglia) that are rela-
tively preserved in mild AD.
2. Training should focus on the acquisition and maintenance of skills that are di-
rectly related to the patient’s everyday life.
We have also developed a greater appreciation of the potential value of participation in

booster training sessions, which are likely to extend the period during which cognitive
and functional gains are maintained.
Many previous intervention studies have failed to address important issues such as
the need to increase cognitive processing speed and enhance prospective memory (i.e., re-
membering to remember an intended action). This omission may be related to the fact
that although prospective memory problems are a common complaint among cognitively
normal and memory-impaired older adults, neuropsychologists rarely assess this impor-
tant aspect of memory. Further, a number of cognitive rehabilitation interventions have
not incorporated compensatory strategies (e.g., memory notebooks) or training of a fam-
ily member or a friend who can assist the patient as a therapy extender when practicing
learned skills at home and in the real-world environment.
To address these weaknesses in other intervention programs, our training program in-
corporates compensatory techniques such as a memory notebook and the training of a fam-
ily member or friend who can integrate the in-office training to the patient’s everyday envi-
ronment. In addition, given that speed of cognitive processing has been postulated to
underlie many component cognitive abilities in the elderly (Salthouse, 1996; Salthouse &
Somberg, 1982), we have incorporated training of cognitive processing speed in our inter-
vention program. Cognitive processing speed has been shown to be improved in cognitively
normal older adults after their participation in a 5- to 6-week cognitive intervention pro-
gram (see Ball et al., 2002). These investigators also demonstrated that individuals who par-
ticipated in postintervention booster sessions were more likely to maintain these gains at 2
years postintervention, as compared to their peers who did not participate in the booster
sessions. Unfortunately, this paradigm has not been well studied in AD.
DATA FROM OUR INTEGRATED COGNITIVE REHABILITATION PROGRAM
The cognitive rehabilitation (CR) intervention developed in our laboratory incorporates

the techniques described above that have been shown to be effective in AD. For example,
we utilized the SRT and dual cognitive support in face–name association training, which also
incorporated the use of phonetic cues related to specific features of the to-be-remembered
face (e.g., Smiling Sam). In addition, our intervention incorporated procedural and motor
memory in the training of specific functional tasks, such as making change for a pur-
chase, balancing a checkbook, and enhancing memory through the manipulation of ob-
jects in a way consistent with their use (e.g., use a hammer as though hammering; use a
can opener as though opening a can). We also employed an orientation and memory
notebook (Loewenstein & Acevedo, 2000a) for in-session exercises that would benefit
from the use of anchoring information that was of relevance to the patient (e.g., birthday,
anniversaries), as suggested by De Vreese and coworkers (2001).
The efficacy of our training program was recently demonstrated in a cognitive reha-
bilitation trial that was funded by the National Institutes of Health/National Institute on
Aging. The study included 44 subjects with probable or possible AD, according to the cri-
teria established by the National Institute of Neurological and Communicative Disorders
and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS–
ADRDA; McKhann et al., 1984). Patients were diagnosed by an experienced neurologist
after a thorough neurological and neurocognitive evaluation, blood laboratories, and
brain magnetic resonance imaging (MRI). Subjects had been on a stable dose of an
acetylcholinesterase inhibitor (AChEI) for at least 8 weeks. In this initial trial (see
Loewenstein, Acevedo, Czaja, & Duara, 2004), we compared the effects of our CR inter-
vention to that of a nonspecific mental stimulation (MS) intervention that consisted of
participation in interesting, commercially available computer games (e.g., “hangman,”
word scramble) that were presented by the therapist. Results of the investigation indi-
cated that subjects in the CR intervention evidenced improvements at both postinter-
vention and 3-month follow-up in cognitive processing speed, face–name association, ori-
entation, and functional skills such as making change for a purchase. As expected, there
were no training effects on traditional neuropsychological measures of component abili-
ties, such as memory, language, visuospatial skills and executive function, that were not
directly targeted by the CR intervention.
We have now collected new data on additional cases, for a total of 57 subjects, who
have completed their 3-month postintervention evaluation. Subjects were randomly as-
signed to the CR (n = 33, 42% females) or MS (n = 24, 50% females) intervention. The
CR group had a mean age of 76.8 years (SD = 4.7), mean education of 12.1 years (SD =
4.3), and a mean score on the Mini-Mental State Examination (MMSE; Folstein, Folstein,
& McHugh, 1975) of 23.5 (SD = 3.1). The MS group had a mean age of 74.8 years (SD =
6.8), mean education of 14.3 years (SD = 3.0), and mean MMSE score of 24.5 (SD =
4.1). Of the total sample, 36 patients (63.2%) were English speakers and 21 (36.8%)
were Spanish speakers, with all components of the program (i.e., in-office sessions, at-
home exercises, neuropsychological functional battery) conducted in patients’ primary
language. The neuropsychological functional battery, which consisted of tests that were
related or unrelated to the CR training tasks, was administered at baseline, postinter-
vention, and at 3 and 6 months postintervention.
To assess the potential impact of the training interventions, we used traditional cog-
nitive measures (e.g., Continuous Performance Test, CPT, Conners, 2000; orientation
subtest of the MMSE) as well as tests developed in our laboratories. The latter included
the Procedural Object-Memory Evaluation (POME; Loewenstein et al., 2004), the Face–
Name Association Test (FNAT; Acevedo & Loewenstein, 2001), the Balancing-A-Checkbook
Task (Loewenstein & Acevedo, 2000b), and the Modified Making Change for a Purchase
Test (Loewenstein & Acevedo, 2000b)—the latter two of which are revised versions of
the corresponding subtests that are part of the Direct Assessment of Functional Status
Scale (Loewenstein, Amigo, et al., 1989). The POME consists of 12 common objects
(e.g., key, straw) that are placed in front of the subject, who is allowed to manipulate
them during the 10-second item exposure time. The subject is asked to recall the items
across three learning trials and after a 30-minute delay. The FNAT involves the presenta-
tion of 10 faces, each with a corresponding name, across three learning trials in which the
faces are presented in a different order. Recall is assessed immediately after each trial,
with corrective feedback provided if the subject was unable to recall the correct name.
Recall is again assessed after a 30-minute delay. In the Modified Balancing the Check-
book Test, the subject is asked to calculate, by hand and with the aid of a calculator, the
balance in a checking account after paying three utility bills (i.e., water, electricity, and
telephone). The Modified Making Change for a Purchase Test consists of five trials in
which the patient is asked to make change of different amounts from a $20 bill. All tests
in the initial and outcome battery that were related to the CR consisted of items that were
different from those used in the training sessions. The only exception was the inclusion in
the CR training sessions of 5 of the 10 faces that comprise the FNAT.
A series of 2 × 3 group (CR or MS) by time (baseline, postintervention, 3-month
follow-up) repeated-measures mixed-model analysis of variance (ANOVA) was con-
ducted using the 57 subjects. Given that education was slightly higher in the MS group,
education was entered as a covariate in all analyses. Table 11.1 depicts the different
means associated with statistically significant group × time interactions. Relative to base-
line, patients in the CR group achieved higher scores on the three-trial learning and de-
layed recall of the FNAT, on the Making Change for a Purchase Task, and on reaction
time on the CPT, both at postintervention and the 3-month follow-up. The CR group
demonstrated improved scores on the Orientation subtest of the MMSE at postinter-
vention relative to baseline, but scores had returned to baseline at the 3-month follow-up.
In contrast, performance of the MS group, which did not evidence improvement on orien-
tation at postintervention, showed deterioration from baseline levels of performance at the
3-month follow-up. Except for higher scores on the three-trial learning score of the FNAT
at postintervention and the 3-month follow-up, and a lower number of commission er-
rors on the CPT at the 3-month follow-up, there were no differences between baseline
and follow-up performance for the MS group. These results remained consistent when
factors such as primary language (i.e., English vs. Spanish) and medication dosage were
entered into the statistical models.
SIX-MONTH POSTINTERVENTION DATA COMPARED TO BASELINE DATA
Our previous data were limited to a 3-month postintervention follow-up. Here we pres-
ent data on 51 of the 57 subjects who completed their 6-month postintervention evalua-
tion. Twenty-seven of these subjects participated in the CR intervention (mean age =
76.86, SD = 4.3; 53% females) and 24 participated in the MS intervention (mean age =
74.61, SD = 6.9; 47% females). The interaction term in a series of 2 × 2 group (CR or
TABLE 11.1. Mean (Standard Deviation) of Cognitive Rehabilitation and Mental Stimulation Groups
on Tasks Related to Cognitive Rehabilitation Training
Group ×
time
3-month interaction
Trained skills Group Baseline Postintervention follow-up p value
FNAT three-trial CR 7.46 (5.5) 14.79 (7.9)*** 14.65 (8.8)*** .022
learning MS 6.95 (5.3) 9.32 (7.4)* 10.43 (7.7)**
FNAT delay recall CR 2.52 (2.5) 5.36 (3.0)*** 5.16 (3.4)*** < .001
MS 3.45 (2.4) 3.73 (3.3) 3.52 (3.0)
Orientation CR 7.63 (1.8) 8.30 (1.4)* 7.84 (1.9) .009
MS 7.79 (2.2) 7.25 (2.1) 6.75 (2.5)**
POME three-trial CR 19.58 (6.2) 20.48 (7.3) 21.36 (7.2) .254
learning MS 20.17 (6.2) 20.13 (7.3) 20.21 (8.1)
POME delay recall CR 5.12 (3.5) 4.97 (3.4) 5.39 (3.8) .681
MS 5.33 (3.4) 5.58 (3.7) 5.38 (3.8)
Making Change for a CR 4.91 (3.2) 6.18 (3.3)* 5.81 (3.4)* .023
Purchase Task MS 5.08 (3.9) 4.00 (4.0) 4.92 (3.9)
Balancing checkbook CR 2.25 (1.7) 2.03 (1.7) 1.97 (1.7) .386
(by hand) MS 1.50 (1.5) 1.63 (1.6) 1.74 (1.5)
Balancing checkbook CR 2.66 (1.6) 3.28 (1.5) 3.25 (1.4) .357
(with calculator) MS 2.71 (1.8) 2.63 (1.6) 2.74 (1.7)
CPT omission errors CR 19.33 (24.0) 18.17 (31.1) 12.29 (40.2) .828
MS 19.50 (19.6) 18.30 (21.4) 17.70 (25.2)
CPT commission errors CR 13.29 (5.2) 16.37 (7.6)* 15.71 (7.9) .014
MS 10.38 (6.6) 8.38 (6.3) 7.60 (5.0)*
CPT reaction time CR 514.50 (153.5) 431.88 (66.2)** 472.44 (133.9)** .005
MS 519.97 (67.1) 506.40 (78.7) 504.51 (78.5)
Note. Mean performance at follow-up and 3-month evaluations for a specific group with a statistically significant in-
teraction term is significantly different from baseline. n = 33 for cognitive rehabilitation (CR) group; n = 24 for mental
stimulation (MS) group. FNAT, Face–Name Association Test; POME, Procedural Object-Memory Evaluation; CPT,
Continuous Performance Test. The bold items are statistically significant at p < .05.
* p < .05; ** p < .01; *** p < .001.
MS) by time (baseline vs. 6-month follow-up) repeated measures ANOVAs revealed that
the CR group evidenced improvement relative to baseline at 6 months postintervention
on the three-trial learning score, F(1,49) = 6.06; p < .02, and the delayed recall score
F(1,46) = 17.39; p < .001, of the FNAT, as well as on reaction time on the CPT, F(1,38) =
4.84, p < .02. CR and MS groups did not differ on Orientation and the Making Change
for a Purchase Task at the 6-month postintervention follow-up.
FURTHER DEVELOPMENT OF COGNITIVE AND

FUNCTIONAL REHABILITATION PARADIGMS
Our previous work indicates that certain cognitive and functional skills can be trained in
mildly impaired patients with AD on AChEIs and that these gains can generally be main-
tained from 3 to 6 months postintervention. Although successful, there were some limita-
tions in our pilot study that we have attempted to address in our ongoing work. First, the
CR intervention consisted mostly of tasks that were cognitive in nature, and it only in-
cluded direct training of a limited number of functional tasks (e.g., making change for a
purchase). In addition, there was limited training to address prospective memory prob-
lems, an aspect of memory with considerable real-world relevance (see Loewenstein &
Mogosky, 1999), and one that constitutes a frequent complaint among both cognitively
intact and memory-impaired elderly patients. Because cognitive and functional training
tasks were presented together, our previous study did not allow us to disentangle the in-
dependent effects of cognitive versus functional approaches as they related to the out-
come measures. Disentangling their relative contributions is important because it has
been postulated that reduced cognitive processing speed may result in impairment in
other component cognitive processes and in functional skills in normal elderly adults
(Salthouse, 1996; Salthouse & Somberg, 1982). Finally, another limitation of our previ-
ous research is the lack of postintervention maintenance sessions, which may have pro-
longed treatment gains over longer periods of time.
CONCEPTUAL DIFFERENCES BETWEEN

COGNITIVE AND FUNCTIONAL TASKS
One of the more complex issues in developing cognitive intervention paradigms is the
theoretical and conceptual delineation between what constitutes a cognitive task and
what constitutes a functional task. Some cognitive scientists believe that functional per-
formance and its measurement can be thought of as cognitive in nature, because a com-
plex array of component cognitive abilities and their interactions underlie many func-
tional skills. This belief has long been held by a number of professionals in the area of
cognitive rehabilitation, which has traditionally attempted to train underlying cognitive
abilities such as memory and attention in an effort to remediate real-world functional
deficits resulting from traumatic brain injury or cerebrovascular events. However, the
available literature in AD does not support the efficacy of training component cognitive
abilities to improve cognitive outcomes; even the results of the large trial by Ball and col-
laborators (2002) with normal elders indicate that training and maintenance of specific
cognitive skills do not result in changes in functional outcomes. Of course, more studies
with further longitudinal follow-up are required.
In a previous analysis of the literature, we argued that a significant amount of vari-
ance in independent ADLs among mild to moderately impaired patients with AD is not
explained by knowledge of neuropsychological test performance alone (see Loewenstein
& Mogosky, 1999). Although our view is that functional capacity and performance on
real-world functional tasks rely on specific cognitive abilities, the traditional view likely
underestimates the complexity of the various factors that underlie relevant real-world
function. In this regard, we believe that internal subject variables (e.g., motivation, fluctu-
ations in alertness) as well as external environmental variables (e.g., task difficulty, con-
textual cues) are critical in the successful completion of functional tasks within the per-
son’s home environment. Thus task performance is affected by (1) cognitive abilities and
other internal characteristics of the individual, (2) the nature of the specific task, and (3)
environmental factors that interact with each other and may affect the relationship be-
tween these variables or their relative importance over time. For these reasons, the study
of both mediator and moderator variables is likely to be critical to our understanding of
these processes. Given that traditional least-square regression models may not be ade-
quate to examine mediating variables and any changes in performance over time, the use
of multilevel models that apply structural equation modeling (SEM) and latent growth
curve approaches seems to be the appropriate way to proceed.
Until more complex conceptual models are developed that better elucidate the rela-
tionship among cognitive and functional variables, we have employed a useful set of
heuristics to help distinguish between cognitively and functionally based training tasks
for mildly impaired patients with AD. This set of heuristics has allowed us build different
types of intervention models that lend themselves to empirical evaluation. We believe that
cognitive rehabilitation intervention and functional enhancement interventions differ in
three important ways: (1) their theoretical foundations, (2) their primary goals, and (3)
their training techniques. The theoretical foundation of the cognitive rehabilitation inter-
vention stems from clinical neuropsychology and cognitive neurosciences, whereas the
functional enhancement intervention has its theoretical foundations in rehabilitation psy-
chology and occupational therapy. The primary goal of the cognitive intervention is the
remediation of cognitive deficits, such as impaired memory and slowed cognitive process-
ing speed. In contrast, the primary goal of the functional enhancement intervention is to
directly train targeted functional tasks that have traditionally been considered to be
IADLs (e.g., making change for a purchase) and that have high correspondence to real-
world situations. It is important to note that the functional enhancement paradigm
acknowledges that component cognitive abilities such as cognitive processing speed may
affect task performance. However, this intervention does not rely on the training of cog-
nitive skills but rather on the training of actual functional tasks. The main techniques
(i.e., spaced retrieval, dual cognitive support) used in the cognitive intervention and in
our previous pilot trial have been associated with improvement in memory and other cog-
nitive domains that are frequently affected in mild AD (see Loewenstein et al., 2004).
Conversely, the primary technique used in the functional enhancement intervention (i.e.,
procedural motor learning) has been associated with improved performance on func-
tional tasks. In summary, although they both have strong theoretical and empirical
foundations, cognitive and functional enhancement interventions are based on different
theoretical models, have different primary goals, and use different techniques to attain
these goals.
DEVELOPMENT OF MORE FUNCTIONALLY RELEVANT OUTCOMES
Although patients with AD are able to learn targeted skills and maintain gains over time,
further work is required to develop training tasks that have real-world counterparts and
functional relevance. Some of these tasks could be related to medication adherence, basic
money management, and learning to interface with existing technology (e.g., use of a cel-
lular telephone, navigating of a telephone menu system to perform specific functions,
such as refilling a prescription or reporting a power outage). Training patients on ways to
improve prospective memory in the real world (e.g., remembering to make a medical ap-
pointment or to take medications) would also have high generalizability to real life. We
have recently conducted pilot work that indicates that it is possible to train prospective
memory in patients with mild AD by utilizing the Orientation and Memory Notebook, in
which prospective memory training is enhanced by the provision of specific cues. Using
this approach, patients have been taught to periodically check their notebooks for specific
to-be-remembered assignments that were previously written by the patients in their note-
books. For example, a patient might be told to page the therapist the following day at
11:30 A.M. or to call our office at 3:00 P.M. on a different day. The use of memory note-
books has been shown to decrease future remembering deficits in brain-injured individu-
als (Mateer & Sohlberg, 1988). Improvement in prospective memory in patients with AD
has also been accomplished by the utilization of SRT and errorless learning techniques
(Kixmiller, 2002).
As mentioned above, Zanetti and coworkers (1994, 1997) found that trained pa-
tients with AD performed trained and untrained ADLs at a faster speed than at baseline.
In our laboratories, we have collected data on a different type of functional skill—the
ability to learn to use a mock menu-driven automated telephone banking system. The sys-
tem, developed by Dr. Sara Czaja and her colleagues at the University of Miami, requires
patients to call a mock bank, where, by selecting the appropriate menus, they could ob-
tain information such as the balance of mock savings, checking, and credit card accounts,
transfer funds, and verify if a payment has been posted to one of the mock accounts (see
Czaja, Sankaran, & Lee, 2002). This mock telephone banking system is similar to those
routinely used by banking institutions. The reliability and validity of the tasks that can be
performed using this system were tested on a group of 14 mildly impaired patients with
AD (6 males and 8 females) with mean Mini-Mental State Examination (MMSE) score of
23.0 (SD = 3.6.) The mean age of this group was 79.9 (SD = 6.9), and the average level of
educational attainment was 12.54 years (SD = 3.6). Test–retest reliability for the total
number of items answered correctly on this telephone banking task was excellent (r = .85;
p < .001). Test–retest reliabilities for specific aspects of the task were also high, especially
for the savings account task, r = .92 (p < .001), the checking account task, r = .77
(p < .01), and the credit card task, r = .65 (p < .02). In a recent pilot study, we trained 13
mildly impaired patients with AD (7 males and 6 females) to use the system. The mean
age of this group was 78.41 (SD = 5.3), the mean level of educational attainment was
13.12 (SD = 3.5), and the mean MMSE was 24.18 (SD = 3.6). Results using similar items
included in the training sessions indicated improvement, as compared to baseline, in the
patients’ ability to use the system to obtain correct financial data related to the mock ac-
counts (df = 12) = 2.9; p < .02. Post-hoc tests demonstrated a particular improvement in
the number of correct responses on questions related to the checking account (12) = 2.3,
p < .04, and in the time it took the patients to complete the task, t(12) = –2.50, p < .04.
Faster rates of completion were also found in a similar task related to the savings ac-
count, t(12) = 2.31, p < .04. (See Attix, Chapter 10, this volume, for a more detailed de-
scription of targeted interventions for specific functional tasks.)
TARGETED INTERVENTIONS
As mentioned above, there is little evidence that merely training component cognitive
skills such as memory, language, attention, or cognitive processing speed in patients with
AD generalizes to performance in real-world tasks. Furthermore, the use of traditional
nonspecific memory drills is of questionable value with patients who have AD. By train-
ing skills that are directly related to important real-world tasks and that allow continued
practice at home, the intervention becomes more meaningful to the patient and his or her
family.
As already discussed, we believe that the effectiveness of cognitive and functional in-
terventions would be extended by the administration of periodic booster sessions that
would give patients the opportunity to practice the skills under the supervision of a
trained professional. Maintaining treatment gains over an extended period of time could
have a significant impact in the independence and quality of life of both the patient and
the caregiver. Further, extending cognitive and functional independence in the patient
with AD for even 6 months to 1 year would result in considerable cost-savings to many
societies. Of course, these aspirational goals can only be attained with continued vigorous
research to develop targeted interventions that would be optimally effective for patients
with AD.
FUTURE DIRECTIONS
There is an emerging literature that demonstrates that mildly and perhaps even moder-
ately impaired patients with AD can learn and maintain cognitive and/or functional gains
over time. The extent to which moderately and more severely impaired patients with AD,
and those with other neurodegenerative disorders, can benefit from integrative cognitive
and functional rehabilitation approaches awaits further research. As newer pharmacolog-
ical agents become increasingly effective, a larger window of opportunity may arise dur-
ing which we would be able to work with patients on both cognitively and functionally
relevant skills. As pharmacological, genetic, or other approaches are developed that can
effectively halt the progression of AD and other dementias, there will continue to be a
critical need to rehabilitate the cognitive and functional sequelae of the already damaged
neural structures and systems that are essential to everyday life. These resultant deficits
may best be addressed with targeted cognitive and functional rehabilitation interventions
that will likely become more sophisticated as we further our understanding of the inter-
vention process.
What only a decade ago seemed quite unlikely, cognitive and functional rehabilita-
tion using specific techniques to bypass the episodic memory deficits associated with AD
seems to hold a refreshing promise. This promise can only be realized through continued
novel research on effective cognitive and functional approaches that have real-life impact
and that increase the quality of life of both the patient and the caregiver. We owe our pa-
tients and their families no less.
ACKNOWLEDGMENTS
This work was supported by the National Institute on Aging (Grant No. R01 AG018401-03) and
by the Johnnie B. Byrd Sr. Alzheimer’s Center and Research Institute, Tampa, Florida (David
Loewenstein, principal investigator).
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12
Spaced Retrieval
A Model for Dissemination of a Cognitive
Intervention for Persons with Dementia
CAMERON J. CAMP
It is not enough to be right—we must also be effective.

—Unofficial motto of the Myers Research Institute
Recently I was presenting a workshop on cognitive interventions for dementia to a

group of staff from nursing homes in the Midwest. One attendee had heard a previous
presentation of mine on an intervention known as spaced retrieval. She related that she
had tried the intervention at her facility with a resident who had dementia and who was a
“low talker,” to use a phrase made famous by a long-running TV sitcom. The resident
usually spoke in an unintelligible whisper. Using this intervention, the attendee trained
the resident to talk louder when she would prompt the resident with the question “How
should you talk to me?” A few weeks later, the resident evidenced a sudden bout of agita-
tion and was pacing up and down the halls, speaking aloud (softly) and grimacing. The
resident ignored questions from staff seeking to discern the source of discomfort. Staff
were deciding whether to attempt to administer an antianxiety drug orally or through in-
jection when the staff member who had trained the resident intervened. The resident was
asked “How should you talk to me?” and responded, “TALK LOUDER.” The staff
member then asked, “What’s wrong?” and the resident shouted in response, “MY FEET
HURT!” The resident’s feet were then examined and treatment administered for an ach-
ing bunion.
Research in neuroscience and cognitive aging must inform and influence treatment
of persons with dementia. A better understanding of the trajectories of different cognitive
abilities over the course of dementia is critical to the continuing evolution of better care
and enhanced quality of life for persons with dementing illnesses. Although cholinergic
drugs work to reestablish neurotransmission in brain regions damaged by dementing ill-
275
ness, they cannot enable reorganization of the nervous system to compensate for deficits
(Requena et al., 2004). This lacuna in treatment argues strongly for the use of cognitive
training interventions in dementia, perhaps in conjunction with pharmacological inter-
ventions (Loewenstein, Acevedo, Czaja, & Duara, 2004; Requena et al., 2004). Findings
from research must be translated into best-care practices and delivered by nonresearchers
as part of job routines. Psychologists can play a vital role in making such transitions a re-
ality.
This chapter focuses on a cognitive intervention for persons with dementia, initially
researched and developed by psychologists, called spaced retrieval (SR). First, the spaced
retrieval technique is described. Research associated with this intervention and possible
mechanisms responsible for the effects produced are reviewed. A case study is then pre-
sented to illustrate the obstacles to adoption of interventions that exist in real-world set-
tings, along with recommendations for overcoming such obstacles.
DESCRIPTION OF THE SR TECHNIQUE
SR refers to a technique in which clients practice the successful retrieval of information

over successively longer time intervals. Camp, Bird, and Cherry (2000) have documented
the evolution of SR from a lab-based research topic to a therapeutic intervention for per-
sons with dementia. Here let us consider an example of how SR might be used to address
a common problem seen in care settings for persons with dementia.
A long-term care resident often complains that her daughter “never comes to visit,”
though the daughter visits two or three times a week, and the resident regularly asks staff
“When is my daughter coming back to see me?” The intervention in this case might involve
two components. First, there is a need to create an external memory aid that can store infor-
mation about past and future visits. This aid might consist of a “guest book” in the resi-
dent’s room. When the daughter comes to visit, she signs the guest book at the end of the
visit, briefly describes the content of their visit, and notes when she will be returning next.
The external aid is a necessary, though not sufficient, aspect of the intervention, for the older
woman must learn to access the guest book when her anxiety rises concerning her daugh-
ter’s visits. This is where SR can be most useful—creating new associations that link an ex-
ternal aid with a strategy for its effective use. (See Bourgeois, Chapter 15, this volume, for
additional illustrations of external aids for persons with dementia.)
To create such an association, the therapist shows the external aid to the resident,
with a page or two filled out, describes its function and content, and asks the resident
“What would you call this?” If the resident supplies a reasonable name for the aid, that
name would be used as the correct response. If no name was suggested, the name “guest
book” would be provided and the resident asked “Does that sound like a good name for
this?” If so, that name would be used for the aid during SR training. To establish the link
between the guest book and its role in reducing visitation-related anxiety, the therapist
would ask “When is your daughter coming to visit you?” When the resident says “I don’t
know” or provides an erroneous response, the therapist says “You can find out about
your daughter’s visit in your guest book. Now, where can you find out about your daugh-
ter’s visit?” The resident, upon this prompt for immediate recall, should answer some-
thing like “In my guest book.”
The therapist would then provide the prompt at expanding intervals, such as after 30
seconds, then after 60 seconds, then 2 minutes, 4 minutes, 8 minutes, and 16 minutes. If
Spaced Retrieval 277
the resident does not provide a correct response, the therapist says the correct response
and then the prompt is given again to elicit immediate recall. Thus each trial ends with a
success. Then the next recall trial is shortened to that of the last previous successful recall
interval. For example, if recall was successful at 2 minutes but not over a 4-minute inter-
val, the next recall interval would be set back to 2 minutes. If the person is successful at 2
minutes, the intervals would begin expanding again.
The SR intervention is usually provided in 15-minute segments, because such seg-
ments are often used as billing increments for provision of rehabilitation (Malone, Camp,
& Rose, 2002). As a result, within a session the longest expansion interval reached is usu-
ally 16 minutes, though this time frame does not have to become an upper limit if circum-
stances allow additional expansion. It is our experience that once expansion intervals be-
gin to exceed 10 minutes, long-term retention of information (i.e., retention across
training sessions) becomes very probable. In some instances, even shorter retention inter-
vals can be predictive of a transfer of information into long-term memory (Camp, Foss,
Stevens, & O’Hanlon, 1996, p. 359).
At the next therapy session, usually 1–7 days later, the therapist begins the session by
providing the prompt. If the client provides the appropriate response, no further training is
given in that session. Appropriate retention at the start of two or three consecutive therapy
sessions signals a transition to maintenance training for the targeted information. If the cli-
ent does not remember the correct response at the start of a session after initial training, the
correct response is provided, immediately followed by another prompt and immediate re-
call by the client. This allows the recall probe trial to end with a success. The next recall trial
interval will be of a length equal to the longest successful recall interval achieved in the pre-
vious therapy session. Expansion or contraction of subsequent recall intervals will depend
on whether the client provides correct or incorrect responses to recall probes.
Brush and Camp (1998a) along with Malone et al. (2002) provide detailed instruc-
tions on the application of SR as a therapeutic intervention. These instructions include
topics such as implementing a quick screening procedure to document evidence that a cli-
ent shows potential to benefit from SR; how to proceed if a client does not answer; how
to proceed if the client does (or does not) provide the correct response at the start of latter
sessions; how to ensure that learned strategies are actually performed; and how to avoid
most common errors in applying SR. Staff from the Myers Research Institute provide
training seminars in appropriate application of SR (for more information, visit our
website at www.myersresearch.org).
ESTABLISHING SR GOALS
SR goals vary according to the needs of clients. At a functional level, the specific cause of
dementia is not as relevant to designing a goal as determining the features that lead to
failure and the abilities that remain, on which to base the intervention. Basic issues in de-
signing goals include:
• Can the client read (and, if so, can the client follow written directions)?
• Can the client manipulate objects?
• Why is the client failing to achieve a goal or engaging in problematic behavior?
• Does the intervention require training the client to remember factual information,
the use of a strategy, the use of an external aid, or some combination of these?
In general, goals for SR involve training clients to learn or remember specific facts (e.g.,
adult children’s names); where they (i.e., the clients) live; their room number; or the use
of a strategy, which often involves the use of external aids (e.g., checking the guest book
when they want to know about visitations). Two case studies illustrating the use of SR
within the context of the Attix intervention model for geriatric neuropsychological inter-
vention (Chapter 10, this volume) are now presented.
CASE EXAMPLES
Case 1. Mr. J, Alzheimer’s Disease—Moderate Level Dementia
Mr. J was referred for intervention because of repetitive questioning. He would repeat-
edly go to the nursing station on his special care unit for dementia, asking when the next
meal would be served.

The client was motivated to be able to find this information for himself. He did not like
to admit to having memory impairment or to have to depend on others to answer ques-
tions. (For repetitive question asking, it is critical to determine whether the behavior is
driven by information seeking or by other factors such as a need for attention, social con-
tact, reassurance, etc. SR can be very useful when repetitive questioning is driven by in-
formation seeking, but not for other causes. See Camp and Nasser [2003] for a discussion
of methods to determine underlying causes and resultant interventions for agitation in
persons with dementia.)

Mr. J had significant difficulties retaining new episodic information for periods longer
than 90 seconds. Mobile, verbal, and intelligent, he was aware of having some memory
difficulties but did not want to discuss them because to do was embarrassing to him.
Affective Status
Mild emotional distress characterized by anxiety and changes in confidence were noted;
his inability to remember mealtimes seemed to trigger increases in anxiety.

Staff tried to be patient with the resident and answer his question whenever he asked
“When is the next meal going to be served?” However, this strategy became stressful
when the frequency of the behavior was high and staff had other demands on their time.
Intervention
The therapist determined that the client could read and comprehend printed instructions,
configured to accommodate changes in vision often seen in persons with dementia (e.g.,
large print size, sans serif font, thick letters, high contrast). A quick evaluation of this
ability is generally part of our initial examination. The therapist also noted that the client
always carried a wallet. The therapist wrote the times of meals on an index card (e.g.,
“Breakfast is at 7 o’clock, lunch is at 12 o’clock, dinner is at 5 o’clock”) and asked the
client to read the card aloud and then put the card in his wallet. The therapist then initi-
ated an SR training session in which the recall probe was “How can you find out when
meals are served?” The client was to respond verbally “I’ve got it in my wallet,” and then
physically take out the card and read it aloud.
Note how practicing both the verbalization of the strategy and the motoric execution
of the strategy—use of an external aid—creates multiple routes to assist the client in im-
plementing the use of the aid. After SR training, the client generally would say the strat-
egy aloud and execute it when his anxiety about mealtimes rose. If he went to the nursing
station and asked the question, nursing staff would respond with the recall probe used
during therapy to help reinitiate the desired response. One month after initial mastery of
SR training, Mr. J was still successfully implementing the technique.
Case 2. Ms. L, HIV-Associated Dementia

Ms. L was referred for intervention because of problems remembering to take her medi-
cations appropriately.

The client wanted to take her medications appropriately and understood that it was im-
portant for her to do this so that she would not start to feel worse.

Ms. L had significant short-term memory deficits, along with evidence of executive dys-
function. She had limited insight into her condition.
Affective Status
Ms. L generally showed no great concern regarding her difficulties with medication ad-
herence, possibly due to lack of insight. However, social isolation was a primary concern
of hers and cause for some distress.

As is typically the case for persons being treated for HIV, the client had been given a pill-
box to organize her medications. However, she was not using it appropriately, though she
was not aware of this.
Intervention
As is always the case, the key to designing a successful intervention was to determine
where and why the client was failing. Discovering this information usually involves a task
breakdown/analysis approach. Ms. L, for example, sometimes forgot to put medications
into slots in her pillbox or she put in incorrect amounts, or she did not remember to take
the pills at the appropriate time.
The intervention involved creating a template with life-size pictures of the pills the
client was to put into the pillbox for the next week. She was trained to put the template
next to the pillbox, to cover all of the pictures on the template with their corresponding
pills, and then to put the pills into the pillbox. This task was to be done each Sunday be-
fore dinner. SR was used to create the association of getting out the template, pills, and
pillbox when setting the Sunday dinner table, and of taking her pills when she heard a
signal from a digital timekeeper set by a staff member. The client liked the template be-
cause it “did not make me have to think about what pills I had to put where.” Interest-
ingly, successful use of the template and the signals led the client to admit that she had
not been as good as she had previously believed at taking her medications appropriately.
A wide variety of goals can be developed for SR interventions. Examples include

safety issues (e.g., remembering to use a walker; “putting nose over toes” before stand-
ing; safe transfer techniques), repetitive questioning, anxiety reduction, anger manage-
ment (e.g., “What should you do when you are about to lose it?”—“Get away and cool
off in my room”). Examples of different goals that have been used with SR are shown in
Table 12.1. In addition, consider the following example.
A long-term care resident was repetitively going to the nursing station on his unit
and asking about his wife and when she would be coming to see him. The man’s wife had
died about 2 years before. Staff generally attempted delaying tactics (“She’ll be here
soon”) or redirection with him, because they did not want to confront him with the bare
fact that his wife was dead. These approaches were becoming less and less effective, and
the resident’s agitation was escalating. The next step seemed to be selecting the appropri-
ate pharmacological intervention and method of its administration.
At that point a therapist who was training in the use of SR intervened. Using SR, she
created the following association for the resident: “What should you do when you want
to know about your wife?”—“Pick up and read the card” (i.e., a card kept at the nursing
station). The therapist had created a card that read “Where is my wife?” on one side and
a series of answers to the question on the other side. During SR training, the resident was
trained to pick up the card (which was facing up with the question “Where is my wife?”
on that side), turn it over, and read the text on the back side of the card. On that side, the
text read:
“My wife isn’t here because she cannot find me.”

This makes no sense. She would move heaven and earth to find me.
“My wife isn’t here because she is ill.”
This probably isn’t true. She was healthy all of her life, and my children would let me
know if she was too ill to see me.
“My wife isn’t here because she doesn’t want to see me.”
This cannot be true. We were in love all of our lives.
“My wife isn’t here because she is with God now.”
She passed away and is waiting for me. I’ll be with her again in heaven.
This man had a strong religious faith, which the therapist took into consideration. When
he first read the text on the back of the card, he nodded silently after seeing each answer.
On completing the last lines of the text, the resident looked at the therapist and said,
“Yes, if God will have her.” These answers satisfied him, and he learned to go to the nurs-
ing station and pick up the card and read it whenever he became anxious about the
whereabouts of his wife.
One way of approaching goal setting is to ask yourself what therapy you would use
if the client did not have an episodic memory deficit for new information. The key is to
identify causes of failure to benefit from therapy along with remaining skills. To the ex-
tent that the inability to remember new information is the chief barrier to benefiting from
therapy, SR can help circumvent such deficits. In other words, SR creates a type of cogni-
tive prosthesis. Of course, this prosthesis generally requires that therapeutic interventions
can be written down or presented in a pictorial or auditory format (e.g., using a tape re-
cording), and that use of such external aids can indeed allow interventions to be executed
by the client.
In addition to its use for a variety of goals, SR also has been shown to work across a
variety of dementing conditions: Alzheimer’s disease (Anderson, Arens, Johnsom, &
Coppens, 2001; Arkin, 1991; Bird, Alexopoulos, & Adamowicz, 1995; Bourgeois et al.,
2003; Brush & Camp, 1998b, 1998c; Camp et al., 1996; McKitrick, Camp, & Black,
1992); dementia related to Parkinson’s disease (Hayden & Camp, 1995) and HIV (Lee &
Camp, 2001; Neundorfer et al., 2004); and mixed dementia (Abrahams & Camp, 1993).
Bourgeois et al. (2003) also demonstrated that SR can produce better learning and reten-
tion than cueing hierarchies (e.g., the use of phonemic and semantic cues to assist recall)
TABLE 12.1. Examples of SR Goals

Type of goal Diagnosis Source
Using a calendar to remember daily tasks AD Camp et al. (1996)
Remembering to redeem a coupon AD McKitrick, Camp, & Black
(1992)
Object naming AD with vascular Abrahams & Camp (1993)
dementia
Remembering to eat HAD Neundorfer et al. (2004)
Describing an item if patient cannot CVA Brush & Camp (1998b)
name it
Remembering room number Dementia Brush & Camp (1998b)
Speaking into a voice amplifier when CVA/dysarthria Brush & Camp (1998b)
talking
Taking a sip of liquid after eating a Dementia/dysphagia Brush & Camp (1998c)
bite of food
Building face–name associations AD Clare et al. (2002);
Loewenstein et al. (2004)
Using a notebook to find answers AD and vascular Bird & Kinsella (1996)
to questions dementia
Addressing “paranoid delusions” and AD Bird (2001)
violent behavior
Addressing obsessive toileting Hypoxic brain damage Bird (2001)
Facilitating anger management Traumatic brain injury M. Bourgeois (personal
communication, March 2004)
Note. AD, Alzheimer’s disease; HAD, HIV-associated dementia; CVA, cerebrovascular accident.
in persons with dementia. Why should this be the case? Possible mechanisms underlying
SR that might be responsible for its effects are examined next. It should be noted that
these mechanisms are not mutually exclusive, and some elements of each may be acting in
concert during therapy sessions in which SR is used.
SR as Spacing Effect
One way of viewing SR is that it represents a variation of a general memory phenomenon
known as the spacing effect. The term spacing effect refers to the finding that information
is learned and retrieved more effectively when learning trials are distributed over time
(i.e., distributed practice) compared to consecutive presentation of all learning trials (i.e.,
massed practice; Camp et al., 2000; Cermak, Verfaellie, Lanzoni, Mather, & Chase,
1996; Ebbinghaus, 1885/1964; Hillary et al., 2003). In the case of SR, the distributed
practice of learning trials includes an expansion function, such that successive trials occur
at ever-increasing intervals.
There are multiple explanations for why the spacing effect should produce better
learning than massed practice (see Braun & Rubin, 1998; Cermak et al., 1996; Green,
1992; Hillary et al., 2003; Hintzman, 1974; Murdock, 2003). A discussion of this topic is
beyond the scope of this chapter. However, a summary comment is possible. Hillary et al.
(2003) noted that any explanation of the spacing effect (and hence of SR) “must accom-
modate the fact that the [spacing effect] is a natural phenomenon of the human memory
system that does not, necessarily, require conscious effort, training, or additional mental
operations by the individual” (pp. 50–51). It is interesting these researchers demonstrated
that the spacing effect was present in a sample of adults with traumatic brain injury
(TBI), who demonstrated impaired memory on a standardized neuropsychological test
battery. Cermak et al. (1996) demonstrated spacing effects for both recognition and recall
in amnesia patients, attributing at least some of the spacing effects in recall to automatic
processes.
SR as Priming
Squire (1992, 1994) describes memory as primarily composed of two systems: declarative
memory and nondeclarative memory (also called procedural memory). The declarative
memory system is believed to involve conscious, effortful learning, such as remembering
what you had for breakfast; what was said to you 5 minutes ago; where you parked your
car; your address when you were in high school; or general information about the world
(the capitals of France and Cambodia). The nondeclarative/procedural memory system is
believed to involve relatively unconscious, automatic, and effortless learning. In Squire’s
model, this system has multiple components, one of which involves priming, a form of
nondeclarative (or implicit) memory in which prior exposure to a stimulus exerts an ef-
fect on the later detection or identification of that stimulus. For example, semantic prim-
ing is the effect in which a response to items from a particular class of words (e.g., ani-
mals) is facilitated by the presentation of a different item from the same semantic class.
Squire (1992, 1994) and other researchers (e.g., Cermak, Talbot, Chandler, &
Wolbarst, 1985; Haist, Musen, & Squire, 1991; Verfaellie & Cermak, 1994; Verfaellie,
Cermak, Letourneau, & Zuffante, 1991; Weingartner et al., 1993) have demonstrated
that persons with memory deficits can show priming effects in the absence of conscious
recollection of practice episodes or of having encountered information previously that
has now been learned (see Reichard, Camp, & Strub, 1995, for an example of this in per-
sons with Alzheimer’s disease). Camp and Foss (1997) have described SR as a form of
“ecologically valid priming” and presented experimental evidence that SR seems to in-
volve nondeclarative/procedural memory systems rather than declarative memory sys-
tems (see also Cherry, Simmons, & Camp, 1999; Cherry & Simmons-D’Gerolamo, 1999,
2005).
SR as Conditioning
Bjork (1988) referred to SR as shaping applied to memory. From this perspective, SR uses
operant conditioning techniques to enable persons with short-term memory deficits to
achieve closer and closer approximations to the desired goal of putting information into
long-term memory. Successful recall serves as an intrinsic reinforcer—perhaps especially
so for persons with memory deficits. Thus, once a goal has been established that is mean-
ingful to the client with dementia, successful SR recall trials are often highly motivating.
Evoking motivation addresses a key component of the model of geriatric neuropsy-
chological intervention described by Attix (Chapter 10, this volume). To the extent that
clients are aware of memory deficits, SR also interfaces with the insight component of
Attix’s intervention model, in that the successful recall performance in SR contrasts with
recall failures under ordinary circumstances in these persons.
An optional way of viewing SR is as a classical conditioning paradigm. Certainly,
strong associations are created between a prompt and the recall of the target behavior af-
ter multiple pairings. In a case study reported elsewhere (Stevens, O’Hanlon, & Camp,
1993), a man with dementia initially had difficulty learning to say the response “Look at
my calendar” when prompted with the questions “How do you know what to do to-
day?” The study describes how the target response was changed from saying the answer
to turning a card over and reading the answer that had been written on the other side (see
the discussion to follow on SR as errorless learning). A fading cues approach was then
used, to the point that the man was able to effectively learn and execute the strategy of
looking at his calendar and following its directions regarding daily chores or appoint-
ments to keep. What was not reported was that initially the participant confided to a re-
search assistant that he “didn’t care for” the lead trainer in the study. This occurred at a
time when the participant was experiencing initial failures in our training. However, after
the training began to involve the use of SR in conjunction with an external cue and motor
response (i.e., turning the card over and reading the answer), the participant confided
that he “really liked” the lead trainer. At the conclusion of the study, the participant
asked if the lead trainer would like to accompany him and his family on their yearly vaca-
tion. The goals and motivation components of the Attix intervention model are impacted
by classical conditioning in SR. The above example also illustrates that SR can be effec-
tive in the absence of significant insight.
This phenomenon is often observed by our rehabilitation staff at Menorah Park,
where clients may not remember sessions they have had with their therapist but will make
positive comments to the therapist, such as saying “I like you—I think you make me
smarter or something.” Whether classical conditioning is the primary mechanism under-
lying SR or a secondary feature of the clinical process remains to be discovered. In either
case the ability to elicit positive associations between clients and their therapists/therapy
sessions is a potent adjunct to the use of SR for persons with dementia, and seems to con-
tribute to its success.
SR as Errorless Learning
Errorless learning involves attempts to reduce or eliminate the production of errors dur-
ing learning trials. This method was first described in the operant conditioning literature,
in which Terrace (1963) used this approach to teach discrimination learning to pigeons.
Barbara Wilson and her colleagues (Baddeley, 1992; Clare et al., 2000; Wilson, Baddeley,
Evans, & Sheil, 1994; Wilson & Evans, 1996) have discussed the need to use errorless
learning when designing training programs for persons with memory impairment. The
idea behind this line of work is that trial-and-error learning is less effective for persons
with memory impairment, including persons with dementia, than learning paradigms that
prevent error. These researchers assume that the automatic nature of procedural/
nondeclarative (implicit) memory makes it particularly vulnerable to interference when
errors occur in learning, especially in persons with impaired declarative (explicit) mem-
ory, because they lack conscious access to recent training trails. This lack of access makes
it difficult for persons with memory impairment (such as persons with dementia) to use
past episodes to evaluate and correct current erroneous responses.
Not all researchers agree that errorless learning is solely dependent on non-
declarative/procedural memory (e.g., Hunkin, Squires, Parkin, & Tidy, 1998; see Ander-
son et al., 2001, for an additional discussion of this topic). Fillingham, Hogsdon, Sage,
and Ralph (2003) offer a model based on Hebbian learning and feedback modulation
that can accommodate errorless learning processes in both normal and memory-impaired
populations. They also make a distinction in the errorless learning literature between
training that involves error elimination versus error reduction, in which errors are re-
duced but not completely eliminated during training. It should be noted that in rehabilita-
tive contexts, where tasks are made gradually harder for clients, error reduction may be a
more realistic goal.
DISSEMINATION OF SR
The biggest barrier to the dissemination of nonpharmacological interventions for persons

with dementia is therapeutic nihilism—the belief that a person or a population cannot
benefit from intervention (see Clark, 1995). In its extreme form, this nihilism assumes
that anyone who attempts to intervene is dishonest and/or naïve and therefore are not to
be trusted, assisted, or believed. As a case in point, until 2002, provision of rehabilitation
services to persons with dementia was severely constricted, especially in the area of cogni-
tive disabilities. The reasoning behind this stance was that persons with AD and related
dementing conditions could not remember what was trained in therapy and thus could
not benefit from it—a clear case of therapeutic nihilism.
However, due to pressure from two forces—consumer groups such as the national
Alzheimer’s Association and a growing body of research indicating that learning could
take place in persons with dementia—this policy was revoked (CMS-Pub. 60AB, dated
9/25/01). Note that the policy revocation occurred in the fall of 2001 but was not publi-
cized until the spring of 2002. Resistance to change is inherent in health delivery systems
(see Berwick, 2003). However, in essence, a new market for services has been opened.
Persons with dementia represent a growing public health concern, so this change in policy
is quite timely.
Therapeutic nihilism exists at many levels of health care systems: in the physician
who refuses to refer a client for therapy; in the reimbursing agency that will not provide
payment for therapy delivered; in the course curriculum of an academic department
where treatment of persons with dementia is either scantily addressed within more ge-
neric course content, or missing entirely; in the family members who tell a clinician that
their older relative will not be able to benefit from a psychosocial intervention; in the
staff members who say that their clients or residents have no capacity to improve. In es-
sence, therapeutic nihilism is an example of learned helplessness at a systemic level. The
chapters in this volume provide examples of a wide variety of efficacious nonpharma-
cological interventions for problems associated with dementia (see also Camp, Cohen-
Mansfield, & Capezuti, 2002), with SR being one weapon in this arsenal. Indeed, other
researchers are now embedding SR within multicomponent interventions for persons
with dementia (Clare et al., 2000; Clare, Wilson, Carter, Roth, & Hodges, 2002; Koltai,
Welsh-Bohmer, & Schmechel, 2001; Loewenstein et al., 2004). But therapeutic nihilism is
a ubiquitous impediment to the implementation of any intervention. How, therefore, can
this insidious obstacle be overcome?
SR as a Case Study
Fillingham et al. (2003) noted that a challenge to the use of errorless learning paradigms
for persons with memory impairment (and, by extension, to any intervention initially fo-
cused on demonstrations of efficacy) is to do so in a cost-effective manner within the con-
straints of standard clinical practice. Many errorless learning paradigms involve proto-
cols that are time intensive. This approach conflicts with a managed care environment
that demands quick, quantifiable improvement. This requirement addresses a necessary
but not sufficient condition for dissemination—an intervention must be shown to be ef-
fective within real-world contexts.
With regard to SR, as described earlier, this intervention utilizes an error-reduction
process in which clients are continually challenged to recall information at longer and
longer intervals. The use of expanding schedules of recall trials makes SR a nonintensive
approach. In addition, we have demonstrated (Brush & Camp, 1998a, 1998b, 1998c;
Brush & Camp, 1999; Malone, Camp, & Rose, 2003) that it can be implemented as a re-
imbursable therapy procedure. But demonstration of the effectiveness, in addition to the
efficacy, of nonpharmacological intervention does not remove most obstacles to dissemi-
nation of interventions for persons with dementia (see Camp, 2001, for a general review
of transitions between efficacy, effectiveness, and dissemination involved in interventions
for dementia).
The Need for Multilevel Intervention

Intervention for this population must occur on many levels. At the level of policy change,
advocacy from organizations such as the American Psychological Association and the
American Psychological Society must be combined with advocacy from consumer groups
such as the Alzheimer’s Association. In addition, data from research demonstrating that
psychosocial interventions developed for persons with dementia are both an efficacious
and cost-effective means of providing better care for these clients must be made available
and their relevance demonstrated to policymakers. Again, the successful attempt to allow
reimbursement for rehabilitation provided to persons with Alzheimer’s disease serves as a
useful template for this process.
At the level of physician referral sources, education regarding psychosocial interven-

tion often lags far behind access to information provided by pharmaceutical companies.
There is no sales force for psychosocial treatment options to compare with that mar-
shaled by drug companies. As a result, therapists wishing to increase referrals from physi-
cians must be entrepreneurial. For example, when we talked to physicians about what
would persuade them to make referrals for psychosocial interventions, their responses
were clear and straightforward:
• The efficacy of the intervention should be research- and evidence-based.

• There should be an indication that a screening process has been used or is avail-
able to indicate that the treatment is both called for and likely to produce positive
results for a particular client.
• The prescription for the intervention should not be viewed as open-ended; there
should be a clear criterion for whether the therapy is generating progress toward a
legitimate goal, as well as a clear criterion for when to stop therapy as a result of
lack of progress or goal attainment.
• There should be a clearly articulated system in place to ensure maintenance of
treatment effects.
As a result of these discussions, SR training provided by staff of the Myers Research Insti-
tute includes provision of templates for letters to physicians addressing each of these is-
sues. We also include pages of research references documenting the effectiveness of SR for
these physicians to peruse. (References are provided in a format usually found in medical
journals, such as The Journal of the American Medical Association.)
At the level of staff, family members, or others responsible for maintenance of effects
produced by therapy, it is important that these individuals overcome a version of thera-
peutic nihilism that contains two “sub-beliefs,” if you will. The first sub-belief is that the
therapist cannot produce positive change in a client with dementia. There is only one way
to address this contention—by demonstrating that the client is capable of improving.
Demonstrating this improvement must be done under the gaze of persons who will then
become responsible for maintaining the effects produced by the therapy. A report of prog-
ress made in an office may not (usually will not?) be believed, and often will not result in
an effective maintenance program.
Consider the case of a nurse assistant on a special care unit for persons with demen-
tia in a skilled nursing facility. A therapist takes a resident off unit and then returns, in-
structing the assistant to undertake additional activities for maintenance of an interven-
tion never seen by him or her. The outcome of this process is as predictable as it is
relatively unavoidable. As a result, we suggest that cognitive interventions be undertaken
on the units where residents live, whenever possible. Client training in an office cannot be
observed by persons who will be asked to maintain therapy outcomes. Additionally, for
persons with dementia, generalization from an office environment to their living environ-
ments may be unrealistic.
The second sub-belief is that the therapist can produce successful outcomes, but not
the caregiver. Again, this perspective can only be addressed by including the caregiver in a
transitional training phase in which the caregiving will take place. Working with a client
at the dinner table will make it easier to enlist and empower a nurse assistant in maintain-
ing effects of cognitive interventions for eating or hydration. Persons charged with main-
taining effects of SR therapy initially can be supervised and coached when SR is provided
in real-world time frames and contexts. In addition, the therapist can discuss the benefits
of SR maintenance and the negative consequences for both the client and the therapy
maintainer, should maintenance not be attempted or continued over time.
For administrators, it is important to link interventions to four key factors. The first
is the mission statement of a facility or organization. It must be made clear that provision
of an intervention, and support for staff working to maintain the intervention, is clearly
connected with the mission of an organization (Jitka Zgola, personal communication,
November, 2003). Establishing this link makes it more difficult for midlevel managers,
unit coordinators, or supervisors who have yet to overcome therapeutic nihilism to un-
dermine interventions: To oppose the intervention is to oppose the mission of their orga-
nization.
The next three factors relate to what is known as the health care triangle model
(Camp & Brush, 2003). These are three key areas of interest to administrators of facilities
providing care for persons with dementia: reimbursement, marketing, and surviving state
inspections. We start with the assumption that for an intervention to be effective in real
long-term care facilities where dementia care is provided, any intervention must be dem-
onstrated to positively impact at least one of these areas (preferably, all three). These are
the areas paramount to chief executive officers, regardless of whether a facility is non-
profit or for profit. Interventions that do not positively address these areas are likely to
disappear as soon as the psychologist responsible for introducing them leaves the build-
ing. It is therefore critical to point out that a good intervention can also mean good busi-
ness, and that provision of a better quality of care makes a facility more competitive in
the marketplace. Once a chief executive approves of an intervention, then work can begin
to convince middle managers and line staff to implement and maintain it.
An example of this dissemination process can be illustrated by the working relation-
ship that exists between Myers Research Institute (MRI) and HCR ManorCare, Inc.
(ManorCare), a for-profit national company that owns skilled nursing facilities, assisted
care facilities, and home health care agencies. After listening to a presentation on SR re-
search for persons with dementia, executive staff of ManorCare expressed an interest in
learning more about the intervention. Further contacts resulted in a demonstration pro-
ject in which speech–language pathologists (SLPs) working for ManorCare in the greater
Cleveland area were trained by staff from the MRI in the use of SR. After ManorCare
conducted an internal study of the effects of this training on measures such as goals at-
tained and increases in billable hours, which were confirmed independently by our own
research (Malone et al., 2003), outcomes were so impressive that MRI was asked to begin
training their therapists nationally. In addition, staff from MRI assisted in development
of a corporate training model so that ManorCare’s staff could begin to disseminate SR
training within their company. To date, SLPs and other therapists from over 100
ManorCare facilities nationally have been trained in the application of SR. For executives
and staff of ManorCare, use of SR is a win–win situation: It increases their billable hours
(addressing the issue of reimbursement, the first component of the health care triangle
model), and provides effective means of addressing a host of goals for their clients with
dementia that could not be addressed as readily before SR was made available to their
therapists.
With regard to marketing, ManorCare now advertises the availability of SR to their
clients. Implementation of SR by their therapists is referred to as their “MemorEase Pro-
gram.” The ability to provide SR is seen as a marketing advantage for ManorCare, thus
addressing the second component of the health care triangle model.
Finally, ManorCare executives view SR as a helpful means of facilitating improve-

ment in quality indicators (QIs), addressing the third component of the health care trian-
gle model. For example, an SLP working for ManorCare related an example to her train-
ers in which she used SR with a client living in a skilled nursing facility. This resident was
not drinking water or fluids when these were placed in front of her. Nursing staff were re-
sorting to the use of IVs to keep the resident hydrated and thereby avoid flagging the resi-
dent for the QI of dehydration. The therapists newly trained in SR used the technique to
train the resident to drink water from her glass when given a verbal prompt. This training
was carried out at the dinner table, during meals, and in the presence of nursing staff who
were charged with administering the IVs to the resident. Given the choice between pro-
viding an IV or a verbal prompt for maintaining the effects of SR, nursing staff immedi-
ately saw the relevance of the therapist’s intervention and enthusiastically adopted it. In
addition, administrators at every level value inexpensive and effective means of providing
good quality care that results in preventing residents from being flagged for QIs.
A final lesson we have learned through this experience is that executives in the busi-
ness of delivering dementia care value research. We are continually asked by administra-
tors and managers if the interventions we propose are supported by research and are
evidence-based. The ability to respond that research on SR has been federally funded and
has generated publications in academic journals is valued in the marketplace. Business-
persons want to know that research involving interventions such as SR have credibility in
the scientific community. Good science is appreciated and seen as enhancing marketabil-
ity of services delivered by this industry.
CONCLUSIONS
Researchers in neuroscience and cognitive aging as well as practicing clinical geropsy-

chologists and neuropsychologists are making great strides in the development and deliv-
ery of efficacious and effective interventions for care of persons with dementia. By train-
ing and circumstance, psychologists in this area have focused on treatment of the
individual client or on training staff within a specific facility. In this chapter, intervention
at a systems level has been discussed. This perspective was taken in the hope that readers
would view their efforts in a larger context, and perhaps that some would begin the work
of attempting to carry forward interventions through the process of dissemination.
Berwick (2003) provides a fascinating overview of the diffusion of innovation (i.e.,
novel interventions) in health care systems. For those readers who have not rejected the
implications of this chapter and who have continued reading to this point, Berwick’s arti-
cle is highly recommended. One component of Berwick’s work (out of many) is a discus-
sion of the five perceived attributes of an innovation that help determine speed of adop-
tion and change.
The first (and most powerful) is the perceived benefit of the change. The intervention
must be helpful, but it must also be viewed as low in risk. Unfamiliar change requires ex-
tra burdens of proof. That is why we consciously consider the health care triangle model
when discussing SR, and why we assume that an intervention such as SR must be seen as
providing benefit with low risk to therapists, clients, and the organization that employs
the therapists.
The second attribute is compatibility. To diffuse quickly, an intervention must be
seen as compatible with the values, history, and current needs of an organization and its
staff. This is why we discuss the mission statement of a facility and organization when de-
scribing SR. Therapists need interventions that are effective, not time intensive, and that
generate both billable hours and continuing referrals because of a good track record.
When we provide training in SR to these persons, we address all of these issues.
For two reasons, the third attribute, simplicity, may be an especially difficult issue
(and barrier) for researchers who wish to see their interventions disseminated. The first,
as Berwick astutely notes, is that “individuals who develop an innovation often are not
its best salespeople, because they are at least as invested in its complexity as its elegance.
They tend to insist on absolute replication, not adaptation” (p. 1971). Simple interven-
tions generally spread more quickly than complicated ones.
This point relates to the second reason: Interventions/innovations do not actually
spread, they are “reinvented.” Adopters will take complex interventions and simplify
them during the implementation process. Adopters will also change interventions to
suit their own needs. Berwick likens this process to the way children learn language. As
he states, “In fact, children who only repeat what they hear are not good learners; they
are autistic. Individuals in organizations are learners. They do not merely repeat what
they hear, they change it” (p. 1971). Furthermore, for interventions to be disseminated
widely, originators must not only accept this change process, they must encourage it.
Readers can judge for themselves how well this principle might be tolerated by re-
searchers.
The fourth attribute is trialability: Interventions must be tested on a small scale be-
fore widespread adoption takes place. At MRI, we are ideally suited for this process. As
part of Menorah Park Center for Senior Living, we can first develop interventions such as
SR “in-house.” Next, we work with nearby facilities, as we did with ManorCare, to test
the intervention on a small scale in new settings before attempting dissemination.
The final attribute is observability, which relates to the ease with which potential
adopters and implementers can watch others try the change first. This is why we insist
that therapists implementing SR must do so in the presence of caregivers who will be
asked to maintain effects of therapy. This is also why we use video recordings extensively
in our training. Adopters must see interventions being implemented, and this process
must result in their belief that they too can utilize the intervention. Only then will the de-
fense of therapeutic nihilism be overcome.
This chapter has not provided a “how to” description of SR. Such instructions
already have been published, as described previously. Instead, this chapter has focused on
the translation of SR into an effective intervention that can be widely disseminated. A de-
scription of the theoretical explanations underlying effects of SR was given. To date, no
single explanation has emerged as definitive, and perhaps no such single explanation will
ever emerge.
A description of the process of dissemination of interventions was then presented. At
MRI we have focused our energies on the dissemination of SR, an intervention that can
help persons with dementia. For whatever underlying reason, SR works (pragmatic valid-
ity, if you will). This process has served as a model for dissemination of other interven-
tions for dementia, such as Montessori-based Dementia Programming. In response to this
second dissemination process, ManorCare, and MRI were jointly awarded recognition
for outstanding achievement in health care practice by the American Society of Aging in
2004. At MRI we take Berwick’s (2003) final admonition for dissemination of innovation
to heart—lead by example.
ACKNOWLEDGMENTS
Preparation of this manuscript was partially supported through Grant No. R21 MH069199 from
the National Institute of Mental Health and Grant Nos. R01 AG17908 and R03 AG19016 from
the National Institute on Aging to Cameron J. Camp. I wish to thank Jennifer Brush, Michelle
Bourgeois, Megan Malone, Jaime Carr, Miriam Rose, Audrey Holland, and Blanche White for their
comments in the development of spaced retrieval as an intervention that could be disseminated on a
large scale. I especially thank the Rehabilitation Department (Rehab Plus) of Menorah Park Center
for Senior Living and the residents and clients of Menorah Park, without whom this work would
not have proceeded.
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13
Multitechnique Program Approaches
LINDA CLARE
Theoretical models from neuropsychology provide a strong rationale for the relevance of
interventions directed at the cognitive difficulties experienced by people with dementia,
especially in the earlier, mild to moderate stages. Understanding of the typical patterns of
preserved and impaired cognitive functions found in different diagnostic subtypes of de-
mentia allows interventions to be targeted accordingly, with the aim of either building on
relatively preserved aspects or making the most of residual abilities in impaired domains
(Clare, 2002, 2003). Evidence from experimental studies clearly shows that people with
dementia (1) can alter their behaviour in response to changed environmental contingen-
cies (Burgess, Wearden, Cox, & Rae, 1992), (2) can learn new skills (Salmon, Heindel, &
Butters, 1992), and (3) can take in and recall new verbal information (Little, Volans,
Hemsley, & Levy, 1986), given appropriate conditions and adequate support (Bäckman,
1992). There is, therefore, a strong foundation on which to base the application of cognition-
focused interventions.
This chapter considers the extent to which we are currently able to make optimal use
of these possibilities to provide clinically relevant interventions that improve well-being
and quality of life for people with dementia and their family members or caregivers. In
this respect, it is essential to begin with methods and techniques for which there is specific
evidence of effectiveness. This is not, however, the sole consideration, and clinically rele-
vant cognition-focused interventions are likely in practice to combine methods and tech-
niques in order to achieve desired outcomes. Furthermore, there are strong arguments for
adopting an integrative approach that addresses not just cognitive functioning but also
affective and interpersonal domains in an holistic, person-centered manner (Kitwood,
1997), based on a biopsychosocial understanding of the impact of dementia. This view is
consistent with a rehabilitation-oriented approach to optimizing functioning and well-
being and reducing excess disability, thus helping to maintain engagement and social par-
ticipation (World Health Organization, 1998).
293
TECHNIQUES OF COGNITION-FOCUSED THERAPY
An extensive literature delineates a number of specific cognition-focused methods that

have been used effectively with people who have dementia, including, for example,
spaced retrieval (Camp, 1989; Camp, Bird, & Cherry, 2000; see also Camp, Chapter 12,
this volume), deep-level semantic processing (Bird & Luszcz, 1991, 1993), self-generation
of cues (Lipinska, Bäckman, Mantyla, & Viitanen, 1994), visual and verbal elaboration
and mnemonics (Hill, Evankovich, Sheikh, & Yesavage, 1987), and various forms of
cueing (Thöne & Glisky, 1995). There is developing evidence to support the value of each
of these techniques in addressing practical difficulties arising from impairments in mem-
ory and other aspects of cognition and thus improving well-being for the person with de-
mentia and caregiver alike. For example, Clare et al. (2000) used a simple cueing tech-
nique to teach a woman with dementia to use a daily calendar as an alternative to
repetitively questioning her husband. The participant, who was very aware of the difficul-
ties caused by her need to ask questions repetitively, was happy to have an alternative
strategy, the husband commented following this intervention that things were “100 per
cent better,” and both were subsequently able to work together to apply a similar prob-
lem-solving approach to other everyday situations.
COMBINING TECHNIQUES TO ADDRESS SPECIFIC REHABILITATION GOALS
Cognitive rehabilitation involves individually designed interventions aimed at addressing

specific practical difficulties relevant to daily life, identified by the person with dementia
and/or the family caregiver. Because of this focus on practical relevance, these interven-
tions are likely to combine techniques in order to optimize the likelihood of a clinically
effective outcome. When applying this approach to the rehabilitation of everyday mem-
ory difficulties, a central concern in early-stage dementia, interventions typically fall into
one of two categories: either making the most of remaining aspects of memory or cogni-
tive functioning, or developing the use of compensatory aids and strategies in order to re-
duce demands on memory.
This kind of approach is demonstrated in a study reporting a series of six single case
studies in which goals for rehabilitation were identified by the person with Alzheimer’s
disease (AD) and his or her family member (Clare et al., 2000). The interventions in-
volved either learning or relearning information, such as names of people in the person’s
social circle (four participants), or learning to use a memory aid as an alternative to repet-
itive questioning of the spouse, as described above (two participants). The aim was to en-
sure effective learning or behavior change by basing the interventions on the twin guiding
principles of effortful processing and errorless learning. Individual interventions drew on
techniques of known efficacy, such as mnemonics and elaboration, spaced retrieval or
vanishing cues, as appropriate to the rehabilitation goal and the person’s neuropsy-
chological profile. For three of the four participants who learned personally relevant
information, techniques were combined to produce a comprehensive approach to ad-
dressing the selected goal; the remaining case allowed a comparison of different tech-
niques, demonstrating differential effectiveness (Clare & Wilson, 2004). Significant im-
provements on targeted goals were achieved for all four of these individuals, with good
long-term maintenance over the following 6–9 months. Two of the cases, which focused
on learning names, were also reported in more detail. For one individual, the intervention
Multitechnique Program Approaches 295
involved a combination of a mnemonic strategy with vanishing cues and expanding re-
hearsal (Clare, Wilson, Breen, & Hodges, 1999); for the other, a combination of mne-
monics and rehearsal was used (Clare, Wilson, Carter, & Hodges, 2003). In one of these
(Clare et al., 1999), a further evaluation over an additional 2-year follow-up period dem-
onstrated very long-term maintenance of gains (Clare, Wilson, Carter, Hodges, & Adams,
2001). This successful approach to learning names of familiar people, using multiple
techniques within an errorless learning paradigm, was subsequently replicated in a con-
trolled group study (Clare, Wilson, Carter, Roth, & Hodges, 2002). Taking a similar ap-
proach, Bird (2001) has applied cognitive rehabilitation methods, again including specific
techniques such as spaced retrieval and fading cues, to help ameliorate significant behav-
ioral difficulties for people with mild to moderate dementia.
A recent comprehensive review (De Vreese, Neri, Fioravanti, Belloi, & Zanetti,
2001) concluded that there is sound evidence to support the effectiveness of this kind of
individual approach to memory rehabilitation for people with early-stage dementia.
However, a systematic review conducted for the Cochrane Collaboration1 (Clare, Woods,
Moniz-Cook, Orrell, & Spector, 2003), and further discussed in Clare and Woods
(2004), found no randomized controlled trials (RCTs) of cognitive rehabilitation and
commented that at present the evidence base is limited, although the indications are cau-
tiously positive. Further, variability in response requires elucidation of the factors that
may impact on outcome for a given individual. Despite these current limitations, this ap-
proach offers a promising way forward that can take into account the needs and context
of each person and adapt the selection of goals and methods accordingly, with the poten-
tial for integration into a broader psychosocial intervention context.
COMBINING TECHNIQUES IN COGNITIVE TRAINING PROGRAMS
The individualized and goal-oriented cognitive rehabilitation approach can be contrasted

with the hitherto more widely used cognitive training model. Cognitive training involves
guided practice on a set of standardized tasks that aims to address several specific aspects
of cognition, such as memory, language, attention, or executive function. Thus this kind
of approach, by definition, is likely to incorporate multiple techniques and methods.
Within the provision of standardized tasks, varying difficulty levels may be offered to
permit a degree of adaptation to different degrees of severity of cognitive impairment. Al-
though this focus on practice with standardized tasks forms the central element of cogni-
tive training interventions, there is considerable variation in the approaches described,
and cognitive training interventions take place in a variety of formats and with varying
content. These include one-to-one training sessions with a therapist, individual computer-
ized practice, and facilitation by family members. Some studies have sought to use cogni-
tive training in conjunction with, or as a comparison for, pharmacological interventions.
A number of studies have evaluated the effects of individual cognitive training
sessions that incorporated a range of techniques. Beck and colleagues (Beck, Heacock,
1 The Cochrane Collaboration (www.cochrane.org) is an international not-for-profit organization, providing

up-to-date information about the effects of health care. The Collaboration includes a specialist dementia group,
the Cochrane Dementia and Cognitive Improvement Group (www.jr2.ox.ac.uk/cdcig). The Cochrane Library
(www.thecochranelibrary.com) contains regularly updated evidence-based health care databases.
Mercer, Thatcher, & Sparkman, 1988) compared cognitive training involving exercises to
improve attention, reading, concentration, and memory, given in 30-minute sessions
three times per week for 6 weeks, with standard treatment for hospital or nursing home
residents with mild/moderate AD or mixed dementia. No significant differences were
found on cognitive tests following treatment. Davis and colleagues (Davis, Massman, &
Doody, 2001) reported an RCT for people with AD in which cognitive training was
compared to a “mock” placebo intervention. The cognitive training, given in weekly 60-
minute sessions over 5 weeks, involved learning face–name associations and using spaced
retrieval to rehearse personal information. The trained group improved significantly,
compared to baseline, on recall of face–name associations and personal information, but
neither group improved on standardized cognitive tests. The only between-group differ-
ence was that the trained group did better on one attentional task; there were no other
differences in cognitive test scores, depression, or caregiver-rated quality of life. As would
be expected, these studies indicate that cognitive training does not significantly improve
performance on standardized measures of impairment. However, they do suggest that it is
possible to demonstrate some training-specific improvements on target tasks; that is to
say, there may be an effect at the level of disability or handicap, with the potential, given
appropriate support, for some generalization to the context of everyday functioning.
An alternative approach to cognitive training, based on enhancement of relatively
preserved aspects of memory (Zanetti et al., 2001), has evaluated the effectiveness of
daily, hour-long procedural memory training sessions given 5 days per week over 3 weeks
for day hospital attenders with mild/moderate AD, in comparison to a control group.
This training focused on practice of 13 basic and instrumental activities of daily living
(ADLs and IALs). Following intervention, the trained group performed the activities sig-
nificantly faster than controls. However, it remains unclear to what extent this change
had any clinical significance and whether gains generalized to the everyday setting. Farina
and colleagues (Farina et al., 2002) compared a similar approach of training residual cog-
nitive functions that focused on impaired elements of memory and involved exercises tar-
geting attention, short-term memory, semantic memory, language, and visuospatial per-
ception. Following intervention, both groups improved significantly on ratings of
functional living skills, but there were no differences between groups on any other mea-
sure of ADL, memory and behavior problems, or quality of life. The only difference on
measures of cognitive functioning was that the procedural memory group did signifi-
cantly better on attentional matrices after training, but there were no differences in mem-
ory or verbal fluency, or in Mini-Mental State Examination (MMSE) scores. These find-
ings were interpreted as showing that procedural memory training was more beneficial
than training of residual cognitive functions.
Some studies have evaluated individual cognitive training delivered by computer.
Schreiber and colleagues (Schreiber, Lutz, Schweitzer, Kalveram, & Jaencke, 1998;
Schreiber, Schweizer, Lutz, Kalveram, & Jaencke, 1999) compared 2 weeks of daily half-
hour computerized cognitive training sessions involving practice of immediate and de-
layed recall with social contact for people with mild/moderate dementia. In a pre–post
comparison of cognitive test results, the training group improved significantly on a test
assessing immediate recall of visual information only, whereas the control group showed
no significant improvement. In a between-group comparison, the training group per-
formed significantly better than the control on this test and on delayed route recall, but
not on other cognitive tests. Heiss and colleagues (Heiss, Kessler, Mielke, Szelies, &
Herholz, 1994) compared twice-weekly 60-minute computerized cognitive training ses-
sions involving practice on memory, perceptual, and motor tasks with a social support
placebo condition for people with mild/moderate AD. The intervention period was 26
weeks. No differences were found between the two groups. These studies, therefore, sug-
gest that computerized cognitive training has few benefits for people with early-stage
dementia.
A different approach to individual cognitive training is reflected in the development
of a cognitive training program facilitated by family members in the home setting
(Quayhagen, Quayhagen, Corbeil, Roth, & Rodgers, 1995; Quayhagen et al., 2000;
Quayhagen & Quayhagen, 2001). This program involved 60 minutes per day of practice
on ecologically valid tasks addressing memory, problem solving, and conversational flu-
ency, facilitated by the family caregiver, and given over an 8- or 12-week period. When
compared to placebo and wait-list control conditions with a group of people having mild
to moderate AD (Quayhagen et al., 1995), there were significantly better outcomes for
the cognitive training group on general and nonverbal memory and fluency, but not ver-
bal memory or problem solving, and the cognitive training group remained stable on
caregiver ratings of behavioral problems, whereas the other groups declined. When this
program was further compared with three other forms of psychosocial intervention and a
wait-list control (Quayhagen et al., 2000), the cognitive training group again performed
significantly better on delayed memory, problem solving, and verbal fluency, and care-
givers of cognitive training group participants were less depressed than caregivers in the
other conditions.
COMBINING COGNITIVE TRAINING TECHNIQUES IN WORKING WITH GROUPS
Coming together in groups may present particular challenges for individuals who are ex-
periencing cognitive difficulties, but it also provides opportunities to harness a wider
range of resources and facilitate the expression of mutual support (Scott & Clare, 2003).
Cognitive training has been applied in group formats in which the groups consist either of
individuals with dementia or of these individuals plus their spouses or other family mem-
bers. In this context, cognitive training principles are likely to be combined with other
elements of intervention, including group discussion, and the group itself provides a
forum for practice of newly introduced strategies and techniques, allowing a sense of eco-
logical validity. A related, though distinct, form of intervention is that of general cogni-
tive stimulation or reality orientation, which involves engagement in a range of group ac-
tivities and discussions aimed at enhancing general cognitive and social functioning
(Breuil et al., 1994; Spector, Orrell, Davies, & Woods, 1998). This approach has usually
been applied with people who have more advanced dementia and therefore is not consid-
ered further here.
Group cognitive training can fit well into residential care provision. Bernhardt and
colleagues (Bernhardt, Maurer, & Frölich, 2002) developed a group memory training
program for residents with a diagnosis of mild/moderate dementia, involving hour-long
sessions given twice weekly for 6 weeks. Following training, the intervention group per-
formed significantly better than the control group on a short standardized cognitive test,
and in a pre–post comparison, significant improvements were found in the memory and
attention subcomponents. There were no significant differences between groups on the
Brief Cognitive Rating Scale, but in a pre–post comparison the trained group members
significantly improved their scores, whereas the control group members’ scores declined.
Participants evaluated the program positively, although they did not consider that their
memory functioning had improved as a result.
Most people with early-stage dementia continue to live at home with family mem-
bers. Some group intervention formats have been extended to allow persons with demen-
tia and their spouse or family member to participate together. Zarit and colleagues (Zarit,
Zarit, & Reever, 1982) compared two forms of group memory training, attended by par-
ticipant–caregiver dyads and involving a series of seven, twice-weekly, 90-minute ses-
sions, and a wait-list control condition. The two forms of training were didactic training
classes, involving training in forming visual mental images and making associations, and
problem-solving classes, involving discussion of practical steps that could be taken to
manage everyday problems. Following intervention, recall scores were better for the two
training groups than for the control group, and it was noted additionally that partici-
pants in the didactic training condition showed within-session gains that were lost by
posttesting. However, caregivers who attended either type of class were more depressed
following intervention than control caregivers, although there were no differences in bur-
den or reports of memory and behavior problems. This finding seems to have resulted in
a widespread negative evaluation of cognitive training and its possible impact on care-
givers (e.g., Small et al., 1997), although the few other cognitive training studies that have
considered outcomes for caregivers report more positive, or at least neutral, findings. An-
other group memory program for people with dementia and their spouses or other family
caregivers (Kesslak, Nackoul, & Sandman, 1997; Moore, Sandman, McGrady, &
Kesslak, 2001; Sandman, 1993), involving a series of five weekly meetings, demonstrated
significant improvements over baseline performance for participants with dementia on re-
call of names and effortful recall, and significant short-term benefits from a “significant
event” technique in which couples were asked to undertake novel, enjoyable activities to-
gether. Participants with dementia improved significantly on one cognitive measure,
Kendrick Digit Copy, and on depression scores, but not in ADL ratings. Caregivers did
not report any differences in level of stress, nor did they rate participants’ memory func-
tioning differently.
Koltai and colleagues (Koltai, Welsh-Bohmer, & Schmechel, 2001) compared indi-
vidual (an average of six sessions) and group memory training (five weekly 60-minute
sessions) in a “memory and coping” program. This program incorporated several
cognitive training techniques, including spaced retrieval, face–name recall, verbal elabo-
ration, and practice on concentration tasks. These techniques were combined with the
introduction of external memory aids and group discussion of coping strategies. Care-
givers joined the last 10–15 minutes of sessions, when available. No differences were
found between the individual and group modalities, or between these and a wait-list
control condition, although sample sizes were small. An important contribution of this
study was the demonstration, through a careful retrospective analysis, of the possible
role that variations in awareness of memory difficulties might play in determining re-
sponse to intervention. Participants who were rated as having greater awareness of
their memory and cognitive difficulties showed improvements following intervention,
whereas those who showed limited awareness did not. This association has now been
demonstrated in a prospective study (Clare, Wilson, Carter, Roth, & Hodges, 2003),
which showed that greater awareness of memory difficulties was associated with better
learning outcomes. These findings highlight the need to target interventions appropri-
ately for each individual, depending on a careful assessment of psychological and social
factors as well as neuropsychological profiles. However, few studies have considered
the factors that may influence outcome in the individual case, and this area requires
further research.
Taken together, the multicomponent cognitive training studies reviewed here suggest
that small gains can be observed in some domains of cognitive functioning in some cases,
although the extent to which these result in clinically significant benefits remains unclear.
One recent comprehensive review (Gatz et al., 1998) describes cognitive training proce-
dures as “probably efficacious” in slowing decline in dementia. However, a systematic re-
view of RCTs of cognitive training for people with early-stage dementia (Clare, Woods,
Moniz-Cook, Orrell, & Spector, 2003) found no significant benefits of cognitive training
in any domain, as measured by standardized cognitive tests. In addition to general diffi-
culties with RCTs of psychosocial interventions, such as impossibility of blinding partici-
pants to condition, this review identified a number of methodological limitations that
may impact the conclusions; many of these limitations apply equally to other studies of
cognitive training that could not be included in the systematic review. Additionally, in any
future developments, it will be important to seek to integrate cognition-focused ap-
proaches with interventions targeting other domains of functioning, and it is to this issue
that discussion now turns.
COMBINING COGNITIVE TRAINING AND PHARMACOLOGICAL INTERVENTION
The realities of clinical practice dictate that psychosocial interventions are likely to be of-
fered alongside other forms of intervention, especially pharmacological treatment. With
the development of pharmacological treatments for people with early-stage dementia, it
might be anticipated that cognition-focused interventions could potentiate drug effects
(Newhouse, Potter, & Levin, 1997), and several studies have explored the combination of
individual cognitive training and drug treatments. Brinkman and colleagues (1982) com-
pared the effects of treatment with lecithin (a putative cognitive enhancer) plus memory
training with placebo for people with mild/moderate AD in a double-blind crossover de-
sign. Lecithin treatment did not produce any beneficial effects on cognitive functioning,
but memory training did produce significant improvements on a memory task compared
to placebo therapy.
In addition to comparing computerized cognitive training (CT) and social support,
as described above, Heiss and colleagues (1994), also considered the possible effects of
combining CT and pharmacological treatment. Two further conditions explored the ef-
fect of adding either pyritinol (CT-P, 600 mg twice daily) or phosphatidylserine (CT-PS,
200 mg twice daily) to the CT. In a between-group comparison, the CT-PS group was sig-
nificantly better than both CT and SS on orientation at 8 and 16 weeks, but at 26 weeks
there were no significant differences on any cognitive measure. In a pre–post comparison,
the CT-P group had significantly improved orientation at 8 weeks and verbal fluency at
16 weeks, and the CT-PS group had significantly improved orientation at 8 and 16 weeks
and Corsi-Block-Tapping-Test at 26 weeks.
De Vreese and colleagues (1998, 2001; de Vreese & Neri, 1999) compared
acetylcholinesterase-inhibiting medication (AChEI), a combination of this with CT
(AChEI + CT), and placebo medication in an RCT with people who had a diagnosis of
mild AD. Medication was given for 6 months. In the AChEI + CT condition, CT was in-
troduced after 3 months on the drug and given for a 3-month period. The authors re-
ported significantly better MMSE and ADL scores for the AChEI + CT group than for
AChEI alone or placebo, and significant improvements on the Alzheimer’s Disease As-
sessment Scale—Cognitive subscale (ADAS-Cog) for both AChEI and AChEI + CT,
which were more marked for the latter group.
Clare and colleagues (2002) were able to compare learning outcomes for partici-
pants who were, or were not, receiving AChEI medication at the same time as engaging in
cognitive rehabilitation, and found no difference between the two groups.
The evidence on combining cognitive training with pharmacological treatments re-
mains equivocal, although the recent work of De Vreese and colleagues provides encour-
aging results, with potential for direct applicability to current clinical practice. At present,
therefore, the availability of some positive results suggests that further work in this area is
warranted in the future.
COMBINING COGNITIVE TRAINING

AND OTHER ELEMENTS IN BROADER PROGRAMS
Although changes in cognition are central to our understanding of dementia, they cannot
be viewed in isolation. People with dementia, and their family members or caregivers,
have a range of emotional, interpersonal, and practical needs. Although it is important to
consider specific domains of functioning and evaluate the effectiveness of interventions
that directly target those domains, it is clinically desirable to address the full spectrum of
need in an integrated way. Therefore, some programs have sought to combine cognitive
training methods with other elements in broad-based programs (see also Loewenstein &
Acevedo, Chapter 11, this volume).
In an early approach to including cognitive training within a broader program
(Brodaty & Gresham, 1989; Brodaty, Gresham, & Luscombe, 1997), a residential 10-day
memory training program was provided either in conjunction with a caregivers’ program
or on a “respite” basis. Caregiver and patient outcomes were better in the caregivers’ pro-
gram group, suggesting that integration with other intervention elements is important. In
keeping with this finding, the Memory Clinic in Basel, Switzerland, offers weekly, hour-
long, group memory training sessions for people with early-stage dementia, as part of a
“milieu therapy” that provides advice and counseling, social activities, exercise, holidays,
caregiver support, and organization of practical help (Ermini-Fünfschilling & Meier,
1995; Meier, Ermini-Fünfschilling, & Zwick, 2000). Patients continue in the group for as
long as needed, typically between 18 months and 3 years. In one study, patients receiving
memory training improved significantly on mood and fluency, but not memory, whereas
a comparison group who did not receive memory training declined. A second study re-
ported that patients who received memory training remained stable on the MMSE and
quality of life, whereas those in the control group declined. This study suggests that mem-
ory training is a useful element within this kind of milieu therapy.
Other studies have taken a more community-based approach, for example, an “elder
rehab” program for people with mild to moderate Alzheimer’s disease, comprising mem-
ory training, language activities, an exercise intervention, and partnered volunteering, as
well as participation in other group events (Arkin, 2001). Both rehabilitation and control
groups improved significantly in mood, and the rehabilitation group scored significantly
better on MMSE and some project-specific measures of memory and language, although
not on other standardized cognitive tests or measures of physical fitness. Werner (2000)
describes a “memory club” that aimed to provide social and clinical support for older
people with severe memory problems living in the community. The club met two or three
times a week for 4 hours at a time. Sessions included practice on memory training exer-
cises alongside other activities. In the context of an overall decrease in MMSE scores over
the year, memory functioning was maintained, with significant improvements only in ver-
bal fluency. However, there was no comparison group, the participants had memory diffi-
culties for a range of reasons (61.3% had a dementia diagnosis), and MMSE scores var-
ied widely (range 0–29), so it is difficult to draw specific conclusions from these findings.
Finally, one study explored the applicability of cognitive training as an element of
physical rehabilitation in medical settings, with the aim of reducing excess disability re-
sulting from a hospital stay (Guenther, Fuchs, Schett, Meise, & Rhomberg, 1991). This
study used cognitive training as an element of rehabilitation in a medical setting for
women who had organic memory impairment but were receiving rehabilitation for a
physical condition. Individual 45-minute sessions were given daily over 9 days. Partici-
pants in the training group improved significantly on task-specific assessments, but the
only difference on standardized measures of cognitive functioning was in object naming.
Trained participants also performed better than controls on evaluations of social behav-
ior, lethargy, and affective disturbance, though not cognitive impairment or somatic prob-
lems. These findings suggest potentially useful avenues, not only for reducing excess dis-
ability among people with early-stage dementia in medical settings, but also perhaps for
helping to ensure that people with dementia receive equitable access to physical health
care and rehabilitation.
CONCLUSIONS
I began this chapter by saying that neuropsychological and experimental studies provide
a strong basis for developing effective cognition-focused interventions, and that specific
techniques of proven efficacy are available. However, in order to develop clinically mean-
ingful interventions that are geared to each individual’s profile of strengths and difficul-
ties, and that take account of the emotional and interpersonal context, a combination of
methods and techniques is likely to be needed (see Attix, Chapter 10, this volume). This
chapter has reviewed a range of studies that demonstrate that some progress has been
made in this direction. See Table 13.1 for an overview of the studies discussed in this
chapter.
Cognitive rehabilitation studies have shown that combining techniques can help
achieve specific rehabilitation goals, but there is a need for more evidence from rigorously
designed trials in order to support the further development and wider application of this
approach. Cognitive training approaches draw on a range of techniques, exercises, and
methods to address a number of domains of cognitive functioning, and these multimodal
cognitive training interventions have been combined, in turn, with other specific forms of
intervention and within broad-based psychosocial intervention programs. Evidence for
the efficacy of cognitive training, as such, remains limited, however. This limitation may
be due, in part, to methodological issues, but it is likely that it also reflects the difficulty
of applying an essentially standardized approach to a very heterogeneous participant
group, in the absence of a clear understanding of the factors that influence individual out-
comes.
In future research on cognitive rehabilitation and cognitive training, it will be impor-
tant to overcome the methodological limitations that are evident in many of the existing
TABLE 13.1. Overview of Multitechnique Studies Reviewed in This Chapter
Study Type Aims Participants/Conditions Interventions Outcomes
Individual goal-oriented cognitive rehabilitation
Clare et al. (1999, Individual goal- Six single case studies 6 people with Learning/relearning Significant improvement on target
2000, 2001, 2003); oriented cognitive mild AD personally relevant goals in 5 of the 6 participants.
Clare & Wilson rehabilitation information or face– No changes on measures of
(2004) name associations (4 cognition or mood, or caregiver
participants); learning to ratings of mood/strain. Long-term
use a memory aid (2 follow-up of one participant
participants). showed benefits were maintained
up to 3 years after the
intervention.
Bird (2001) Individual goal- Two case studies 2 people with mild/ Application of spaced Successful outcome in both cases.
oriented cognitive moderate dementia retrieval and fading cues
rehabilitation methods to address
behavioral problems.
302
Cognitive training in individual sessions
Beck et al. (1988) Cognitive training in Assess effectiveness of 20 people with AD or 1. Cognitive skills No significant differences between
individual sessions cognitive skills mixed dementia resident remediation training groups on tests of attention,
remediation training in VA hospital or given individually in reading, remembering, or
compared with standard nursing home (method 30- to 40-minute concentrating on detail.
treatment of assignment unclear). sessions, three times a
week for 6 weeks.
2. Standard treatment
only.
Guenther et al. Cognitive training in Evaluate efficacy of 14 women with organic 1. Cognitive training Training group improved
(1991) individual sessions cognitive training as cognitive impairment, (n = 7) performance on each component
part of rehabilitation receiving rehabilitation 2. Control (n = 7); of training; controls showed no
within medical setting for a physical health general conversation change. Training group improved
condition with organic with therapist compared to controls on some
supported by relative cognitive subtests but not others,
report of decline since and caregivers reported
admission improvements in some behavioral
domains for the training group.
Davis et al. (2001) Cognitive training in RCT comparing 37 people with 1. Cognitive training Cognitive training group improved
individual sessions cognitive training and probable AD (16 male, (n = 19)—1-hour on recall of face–name associations
placebo in crossover 21 female) individual session and personal information. No
design weekly for 5 weeks, significant changes for either group
and home practice in cognitive functioning, and no
2. Placebo (n = 18)— significant differences between
“mock” intervention groups on depression or quality-of-
life scores.
Zanetti et al. (2001) Cognitive training in Evaluate effectiveness of 18 day-hospital 1. Procedural memory Training group were significantly
individual sessions procedural memory attenders with mild/ training (n = 11)— faster in completing ADLs than
training on 13 basic and moderate AD 1-hour session each controls following intervention.
instrumental activities of day for 5 days per
daily living (ADLs, week for 3 weeks
IADLs). 2. Control (n = 7)—
unspecified
Farina et al. (2002) Cognitive training in Compare two cognitive 22 consecutive 1. Procedural memory Postintervention, both groups
individual sessions training programs outpatients with mild/ training (n = 11) improved significantly on
moderate AD 2. Training of residual performance of functional living
303
sequentially allocated to cognitive functions skills. The procedural training
one or other group (n = 11) group was better than the
Both groups had two comparison group on attentional
45-minute individual matrices, but there were no
sessions per day for 3 differences on other cognitive tests
days per week over 5 or questionnaire measures. At 3-
weeks. month follow-up both groups had
returned to baseline levels of
performance.
Clare et al. (2002) Cognitive training in Group replication of 12 people with Training in face–name Significant improvement from
individual sessions Clare et al. (1999) mild AD associations using baseline to postintervention for
paradigm developed in recall of trained but not control
1999 paper. items. No changes on measures of
mood or general tests of cognition.
Awareness assessed prior to
intervention predicted outcome;
higher levels of awareness were
associated with better learning
outcomes.
(continued)
Computer-based cognitive training
Schreiber et al. Computer-based Evaluate effects of 14 people with mild/ 1. Training (n = 7) Training group performed
(1998, 1999) cognitive training in interactive computer- moderate dementia, 2. Control (n = 7); chat significantly better on two subtests
individual sessions based memory training alternately assigned to with a psychologist (immediate visual recall and
program treatment or control Ten 30-minute sessions, delayed recall of a route)
group; assessment blind held on 5 days per compared to controls; this
to group allocation week, over 2 weeks represented a significant
improvement, compared to
baseline, for immediate visual
recall.
Cognitive training in group sessions

Zarit et al. (1982) Cognitive training in Compare two types of 35 people with 1. Didactic training Recall scores better for the two
groups cognitive training and dementia and their classes (n = 14) twice training groups than controls. No
wait-list control family caregivers weekly for 90 minutes differences in recognition scores.
for 3.5 weeks Caregivers who attended the
304
2. Problem-solving classes (in either condition) were
classes (n = 11) twice significantly more depressed
weekly for 90 minutes afterward.
for 3.5 weeks
Patients and caregivers
attended together,
with 6–8 people per
group.
3. Wait-list control
(n = 10)
Brodaty & Gresham Cognitive training in Reduce psychological 96 patient–caregiver 1. Caregivers’ program Caregivers receiving the caregivers’
(1989); Brodaty et groups distress and improve pairs; patients had mild/ (n = 33)—couples program had significantly better
al. (1997) coping skills in moderate dementia admitted together in scores for general well-being after
caregivers of people cohorts up to 4. 12 months, and there was a
with dementia Caregivers had 10 significantly higher rate of survival
days training in at home for the people with
coping. Patients had dementia for whom they cared.
memory training The people with dementia
sessions. otherwise showed no differences.
2. Respite for caregivers At 8-year follow-up, patients
(n = 31)—patients whose caregivers had received the
admitted alone and caregivers’ program stayed at
had memory training. home significantly longer and
3. Wait-list control tended to live longer.
(n = 32)
The 1997 paper reports
an 8-year follow-up.
Sandman (1993) Cognitive training in Evaluate 4-week 11 people with mild/ Group of two to four People with dementia were able to
groups memory group moderate AD and their dyads met for four learn and recall names of other
305
spouses weekly sessions. participants by session 3 or 4. On
remembering details from a TV
program, learning with “extra
effort” produced equivalent
performance to that of spouses
learning under normal conditions.
People with dementia recalled
more on planned “special event”
days than noneventful days.
Kesslak et al. (1997) Cognitive training in Evaluate efficacy of a 4- 11 people with mild/ Group of two to four People with dementia improved on
groups week memory training moderate dementia and dyads met for four task-specific measures of name
program their spouses, who weekly sessions. recall, on a digit copying task, and
acted as age-matched on depression scores, and rated
controls themselves as having improved
(although caregivers disagreed).
Caregivers also showed
improvements on task-specific
measures.
(continued)
Moore et al. (2001) Cognitive training in Evaluate efficacy of 25 people with mild/ Group of two to four People with dementia improved on
groups 5-week memory moderate dementia and dyads met for five task-specific measures of name
training program their caregivers, who weekly sessions. recall, on a digit copying task, and
acted as age-matched Additional caregiver on depression scores, and rated
controls support provided. themselves as having improved
(although caregivers disagreed).
Caregivers also showed
improvements on task-specific
measures but no reduction in
caregiver stress.
Bernhardt et al. Cognitive training in Evaluate efficacy of 26 people with 1. Cognitive training The cognitive training group
(2002) groups cognitive training dementia living in (n = 13)—two 1-hour performed significantly better than
program designed to seniors homes sessions per week for controls on the short cognitive
generalize to daily life 6 weeks; two groups test. Training group improved own
each with six or seven performance on memory and
306
members. attention, and were rated better on
2. Control (n = 13)— cognitive function than before
weekly 1-hour intervention, but did not differ
conversation group significantly from controls.
Cognitive training comparing individual and group sessions

Koltai et al. (2001) Cognitive training in Evaluate effects of a 24 participants with 1. Individual memory No significant differences in
individual or group memory and coping mild/moderate dementia and coping program depression and memory ratings or
sessions intervention; RCT (n = 8)—individual on cognitive tests; participants
sessions (mean of 6). with higher levels of awareness
2. Group memory and reported fewer memory failures
coping program after treatment.
(n = 8)—five 1-hour
weekly sessions in
groups of 4
(n = 8)
Cognitive training facilitated by family carers
Quayhagen et al. Cognitive training RCT comparing 79 people with mild/ 1. Cognitive training Significantly better outcome for
(1995) facilitated by family cognitive training with moderate AD and their (n = 25)—60 minutes/ cognitive training group on general
caregivers placebo and wait-list family caregivers (data day facilitated by cognitive functioning and
control available for 78) caregiver. composite scores for general and
2. Placebo (n = 28)— nonverbal memory and fluency,
passive observation of but not verbal memory or problem
cognitive training solving. Significantly fewer
activities. behavioral problems reported for
3. Wait-list control cognitive training group.
(n = 25)
Duration: 12 weeks
Quayhagen et al. Cognitive training RCT comparing 103 people with mild/ 1. Cognitive training Cognitive training group
(2000) facilitated by cognitive training with moderate dementia (n = 21), facilitated significantly better on delayed
caregivers three other psychosocial (AD, VaD, Parkinson’s) by spouse memory, problem solving, and
interventions and wait- and their spouse 2. Dyadic counseling verbal fluency. Caregivers of
list control caregivers (n = 29) participants in this group were less
3. Dual supportive depressed.
seminar groups
307
(n = 22)
4. Early-stage day care
(n = 16)
(n = 15)
Duration 8 weeks
Quayhagen & Cognitive training Compare two studies Study 1—56 couples, Each study had cognitive Both cognitive training groups
Quayhagen (2001) facilitated by using different forms of in which one partner training, placebo (passive improved on immediate memory,
caregivers cognitive training had mild to moderate stimulation), and wait- delayed memory, verbal fluency,
intervention dementia list control groups. The and problem solving, indicating
Study 2—30 couples, two cognitive training that shortening the program did
in which one partner conditions were: not affect outcome.
had mild to moderate Study 1—12 weeks
dementia Study 2—8 weeks
(continued)
Cognitive training combined with pharmacological interventions
Brinkman et al. Cognitive training in Compare lecithin + 10 people with mild/ Lecithin + memory Lecithin did not produce any
(1982) individual sessions memory training with moderate AD training condition: 35 beneficial effects on memory.
combined with drug placebo drug and mg/day of lecithin for 2 Memory training produced
treatment therapy in double-blind weeks. During last 5 significant improvements compared
crossover design days had daily 45- to to placebo.
60-minute individual
memory training
sessions. Placebo
condition: placebo
medication for 2 weeks.
During last 5 days had
45- to 60-minute
individual unstructured
conversation sessions.
308
Heiss et al. (1994) Computer-based Evaluate efficacy of 70 people with 1. CT (n = 18)—1 hour No significant differences
cognitive training in computer-based probable AD, mild/ twice a week of between groups in MMSE scores
individual sessions cognitive training given moderate; MMSE score computer-based after 26 weeks. On cognitive
combined with drug alone and with two range 13–26 training tests there were no significant
treatment different drugs, 2. CT-P—CT plus between-group differences. In
compared with social pyritinol 600 mg pre–post comparison, the CT—
support placebo twice daily PS group had improved visual
(n = 17) span at 26 weeks.
3. CT-PS—CT plus
phosphatidylserine
200 mg twice daily
(n = 18)
4. Social support
placebo—1 hour
weekly talking about
past and present
experiences and
personal issues
(n = 17)
Intervention lasted 26
weeks.
De Vreese et al. Individual cognitive Compare CT alone, (2001 paper) 1. 27 1. AChEI alone (n = 9), AChEI + CT group significantly
(1998, 1999, 2001); training combined AChEI alone, CT plus people with mild AD 6 months better on scores for general
unpublished data with drug treatment drug, and placebo (1998 (MMSE score range 2. AChEI + CT in twice cognitive functioning and ratings
provided by author paper). Design later 20–26) weekly individual 45- of ADL performance.
amended (2001 paper) minute sessions. CT
to drop the cognitive introduced after 3
training alone condition months on drug and
lasted 3 months
3. Placebo medication
(n = 9), 6 months
Cognitive training as part of a broader psychosocial intervention program

Ermini- Cognitive training in Evaluate efficacy of People with mild Memory training in Study 1: Training group
Fuenfschilling & group sessions as memory training offered dementia (MMSE score weekly 1-hour sessions significantly improved in mood,
Meier (1995) part of broad-based as component of “milieu at least 23) in groups of 8. People verbal fluency, nonverbal fluency.
program therapy” Study 1—44 patients; continue as long as No improvement in memory.
treatment group n = 22; needed in the group (AD Control group worsened on all
309
control n = 22 patients typically 18 aspects.
Study 2—53 patients; months; other patients Study 2: Patients in training group
treatment group n = 17; 2–3 years). This is part were stable on MMSE scores and
control n = 36 of a wider program run quality-of-life ratings, whereas
by the Memory Clinic. control group worsened.
Control group: no Caregivers of patients in the
memory training, but training group improved on
receive all other aspects quality-of-life ratings.
of program.
(continued)
Werner (2000) Cognitive training in Evaluate effectiveness of 31 older persons, of Meetings took place MMSE scores decreased
groups as part of a “memory club” for whom 61.3 % had a twice or three times a significantly over the year.
broad-based program people with cognitive dementia diagnosis week for 4 hours each Memory functioning, in general,
impairment over a 1- time was maintained over the year.
year period
Arkin (2001) Cognitive training in Evaluate efficacy of 11 persons with mild/ 1. Rehabilitation group Rehabilitation group significantly
individual sessions as rehabiliation program moderate AD (n = 7)—range of better on MMSE scores, on
part of broad-based conducted by students activities with student project-specific biographical
310
program under supervision partner. memory test, some aspects of
2. Control group (n = language function, and physical
4)—unstructured time ability, but not on other cognitive
with student. tests. Both groups showed
significant improvements in mood.
Note. AchEI, acetylcholinesterase inhibitor; AD, Alzheimer’s disease; ADLs, activities of daily living; CT, cognitive training; CT-P, cognitive training plus pyritinol; CT-PS, cognitive train-
ing plus phosphatidylserine; IADLs, instrumental activities of daily living; MMSE, Mini-Mental State Examination; RCT, randomized controlled trial; VA, Veterans Administration; VaD,
vascular dementia.
studies. These include limited statistical power due to small sample sizes; insufficient du-
ration and intensity of intervention; comparison with other active treatments rather than
placebo; repetition of neuropsychological tests as outcome measures over short intervals,
rendering the results liable to practice effects; and selection of outcome measures that re-
flect impairment rather than disability and therefore fail to capture some changes that do
occur as a result of intervention (Clare, Woods, et al., 2003). Future well-designed trials
should provide more reliable evidence. However, any further research in this area should
seek to demonstrate an impact on disability, rather than impairment, and should attempt
to produce benefits that are of significance for everyday functioning and quality of life.
Attention must also be paid to an exploration of the factors that influence outcome at the
individual level. Most importantly, it will be necessary to ensure that the implications of
any findings are integrated into general clinical practice with people who have early-stage
dementia.
In summary, future research will need to build on existing knowledge in this area in
order to develop clinically relevant and personally meaningful interventions that take ac-
count of individual differences, and to evaluate outcome in terms of the impact on dis-
ability and the potential for improving quality of life for persons with dementia and their
family members and supporters.
ACKNOWLEDGMENTS
This chapter draws on an earlier review article (Clare, 2003b).
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14
Language Interventions in Dementia
CYNTHIA K. THOMPSON
NANCY JOHNSON
Most of the literature in the area of language rehabilitation has focused almost exclu-
sively on the treatment of aphasia due to stroke. Although the techniques described in
this chapter are also applicable to specific language impairments that occur as a result of
cerebrovascular accidents, we focus on the management of progressive language impair-
ments in individuals with primary progressive aphasia (PPA), a form of dementia.
Because this form of dementia is relatively rare, the first section of the chapter provides
additional background information, including clinical presentation and diagnosis, neuro-
imaging and genetic findings, and neuropathological substrates associated with this clini-
cal syndrome.
OVERVIEW OF PPA
PPA is a form of dementia defined by the insidious onset and progressive dissolution of
language skills, despite the relative sparing of other cognitive domains, specifically mem-
ory, for at least 2 years. Language impairments are readily detected on formal neuropsy-
chological measures, but patients with PPA may also score abnormally on tests of mem-
ory or attention and on standard dementia screening batteries, due to the dependence of
these measures on verbal instructions and responses. Patients with PPA typically remain
independent well into the middle and advanced stages of the disease, demonstrating
sound judgment, preserved social skills, and intact ability to recall daily events (Mesulam,
2001). PPA can be differentiated from the clinical syndrome typical of Alzheimer’s disease
(AD) by the relative preservation of memory (especially nonverbal and episodic memory),
and from frontotemporal dementia (FTD) by the relative sparing of frontal lobe functions
and appropriateness of behavior.
Several related clinical syndromes have been described as subtypes of frontotemporal
lobar degeneration (FTLD). Neary, Snowden, et al. (1998) have designated one subtype
315
as “progressive nonfluent aphasia,” which, in this nomenclature, is characterized by im-

pairments in expressive language (e.g., effortful speech production; word-retrieval defi-
cits) but relatively preserved comprehension. Another subtype, defined by a severe nam-
ing deficit and language comprehension and visual recognition deficits, but with intact
fluency, has been termed “semantic dementia.” According to our nomenclature, however,
PPA encompasses all types of aphasia, both with and without comprehension deficits.
The diagnosis of PPA is not made if visual recognition deficits are also present.
In order to distinguish PPA from other forms of degenerative diseases that also in-
volve progressive aphasia, it is important to monitor the course of symptoms over time.
When aphasia remains the only symptom for many years (at least 2 years, but 5 years on
average), the diagnosis is consistent with PPA. Aphasia that occurs along with problems
in strength and movement is referred to as cortical–basal ganglionic degeneration
(CBGD; Mimura, Oda, et al., 2001). When aphasia occurs in conjunction with alter-
ations in personality and behavior, the clinical syndrome is known as frontal lobe demen-
tia. Aphasia can also occur in the context of significant memory loss, and in those cases,
the symptoms would be consistent with a diagnosis of AD. In rare cases, individuals may
present exclusively with problems in articulation, with preservation of underlying lan-
guage functions; this condition is referred to as progressive dysarthria (Broussole,
Bakchine, et al., 1996). In some cases, a condition may start as PPA and then develop into
one of the other disorders described above.
The course of symptom progression in PPA has been investigated in a few individual
case studies and in group studies with relatively small sample sizes (De Oliveira, Castro,
& Bittencourt, 1989; Pachana, Boone, Miller, Cummings, & Berman, 1996; Sapin, An-
derson, & Pulaski, 1989). Some cases have been described in which anomia remains the
primary symptom for many years. In other cases, language dysfunction may progress to
include comprehension deficits and agrammatism. Weintraub, Rubin, et al. (1990), for
example, followed four patients with a nonfluent profile of PPA for a period of 3–5 years,
using a battery of neuropsychological tests. All patients declined in naming, based on
scores on the Boston Naming Test (Kaplan, Goodglass, et al., 1983). In addition, declines
in auditory comprehension, repetition of words and sentences, oral reading, and word
fluency were noted. Relative stability of memory, visuospatial skills, reasoning, comport-
ment, and most activities of daily living (ADLs) was observed. Cognitive decline in
nonlanguage areas, however, has been noted in some patients, often occurring after the
initial 2 years, but the language deficit remains the most salient aspect of the clinical pic-
ture. The time course for the emergence of other symptoms is variable (Green, Morris,
Sandson, McKeel, & Miller, 1990; Karbe, Kertesz, et al., 1993; Kempler, Metter, et al.,
1990; Weintraub, Rubin, et al., 1990).
An important issue pertaining to the progression of symptoms concerns the language
profile of the patient with PPA. Patients with aphasia resulting from stroke are often
characterized as fluent versus nonfluent, based on patterns of spoken language and com-
prehension deficits. Fluent patients generally produce speech at normal to fast rates and
show relatively normal phrase length, with often marked difficulty in auditory compre-
hension; in contrast, nonfluent patients show slow rates of speech with effortful produc-
tion, reduced phrase length, and relatively spared auditory comprehension. The language
disorder seen in PPA rarely fits neatly into these two categories (Mesulam, 1987). It has
been suggested that patients with PPA who have early complaints of auditory comprehen-
sion difficulty and nonverbal semantic deficits and who fulfill criteria for a diagnosis of
semantic dementia eventually exhibit fluent production patterns (Hodges & Patterson,
Language Interventions in Dementia 317
1996), whereas those with nonfluent aphasia exhibit preserved language comprehension
in early stages. It has also been suggested that patients with a fluent deficit may evidence
an earlier course of generalized cognitive involvement, as compared to patients showing a
nonfluent profile (Snowden, Neary, et al., 1992). However, this observation has not been
replicated, and in our own clinical experience, patients with nonfluent PPA may also de-
velop additional comportmental and executive function deficits in later stages.
Further research is needed to clarify not only patterns of language deficits and de-
cline, but also patterns of decline in nonlanguage domains. However, it is important to
keep in mind that patients with PPA do not represent a homogeneous group. Indeed, in a
review of published cases of patients with PPA, Westbury and Bub (1997) reported that
word-finding and naming difficulty was prevalent in 41% of cases, 28% showed diffi-
culty with language production; and 20% showed impairments in comprehension. Some
patients also presented with difficulties in reading and writing. Symptoms vary across pa-
tients and within patients over time. Thus clinical management for these patients will also
vary, to some degree, as we address below.
Multiple studies have demonstrated both structural and functional disruption in the
language network in PPA. This network is almost always located in the left hemisphere
and includes perisylvian parts of the inferior frontal and temporoparietal regions, respec-
tively known as Broca’s and Wernicke’s areas, as well as surrounding regions of the
frontal, parietal, and temporal cortices. Many patients with PPA display cortical atrophy
(indicative of neuronal loss), electroencephalographic slowing, decreased blood flow
(measured by single-photon emission computed tomography [SPECT]) and decreased
glucose utilization (measured by positron emission tomography [PET]) in these regions of
the brain (Catani, Piccirilli, et al., 2003; Chawluk, Mesulam, et al., 1986; Kempler,
Metter, et al., 1990; Mesulam & Weintraub, 1992; Tyrrell, Warrington, et al., 1990). The
clinical focality of PPA is thus matched by the anatomical selectivity of the underlying
pathological process. This distribution of structural and functional deficits is distinctly
different from what is seen in typical AD. Patients with nonfluent PPA and intact lan-
guage comprehension tend to have metabolic dysfunction within anterior perisylvian
language areas, including the left inferior frontal cortex, whereas fluent patients with
comprehension deficits tend to have dysfunction that favors the middle, inferior, and polar
parts of the temporal lobe (Abe et al., 1997; Mummery et al., 1999). Despite marked left-
hemisphere dysfunction, the metabolic state of the contralateral right hemisphere can
remain within the normal range, especially early in the disease (Chawluk et al., 1986).
Functional neuroimaging allows the identification of brain areas that become en-
gaged in the performance of specific cognitive tasks. In one study of word processing, pa-
tients with PPA activated components of the language network to the same extent as age-
matched controls. The one significant abnormality in the patients consisted of greater
neuronal activation during the performance of the language tasks, but in areas outside of
the traditional language network (Sonty, Mesulam, et al., 2003). The magnitude of this
compensatory or deviant activation was correlated with the degree of impairment in a
standardized naming test.
Recent research has begun to explore the molecular basis of PPA and other focal de-
generations. Patients with PPA have apoE genotypes that are distinctly different from
those of patients with AD (Mesulam, Johnson, et al., 1997) and also display an
overrepresentation of the tau H1 haplotype (Sobrido, Abu-Khalil, et al., 2003). No differ-
ences have been found, to date, in either tau haplotype or genotype distribution on the
basis of fluent and nonfluent clinical subtypes of PPA.
Neuropathological studies in PPA have revealed heterogeneous findings. Individual

cases of PPA have shown an association with the neuropathology of AD (Benson &
Zaias, 1991; Cummings et al., 1985; Galton, Patterson, et al., 2000; Green et al., 1990;
Greene, Patterson, et al., 1996; Kempler, Metter, et al., 1990; Li, Iseki, et al., 2000),
Pick’s disease (Graff-Radford et al., 1990), Creutzfeldt–Jakob disease (Mandell et al.,
1989), and “nonspecific focal atrophy” (also referred to as “dementia lacking distinctive
histology” [DLDH]; Kertesz et al., 1994; Kirshner et al., 1987; Mesulam, 1982; Snowden
et al., 1992). In a review of 16 autopsied published cases of PPA, Westbury and Bub
(1997) found that approximately 20% of cases were associated with AD pathology, 15%
were associated with Pick’s disease, and the majority was described pathologically as
DLDH. More recent advances in immunohistochemical subtyping of the frontotemporal
dementias (FTDs) suggest the possibility that many cases previously diagnosed as DLDH
would now be shown to have tau- or ubiquitin-positive inclusions characteristic of “FTD
with motor neuron disease-like inclusions,” “cortical–basal ganglionic degeneration,” or
other non-AD tauopathies (Lipton et al., 2001).
Because of the clinical heterogeneity in symptoms of language impairment, it has
been hypothesized that there may be pathological subtypes of PPA. In a study of three pa-
tients with nonfluent aphasia, Turner et al. (1996) demonstrated that the neuropath-
ological findings on autopsy were consistent with DLDH. The authors reviewed other
autopsied cases of PPA and found that DLDH was associated significantly more often
with nonfluent aphasia, whereas AD, Pick’s disease, and Creutzfeldt–Jakob disease were
associated most frequently with fluent forms of PPA. However, although this study dem-
onstrates a possible relationship between aphasia type and neuropathological findings,
both nonfluent (Turner et al., 1996) and fluent aphasia (Schwarz et al., 1998) have been
associated with nonspecific focal atrophy at autopsy. Neuropathological data from a
larger sample of clinically well-characterized patients is needed to clarify the relationship
between neuropathological processes and clinical presentations.
LANGUAGE DEFICITS AND THE DECLINE OF LANGUAGE IN PPA
As noted above, the symptoms of PPA vary from individual to individual; however, word
finding and naming difficulties are the most commonly reported deficits, at least in the
early phases. As the disease progresses, other domains of language become affected. The
specific language functions that become impaired may also differ from one patient to an-
other. In an in-depth study of language decline in four patients with nonfluent-type PPA
who experienced difficulty retrieving words in the early phases of PPA, we noted two pat-
terns of language decline (Thompson et al., 1997). Using spontaneous language samples
collected for up to 11 years post-onset of PPA symptoms, extensive analysis of lexical and
morphosyntactic variables was undertaken, revealing that three of the patients experi-
enced declines in grammatical aspects of production, showing language behavior similar
to that of patients with agrammatic aphasia resulting from stroke. These patients showed
increasing difficulty with morphology and syntax—verb endings and other affixes were
deleted from words, small grammatical words such as prepositions were omitted, and
sentences were ill-formed. For example, the words in sentences were not produced in
proper order, and verbs were often missing. The fourth patient showed a very different
pattern that was characterized by advancing naming difficulty. He had little difficulty
with morphology or syntax; his main problem remained one of word retrieval, which
affected primarily nouns. Although there are other patterns of language decline that may
be seen in patients with PPA, our study highlights the fact that different patients present
with different patterns of decline. Thus it is important that (1) the language abilities of
patients with PPA be carefully examined before treatment is applied, (2) treatment be ap-
plied to aspects of language that are impaired, and (3) the patient’s language abilities be
followed as they decline, with treatment adjusted accordingly.
TREATMENT OF PPA
The primary goal of treatment for individuals with PPA is to improve their ability to com-
municate. In order to fully address how best to accomplish this goal, we make reference
to the World Health Organization (WHO; 1980, 1997) model of disablement. According
to this model, disablement is considered on three levels: the impairment (impairment
level), the impact of the impairment on performance of activities (activity limitation or
functional level), and the impact of the impairment on participation in life (participation
restriction level). Although the WHO model was developed to conceptualize problems as-
sociated with any disease entity, it is particularly applicable to patients with PPA. These
individuals clearly show language impairments, as described above; because of these im-
pairments they often evidence difficulties carrying out ADLs that require language com-
prehension or use (e.g., talking on the telephone; reading train schedules), and their lan-
guage deficits often limit or restrict their access to opportunities associated with full
participation in society (e.g., carrying out family and work responsibilities; involvement
in social activities). Like the language impairment itself, the impact of the impairment on
activities and participation also varies across patients and is associated with many fac-
tors, including personality and motivation to improve communication.
Assessment of Language
Because the language deficit in patients with PPA differs from individual to individual
and changes over time, it is important that a careful assessment of language be performed
early after the onset of symptoms, as well as periodically as symptoms progress. Although
a review of assessment tools for aphasia is beyond the scope of this chapter, we recom-
mend using a full aphasia test battery such as the Boston Diagnostic Aphasia Examina-
tion (BDAE; Goodglass & Kaplan, 2001) or the Western Aphasia Battery (WAB; Kertesz,
1982), as well as tests designed to examine naming of both nouns and verbs. The Boston
Naming Test (BNT; Kaplan et al., 2001) is recommended to test naming of nouns, and
the Object and Action Naming Test (Druks & Masterson, 2000) or the Verb and Sen-
tence Test (VAST; Bastiaanse, Edwards, & Rispens, 2002) may be used to examine the
naming of verbs. We also note that the Northwestern Naming Battery (Thompson &
Weintraub, 2004) will be available soon. It is designed to examine naming of nouns by
semantic category and verbs based on their syntactic status. Tests designed to examine the
source of naming failure, such as the Psycholinguistic Assessment of Language Skills
(PALPA; Kay et al., 1992), are also recommended, as are tests designed to examine com-
prehension and production of sentences of varying syntactic difficulty (e.g., the VAST).
Tests examining grammatical morphology and phonology also may be indicated for some
patients; subtests of the PALPA and/or the BDAE may be utilized for this purpose. Narra-
tive language analysis also helps to establish patterns of production deficits across lan-
guage domains (e.g., semantic, syntactic, morphological, and phonological deficits pat-
terns). In addition, functional assessment of communication is important, using tests such
as the American Speech-Language-Hearing Association Functional Assessment of Com-
munication Skills for Adults (ASHA FACS; Frattali, Thompson, Holland, Wohl, &
Ferketic, 1995). Data derived from these tests should be used to guide treatment.
Approaches to Treatment
There are two basic approaches to treatment for PPA. One approach is to focus treat-
ment directly on the language impairment—that is, on the language skills that show
impairment on testing. The other approach is to focus on functional language ability
(the WHO activities/limitation level). Augmentative/alternative communication (AAC)
strategies or devices also are provided, in anticipation of future declines in language.
We recommend that, at least in early stages of language decline, both impairment-
based and functional treatment approaches be used. When the language intervention is
focused on the impairment, functional language targets should be provided as much as
possible, and opportunities to practice using language in functional contexts with com-
munication partners should be included. AAC strategies also should be introduced
early in treatment, with instruction about how to use them, so that patients can prac-
tice using them for functional communication. In later stages of language decline, im-
pairment-based treatment may be discontinued as the focus shifts to functional com-
munication using AAC strategies.
We emphasize the importance of impairment-level treatment for PPA, even though
the degree to which such treatment will improve language function or retard its decline
is largely unknown. Based on what is known about neural plasticity—that is, that the
brain has the capacity to reorganize after injury, even in adulthood—we suggest that
such treatment may result in recruitment of uncompromised neural tissue. For exam-
ple, extra perisylvian areas in the left hemisphere and/or right hemisphere areas of the
brain have been shown to be recruited to support language recovery in stroke patients
with aphasia (Calvert et al., 2000; Heiss, Kessler, Thiel, Ghaemi, & Karbe, 1999;
Thompson, 2000; Thulborn, Carpenter, & Just, 1999). It is thus reasonable to assume
that unimpaired cortical tissue may be utilized by patients with PPA for language pro-
cessing (Sonty, Mesulam, et al., 2003). In the following sections we highlight potential
approaches for training patients who have impairments in naming, sentence compre-
hension, and production. We follow this with a discussion of some augmentative/alter-
native approaches to treatment. It is important to recognize that because PPA is caused
by a degenerative brain disease, the goals of treatment are very different from tradi-
tional language intervention for aphasia due to stroke or head injury. As in other
neurodegenerative diseases, the goals of treatment are to (1) maintain functional com-
munication skills for as long as possible, and (2) retard decline of communication skills
over time as the disease progresses.
Approaches to Training Naming

Because most patients with PPA evidence early word-finding or naming difficulty, treat-
ment focused on enhancing access to words will likely be appropriate. Whether treatment
is focused on nouns or verbs (or other word classes) will depend on the results of lan-
guage testing. In addition, tests revealing the source of naming errors will help to guide
treatment. For example, some patients may show difficulty naming and orally reading
nouns but have no difficulty comprehending or repeating words or nonwords. Such a
profile would indicate problems in accessing the phonological form of words; thus treat-
ment aimed at improving phonological access would be indicated. Other patients may
show reduced naming secondary to difficulty accessing the meaning representation of cer-
tain words. These patients often have difficulty both comprehending and producing
words, and they show semantic deficits on subtests of the PALPA (Kay et al., 1992), such
as, for example, Spoken Word to Picture Matching and Auditory Word Pair Judgment.
Patients presenting with this profile might benefit from treatments focused on the seman-
tic aspects of words.
Numerous researchers have undertaken studies aimed at examining the effects of
treatment for naming deficits in patients with aphasia resulting from stroke. These treat-
ments also may be used successfully with patients who have PPA. Many such treatments
are focused on the source of impaired naming. For individuals with phonological access
problems, cueing hierarchies have often been employed. For example, Thompson and
Kearns (1981) used sentence completion cues, phonetic cues, and verbal modeling to
train a patient with anomic aphasia to improve naming. Raymer, Thompson, Jacobs, and
LeGrand (1993) used a similar approach with nonfluent aphasic patients who had nam-
ing deficits. They used a phonologically based cuing hierarchy, first presenting pictures of
words to name (e.g., cat), then presenting a word rhyming with the target word (e.g.,
hat), next presenting the first phoneme of the word (e.g., /k/), and finally presenting the
target word for the patient to repeat. This strategy improved both naming and oral read-
ing of target words.
Treatments aimed at improving access to semantics also have been useful for aphasic
patients. The most successful treatments are those that exploit what is known about nor-
mal language representation and processing. The mental lexicon is thought to be orga-
nized (at least, in part) by networks of items, based on features defining their semantic
class. Drew and Thompson (1999) trained nonfluent aphasic patients who showed
semantic deficits to name items within semantic categories by training them to (1) sort
items by semantic class, (2) sort items by perceptual and functional features, (3) match
written words to pictures and names to definitions, and (4) answer questions involving
the semantic attributes of words. Boyle and colleagues have used a similar approach,
known as semantic feature analysis (Boyle & Coelho, 1995). This approach involves
training patients to name the semantic category of selected items, the use of the item, its
action, physical properties, usual location, and something typically associated with it. Re-
sults of this treatment have indicated improved naming in case studies of patients with
several types of aphasia.
Another semantic approach is one based on the typicality of items within semantic
categories. Kiran and Thompson (2003) trained four fluent aphasic patients to name
items within the categories of birds and vegetables by controlling the featured details of
items. Some items within categories were typical (e.g., a robin is a typical bird that flies,
has a beak, etc.), and some items were atypical (e.g., an ostrich is an atypical bird that
does not fly but has some features that are similar to typical birds). Training aphasic pa-
tients to name atypical items resulted not only in improved production of the trained
items, but also improvement on untrained items within category (e.g., training the nam-
ing of ostrich improved the naming of robin). Interestingly, however, training patients to
name typical items improved naming of these items, but had no affect on naming atypical
items. These findings suggest not only that naming can be improved with treatment, but
that treatment of more complex items (e.g., those with features that are distant from the
prototype) facilitates generalization to less complex items (typical items). Although seem-
ingly counterintuitive, this finding is in keeping with Thompson et al.’s complexity ac-
count of treatment efficacy (CATE) for aphasia (Thompson, Shapiro, et al., 2003), sug-
gesting that treatment beginning with more complex material will result in generalization
to less complex material that is linguistically related. Training typical items repeatedly
emphasized only a few features that were in common among items within categories;
training atypical items highlighted the featural variation with categories.
Although there are few reports of the effects of naming treatment for patients with
PPA in the literature, there is evidence that treatments focused on word-retrieval skills
may prove useful. McNeil and colleagues (McNeil, Small, et al., 1995), for example, re-
ported improved word-finding ability in their patient with PPA when treatment focused
directly on word finding was provided. Interestingly, throughout the training period, their
patient showed declines in aspects of language that were not treated, suggesting, albeit in-
conclusively, that treatment may retard the decline of language. Further research explor-
ing the effects of naming treatment in patients with PPA is needed, particularly studies
examining the effects of various treatment approaches that have been shown to be suc-
cessful in stroke patients. In patients with PPA who have not completely lost their access
to language, training more complex material prior to training less complex material may
prove beneficial.
Approaches to Training Sentence Comprehension and Production Deficits

There are several approaches to training sentence comprehension and production in pa-
tients with aphasia resulting from stroke. These approaches vary from direct-produc-
tion treatment focused on the surface form of sentences (e.g., syntax stimulation;
Helm-Estabrooks & Ramsberger, 1986) to approaches that are based on theories of
language disruption in aphasia (e.g., mapping therapy; Byng, 1988; Haendiges, Berndt,
& Mitchum, 1996; Jones, 1986; Mitchum, Haendiges, & Berndt, 1995; Schwartz et
al., 1994); and treatment of underlying forms (TUF; Thompson, 2001; Thompson,
Ballard, & Shapiro, 1998; Thompson, Shapiro, Tait, Jacobs, & Schneider, 1996;
Thompson et al., 1997; Thompson et al., 2003). Mapping therapy is based on models
of normal sentence production (e.g., Bock & Levelt, 1994; Garret, 1975, 1980; Levelt,
1999) and focuses on the link between sentence meaning and sentence structure. The
aim of treatment is to help patients understand the relation between the verb(s) and
nouns in sentences, using both simple active and complex (e.g., passive) sentences and
probe questions, such as “What is the verb?”, “Who is doing the verb-ing?”, and
“Who or what is [he or she] verb-ing?”
TUF is similar to mapping therapy. However, the theoretical framework is slightly
different. TUF is based on linguistic theory as well as what is known about normal lan-
guage representation and processing. In addition, in TUF, both comprehension and pro-
duction of sentences are trained; the focus is on complex rather than simple sentences;
and, in addition to emphasizing the relation between the verb(s) and nouns in sentences,
as occurs in mapping therapy, the linguistic operations required to derive complex from
simple sentence structures are emphasized.
In general, all approaches used with stroke patients have shown that sentence deficits
can be improved with treatment. In some cases, however, generalization to untrained
structures may be limited, in particular, with direct-production approaches (Doyle,
Goldstein, & Bourgeois, 1987; Wambaugh & Thompson, 1989). Such treatments, fo-
cused on the surface form of structures, give little attention to the lexical and syntactic
properties of constructions learned in treatment and those tested for generalization. In
contrast, more successful generalization appears to occur when treatment considers im-
portant linguistic aspects of sentences. Then generalization occurs across structures that
are linguistically related to one another. For example, using TUF for training complex
sentences with object relative clauses—for example, “The man saw the child whom the
doctor saved”—improves both comprehension and production of untrained sentences of
this type. In addition, generalization is seen to untrained but linguistically related struc-
tures such as wh- questions (e.g., “Whom did the doctor save?”). We (Thompson et al.,
2003) also have found better generalization from complex (e.g., object relatives) to sim-
ple sentences (e.g., wh- questions), than from simple to complex sentences, again across
sentences that are linguistically related. For example, of 17 patients trained using TUF,
70% (seven of ten) showed generalization from complex to simple structures, whereas
only 14% (one of seven patients) showed generalization from simple to complex struc-
tures.
Interestingly, the one patient who showed generalization from simple to complex
sentences was a 62-year-old woman with PPA. At the time of treatment, she was 1-year
postsymptom onset, and language testing showed a mild aphasia. Her aphasia quotient
(AQ) on the Western Aphasia Battery was 93.6; she showed mild sentence comprehen-
sion deficits (i.e., she scored 92% correct comprehension of complex sentences and 100%
correct of simple active sentences); naming was mildly impaired (i.e., she scored 98 on the
Test of Adult/Adolescent Word Finding (TAWF; German, 1990); and she showed mild to
moderate difficulty with sentence production (i.e., in narrative language samples she
showed a reduced mean length of utterance (MLU; 6.06) as compared to normal (13.57);
she produced more simple sentences (59%) than normal (45%) and a lower proportion
of grammatical sentences (38%) than normal (88%).
Because of her difficulty with sentence comprehension and production, she was pro-
vided with 10 weeks of TUF focused on simple wh- questions (e.g., “Whom did the man
follow every morning?”), which resulted in several interesting patterns of acquisition and
generalization. First, training who-questions resulted in improved who-question compre-
hension and production. In addition, improved what-question comprehension and pro-
duction was noted (e.g., “What did the horse follow every morning?”). Secondly, training
wh- questions with both direct and indirect objects (e.g., “Whom did the man chase every
morning?”) resulted in improved production and comprehension of simpler wh- questions
with only a direct object (e.g., “Whom did the woman follow?”). These two patterns
were also noted in our patients with Broca’s aphasia (focal lesions); that is, treatment re-
sulted in improvement on structures that are linguistically related to one another (e.g.,
who- and what-questions), and improvement on structures that are simpler than those
trained (e.g., from questions with three constituents to those with only two). In addition,
improvement was noted in narrative language production, with an increase in production
of grammatical sentences (57%). However, unlike our patients with aphasia resulting
from stroke, treatment in the patient with PPA also improved more complex, linguisti-
cally related object-cleft sentence comprehension and production (e.g., “It was the
woman whom the man chased”). This latter finding may have occurred because the pa-
tient’s language network was only mildly impaired at the time of treatment; thus treat-
ment likely enhanced access to normal (and still available) language comprehension and
production routines.
Augmentative/Alternative Communication Strategies
AAC strategies also should be used. We suggest that, even in early stages of language de-
cline, the patient (and family members) be trained in nonverbal communication strate-
gies. For example, a gesture + verbal treatment strategy, in which patients are trained to
produce gestures and words simultaneously, may be useful for improving word-retrieval
skills. The gestures may, at first, serve to augment verbal communication. In later stages
of decline when verbal language is no longer available, they may serve as an alternative
communication system.
We (Schneider, Thompson, & Luring, 1996) used this strategy with one of our pa-
tients who was 2½ years postdiagnosis of PPA. At the time, she had some difficulty re-
trieving words, but she had greater difficulty putting words together in sentences and us-
ing proper verb tense. We selected several verbs and nouns that could be combined to
form sentences. Then we selected gestures to go with each of the words as well as gestures
to denote grammatical morphemes for present, past, and future tense (the patient helped
select the gestures that she wanted to use). Iconic gestures—that is, gestures that look
much like the words that they depict—were used and were easily understood by others.
The therapy involved training gestures for the nouns, verbs, and grammatical mor-
phemes, followed by practice producing a variety of sentences by pairing spoken words
with corresponding gestures. Results of treatment showed improved production of
trained and untrained sentences, both on clinical testing and when she communicated
with others outside of treatment. Interestingly, we noted that when she did not use the
gestures, her ability to produce sentences was much poorer. Following treatment, the patient’s
language skills continued to decline; she was nearly nonverbal at 5 years postdiagnosis.
However, she continued to use gestures as a primary means of communication.
Other nonverbal strategies that can be paired with verbal production include writing
and drawing. Provided with pencil and paper, patients can often cue verbal language by
writing the first letter of words, or they may draw pictures that depict the ideas that they
wish to communicate. A treatment program developed by Morgan and Helm-Estabrooks
(1987) called Back to the Drawing Board, involves training patients to draw pictures with
increasing detail and speed to communicate. For example, patients are trained to draw static
representations of objects or places, or to depict events by drawing sequences of pictures.
Patients also may be provided with communication devices, including communica-
tion notebooks containing pictures, written words, or electronic voice output devices.
Communication notebooks are personalized for individual patients, often organized by
category (e.g., family members, including a family tree), food items, greetings, questions/
requests, emotional expressions) or by topics (e.g., words or phrases used in certain com-
munication contexts or conversational situations, such as visiting the doctor or talking to
grandchildren). Maps and calendars are also often included to help the patient communi-
cate about places and time. Alphabet boards (or an alphabet page in the communication
notebook) can be useful to help patients cue their communication with letters. (See Rog-
ers et al., 2000, for an excellent discussion of communication notebook construction.)
Importantly, the patient and his or her communication partner(s) should be consulted to
determine the content and organization of communication notebooks and given training
in how they can be used to facilitate successful communication. In addition, because
patients’ communication needs change as their language declines, the communication
notebook will require periodic updating and adaptation (e.g., a switch from words to pic-
tures; changes in communication topics and vocabulary).
There are several voice output devices available commercially, a review of which is
beyond the scope of this chapter. Again, these should be personalized as much as possible
and provided in early stages of language compromise, even if they are not used exten-
sively until later in the course of language decline. In addition, training of communication
partners is necessary to familiarize them with how the communication device can be used
and to train them to provide prompts and assistance during communication attempts.
Finally, electronic devices require modification over time and are sometimes discontinued
as language deteriorates.
Regardless of which strategy is provided to patients, it is important to encourage
their use of the strategy outside of the therapy environment. Murray (1998) reported the
results of a case study with a patient with PPA in which drawing treatment was provided.
Despite positive treatment effects in the clinic, the patient showed little use of drawing in
other situations. This is a common problem when alternative communication strategies
are used. Practicing functional use of the strategy during therapy and involving family
members in treatment may help patients to use trained strategies more successfully in the
natural environment.
In conclusion, the following guidelines are offered for intervention with patients who
have PPA:
• A complete evaluation of speech, language, and other cognitive skills should be

completed in early stages of PPA.
• Frequent follow-up evaluations are needed to determine patterns of language de-
cline and corresponding treatment needs.
• Treatment should be provided in early stages, focused directly on aspects of lan-
guage that are impaired; approaches used successfully with patients who have
aphasia resulting from stroke may also be useful for patients with PPA.
• The focus of treatment should be adjusted as language abilities decline.
• AAC strategies should be introduced in early stages; patients shown these strate-
gies in later stages of language decline may have difficulty learning to use them.
• Involvement of family members or other individuals with whom the patient com-
municates is important, not only to enhance awareness of successful communica-
tion strategies but also to practice using these strategies with the patient.
• As language declines, patients will rely more on AAC strategies; some strategies
may be more useful than others, and some patients may use more than one.
• Treatment likely will not reverse the progression of the aphasia; however, it may
retard the decline of language, and it will greatly enhance communication ability,
diminish isolation, and give the patient a sense of control.
CASE EXAMPLE1
Relevant History
RP was referred for a comprehensive evaluation in the Northwestern Alzheimer’s Disease
Center PPA Program by his primary care physician. He reported an approximately 4-year
history of progressive word-finding difficulties. These problems began following vascular
1Some details have been changed to maintain confidentiality.

surgery, but had worsened progressively since that time. His daughter stated that RP fre-
quently appeared to have problems expressing his thoughts, may use the wrong word in
conversation, and occasionally had difficulty understanding single words. For example,
when asked by his daughter to get the margarine out of the refrigerator, he asked her
what margarine was. He recently told his daughter he was going outside to “cut the sand-
wich,” when he meant to say “cut the grass.” RP remains relatively independent in all
ADLs. He continues to drive and has had no accidents or tickets and has not gotten lost.
He continues to manage his finances, including paying bills on time, balancing his check-
book, and making purchases. His daughter recently began to help him write out checks
due to problems in writing. RP has always been very handy with home repairs and
woodworking, and no decline in these skills has been noted. He continues to make house-
hold repairs without error, including recently rewiring a room in his daughter’s basement.
RP has withdrawn somewhat from social interactions outside of his immediate family. He
reported it is becoming more difficult for him to follow conversations in a group setting
and that he is hesitant to speak in public because he is embarrassed by his word-finding
difficulties.
Demographic Information
RP is a 58-year-old, right-handed European American male with a bachelor’s degree in
education. He had worked as a high school geometry teacher but was forced to retire 6
months prior to the evaluation because of language difficulties. RP is widowed and lives
alone, although his daughter and son-in-law live nearby.
Medical/Family History
RP’s medical history was significant for hypertension, hypercholesterolemia, and arthri-
tis. His medications included Toprol, simvistatin, and Celebrex. There is no reported
family history of dementia or other neurological disorders in his parents, siblings, or chil-
dren.
Evaluation Results
Neurological Evaluation
A brain magnetic resonance imaging (MRI) done 2 years ago was unremarkable. A PET
scan done approximately 6 months prior showed marked decrease of metabolism in the
temporal lobes bilaterally, but greater decrease on the left side. Additional areas of
hypometabolism were noted in the parietal lobes bilaterally and the anterior frontal
lobes. All laboratory investigations (homocysteine, thyroid-stimulating hormone, Vita-
min B12, complete blood count) and electroencephalogram were normal. Examination of
cranial nerves and sensory motor function was normal, and there was no evidence of
fasciculations.
Neuropsychological Evaluation
All nonverbal testing, including nonverbal reasoning, spatial and form perception, and
attention were within normal limits for age and education. Memory scores were below
normal for both verbal and nonverbal information, although by report, his memory in
day-to-day activities was intact.
Speech and Language Evaluation

RP was tested with the Western Aphasia Battery (WAB; Kertesz, 1982), and the Boston
Naming Test—Second Edition (BNT; Kaplan et al., 2001). A narrative retell, an oral–
motor assessment, and hearing screening were also completed. The results of the evalua-
tion were consistent with an anomic aphasia. Verbal output was fluent and appropriate,
but word-finding difficulties were frequently observed. Circumlocution attempts and re-
visions were demonstrated with occasional hesitations and interjections. Confrontation
naming impairments were present for both high- and low-frequency nouns. Naming was
better for colors, body parts, and verbs compared to objects and shapes. Errors in naming
were frequently phonemically or semantically related to the target. In attempting to gen-
erate the name, associated gestures were produced on some items. Tactile cues were not
helpful, and phonemic cues were of limited benefit. Although the main difficulty was in
oral expression, semantically related errors occurred occasionally on single-word audi-
tory verification tasks, reading comprehension, and written expression tasks.
Treatment Recommendations
General Communication Aids
Initially, communicative gesture techniques were introduced. Handouts containing gen-
eral communication strategies with individuals with PPA were provided to RP and his
family. A communication card in the form of a business card containing emergency infor-
mation and an explanation of PPA was provided (see Figure 14.1).
FIGURE 14.1. PPA Card.

Guidelines for Ongoing Treatment

Goals of language treatment were to develop strategies and techniques to maximize cur-
rent communication as well as establish compensatory skills, given the potential for addi-
tional language decline. Suggested treatment activities included:
1. Self-cueing methods to facilitate lexical access:

a. Gesture plus verbal techniques
b. Associative and automatic phrases to cue closure techniques
c. Generating verb phrase starters to cue nouns
2. Techniques to compensate for word finding difficulties:
a. Semantic description
b. Representational gesture
c. Communicative drawing
TABLE 14.1. General Language Stimulation Activities

Listening
Retrieving specifically requested objects when assisting with a project
Listening to and following directions read aloud (games, cooking crafts)
Listening to and discussing a letter than has been read aloud
Listening for specific information such as weather reports and sports scores, while watching the news
or listening to the radio
Listening for specific information on pre-recorded messages (movie times, store hours, etc).
Listening for specific songs on a CD or tape
Reading
Reading signs in the environment such as street names, restaurant names, gas stations, traffic signs,
information signs, store hours, billboards
Looking through the newspaper for ads, coupons or logos
Sorting coupons
Sorting the mail
Reading cards
Reading mail
Alphabetizing
Reading daily appointments from a calendar or daily planner
Reading labels on household products
Reading advertisements in newspapers and magazines
Completing word search puzzles
Reading recipes
Looking up information in the newspaper (weather, horoscope, special events)
Reading newspaper articles
Reading stories aloud to children
Writing
Signing, writing, or copying name
Copying important names, addresses and phone numbers onto a reference sheet
Writing grocery lists, shopping lists, or “to-do” lists
Entering appointments and activities onto a calendar or daily planner
Labeling photographs
Writing captions for pictures in photo albums or scrapbooks
Writing the names of household objects
Copying a recipe from a book or magazine
Writing a summary of an event
Writing phone messages from the answering machine
3. Development and generalization of communication cards to facilitate receptive

and expressive skills. Initial content may include situationally relevant terminol-
ogy and categories, as well as specific names.
4. Semantic stimulation exercises, including semantic sort/resort tasks and alternate
formulation activities.
5. Language stimulation program for home practice to facilitate generalization and
carryover of skills addressed in treatment. Supplemental language stimulation ex-
ercises can also be completed individually. Table 14.1 includes list of general lan-
guage stimulation activities related to daily living activities.
6. Computer-based language stimulation and functional communication activities
(e.g., Web-based searches, e-mail, word games) may also be utilized.
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15
External Aids
MICHELLE S. BOURGEOIS
When memory deficits interfere with everyday functioning, the recall of familiar words,
and the recognition of everyday objects, external memory aids are useful compensatory
and supportive strategies for persons with dementia and their caregivers. In contrast to
internal memory aids that require effortful cognitive processing, external aids that exist in
the physical environment are considered memory prostheses. Their sensory characteris-
tics and structural features may be so strongly associated with past experiences that sim-
ply encountering them triggers memories and behaviors relevant to everyday functioning.
The challenge for caregivers and professionals is to discover which external cues are im-
portant to the individual and then engineer the environment to provide these cues in
meaningful contexts. The purpose of this chapter is to review the literature on successful
use of external aids with persons with dementia and to suggest future research to further
our knowledge of this intervention approach.
WHAT ARE EXTERNAL MEMORY AIDS?
Cognitive rehabilitation therapists have described an extensive array of compensatory ex-

ternal aids as prosthetic devices (i.e., a device that substitutes for a memory function,
such as alarm clock, watch, sign, calendar, cards) and cognitive orthotics (i.e., a device
that performs a memory function, such as computer software, spell checkers, automated
telephone; Harrell, Parente, Bellingrath, & Lisicia, 1992). Others categorize external
memory aids as environmental (i.e., part of the person’s environment, such as labeled
storage units and signs) and portable (i.e., can be moved to another location, such as
notebooks and electronic organizers; Kapur, 1995). I (Bourgeois, 2002) organized mem-
ory aids within a theoretical model of memory functioning that accounts for the sensory
registration of information, the encoding and storage of information, and the retrieval of
information, all of which are vulnerable in dementia (Baddeley, 1995). External aids can
333
compensate for sensory, encoding, and retrieval deficits that underlie a variety of behav-
ioral expressions of these memory failures, such as failure to recognize familiar persons,
repeated questions, and word retrieval problems.
EXTERNAL MEMORY AIDS FOR MEMORY ENCODING DEFICITS
The hallmark memory symptom in dementia is short-term memory, or encoding, deficits.

Caregivers report frequent repetitive questions or demands and having to provide re-
peated reminders of what to do, where to go, and what they were saying. Typically, de-
sired information is conveyed verbally, is recognized and acknowledged as the answer to
a question or a reassuring statement of fact, but is not processed and stored for later
retrieval. The information has to be presented repeatedly, often because the amount of in-
formation to be processed or encoded exceeds the processing capacity. Complex auditory
information may require even more time to process and comprehend. If urged to respond
before having processed the instruction completely, the person with memory impairments
may provide a negative response reflecting frustration, anger, and lack of comprehension.
Reducing the amount of verbal information presented at a time, altering caregivers’ ex-
pectations for quick responses, and training caregivers to use facilitative methods to
encode the desired information are strategies that should improve these interactions.
Compensatory memory strategies can facilitate the transfer of new information from
working to long-term memory or circumvent the encoding process by providing access to
the desired information in such a way that it becomes part of the environment and does
not need to be stored for later retrieval.
The primary way to address an encoding deficit is to provide a structured and consis-
tent procedure for ensuring that the information to be remembered is encoded. Rehabili-
tation therapists have a long history of training persons with memory impairments due to
brain injuries to use written strategies, such as memory notebooks, diaries, note taking,
appointment calendars, and planners (Harrell et al., 1992; Sohlberg & Mateer, 2001). If
important information that is presented verbally is written down immediately, the odds
of being able to remember that information (because the person can read it) are in-
creased. This commonsense approach is a typical strategy reported by young and older
respondents without diagnosed memory impairments (Harris, 1980). It is only when the
frequency of note taking becomes extreme, to the point that family members find hand-
fuls of notes on scraps of paper, that memory concerns are voiced. Persons in the early
stage of dementia can be aware of their deficits and use this strategy on their own to
mask their symptoms. These written notes become external memory aids for important
information that needs to be remembered; having a concrete, tangible written note obvi-
ates the need to encode and store it internally. Busy professionals, students, and almost
anyone faced with a myriad of facts to remember in their daily life, use appointment cal-
endars and planners routinely to circumvent the need to encode and store all of that in-
formation. Audio tape recorders, telephone answering machines, voice message devices,
and speech compression tape recorders, several of which use a tape loop feature for con-
tinuous reminders, are used for a similar purpose: to record information to be remem-
bered later in a form external to the person. Woods (1983) taught a person with severe
memory impairment to use a diary (appointment book) to retrieve personal information;
Hanley and Lusty (1984) taught another patient to use a diary and a watch to retrieve
orientation information that improved her appointment keeping.
External Aids 335
Even though these types of memory aids are commonly used by people in their daily
lives, and some people instinctively develop a system that meets their individual needs,
there are many others who may require some training to design and implement an effi-
cient and effective system. For example, elders with clinically significant memory impair-
ments may need structured training to use a simple calendar reliably. Camp, Foss,
O’Hanlon, and Stevens (1996) demonstrated positive outcomes when training persons
with dementia to incorporate calendar use into their daily routine via a spaced-retrieval
training protocol. Anecdotal reports of overly complex and cumbersome routines (e.g.,
multiple bell timers to remember several steps in a task or overly detailed computer calen-
dars) that become the focus of one’s daily life, to the detriment of other activities, suggest
the need for memory strategy classes or counseling sessions for the general public as well
as those with diagnosed memory impairments.
When the person with dementia can no longer write down information reliably for
him- or herself, caregivers can use external aids in the form of written notes for a variety
of encoding-related problem behaviors. I (Bourgeois, 1994) reported decreasing the repet-
itive questions of a father to his daughter concerning the whereabouts of his wife with a
page in his memory book that said, “My wife, Lilian, died of heart disease in 1967.” In
another study, I and my colleagues taught caregivers to use a variety of written cues (i.e.,
memory book pages, cue cards, dry erase memo boards) for reducing the repetitive ver-
balizations of their spouse with dementia (Bourgeois, Burgio, Schulz, Beach, & Palmer,
1997). Repeated requests to leave the house, to answer a question, and to go home were
reduced by having the caregivers redirect their spouse to the memory aid by saying, “The
answer is in your memory book [memo board/card],” or “Read this [written instruction
for alternate activity].” The frequency of repetitive questions was significantly reduced
after treatment. Caregivers reported generalizing the use of reminder cards to a variety of
situations; one wife kept index cards in the car on which to write the answer to the con-
stant query, “Where are we going?” Others used cards in church and on a bus trip; an-
other caregiver designed a fake letter from the Internal Revenue Service to remind her
husband that he had submitted his tax return and that his refund check had been depos-
ited in his bank account.
Practical applications of these external aids in the nursing home with persons with
advanced dementia were reported by Bourgeois, Dijkstra, Burgio, and Allen-Burge
(2001). Nursing aides were trained to use communication, or reminder, cards with their
resident with dementia when they were providing care, such as showering or feeding.
Each resident had a collection of personalized cards that addressed problems identified by
their nursing aide, such as “Showering makes me feel warm and clean,” “My nurse Betty
helps me get dressed every day,” or “Eating helps me stay strong and healthy.” Nursing
aides presented the appropriate card to residents, asked them to read it, and then asked
them to proceed with the activity. Nursing aides reported increased compliance and coop-
eration with care activities and decreased negative reactions subsequent to using the
cards. An interactive CD-ROM program for training reminder card use by nursing aides
in the nursing home has been demonstrated to increase nursing aide knowledge of, and
intention to use, the strategy and perceived self-efficacy in managing resident problem be-
haviors (Irvine, Bourgeois, & Ary, 2003).
When written cues are found to be successful with the person with dementia, and the
caregiver has many cards and written notes around the house, it may become important
to organize the individual statements or cards into a memory wallet or memory book for
more efficient access whenever desired (Bourgeois, 1990, 1992a). At this point, the col-
lection of facts to be remembered serves an external memory storage function for the re-
trieval of information that may be or should be stored in long-term memory.
EXTERNAL MEMORY AIDS FOR LONG-TERM

MEMORY AND RETRIEVAL DEFICITS
Anomia, or word-finding difficulty—a failure to retrieve words from long-term storage—

is typically the earliest language and memory symptom in dementia. Because normally ag-
ing adults compensate for word-finding problems by substituting similar words or talking
around the missing word, it is often overlooked as one of the early warning signs of the
pervasive loss of semantic information in dementia (Craik, Anderson, Kerr, & Li, 1995).
The retrieval of other factual, conceptual, and procedural information thought to be
stored in long-term memory becomes increasingly impaired as the disease progresses. The
difference between the experience of normal forgetting and memory loss associated with
dementia is that once the retrieval problem interrupts their train of thought, individuals
with memory impairment often digress to another topic and forget the earlier topic. Over
the degenerative course of the disease, word-finding and other semantic retrieval prob-
lems become more obvious and in need of strategies that provide alternate access routes
to the information. External memory aids in print and electronic formats have been de-
veloped to access semantic storage via alternate pathways.
The electronics boom has triggered a plethora of devices to store information, to
prompt owners to attend to the information with a variety of alarm and messaging fea-
tures, and to retrieve the relevant or desired information. Electronic calculators, planners
(e.g., Daytimers, Dayrunners, Franklin), personal data storage devices (e.g., Rolodex,
Texas Instruments, Casio) and watches (e.g., Telememo watch; Naugle, Prevey, Naugle,
& Delaney, 1988) are available in infinite combinations of size, price, keyboard style,
alarm, and ease of manipulation features (Harrell et al., 1992; Kapur, 1995; Parente &
Hermann, 1996). Computerized systems add another level of complexity and multiplicity
of features, including the transfer of information from one device to another (e.g., Palm
Pilot, the Timex Data Link Watch, and the NeuroPage; Glisky, 1995; Sohlberg & Mateer,
2001). To date, the efficacy literature on these electronic storage devices is limited to per-
sons with memory impairments due to brain injury, encephalitis, epilepsy, multiple sclero-
sis, and Parkinson’s disease, with mixed results (Kapur, 1995). The complexity of training
multiple performance steps and the time required to master the routines led to cautious
endorsement of these products by the trainers. The cost of training, in addition to the cost
of the devices themselves, may prevent the routine use of electronic devices unless the per-
son had been a proficient user premorbidly. Low-cost and low-tech print formats seem to
be more feasible alternatives for persons with dementia.
The most commonly used external memory aids for long-term memory storage and
retrieval are the memory book and memory wallet (Bourgeois, 1990, 1992a, 1992b).
Memory books and wallets present factual information in a written and picture format,
activating visual pathways through reading. In one study (Bourgeois, 1990), memory
wallets contained 30 pages with one sentence and one picture depicting a single statement
of fact on each page. In baseline conversations without a memory wallet, subjects with
moderate dementia provided limited and repetitive information when prompted to talk
about their family, their life, and their daily schedule. Access to the memory wallet during
the treatment condition enabled them to read aloud each sentence and then elaborate
External Aids 337
about the topic, increasing the number of factual statements significantly and decreasing
repetitiveness and ambiguity. Systematic replications of this study with patients more im-
paired cognitively and with greater sensory deficits revealed the efficacy of this approach
as long as the visual-stimulus characteristics of the memory aid matched the patients’ def-
icits (Bourgeois, 1992a). That is, the font size of the type was increased until it was read
easily, and the size of the memory aid was prescribed for ease of physical manipulation;
some persons required 8 × 11-inch pages and plastic page protectors to improve page
turning, whereas others required lightweight, laminated 3 × 5-inch pages in a portable
format (i.e., on a book ring and lanyard, necklace, wristband, or belt). Also, the number
of pages varied depending on the extent of the content desired to be included in the aid;
persons with more severe impairments required fewer pages (i.e., 10–15). McPherson et
al. (2001) replicated the effects of these studies with subjects who had severe memory def-
icits.
External aids for storing important information about the person with dementia for
future retrieval have also been developed for safety purposes. Information pendants,
medic alert devices, and safe-return bracelets containing personal information (i.e., name,
address) and medical information (i.e., diagnosis, allergies) are widely advocated and dis-
tributed by the Alzheimer’s Association and other supportive organizations (Alzheimer’s
Association, 2003). To date, there has been no research on the ability of persons with de-
mentia themselves to retrieve relevant information from these external aids.
EXTERNAL MEMORY AIDS TO MODIFY BEHAVIOR AND SUPPORT FUNCTION
External memory aids have successfully modified a variety of problem behaviors, such as
wandering, lack of initiation/cooperation, and sundowning, which could be explained as
problems with the integration of sensory input, encoding, and retrieval processes. For ex-
ample, wanderers may not remember what they could be doing (e.g., a favorite pasttime
or hobby) or where they are going (e.g., to the kitchen for a drink, to the bathroom). The
cues that initially may have suggested a trip to the kitchen for a drink may be supplanted
by new cues along the route (e.g., a picture on the piano, the laundry basket on the coun-
ter). A portable memory aid consisting of cards with activity suggestions or a single in-
struction card that states, for example, “I’m going to the kitchen for a drink,” could help
keep the relevant information in focus until the task was completed. Similarly, a person’s
apathy or inactivity may be due to the fact that access to long-term memory for familiar
favorite activities is impaired and activity materials are not recognizable or too complex.
Simple, written activity instructions and labels on the materials could increase recogni-
tion and participation. Alternatively, a memory album consisting of pictures of a favorite
hobby or interest (e.g., “All about Roses,” “My Book of Baseball,” “My Trips around
the World”) could capture the person’s attention, enabling him or her to engage with the
materials for a significant amount of time.
Agitated behaviors may reflect problems with several memory systems simulta-
neously. For example, agitation attributed to boredom may reflect an inability to access
words (long-term retrieval) to explain the need for a purposeful activity in the presence of
an object that is no longer familiar (i.e., a sensory memory deficit; Volicer & Bloom-
Charette, 1999); a memory book with pages depicting preferred activities with specific
objects could help patients communicate their needs. Resistance or lack of cooperation
may result from patients not understanding verbal directions and not being able to ex-
plain that they do not understand what is expected of them; the communication cards
used by nursing aides addressed this problem (Bourgeois et al, 2001). Persons who ex-
hibit sundowning behaviors, such as saying they need to go home, packing a suitcase or
shopping bags, or exit seeking, may not remember that they are in their own home be-
cause familiar visual cues have lost their salience; I (Bourgeois, 1990) reported a caregiver
independently using a page in his wife’s memory book to remind her that she was at
home (“I have lived at 123 Elm Street for 45 years” + picture of home).
Lack of access to the words to express wants, needs, frustration, boredom, loneli-
ness, and confusion results in many problem behaviors, such as sundowning, restless pac-
ing, or yelling and crying out for help (i.e., disruptive vocalization). The range of chal-
lenging behaviors of persons with dementia is thought to be the result of unmet needs
(Algase et al., 1996, Beck et al., 1998; Cohen-Mansfield, 2000). These communication
problems are often responded to by concerned questioning, but when the person is un-
able to express a specific need, the need remains unmet, resulting in increased disruptive
behavior. External memory aids in the form of memory books with pages depicting de-
sired activities, typical need resolutions, and comforting messages could mediate these
deficits. At late stages of dementia, when access to vocabulary is severely limited, it is im-
perative that disruptive vocalization be interpreted by caregivers as communicative at-
tempts, albeit unsuccessful ones, and strategies be attempted to address clients’ needs.
EXTERNAL AIDS FOR SENSORY MEMORY AND REGISTRATION DEFICITS
When the person with dementia has trouble recognizing familiar objects or persons . . .
when he or she loses his or her way inside his or her own home . . . when a shadow in a
darkened room creates the delusion of a stranger . . . or when the waste basket is mis-
taken for the toilet, he or she may be experiencing a failure of sensory input to be regis-
tered, recognized, and understood. The salience of visual features may degrade over time,
causing familiar objects to look strange or new. Auditory information can become dis-
torted or inaudible due to age-related sensory-neural hearing deficits. In the latter stages
of dementia, persons may attempt to gain sensory information from objects they pick up
and fondle or from patting a tabletop. Failure to recognize the familiar can create confu-
sion, frustration, or apathy. Rehabilitative strategies—particularly external aids that ad-
dress the sensory features of stimuli by enhancing them, making them more salient, visi-
ble, heard, and felt in order to activate the visual, auditory, and tactile pathways that
access their semantic counterparts—should be helpful.
External memory aids can enhance sensory or environmental features and signal or
cue behavior by triggering associations between auditory, visual, or tactile features and
past experiences of the person with memory impairment (Garrett & Yorkston, 1997;
Sohlberg & Mateer, 2001). Auditory signals such as doorbells, car door alarms, ringing
telephone, kitchen/oven timers, and whistling tea kettles, may have been experienced for
so many years that recognition of the meaning of these signals is automatic, unconscious,
and resistant to memory decay. Caregivers have reported using door alarms that emit
loud, noxious sounds to prompt the person with dementia to recognize a dangerous situ-
ation and to reduce exit-seeking behaviors. Auditory cueing systems exist along a contin-
uum of sound-enhancing technology, from personal hearing aids, to assistive listening de-
vices for the television and telephone, and signaling/alerting systems such as bells, ringers,
and vibrating devices (Weinstein, 1991). Voice mail and telephone reminding systems, in
External Aids 339
addition to pill dispensers with timed alarms, have successfully increased medication ad-
herence and appointment attendance (Azrin & Powell, 1969; Leirer, Morrow, Pariante,
& Doksum, 1988; Leirer, Morrow, Tanke, & Pariante, 1991). Two caveats concerning
external aids in the form of auditory cues should be noted. First, if the cue is nonspecific
(i.e., a kitchen timer or alarm clock), it may remind the person that something, but not
what, needs to be remembered, causing frustration or confusion (Woods, 1996). Sec-
ondly, the compromised hearing status of many elderly persons can adversely impact
cognitive performance based on auditory or verbal cues; and persons with dementia are
at increased risk for disorientation, confusion, and impaired comprehension when infor-
mation has not been processed completely due to reduced hearing (Weinstein, 1991).
These individuals may be cued more effectively using their visual and tactile modalities or
cue combinations.
Visual external aids such as written signs for labeling the contents of drawers and
closets, name tags, grocery lists, activity schedules, wall calendars, orientation and mes-
sage boards, cue cards and Post-it notes, medication organizers, maps and floor plans
take advantage of the unconscious, automatic, and relatively preserved processes in-
volved in reading comprehension (Bourgeois, 2001). Other visual cues such as clocks,
single-button dialing telephones, traffic signs, and photographs trigger long-term memo-
ries for iconic symbols that are recognized with little effort. When stimuli are altered to
enhance their visibility, associated stored memories can be triggered. For example, enlarg-
ing the print, using bright or neon colors, highlighting, creating high-contrast situations,
or using personal objects can increase a person’s attention to the importance of the cue.
Visual cueing in its simplest form may well be the use of a routine place and location for
specific objects; hanging the car keys by the door to the garage, keeping a note pad for
messages by the telephone, and placing bills to be paid in a specific letter tray on the desk
are strategies used by many individuals who report using memory strategies routinely
(Harris, 1980). Organizational strategies similarly address the visual salience of objects in
specific locations; for example, silverware trays, desk supply organizers, and closet orga-
nizers for ties and belts facilitate finding and recognizing desired objects.
Caregivers are often advised to place a particular activity or materials along the pac-
ing route of an individual to cue him or her to engage in an alternate activity (e.g., a laun-
dry basket with towels to be folded). Bourgeois et al. (1997) taught caregivers to place
important written messages and activity suggestions on an erasable memo board magnet-
ically attached to the refrigerator for persons whose pacing route included the kitchen. A
variety of disruptive behaviors were decreased and desired behaviors increased with this
simple visual strategy. When the cue is visual and in the environment, the opportunity for
it to be noticed and recognized by the individual is enhanced without overt prompting to
look at it or to use it. Smith (1988) used cue cards to reduce disruptive behaviors of per-
sons with dementia. Park and Kidder (1996) reviewed the literature on external aids for
medication adherence, including 1-day and 7-day (with and without times—morning,
noon, dinner, evening) medication organizers. The most effective aids for elderly users
were those with the most compartments (7 days with time; 28 places; Rehder, McCoy,
Blackwell, Whitehead, & Robinson, 1980) and those used in combination with a visual
organizational chart (Park, Morrell, Frieske, & Kincaid, 1992). Other researchers have
found that external visual aids in the form of a tear-off calendar (MacDonald, MacDon-
ald, & Phoenix, 1977) and a check-off chart (Gabriel, Gagnon, & Bryan, 1977) increased
adherence by elderly users. Hussian and Brown (1987) placed a two-dimensional grid
pattern on the floor in front of an exit and thereby reduced the hazardous ambulation of
nursing home patients. Similarly, Namazi, Rosner, and Calkins (1989) found that visual
concealment in the form of a cloth panel was successful at preventing exit through an
emergency door. Leseth and Meader (1995) used a vase of bright red flowers to cue a per-
son to her assigned table in the dining room. Nursing home residents were cued effec-
tively to find their own rooms and prevent unwanted access to other resident rooms using
personal photographs and large-print name plates (Nolan, Mathews, & Harrison, 2001).
Visual cues have become a popular marketing strategy for residential facilities; color
schemes, street signs, personalized front doors and mailboxes, and mail baskets or flower
boxes are designed to enhance recognition memory for the familiar in the context of a
new environment (Zeisel, Hyde, & Shi, 1999). Researchers have found, however, that
simply placing visual cues in the path of the person with dementia may not ensure that he
or she sees it, recognizes it, and responds to it, as desired. Some concerted effort to point
out, identify, and rehearse the cue with the person may be necessary to keep it salient.
The use of signs, signposts, and labels on drawers and cupboards was found to be en-
hanced when staff members were involved in practicing the environmental cues with pa-
tients (Gilleard, Mitchell, & Riordan, 1981; Hanley, 1981; Josephsson et al. 1993; Lam
& Woods, 1986).
Tactile cues in the form of objects and textures have also been found useful for trig-
gering associated memories, particularly with the most impaired individuals. Hopper,
Bayles, and Tomoeda (1998) found that tangible stimuli in the form of dolls and stuffed
animals improved the meaningfulness and relevance of conversations of persons with de-
mentia. External aids in the form of dolls have also been used to prompt positive alterna-
tive behaviors in persons who exhibited troublesome behaviors (Ehrenfeld, 2003;
Godfrey, 1994). Similarly, Buettner (1999) demonstrated decreased patient agitation and
improved family visiting with a variety of handmade, therapeutically based sensory-
motor recreational items (e.g., activity apron, electronic busy box, “look inside purse,”
“squeezies”) were given to nursing home residents with dementia.
External memory aids that combine sensory features may have increased salience.
The keyless car door opener that beeps and causes the headlights of the car to flash when
the doors are locked and unlocked remotely is one of the latest external memory aids—in
effect, a car finding device for those who lose their cars in large parking lots. Medication
organizers may have alarms to signal when to look for the appropriate medication for
that time period. The NeuroPage device is an auditory pager that signals the user to look
at the message screen for the next written appointment prompt (Hersh & Treadgold,
1994).
Although most caregiver guidebooks recommend the use of these commonsense
strategies that are based on positive anecdotal reports (i.e., Hoffman & Platt, 1991; Mace
& Rabins, 1981), more experimental research is needed to document the effectiveness of
visual external aids, especially with persons who have dementia or memory impairments.
Empirical investigations have suggested that enhanced stimuli alone cannot produce de-
sired changes in patient functioning, training, or routine, and that repetitive exposure is
required (Cohen & Weisman, 1991; Zeisel et al., 1999).
TRAINING CONSIDERATIONS
Many of the external memory aids described above may require training to ensure their
routine use and to retain their recognition, organizational, and memory-supporting value.
External Aids 341
The range of aids—from computers, electronic organizers, and personal data storage
devices to written planning systems, organizers, and memory notebooks with divided sec-
tions for daily, weekly, and monthly events, telephone directory, and notes—may require
a significant amount of time to learn how to use and to incorporate into daily life. Even
simple environmental aids, such as signs and labels, may need periodic time investments
so that the person can practice identifying, reading, and discussing them to maintain their
salience and intended function. A deterrent to the use and training of many memory aids,
however, is the belief that persons with dementia and encoding memory deficits are un-
able to acquire new information and demonstrate new learning. This belief, however, has
been challenged by Camp (1999) and others with evidence that persons with dementia
can learn new information using spaced retrieval (described extensively in Camp, Chap-
ter 12,this volume).
Spaced retrieval involves recalling information over increasingly longer periods of
time and has been used to teach persons with dementia (1) to remember the names of
common objects (Abrahams & Camp, 1993), (2) to remember to perform a future action
(Camp, Foss, Stevens, & O’Hanlon, 1996), (3) face–name and object–location associa-
tions (Camp & Stevens, 1990), (4) to use a strategy (e.g., “Look at the calendar”; Camp,
Foss, O’Hanlon, & Stevens, 1996), and (5) to use external memory aids (Bourgeois et al.,
2003). In a spaced-retrieval training session, the therapist prompts the person with de-
mentia to produce the target response by saying, “How do you remember where your
room is?” The person with dementia responds, “I look at my reminder card.” The thera-
pist replies, “That’s correct, and I want you to remember that because I will be asking
you again in a few minutes.” After a specified time interval, the therapist repeats the
prompt, “How do you remember where your room is?” Each correct response results in
doubling the time interval time before the next prompt. Incorrect responses elicit the
modeling and repetition of the correct response. This procedure results in rapid and dura-
ble acquisition of the target response (Bourgeois et al., 2003; Camp, Foss, O’Hanlon, &
Stevens, 1996).
Factors to consider before selecting an external memory aid and a potential training
regimen include the individual’s level of literacy, prior experience with reminding systems,
degree and severity of cognitive impairment, level of awareness regarding the memory
problems, and motivation to compensate for them. As described in Attix (Chapter 10,
this volume), intervention targets and training techniques vary depending on stage and se-
verity of the cognitive deficits. Persons with a mild cognitive impairment may begin to re-
activate formerly useful reminding systems independently (e.g., the retired businessman
who starts to use a planner again, or the retired college professor who keeps a small note-
book to record people’s names and words he has stumbled over recently). Persons with
mild memory impairment usually request memory rehabilitation efforts and participate in
the development and evaluation of their own functional systems. As memory deficits
worsen, successful memory-enhancing systems require premorbid familiarity, salient
multisensory features, or specific training protocols (e.g., spaced retrieval). When intro-
ducing a novel cueing system, such as an enlarged plate switch with a picture of a nurse
taped to it as an alternative call button, training the person with dementia “to touch the
picture when you need a nurse” would be necessary (Garrett & Yorkston, 1997). Many
examples of successful training in the use of external memory aids have been reported in
the literature, including the use of a palmtop computer to get to scheduled appointments
and take medication (Kim, Burke, Dowds, & George, 1999), and a portable paging and
text screen system, the NeuroPage (Hersh & Treadgold, 1994). Enwefa (1999) trained 10
persons with dementia to use communication wallets and the Alpha Talker, an augmenta-
tive communication device with preprogrammed phrases, and measured more conversa-
tional content with the electronic device. Lekeu, Wojtasik, Van der Linden, and Salmon
(2002) used cue cards and spaced retrieval to teach two persons with dementia to use a
mobile phone; although both eventually learned to use their phones correctly, one person
required much more training than the other.
Not all efforts at training the use of electronic memory aids have been successful,
however. Kapur (1995) detailed efforts to train patients with a range of memory disor-
ders to use electronic organizers; two of five subjects failed to learn and two others only
reduced their memory lapses by 50%. The only successful user was a bank clerk who
learned to use a Tandy organizer in two training sessions; she then used it daily in per-
forming the duties of her job. The educational level of the participants, degree of impair-
ment, motivation to use the devices, and degree of appropriateness of the training tech-
niques were thought to contribute to the difficulties encountered by the unsuccessful
participants. Sohlberg and Mateer (2001) have suggested the use of training protocols
that incorporate a variety of effective instruction techniques, including functional task se-
lection, task analysis, errorless instruction, prompting, cueing, feedback, and reinforce-
ment. In addition, the role of the caregiver in facilitating the use of external aids cannot
be overlooked. Many of the reports of successful aid use have involved family and nurs-
ing aides who ensured that the aids were available and prompted their use at appropriate
times (Bourgeois et al., 1997, 2001). Much of the literature on training external aid use
has been with persons who have sustained memory loss due to head injury or other etiol-
ogies; more research is needed to find efficacious ways to enable persons with memory
loss due to the degenerative process of dementia to use external aids effectively.
Although additional research is still needed, this emerging literature is encouraging
in the diversity of evidence that is accumulating, debunking the myths that persons with
cognitive deficits could not learn new information or maintain treatment effects over the
long term. It should be clear from this review that the maintenance of functional memory
skills is possible when individuals are provided with the appropriate system of external
cues and training procedure for their condition.
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Woods, R. T. (1996). Psychological “therapies” in dementia. In R. T. Woods (Ed.), Handbook of the
clinical psychology of ageing (pp. 575–600). New York: Wiley.
Volicer, L., & Bloom-Charette, L. (1999). Assessment of quality of life in advanced dementia. In L.
Volicer & L. Bloom-Charette (Eds.), Enhancing the quality of life in advanced dementia (pp. 3–20).
Philadelphia: Taylor & Francis.
Zeisel, J., Hyde, J., & Shi, L. (1999). Environmental design as a treatment for Alzheimer’s disease.
In L. Volicer & L. Bloom-Charette (Eds.), Enhancing the quality of life in advanced dementia
(pp. 206–222). Philadelphia: Taylor & Francis.
Section B
Psychotherapeutic Interventions
In Section B of Part II we primarily focus on psychotherapeutic interventions that target

emotional distress or behavioral problems. Although these symptoms remain our primary
targets, we also recognize that their amelioration has other tangible impact beyond symp-
tom relief. We thus encourage consideration of important secondary outcomes that
follow from the successful treatment of depression and problem behaviors: namely, im-
proved quality of life, reduction of family and caregiver stress, and potentially reduced
health care utilization, given the well-established link between depression and health care
status.
In the chapters that follow as well as those in the preceding section, it again becomes
clear that different methodologies or treatment modalities can be used to address similar
problems. The reader is thus referred to the general intervention model in Chapter 10 for
consideration of the variables that assist in the selection of intervention targets and tech-
niques.
Chapter 16 leads off with discussion of nonpharmacological behavioral approaches
to reduce depression. This contribution is by authors whose work historically sets strong
examples of rigorously designed intervention outcomes research, which the field urgently
needs. It also nicely demonstrates our belief that inactivity breeds depression.
Chapter 17 focuses on modifying problematic or maladaptive behavior rather than
emotional distress. This work is included in this section rather than the cognitive training
section because the methodology involves application of behavioral principles and tech-
niques to achieve improved functional outcomes. This is in contrast to the functional
skills training described earlier in the book (Chapter 11), which directly trains the specific
skill using a combination of cognitive techniques and practice of functional skills. This
chapter is an essential component of this text, given that so much of intervention draws
upon behavioral techniques and principles.
Chapter 18 outlines the literature and provides details from experience in conducting
psychotherapeutic group therapy with geriatric patients who have neuropsychological
deficits. The chapter explores important conceptual issues involving the application of
these approaches with cognitively impaired groups and discusses the patient and care-
giver perspectives of treatment.
Finally, realizing that this type of intervention work occurs within the context of
other types of approaches, Chapter 19 concludes the text with a review of pharmacologi-
347
cal treatments in memory-impaired patients. The chapter discusses the impact of

pharmacotherapy on symptom expression and progression in Alzheimer’s disease and re-
lated dementias. Considered in this chapter is the design of clinical trials for treatment of
dementia as well as for primary prevention of disorders in normal older groups who do
not express the disease or who are experiencing mild symptoms suggestive of prodromal
disease, so-called “secondary prevention.” The chapter provides a broad overview of the
medications currently on the market or in clinical trial and also considers approaches that
show future promise for either delaying symptom onset or slowing rates of progression so
as to maintain optimal function for extended periods of time. We include this chapter to
consider the larger treatment context within which intervention work proceeds.
16
Behavioral Treatment of Affective

Disorders and Associated Symptoms
REBECCA G. LOGSDON
SUSAN M. MCCURRY
LINDA TERI
Although memory loss and other cognitive changes are the defining indices of dementia,
disruptive or distressing behaviors are often cited as the most difficult aspect of care,
leading to greater functional impairment in the person with dementia and increased bur-
den in the caregiver (Burns, 1996; Cummings & Kaufer, 1996; Fitz & Teri, 1994; Teri,
1992). Affective disturbances such as depression, anxiety, and sleep difficulties may par-
ticularly interfere with care and decrease quality of life of both the affected individual and
his or her family (Teri et al., 1992; Vitaliano, Young, & Russo, 1991; Wagner, Logsdon,
Pearson, & Teri, 1997). Thus it is essential that mental health providers are aware of the
most effective ways to assess and treat these problems. Failure to do so may compound
the disability of patients and their caregivers. Furthermore, when behavioral and mood
disturbances are severe or cause safety concerns, the use of behavioral or social support
interventions may delay the need for institutionalization (Carlson, Fleming, Smith, & Ev-
ans, 1995; Mittelman et al., 1993; Mittelman, Ferris, Shulman, Steinberg, & Levin, 1996;
Steele, Rovner, Chase, & Folstein, 1990).
This chapter provides a review of affective problems seen in cognitively impaired
older adults, focusing on depression, anxiety, and sleep difficulties, and describes a frame-
work for an empirically validated behavioral approach to care. We focus on the behav-
ioral treatment of community-residing individuals with Alzheimer’s disease (AD) or re-
lated dementia. Practitioners interested in pharmacological treatment approaches are
referred elsewhere (Sano, Chapter 19, this volume; Raskind & Peskind, 2001; Teri,
Logsdon, & Schindler, 1999; Weiner, Schneider, Gray, & Stern, 1996), as are those who
are working in residential care settings (Allen-Burge, Stevens, & Burgio, 1999; Camp,
Cohen-Mansfield, & Capezuti, 2002; Snowden, Sato, & Roy-Byrne, 2003; Sutor, 2002).
349
COMMON AFFECTIVE DISTURBANCES IN DEMENTIA
The constellation of behavioral disturbances that includes depression, anxiety, and sleep
difficulties affects up to 80% of individuals with dementia during the progression of the
disease, and comorbidity is the rule, rather than the exception (Lyketsos et al., 2001; Teri
et al., 1999).
Depressive symptoms in clinical and population-based studies have been reported to
occur in 30–70% of individuals diagnosed with dementia (Lyketsos et al., 2002; Lyketsos
et al., 2001; Teri, Baer, & Reifler, 1991; Weiner, Edland, & Luszczynska, 1994). Unhap-
piness, withdrawal, inactivity, fatigue, expressions of guilt and worthlessness, tearfulness,
and loss of interest are all symptoms of depression and contribute to excess disability,
compounding the distress of both the person with dementia and the caregiver (Brodaty &
Luscombe, 1998; Fitz & Teri, 1994; Teri et al., 1992).
Studies of community-residing individuals with dementia, using a variety of well-
established scales, have found that as many as 71% of subjects had anxiety symptoms,
including irritability, agitation, day/night disturbance, and motor restlessness (Eustace et
al., 2002; Lyketsos et al., 2002; Mega, Cummings, Fiorello, et al., 1996; Reisberg et al.,
1987). The rates of anxiety symptoms among both hospitalized and community-dwelling
patients with AD are higher than in healthy elderly peers (Mega et al., 1996; Orrell &
Bebbington, 1996).
Comorbidity of depression and anxiety is common in older adults, with 30–60% of
older adults who are diagnosed with clinically significant anxiety or depression meeting
DSM-IV (American Psychiatric Association, 1994) criteria for both disorders (Schneider,
1996). This relationship also holds for individuals with dementia (Teri, Ferretti, et al.,
1999). Anxiety in dementia is associated with increased behavioral disturbances, and
comorbid anxiety and depression are associated with greater functional impairment
(Ferretti, McCurry, Logsdon, Gibbons, & Teri, 2001; Teri, Ferritti, et al., 1999).
Sleep and nighttime behavioral disturbances are also common among persons with
dementia and are associated with both depression and anxiety. Among outpatients with
dementia, prevalence rates of 11–51% for sleep disturbances have been reported (Car-
penter, Strauss, & Patterson, 1995; Eustace et al., 2002; Ferretti et al., 2001; Lyketsos et
al., 2002; Zubenko et al., 2003). The co-occurrence of sleep complaints in nondemented
adults who have depressive or anxiety disorders is well known (Foley, Monjan, Izmirlian,
Hays, & Blazer, 1999; Ohayon, Cauclet, & Lemoine, 1998), and there is evidence that
these conditions also impact the sleep quality of affected demented individuals (McCurry,
Gibbons, Logsdon, & Teri, 2003a; Zubenko et al., 2003).
ASSESSMENT OF AFFECT: IDENTIFYING PROBLEMS
The most common method for assessing affective disturbance in cognitively impaired
older adults is a detailed clinical interview with the patient and an informant familiar
with the patient’s day-to-day functioning, such as a family member or caregiver. It is
essential to interview an informant because patients who have memory loss often have
difficulty accurately describing the frequency and severity of their own symptoms. It is
usually helpful to interview the patient and informant together initially to obtain an over-
view of the patient’s history and to observe the interaction between the two of them.
Whenever possible, it is also advisable to interview them individually, to give each an op-
Affective Disorders and Associated Symptoms 351
portunity to discuss problems or concerns privately. Often family members are hesitant to
bring up topics that may be “sensitive” in front of the affected person, and the person
with dementia may have important information to provide privately about his or her con-
cerns or relationship with the caregiver. In the interview, the patient and informant are
generally asked about the occurrence, frequency, and severity of typical problems, includ-
ing depression, tearfulness, sleep disturbance, loss of interest in activities, verbal expres-
sions of hopelessness, sighing, complaining, etc. To assure that the full spectrum of prob-
lems is assessed in an efficient and thorough manner, a standardized inquiry list is
recommended as a valuable tool. By asking about the presence or absence of a variety of
potential problems, the clinician can focus on the ones that are of greatest concern. This
type of assessment provides an objective method for evaluating outcomes of any interven-
tions that are attempted.
A variety of mood and behavior assessment measures with good psychometric prop-
erties have been developed. Table 16.1 shows a representative sampling of instruments
that has been used to measure affective disturbances in clinical controlled trials with de-
mentia subjects. Some measures are paper-and-pencil informant report; others require
TABLE 16.1. Common Affective Assessment Instruments for Dementia

Informant
report Interviewer Reliability/validity Used in clinical
questionnaire administered data controlled trials
Cornell Scale for Depression in × Mack & Patterson, Lyketsos, Lindell
Dementia (CSDD; Alexopoulos 1994; Perrault et al., Veiel, Baker, &
et al., 1988) 2000 Steele, 1999;
Teri et al., 1997
Dementia Mood Assessment Scale × Onega & Abraham, Lawlor, Aisen,

(DMAS; Sunderland, Hill, Lawlor, 1997; Perrault et al., Green, Fine, &
& Molchan, 1988) 2000 Schmeidler, 1997
Geriatric Depression Scale (GDS; × Logsdon & Teri, Teri et al., 1997
Yesavage et al., 1983) 1995
Hamilton Depression Rating Scale × Logsdon & Teri, Teri et al., 1997;
(HDRS; Hamilton, 1960) 1995 Teri, McCurry,
et al., 1998
Neuropsychiatric Inventory (NPI; × Perrault et al., 2000 Olin &

Cummings et al., 1994) Schneider, 2001;
Teri et al., 2002
Revised Memory and Behavior × Weiner et al., 2000 Teri et al., 1997;
Problem Checklist (RMBPC; Teri, Logsdon,
Teri et al., 1992) et al., 1998
Epworth Sleepiness Scale (ESS; × Johns, 1991; Johns, Lind et al.,

Johns, 1991) 2000; Osman, 2003; Massie &
Osborne, Hill, & Hart, 2003
Lee, 1999
Time-Based Behavioral Disturbance × Friedman et al.,

Questionnaire (Bliwise, Yesavage, & 1997
Tinklengerg, 1992)
structured interviews with trained clinicians or direct behavioral observation. Some (e.g.,
the Cornell Scale for Depression in Dementia; Alexopoulos, Abrams, Young, & Shamoian,
1988) provide information on the severity of symptoms; others (e.g., the Revised Mem-
ory and Behavior Problems Checklist [RMBPC]; Teri et al., 1992) rate behaviors on the
frequency of their occurrence and provide information on caregiver distress about spe-
cific behaviors when they do occur. For some measures (e.g., the Neuropsychiatric Inven-
tory; Cummings et al., 1994), subscale information is computed from a combination of
frequency and severity ratings for individual behavioral symptoms. A number of self-
report instruments also have been shown to be valid when completed by surrogate infor-
mants such as dementia caregivers (Logsdon & Teri, 1995).
As can be seen from Table 16.1, no single instrument has been adopted for univer-
sal use with patients who have dementia. In selecting an appropriate strategy for be-
havioral assessment, clinicians and researchers should consider the length of the mea-
sure, its reported sensitivity to change, and specific behaviors of concern for their
clinical population. Providers caring for populations that include non-English-speaking
individuals from multicultural backgrounds or persons with limited education or read-
ing skills particularly need to evaluate the validity of a given instrument for their pa-
tients. A number of excellent comprehensive reviews of behavioral screening instru-
ments used in dementia care and research is available for those who require additional
information (Katz, 1998; Kluger & Ferris, 1991; Perrault, Oremus, Demers, Vida, &
Wolfson, 2000; Sky & Grossberg, 1994; Snowden et al., 2003; Teri & Logsdon, 1995;
Weiner et al., 1996).
Once specific problems are identified, a thorough assessment of possible causes is es-
sential. Common causes of affective disturbance in dementia include medical illness or
medication side effects, loss of pleasant activities due to cognitive and functional decline,
environmental changes, or interpersonal conflicts. For example, anxiety or restlessness
may be triggered by an acute medical condition, such as a urinary tract infection, or by a
change in medication. Restlessness may also result from changes in brain functioning sec-
ondary to the dementing process, or it may be related to environmental triggers, such as
lack of appropriate activity, too much noise or stimulation, or conflicts with people with
whom the patient comes into contact. Thus assessing affective disorders often involves
behavioral observation to obtain a baseline profile and identify the antecedents and con-
sequences of problem behaviors. In turn, this assessment leads directly to the develop-
ment of behavioral treatment programs.
RATIONALE AND THEORETICAL BASIS FOR BEHAVIORAL

TREATMENT OF AFFECTIVE DISTURBANCES IN DEMENTIA
Although antidepressants have been widely used in treating depression in dementia, re-
ports of their effectiveness have been mixed, and many older adults experience side ef-
fects or interactions with other medications (Lyketsos & Olin, 2002; Raskind, 1993).
Furthermore, as noted, cognitive and environmental factors (e.g., lack of pleasant events)
or interpersonal factors (e.g., conflicts with caregivers) are frequently the primary triggers
of depressive or anxious behaviors, and lack of activity or poor sleep hygiene practices
often lead to sleep disturbances. Caregiver education, support, and training in behavioral
strategies for management can be quite effective in alleviating or preventing affective dis-
turbances. Consequently, nonpharmacological treatments are often the most appropriate
initial strategy for dealing with these disturbances (Rabins, 1994; Teri, 1986; Teri,
Logsdon, & McCurry, 2002).
Behavioral theory postulates a cycle of affective disturbance that is applicable to in-
dividuals with dementia. As formulated by Lewinsohn and colleagues with nondemented
older adults, decreased positive person–environment interactions and increased aversive
interactions trigger depressed or anxious behaviors (Lewinsohn, Antonuccio, Steinmetz,
& Teri, 1984; Lewinsohn, Sullivan, & Grosscup, 1980). The depressed person is often
withdrawn and apathetic, showing little interest in activities he or she once enjoyed; the
less active he or she is, the more depressed he or she becomes; the more depressed, the less
active, and so on. Likewise, lack of activity may lead to restlessness or anxiety, which in
turn may lead to agitation or other behavioral disturbances that further limit the avail-
ability of opportunities to engage with other people or activities. This same cycle can be
seen in individuals with dementia and depression (Teri, 1986, 1994). Due to cognitive im-
pairment, these individuals lose the ability to do many of the activities they once enjoyed.
They can no longer function as independently as they once did, and they must rely on
others to initiate and maintain activities. The fewer pleasant events they experience, the
more depressed or anxious they feel; the more depressed or anxious they become, the less
they do, and so on. Furthermore, family members or caregivers may perceive the affected
individual as increasingly difficult and therefore be less likely to engage in pleasant social
interactions with him or her.
Behavioral treatment of affective disturbance in dementia disrupts this cycle by alter-
ing the contingencies that initiated and maintain the depressive or anxious behavior (i.e.,
antecedents and consequences; Teri, 1986; Teri et al., 2002) in two salient ways: (1) by
identifying and reinforcing incompatible nondepressive behaviors (i.e., pleasant events;
Logsdon & Teri, 1997; Teri & Logsdon, 1991); and (2) by changing the caregiver–care
recipient interaction that is the context in which the nonadaptive contingencies are
maintained (Logsdon, McCurry, Moore, & Teri, 1997). The frequency and severity of af-
fective disturbances are thus decreased.
Emotional and cognitive symptoms of depression are not ignored under this concep-
tualization. They are simply viewed as other forms of behavior that respond to behav-
ioral principles and therefore are equally modifiable. This is not to imply that individuals
with dementia will “learn” new skills, but rather that their behavior responds to rein-
forcement, and modifying the contingencies of a given behavior will alter that behavior.
Although individuals with dementia have difficulty learning and may not “remember”
the reinforcements, they still respond to them.
OVERVIEW OF NONPHARMACOLOGICAL
TREATMENT STRATEGIES IN DEMENTIA CARE
Providing education, support, and advice to help families better understand and cope
with dementia has a long clinical history. Practitioners often advise families to adapt the
environment and modify their own behaviors in order to provide better care for patients.
The amount and popularity of this kind of information have grown exponentially in re-
cent years, as evidenced by the proliferation of books, training materials, informational
handouts, videos and websites. For example, The 36-Hour Day (Mace & Rabins, 1991),
long considered a staple of information to families, is in its second printing with over
one-half million copies sold worldwide. The Alzheimer’s Association, another popular re-
source, provides extensive information for health care providers, families, and affected
individuals on its website (www.alz.org).
Published reports of behavioral treatment of dementia span two decades. Early
case studies demonstrated that caregivers were able to learn specific techniques and
successfully reduce problematic behaviors (Aronson, Levin, & Lipkowitz, 1984; Haley,
1983; Pinkston & Linsk, 1984; Zarit, Anthony, & Boutselis, 1987). Later, case-con-
trolled and randomized controlled trials investigated the effectiveness of behavioral
treatment in reducing agitation and depression or delaying institutionalization in pa-
tients with dementia. Three investigations included behavior training as part of a larger
psychoeducational and social support program that examined general behavioral out-
comes and delayed patient institutionalization (Carlson et al., 1995; Mittelman et al.,
1996; Mohide et al., 1990). One study provided focused behavioral training to reduce
patient depression (Teri, Logsdon, Uomoto, & McCurry, 1997), and another compared
nonpharmacological to pharmacological approaches to reduce patient agitation (Teri et
al., 2000; Teri, Logsdon, et al., 1998). Although certainly not conclusive, results thus
far suggest that nonpharmacological interventions can significantly reduce general pa-
tient behavioral problems (Mohide et al., 1990; Teri, Logsdon, et al., 1998), decrease
patient depression (Teri et al., 1997), delay institutionalization (Mittelman et al.,
1996), and increase caregiver satisfaction (Mittelman et al., 1993). (For more detailed
reviews of nonpharmacological treatments, see Bourgeois, Schulz, & Burgio, 1996;
Teri, Logsdon, et al., 1999.)
GENERAL GUIDELINES FOR BEHAVIORAL INTERVENTION IN DEMENTIA
Since patients with progressive dementia are significantly limited in their ability to learn
new material, behavioral treatment focuses on teaching caregivers strategies to use in
working with the patient on a daily basis. Caregivers may include family members, un-
paid caregivers, and paid caregivers who have a role in the patient’s day-to-day care. In
planning management strategies it is important to have a good understanding of the re-
sources of both the patient and the caregiver. In particular, the degree of the patient’s cog-
nitive impairment impacts his or her ability to perform particular behaviors, and the de-
gree of stress the caregiver is experiencing will impact his or her ability to carry out
recommended changes. The past and present relationship between patient and caregiver
will also influence the occurrence and treatment of depressive behaviors. Programs must
be tailored to the individual in order to be most effective. Flexibility and creativity are
needed to find solutions to problems, and because dementia typically progresses over
time, it is necessary to repeatedly modify and adapt solutions to the patient’s current
problems. Finally, it is important to respect the dignity of both the patient and the care-
giver when developing behavioral management strategies, and to encourage each of them
to participate as much as possible in the treatment.
SPECIFIC INTERVENTIONS FOR AFFECTIVE DISTURBANCES IN DEMENTIA
We have developed systematized behavioral interventions to train caregivers to reduce de-

pression (Teri et al., 1997), agitation (Teri et al., 2000; Teri, Logsdon, et al., 1998) and
sleep disturbances (McCurry, Gibbons, Logsdon, Vitiello, & Teri, 2005; McCurry,
Logsdon, Vitiello, & Teri, 1998; McCurry, Reynolds, Ancoli-Israel, Teri, & Vitiello,
2000) in patients with dementia. As described above, affective disturbances are viewed as
a series of observable and modifiable behaviors that are initiated and maintained by
person–environment interactions. Caregivers are taught to alter these interactions in a
way that results in decreased problem behaviors. Treatment is systematic but individual-
ized, focusing on the current observable interactions of direct relevance to the problem
under consideration.
A video training program, “Managing and Understanding Behavior Problems in Alz-
heimer’s Disease and Related Disorders” (Teri, 1990), teaches caregivers to use a behav-
ior management approach with individuals with dementia. This series of videotapes uses
didactic information along with vignettes of specific problems and solutions to guide
caregivers through a systematic process called the “A-B-C’s of Behavior Change.” In this
approach, caregivers learn that “A” is the antecedent or triggering event that precedes the
problem behavior, “B” is the behavior of concern, and “C” is the consequence of that
behavior. Caregivers are thus introduced to the importance of behavioral observation and
are taught problem-solving strategies. This video series has been successfully used with
both family members and professional caregivers as an adjunct to one-on-one and group
training in behavior therapy.
Once the caregiver understands and can identify the A-B-C’s of a problem, a step-by-
step problem-solving strategy is implemented. The following six steps can be applied to a
variety of problems, including affective disturbances such as social withdrawal, tearful-
ness, restlessness, aggression, anxiety, and sleep disturbances.
1. Identify the problem. A clear definition of the problem behavior is the first step
in changing it. This is the “B” of the A-B-C’s. The more clearly a caregiver can define a
problem, the more likely he or she will be able to carry out an effective course of action.
It is best to begin with one specific problem that occurs frequently and is easily observ-
able.
2. Gather information about the problem. Once the problem is identified and can
be observed, gather as much information as possible about it: When does it happen? How
often? Where does it happen most? Caregivers may be able to recall the last few weeks
and provide some information about the problem, but it is also often helpful to have
them keep notes, or a “diary,” about the behavior for a few days.
3. Identify what happens before and after the problem. While observing the person
with dementia, the caregiver should carefully note what happens immediately before the
problem occurs and what happens immediately after the problem begins. These are the
“A” (antecedents) and “C” (consequences) of the A-B-C’s. Many problems will have
more than one antecedent and consequence, and the more the therapist and the caregiver
understand how they fit together, the more likely they will be able to intervene success-
fully.
4. Set realistic goals and make plans. For a plan to work it must be creative but re-
alistic and tailored to the individual patient and caregiver. Involve the patient as much as
possible, and work closely with the caregiver to establish the goals. Start with a small,
achievable goal and proceed step by step. Be practical and allow plenty of time for change
to occur. Do not expect major changes overnight. Work with the caregiver to anticipate
problems that may occur and discuss how they may be solved.
5. Acknowledge and reinforce any effort on the part of both the patient and care-
giver to make changes. Changing behavior is hard work for everyone involved. It is very
important for caregivers to feel good about their accomplishments, no matter how small.
The patient with AD will also benefit from being praised for doing a good job.
6. Repeatedly evaluate and modify plans. It is important that caregivers be consis-
tent yet flexible in carrying out plans. Strategies will change as they discover what does
and does not work. Decide how to determine whether the plan is working—by monitor-
ing the amount of time the behavior occurs, the number of instances of the behavior, or
whatever makes the most sense.
Depression
Many of the behavioral triggers of depressive behaviors in dementia are associated with
inappropriate activities or with too little activity. Identifying activities that the person
with dementia finds enjoyable and providing opportunities for him or her to engage in
them successfully on a daily basis, may be effective alternatives to medication. This ap-
proach appeals to many caregivers because it provides opportunities for positive interac-
tions and social contact and contributes to a more pleasant environment for both the per-
son with dementia and the caregiver. However, identifying pleasant activities that are
appropriate to the person’s level of functioning can be difficult, particularly for caregivers
who are already taxed by routine daily responsibilities. The challenge is also an ongoing
process because as dementia progresses, activities must be modified to fit the changing
needs and abilities of the individual. Behavior therapy with the caregiver and person with
dementia can facilitate this process.
In a controlled clinical investigation of behavioral treatment for depression in pa-
tients with AD, Teri et al. (1997) compared two active behavioral interventions, one em-
phasizing patient pleasant events (BT-PE) and one emphasizing caregiver problem solving
(BR-PS), to an equal-duration-typical-care control condition (TC) and a wait-list control
(WL). Seventy-two patient–caregiver dyads were randomly assigned to one of the four
conditions and assessed pre-, post-, and at 6-month follow-up. A significant overall treat-
ment effect was obtained for patient depression, F(3,71) = 4.52, p < .001. Post hoc analy-
sis indicated that subjects in the two active treatment conditions (BT-PE and BT-PS) did
not differ significantly from one another, but that each active treatment resulted in signifi-
cant improvement, as compared to the two control conditions.
In this investigation no significant changes were hypothesized for caregivers, because
the focus of intervention was the patients. Unexpectedly, an overall treatment effect was
found for caregiver depression on the Hamilton Depression Rating Scale (HDRS),
F(3,66) = 4.73, p < .01. Post hoc analysis revealed that BT-PE and BT-PS caregivers did
not significantly differ from one another, but that caregivers in either of the active condi-
tions improved significantly more than caregivers in the control conditions.
The clinical significance of change in test scores was also examined by evaluating
change in depression diagnosis. Twenty-five subjects (60%) in the active treatment condi-
tions showed clinically significant improvement, whereas only six subjects (20%) in the
TC or WL conditions showed improvement. Twenty-one subjects in the control condi-
tions (70%) showed no change in diagnosis, and three (10%) worsened. No subject in ac-
tive treatment worsened, χ2(6, n = 72) = 18.48, p < .005.
Six month follow-up data on subjects in the active treatment conditions (BT-PE and
BT-PS) indicated that both patients and caregivers maintained significant improvement
over pretest scores (patient HDRS: F(60,2) = 31.47, p < .001; caregiver HDRS: F(60,2) =
4.28, p < .05). The clinical significance of these change scores was evaluated by examin-
ing depression diagnosis at 6-month follow-up as compared to posttreatment. Twenty-

two (69%) subjects maintained their improvement or improved further, whereas 10
(31%) relapsed during the 6-month follow-up period.
Methods to modify antecedents and alter consequences to depressive behaviors in-
clude the following:
• Increase and encourage enjoyable activities by identifying activities that the person
has enjoyed in the past and modifying them to be appropriate for the patient’s current
level of functioning. The Pleasant Events Schedule—AD (Logsdon & Teri, 1997; Teri &
Logsdon, 1991), a 53-item inventory, was designed to help caregivers identify simple, ev-
eryday pleasant activities that might be incorporated into the daily care of patients with
dementia. Items include being outside, listening to music, having meals with family or
friends, helping around the house, exercising, and going for a ride in the car.
• Use redirection and distraction to help depressed patients stay focused on positive
experiences and pleasant memories. Memory books (Bourgeois, 1992) with pictures of
happier times, reminiscing of pleasant experiences, or having cheerful conversations can
be quite helpful.
• Initiate pleasant social activities that keep the patient alert and involved, such as
outings with someone whose company the patient enjoys, particularly if the patient com-
plains of feeling isolated or lonely. If the patient has had to stop driving, arrange trans-
portation to activities the patient enjoys but is no longer able to attend without assis-
tance.
• Eliminate sources of conflict and frustration by helping caregivers recognize and
modify activities the patient can no longer perform successfully. By ensuring that patients
are not continually challenged and frustrated, sources of conflict and frustration can be
alleviated (and sometimes eliminated), fostering a more contented patient.
• If the patient lives with a caregiver, evaluate and discuss the caregiver’s own affec-
tive state. Depressed patients often have depressed caregivers (Teri & Truax, 1994), and
improving caregiver mood is likely to have a positive outcome on the patient’s behavioral
problems.
Anxiety
Symptoms of anxiety, such as worrying, tension, somatic symptoms, fearfulness, exces-
sive concern about health, anger, irritability, and psychomotor agitation affect between
70 and 90% of patients with dementia at some point during the course of the disease
(Devanand et al., 1997; Lyketsos et al., 2002; Mega et al., 1996). As with depression,
anxiety may have a variety of causes, including physiological, environmental, and inter-
personal triggers. Furthermore, these causes often interact. For example, patients may
have decreased tolerance for stimulation, fearfulness caused by environmental changes,
or decreased inhibition of inappropriate behaviors due to neurological changes. They
may experience anxious or catastrophic reactions in response to environmental triggers
such as overstimulation or activities they do not understand (e.g., being bathed by a care-
giver they do not know or remember). The key to nonpharmacological intervention for
episodes of anxiety is to identify and avoid their triggers, thus reducing their frequency
and impact.
Research on behavioral interventions that specifically target anxiety (as distin-
guished from agitation or other more severe behavioral disturbances) in patients with de-
mentia is virtually nonexistent. In a post hoc analysis of data from the depression treat-
ment study described previously (Teri et al., 1997), anxiety was measured using seven
items from the Schedule for Affective Disorders and Schizophrenia (worrying, somatic
anxiety, psychic anxiety, excessive concern about health, anger, irritability, and psycho-
motor agitation). Fifty percent of subjects experienced at least mild levels of anxiety, and
30% experienced moderate levels of these symptoms. Although the depression interven-
tion did not specifically target anxiety, a significant overall treatment effect on reduction
of anxiety was found, F(1,68) = 17.84, p < .000. Factors predictive of improvement on
anxiety symptoms included behavioral depression treatment (AR2 = .18), lower level
caregiver of burden (AR2 = .03), and lower patient Mini-Mental State Examination
(MMSE) score (AR2 = .08). Thus it appears that for many patients with AD, it is impor-
tant to address both depression and anxiety in evaluating and treating psychological dis-
tress; behavioral treatment may successfully reduce symptoms of both.
Specific methods for modifying antecedents and altering consequences to anxious be-
haviors include the following:
• Identify triggers and intervene early to prevent anxiety and catastrophic reactions.
• Work with caregivers to develop new communication skills; for example, using a
reassuring and gentle voice to help calm the patient. Approach an anxious patient
slowly, from the front, and tell him or her what you are going to do, to avoid star-
tling him or her.
• Distract the patient with questions about the problem and gradually turn his or
her attention to something unrelated and pleasant. Change activities, go to an-
other room, or temporarily leave the situation.
• Use touch judiciously and gently. Sometimes a touch can be reassuring or comfort-
ing to an anxious person. Other times, a touch will be unwelcome and may trigger
an aggressive response.
• Use nonthreatening postures when dealing with an anxious patient. Stand or sit at
eye level, rather than standing over the person.
• Establish a calm, quiet environment with soft lighting and music.
• Avoid arguing or trying to reason with the person to allay anxiety. Arguing almost
always causes anxious behaviors to escalate.
• Avoid physical restraint. Restraints can increase the patient’s perception of threat
and cause anxiety to escalate into agitation or aggression.
Sleep Disturbances
Wandering at night, bedtime agitation, disturbed sleep, and night–day reversal are com-
mon problems for persons with dementia (McCurry et al., 1999). Patients with AD are
more likely to awaken during the night, nap during the day, and in some cases develop
complete day–night sleep pattern reversals (Prinz, Poceta, & McCurry, 2002). Sleep prob-
lems in patients with dementia can be caused by physical conditions such as incontinence
and chronic pain; they are also highly correlated with anxiety and depression (McCurry,
Gibbons, Logsdon, Vitiello, & Teri, 2003b; Vitiello & Borson, 2001). Whatever the
cause, sleep disturbances are very stressful for family members (McCurry et al., 1999).
Caregivers who are awakened frequently during the night to reassure or assist the patient
eventually become exhausted. This exhaustion, and its associated impact on physical and
emotional health, is one of the most common reasons caregivers are forced to institution-
alize their loved ones (Hope, Keene, Gedling, Fairburn, & Jacoby, 1998; Pollak &
Perlick, 1991).
Like depression and anxiety symptoms, sleep disturbances in dementia can have en-
vironmental and behavioral activators that lend themselves well to behavior therapy. For
example, Alessi and colleagues (Alessi, Yoon, Schnelle, Al-Samarrai, & Cruise, 1999)
found that a combination of light physical exercise and other behavioral strategies (e.g.,
keeping patients out of bed in the late afternoon and evening or providing quiet nighttime
incontinence care) produced significant improvements in actigraphic measures of percent
of total sleep and duration of sleep episodes in nursing home residents. There is also a
growing literature suggesting that timed bright light exposure may be helpful in reducing
the sleep disturbances found in institutionalized patients with AD (Ancoli-Israel et al.,
2003; Ancoli-Israel, Martin, Kripke, Marler, & Klauber, 2002; McCurry et al., 2000; van
Someren, Kessler, Mirmiran, & Swaab, 1997).
Two studies conducted in community settings support the efficacy of teaching family
caregivers of patients with dementia to use behavioral interventions for sleep distur-
bances. In the first, subjective caregiver sleep self-reports were improved with a 4- to 6-
week program that provided education about good sleep habits, training in management
of patient nighttime disruptive behaviors, and caregiver support (McCurry et al., 1998).
More recently, a randomized controlled clinical trial, called NITE-AD (Nighttime Insom-
nia Treatment and Education for Alzheimer’s Disease), examined whether caregivers
could carry out a behavioral intervention using structured activity and increased daytime
light exposure to reestablish normal sleep patterns in community-dwelling persons with
dementia (McCurry et al., 2005). Subjects were 36 patients with AD (mean age = 77.7
years; mean AD duration = 5.8 years; 56% male) and their family caregivers, who were
randomly assigned into either an active treatment or a contact control condition. Mean
patient MMSE score was 11.8. Caregivers (mean age = 63.6 years; 72% female; 58%
spouses) reported all patients had at least two sleep problems, occurring three or more
times per week (mean = 4.1; range 2–8 problems).
All participants received six 1-hour in-home treatment sessions over a 2-month
period, which included written information about standard principles of good sleep hy-
giene, sleep changes associated with normal aging, and general strategies for improving
the sleep of persons with dementia. Caregivers in active treatment were also guided to de-
velop a sleep hygiene program for the patient, with a particular emphasis on establishing
a consistent bed and rising time, reducing daytime napping, and walking 30 minutes per
day. Active treatment patients were further instructed to sit for an hour a day in front of a
light box at an exposure level of 2,500 lux during a 3-hour window before each patient’s
habitual bedtime.
Longitudinal analyses were conducted at 3 and 6 months. Patients in active treat-
ment were found to have significantly fewer total nighttime awakenings (p < .05), fewer
awakenings per hour (p < .05), and spent less time awake at night (p < .05) than control
subjects. Forty-four percent of NITE-AD subjects who entered treatment with average
nighttime wakefulness greater than 1 hour were awake less than 1 hour at posttest, com-
pared to 14% of controls, representing a treatment effect size of 0.65 for the primary out-
come in the proposed study. Patient depression on the RMBPC was also significantly
lower (p = .01) at 6 months, compared to control subjects. Of the six patients (17%) who
were institutionalized during the study period, all were either control subjects (n = 4) or
treatment subjects who dropped out immediately after baseline testing (n = 2) before
receiving any active treatment, indicating that behavioral treatment may have a positive
impact on caregivers’ ability to keep patients at home for longer periods of time. These
results support the use of nonpharmacological interventions for sleep problems in
community-dwelling patients with AD (McCurry et al., 2005).
Specific suggestions for modifying antecedents and altering consequences associated
with sleep disturbances in persons with dementia include the following:
• Strive for consistent bedtime and rising times. Regular sleep time habits and rou-
tines help reinforce time cues for individuals with dementia, and may also promote circa-
dian rhythmicity by maximizing cues to the brain’s time-keeping system. Although there
have been no clinical trials demonstrating the value of consistent sleep habits in patients
with dementia, sleep regularity and prevention of sleep disturbances in all older adults are
considered important aspects of the treatment (Taylor, Friedman, Sheikh, & Yesavage,
1997).
• Limit daytime napping. In the later stages of disease, many persons with dementia
spend a significant proportion of their daytime hours asleep (Ancoli-Israel, Klauber,
Gillin, Campbell, & Hofstetter, 1994; Dowling & Wiener, 1997). Reduced daytime nap-
ping, particularly when combined with increased physical activity, can increase the likeli-
hood that the patient will have longer, more consolidated nighttime sleep.
• Restrict use of alcohol and caffeinated beverages (including chocolate products).
When consumed close to bedtime, these can disrupt sleep and exacerbate the preexisting
tendency of patients to awaken more often and spend less time in deep (slow-wave) sleep.
However, a light bedtime snack on foods that promote sleep, such as milk, bananas, or
cheese, may reduce patient awakenings that are caused by nighttime hunger.
• Avoid excessive evening fluid intake and assure emptying of the bladder before
patient retires for the night. For patients with nocturia, scheduled nighttime bathroom
trips can be helpful.
• Eliminate or reduce environmental nuisance factors that may interrupt sleep.
Reductions in light levels and nighttime noise have been shown to be critical for the alle-
viation of sleep disturbances for nursing home residents (Alessi & Schnelle, 2000). In
community home settings, potential environmental causes of disturbed patient sleep that
should also be evaluated include the impact of household pets, live-in adult children or
grandchildren, caregiver snoring, and outside traffic noise.
• Be aware that changes in daily routine, such as family get-togethers or holidays,
may produce a worsening in nighttime sleep. Try to plan ahead and build in some quiet
“catch up” time following any out-of-the-ordinary planned activity.
SUMMARY
In summary, patients with AD and their caregivers are confronted with a variety of affec-
tive disturbances that may have a devastating impact on all involved. It is important for
clinicians to assess the occurrence and impact of these behaviors, in order to best care for
their patients with AD. Measurement tools can augment the clinical interview to help the
practitioner obtain a thorough assessment of behavioral problems and provide a means
of evaluating the success of interventions. Once they are identified, affective problems are
often responsive to a coordinated behavioral treatment plan that teaches caregivers to an-
alyze the antecedents and consequences of behavioral problems and to develop effective
strategies for amelioration. The studies described in this chapter represent a behavioral
treatment approach used in clinical practice and research with community-residing

patients and caregivers. Existing research is promising, and similar interventions have
been used in institutional care settings. Further, these interventions offer an alternative to
pharmacological interventions and are often just as effective as medications, with fewer
side effects. However, we have only just begun to understand and successfully apply be-
havioral treatment to patients with dementia and their caregivers. Additional controlled
clinical research is needed to clarify how to best use these approaches and how to maxi-
mize their effectiveness and clinical significance with this population.
ACKNOWLEDGMENT
Preparation of this chapter was supported in part by grants from the National Institutes of Health
(Nos. AG10483, AG10845, and MH01644).
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17
Behavioral Treatment of Impaired

Functioning and Behavioral Symptoms
ANN LOUISE BARRICK
Most individuals with dementia display behaviors that challenge personal and profes-
sional caregivers. Dementia causes progressive cognitive changes that make a wide range
of behavioral challenges likely. The person may have difficulty carrying out everyday
activities such as looking up a phone number and dialing it, grocery shopping, keeping
track of his or her schedule, or picking up the mail, as described in Marson, Chapter 7,
this volume. The person may also misunderstand what other people say, have difficulty
initiating activities or keeping occupied, have problems sleeping, or may even become
violent. An estimated 23% of individuals over age 65 living in the community have diffi-
culty performing at least one activity of daily living. It is not always clear whether these
deficits are physical, cognitive, environmental, or a combination of these factors (Na-
tional Center for Health Statistics, n.d.).
The accumulation of deficits often leads to nursing home placement. As many as
88% of residents in nursing homes require assistance (National Center for Health Statis-
tics, n.d.). Although the reported prevalence of physically and verbally aggressive behav-
ior varies considerably, depending on methods, as many as 50–90% of persons with mod-
erate to severe dementia exhibit clinically significant behaviors sometime during their
illness (Allen-Burge, Stevens, & Burgio, 1999). Physically and verbally aggressive behav-
iors occur most frequently during assistance with personal care, because these activities
involve touch and invasion of personal space. Such behaviors do not occur in a vacuum;
dementia can best be understood as an interaction of medical, psychological, social, and
environmental processes. Even though we cannot alter the medical mechanism of demen-
tia, we can change how we interact with the person who has dementia as well as aspects
of his or her environment, which may result in a substantial change in the person’s level
of functioning. In the absence of effective biological treatments, behavioral strategies are
often a powerful approach for treating the challenging behaviors that emerge with de-
mentia.
367
This chapter reviews the behavioral symptoms commonly found in persons with de-
mentia and discusses interventions that have been found to be helpful with specific be-
haviors. Strategies for developing individualized behavioral intervention plans are also
described.
TYPES OF BEHAVIORAL SYMPTOMS
Behaviors associated with dementia have been defined in different ways. Early in the dis-
ease process we typically find impairments in functional skills such as higher-level activi-
ties of daily living. As the disease progresses, behaviors requiring intervention have
usually been classified in one of two categories: deficits or excesses.
Behavioral deficits are those behaviors that are absent despite the physical ability to
carry out the components of the behavior. An example would be the failure to self-feed in
a person who has preserved motor control and moderate dementia. Agitation and aggres-
sion are the most common behavioral “excesses” requiring intervention. These disruptive
or problem behaviors include pacing, grabbing, hitting, and verbal abuse. Also included
in this category are screaming and repetitive requests, which have been called disruptive
vocalizations. However, when considering the behavior of a person with dementia within
the context of cognitive impairment, it can be argued that the behavior is actually a
method of communicating and therefore adaptive. The behaviors are not always disrup-
tive, as in pacing or “wandering.” Because these behaviors can teach us about the internal
state of the person and the person’s needs, they may actually be more accurately de-
scribed as behavioral symptoms. The most common behavioral symptoms requiring in-
tervention are described in Table 17.1.
IMPACT OF BEHAVIORAL SYMPTOMS
Behavioral symptoms have been found in individuals who live in both community and in-
stitutional settings. From the perspective of family caregivers, these challenging behaviors
can impact relationships by exacerbating conflicts, increasing anxiety and depression of
the caregiver, and often resulting in institutionalization (Aneshensel, Pearlin, & Schuler,
1993; Davis, 1997; Schulz, O’Brien, Bookwala, & Fleissner, 1995). In fact, behavioral
symptoms have been found to be among the main reasons for institutionalization (Moak
& Fisher, 1990; Petrie, Lawson, & Hollendar, 1982). Nursing facility staff also experi-
ence stress when dealing with these behaviors. Aggressive behaviors are the most distress-
ing form of behavioral symptom that occurs during caregiving (Everitt, Fields, Soumerai,
& Avorn, 1991). Being subjected repeatedly to such behavior has been linked to declines
in physical and mental health status (Miller, 1997), frustration with caregiving (Mentes
& Ferraro, 1989), job dissatisfaction and burnout (Colenda & Hamer, 1991), and turn-
over (Burgio, Butler, & Engel, 1988 ). However, the reaction of staff members differs with
their understanding and interpretation of aggressive behavior within the context of the
disease process and the caregivers’ experience (Hallberg & Norberg, 1993) and is possi-
ble to change (Feldt & Ryden, 1992; Hallberg & Norberg, 1993; Hoeffer, Rader,
McKenzie, Lavelle, & Stewart, 1997). For example, Hoeffer et al. (2005) investigated
caregiver outcomes as part of a larger study of person-centered interventions to reduce
aggression and agitation during bathing. They found that they were able to teach nursing
Impaired Functioning and Behavioral Symptoms 369
TABLE 17.1. Common Behavioral Symptoms in Persons with Dementia

Behavior Examples
Difficulty with personal tasks Failure to dress or bathe self despite physical and cognitive ability
to do so
Urinary incontinence Urinating outside the bathroom facilities; frequent wetness
Sleep problems Difficulty falling asleep, getting up during the night, wakes and
dresses at night, early morning awakening
Wandering Attempts to exit; excessive pacing trying to get to a different place
Agitation General restlessness, excessive fidgeting;, performing repetitive
mannerisms or activities; constant unwarranted requests; resists
ADLs; repeatedly dresses and undresses; picking behavior
Aggression Physical aggression: grabbing, kicking, hitting, and dangerous
assaulted behaviors
Verbal aggression: verbal threats, cursing
Excessive vocalization Loud screaming, excessive self-talk, frequent loud requests
Suspiciousness, paranoia Fear of harm, theft, spousal affair; family/staff seen as imposters;
misinterpreting actions or words of others; talks to the TV
Inappropriate or impulsive Touching another person sexually; excessive requests for sexual
sexual behavior contact; repetitive obscene gestures, remarks; kisses or attempts
to kiss others
Note. ADLs, activities of daily living.
assistants to use a person-centered approach that viewed behaviors as symptoms of un-

met needs. This approach decreased the distress experienced by the nursing assistants and
increased satisfaction with, and preparedness for, assisting during bathing. Improving the
understanding of behavioral symptoms is thus critical to improving the experience of
caregivers as well as the care they give recipients.
Behavioral symptoms can also affect the person with dementia. Additionally, these
behaviors can affect the staff–resident relationship and result in the reduction of
caregiving services (Burgio, 1996) and the avoidance of residents (Meddaugh, 1990). In-
dividuals who display behavioral symptoms tend to deteriorate faster than those without
symptoms.
ETIOLOGY OF BEHAVIORAL SYMPTOMS
One of the most important factors in treating behavioral symptoms in persons with de-
mentia is understanding the triggers or causes of the behavior. These include both per-
sonal and environmental factors and are described below. A list of some of the common
triggers to behavioral symptoms can be found in Table 17.2.
Personal Factors
Neurological Factors
The relationship of cognitive deficits to behavioral symptoms remains somewhat unclear.
For example, not surprisingly, Teri, Borson, Kiyak, & Yamagishi (1989) found that con-
fusion, disorientation, and memory loss were the symptoms most strongly associated
with level of cognitive functioning. Additionally, persons with more cognitive impairment
TABLE 17.2. Common Triggers of Behavioral Symptoms

Emotional/ Cognitive/
Physical psychological Interpersonal Environmental neurological
• Response to • Fear/anxiety • Lack of attention • Overstimulation • Misinterpretation
medication • Depression to personal • Understimulation of environmental
• Pain • Loneliness preferences • Change in routine cues
• Thirst • Boredom • Perceived loss of • Task demands that • Unable to
• Hunger • Grief personal control exceed capacity understand words
• Cold • Frustration • Changes in • Overcrowding • Unable to express
• Acute illness • Irritability caregiver • Noise needs verbally
• Infection • Apathy • Confrontation • Inability to start or
• Touch • Suspiciousness • Rushed approach stop a task
• Fatigue • Perceived invasion • Short attention
• Poor sleep of space span
• Poor vision • Reinforced • Failure to recognize
• Hearing loss dependency caregiver
• Lack of insight
• Impaired decision
making
• Poor impulse
control
had more difficulties with instrumental activities. However, in this study, no single behav-
ioral symptom such as aggression was related to overall level of cognitive impairment.
Other authors have found that the types of behavioral symptoms vary with the level
of cognitive impairment. Wandering has been associated with greater cognitive impair-
ment in language, memory, orientation, and concentration (Algase, 1992). Hoeffer et al.
(1997) reported that physical aggression was more common during caregiver activities
among persons with moderate to severe levels of dementia. Barrick, Rader, Hoeffer, and
Sloane (2002) reported different kinds of behavioral symptoms during bathing at differ-
ent stages of dementia. For example, a person in the early stages of dementia is more
likely to verbally refuse the bath by saying, “I’ve already had a bath.” Persons with mod-
erate dementia may say “Stop!” as they approach the bathroom or hold firmly to the
doorjamb and refuse to enter the bathroom. Severely demented persons often moan or
cry when they enter the bathroom. Matteson, Linton, and Barnes (1997) prescribed be-
havioral interventions based on the Piaget model, suggesting that interventions could be
linked to disease stage.
Behavioral symptoms have also been associated with different disorders. For exam-
ple, in Alzheimer’s disease (AD), agitation and psychosis have been associated with
neurofibrillary tangles in the frontal lobes (Tekin et al., 2001). Persons with fronto-
temporal dementia (FTD) are often apathetic or disinhibited (Levy et al., 1996). Other
symptoms seen in FTD include inappropriate affect with unusual laughter, tactlessness,
and lack of concern for others. The neurobehavioral features of vascular dementia are
variable; psychomotor retardation and emotional lability are common. These illnesses are
detailed in Welsh-Bohmer and Warren (Chapter 3, this volume).
Persons with central nervous system dysfunction frequently misinterpret what others
are doing or saying and can respond in a way that is inappropriate to the situation. For
example, disinhibition from neurological damage may cause some persons to engage in
inappropriate sexual behavior. Misperception may result in such behaviors as a woman
following a man she thinks is her husband. The man, not recognizing her or understand-
ing that she is cognitively impaired, may then hit the woman in an effort to keep her
away from him. Other behaviors may actually be the result of self-care deficits, as when a
person with dementia looks disheveled and is unaware of his or her poor hygiene.
Physical Factors
Several basic physical factors can trigger or worsen behavioral symptoms (Hall, Gerdner,
Zwygart-Stauffacher, & Buckwalter, 1995). These include fatigue, pain, infection, acute
illness, and sensory and perceptual deficits. Infectious or other processes may cause delir-
ium and a sudden change in behavior. Urinary tract infections can produce pain that may
go undetected because the person is unable to express discomfort. Other frequent causes
of pain include arthritis, osteoporosis, back problems, constipation, contractures, and
dental problems. The anticipation of pain has also been reported as a cause of behavioral
symptoms (Cohen-Mansfield et al., 1990b). Other sources of discomfort include sensitiv-
ity to cold, sensitive skin and feet, and problems with mobility such as stiffness on move-
ment.
Sensory and perceptual deficits may affect perception of situations or requests. For
example, a person may not have a hearing aid turned on during personal care and there-
fore be unable to understand what the caregiver is telling him or her. He or she may
respond aggressively out of fear and a perceived need for self-defense. Perceptual deficits
can also make it difficult for a person to do such tasks as sitting down in a bathtub.
Visual neglect due to a stroke may contribute to poor food intake and other deficits in
self-care.
Emotional/Psychological Factors
Several emotions are related to the occurrence of behavioral symptoms. Frustration with
ability to perform daily tasks independently has been reported to cause behavioral symp-
toms (Cohen-Mansfield, Marx, & Rosenthal, 1990). Swearer, Drachman, O’Donnell,
and Mitchell (1988) noted that angry outbursts were significantly related to anxiety. A
cognitively impaired person may misjudge the dangerousness of a situation, and this error
in judgment may result in anxiety. Given the limited ability of the person to cope with
anxiety-provoking situations, he or she may become aggressive.
Other behaviors, particularly those not related to suffering, such as aimless wan-
dering, occur under normal conditions and may be adaptive and provide stimulation.
Individual differences that have been associated with wandering behavior include stress
and coping patterns and tendencies toward greater socialization needs (Goldsmith,
Hoeffer, & Rader, 1995). Although wandering can cause safety and health problems, it
also provides both stimulation and exercise and is therefore reinforcing for residents of
nursing homes (Cohen-Mansfield et al., 1998). Individuals find different objects, such
as doorknobs, to touch and rub as they explore their environment, or they may be fol-
lowing other persons who are walking around, modeling the behavior they see from
others.
Interpersonal Factors
Relationships with individuals in the care environment can often trigger dependency or
distress. Behavioral deficits are often the result of interpersonal factors. Available evi-
dence suggests that there is a relationship between functional abilities and the need for in-
terpersonal contact in residents in nursing homes (Willis et al., 1998). Everyday tasks
such as bathing and dressing involve social interaction with staff. Dependency is rein-
forced as it increases staff contact (Baltes & Baltes, 1990). Baltes labeled the patterns of
overcare displayed by caregivers the dependency–support script (Baltes & Wahl, 1992).
Older adults learn that being dependent allows them to gain control, attention from oth-
ers, and the opportunity to choose where to expend their energies.
Caregivers may also reinforce many dependent behaviors when they underestimate
the person’s resources and provide more care than is necessary (Baltes & Werner-Wahl,
1987). Caregivers, believing that older adults are in need of help, may feel altruistic pro-
viding this assistance. However, this extension of assistance can result in increased social,
physical, and psychological dependency (Wilson, Cockburn, & Halligan, 1987). Neu-
mann (as cited in Baltes & Werner-Wahl, 1987) also found that staff in institutions gave
immediate help to residents rather than giving them time to perform the task independ-
ently, thus reinforcing dependent behavior. There is pressure to complete tasks quickly,
such as dressing or bathing, and caregivers often find it faster to provide extensive assis-
tance to the person rather than encouraging independence, thus reinforcing passive–
dependent behaviors.
Studies of resistive and aggressive behavior during activities of daily living (ADLs)
indicate that caregivers often unknowingly initiate or perpetuate inappropriate responses.
Caregiver behaviors that impact the relationship include tone of voice, facial expressions,
and gestures that often communicate more than words. Burgener and colleagues
(Burgener, Jirove, Murrell, & Barton, 1992) found that rigid and tense caregiver behav-
iors were significantly associated with agitated behaviors, whereas relaxed and smiling
caregiver behaviors during ADL care were significantly associated with calm and attend-
ing behaviors of residents. Change of caregiver can also trigger behavioral symptoms
(Hall et al., 1995). Other documented causes of behavioral symptoms, particularly ag-
gression toward staff during care include touch or the invasion of personal space (Marx,
Werner, & Cohen-Mansfield, 1989; Rossby, Beck, & Heacock, 1992; Ryden, Bossen-
maier, & McLachlan, 1991), perceived loss of personal control or choice (Meddaugh,
1990; Winger, Schirm, & Steward, 1987), efforts to attain or share control (Kovach &
Meyer-Arnold, 1996), attempts to avoid a stimulus such as a nurse’s request (Bridges-
Parlet, Knopman, & Thompson, 1994), and lack of attention to personal needs or prefer-
ences (Chrisman, Tabar, Whall, & Booth, 1991). Social factors such as poor quality of
relationships or a decrease in social contacts have also been predictive of a change in
aggression (Cohen-Mansfield & Werner, 1998). Finally, providing less compensation for
the person’s disabilities—in other words, doing less for the person—has been related to
calmer and more functional behaviors (Burgener et al., 1992).
Environmental Factors
The environment can impact behavior; ADL deficits may be related to the surrounding
environment. An environment that demands more independence or presents more stimuli
than a person with cognitive deficits is capable of managing may result in maladaptive or
reduced functioning. For example, too many clothing choices may overwhelm the person,
leaving him or her unable to make a decision. Equipment may not match physical needs;
for example, the handles on eating utensils may be too small to grasp easily. Shower
chairs may be unpadded and cause pain. Other physical environmental factors that con-
tribute to behavioral symptoms include lighting, noise level, temperature of the room,
cluttered or crowded space, and unpleasant odors.
Rigid administrative policies and practices impact behavior and the environment of
care. Both anecdotal and research findings report that task completion and adherence to
a strict care schedule are often a priority. A philosophy of care that does not allow for
flexibility in determining when and how care activities such as dressing and bathing are
performed may result in residents feeling coerced, triggering aggression or agitation. An
emphasis on the completion of personal care tasks, at the expense of the emotional needs
of the person, can have a similar result.
THE INTERVENTION PROCESS
Behavioral treatments have been found to be effective for many different behaviors.
Nonpharmacological interventions are often used because they avoid the adverse side ef-
fects and drug–drug interactions of medications. In addition, medications have limited ef-
ficacy in treating these problems. In persons with dementia, it is sometimes possible to
use a traditional behavioral approach and intervene directly. Following are helpful types
of interventions:
• Differential reinforcement of other behavior (DRO). Reinforce the nonoccurrence

of a prespecified problem behavior by scheduling reinforcement on a fixed interval
of time and omitting the next scheduled reinforcer if the problem behavior occurs
during the interval.
• Extinction of positively reinforced behavior. Identify a reinforcer that maintains a
problem behavior and remove it.
• Stimulus control. Reinforce a behavior only in the presence of an antecedent event
or stimulus that facilitates the behavior, and provide no reinforcement in the ab-
sence of that stimulus. This approach is helpful when a behavior exists but in the
wrong situations, or occurs too frequently or not frequently enough.
• Shaping. Reinforce successive approximations to desired behavior, until the de-
sired behavior occurs.
• Prompting. Provide extra verbal or physical cues to elicit the behavior. Prompts
for appropriate behavior may include gesturing or pointing, verbalizations, man-
ual guidance, and praise for desired behavior. Once the behavior occurs consis-
tently with prompting, the caregiver needs to fade out prompts until the behavior
occurs without prompts.
For example, independence in ADL care (e.g., dressing, bathing) may be increased
by giving prompts for each step of the process (prompting). Providing a reinforcer,
such as giving praise or something to eat, when the person performs each step of the
process can be used to shape behavior. For example, a person fearful of bathing in the
tub can be given candy as a reinforcer for each successive step toward the goal of
bathing in the tub. Or if a person has too many somatic complaints, it may be helpful
to establish a plan allowing the person to make these complaints only to the nurse
(stimulus control).
More often when working with someone who has dementia, impairments in mem-
ory, communication, and reasoning limit the effectiveness of behavioral interventions that
require learning new information, language comprehension, or the formation of insights.
It is then necessary to focus on preventing maladaptive behavior by changing the environ-
ment or how other people respond to the person to optimize the person’s functioning.
Moreover, behaviors may look alike (e.g., hitting by two different persons) but have very
different etiologies and respond to very different interventions. The main objective is to
identify treatable or modifiable aspects of the particular situation for the individual and
develop a plan that promotes specific, individualized goals.
Behavioral interventions focus on the interaction between the person and the envi-
ronment. The process includes three steps: (1) assessment to identify the behavior and
factors related to its occurrence; (2) development and implementation of the plan; and
(3) monitoring and revising the plan, as needed. Treatment recommendations are de-
signed to change antecedent conditions and/or provide different consequences for dif-
ferent responses in order to compensate for losses while preserving remaining abilities.
Monitoring is essential to track the success of the plan and guide the revision process.
Assessment
Understanding the Person
Knowing as much as possible about the person will help determine why the behavior
might be occurring as well as develop individualized strategies to change it. The most
common personal causes of distress and behavioral symptoms are related to physical and
emotional needs and problems related to cognitive deficits. Identification of factors such
as physical health, personality, psychosocial well-being and mood, personal history, and
neurocognitive deficits is essential to understanding the behavior and developing a plan
that will be effective. The assessment described in Marson and Hebert (Chapter 7, this
volume) provides much of the information about personal factors that may be associated
with behavioral symptoms.
Describing the Behavior

The assessment begins with identifying the behavior. Many scales have been developed that
focus on the identification of target behaviors and the frequency and intensity of these be-
haviors in older adults. These scales are useful for obtaining baseline levels of behavior and
for monitoring the effects of interventions. Instruments vary in length, time frames, do-
mains covered, and ease of administration. The final choice of instrument depends on the
purpose of the assessment. Those with adequate interrater reliability and demonstrated use-
fulness in the assessment of behavioral symptoms are listed in Table 17.3.
As with all geriatric cases, it is helpful to consult with those who know the person
best. Sources of information include the family; friends; other caregivers; other staff such
as housekeepers, social workers, activity coordinators; and the medical record. If the per-
son is only mildly impaired, he or she can provide useful input as well. Ratings can be
subjective, with some informants underreporting and others overreporting, depending on
their level of stress and their beliefs about the consequences of the assessment. However,
if accuracy can be stressed, they can provide useful data to measure the occurrence of be-
haviors and the effect of interventions.
TABLE 17.3. Sample of Behavior Rating Scales for Older Adults

Primary Population
Scale name reference Rater source rated Behaviors measured
Behavioral Reisberg et al. Clinician Patients with Paranoid and delusional
Pathology in (1987) (interview with AD ideation, hallucinations,
Alzheimer’s Disease patient and activity disturbance,
Scale (BEHAVE- caregiver) aggressiveness, diurnal
AD) disturbance, and anxieties/
phobias exhibited 2 weeks
prior to interview and global
rating of distress to
caregiver
Caretaker Drachman Caregiver Outpatients, Frequency and severity of

Obstreperous et al. (1992) (questionnaire) nursing home aggressive/assaultive
Behavior Rating residents, with behavior, disordered ideas/
Assessment Scale dementia personality, mechanical/
(COBRA) motor and vegetative
behaviors (including hyper/
hyposexuality)
Cohen-Mansfield Cohen- Nursing staff Nursing home Frequency of physical

Agitation Inventory Mansfield residents aggression toward self or
(CMAI) et al. (1989) others; physically or verbally
disruptive, but not
aggressive, behavior; socially
inappropriate behaviors
Cornell Scale for Alexopoulos Clinician Older adults A broad spectrum of

Depression in et al. (1988) (interview with with dementia depressive signs and
Dementia (CSDD) caregiver) or symptoms observed during
caregiver the prior week: mood-
questionnaire related signs, behavior
disturbance, physical signs,
cyclic disturbance, and
ideational disturbance
Dementia Behavior Baumgarten Clinician Community- Frequency of a broad range

Disturbance Scale et al. (1990) (interview with residing older of behaviors
(DBD) caregiver) or adults
caregiver
questionnaire
Disruptive Mungas et al. Nursing staff Nursing home Severity of verbally and
Behavior Rating (1989) residents physically aggressive
Scale (DBRS) behaviors, agitation, and
wandering; Ratings made
weekly
Pittsburgh Burgio et al. Direct Older adults Aberrant vocalizations,

Agitation Scale (1994) observation by with dementia motor agitation,
clinical staff aggressiveness, and resisting
care
Pleasant Events Teri & Caregiver Outpatients Helps identify and monitor
Schedule—AD Logsdon (questionnaire) with AD participation in pleasurable
(PES-AD) (1991) activities
Ryden Aggression Ryden (1988) Caregiver Community- Frequency of physical,

Scale (RAS) (questionnaire) residing older verbal, and sexual
adults aggression
Looking for Causes

Behavioral symptoms can be caused by antecedent factors that trigger the behavior; they
can also be the result of consequences that maintain the behavior through positive or neg-
ative reinforcement. Rarely is there only one cause to a behavior. Identification of the
causes of the symptoms can be particularly challenging when an individual has a degener-
ative condition such as AD, because similar behaviors may have different etiologies over
the course of the disease. Given the significant variation in cognitive abilities and health
of older adults, the identification of the causes of behavioral symptoms is best considered
within an interactional model that includes personal, interpersonal, and environmental
factors. The Behavior Observation Record (BOR) or the Behavior Tracking Log (BTL)
(see Figures 17.1 and 17.2) can be used when assessing these factors. Observations re-
lated to the ABC’s of behavior as well as the duration of specific behaviors are docu-
mented on the BOR. The behavior, its antecedents, any interventions tried, and the per-
son’s response to interventions are recorded over the course of a 24-hour period on the
BTL. Using these kinds of tools can give the clinician a baseline measure of the percentage
of time in which the behavior is occurring as well as clues to the causes of the behavior.
Other data-gathering tools can also be designed. The important point is to select a
method that will provide reasonably accurate data on the factors described below.
Personal Factors. Assessing and treating physical symptoms first may eliminate the
behavior and avoid the need for more in-depth assessment. For example, does the person
have a urinary track infection or is he or she dehydrated? If pain is suspected, it would be
helpful to complete a thorough pain assessment. If the person is able to communicate,
use a verbally administered questionnaire such as the McGill Pain Questionnaire
(Melzack, 1975). If the person is severely impaired, it is usually necessary to rely on direct
observation methods, such as the Discomfort Scale—Dementia of the Alzheimer’s Type
(Hurley, Volcier, Hanrahan, Houde, & Volcier, 1992). In addition, the direct caregiver
can complete a pain flow sheet with all possible behavioral manifestations of the pain
experience.
It is important to consider medications and any changes in them. Older adults are at in-
creased risk for iatrogenic effects associated with drug toxicity, drug interactions, and drug
withdrawal. (Gerdner & Buckwalter, 1994). One medication may negate or alter the effects
of another and result in behavioral symptoms. Neuroleptics, benzodiazepines, and nonpre-
scription medication with anticholinergic properties have been found to contribute to agita-
tion in older adults (Fisher, Swingen, & Harsin, 2001). Psychiatric review of medications
can often be quite instrumental in identifying the causes of behavioral symptoms.
There is a great deal of variance in how people with dementia communicate their
psychological needs. Watch for signals that suggest that the person is generally fearful or
afraid of specific objects or events. Look for such clues as wide open eyes, open or tense
mouth, or eyebrows in a straight line. The need for control may be expressed through de-
mands, threats, or refusals to cooperate. Depression may be expressed through restless-
ness, irritability, numerous complaints, and lack of interest in doing things or being with
people. Always keep in mind the personal history and preferences of the individual. For
example, a resident of a facility who refused to attend activities went happily when given
the role of “judge” of a teddy bear contest. She was used to being “in charge,” and the
role fit her perception of herself. A person who has always bathed in the evening may re-
fuse a bath offered in the morning but accept it in the evening, just before bedtime.
Patient: Date:
Behavior(s) being monitored:
Location:
Date Time ANTECEDENT BEHAVIOR Duration CONSEQUENCE

What was Describe what the of the What happened
going on before person did. incident after, or as a result
the behavior? (minutes) of, the behavior?
What did peers or
staff say or do?
FIGURE 17.1. Behavior observation record.
Interpersonal Factors. Relationships with individuals in the care environment can

often trigger distress. Watch to see if caregivers respond promptly with apologies or
change of technique to complaints of pain or cold. Are caregivers calm or moving too
fast, frowning, or talking to someone else in the room? Does the person get caregiver at-
tention only when this behavior occurs? Does the level of assistance fit the needs of the
person? Do the behaviors occur only when specific caregivers are present? Are interac-
tions culturally appropriate?
Environmental Factors. Assess all aspects of the environment in order to understand

causes of behavioral symptoms. Check to see if there is enough nonglare lighting for the
older person to be able to see, that room temperature and the equipment are comfortable,
and that the area is not noisy or cluttered. Do the demands of the environment exceed
the person’s ability to cope? Does the behavior result in the termination of the task
and removal of an aversive stimuli? Assess the effect on the behavior of the daily sched-
ule, caregiver support and education, and the availability of adaptive equipment and sup-
plies.
Name/Date:
BEHAVIOR: 1 = calm 2 = yelling 3 = cursing 4 = physically 5 = other—
aggressive describe
INTERVENTION: 1 = 1:1 2 = music 3 = offered 4 = ignored 5 = distracted 6 = other—
snack with activity describe
RESULTS: 1 = made it 2 = didn’t 3 = helped
worse help
Time Behavior If not calm, what happened Interventions Results Initials
(trigger) before he/she tried
became upset?
6:00 A.M.–
7:00 A.M.
7:00 A.M.–
8:00 A.M.
8:00 A.M.–
9:00 A.M.
9:00 A.M.–
10:00 A.M.
10:00 A.M.–
11:00 A.M.
11:00 A.M.–
12:00 noon
12:00 noon–
1:00 P.M.
1:00 P.M.–
2:00 P.M.
2:00 P.M.–
3:00 P.M.
3:00 P.M.–
4:00 P.M.
4:00 P.M.–
5:00 P.M.
5:00 P.M.–
6:00 P.M.
6:00 P.M.–
7:00 P.M.
7:00 P.M.–
8:00 P.M.
8:00 P.M.–
9:00 P.M.
9:00 P.M.–
10:00 P.M.
10:00 P.M.–
11:00 P.M.
11:00 P.M.–
12:00 A.M.
12:00 A.M.–
1:00 A.M.
1:00 A.M.–
2:00 A.M.
2:00 A.M.–
3:00 A.M.
3:00 A.M.–
4:00 A.M.
4:00 A.M.–
5:00 A.M.
5:00 A.M.–
6:00 A.M.
FIGURE 17.2. Behavior tracking log.

INTERVENTION PLANNING AND IMPLEMENTATION
Behavior can have many causes and respond to different interventions depending on
whether the cause is personal, interpersonal, environmental, or a combination of these
factors. When developing a plan, utilize available data to specify goals and interventions,
monitor the results, and revise the plan as needed.
Behavioral Interventions in the Literature

Research is available on methods of addressing functional behavioral deficits such as
incontinence, sleep disturbances, wandering, physical and verbal aggression, excessive
vocalizations, and inappropriate sexual behavior. Much of this research has limitations
due to small samples and the implementation of interventions by research staff rather
than regular staff. However, there are many promising interventions. Overall, the studies
that show the most promise incorporate comprehensive environmental interventions with
careful assessment of the individual.
Behavioral Deficits
Independence in self-care skills such as bathing, eating, dressing, and toileting are im-
portant for older adults living in the community as well as those in nursing facilities.
Various types of behavioral approaches have been used to increase these self-help be-
haviors. Operant techniques such as verbal prompting, combined with stimulus con-
trol, immediate reinforcement, and time out for inappropriate behavior, have resulted
in an increase in self-feeding (Baltes & Zerbe, 1976). Hussian and Davis (1985) were
able to increase appropriate eating behavior by reinforcing these behaviors with favor-
ite foods or drinks.
A series of studies conducted by Cornelia Beck and her associates over several years
has demonstrated that behavioral interventions can increase the functional ability of per-
sons with cognitive impairment. Seven out of eight cognitively impaired persons living at
home required less assistance with dressing after caregivers were taught behavioral strate-
gies such as stimulus control, reinforcement, and verbal prompts to increase independ-
ence of participants (Beck, 1988). Similar results were found in long-term care studies
(Beck, Heacock, Rapp, & Mercer, 1993).
Hussian and Davis (1985) suggested the use of stimulus control to increase dressing
and grooming competence in persons with severe memory loss. These activities were per-
formed in a consistent manner, at the same time each day, in the same area, with the same
materials. Performing these tasks in the presence of a specific antecedent stimulus (i.e.,
the same area, the same materials) increased the likelihood that the behavior would occur.
Urinary Incontinence
Prompted voiding, a procedure that uses verbal prompts and positive reinforcement, has
been successful in improving bladder control. However, studies are very limited. Adkins
and Mathews (1997) taught in-home caregivers to use prompted voiding to reduce the in-
continence of two cognitively impaired older adults. Hussian (1981) successfully used
stimulus control, feedback, and positive reinforcement contingent on appropriate voiding
to reduce urinary incontinence in 12 residents of a long-term care facility. Residents were
toileted 15 minutes after awakening, every hour unless no voiding occurred in 4 hours,
then every half hour, then every 15 minutes after an accident. Residents were praised for
dryness and told if they had not voided or if they were wet. Although successful with
some persons, such a prompted voiding system is difficult to maintain and requires a spe-
cialized program with careful monitoring and supervisory feedback to staff when done in
facilities.
Sleep Disturbance
Environmental interventions have also been effective in increasing sleep. For example,
Alessi et al. (1999) increased daytime activities and introduced a nighttime program to
decrease disruptive noises; this approach resulted in a 10% increase in nighttime sleep
and a 32% decrease in time in bed during the day. White noise has been effective in some
cases in decreasing nocturnal wandering and increasing sleep (Young, Muir-Nash, &
Ninos, 1988).
Physically Aggressive Behaviors

Techniques such as differential reinforcement of incompatible behavior (DRI) and stimu-
lation have been effective in reducing aggression. Rosenberger and MacLean (1983) were
able to reduce the aggressive behavior of a 79-year-old stroke patient who was partially
paralyzed by using DRI. Prior to the intervention, this person received caregiver attention
primarily when she was aggressive toward others; this pattern seemed to be maintaining
the behavior. The plan involved staff members greeting and praising her for appropriate
behaviors. Aggressive behaviors were followed by brief periods of time out. In 3 weeks
the woman was no longer aggressive. Fisher (1995) found that aggressive behavior was
an effort to escape from an aversive situation or event. Reducing the anxiety-provoking
characteristics of the demand tasks was accomplished by the use of a stimulus to distract
the person from the aversive situation. For example, during caregiving activities persons
with dementia were presented with a stimulus that interested them, such as a live animal,
a magazine, or a stuffed toy. This added stimulus altered the situation, refocused atten-
tion, and reduced aggression.
Behavioral techniques designed to fit individual resident needs have also been suc-
cessful in the reduction of physical aggression (Burgio & Bourgeois, 1992; Burgio &
Stevens, 1999; Sloane et al., 2004). For example, in a controlled trial of two bathing in-
terventions in 15 nursing homes, Sloane et al. (2004) found a 29% reduction in the rate
of physical aggression during showering of persons with dementia. Personal, interper-
sonal, and environmental factors were examined to determine antecedents and conse-
quences of aggressive and agitated behaviors. This information was used to develop a
person-centered care plan that focused on patient comfort and preferences. The caregiver
sought to individualize the experience of the bath to change the bathing environment and
meet the physical and emotional needs of the person by using the wide variety of tech-
niques that modified the setting events or antecedent stimuli. These included such simple
changes as covering the person with towels to maintain warmth, distracting attention
(e.g., providing food), using bathing products recommended by family and staff, using
no-rinse soap, offering choices, and modifying the shower spray to soften its impact. Sim-
ilar results were found in a small sample intervention study with 10 intermediate care res-
idents by Hoeffer et al. (1997). In both studies the larger interpersonal and environmental
systems in which physically aggressive behaviors occurred were considered when devel-
oping the intervention.
Wandering
Environmental interventions have been useful in curbing wandering behavior. The use of
a stimulus control, such as a picture of a toilet on the bathroom door, as well as contin-
gent staff attention for nonwandering have shown some success in reducing wandering
(Hussian, 1981; Hussian & Davis, 1985). Cohen-Mansfield and Werner (1998) enhanced
the nursing home environment with visual, auditory, and olfactory stimuli that simulated
the home and natural outdoor environment. Results indicated that residents spent more
time in enhanced environments than regular nursing home space. There were also trends
toward less trespassing, exit seeking, and agitated behavior as well as an increase in plea-
sure when the residents were at the nature scene in comparison with the regular nursing
home unit. Rather than try to reduce wandering, Burgio, Cotter, and Stevens (1996) pro-
vided residents of a nursing facility with a secure place to walk.
Another intervention to decrease wandering is increasing staff–resident interactions.
Goldsmith et al. (1995) reported that an increase in the amount of staff time spent inter-
acting with residents reduced wandering behavior. Similarly, Okawa et al. (1991) found a
30% reduction in wandering of persons with dementia with increasing social interaction
with nursing staff.
Finally, Heard and Watson (as cited in Cohen-Mansfield, 2001) used differential re-
inforcement and extinction to reduce wandering. Tangible reinforcers (e.g., food) and at-
tention were given when subjects were not wandering
Excessive Vocalizations
Excessive vocalizations are often the result of overstimulation, understimulation, or affec-
tive or physiological pain. When excessive vocalizations were thought to result from a
lack of, or excess, environmental stimulation, Burgio et al. (1994) tried adding auditory
and tactile stimulation, but none of their interventions was reliably associated with de-
crease in the vocalizations. However, the researchers noted that some subjects responded
to each of the interventions, suggesting that an individualized approach is necessary. An
unexpected finding of this study revealed that residents under the hairdryer had a very
low rate of vocalizations, suggesting that white noise might be effective in reducing vocal-
izations. Burgio, Scilley, Harding, Hsu, and Yancy (1996) piloted the use of white noise
by using gentle ocean and mountain stream audio tapes, played through headphones, to
decrease the frequency of vocalizations among residents displaying significant baseline
rates of vocalizations. Although this was a very small study, there was a 23% decrease in
vocalizations when listening to the audiotapes.
Buchanan and Fisher (2002) reported a decrease in excessive vocalizations by two
elderly persons with dementia who were residing in a nursing home. These researchers
used noncontingent reinforcement (NCR), a procedure that involves presenting a stimu-
lus with a known reinforcing value on a specific schedule regardless of what the person is
doing. A functional analysis was performed to determine stimuli that were reinforcing.
Music and attention were provided continuously to one subject, and attention alone on a
fixed schedule (every 160 seconds) to the other subject. The intervention resulted in a de-
crease in vocalizations for both subjects. Unfortunately, only modest reductions were
achieved for the second subject, despite a significant amount of attention. Behavioral
techniques can thus be effective. However, as this study highlights, the positive effects
gained need to be considered within the context of the labor required to accomplish the
results. In situations where the behavior is very disruptive, it is often worth the added ef-
fort and improves the quality of life of all involved.
Woods and Ashley (1995) reported a significant reduction of vocalizations through
the use of simulated presence therapy (SPT). A “significant other’s” presence is simulated
in the person’s environment via an audiotape that plays half of a normal spontaneous
conversation and recounts cherished memories. Nursing staff turned on the audiotape
when an individual’s vocalizations were most likely to occur. Audiotape use is intended to
increase social interaction. Other studies have not found significant results using SPT.
However, treatment fidelity data indicated very low use of the audiotapes, which may
have contributed to the lack of significant results. Video respite (VR), a technique involv-
ing simple, engaging videotapes made professionally or informally by family members,
has been used as a distraction for older adults with vocalizations. Lund, Hill, Caserta,
and Wright (1995) reported a decrease in vocalizations and agitation with the use both a
53-minute music tape made by a professional music therapist inviting the listener to sing
along, and a 33-minute “friendly visitor” tape that asked questions about familiar things
such as parents, childhood, animals, and holidays. Although these studies have limita-
tions, the interventions show promise and are being investigated in newer, better con-
trolled studies.
Sexually Inappropriate Behavior

Although relatively infrequent, when this behavior does occur, it is particularly trouble-
some to family members and observers. Few studies of behavioral techniques to manage
this behavior have been conducted. Stimulus control has been effective with brain-injured
clients (Zencius, Wesolowshki, Burke, & Hough, 1990) and may be helpful in persons
with dementia.
Goal Setting
Behavioral interventions are designed to change factors in the environment in order to
eliminate, decrease, increase, or change countable and observable behaviors. Identify spe-
cific, measurable changes in the behavior that indicate that the intervention has been suc-
cessful in meeting the goal. These can described in terms of an increase in positive behav-
iors, such as engagement in conversation when approached by a caregiver for a person
who has been withdrawn. They may also be stated as a decrease in the number of nega-
tive behaviors, such as the number of times a person hits or yells in a specified time
frame.
Developing the Plan

Information gathered during the assessment phase should be used to develop hypothe-
ses about the factors related to the behavior. For example, a person’s polite refusal to
take a bath may be ignored by the caregiver. This failure to comply with the person’s
wishes may lead to resistance or aggression when the caregiver attempts to proceed
with the unwanted bath. Interventions are designed using hypotheses regarding the eti-
ology of the behavior as well as knowledge of the person’s skills, deficits, and prefer-
ences. For instance, if it appears that the person’s behavior is the result of specific cog-
nitive deficits, a method for utilizing the person’s cognitive strengths to compensate for
these deficits should be devised. If the person’s distress is caused by pain, treatment of
physical illnesses and medication adjustments may be needed. Other interventions for
pain include altering the response of caregivers or suggesting the purchase of different
equipment and supplies. As stated in Attix (Chapter 10, this volume), interventions
must be developed with input from those involved and be both practical and realistic.
Discuss the pros and cons of each potential intervention with the caregiver to judge
which is most likely to be effective.
Monitoring and Revising the Plan

Once interventions have been implemented, monitor the results closely. Data on the suc-
cess of the interventions can be gathered on the same instruments used for assessment, or
a special record sheet can be developed and completed by the caregiver. Other useful tools
for monitoring progress and assess changes in antecedents and consequences of the be-
havior are the BTL and the BOR (see Figures 17.1 and 17.2).
If the plan is successful and the behavior improves, continue with the plan. If the tar-
geted behavior gets worse or does not improve, then look for other possible causes and inter-
ventions. Change the plan as new hypotheses emerge. For example, a Spanish-speaking,
cognitively impaired patient at a local hospital refused to wear his identification bracelet.
Because this bracelet was essential for identification of his medications and other treat-
ments, the team referred the patient for a behavior plan. On initial assessment, we learned
from an interpreter that the reason for the refusal was that the patient’s name was misspelled.
A new bracelet was made, but the patient still would not wear it. When talking with nursing
staff, we learned that the patient liked jewelry. A metal identification bracelet was consid-
ered, but we decided to try a watch with the patient’s name and hospital number on the band
first, because it would be something that was familiar to the patient. The patient was de-
lighted with his new watch and has been wearing it without problem for over 2 months.
The intervention planning and implementation process is highlighted in a case study
described in Table 17.4. As with many cases, working with the person involved a trial-
and-error process, and the initial plan needed revision. However, the result was an indi-
vidualized bathing care plan that kept Mrs. P comfortable and warm. She no longer cried
in the shower, and her complaints of pain and cold were greatly reduced.
GENERAL GUIDELINES AND TIPS FOR SPECIFIC BEHAVIORAL SYMPTOMS
Simple interventions can often be surprisingly effective in reducing behavioral symptoms.

Although similar behaviors may have different etiologies and meanings for different indi-
viduals, there are some general strategies that are helpful when working who display per-
sons with behavioral symptoms. These include the following:
• Assess and treat physical factors first. Changes in medication, sudden illness, nu-
tritional deficiency, and sensory/perceptual changes can all impact the person’s be-
havior. Check these before initiating behavioral treatment.
TABLE 17.4. Case Study of Implementation and Planning

Describe the behavior
Mrs. P did not want to shower and refused to be showered at least 50% of the time. She had an
odor, her hair looked dirty, and her son asked that she be showered more frequently. When
transferred to the shower chair, she looked anxious and shouted. While being showered, she cried
and complained of pain and being cold almost constantly. She also asked staff to hurry up.
Sometimes she mixed up words, saying, for example, that the water was too hot when she really
meant too cold.
Describe personal factors

Mrs. P was 93 years old and very proud of having been a school teacher. She had one son, who
visited regularly. She had been very active in her church and had also enjoyed reading, cooking, and
baking. She made women’s clothes, liked fashion, and was careful about her appearance. She had
entered a nursing home 2 years prior, after fracturing her hip. Her affect was usually bright and she
enjoyed activities and visiting with friends and family. Her diagnoses included arthritis, peripheral
neuropathy (from diabetes), limited vision and hearing, and AD. The diabetes was controlled by diet.
She had an order for acetaminophen four times a day, as necessary, for pain, but she rarely received
it. She was nonambulatory and incontinent of both urine and stool. She could feed herself but
required assistance. Neuropsychological testing was not done because the diagnosis was clear. She
had severe deficits in memory and executive functioning. She could understand one-step instructions
but sometimes had difficulty expressing her needs verbally. She lacked insight into her deficits but
was cooperative with care, with the exception of showering.
Describe environmental factors

The bathing chair in the bathroom was a standard one, made of plastic pipe with a hard seat, and
the room temperature was cool. There were no wall decorations and the room had an institutional
look.
Develop a hypothesis regarding the antecedents/triggers to the behavior

After this initial assessment, it was felt that her major sources of distress came from her needs for
comfort, warmth, and security. She had many possible sources of pain—arthritis, her previous hip
fracture, and peripheral neuropathy. The initial plan, therefore, focused on personal and
environmental triggers and interventions to reduce pain and increase warmth.
Plan
It was recommended that acetaminophen be given routinely early in the morning, so that it would be
effective by shower time. The shower chair was cushioned with a padded seat, and the room was
warmed by turning on the heat lamp before bringing her in. She was kept covered with towels while
showering; the caregiver lifted the towels to wash small areas and then rinsed them with a hand-held
nozzle. In addition, church music was played softly in an effort to distract and relax her, though it
was difficult to know how much she understood because of her hearing loss and the fact that the
music echoed in the bathroom.
Assessment and modification of plan

Mrs. P’s complaints decreased, but she continued to cry for at least 50% of the shower. Additional
pain medication (a narcotic) was tried prior to the shower, but her pain complaints, mostly related to
being moved, did not change, and the medication only made her drowsy. Looking again at the
physical environment, the water spray of the hand-held nozzle seemed to trigger her cries and
increase her discomfort and her leg pain. In response to this observation she was washed with baby-
soft washcloths, using a no-rinse soap solution in a basin; the caregiver kept her covered and warm
the entire time, lifting the towels to wash each area.
At the same time, different distraction interventions were tried when she appeared anxious. The
nursing assistant sang hymns with her; “The Old Rugged Cross” was a favorite. Mrs. P was given
small plastic figurines to hold and comment on, and the nursing assistant talked with her about her
son or her work in the church. This plan worked especially well just before a difficult procedure,
such as washing her buttocks. Before the nursing assistant touched an area that might be painful or
experienced as intrusive, she also told Mrs. P that she was going to touch her and assured her that
she would be careful. If Mrs. P complained, the nursing assistant apologized and adjusted her
approach to address Mrs. P’s need, such as covering an area or readjusting her in the shower chair.
Her feet were soaked in a basin of comforting warm water while other parts of her body were being
washed, and she found this soothing.
We consulted a physical therapist to learn techniques to make transfers less painful. A sliding
board transfer was recommended. This method decreased Mrs. P’s complaints slightly. Because it
seemed that fear and anxiety were also playing a role, we asked her to count with the nursing
assistant before being transferred; this yielded fewer complaints of pain and fear.
Finally, recalling that she had been careful about her appearance in the past, we gave her a mirror
to hold. As Mrs. P held the mirror, the nursing assistant commented on how nice she would look
after the bath. The nursing assistant also shared simple jokes with her and sometimes could get her
to laugh.
Because Mrs. P disliked having her hair washed, an appointment was made for her at the beauty
parlor. Since this was an activity she enjoyed prior to the onset of dementia, she tolerated the process
and expressed few complaints.
Results
This was a trial-and-error process. The result was an individualized bathing care plan that worked
for Mrs. P. Measurable improvements included the following behaviors:
• She showered willingly.
• She no longer cried.
• Complaints of pain decreased from 10 per bath to fewer than 5 per bath.
• Complaints of being cold decreased from 15 per bath to fewer than 3.
• She showed interest in the conversation with the nursing assistant and in the objects presented to
her as a means of distraction.
• She thanked the nursing assistant for her help.
Note. Adapted from Barrick, Rader, Hoeffer, and Sloane (2002). Copyright 2002 by Springer Publishing Company.
Adapted by permission.
• Keep it simple. Simple, well-established routines can help persons with dementia
remain calm and perform to the best of their abilities.
• Reduce environmental stress. Environments can be confusing to persons with de-
mentia. Reduce unnecessary noise and extra people and remove misleading stim-
uli.
• Be flexible. Modify the approach to meet the person’s need. Modification may in-
volve adapting the method, the physical environment, and/or the procedure. For
example, a bed bath rather than a shower may be indicated if a person is anxious,
afraid, or in pain due to the equipment or the procedure of showering.
• Focus more on the person than the task. The process and relationship are more
important than the task; meeting the individual preferences of the person requires
observing his or her feelings and reactions and adapting the approach to fit his or
her needs.
• Respond to the person’s feelings rather than the facts of the situation. The person
may misperceive the situation; empathize and reassure rather than trying to
explain.
In difficult cases, to get the best results, tailor interventions to the specific needs of the
person and symptom. Suggested strategies for potential causes of specific behaviors are
listed in Table 17.5. These strategies are based primarily on clinical experience and are
not exhaustive.
TABLE 17.5. Suggested Strategies for Management of Behavior Problems in Patients with Dementia
Behavior Potential causes or antecedents Management strategies
Difficulty with • Task too difficult or overwhelming • Divide task into small, successive steps.
personal care • Caregiver impatience, rushing • Be patient, allow ample time, or try
tasks • Cannot remember task again later.
• Pain involved with movement • Demonstrate action or task; allow
• Cannot understand or follow caregiver person to perform parts of the task that
instructions can still be accomplished.
• Fear of task; cannot understand need • Treat underlying condition; consider
for task or instructions pain medication or physiotherapy;
• Inertia, apraxia; difficulty initiating modify or assist the movement needed.
and completing a task • Repeat request simply; state instructions
one step at a time.
• Reassure, comfort, distract from task
with music or conversation; ask patient
to help perform the task.
• Set up task sequence by arranging
materials (such as clothing) in the order
to be used; help begin the task.
Incontinence • Infection, prostate problem, chronic • Evaluate medically.

illness, medication side effect, stress • Place signs/picture on door; ensure
or urge incontinence adequate lighting.
• Difficulty in finding bathroom • Provide for privacy.
• Lack of privacy • Simplify clothing; use elastic waistbands.
• Difficulty undressing • Use contrasting colors on toilet and
• Difficulty in seeing toilet floor.
• Impaired mobility • Evaluate medically, treat associated pain
• Dependence created by socialized (include physiotherapy); provide a
reinforcement commode; reduce diuretics when
• Cannot express need possible.
• Task overwhelming • Provide increased attention for
continence rather than incontinence;
allow independence whenever possible,
even if time consuming.
• Schedule toileting (such as every 2
hours while awake); reduce diuretics
and bedtime liquids when possible.
• Simplify; establish step-by-step routine.
Sleep • Illness, pain, medication effect (e.g., • Evaluate medically.

disturbance causing daytime sleep or nocturnal • Prescribe antidepressant (consider
awakening) bedtime sedative such as trazodone).
• Depression • Schedule later bedtime; allow activities
• Less need for sleep or tasks safely done at night; plan more
• Too hot, too cold daytime exercise.
• Disorientation from darkness • Adjust temperature.
• Caffeine or alcohol effect • Use night-lights.
• Hunger • Reduce or eliminate alcohol; limit
• Urge to void caffeine after noon.
• Normal age- and disease-related • Provide nighttime snack.
fragmentation of sleep (like that of • Ensure clear, well-lit pathway to
an infant or toddler) bathroom.
• Daytime sleeping • Accept; plan for safety.
• Fear of darkness; restless • Eliminate or limit naps; provide activity
and exercise instead; for naps, use
recliner rather than bed.
• Provide soft music, massage, night-light.
Wandering • Stress—noise, clutter, crowding • Reduce excessive stimulation.

• Lost; looking for someone or • Provide familiar objects, signs, pictures;
something familiar offer to help find objects or place;
• Restless, bored—no stimuli reassure.
• Medication side effect • Provide meaningful activity.
• Lifelong pattern of being active or • Monitor, reduce, or discontinue
usual coping style medication.
• Needing to use the toilet • Respond to underlying mood or
• Environmental stimuli—exit signs, motivation; provide safe area to move
people leaving about (e.g., secured circular path).
• Institute toileting schedule (such as
every 2 hours); place signs or pictures
on bathroom door.
• Remove or camouflage environmental
stimuli; provide identification or alarm
bracelets.
Agitation (also • Discomfort, pain • Assess and manage sources of pain,

“sundowning,” • Physical illness (such as urinary tract constipation, infection, or full bladder;
catastrophic infection) check clothing for comfort.
reactions) • Fatigue • Evaluate medically; eliminate caffeine
• Overstimulation—noise, overhead and alcohol.
paging, people, radio, television, • Schedule adequate rest; monitor activity.
activities • Reduce noise, stress; remove from
• Mirroring of caregiver’s affect situation; use television sparingly; limit
• Overextending capabilities (resulting crowding (e.g., dining hallways just
in failure); caregiver expectations too before meals).
high • Control affect; model calmness with low
• Patient is being “quizzed” (multiple tone and slow rate; use support system
questions that exceed abilities) and groups for outlet.
• Medication side effect • Do not put person in failure-oriented
• Patient is thwarted from desired situations or tasks; understand losses
activity (e.g., attempting to escape) and reduce expectations accordingly.
• Lowered stress threshold • Avoid persistent testing of memory;
• Unfamiliar people or environment; pose one question at a time; eliminate
change in schedule or routine questions that require abstract thought,
• Restless insight, or reasoning.
• Assess, monitor, and reduce medication
if possible; monitor health concerns.
• Redirect energy to similar activity; ask
patient to help with meaningful activity;
have diversionary tactics for outbursts;
choose battles—assess whether behavior
is merely irritating, rather than
compromising patient safety or
obstructing care.
• Simplify tasks, create calm; lower
expectations and demands; avoid
arguments and reprimands.
• Be consistent; avoid changes, surprises;
introduce any change gradually.
• Plan calming music, massage, or
meaningful activities; assign tasks that
provide exercise.
(continued)

Behavior Potential causes or antecedents Management strategies
Aggression • Discomfort, pain • Assess and manage source of pain;
(physical, • Doesn’t understand what’s happening provide ample support on transfers;
verbal) • Fatigue adapt equipment; stop what you are
• Fear doing; apologize; warn; distract.
• Physical illness • Explain each step; match
• Feeling lack of sense of control communication to abilities; slow down;
• Hunger distract.
• Cannot inhibit behavior • Come back later.
• Provide physical and verbal support;
reassure; distract (e.g., engage in
singing, give something of interest to
hold, take to quiet environment).
• Evaluate medically.
• Honor preferences; give choices; be
flexible and stay calm; have the person
help; ask permission; tell the person
firmly that the behavior is unacceptable,
such as “Stop hitting” or “That hurts.”
• Give something to eat or drink.
• Identify mildly agitated behaviors and
take action before behavior escalates.
Suspiciousness, • Forgot where objects were placed Offer to help find; have more that one of
paranoia • Misinterpreting actions or words same object available; have a list where
• Misinterpreting who people are; objects should be placed; learn favorite
suspicious of their intentions hiding places.
• Change in environment or routine • Do not argue or try to reason; do not
• Misinterpreting environment take personally; distract.
• Physical illness • Introduce self and role routinely; draw
• Social isolation on old memory, connections; do not argue.
• Someone is actually taking something • Reassure, familiarize, set routine.
from patient • Assess vision, hearing; modify
environment, as needed; explain
misinterpretation simply; distract.
• Evaluate medically.
• Encourage and provide familiar social
opportunities.
• Verify the situation.
Inappropriate • Dementia-related decreased judgment Do not overreact or confront; respond

or impulsive and social awareness calmly and firmly; distract and redirect.
sexual • Misinterpreting caregiver’s interaction • Do not give mixed sexual message (e.g.,
behavior • Uncomfortable—too warm, clothing double entendres and innuendos, even
too tight; need to void, genital in jest); avoid nonverbal messages;
irritation distract while performing personal care,
• Need for attention, affection, bathing.
intimacy • Check room temperature; assist with
• Self-stimulating, reacting to what comfortable weather-appropriate
feels good clothing; ensure that elimination needs
are met; examine for groin rash,
perineal skin problems, stool impaction.
• Increase or meet basic need for touch
and warmth; model appropriate touch;
offer soothing objects (such as stuffed
animals); provide hand or back
massage.
• Offer privacy; remove from
inappropriate place.
Note. Adapted from Carlson, Fleming, Smith, and Evans (1995). Copyright 1995 by the Mayo Clinic. Adapted by per-
mission.
PHARMACOLOGICAL TREATMENTS
When a person is not responding well to behavioral treatment alone, a psychiatric refer-
ral for consideration of medication may be necessary and beneficial. Individuals vary
greatly in their response to medication, and several factors must be considered. These in-
clude stability of medical problems, past response to medications, family history of re-
sponse to medications, and tolerance for side effects. Expert consensus guidelines have
been developed to assist in the selection of first- and second-line treatments (Alexopoulus,
Abrams, Young, & Shamoian, 1998). For example, in the guidelines conventional high-
potency antipsychotics such as Haldol in small doses have been recommended for psy-
chosis and severe aggression. For mild, long-term aggression, selective serotonin reuptake
inhibitors (SSRIs), trazodone, and busiprone may be beneficial. Depakote has been help-
ful in the treatment of aggression, anger, and hypersexual behavior. Trazodone, although
technically an antidepressant, is commonly prescribed for insomnia. Benzodiazepines can
be used but are recommended for only short periods.
SUMMARY
Dementia is often accompanied by noncognitive symptoms such as combativeness, agita-

tion, and functional behavioral deficits. These symptoms have a significant impact on the
lives of those with the disease and their caregivers. The causes of these symptoms are of-
ten an interaction between the person, individuals in the care environment, and physical
environmental factors. Behavioral interventions can be very effective in managing these
symptoms and improving the quality of day-to-day life. Several researchers have reported
promising results in the prevention of functional behavioral deficits, incontinence, and
sleep disorders as well as the reduction of agitation, aggression, and other behavioral
“excesses.”
Implementation of behavioral interventions requires assessment of the person, the
behavior, and the possible causes or triggers of the behavior; identification of specific,
measurable goals; development and implementation of an individualized plan; and revi-
sion of the plan, as needed. Methods for assessment, intervention, and evaluation are de-
scribed as well as a number of interventions that have been successful in clinical practice
and research studies. A case study is included that illustrates this process.
Behavioral interventions, although efficacious, can be labor intensive. The realities of
clinical practice often mean that time is limited and data are incomplete. Caregivers may
need to be trained in such areas as gathering data and assessing causes. They may also
have to learn to make consistent, supportive responses when behaviors occur. Available
equipment may have to be adapted when resources are limited. However, there are a vari-
ety of ways to deal with a problem, and interventions can be adapted to fit the needs of
the situation.
Often simple, safe, and practical behavioral interventions can result in significant im-
provement in symptoms. Sometimes something as simple as attending to a person’s needs
by using towels to keep him or her warm during a bath or distracting a person with
candy or conversation during a painful care task can reduce agitation by as much as
50%. At other times a combination of behavioral and pharmacological treatments, such
as pain medication or neuroleptics, is necessary. The improved care experience can have a
very favorable effect on both the person with dementia and his or her caregivers. It is a
“win–win” situation!
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18
Group Psychotherapy
Approaches for Dementia
GUY G. POTTER
DEBORAH K. ATTIX
CORY K. CHEN
As has been well expressed in other chapters of this book, cognitive impairment in older
adults has multiple etiologies that produce a range of neuropsychological and behavioral
manifestations. Because of this range, treatment of cognitive impairment in older adults,
particularly with regard to dementia, requires multimodal intervention strategies that are
informed by a solid scientific understanding of the etiology and symptomatology of this
condition. Although there have been significant advances in identifying the neuropsy-
chological and behavioral sequelae of geriatric cognitive disorders, less is known about
intrapersonal factors and how these contribute to treatment outcome. What is known is
that these individuals experience depression, social isolation, grief, family discord, and
other forms of psychological distress that can exacerbate cognitive and functional disabil-
ity when left untreated (Koltai & Branch, 1999). Behavior problems resulting from psy-
chological distress are associated with decreased caregiver well-being (Ballard, Lowery,
Powell, O’Brien, & James, 2000) and increased likelihood of institutionalization (Balesteri,
Grossberg, & Grossberg, 2000). Fortunately, psychological distress is a modifiable factor
that can often be improved through psychotherapy—which makes this mode of interven-
tion an important part of a comprehensive strategy for managing dementia.
Psychotherapeutic treatments for geriatric cognitive disorders include individual,
group, and caregiver-based interventions. Interventions for patients with Alzheimer’s dis-
ease (AD) predominate over those for other cognitive disorders, owing to its prevalence
and the care demands associated with its typical course of progressive debilitation. Al-
though interventions for dementia and other geriatric cognitive disorders have long been
practiced, empirical studies of treatment outcomes have been slower to emerge. In the
current care climate, however, the increasing number of individuals diagnosed at early
stages of cognitive impairment, in conjunction with demand for clinically efficacious
394
Group Psychotherapy Approaches for Dementia 395
treatments, has highlighted the need for psychotherapeutic interventions that have empir-
ical support. Reviews of the psychotherapeutic treatments for dementia do identify inter-
ventions that appear efficacious, but conclude that, on the whole, there is still limited em-
pirical support to guide treatment planning for the diverse treatment needs of individuals
and families living with dementia (Kasl-Godley & Gatz, 2000; Scott & Clare, 2003).
This chapter focuses on the conceptualization of group-based approaches to treating
the psychological and behavioral symptoms of geriatric cognitive impairment, principally
represented by AD and related dementias. According to Cheston (1998), group-based in-
terventions for dementia have traditionally been more prevalent than individually ori-
ented interventions, and Scott and Clare (2003) note that group therapies were important
in establishing the usefulness of therapy for people with dementia. We discuss the merits
of group psychotherapy for addressing emotional and behavioral issues in people with
dementia, as well as modifications that may be necessary for conducting group work with
a cognitively impaired population. We discuss how factors such as treatment targets,
neuropsychological function, and diagnosis contribute to the conceptualization of group
interventions for individuals with cognitive impairment, and we also review the extant lit-
erature on group psychotherapies for this population. The chapter is written from the
perspective that the implementation of empirically guided psychotherapies for dementia
groups is still a work in progress. We approach these issues with the belief that clinical
practice with the best available evidence will move the field toward greater use of
evidence-based treatment in general. Finally, we offer examples from our own clinical ex-
perience in conducting group psychotherapy with cognitively impaired individuals to il-
lustrate vital caregiver and patient perspectives regarding the role and significance of this
type of intervention, as well as some of the challenges of applying empirical principles to
clinical practice.
GROUP PSYCHOTHERAPY
There are many characteristics of group psychotherapy that make it a desirable treatment
option for individuals living with cognitive impairment. One characteristic is that group
therapy offers a sense of belonging to individuals who may be feel isolated by their im-
pairments (LaBarge & Trtanj, 1995). Isolation often arises from social withdrawal, such
as when an individual avoids interacting with others out of sensitivity to his or her cogni-
tive decline. Loss of mobility and independence, such as might occur when an individual
stops driving, can also limit social interaction and increase feelings of isolation. Therapy
groups offer a positive response to social isolation because they provide a context for
meaningful interactions and a supportive forum for sharing the problems of cognitive im-
pairment with others who have similar experiences. Such social stimulation is associated
with positive cognitive and emotional responses in normally aging people (Fillit et al.,
2002) as well as those with dementia (Koh et al., 1994), which suggests that social inter-
action alone can be therapeutic. Whereas certain group interventions do rely primarily on
social interaction as the therapeutic catalyst, nearly all group formats provide this benefit
to some extent.
Another therapeutic characteristic of group psychotherapy is the beneficial effects of
social learning. The benefits of social learning in group therapy occur via: (1) interper-
sonal exchange, (2) behavioral modeling, and (3) information sharing. Saiger (2001), for
instance, described the therapy group as a social microcosm in which the positive and
negative effects of an individual’s interpersonal behavior can be identified and discussed

in a supportive context. The dynamics of interpersonal exchange and the feedback re-
ceived from these interactions are essential aspects of social learning. The therapy group
can also function as a learning environment in which individuals can observe and model
the coping strategies of successful peers (Solomon & Szwabo, 1992). Finally, an impor-
tant aspect of social learning that is a primary component of many therapy groups is
sharing knowledge of resources that are available outside of the group setting per se
(Yale, 1999). As with the social interaction benefits of group therapy, social learning
benefits are present to some extent across most groups, though some approaches
make this a more explicit focus of the intervention than do others (Barton, Levene,
Kladakis, & Buttersworth, 2002; Bednar, Weet, Evensen, Lanier, & Melnick, 1974; Dia-
mond, 1974).
One characteristic of group interventions that is more pragmatic than therapeutic is
that group treatment is often more cost-effective than individual therapy. Although the
rates of group therapy vary depending on the therapist and type of intervention, the aver-
age group therapy session is approximately half the cost of an individual session (Ameri-
can Group Psychotherapy Association, 2004). Additionally, across a wide variety of
populations, group interventions have been found to produce treatment outcomes com-
parable to individual interventions (DeRubeis & Crits-Christoph, 1998; Dugas et al.,
2003; Marques & Formigoni, 2001; Yalom, 1995). The lower cost of group therapy
combined with equal and sometimes better outcomes relative to individual interventions
can mean higher cost-effectiveness across a variety of intervention approaches and pa-
tient populations (Bastien, Morin, Ouellet, Blais, & Bouchard, 2004; McFarlane et al.,
1995; Shapiro, Sank, Shaffer, & Donovan, 1982). The lower cost associated with group
treatment can be important to individuals with financial limitations, especially when ex-
tensive diagnostic workups often precede the treatment-planning stage. Group therapy is
used effectively in inpatient settings, where time and budget constraints preclude exten-
sive one-to-one treatment. It is important to note, however, that group therapy should
not serve as a substitute treatment for those individuals whose treatment needs clearly re-
quire a one-to-one relationship.
CONCEPTUALIZING GROUP INTERVENTIONS
Yalom (1995) advises clinicians to develop group intervention plans that are informed by
a clear understanding of the relevant clinical issues, with attention to specific treatment
goals and the methods most appropriate for achieving them. As detailed by Attix’s inter-
vention model (Chapter 10, this volume), the efficacy of a particular intervention is facili-
tated by proper matching of a patient’s characteristics to his or her treatment. In the case
of group therapy, several factors play a role in determining the suitability of an individual
for a particular intervention approach: (1) potential to engage in treatment, (2) treatment
targets, (3) neuropsychological profile, (4) diagnosis, (5) symptom severity, and (6) thera-
peutic context.
Potential to Engage in Treatment

Group therapy is not appropriate for every individual living with cognitive impairment
(Cheston, Jones, & Gilliard, 2003). Many individuals find the experience of sharing their
emotions within a group to be threatening and thus can be resistant to engaging in the
key therapeutic experiences of a group. In addition, the lack of engagement on the part of
one individual may hinder the treatment progress of the group as a whole. Some individu-
als may engage emotionally but still not acknowledge their disorder. The capacity to ac-
knowledge the presence of cognitive difficulties is not necessarily a prerequisite for join-
ing a therapy group, but progress on many treatment targets is likely to remain limited if
the individual does not eventually accept his or her condition. Challenges also exist when
the lack of acknowledgment is one of the actual features of the condition, as is the case
with anosognosia (Koltai, Welsh-Bohmer, & Schmechel, 2001).
An individual’s motivation to actively participate in group psychotherapy is essential
to treatment success. One source of poor motivation stems from the fact that behaviors
that are viewed as problematic by caregivers may not necessarily be distressing to the
patient (Lyman, 1989). Thus, resistance is not uncommon for individuals who attend
therapy based on the wishes of others. Resistance that results in poor group participation
can be detrimental to the progress of other group members and should be promptly ad-
dressed by the therapist; however, this problem can be minimized through careful assess-
ment and intervention planning. Different issues arise when motivational problems reflect
a stable feature of an individual’s condition, such as the amotivational tendencies and ap-
athy that occur in many dementias. Individuals with acquired deficits in motivation or in-
sight are typically better suited for more behaviorally oriented groups and/or those in
which the therapist is a directive presence (Teri & Gallagher-Thompson, 1991).
Treatment Targets
The selection of an appropriate group intervention depends in large measure on treat-
ment targets. It is important to recognize in this context that although a condition such as
AD is not currently reversible, it is possible to treat associated behaviors and feelings that
create additional distress, burden, or disability. Zarit and colleagues (Zarit, Femia, Wat-
son, Rice-Oeschger, & Kakos, 2004) have identified several global targets for individuals
with dementia and their caregivers, including:
• Facilitating communication between patient and caretaker.

• Addressing relationship issues with other friends and family members.
• Developing coping strategies for memory loss.
• Finding ways for the patient to feel useful.
• Dealing with grief and loss.
• Acquiring disease- and treatment-related knowledge.
Indeed, we find these targets to be accurate. In addition, we have found the following
goals to be important to treatment success:
• Forging relationships/friendships (for patients as well as caregivers).

• Providing a sanctuary from fear and criticism—an environment of acceptance and
support.
• Learning behaviorally appropriate methods of interacting with and supporting
others.
• Generating appropriate ideas to maintain and enhance behavioral activity.
Although there is growing appreciation of the needs and experiences of individuals

diagnosed with cognitive impairment (Woods, 2001), treatment targets have been histori-
cally defined by the perspective of the caregiver. One survey of caregivers of individuals
with AD found that over 70% of those with early-stage symptoms manifest behavioral
disturbance during the course of their illness (Harrell et al., 1995). Most often, the prob-
lem behaviors relate to anxiety and mood disturbance, not to more intractable symptoms
such as delusions and hallucinations. Teri and colleagues (Teri et al., 1992) found that
whereas memory-related behaviors such as repetitive question asking were reported by
caregivers as most frequent in occurrence, depression was rated as most distressing. Simi-
lar to the findings of Harrell and colleagues (1995), behaviors such as delusions and hal-
lucinations were found to be infrequent prior to the latter stages of dementia. Although
the problems with depression and anxiety that cause most distress for caregivers in the
early stages of dementia can be addressed in the context of numerous group-based ap-
proaches, hallucinations and delusions are often more idiosyncratic in their presentation
(Teri et al., 1992) and would be better targeted by an individually oriented intervention
and possibly pharmacological management.
From a patient-oriented perspective, the range of individual responses to dementia is
varied and personal. For instance, catastrophic reactions have been reported to occur in
approximately 16% of individuals in response to their diagnosis (Tiberti et al., 1998). In
contrast, other individuals minimize or deny their deficits. These responses have been in-
terpreted as a protective reaction to a frightening threat to one’s sense of self (Clare,
2003). Several authors have recognized depressive symptomatology as the most prevalent
emotional response among individuals with dementia, frequently associated with grief
about lost cognitive and functional abilities (Cheston & Bender, 1999; Solomon, 1982).
In this context, depression may be accompanied by anxiety regarding the consequences of
the cognitive and functional losses, as well as by feelings of anger and frustration. Other
common experiences reported by individuals with dementia include (1) fear of being out
of control or perceived as out of control, (2) feeling lost, (3) losing a sense of meaning,
and (4) concerns about being a burden on family members (Kitwood, 1997).
Many studies of the coping process of individuals with dementia identify a progres-
sion of stages similar to that of other individuals confronted with the anticipated and ac-
tual losses of serious illnesses: denial, anger, guilt, sadness, and eventually adaptation
(Cohen, Kennedy, & Eisdorfer, 1984; Kubler-Ross, 1969). Similarly, Clare (2003) out-
lines five types of reactions to changes caused by dementia: (1) registering, (2) reacting,
(3) explaining, (4) experiencing, and (5) adjusting. She describes the interaction among
these responses as an individual attempts to balance fighting his or her illness against
accepting it. This model does not posit a stage-like progression of responses, but rather
emphasizes the importance of understanding the implications of each of these responses
for the individual. These models of coping provide an effective framework for group ther-
apy, where the principles of modeling, sharing, social feedback, and validation can facili-
tate therapeutic change.
We have found that the intervention process often yields a transformation in the pa-
tient’s perception of self and role identities. As noted in Attix (Chapter 10, this volume),
our definition of intervention involves a restructuring of the individual’s responsibilities,
expectations, and sense of self, largely to yield a transformation in role identity that is
adaptive in the behavioral context of the illness. Although this transformation may be a
direct target of treatment in certain cases, it often occurs as a secondary result of moving
through grief stages and adopting alternative behaviors and activities in line with new re-
alities of living with cognitive impairment. We have found it instructive and beneficial in
treatment planning to periodically consider a patient’s standing in this regard, because it
is a useful marker of intervention progress.
Assessing an individual’s level of general neurocognitive functioning is an essential con-
sideration in formulating a treatment plan for group therapy, but the presence of even
moderate deficits should not necessarily preclude an individual from benefiting from
some form of group psychotherapy. Because mild cognitive impairment often takes
months to years to progress, there is a substantial amount of time during which individu-
als can productively engage in a cognitively demanding task such as psychotherapy
(Jutagir, 1993). In addition, individuals with mild cognitive impairment can be expected
to comprehend treatment goals, engage in therapeutic discourse, and complete assign-
ments between sessions in a manner similar to noncognitively impaired peers (Teri &
Gallagher-Thompson, 1991). Impairments in areas such as memory, executive function,
or language are often specific targets for intervention, but they are also treatment modifi-
ers because these deficits can alter an individual’s retention, conceptualization, or com-
munication in therapy (see Kasl-Godley & Gatz, 2000, for additional discussion of how
cognitive impairment may influence specific therapeutic approaches for dementia).
Whereas there are numerous modifications that can be made to compensate for deficits in
memory and other cognitive processes that accompany early cognitive decline, the progres-
sion to moderate decline produces deficits in domains such as attention, self-monitoring,
and language, which make it difficult to implement approaches that rely on insight or ex-
tensive therapeutic dialogue. This progression of cognitive impairment may narrow the
range of appropriate interventions to supportive and behavioral strategies. The restriction
of strategies for intervention is typically concomitant with a parallel evolution of treat-
ment needs.
Memory
In addition to considering an individual’s general level of cognitive functioning in treat-
ment planning, patterns of impaired and preserved abilities also dictate the choice of
group intervention. Because memory loss is a defining characteristic of most dementing
disorders, many interventions are specific to memory skills training (see chapters in Part
II, Section A: Cognitive Training and Compensatory Techniques). Although compensat-
ing for mild memory loss with note taking and audiotaping can help some individuals im-
prove carryover from session to session, our experience with the former has been that
group members often find note taking to be an additional cognitive burden that detracts
from their ability to focus on therapy in the present moment. Individuals with more pro-
found memory loss can of course be expected to demonstrate decreased retention of com-
plex themes, but in our experience they can retain general themes if they are repeated
within a session or over the course of several sessions. In fact, we have been surprised at
the degree of retention and integration of therapeutic themes, as is evidenced by current
group members when they orient new members to therapy. Finally and importantly, spe-
cific memory problems can be used therapeutically. For instance, it is not uncommon for
individuals to experience difficulty remembering the names of other group members.
Such events provide an opportunity for the therapist to normalize episodes of forgetful-
ness, and in certain groups they may present an entrance point for discussing and practic-
ing mnemonic strategies.
Executive Functions
Decline in executive functions can present challenges in psychotherapy due to problems
with abstraction and insight, but additional challenges exist in group psychotherapy due
to the potentially overstimulating and distracting nature of group dialogue. Because indi-
viduals with deficits in executive functions may have difficulty with the cognitive
demands of tracking a dialogue among multiple participants (Alberoni et al., 1992), ther-
apists must be attentive to managing the group dialogue by using core therapeutic tech-
niques such as reframing. In relation to this point, Morris (1994) suggests that keeping
group membership small is a useful accommodation to executive and other neuro-
cognitive deficits. Executive deficits that involve impulsivity, which can be seen in condi-
tions such as frontotemporal dementia, may further affect group dynamics. Impulsive or
disinhibited comments can be disruptive and/or inadvertently offensive, but a therapist
can often address these in context, using therapeutic techniques such as modeling or
reinforcement to teach appropriate alternative responses. Severe deficits in executive
functions, however, may prove too disruptive for group therapy and require one-to-one
treatment.
Language
In contrast to memory, moderate to severe language deficits such as those associated with
stroke or primary progressive aphasia indicate a poor prognosis for most group therapies,
but some specialized groups do exist (see Johnson, Chapter 14, this volume, for a more
detailed review of interventions for language deficits). Mild word-finding problems are
common across many cognitive disorders, and these often can be addressed through the
therapist’s ability to facilitate communication during sessions. In one clinical experience,
however, we had an individual who could not participate productively in group therapy
because of declining insight and language abilities, but who ultimately found a social and
experiential outlet through art therapy. This non-language-based activity proved to be a
soothing counterpoint to the individual’s verbal struggles and had a notable impact on
quality of life through his enjoyment of producing art and interacting with others.
Diagnosis
As mentioned previously, most group interventions for geriatric cognitive disorders are
targeted to patients with AD, so one important treatment planning issue is whether indi-
viduals with different dementia diagnoses can be combined in the same treatment group.
Unfortunately, there is limited research on psychotherapeutic intervention with diagnoses
other than AD from which evidence-based conclusions can be drawn. Diagnostic re-
search, however, informs us that many dementing conditions are similar to each other in
that multiple cognitive and functional domains are affected, along with relatively consis-
tent intrapersonal reactions of depression, anxiety, and adjustment issues. We have also
experienced this similarity in our clinical practice, where we have had success integrating
individuals with different diagnoses but similar cognitive and behavioral profiles (e.g.,
primary executive and memory deficits accompanied by depression). The key elements
appear to be that all members can engage in personal reflection, share their reflections
with the group, and validate the reflections of others.
When individuals lack the cognitive capacity to reflect, share, and validate emotional
experiences, the progress and benefits associated with group treatment are likely to be
compromised. For instance, during one phase of group treatment in our practice, a new
participant with deficits in insight and verbal expressive abilities initially found it socially
stimulating to attend therapy sessions, but his inability to respond meaningfully to other
group members limited the treatment progress of both the individual and the group as a
whole. Although some current group members were able to discern that this individual’s
upbeat denials of deficit were related to his particular disease presentation and direct
their questions to him accordingly, other members found it difficult to relate to an indi-
vidual who did not appear to be experiencing the same processes of frustration, confron-
tation, and adaptation that were central group themes. As this example illustrates, the
prospects for successfully integrating individuals with different diagnoses become more
challenging when neuropsychological profiles differ substantially across group members,
or when specific behavioral deficits such as anosognosia are prominent. Groups interven-
tions designed specifically for conditions such as stroke (Welterman et al., 2000) or Par-
kinson’s disease (Charlton & Barrow, 2002) reflect increasing recognition of the benefits
of selecting group members who have similar experiences and display similar symptom
presentations. Although promising, additional research on the efficacy of these treat-
ments is needed.
Symptom Severity
Assuming that homogeneity in specific diagnoses of group members is less important
than ensuring that group members share comparable cognitive ability and treatment
needs, it is important to consider the impact of differing levels of dementia severity on the
dynamics and productivity of a treatment group. Goldwasser and colleagues (Gold-
wasser, Auerbach, & Harkins, 1987) comment from experience with outcome research
that treatment difficulties can arise when mildly impaired but functional individuals share
a group with individuals whose behavioral and functional deficits are more profound.
For instance, less impaired group members may resent being placed with more impaired
individuals and find their greater confusion and disruptiveness to be a distraction; how-
ever, Goldwasser and colleagues also noted that positive therapeutic changes occurred
among group members, despite these difficulties. Divergence in the severity of cognitive
impairment among group members should be anticipated in groups with stable member-
ship that are conducted on an ongoing basis. LaBarge and Trtanj (1995), for instance, re-
ported the experience of having specific group members demonstrate cognitive decline
over the course of several group sessions, and noted that other group members were able
to respond with appropriate emotional support. As the divergence in severity grows,
however, the focus and composition of group membership may need to be reconsidered.
Therapeutic Context
The therapeutic context in which group psychotherapy occurs often plays a significant
role in the selection of treatment goals and intervention strategy. Much of early empirical
research on group psychotherapy for persons with dementia was conducted in inpatient
settings. Because greater cognitive and behavioral symptoms increase the probability of
institutionalization, these settings tend to have a more cognitively impaired population

than community settings. Depending on the resources of an inpatient facility, there may
not be enough individuals who can participate in a cognitively demanding, insight-
oriented therapy. Inpatient groups may by necessity have a greater range of dementia
severity and intermingling of treatment goals and diagnoses, which can make interven-
tion planning more challenging. On the other hand, individuals in an inpatient setting can
often meet longer and more frequently than is feasible on an outpatient basis, and some
treatment goals can be reinforced by staff members outside of the therapy session. Avail-
ability of consistent reinforcement becomes particularly important in the latter stages of
dementing illnesses, when behavioral and environmental modifications tend to be the
predominant method of intervention.
Outpatient therapy groups provide a different set of benefits and challenges. One ad-
vantage is that individuals may be more specifically matched to groups based on their
deficits and treatment needs. In an active therapy practice, individuals may be able to
make transitions between groups as their level of function and treatment targets change.
There are also challenges to conducting outpatient groups, many of which are practical in
nature. One of these is that as individuals progress in a dementing illness, they may be-
come more reliant on a caregiver for scheduling and transportation. Often, the continuity
of a group depends in part on the therapist’s ability to establish rapport with caregivers.
In our practice we encourage caregivers, typically spouses, to meet at the end of therapy
sessions for a brief summary of therapeutic issues and to address subsequent scheduling.
This approach is consistent with research highlighting the benefits of including caregivers
in treatment planning (Teri, Logsdon, Wagner, & Uomoto, 1994). Caregivers often re-
main in our clinic for all or part of the patient’s session, and it is not uncommon for a sec-
ondary “support group” to emerge from their dialogue with each other. We have found
that facilitating the development of these informal relationships among spouses enhances
the overall commitment to the patients’ therapy.
THERAPIST ADJUSTMENTS FOR GROUP THERAPY
The previous sections illustrate that conducting psychotherapy among individuals with
cognitive impairment requires an awareness of the common neurocognitive deficits and
an ability to make appropriate modifications for them. Although this awareness is also
required in conducting individual therapy, it becomes more salient in the group setting
because of the multiple and competing stimuli that are inherent in group interactions;
hence the adjustments highlighted in the previous discussion of group conceptualization
are summarized here in brief. In terms of cognitive modifications, therapists should be
mindful to speak in concrete and specific terms. Deficits in memory, attention, and recep-
tive language capabilities require simplified explanations of psychological constructs that
may need to be repeated throughout a session in order to bolster retention. Therapists
should also be prepared to “direct traffic” by verbally guiding individuals back to the
prevailing discussion of the group and assisting participants with expressive difficulties
by interpreting and reframing their comments for the benefit of other group members.
Therapists should look for opportunities to validate adaptive behaviors that can be mod-
eled by other group members. Behavioral modifications such as handouts, diagrams, and
even audio- or videotaping may be appropriate in certain situations to complement or re-
inforce the verbal content of the therapy session.
There are also several practical issues to consider when planning a therapy group for
patients with cognitive compromise. Whereas some authors have suggested that briefer
sessions may be more effective for patients in individual therapy as their cognitive impair-
ment progresses (Hausman, 1992; Solomon & Szwabo, 1992), we and others (LaBarge
& Trtanj, 1995) have found 60- to 90-minute sessions to be appropriate for groups in-
volving mildly impaired participants with capacity for verbal engagement. Consistency in
time, day, and place of session meetings can provide important structure for individuals.
Our group sessions are typically held in the morning, which is the time of day when most
older adults are at their peak cognitive efficiency (May, Hasher, & Stoltzfus, 1993). The
quality of the room environment—good lighting, proper ventilation, and quiet surround-
ings—can help minimize cognitive distractions and the effects of vision and hearing defi-
cits. It is also important to allow adequate space for individuals with mobility problems.
EMPIRICAL REVIEW OF GROUP THERAPY APPROACHES
The preceding discussion focused on conceptualization and application of group therapy

principles to individuals with dementia and other geriatric cognitive disorders. This sec-
tion focuses on the outcomes of several approaches to group psychotherapy with patients
having cognitive compromise. As mentioned previously, there are presently limited data
on approaches that would meet a codified definition of treatment efficacy (Chambless et
al., 1998; Gatz et al., 1998), much less Camp’s (2001) definition of treatment effective-
ness, which requires positive effects across diagnostic groups and real-world treatment
contexts. Extant studies are limited by unclear distinctions between levels of dementia se-
verity, lack of controlled designs, and inconsistent use of quantifiable outcome measures.
Scott and Clare (2003) raise important questions about which outcomes best capture the
effects of group intervention and how to properly operationalize these outcomes. In addi-
tion, they note that individuals differ in their response to the same group experience, and
that this difference requires a particular flexibility in clinical practice to balance individ-
ual and group needs. Thus, whereas some empirical standards for treatment outcome re-
search will be challenging to attain in the reality of clinical care, we nevertheless believe
that an empirically informed approach to conceptualizing and treating dementia should
be practiced, even when the idealized environment of a controlled trial cannot be
achieved. We also recognize that qualitative observations of therapeutic process can be
valuable sources of information when they are systematically obtained. As a result, we do
not limit the following reviews to quantitative outcomes alone, and we leave it to the
reader to draw an informed opinion from these appraisals.
Behavioral and Cognitive-Behavioral Groups

Although distinctions can be made between purely cognitive and purely behavioral treat-
ment approaches, in practice these interventions draw upon a mix of cognitive and be-
havioral elements. On the cognitive end of the spectrum, interventions focus on changing
maladaptive patterns of thinking that contribute to depression, anxiety, and undesirable
behaviors. Behavioral interventions focus on learning and reinforcement principles to in-
crease positive experiences and decrease negative ones. Common treatment targets in-
clude management of depression, anxiety, and agitation. Although behavioral approaches
to treating targets such as depression in patients with dementia have among the strongest
empirical support (e.g., Teri, Logsdon, Uomoto, & McCurry, 1997; Teri & McCurry,
2000), these findings are largely based on interventions with individuals and patient–
caregiver dyads.
Among the studies that focus on group interventions, Abraham et al. (Abraham,
Neundorfer, & Currie, 1992) divided 76 depressed individuals with mild to moderate
cognitive impairment into three treatment groups: (1) cognitive-behavioral therapy
(CBT), (2) visual imagery, and (3) a psychoeducational discussion group. They found no
change in measures of depression, hopelessness, or life satisfaction across the three condi-
tions over the course of the treatment; however, individuals in both CBT and imagery
groups demonstrated an increase in cognitive performance on a brief mental status mea-
sure. The negative findings for the noncognitive treatment targets are in contrast to posi-
tive findings with healthy older adults (Teri & McCurry, 2000), and with those from one
small study of demented individuals (Kipling, Bailey, & Charlesworth, 1999). The lack of
noncognitive treatment effects in the Abraham et al. study may have been due to the in-
clusion of the physically frail along with both mildly and moderately impaired group
members, the latter of which could have been a poor neuropsychological fit for the inter-
vention. This explanation would be consistent with Kasl-Godley and Gatz’s (2000) argu-
ment that mildly impaired individuals can be successful with interventions based on cog-
nitive and learning principles, whereas individuals with moderate or greater impairment
may respond best to more simplified principles of reinforcement.
Psychodynamic Psychotherapy
Like other therapeutic approaches, the goal of psychodynamic psychotherapy is to ame-
liorate psychological distress. As described by Hausman (1992), the therapeutic tech-
niques to achieve treatment goals include (1) establishing a validating relationship, (2)
providing an outlet for emotional catharsis, (3) promoting self-esteem and self-efficacy,
(4) promoting adaptive over maladaptive defense and coping mechanisms, (5) and pro-
moting self-insight. Whereas these goals are achieved in individual therapy through the
dynamic of the relationship between therapist and patient, the dynamic in group therapy
is additionally influenced by relationships among group members and between the group
and the therapist. In this way, group psychodynamic therapy is similar to other ap-
proaches that use the dynamic of the group to achieve therapeutic effects, but a
psychodynamic orientation specifically includes the therapist’s interpretations of the emo-
tional content of a group’s conversations (Solomon & Szwabo, 1992). With regard to an
individual’s appropriateness for a psychodynamic group, Hausman argues that entry into
therapy at the earliest indication of a dementing illness offers the best prognosis for effec-
tive engagement in treatment. Solomon and Szwabo, however, argue that psychodynamic
treatment becomes increasingly difficult beyond the stage of mild impairment.
Evidence for the efficacy of psychodynamic therapy groups with cognitively im-
paired patients comes largely from qualitative analysis of therapist notes and observation
of sessions. For instance, Akerlund and Norberg (1986) described improvement in their
treatment group after changing from a reality orientation (RO) model to a psycho-
dynamic model. Based on retrospective clinical observations and review of session video-
tapes, the authors identified a pattern of more active participation and more cognitively
sophisticated processing, compared to behavior during the RO period of treatment. From
a methodological perspective, criticisms include a lack of psychometrically sound out-
come measures, nonblinded raters, and a small sample (n = 9), but the authors’ impres-
sions are consistent with expectations of a psychodynamic treatment model. An older but
larger study (Birkett & Boltuch, 1973) included random assignment of patients to
psychodynamic group therapy versus another treatment (remotivation therapy). After
weekly 1-hour sessions over a 12-week period, raters blinded to treatment condition
found improvement for both groups but no difference between groups.
Support Groups
The basic premise of most support groups is that sharing common experiences is thera-
peutic. Yale (1995), who has written extensively about grief work in AD, stated that
treatment targets for support groups often include working through grief issues, decreas-
ing social isolation, and encouraging group members to adopt a positive identity regard-
ing their diagnosis. Support groups have long been available to family members of indi-
viduals with dementia, but there has been a more recent increase in the availability of
support groups for the patients themselves, as well as for groups that include both pa-
tients and caregivers (Snyder, Quayhagen, Shepard, & Bower, 1995). Support groups can
vary widely in format, from nondirective process groups driven by patients’ current con-
cerns, to structured, topic-driven groups directed by the therapist. Because a key element
of support groups is the shared coping experience, they are not necessarily organized
around a specific psychological model. According to Yale (1995), individuals with mod-
erate to severe dementia would be less likely to benefit from support groups.
Drawing conclusions from the empirical literature on support groups is challenging
because of the diversity of support group formats. Further, most outcome measures are
based on clinical observations and the self-report of participants. In one of the more com-
prehensive studies of support groups, Yale (1995) reported a treatment–control study of
15 individuals with early AD. The treatment condition involved eight weekly sessions
lasting 90 minutes, with caregivers included in the final session. The control condition
was care as usual. The authors assessed cognitive and social functioning, but did not find
significant group differences for posttreatment or follow-up intervals. Process notes from
the therapists were qualitatively assessed and indicated that the members of the treatment
group were more likely to discuss illness-related issues, and that they provided an overall
positive report of their experience. Other studies (e.g., LaBarge & Trtanj, 1995) from
small samples offer similar findings of positive experiences by participant report and ob-
servations of increased discussion of illness-related issues, but no clear change for specific
treatment targets such as depression or anxiety. Studies of groups including both patients
and caregivers are similar in methodology and outcome (Snyder et al., 1995). Studies of
conjoint support group approaches (e.g., McAfee, Ruh, Bell, & Martichuski, 1989) re-
port positive evaluations from both patients and caregivers, but they do not address the
issue of whether the conjoint approach improves communication between the patient and
the caregiver—often a key treatment goal.
Reminiscence Groups
Whereas the act of reminiscence was at one time considered a negative sign among de-
mented individuals (Watt & Wong, 1991), reminiscence therapy is actually supported by
a number of empirical studies. The goal of reminiscence therapy is to help demented pa-
tients recall past events and experiences as a means to improve social interaction and pro-
mote a general sense of well-being. Although these groups do not typically emphasize
treatment of specific psychological issues or behaviors, they have been found to be associ-
ated with increases in meaningful discourse among individuals with mild to moderate im-
pairment (Moss, Polignano, White, Minichello, & Sunderland, 2002). Reminiscence
groups may tap some of the residual cognitive abilities of individuals who have the most
common forms of dementia, later into the disease course than other types of intervention
(Rentz, 1995).
Regarding empirical studies of reminiscence therapy, Goldwasser and colleagues
(Goldwasser et al., 1987) compared a reminiscence group to a nonspecific support group
and a no-treatment group (n = 27) and found an improvement in depression among remi-
niscence treatment group members compared to those in the other two groups. They did
not, however, find a significant treatment effect after a 5-week follow-up period. Interest-
ingly, the authors describe a technique that incorporates behavioral training elements:
guiding patients to generate internal retrieval cues. Baines and colleagues (Baines, Saxby,
& Ehlert, 1987) compared a reminiscence therapy group to an RO group and a no-treat-
ment group in a nursing home setting (n = 15). They used a crossover design in which
each group received the intervention for a half-hour each day over a 4-week period, with
a 4-week no-treatment period between the intervention periods. Patients in the reminis-
cence group demonstrated maintenance of cognitive function after treatment and 4-week
follow-up, but no changes on behavioral or life satisfaction measures. On the whole, rem-
iniscence groups may have positive effects on depression as well as other nonspecific
effects on the overall function of individuals with moderate levels of dementia.
Reality Orientation Therapy

Like reminiscence therapy, RO therapy is used with individuals who have greater levels of
cognitive impairment (Donahue, 1984; Taulbee, 1984). The goal of RO is to reorient pa-
tients by means of continual stimulation and repetitive orientation to their environment.
Typically, daily group sessions are held that contain a didactic component designed to
help orient and engage group members (Holden & Woods, 1988). A number of studies
have reported positive changes associated with RO, including improvements in orienta-
tion, memory of personal facts and appointments, and general cognitive functioning
(Hanley, 1981; Hanley & Lusty, 1984). Two studies have shown that RO may slow the
decline in global cognitive status over time, as measured by change in Mini-Mental
State Examination (MMSE) scores (Baldelli et al., 1993; Zanetti et al., 1995), but there
were no effects for improving affective status or activities of daily living (see also Bates,
Boote, & Beverley, 2004). Although there is empirical support for RO therapy, some au-
thors report that certain patients may become emotionally upset during treatment and
that an alternative approach may be more appropriate (Zanetti et al., 1995). Validation
therapy, which is based on empathic listening, has been proposed for patients with
greater levels of cognitive impairment who do not respond well to RO (Dietch, Hewett,
& Jones, 1989; Zanetti et al., 1995); however, few well-designed studies have examined
its effectiveness.
ECLECTIC PSYCHOTHERAPIES
In the reality of current clinical practice, an eclectic approach to group therapy may be
more common than one that strictly follows a single treatment methodology. Koltai and
Branch (1999), for instance, argue that combining elements from different therapeutic
approaches enhances the potential for clinical gain. Eclectic intervention strategies, when
systematically designed and implemented, offer flexibility in responding to the specific
needs of the individuals in the group. Given the nature of progressive neurodegeneration
and the shifting needs and challenges faced by many individuals and families as they at-
tempt to cope with the changing nature of symptoms and impairments, intervention ap-
proaches that have access to a wide variety of tools allow the person with dementia to re-
main central in defining the intervention. Dhooper and colleagues (Dhooper, Green,
Huff, & Austin-Murphy, 1993) reported the outcome of an eclectic treatment approach
that combined elements of reminiscence, emotional processing, and problem-solving
skills in 16 elderly nursing home residents experiencing mild to moderate depression.
They reported significant changes in depression following the intervention when com-
pared to a no-treatment control group. Despite these positive findings, the lack of an ac-
tive treatment control condition limits the support that these findings provide for their as-
sertion that an eclectic treatment approach is more broadly effective than other treatment
modalities. Our experience with one eclectic approach (Koltai et al., 2001) combined em-
pirically guided intervention strategies and clinical approaches involving multiple cogni-
tive, compensatory, and coping strategies. These results revealed significant improvement
in perceived memory functioning among individuals with dementia who had intact in-
sight. Other combined cognitive coping approaches are reviewed in Clare (Chapter 13,
this volume).
Cheston and colleagues (2003) recently described a psychotherapeutic intervention
for individuals with dementia called the Dementia Voice Group Psychotherapy Project.
The project involved a 10-week therapy group that was conducted at several different
sites. Groups consisted of individuals with AD and other dementias who were character-
ized as mildly impaired and who all had MMSE scores greater than 18. Participants in
these groups were asked to reflect on the emotional significance of their experience of
memory loss, with a focus on “here-and-now” issues, such as the impact of memory diffi-
culties on their interpersonal relationships. Data were reported for 19 individuals who
participated in preintervention testing, the full course of therapy, and a 10-week follow-
up assessment. Although the study lacked a control group, the authors found that group
members had decreased levels of depressive symptomatology from baseline, both for the
duration of therapy and follow-up assessment. Marginally significant treatment effects
for anxiety were reported as well.
GROUP PERSPECTIVES FROM CLINICAL PRACTICE
Our psychotherapeutic intervention group has been meeting for approximately 3 years.
The group was initiated when three patients were referred to one of us (DKA) for in-
tervention to address depression, anger, and memory compensatory strategy training.
The three were all considerably distressed, having experienced recent declines and diag-
noses. All had similar cognitive profiles at the time (primary executive dysfunction,
memory deficits, and word-finding difficulties), as well as similar losses of role function
(sudden unanticipated retirement, cessation of driving privileges) and accompanying
emotional responses (primarily depression, with some anger and anxiety). One individ-
ual was in his early 50s, another in his mid-50s, and the third in his early 60s. Over
the course of the group to date, three others have joined and participated from 2 to 12
months, but the original three members have remained the consistent core of the
group.
The group has met every 2–3 weeks over the past 3 years. The themes and goals of
treatment have evolved over time to accommodate the cognitive and functional changes
of the group members. It is best described as utilizing a combination of behavioral and
grief models of psychotherapy. We often integrated the two approaches; for instance, em-
phasizing participation in pleasant and rewarding activities as a behavioral response to
negative feelings about functional loss or perceptions of decreased usefulness. Like Teri
and colleagues (1997), we found promoting or maintaining rewarding activity to be a
particularly valuable component of the treatment.
Consistent with the perspective of this chapter, we have attempted to conduct our
treatment in accordance with empirical knowledge about the symptoms and expres-
sions of cognitive impairment, and to integrate therapeutic models that have been
honed by research; however, quantifying treatment progress in small groups such as
ours has been challenging. In part, this is because a small group does not necessarily
have a normative experience on a specific outcome measure. For instance, although the
Geriatric Depression Scale was useful in assessing baseline distress and subsequent im-
provement among most group members, one member who entered therapy with a
“motivated denial” about his deficits actually reported increased depression as treat-
ment progressed. In this case, the increase in negative affect was a reflection of the pa-
tient’s evolving acceptance of his dementia and its implications, which reflects treat-
ment success in terms of insight and adaptation. Because of similar experiences, we
have found that our empirical outcome measures are a useful adjunct to treatment
when they are interpreted in the context of feedback from patients, spouses, and often
the referring physicians. To this purpose, and also to highlight the personal and experi-
ential nature of group treatment, we present perspectives of group members and
spouses on the process of therapy
The quotes in the following section are from our group members (directly or with as-
sistance) and their spouses, which we have obtained from taped conversations and writ-
ten responses. These couples have previously shared their experiences with a large audi-
ence at a regional AD conference. They continue to remember this experience well and
fondly, and have been eager for other outlets to express themselves. Although their ability
to articulate their message has changed over time, the message itself has remained consis-
tent with themes discussed previously in this chapter.
Regarding Loss and Adaptation
“We know there are things we cannot do that we wish we could do, and it is not an easy
process to let these go. There are a lot of things we can do, though, and we need you to
see this.”
“By being in group—it helps each other. Others can get by with better help. Others
can feel better once they knock the wall down, by being mad and mean and crying
. . . you’ve done that and you can put it back together.”
“There is no point of focusing on the negative and the losses. Yes, they are there, but
where do we get thinking only about these? We have to focus on who we are and
what we can do.”
On the Interpersonal Experience of Therapy
“The friendships we have forged are extremely powerful emotionally.”

“We offer each other ideas. We offer each other acceptance. We will confront each
other when that is needed, in instances of unsafe or unhealthy behavior. We do not
give up on each other.”
“This group has been very important to me because I don’t have to worry about
making mistakes. . . . It’s okay not to remember and not to be able to get the words
out. . . . It has been the most helpful thing for me, other than my wife. . . . I think
this type of group would help anyone with our problems, and I hope there will be
more groups like this everywhere.”
“We are here. Our memories and words might not always be, but we are.”
The following quotes about group therapy are from the spouses’ perspectives.
On the Significance of Group Therapy to Healthy Adjustment
“He knows that no matter how overwhelming things seem for him sometimes, he can
go to group and talk about it and be heard and understood. There is no criticism in
group, but there is encouragement and support. The group’s themes of accepting
yourself the way you are and realizing that you can’t do the things you used to do but
you are still the person you always were have been very helpful to him. . . . ”
“[My husband] was very depressed, negative, angry, and lethargic. . . . Group has
been very beneficial in processing the fear and anger and moving [him] on to the ac-
ceptance stage. . . . The consistent support over the years has provided an under-
standing that they are not alone in their challenges . . . they have shed their tears,
expressed their frustrations, and faced their fears together. . . . The group sessions
have enabled him to process the stages of grief and loss of himself. . . . I cannot be-
gin to tell you how important [group] is to the well-being of the patient. . . . With-
out group, we probably would have isolated ourselves and wallowed in our
rollercoaster of emotions.”
On the Meaning of Group to the Spouses
“For me, as a spouse, group has meant the opportunity for wives to have regular ‘meet-
ings of the minds,’ ‘sharings of the heart,’ and ‘barings of the soul’—in essence—to
form a unique sisterhood of support for one another. I can share with [the other
spouses] things about daily struggles, discoveries, resources, and dark nights that I
share with no one else.”
On What Patients and Spouses Want Care Providers to Know
“Group support has not been wasted on the ‘forgetful.’ Even though communication
and remembering are very difficult, the messages are still inside the heart and soul.
These guys have tremendous value and can still make a contribution. Friends, family
members, and caregivers must recognize and respect the individual as a wonderful
value and a gift to life. Although the challenges are great, there is much still to be
learned if we just spend time and listen.”
The preceding perspectives from group members and their spouses express impor-
tant aspects of the group therapeutic process that we as scientist-practitioners often find
challenging to capture empirically. Treatment providers need to balance both idiographic
(individually oriented) and nomothetic (normatively based) methods of conceptualizing
and evaluating outcomes. They are not mutually exclusive, but complementary, and
methods such as case studies and treatment outcome research can contribute to the ad-
vancement of group therapy for dementia and other geriatric cognitive disorders. Regard-
less of the approach, it is important to integrate clinical techniques with empirical knowl-
edge of brain–behavior relationships to promote optimal growth for patients and to
consistently assess progress with attention to cognition, function, affect, and quality of
life as they pertain to the individual and those within the care environment.
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19
Pharmacological and
Other Treatment Strategies
for Alzheimer’s Disease
KATHLEEN HAYDEN
MARY SANO
T he treatment of Alzheimer’s disease (AD) has a modern-day history that begins in the
early 1990s and continues to expand today, with clinical research initiatives addressing
preventive strategies and treatments for other forms of dementia and memory loss. To
this end, it is now generally recognized that AD is a protracted process in which the
neuropathological events occur years, and perhaps decades, before diagnosis. As such,
there are three distinct stages along the pathological cascade at which point interventions
may be implemented: (1) a “preclinical” asymptomatic phase; (2) a “prodromal” or early
symptom state; and (3) the fully expressed disease stage. It cannot be assumed that treat-
ments for AD are equally effective at all stages of the disease; in fact, there is evidence
that some pharmacological interventions are potentially useful in primary and secondary
AD prevention but essentially ineffective at the later stages of the illness in affecting dis-
ease progression (e.g., Zandi, Anthony, et al., 2002). The situation is not unique to AD.
Analogous scenarios exist for many progressive medical illnesses, for which the aggres-
siveness of the indicated therapy depends on the stage of the underlying disease state.
This chapter focuses on the pharmacological treatment of AD and similar disorders.
First, we provide a review of the drug development and approval process for AD com-
pounds and discuss the currently available treatment options for patients affected by the
disease. We then address the notion of extending current treatment to new indications,
which includes disease prevention options and suggested therapeutic mechanisms for
slowing progression. This section summarizes some of the new and novel approaches that
are aimed at the fundamental neuropathological mechanisms of the disease and hold po-
tential promise of treating the disease even when it is fairly advanced. We conclude the
chapter with a discussion of topical areas in which clinical trials can provide important
414
Pharmacological and Other Treatment Strategies 415
answers. Our intention in this chapter is to provide practicing neuropsychologists with

information regarding the treatment options for currently affected dementia patients and
an overview of ongoing research directions in developing effective treatment options for
the future.
TREATING LATE-LIFE COGNITIVE DISORDERS
Medical treatment of the last two decades includes pharmacological interventions for pa-
tients with AD. Although still in its infancy, five drugs are approved for use in the United
States, and there is robust interest in development of better agents that may modify dis-
ease progression and prevent disease onset. Researchers have experienced monumental
steps forward as well as disappointing results, and enthusiasm remains high—which is
not surprising given the estimates of growth in prevalence and incidence of this disease
(Brookmeyer, Gray, et al., 1998). Perhaps in part due to the availability of treatment for
cognitive symptoms, there is growing interest in identifying treatment of other forms of
memory loss and dementia associated with diseases of aging. These include vascular dis-
ease, neurodegenerative diseases, prodromes to disease such as mild cognitive impairment
(MCI), and other forms of age-related cognitive decline. The success in identifying treat-
ments for AD has been aided by regulatory guidelines for drug approval. A review of this
process may outline the efforts needed to make similar progress for drug approval for
other indications.
THE REGULATORY APPROVAL PROCESS
In the United States, the Food and Drug Administration (FDA) approves new drugs for
marketing based on a New Drug Application (NDA) that provides evidence of (1) effi-
cacy for the specified indication and (2) safety in the population for which it is to be used.
Based on draft guidelines from 1990, the FDA requires that the efficacy of drugs for this
indication be demonstrated in at least two separate randomized, double-blind, placebo-
controlled trials that are each of at least 3–6 months’ duration. A further requirement is
that efficacy should be determined by demonstrating benefit in two prespecified primary
outcome measures, one of which should assess cognitive function and the other should be
either a clinician’s overall impression of benefit (including cognition, function or behav-
ior) or a measure of activities of daily living (ADLs). The guidelines recommend that
superiority of treatment over placebo be demonstrated for each of the two prestated out-
comes by statistical significance at the p < .05 level (Mani, 2004).
Currently there are four drugs approved for the treatment of mild to moderate de-
mentia of the AD type; all are of the same class of cholinesterase inhibition. Memantine,
an (NMDA) receptor antagonist (mechanism of action explained on p. 432), has been
approved for the treatment of moderate to severe dementia. It is unclear how useful the
indication by disease stage will be in clinical practice. The specific labeling for these treat-
ments includes statements that there is no evidence that the drug in question alters the
course of the underlying dementia.
At present there are no guidelines for the approval process for other dementias such
as vascular and mixed dementias. One limitation is inadequate knowledge about appro-
priate outcome measures. Approaches to trial design in these diseases consist of using as-
sessments developed for patients with mild to moderate AD, which may not be the most
appropriate for capturing benefit in other conditions.
Interest in the prevention of AD has grown, and the identification of mildly symp-
tomatic individuals typically labeled with MCI has provided a model for trials of second-
ary prevention of AD. Methodological reports from such studies describe these individu-
als and have estimated the likelihood of their progression to AD. Results from clinical
trials in patients with MCI are becoming available and may provide information to deter-
mine the best approach to treatment. By and large, the agents under study have been
those used to treat AD or which theoretically could treat AD.
TOOLS FOR ASSESSING DEMENTIA IN CLINICAL TRIALS
The FDA requires a demonstration of improvement in cognition and either clinical global
change or improvement in ADLs. As awareness of the breadth of symptomatology and
social and economic impact has grown, clinical trials for AD have come to include mea-
sures of behavioral disturbance, quality of life, and cost effectiveness. In addition, several
efforts have been made to specify the nature of cognitive benefit. Table 19.1 summarizes
instruments that have been used to assess efficacy in these domains in clinical trials for AD.
Numerous tests are available to evaluate each of these domains. The cognitive
subscale of the Alzheimer’s Disease Assessment Scale—Cognitive subscale, or ADAS-Cog,
is the most widely used scale to evaluate cognition. This scale evaluates spoken language
ability, comprehension, recall of test instructions, word finding, following commands,
naming objects, constructional praxis, ideational praxis, orientation, word recall, and
word recognition. The Mini-Mental State Examination (MMSE) is frequently used by cli-
nicians in practice as a screening device in research studies and as a secondary outcome
measure of cognition in clinical trials. The Severe Impairment Battery (SIB) has been used
to demonstrate efficacy in patients with low MMSE scores and consists of praxis items as
well as simple memory items. Like the ADAS-Cog, it has been used to support an NDA
application for a currently approved drug. The Syndrome Kurtz Test (SKT) has also been
used in clinical trials to evaluate cognitive change, although it is not commonly used in
the United States. All of these tests are administered to the patient and therefore are direct
assessments of cognitive function.
An estimate of a clinician’s impression of change is generally measured via the Clinical
Global Impression of Change (CGI) or the Clinician’s Interview-Based Impression of
Change plus Caregiver Input (CIBIC-Plus). These tests are standardized ratings given by a
clinician after interviewing the patient, and caregiver input is considered as well. Other tests
of global function include the Clinical Dementia Rating Scale (CDR), which uses a
semistructured interview to independently assess patient and informant. The Global Deteri-
oration Scale (GDS) is a staging instrument that is completed after a clinical examination.
The most commonly used measure of functional ability is the Alzheimer’s Disease
Cooperative Study—Activities of Daily Living (ADCS-ADL). This scale was empirically
derived and has specific versions for disease stage. It has been useful in many trials in
demonstrating efficacy in the functional domain. Other measures include the Interview
for Deterioration in Daily Living Activities in Dementia (IDDD), the Functional Activities
Questionnaire (FAQ), and the Disability Assessment for Dementia scale (DAD). These
tests are administered to an informant or caregiver. Finally, the Physical Self Maintenance
Scale (PSMS), which can be self-rated, is typically rated by an observer in AD trials.
Behavioral symptoms are an important clinical aspect of dementia, and outcome
TABLE 19.1. Instruments and outcome measures commonly used in clinical trials for Alzheimer’s disease
Outcome
Domain Test Reference Score measures Comments
Cognitiona ADAS-Cog Mohs et al. • Range: 0–70 Severity of • “Gold standard”
(Alzheimer’s (1997); Rosen • Higher scores symptoms cognitive outcome
Disease Assessment et al. (1984) indicate measure for AD
Scale—Cognitive increased • Administered to
subscale) severity patient
MMSE (Mini- Folstein et al. • Range: 0–30 Onset, stability, • Secondary
Mental State (1975) • Low scores and severity of outcome measure;
Examination) indicate cognitive used for screening
increased symptoms • Administered to
severity patient
SIB (Severe Schmitt et al. • Range: 0–100 Cognitive • Primary outcome
Impairment (1997) • Higher scores function in measure for severe
Battery) reflect higher severe dementia impairment
cognitive ability • Administered to
patient
SKT (Syndrom Erzigkeit • Range: 0–27 Memory and • Primary outcome
Kurtz Test) (1989); Lehfeld • Lower scores attention measure
& Erzigkeit show • Administered to
(1997) improvement patient Timed test
Clinical CGI (Clinical Schneider et al. • Range: 1–7 Cognitive, • Alzheimer’s

global Global Impression (1997) • Higher scores behavioral, Disease
changea of Change) indicate social, and Cooperative Study
increased daily (ADCS) version
severity functioning • Standardized
rating given by
clinician; patient
and informant
interviewed
CIBIC-Plus Knopman et al. • Range: 1–7 Four major • Semistructured
(Clinician’s (1994) • Higher scores areas of review
Interview-Based indicate function: • Rating of patient
Impression of increased general, given by clinician
Change Plus severity cognitive, with informant
Caregiver Input) behavioral, input
and ADLs
CDR-SB (Clinical Berg (1988) • Range: 0–18 Presence and • Structured
Dementia Rating— • Higher scores severity of interview
Sum of Boxes) indicate dementia • Evaluates six
increased categories of
severity function: memory,
orientation,
judgment and
problem solving,
community
affairs, personal
care
• Administered to
patient and
informant
GDS (Global Reisberg et al. • Range: 1–7 Rates seven • Informant not
Deterioration (1982) • Higher scores stages of required
Scale) indicate dementia • Structured
increased interview not
severity required
(continued)

Outcome
Domain Test Reference Score measures Comments
Functional IDDD (Interview Teunisse & • Range: 1–7 Severity of • Structured
for Deterioration Derix (1991) • Higher scores functional interview
in Daily Living indicate impairment; • Administered to
Activities in increased ability to informant
Dementia) severity perform
activities of
daily living
(ADLs and
IADLs)
ADCS-ADL Galasko et al. • Range: 0–78 Assesses • Administered to
(Alzheimer’s (1997) • Higher scores level of informant
Disease Cooperative indicate higher independence • Inventory of items
Study—Activities function varies according
of Daily Living) to severity of
dementia being
assessed
FAQ (Functional Pfeffer et al. • Range: 1–7 Evaluates • Administered to
Activities (1982) • Higher scores performance informant
Questionnaire) indicate on ten complex
increased activities of
severity daily living
DAD (Disability Gelinas et al. • Range: 0–100 Assesses basic • Administered to
Assessment for (1999) • Higher scores and informant
Dementia Scale) indicate instrumental
improvement ADLs, leisure
activities,
initiation,
planning,
organization,
and effective
performance
PSMS (Physical Lawton & • Range: 6–30 Assesses ability • Observer version
Self Maintenance Brody (1969) • Lower scores to feed, toilet, and self-rated
Scale) indicate better dress, groom, versions available
self-maintenance walk, and
bathe
Behavioral BEHAVE-AD Reisberg et al. • Range: 0–75 Assesses • Able to

(Behavioral (1987) plus global behavioral distinguish
Pathology in rating symptoms cognitive
Alzheimer’s • Higher scores symptomatology
Disease Scale) indicate more from
severe problems pharmacologically
remediable
behavioral
symptoms
• Administered to
informant
NPI Cummings • Range: 0–120 Assesses • Behavioral change

(Neuropsychiatric et al. (1994) • Higher scores delusions, usually within a
Inventory) indicate hallucinations, defined period of
increased agitation/ time
severity aggression, • Administered to
depression, informant
anxiety, elation,
apathy,
disinhibition,
irritability,
aberrant motor
behavior, sleep,
and appetite
CMAI (Cohen- Cohen- • Range: 1–7 Rating of

Mansfield Mansfield • Higher scores agitated
Agitation (1986) indicate behaviors
Inventory) increased
severity
Quality ADRQL Rabins et al. • Range: 0–100 Evaluates • Administered to

of life (Alzheimer (1999) • Higher scores behaviors primary caregiver
Disease-Related indicate better associated with
Quality of Life) QoL five domains
QOL-AD (Quality Logsdon et al. • Range: 13–52 Assesses • Administered to
of Life— (2002) • Higher scores domains of patient
Alzheimer’s indicate greater behavioral
Disease scale) quality of life competence,
psychological
status, physical
function, and
interpersonal
environment
DQOL (Dementia Brod et al. • 29 items scored Five subscales • Administered to
Quality of Life (1999) on 5-point assess 10 patients with
instrument) Likert scale domains of MMSE scores >12
quality of life
CBS (Cornell– Ready et al. • Range: –38–+38 Rating based • Semistructured
Brown Scale for (2002) • Negative scores on positive/ interview
Quality of Life in represent poor negative affect, • Administered to
dementia) QoL ratings physical patient and
complaints, and informant
satisfaction
Caregiver BGP—Care van der Kam • Range: 0–70 Assesses • Reflects cognitive
measures Dependency et al. (1971) • Higher scores cognitive and and functional
subscale indicate functional characteristics
(Behavioral Rating increased characteristics associated with
Scale for Geriatric severity associated with increased need for
Patients, Care need for care care
Dependency
subscale)
SCB (Screen for Vitaliano et al. • Range: 0–25 Rapidly • Administered to
Caregiver Burden) (1991) for objective identifies caregiver
burden; 0–75 distressing
for subjective caregiver
burden experiences
• Higher scores
indicate greater
burden
a FDA requires evidence of benefit in these domains.
measures in clinical trials frequently include assessment of this domain. The Neuropsy-
chiatric Inventory (NPI), currently the most commonly used instrument, is a structured
interview administered to a caregiver or knowledgeable proxy informant that addresses
12 domains of behavior, including agitation, irritability, anxiety, dysphoria, hallucina-
tions, delusions, apathy, euphoria, disinhibition, aberrant motor behavior, nighttime dis-
turbances, and abnormalities in appetite or eating habits. The score is a composite of fre-
quency and severity ratings of each item. Caregiver distress is rated for each item,
although it is not typically included in the overall score. The Behavioral Pathology in Alz-
heimer’s Disease Scale (BEHAVE-AD) is a 25-item scale that uses input from the caregiver
and direct observation to assess the behavioral symptoms of delusional ideation, halluci-
nations, activity disturbances, aggressiveness, sleep disturbance, affective symptoms, and
anxiety. The Cohen-Mansfield Agitation Inventory (CMAI) is a caregiver questionnaire
that provides an overall measure of agitation and behavioral problems.
Recently, several scales have been developed to evaluate the quality of life (QOL) of
patients with dementia. These scales are being incorporated in clinical trials. Tests include
Alzheimer Disease-Related Quality of Life (ADRQL), Quality of Life—Alzheimer’s
Disease scale (QOL-AD), Dementia Quality of Life instrument (DQoL), and the Cornell–
Brown Scale for Quality of Life in dementia (CBS). Finally, changes in the level of care-
giver burden can be evaluated with the Behavioral Rating Scale for Geriatric Patients
(BGP)—Care Dependency subscale and the Screen for Caregiver Burden (SCB).
TREATMENT FOR AD WITH APPROVED AGENTS

Cholinergic Stimulation
Observed deficits in cholinergic neurotransmission in AD led to the development of the
first symptomatic treatments for the disease. These treatments are designed to inhibit the
breakdown of acetylcholine in the synaptic cleft, thus enhancing cholinergic neuro-
transmission. To date, there are four FDA-approved cholinergic agents available in the
United States.
Tacrine
In September 1993 tacrine became the first agent approved by the FDA in the
cholinesterase inhibitor class. Tacrine requires multiple daily dosing (four times per day)
from initial doses of 10 mg, four times per day, to a maximum total of 160 mg/day. Titra-
tion should be done at 4-week intervals, with slow titration of dose into the effective
range (i.e., 16 weeks) in order to minimize cholinergic side effects. Tacrine has 5–30%
absolute bioavailability after absorption and is diminished with food, requiring adminis-
tration on an empty stomach. Tacrine has limited tolerability of about 65% at the highest
dose and requires monitoring of liver enzymes (Knapp, Knopman, et al., 1994). Contra-
indications include hepatic impairment, cardiac arrhythmias or cardiac disease, chronic
obstructive pulmonary disease, gastrointestinal (GI) bleeding, hepatic disease, hypoten-
sion, jaundice, and Parkinson’s disease, among others. Interactions with antimuscarinic
agents, other cholinesterase inhibitors, estrogens, general or local anesthetics, neuromus-
cular blockers, nonsteroidal anti-inflammatory drugs, parasympathomimetics, phenothiazines,
sedating H1 blockers, tricyclic antidepressants, and others are noted. Side effects associ-
ated with tacrine include nausea, diarrhea, vomiting, exacerbation of hypotension or
syncope, weight loss, elevation of liver enzymes, seizures, vagotonic effects, broncho-
constriction, and exaggerated muscle relaxation. Due to the profile of side effects, the
need to monitor liver enzymes with routine blood tests, and compliance problems associ-
ated with multiple daily dosing, tacrine is generally no longer prescribed. Newer cholin-
ergics require less frequent daily dosing and do not require monitoring of liver enzymes.
Donepezil
The second agent to be approved by the FDA (November 1996), donepezil, is a reversible
inhibitor of the enzyme acetyl cholinesterase, and is used for symptomatic management
of mild to moderate AD. Donepezil is administered once daily and does not require moni-
toring of liver enzymes. Maximum dosage is 10 mg/day, although there is no clinical
evidence of greater effect at 10 mg/day than 5 mg/day. Titration from 5 mg to 10 mg can
occur after an interval of 4–6 weeks. Donepezil is well absorbed with 100% bio-
availability and no food limitations to absorption. The most common adverse events are
nausea, diarrhea and vomiting, insomnia, muscle cramps, and anorexia, with more study
withdrawals from those on 10 mg than 5 mg. Side effect rates were reduced at the 10-mg
dose when the titration interval between 5 and 10 mg was increased from 1 to 6 weeks.
Sleep disturbance may occur, perhaps because recommended dosing instructions suggest
evening administration; modification of the time of administration may minimize this ef-
fect (Geldmacher, 1997).
A number of randomized clinical trials has been conducted to evaluate the efficacy of
donepezil for patients with AD. A recent meta-analysis of 16 trials examined donepezil
use in 4,365 patients with mild, moderate, or severe AD (Birks & Harvey, 2003). The tri-
als varied in length from 12 to 52 weeks. Outcomes studied included cognitive function
and global clinical state, the two outcomes required by the FDA for approval. Statistically
significant improvements in cognition were shown for both 5- and 10-mg/day treatment.
Clinical global measures also showed improvement, and some studies reported benefit in
ADLs and behavior, mostly with the 10-mg/day treatment.
There are few long-term randomized controlled trials, but efficacy has been demon-
strated in a 1-year study (Winblad, Engedal, et al., 2001). More recently, the AD2000
Collaborative Group studied long-term donepezil treatment in 565-community residing
patients and reported findings of better cognition and functionality compared to a pla-
cebo over a 2-year period, though there were no differences in behavioral and psychologi-
cal symptoms, time to nursing home placement, caregiver psychopathology, formal care
costs, unpaid caregiver time, adverse events, or deaths (Courtney, Farrell, et al., 2004).
Rivastigmine
The next agent to appear on the market was rivastigmine (approved April 2000), also a
reversible acetylcholinesterase inhibitor. Rivastigmine inhibits both acetyl- and butyl-
cholinesterase; however, there is little information on the relationship of the latter to the
clinical impact of the drug. The maximum dose administered is 12 mg/day. The drug is
completely absorbed, and absolute bioavailablilty is 36%. Food helps to enhance the
bioavailability and increases tolerability of the medication. Patients take 1.5 mg twice
daily with food and may increase to 3 mg after 2 weeks. Usual maintenance dosages are
between 3 and 6 mg twice a day. If medication is discontinued at any point for more than
a few days, it is recommended that the treatment be reinitiated at the lowest dose and
titrated as described above. Side effects include dizziness and GI disorders such as nausea,
vomiting, and diarrhea. Drug interactions may occur with antimuscarinics, other cholin-
esterase inhibitors, general and local anesthetics, and other drugs.
A Cochrane Review of eight trials of rivastigmine use in mild to moderate AD showed
benefits in cognition, global measures, and ADLs with 6–12 mg/day over an interval of 26
weeks (Birks, Grimley Evans, et al., 2004). Although higher doses showed greater benefits,
patients on higher doses experienced more side effects. The authors suggest that smaller
doses administered more frequently may ameliorate this problem. Patients who took lower
doses (4 mg/day) showed statistically significant improvements in cognition.
Galantamine
The most recent cholinesterase inhibitor to receive approval from the FDA for treatment
of mild to moderate AD is galantamine (February 2001). This drug is a specific, revers-
ible, competitive acetylcholinesterase inhibitor and an allosteric modulator at nicotinic
cholinergic receptor sites. Originally isolated from various plants, including daffodil
bulbs, galantamine is now synthesized (Olin & Schneider, 2004). The maximum dose ad-
ministered is 24 mg/day. Galantamine is completely absorbed, and the bioavailability ap-
proaches 90%. The initial dose is 4 mg twice a day taken with food. After 4 weeks the
dose can be increased to 8 mg two times per day and increased in 4-mg increments to the
maximum of 24 mg/day.
A systematic review of seven trials, varying in length from 12 weeks to 6 months,
showed improvements in cognition, global ratings, ADLs, and behavior. Doses above 8
mg/day showed statistically significant results; however, no dose–response effect was
found among higher doses. The most common adverse effects, similar to other cholin-
esterase inhibitors, were nausea, vomiting, diarrhea, anorexia, and weight loss. Dosage
increases were associated with GI symptoms and discontinuation. Galantamine was best
tolerated when there was a slow titration (4 weeks) to a dose of 16 mg/day (Olin &
Schneider, 2004). Administration with food, the use of antiemetic medication, and ensur-
ing adequate fluid intake may reduce the impact of GI disturbance.
Considerations for Cholinesterase Inhibitor Use in AD

In the treatment of mild to moderate AD, cholinesterase inhibitors are efficacious in
slowing cognitive decline and may be effective for up to 2 years. Side effects tend to be
relatively benign and can be mitigated by slow titration to optimal dosages. Practical
issues of drug administration, such as the availability of a caregiver to administer and/or
supervise treatment and manage side effects, and the frequency of dosing may be important
in the selection of an agent. Patients should be monitored for side effects. Improvement or
stabilization may not be apparent for several months after the initiation of treatment.
No guidelines currently exist for the selection of one drug over another, and few
studies have been conducted to compare treatments. Recently, a study by Jones et al.
(Jones & Soininen, 2004) compared donepezil and galantamine in a head-to-head open-
label trial. Donepezil showed greater effects on cognition, ADLs, and tolerability than
galantamine. Although the galantamine group was older and had a greater number of
females—both potential reasons for poor tolerability—the authors reported that no treat-
ment-by-gender interactions were found. Generally, the experience of the family members
as well as patients will play a key role in weighing benefits of any treatment. Although
data support benefits in areas that should have an important impact on quality of life and
economic value, no such results have been observed.
Glutamate and the NMDA Receptor

Memantine, the newest drug on the market for treatment of AD symptoms, is different
from cholinesterase inhibitors in two respects: mechanism of action and specific indica-
tion. First, memantine is a noncompetitive N-methyl-D-aspartate (NMDA) receptor an-
tagonist. The action of this drug is to protect cells from excitotoxicity by blocking the
uptake of glutamate at the NMDA receptor site. Second, the drug has been approved for
use in moderate to severe AD. (It should be noted that the cognitive assessment used in
clinical trials of patients at this stage of the disease is the SIB rather than the ADAS-Cog).
The half-life of memantine is 60–80 hours with the peak concentration reached in 3–7
hours. The recommended starting dose is 5 mg once a day with an increment of 5 mg/day
at weekly intervals until the maximum dose of 20 mg/day is achieved. It is recommended
that twice-daily dosing be observed with the first dose escalation.
Three trials, including 973 patients with moderate to severe AD and lasting 12–28
weeks, have been published. In one, memantine alone demonstrated benefits in cognition
over placebo (Reisberg, Doody, et al., 2003). In another randomized trial, the combined
use of memantine plus donepezil demonstrated benefits over donepezil alone, in terms of
effects on cognition, a clinical global measure, and behavior (Tariot, Farlow, et al., 2004).
Although a third study did not use a cognitive measure (Winblad & Poritis, 1999), all
three studies assessed clinical global benefits. Two of the three studies demonstrated a sta-
tistically significant benefit of memantine over placebo using an intention-to-treat (ITT)
analysis. Additionally, all three studies demonstrated efficacy in analyses of completers.
Memantine was well tolerated in clinical trials. An increase in confusion (7.9 vs. 2%) was
reported in one study (Tariot, Farlow, et al., 2004) but no consistent pattern of side ef-
fects has emerged. Clinical exposure to this agent is minimal compared to cholinesterase
inhibitors, and it may be too early to know the complete side effect profile.
Early reports of the use of memantine in mild to moderate AD in combination with a
cholinesterase inhibitor failed to demonstrate efficacy, though the details of the study are
not available at this writing. A study examining the effect of memantine in this patient
population in the absence of other treatments yields small but significant effects on cognition
and clinical global measures (Pomara, Peskind, et al., 2004). Additional studies are needed to
provide support for the use of this agent in patients at milder stages of the disease.
Table 19.2 summarizes the data on FDA-approved therapeutic agents for treatment
of AD.
TREATMENT OF OTHER DEMENTIA AND COGNITIVE DEFICITS

Vascular Dementia
The development of treatments for AD was advanced by uniform diagnostic criteria
(American Psychiatric Association, 1987; McKhann, Drachman, et al., 1984). In the ab-
sence of biomarkers, these clinical criteria play a key role in identifying a homogeneous
population in which to demonstrate reliable treatment effects. Such criteria are less well
established for other conditions, though there is a growing awareness of the need and
many attempts to develop consensus around diagnoses.
TABLE 19.2. FDA-Approved Therapeutic Agents

Beneficial effects: mean difference
in change score for treated vs.
nontreated
Most
frequent Global
adverse impression
Agenta Action Indication Dosing events Cognitive of change
Tacrine Cholinesterase Mild to 160 Nausea ADAS-Cog 2.07 CIBIC-Plus
(Cognex) inhibitor (inhibits moderate mg/day Diarrhea for average 0.58 for
acetyl- and DAT Vomiting doses of 39–135 average doses
butylcholinesterase) Syncope mg/day of 39–135 mg/
day
Donepezil Reversible selective Mild to 5–10 Nausea ADAS-Cog 2.7– CIBIC-Plus

(Aricept) acetylcholinesterase moderate mg/day Diarrhea 3.1 for doses 0.35–0.39 for
inhibitor DAT at night Vomiting of 5 to 10 doses of 5–10
mg/day mg/day
Rivastigmine Pseudo-irreversible Mild to 6–12 Nausea ADAS-Cog 0.2– CIBIC-Plus

(Exelon) noncompetitive moderate mg/day Vomiting 4.9 for doses of 0.14–0.41 for
acetylcholinesterase DAT with food Dizziness 1–12 mg/day doses of 1–12
inhibitor Diarrhea mg/day
Galantamine Specific, reversible, Mild to 16–24 Nausea ADAS-Cog 1.7– CIBIC-Plus

(Reminyl) competitive moderate mg/day Vomiting 4.1 for doses of 0.15–0.47 for
acetylcholinesterase DAT with food Diarrhea 8–32 mg/day doses of 8–32
inhibitor mg/day
Memantine Uncompetitive Moderate 20 Dizziness SIB 3.3–5.7 for ADCS-ADL

(Namenda) NMDA-receptor to severe mg/day Headache doses of 5–20 1.6–3.4 for
antagonist DAT Confusion mg/day doses of 5–20
Constipation mg/day
Note. ADAS-Cog, Alzheimer’s Disease Assessment Scale, Cognitive subscale; ADCS-ADL, Alzheimer’s Disease Cooperative
Study—Activities of Daily Living inventory, used here to assess day-to-day function; CIBIC-Plus, Clinician’s Interview-Based
Impression of Change Plus Caregiver Input; DAT, dementia of the Alzheimer’s type; SIB, Severe Impairment Battery, used to
assess cognitive performance. Data sources: for tacrine, Qizilbash et al. (1998); for donepezil, rivastigmine, galantamine, and
memantine, FDA package labeling.
a Trade name in parentheses.
One such condition of interest for treatment is vascular dementia (VaD), driven in
part by the advances made in the diagnosis and treatment of AD. Clinically it can be very
difficult to make the distinction between AD and VaD, as noted in previous sections of
this text. Briefly, the two entities frequently coexist, and it is not obvious to what degree
each contributes to the dementia symptomatology. Also, it is less clear what role memory
impairment plays in VaD. There may be similarities in the pattern of cognitive deteriora-
tion in AD and VaD, and these have led to comparable clinical trial designs. Clinical, pi-
lot, and open longitudinal studies (Li, Meyer, et al., 2002; Mendez, Younesi, et al., 1999;
Meyer, Chowdhury, et al., 2002) showed the potential for the use of cholinesterase inhibi-
tors in VaD. Several studies have examined agents in patients with AD and some degree
of vascular disease as well as in individuals described as having probable or possible vas-
cular disease (see Table 19.3). Perhaps the largest database exists for donepezil, with pub-
lished clinical trials including over 1,200 individuals with possible or probable VaD or
cognitive decline (Birks & Harvey, 2003).
To date, two large randomized, double-blind, placebo-controlled trials for the use of
donepezil in VaD have been completed (Black, Roman, et al., 2003; Wilkinson, Doody, et
al., 2003). These two studies recruited 1,219 patients diagnosed with probable or possi-
ble vascular cognitive impairment, based on the National Institute of Neurological Disor-
ders and Stroke–Association Internationale pour la Recherche et l’Enseignement en
Neurosciences (NINDS–AIREN; Roman, Tatemichi, et al., 1993) criteria, for a 24-week
trial. Results demonstrated significant improvement from baseline in ADAS-Cog scores
for a 5-mg/day treatment group compared to placebo (p = .003). Of those VaD patients
receiving 5-mg/day treatment, 41% showed improvement in global function on the
CIBIC-Plus after 24 weeks compared to placebo, whereas 38% showed no change and
21% worsened (Goldsmith & Scott, 2003). Wilkinson et al. (2003) reported even greater
drug–placebo differences in dementia severity with a 10-mg/day treatment. A Cochrane
meta-analysis evaluated these two studies looking at both completers and ITT analysis
(Malouf & Birks, 2004). Significant improvement was shown for both analyses on the
ADAS-Cog and the MMSE. When ITT analyses were applied, only the 10-mg/day group
showed benefit. Both studies reported acceptable tolerability for the drug. Clinical global
improvement in the ITT analysis was observed in one study (Wilkinson et al., 2003) but
not in others, although significance was observed at 5 mg but not at 10 mg in an ob-
served cases analysis.
There have been no randomized trials of rivastigmine for the treatment of VaD. A
reanalysis of a trial of patients with AD (Kumar, Anand, et al., 2000) suggested that benefit
may still be apparent when a mild amount of vascular risk factor, as measured by the modi-
fied Rosen–Hachinski Scale (Rosen, Terry, et al., 1980), is present. A 22-month open study
of rivastigmine conducted by Moretti et al (Moretti, Torre, et al., 2002) evaluated treatment
of VaD with rivastigmine at 3–6 mg/day. All subjects met NINDS–AIREN criteria for prob-
able VaD and subcortical VaD as determined by computed tomography (CT) scan. In this
small study (n = 16), patients on rivastigmine showed improvement over baseline on the
Ten-Point Clock Test (Tuokko, Hadjistavropoulos, et al., 1992), the Neuropsychiatric In-
ventory (NPI), and the Clinical Dementia Rating (CDR). However, in open trial designs it is
difficult to rule out practice and attention effects. The results support the need to conduct
rigorous studies to determine efficacy with this agent in a VaD population.
Erkinjuntti, Kurz, et al. (2002) conducted a multicenter, placebo-controlled, double-
blind trial for the use of galantamine in patients with dementia and vascular disease. Cen-
ters in 10 countries participated in this study, which had a 4-week run-in period followed
by 6-week titration at 4 mg/day for the first week to 24 mg/day in the sixth week and
continued for 6 months. The ITT analysis demonstrated significant benefit on the ADAS-
Cog (p < .0001) and on the CIBIC-Plus (p = .001) in those receiving galantamine com-
pared to those receiving placebo. In a post hoc analysis, subjects were subdivided into
those with possible AD and vascular disease (n = 239) and those with probable VaD
(NINDS–AIREN criteria; n = 188). In this secondary analysis the VaD group showed im-
provement from baseline, which did not reach significance on the ADAS-Cog (2.4 points,
p = .06), whereas the possible AD plus vascular disease group showed significant benefit
in cognition. The opposite was true for measures of global function. On the CIBIC-Plus,
the VaD group showed no improvement at 6 months over placebo (p = .23), and the
possible AD plus vascular disease group showed significant benefit (p = .019). In an open-
label extension of this trial, Erkinjuntti et al. (Erkinjuntti, Kurz, et al., 2003) showed
sustained benefits in cognition, functional ability, and behavior after 12 months for both
the VaD and AD groups, as measured by the ADAS-Cog, the Disability Assessment for
Dementia scale (DAD), and the NPI.
TABLE 19.3. Clinical Trials for Vascular Dementia Treatments
Primary Secondary
Author Primary No. of Analytic Study Dropout Daily outcome outcome
(year) diagnoses subjects approach design Duration rate (%) dose Treatment measures measures
Kumar et al. DAT with 699 OC Randomized, 26 weeks 22 12 mg/day Rivastigmine ADAS-Cog, MMSE, GDS
(2000) vascular double-blind, 4 mg/day CIBIC-Plus, PDS
placebo-
controlled
Pantoni et al. Subcortical 259 LOCF Randomized, 6 months 8 30 mg/day Nimodipine GBS, ADL, ZVT-G, FOM,
(2000) VaD double-blind, IADL, RDRS, digit span, MMSE
placebo- CDR
controlled
Erkinjuntti VaD and 592 ITT Randomized, 6 months 22.8 24 mg/day Galantamine ADAS-Cog,
426
et al. (2002) mixed double-blind, CIBIC-Plus
dementua placebo-
controlled
Moretti et al. Subcortical 16 OC Open label 22 months 0 6 mg/day Rivastigmine MMSE, TPC, ADL, IADL, CDR,
(2002) VaD WFs, WFp NPI, RSS
Wilcock et al. Probable 579 ITT Randomized, 28 weeks 20 20 mg/day Memantine ADAS-Cog, MMSE, NOSGER,
(2002) VaD double-blind, CGI-C GBS
placebo-
controlled,
parallel group
(continued)
Primary Secondary
Black et al. VaD 603 ITT Randomized, 24 weeks 20.3 10 mg/day Donepezil ADAS-Cog, MMSE, CDR-SB,
(2003) double-blind, 5 mg/day CIBIC-Plus ADFACS
placebo-
controlled,
parallel group
Erkinjuntti VaD and 459 ITT Open label 6 months 18.5 24 mg/day Galantamine ADAS-cog,
et al. (2003) mixed DAD, NPI
dementia
427
Wilkinson VaD 616 ITT Randomized, 24 weeks 20.3 10 mg/day Donepezil ADAS-Cog, MMSE, CDR-SB,
et al. (2003) double-blind, 5 mg/day CIBIC-Plus ADFACS
placebo-
controlled
parallel group
Note. DAT, dementia of the Alzheimer’s type; ITT, intent-to-treat; LOCF, last observation carried forward; OC, observed cases; VaD, vascular dementia; outcome measures: ADAS-Cog,
Alzheimer’s Disease Assessment Scale—Cognitive subscale (Mohs et al., 1997; Rosen et al., 1984); ADFACS, Alzheimer’s Disease Functional Assessment and Change Scale (Mohs et al.,
2001); ADL, Activities of Daily Living for Dementia (Katz et al., 1963); CDR, Clinical Dementia Rating (Hughes et al., 1982); CDR-SB, Clinical Dementia Rating—Sum of Boxes (Berg,
1988); CGI-C, Clinical Global Impression of Change (Guy, 1976); CIBIC-Plus, Clinician’s Interview-Based Impression of Change Plus Caregiver Input (Knopman et al., 1994); DAD, Dis-
ability Assessment for Dementia scale (Gelinas et al., 1999); FOM, Fuld Object–Memory Evaluation (Fuld, 1978; LaRue, 1989); GBS, Gottfries–Bråne–Steen scale (Gottfries et al., 1982);
GDS, Global Deterioration Scale (Reisberg et al., 1982); IADL, Instrumental Activities of Daily Living (Lawton & Brody, 1969); MMSE, Mini-Mental State Examination (Folstein et al.,
1975); NOSGER, Nurses’ Observation Scale for Geriatric Patients (Spiegel et al., 1991); NPI, Neuropsychiatric Inventory (Cummings et al., 1994); PDS, Progressive Deterioration Scale
(DeJong et al., 1989); RDRS, Rapid Disability Rating Scale (Linn, 1967); RSS, Relative Stress Scale (Greene et al., 1982); TPC, Ten-Point Clock Test (Manos, 1997); WFp, Word Flu-
ency—Phonological (Wechsler, 1981); WFs, Word Fluency—Semantic (Wechsler, 1981); ZVT-G, Zahlen–Verbindungs Test—Geriatric (Oswald & Roth, 1978).
Memantine has also been examined in trials of patients with VaD. Currently, several
ongoing clinical trials are attempting to determine the efficacy of memantine use in mild
to moderate (MMM) VaD. Initial results reported in a Cochrane Review (Areosa &
Sherriff, 2003) showed findings from two studies: MMM300 (Orgogozo, Rigaud, et al.,
2002) and MMM500 (Wilcock, Mobius, et al., 2002). A significant change from baseline
in cognition was reported with 20 mg/day (p < .0001); however, there were no significant
differences for ADLs assessed with the Nurses’ Observation Scale for Geriatric Patients
(NOSGER) scale (Spiegel, Bruner, et al., 1991), the Gottfries–Brane–Steen (GBS) scale
(Gottfries, Brane, et al., 1982), or clinical impression of change with the CIBIC-Plus. The
authors correctly note that the cognitive tests used for AD may not be sensitive to the pat-
tern of cognitive deterioration in VaD. They propose that measures of executive function
would be more appropriate for the evaluation of VaD. More trials with clearly defined
patient groups are suggested.
Although stabilization and treatment of cardiovascular conditions have been shown
to slow cognitive decline in VaD (Forette, Seux, et al., 1998; Meyer, Judd, et al., 1986),
other agents have been studied. Aside from cholinergic treatments, aspirin has often been
prescribed to VaD patients, although there is little empirical evidence for its efficacy in
treating cognitive symptoms in VaD (Rands, Orrel, et al., 2004). One retrospective case
study reported that regular low-dose aspirin may be beneficial (Devine & Rands, 2003).
Others have noted that depending on the underlying cause of the VaD, treatment with as-
pirin may increase the risk of cerebral hemorrhage (Rands et al., 2004; Sachdev, Brodaty,
et al., 1999). Nimodipine, a calcium channel blocker that crosses the blood–brain barrier,
is another agent that has been studied for treatment of VaD. Lopez-Arrieta and Birks’
(2004) Cochrane review of nimodipine identified nine clinical trials conducted on pa-
tients with cerebrovascular dementia. At doses of 90 mg/day, they concluded that
nimodipine can be an option for treatment and offers some improvement in overall global
impression on the CGI, and cognitive function using the Sandoz Clinical Assessment—
Geriatric (SCAG) scale (Shader, Harmatz, et al., 1974, 1976). There was no improvement
in ADLs or disease status. Pantoni, Rossi, et al. (2000) studied the effects of nimodipine
specifically in cases of subcortical VaD in a post hoc analysis of data from the Scandina-
vian Multi-Infarct Dementia Trial. They concluded that individuals with subcortical VaD
benefited, showing significant differences on several neuropsychological tests, whereas
those with multi-infarct dementia did not benefit.
Other agents have been studied in the past, including vinpocetine and hydergine, but
these older studies did not offer differentiation of dementia subtypes or have enough
power to determine effects (Schneider & Olin, 1994; Szatmari & Whitehouse, 2003).
Propentofylline has been studied as a treatment for both AD and VaD. Although results
from several trials appeared promising (Kittner, Rossner, et al., 1997; Mielke, Moller, et
al., 1998; Rother, Erkinjuntti, et al., 1998), a systematic review by Frampton, Harvey, et
al (2003) showed that there was limited evidence of benefit.
Lewy Body Dementia and Parkinson’s Disease Dementia

Work with other dementias, beyond AD and VaD, has been more obscure. Lewy body de-
mentia (LBD) is now recognized as a common type of progressive dementia (McKeith,
Mintzer, et al., 2004), and patients with Parkinson’s disease (PD) often have cognitive
symptoms, with dementia occurring in approximately 20–30% of PD cases (Parkinson’s
disease dementia [PD-D]; Aarsland, Andersen, et al., 2001; Mayeux, Denaro, et al.,
1992). Both LBD and PD-D are synucleinopathies and are likely part of the same disease
spectrum (McKeith & Burn, 2000). They share characteristic motor impairments and
features, including hallucinations and delusions (see Welsh-Bohmer & Warren, Chapter
3, this volume, for more detail). The cognitive profiles of the two diseases are similar
(Aarsland, Litvan, et al., 2003). Treatment is often focused on reduction of behavioral
and psychotic symptoms and motor disturbances in addition to treatment of cognitive
symptoms. Although LBD may have a presentation of cognitive deficits similar to that of
AD, treatment of LBD is difficult because antipsychotics worsen the extrapyramidal
features and in 50% of cases can trigger severe neuroleptic sensitivity reactions, with an
increased risk of mortality (McKeith, Del Ser, et al., 2000). Treatment with anti-
Parkinsonian medication to improve motor symptoms may increase confusion and hallu-
cinations (McKeith 2000). Because the treatment of one symptom can exacerbate
another, patients and caregivers should decide which problem is the most distressing be-
fore deciding upon a treatment (Burn & McKeith, 2003). Currently, criteria in clinical tri-
als for treatment of LBD are similar to those of AD, requiring improvement in cognition
and a clinical global measure of improvement.
There are few randomized clinical trials in the literature for the treatment of cogni-
tive problems in LBD and PD-D (see Table 19.4). One study (McKeith, Del Ser, et al.,
2000) involved a 20-week randomized, double-blind, placebo-controlled trial of 120
male and female patients with probable LBD. Patients were randomized to rivastigmine
or placebo for 20 weeks followed by a 3-week rest period. Doses were titrated to 6 mg
twice a day over an 8-week period. More of the patients on rivastigmine had adverse
cholinergic effects. Using ITT analysis, differences between the treatment and placebo
groups were not significant; however, differences on the NPI-4 showed a significant per-
centage of patients with a >30% improvement from baseline to week 20. Effects were re-
versed after the 3-week rest period. Clinically relevant improvements included decreases
in apathy, anxiety, delusions, and hallucinations. No change was seen on the Unified Par-
kinson Disease Rating Scale (UPDRS; Fahn, Elton, et al., 1987). In another open-label
study (Minett, Thomas, et al., 2003), patients with LBD and PD-D were treated with 10
mg/day donepezil for 20 weeks followed by a 6-week withdrawal period. The aim of the trial
was to compare the responses of LBD and PD-D and to determine the effects of donepezil
withdrawal. Although the trial was small, significant improvements were shown on the
MMSE at week 20 for both LBD and PD-D groups compared to baseline scores (LBD
mean difference = 4.1, p = .007; PD-D mean difference 3.8, p = .002). There were no sta-
tistically significant changes from baseline on the NPI, although clinically significant
changes were seen in most of the LBD patients and about a third of the PD-D patients.
There has been at least one double-blind, placebo-controlled trial of donepezil for
cognitive impairment in Parkinson’s disease (Aarsland, Laake, et al., 2002). Fourteen pa-
tients with mild to severe Parkinson’s disease and evidence of memory impairment
(MMSE scores 16–26) participated in the trial. Significant improvement on the MMSE
(p = .013) and the CIBIC-Plus (p = .034) were shown in the treatment groups compared
to placebo. The crossover design showed no carryover effects from treatment. Leroi,
Brandt, et al. (2004) conducted a small randomized, double-blind, placebo-controlled
study of donepezil in PD-D. Sixteen PD patients with clinical diagnoses of dementia or
cognitive impairment were randomized to placebo or treatment with 10 mg donepezil per
day, titrated over 6 weeks and continued for a total of 18 weeks. There were no signifi-
cant differences between groups on psychiatric measures or in cognition measured with
the MMSE and DRS total scores. A significant improvement with treatment over placebo
TABLE 19.4. Clinical Trials for Lewy Body Dementia and Parkinson’s Disease Dementia
Daily Primary Secondary
Author Primary No. of Analytic Study Dropout dose outcome outcome
(year) diagnoses subjects approach design Duration rate (%) (mg/day) Treatment measures measures
McKeith, LBD 120 ITT, Randomized, 23 weeks 23 12 Rivastigmine NPI-4, NPI-10, MMSE
Del Ser, et al. LOCF, OC double-blind, computerized
(2000) placebo- tests of attention,
controlled, working memory,
multicenter and episodic
memory
Aarsland PD 12 LOCF Randomized, 2 periods, 14 10 Donepezil MMSE, CIBIC- NPI

et al. (2002) double-blind, 10 weeks Plus, UPDRS—
placebo- each Motor subscale
controlled,
crossover study
Leroi et al. PD and 16 LOCF Randomized, 18 weeks 25 10 Donepezil NART, MMSE, NPI, CSDD,
(2004) cognitive double-blind, DRS, BTA, DRS UPDRS Motor
430
impairment placebo- Attention subscale, Hoehn
controlled subscore, and Yahr Stage,
TMT-A/B, DRS UPDRS, ADL &
Initiation– Complications of
Perseveration Therapy subscale
subscore, DRS
Conceptualization
subscore, Verbal
Fluency, HVLT,
DRS Memory
subscale, VMI
Minett et al. LBD, 19 OC Open label 12 months 21 10 Donepezil MMSE, NPI,

(2003) PD-D UPDRS
Note. LBD, dementia with Lewy bodies; PD, Parkinson’s disease; PD-D, Parkinson’s disease with dementia; ITT, intent-to-treat; LOCF, last observation carried forward; OC, observed
cases; outcome measures: BTA, Brief Test of Attention (Schretlen, Bobholtz, et al., 1996; Schretlen, Brandt, et al., 1996); CIBIC-Plus, Clinician’s Interview-Based Impression of Change
Plus Caregiver Input (Knopman et al., 1994); CSDD, Cornell Scale for Depression in Dementia (Alexopoulos et al., 1988); DRS, Dementia Rating Scale (Mattis, 1976; Mattis, 1989);
Hoehn and Yahr Stage (Hoehn & Yahr, 1967); HVLT, Hopkins Verbal Learning Test (Brandt, 1991); MMSE, Mini-Mental State Examination (Folstein et al., 1975); NART, National
Adult Reading Test (Nelson, 1982); NPI, Neuropsychiatric Inventory (Cummings et al., 1994); NPI-4, Neuropsychiatric Inventory 4-item subscore: delusions, hallucinations, apathy, and
depressioin; NPI-10, Neuropsychiatric Inventory total of items 1–10; TMT-A, Trail Making Test—Part A (Lezak, 1995); TMT-B, Trail Making Test—Part B (Lezak, 1995); UPDRS,
Unified Parkinson Disease Rating Scale (Fahn et al., 1987); Verbal Fluency (Barr & Brandt, 1996); VMI, Visual–Motor Integration (Beery, 1989).
was found in the Dementia Rating Scale (DRS) Memory subscore (p < .05). There was
also a trend toward improvements in processing speed and attention. The authors noted a
high dropout rate in both groups and suggested this may be due to the frailty of these
older patients. Four of seven randomized to donepezil dropped out for adverse side ef-
fects and one for relapse of a preexisting mood disorder. There were no significant
changes in UPDRS Motor or ADL subscales. Taken together, these studies show encour-
aging results for the use of cholinergics in the treatment of cognitive impairments in LBD
and PDD. Future work in this area should consider appropriate outcomes, side effects of
cholinergic treatment, and the effect of dropouts on study results.
Frontotemporal Dementia
Another form of dementia, frontotemporal dementia (FTD), is estimated to be present in
up to 20% of patients appearing in memory clinics (Snowden, Neary, et al., 2002) and
can be mistaken for AD (see Welsh-Bohmer & Warren, Chapter 3, this volume). Because
the first symptoms of FTD are often behavior changes, treatment of the disorder is initi-
ated for behavioral problems. However, it has been argued that the action of cholin-
esterase inhibitors would likely benefit FTD patients if the benefit were mediated via the
nucleus basalis of Meynert (nbM), where cholinergic activity is decreased in both AD and
FTD (Perry & Miller, 2001).
Large-scale trials of standard treatments in FTD are difficult to conduct, due in part
to traditionally low rates of case ascertainment in clinical settings. The recent develop-
ment of diagnostic criteria has led to the appearance of case reports of patients with stan-
dardized diagnoses (McKhann, Albert, et al., 2001). One such report of nine FTD pa-
tients suggested that cholinesterase inhibitors had a beneficial effect on cognitive testing
and single-photon emission computed tomography (SPECT) imaging in approximately
half of the patients (Lampl, Sadeh, et al., 2004). The need to conduct well-controlled
multicenter trials is apparent and likely to occur in the near future, now that diagnostic
criteria have been established.

Another recently recognized entity is MCI (see Smith & Rush, Chapter 2, this volume).
This condition is initially characterized by the presence of significant memory impairment
with other aspects of cognition and function remaining relatively intact (Petersen, Smith,
et al., 1999). MCI is different from age-associated memory impairment (AAMI) in that
the former characterizes impairment in comparison to others of a comparable age,
whereas the latter defines impairment with age when compared to a young normative
sample. Several studies have demonstrated that individuals with MCI are at increased risk
for a diagnosis of dementia, and some studies have suggested that about 25–45% of the
MCI population will have a diagnosis of AD within in 3 years. Clinical trials have re-
cruited individuals with this condition to determine if specific agents could delay the time
to dementia onset. These trials constitute a form of secondary prevention of dementia,
with MCI defining the early, symptomatic stage of disease.
The baseline characteristics of one multicenter clinical trial population of subjects with
MCI have been described (Grundman, Petersen, et al., 2004), and several large clinical trials
of MCI have been reported in abstract form (Gold, Francke, et al., 2004; Petersen,
Grundman, et al., 2004; Visser, Thal, et al., 2003). The first to be reported (Visser et al.,
2003) examined the selective cyclooxygenase-2 (COX-2) inhibitor, rofecoxib, and found no
effect in conversion to dementia, with mildly increased risk of dementia in those on drug. A
significant difference in conversion to AD, was found with more conversion in the treatment
group (6.4% vs. 4.5%; hazard ratio [HR] = 1.46; confidence interval [CI]: 1.09–1.94;
p = .11). Secondary outcomes of cognition and function showed no treatment effect.
A large multicenter trial, by the AD2000 Collaborative Group (Petersen, Thomas, et
al., 2005) sponsored by the National Institute on Aging (NIA) examined the chol-
inesterase inhibitor donepezil and vitamin E and found a reduction of conversion to AD
in the first 18 months of treatment with donepezil. In addition, a benefit on cognitive
measures was noted, lasting about the same time. However, the initial trial proposed to
assess outcomes at 3 years, and there was no treatment effect in these a priori analyses.
Also, the study was unable to detect any effect with vitamin E. Similar findings have been
reported with other cholinesterase inhibitors. The largest effect is seen in those with poor-
est performance at baseline, and the duration of efficacy parallels that seen in the
AD2000 trial. Taken together these results suggest that these studies capture a very early
stage of dementia and not necessarily a prodromal phase.
DEVELOPING NEW APPROACHES TO AD TREATMENT

Attacking Amyloid
The hallmark of AD pathology is the amyloid plaque found in the brain. The develop-
ment and build up of amyloid plaques are generally considered the primary underlying
mechanism and etiology of the disease. Interventions that reduce amyloid plaque burden
by altering amyloid metabolism or by maximizing clearance are potential mechanisms,
although they remain theoretical. Plaque formation may be determined by the metabo-
lism of an amyloid precursor protein (APP). Non-amyloidogenic, soluble APP (sAPP) is
created when APP is cleaved by the β-secretase enzyme. Cleavage of APP by amyloid-β
cleaving enzyme and then by γ-secretase leads to the formation of two species of amyloid-
β(Aβ): Aβ1–40 and Aβ1–42, the latter of which is prone to self-aggregation, leading to
plaque formation. Although environmental factors may influence the ratio of Aβ1–40 to
Aβ1–42, therapeutic development has focused on affecting these pathways via enzyme
modulators. Although selective enzyme inhibitors have been proposed, to date, clinical
trials with such molecules have not gone forward because the targeted enzymes are ubiq-
uitous and involved in other necessary processes, and inhibition of these processes could
lead to mechanism-based toxicity.
Protein phosphorylation regulates APP cleavage by stimulating the α-secretase
pathway, leading to the relatively nontoxic sAPP. Stimulation of protein kinase-C through
steroid hormones such as 17-β-estradiol or DHEA have been shown to stimulate this
pathway in vitro, but attempts to examine these approaches in clinical trials have not
been fruitful, suggesting either that the model is not viable or the specific agents are not
sufficiently selectively effective.
Active vaccination strategies in animal models have examined vaccination with Aβ
and demonstrated that antibodies can be generated and can achieve clearance of plaque
with some behavioral benefit. Human trials have not demonstrated very clear evidence of
selective clearance, however. The only trial of the vaccine examined, to date, has shown
reduced amyloid levels in some subjects as well as reduced brain volume, making it diffi-
cult to interpret these results (Fox & Schott, 2004).
Lowering Homocysteine
Recent studies have suggested that there may be an overlap in risks for cardiac disease
and risks for AD, even when VaD is excluded. One potential risk factor is elevated
homocysteine. This amino acid is involved in methionine and cysteine metabolism, and it
plays a role in methylation reactions. The role of homocysteine as risk factor for athero-
sclerosis, cardiovascular disease (Bostom, Silbershatz, et al., 1999; Bots, Launer, et al.,
1997) and stroke has been well established. Several studies have demonstrated that
hyperhomocysteinemia is associated with AD in the absence of folate or vitamin B12 defi-
ciency (Quadri, Fragiacomo, et al., 2004; Seshadri, Beiser, et al., 2002). When age-based
norms for plasma homocysteine are divided into tertiles, the risk of AD in subjects in the
highest tertile of homocysteine levels is more than four times higher than those in the
lowest (McCaddon, Davies, et al., 1998; Seshadri et al., 2002). However, recent prospec-
tive epidemiological studies have not been able to find this association (Luchsinger, Tang,
et al., 2004). Other evidence for a role for homocysteine in AD comes from data indicat-
ing that elevated plasma homocysteine occurs in neuropathologically confirmed cases of
AD, in the absence of any vascular neuropathology (Clarke, Smith, et al., 1998). Also,
among AD cases, higher levels of homocysteine are associated with more rapid radiologi-
cal disease progression.
Folate, as well as vitamins B12 and B6, are cofactors in metabolic reactions involving
homocysteine and are very effective in lowering homocysteine levels (Homocysteine
Lowering Trialists’ Collaboration, 1998). In addition, folate improves nitric oxide avail-
ability in the brain. It also plays a number of other roles, such as acting as a coenzyme in
the synthesis of serotonin and catecholamine neurotransmitters and of S-adenosylmethionine,
and these have been reported to have antidepressant properties. Thus the use of folate
may offer benefits through several mechanisms. It is therefore reasonable to postulate
that lowering homocysteine with these vitamins would provide cognitive benefit or pro-
tection from cognitive decline. It has been demonstrated that supplementation with fo-
late, vitamin B12, and vitamin B6 can lower homocysteine levels in patients with AD, even
in those with already normal levels (Aisen, Egelko, et al., 2003), although the ability to
affect cognition has not yet been demonstrated.
Several clinical trials have assessed folate effects on cognition in a range of popula-
tions. Four randomized trials were identified in a recent review (Malouf, Grimley, Evans,
et al., 2003); one enrolled healthy women only (Bryan, Calvaresi, et al., 2002), and three
others recruited people with mild to moderate cognitive impairment or dementia (Clarke
et al., 1998; Fioravanti, Ferrario, et al., 1997; Sommer, Hoff, et al., 1998). Although folic
acid plus vitamin B12 was effective in reducing serum homocysteine concentrations, a
meta-analysis of these studies found no benefit from folic acid with or without vitamin
B12 in comparison with placebo on any measures of cognition or mood for healthy,
cognitively impaired, or demented people. Folic acid was well tolerated, and no adverse
effects were reported. Several limitations of these studies include brief exposure periods,
lack of standardized diagnosis, and lack of surety about appropriate outcome measures.
Effective lowering of homocysteine levels can be achieved with folate and vitamins
B12 and B6, even when levels are in the relatively normal range and in the presence of for-
tified grain (Aisen, Egelko et al., 2003). On this basis, and given its relative safety, it is
reasonable to hypothesize that vitamin supplementation may lower the risks of cognitive
decline and dementia in older adults. Because ongoing trials of high doses of supple-
mentation continue to prove safe in aging populations, intervention with these supple-
ments is worthy of study as a treatment strategy for primary prevention of cognitive loss
and dementia in aging.
Lowering Lipids
There is compelling evidence from laboratory research in animal models and cell-culture
systems, observational epidemiological studies, and small clinical trials that lowering cho-
lesterol may reduce the pathology of AD. In support of the link between cholesterol and
AD are in vitro studies demonstrating that cholesterol levels modulate the enzymatic pro-
cessing of APP and, consequently, Aβ production. Dietary manipulation to increase cho-
lesterol in rabbits, rats, and transgenic mice demonstrated that high cholesterol yields in-
creased secretion of amyloidagenic Aβ1–40 and Aβ1–42, as well as increasing size and
number of amyloid plaques. Lipid lowering agents can reduce these findings both in cell
cultures and in animals.
Epidemiological data have suggested that use of some lipid-lowering drugs is associ-
ated with a reduced risk of AD. Observational studies using existing clinical practice reg-
istries have reported an inverse association between statin use and risk of AD. Wolozin,
Kellman, et al. (2000) reported cross-sectional examination of computerized medical re-
cords from 3 hospitals and demonstrated that the prevalence of diagnosed AD in patients
taking lovastatin or pravastatin was 60–73% lower than the entire patient population
during the period from 1996–1998. Jick, Zornberg, et al. (2000) examined the General
Practice Research Database in the United Kingdom and reported reduced risk of AD with
statin use. In this study the 284 cases were patients who developed a first-time diagnosis
of dementia or AD between 1992 and 1998. Rockwood, Kirkland, et al. (2002) reported
a reduced risk of AD among those using statins and other lipid-lowering agents (odds ra-
tio [OR] = 0.26; 95% CI: 0.08–0.88). These authors noted no effect of statins among
those over 80, though very few in that age group were taking statins. It is not clear that
lowering cholesterol can help patients with AD, and retrospective studies have not sup-
ported that connection. However, well-controlled clinical trials could answer this ques-
tion directly.
Despite these epidemiological findings, two recent large-scale trials conducted “add-
on” studies to assess cognition. The Heart Protection Study (HPS, 2002) also examined
the effect of simvastatin, a cholesterol-lowering agent, on the large cohort with the Tele-
phone Interview for Cognitive Status (TICS). There were no difference in the percentages
of participants classified as cognitively impaired (23.7% simvastatin-allocated vs. 24.2%
placebo-allocated) or having incident dementia during follow-up (0.3% vs. 0.3%). In a
trial of pravastatin in over 5,000 individuals ages 70–82, cognitive testing administered
before and after treatment found no effect on measures of learning, memory, attention,
speed of processing, mental status, or ADLs (Shepherd, Blauw, et al., 2002). Although
these studies used large samples, the studies may have been too brief to observe the tran-
sition from normal cognition to dementia, resulting in insufficient power to observe an
effect in this intact population.
The relative safety of these drugs has led to their use in trials to slow disease progres-
sion in AD. A single-site study of atorvastatin in patients with mild to moderate AD sug-
gested a beneficial effect in cognitive and clinical global outcome measures (Sparks,
Connor, et al., 2002). At this writing there are two ongoing multicenter trials of statins
that will examine the rate of change on cognition and clinical global benefit over an
18-month period in patients with mild to moderate disease. Changes in cognition in de-
mentia are rapid enough that trials of this duration should have sufficient power to detect
effects.
PRIMARY PREVENTION OF AD
Although the exact cause of AD and some other dementias is not known, researchers can
still investigate the efficacy of preventive agents that may have been identified in cohort
studies. These agents include estrogens, antioxidants, anti-inflammatory drugs, and
omega-3 fatty acids. We review the status of each agent as of December 2004 in the text
that follows. The final analyses of these studies are projected into 2005 or beyond, and
hence definitive information regarding safety and efficacy is forthcoming.
Estrogen
The surprising results of the Women’s Health Initiative (WHI) illustrate the need to con-
duct randomized clinical trials to obtain accurate information about efficacy. Although
efforts to examine the role of estrogen in many laboratory models and observational
studies of dementia led to the expectation of benefit, such effects have not been realized
in clinical trials. Estrogen receptors are colocalized with neurotrophin receptors in the
basal forebrain, center of AD pathology. Estrogen has been associated with enhancing
cholinergic neurons and promoting survival of hippocampal neurons exposed to excito-
toxins, oxidative stress, or amyloid-β (Aβ). This hormone may also reduce the generation
of Aβ1–40 and Aβ1–42 fragments. Animal studies demonstrate increased levels of Aβ1–40
and Aβ1–42 following ovariectomy, suggesting that menopause may accelerate Aβ forma-
tion in a period in which accumulation would be incipient. Observational studies sup-
ported the notion that estrogen use by women during the postmenopausal period may
substantially reduce their risk of developing clinically diagnosed AD (e.g., LeBlanc,
Janowsky, et al., 2001; Yaffe, Gawaya, et al., 1998; Zandi, Carlson, et al., 2002).
However, randomized clinical trials (RCTs) tell a very consistent story that contra-
dicts these results. In women with AD, negative results have been reported repeatedly
from studies of conjugated equine estrogens (CEE) for periods ranging from 3 months to
1 year and included 42, 50, and 120 subjects, respectively (Henderson, Paganini-Hill, et
al., 2000; Mulnard, Cotman, et al., 2000; Wang, Liao, et al., 2000).
Most disappointing has been the results in prevention trials. Results of the Women’s
Health Initiative Memory Study (WHIMS), an add-on to the WHI, suggest that treatment
with combined estrogen and progesterone (hormone replacement therapy or HRT) in-
creases the risk of dementia and has a deleterious effect on mental status test scores
(Rapp, Espeland, et al., 2003; Shumaker, Legault, et al., 2003). In the cohort of 4,532
women over the age of 65, followed for 4 years, the incidence of dementia with HRT was
increased two-fold (relative risk [RR] = 2.0; CI: 1.2–3.5) compared to placebo (Shumaker
et al., 2003). Although both the HRT and placebo groups demonstrated improved scores
over time, the HRT group had smaller increases (annual point change: 0.15 vs. 0.21;
p = .03) in mental status testing over time (Rapp et al., 2003). Results from the estrogen-
only arm of this study are equally disappointing, and although smaller sample sizes pro-
vided less power to see a statistical effect, the trend toward increased dementia, MCI, and
declining performance on mental status examinations was apparent (Espeland, Rapp, et
al., 2004; Shumaker, Legault, et al., 2004). Given that these agents apparently increase
risk of vascular disease, it is possible that the dementia result is mediated through vascu-
lar mechanisms. This distinction may be important if positive and negative effects of the
molecule are mediated through separate receptors. This possibility might permit the iden-
tification of a molecule with selective receptor modulation that could offer specific bene-
fit without the associated vascular risk.
Antioxidants
The role of oxidative stress as a pathological mechanism in aging and dementia is supported
by several lines of evidence. Biological studies demonstrate that the accumulation of free
radicals is associated with damage to lipids, cell membranes, and proteins, including DNA
and RNA. These oxidative byproducts induce the production of APP, already noted as the
hallmark of AD pathology. The accumulation of Aβ fragments may reduce compensatory
antioxidant ability resulting in further increases in Aβ deposition, synapse loss, DNA dam-
age, neuronal dysfunction, and cell death. Free radical scavengers sequester free radicals,
thereby rendering them impotent, minimizing oxidative reactions, and minimizing cellular
damage (for a review of these potential mechanisms, see Butterfield, Griffin, et al., 2002).
Compelling support for the link between oxidative stress and Aβ comes from a re-
cent study which crossed mice that had a knockout of one allele of a critical antioxidant
enzyme (manganese superoxide dismutase: MnSOD) with a mouse that overexpressed a
doubly mutated human β-amyloid precursor protein (i.e., Tg19959). Previous work es-
tablished the MnSOD to cause elevated oxidative stress; the mice of the resulting cross
demonstrated increases in both amyloid plaque burden and amyloid levels (Li, Calin-
gasan, et al., 2004).
Evidence for a benefit of antioxidant agents comes from observational studies. Two
prospective studies examined the association of dietary antioxidants and incident AD and
provided evidence of reduced risk of AD (Engelhart, Geerlings, et al., 2002; Morris, Evans,
et al., 2002). Daily intake of antioxidants, including vitamin E, vitamin C, beta-carotene,
and flavenoids, was assessed with food-frequency questionnaires. In one study of over
800 subjects, followed for a mean of nearly 4 years, the group in the highest quintile of
vitamin E intake had a relative risk of AD of 0.36 (95% CI: 0.11–1.17) compared to the
group in the lowest quintile (Morris et al., 2002). Other antioxidants had no effect. In an-
other study of more than 5,000 individuals followed for a mean of 6 years, a reduced risk
of AD was reported with vitamin E and vitamin C intake (RR = 0.82; 95% CI: 0.66–
1.00). Both reports failed to demonstrate a benefit to the use of antioxidant supplements,
even though they increased the intake levels by 50% or more (Sano, 2002).
Data from the multi-ethnic cohort of the Washington Heights–Inwood Columbia
Aging Project, in New York City, examined both dietary intake and supplemental use of
antioxidant vitamins. Elderly subjects (n = 980) were followed for a mean of 4 years and
nutrient data was gathered with a standardized food-frequency questionnaire, which also
gathered data on supplement intake. This report found neither evidence of risk reduction
nor a trend toward reduction with vitamins E, C, or carotenoids in any combination
(Luchsinger, Tang, et al., 2003). Recently, a study from the well-described cohort of the
Cache County Study of Memory, Health and Aging in Utah examined the effect of sup-
plement intake on both prevalent and incident dementia. This report described a reduc-
tion in both prevalence and incidence with the combination of vitamins C and E, but not
with either alone. A trend toward lower incidence of AD was associated with vitamin E
in combination with a multivitamin possibly containing C, but not with a multivitamin
alone (Zandi, Anthony, et al., 2004).
Typically, we move from observational studies to clinical trials to test hypotheses

about potential treatments. A range of agents has been tried in clinical trials for the treat-
ment of AD. As described below, early trials provided promising evidence of benefit with
antioxidant therapies, but longer and larger trials have been disappointing.
Vitamin E
One study reported a benefit to AD with vitamin E, which was associated with a delay in
clinical milestones compared to a placebo group among moderately impaired patients with
AD, though no benefit was observed on standardized cognitive tests (Sano, Ernesto, et al.,
1997). In the same study selegiline, a selective inhibitor of monoamine oxidase-B, was also
effective, but the combination of drugs had no additional benefit. Physicians commonly recom-
mend vitamin E as treatment for AD. Although no data are available for the combination, it
is often given along with cholinesterase inhibitors, probably based on its perceived safety.
Two trials have reported the outcome of cognitive add-ons to other studies. One is
the antioxidant arm of the HPS (1999). This large trial of over 20,000 enrollees, ages 40–
80 years, selected subjects who were at risk for cardiovascular disease. The study used a
2 × 2 factorial design in which one agent was simvastatin and the other was an antioxi-
dant combination of vitamin E (600 mg), vitamin C (250 mg), and beta-carotene (20 mg).
Although no initial cognitive assessment was conducted, at the final visit the modified
TICS (TICS-m) (Brandt, Spencer, et al., 1988; Welsh, Breitner, et al., 1993) was adminis-
tered. Using an established cutoff score to identify cognitive impairment (22 of 39), no
significant difference was found between the treatment groups in the percentages of the
cognitively impaired (23.4% vitamin group vs. 24.4% placebo group). There was also no
difference in the mean TICS-m score, and similar numbers of participants in each treat-
ment group were reported to have developed dementia (0.3%) or other psychiatric disor-
ders (0.6%). This rate of incident cases appears quite low, given the age range of the sub-
ject population, suggesting that this methodology may have been inadequately sensitive
to cognitive change. Interestingly, these supplemental doses are far above the range in
which dietary antioxidants were reported to have an effect.
The DATATOP study was a trial of over 800 subjects, newly diagnosed with Parkin-
son’s disease, who were treated with selegiline or vitamin E (2000 international units
[IU]) in a 2 × 2 factorial design. Cognitive assessments consisted of a battery of tests, in-
cluding memory tests. No significant difference was noted among the groups (Kieburtz,
McDermott, et al., 1994). Whether these results from this specialized population can be
generalized is difficult to know, because the study population was relatively young and all
had early/mild Parkinson’s disease. Nevertheless, in this cognitively fragile cohort, high-
dose vitamin E was unable to modify cognition.
An ongoing study known as PREADVISE, an “add-on” study, is examining the pre-
ventive effect of various antioxidants on prostate cancer (Kryscio, Mendiondo, et al.,
2004). The parent study recruits men ages 60 years and over, who are randomly assigned
to receive 200 micrograms of selenium and 400 IU of vitamin E per day, and are then
monitored for prostate cancer. Participants randomized to assess antioxidant effects on
prostate cancer may enroll in this cognitive add-on study, which will assess cognition and
dementia with a brief screen followed by a more comprehensive workup. The relatively
young age of the cohort may make it difficult to observe a cognitive change, and follow-
up may be confounded by results or new findings with bearing on prostate treatment.
Nevertheless, this study offers an opportunity to observe cognition in this unique cohort.
A recent meta-analysis of vitamin E trials suggests that high doses (400 IU) may be
associated with increased risk of mortality, whereas lower doses might provide reduced
risk of mortality (Miller, Pastor-Barriuso, et al., 2004). The mortality effect was not ob-
served in persons with neurodegenerative disease, although these studies were included in
the meta-analysis. The highest risk appears in studies that include individuals with car-
diovascular risk factors, which increase with age and therefore may overlap with demen-
tia risk. This observation will add additional caution to future research of vitamin E as a
preventive measure for dementia.
Ginkgo Biloba
Ginkgo biloba is a plant extract containing flavenoids, which act as free radical scaven-
gers that may protect cells from excessive lipid peroxidation and neuronal membrane
breakdown (Scholtyssek, Damerau, et al., 1997). Laboratory studies indicate that Ginkgo
biloba may maintain neuronal function in the hippocampus, with evidence of neuro-
trophic effects in mossy fibers and maintenance of age-related adrenergic and seroton-
ergic receptor loss (Barkats, Venault, et al., 1995). Clinical trials of this drug (Table 19.5)
in cognitively impaired populations have yielded mixed results, with reports of benefit in
some but not all outcomes (van Dongen, van Rossum, et al., 2000).
A meta-analysis by Oken et al. (Oken, Storzbach, et al., 1998) found small but sig-
nificant improvements in cognition in patients with AD who received 3–6 months of
treatment with 120–240 mg of Ginkgo biloba extract (mean effect size = 0.41, 95% CI =
0.22–0.61). Evidence of improvement in other outcomes was inconclusive. These trials
suggest that antioxidants, which appear to be well tolerated, may have a role in the treat-
ment of AD, though sufficient evidence is not yet available (Oken et al., 1998).
A recent Cochrane Review of Ginkgo biloba for cognitive impairment and dementia
expanded on the Oken analysis, identifying 33 studies (Birks & Grimley Evans, 2004). Of
these studies, ranging from 3 to 52 weeks in duration, most were 12 weeks long and used
comparable standard ginkgo biloba extracts. The review identified benefits on the CGI scale
at 24 weeks (OR 2.16, 95% CI = 1.11–4.20, p = .02) and in cognition (standardized mean
difference = –0.17, 95% CI = –0.3 to –0.02, p = .03). Measures of ADLs and mood and emo-
tional function also showed benefits. The reviewers noted, however, that there was varia-
tion in the methodology of the studies, and evaluation of diagnostic categories was difficult
because many trials did not distinguish between them. Few studies used the more rigorous
ITT analysis, and thus conclusions were based on completers and may be biased. Because of
mixed results in more recent trials and a low profile of side effects, additional large trials
with modern methodology, diagnostic categories, and ITT analyses were recommended.
Currently, the Ginkgo Evaluation of Memory (GEM) study, a primary prevention
trial sponsored by the National Center for Complementary and Alternative Medicine and
the National Institute on Aging, is underway. The GEM study is a large multicenter trial
including approximately 3,000 participants in four states, ages 75 years or older, who
have been randomized to receive either Ginkgo biloba (240 mg/day) or placebo for 5
years. The primary outcome measure is dementia with a specified analysis for the diagno-
sis of AD; secondary outcome measures include a cognitive battery and tests of other do-
mains typically used in clinical trials for AD.
In general, although antioxidant treatments appear to be safe, results from supple-
ment trials in the area of cognition have been disappointing. There appear to be many
methodological challenges to previously reported trials, so hopefully future studies will
utilize more definitive trial designs.
TABLE 19.5. Clinical Trials for Ginkgo Biloba
Primary Secondary
Hofferberth AD 40 12 weeks 5 240 mg/day Egb 761 SKT SCAG, EEG
(1994)
Le Bars et al. AD, MID 309 ITT Randomized, 52 weeks 20 120 mg/day EGb 761 ADAS-Cog CGI,
(1997) double-blind, GERRI
placebo-controlled,
fixed dose, parallel
group, multicenter
trial
Kanowski DAT, MID 216 PP Randomized, 24 weeks 30 240 mg/day EGb 761 SKT CGI
et al. (1996) double-blind,
placebo-controlled,
multicenter
Wesnes et al. AD 54 Randomized, 12 weeks 7 120 mg/day Tanakan 10-item battery; QOL
439
(1987) double-blind, (Ginkgo) BVRT, digit
placebo-controlled symbol, word
recall, reaction
time
Rai et al. AD 27 Double-blind 24 weeks 9 120 mg/day Tanakan MMSE, KDCT, EEG
(1991) placebo-controlled, (Ginkgo) KOLT, digit recall,
parallel group classification
task
Van Dongen AD, VaD, 123 ITT Randomized, 24 weeks 8 240–160 Egb 761 SKT, CGI-2 NAI-NAA
et al. (2003) AAMI double-blind, mg/day
placebo-controlled,
parallel group,
multicenter trial
(continued)
Primary Secondary
Kanowski & DAT, MID 205 ITT Randomized, 24 weeks 8 240 mg/day Egb 761 Estiamted ADAS-
Hoerr (2003) double-blind, Cog scores from
placebo-controlled, SKT, CGI-2
fixed dose, parallel
group
Solomon et al. Healthy 60+ 219 ITT Randomized, 6 weeks 12 40 mg three Ginkgo OTC CVLT, WAIS-R,
(2002) double-blind, times per day formula WMS-R
placebo-controlled
Note. AAMI, age-associated memory impairment; AD, Alzheimer’s disease; DAT, dementia of the Alzheimer type; EEG, electroencephalograph; ITT, intent to treat; MID, multi-infarct demen-
tia; PP, per protocol; VaD, vascular dementia; outcome measures: ADAS-Cog, Alzheimer’s Disease Assessment Scale—Cognitive subscale (Mohs et al., 1997; Rosen et al., 1984); BVRT, Benton
Visual Retention Test (Benton, 1963); CGI-C, Clinical Global Impression of Change (Guy, 1976); CGI-2, Clinical Global Impression of Change, item 2; CVLT, California Verbal Learning Test
(Delis et al., 1987); GERRI, Geriatric Evaluation by Relatives Rating Instrument (Schwartz, 1983); KDCT, Kendrick Digit Copying Test (Kendrick et al., 1979); KOLT, Kendrick Object
Learning Test (Kendrick et al., 1979); NAI-NAA, Nuremberg Gerontopsychological Rating Scale for Activities of Daily Living, Nurnberger Alters Inventar (Oswald & Fleischmann, 1995);
QOL-AD, Quality of Life—Alzheimer’s Disease (Logsdon et al., 2002); SCAG, Sandoz Clinical Assessment—Geriatric Scale (Shader et al., 1974; Shader et al., 1976); SKT, Syndrom Kurz Test
440
(Overall & Schaltenbrand, 1992); WAIS-R, Wechsler Adult Intelligence Scale—Revised (Wechsler, 1981); WMS-R, Wechsler Memory Scale—Revised (Wechsler, 1987).
Anti-Inflammatory Agents
The use of anti-inflammatory agents as a preventive measure for AD is supported by sev-

eral lines of evidence. Inflammatory processes play a role in the development of AD as ev-
idenced by the wide range of proteins that appear in proximity to Aβ plaques in the
brain. These proteins include β1–antichymotripsin, ICAM-1, and β2-macroglobuline and
are presumed to be produced in the brain. Additionally, messenger ribonucleic acid
(mRNA) for complement factors and complement proteins are found in neurons but not
glial cells, supporting evidence of an inflammatory response to neural injury. Animal
studies have shown that inflammation-related proteins are associated with higher amy-
loid load (Nilsson, Bales, et al., 2001), and that inhibition of complement factors lowers
amyloid burden (Bales, Verina, et al., 1997). Autopsy studies have shown correlations be-
tween microglial cells and plaque deposits in the cerebral cortex of brains with AD but
not with Aβ or tau markers of disease progression. Thus it is possible that inflammation
is an early response to the disease process (Eikelenboom, van Gool, et al., 2004).
Several epidemiological studies support the association between inflammation and
AD, based on the finding of lower prevalence and incidence of AD among users of
nonsteroidal anti-inflammatory drugs (NSAID; Etminan, Gill, et al., 2003; in t’ Veld,
Ruitenberg, et al., 2001; Zandi, Anthony, et al., 2002). A meta-analysis of epidemio-
logical studies (Szekely, Thorne, et al., 2004) reported a combined OR of 0.51 (95%
[CI] 0.40–0.66) from cross-sectional evaluations in seven studies and a total of 12,979
subjects. Three studies, totaling 11,902 subjects, prospectively examined NSAID use
for a duration of ≥ 2 years, and the authors reported a combined relative risk (RR) of
AD of 0.42 (95% CI 0.26–0.66). These reports indicate that the strength of the associ-
ation is in studies with exposure 1–2 years prior to the onset of disease, implying that
NSAID protection can only be observed in the intact brain and is not likely to be ap-
parent as a treatment effect.
Thus far, clinical trials of anti-inflammatory drugs in AD (Table 19.6) have been dis-
appointing, although many were designed as treatment studies rather than as prevention
trials. Glucocorticoids have not been proven to be beneficial in treating AD in clinical tri-
als. A multicenter randomized clinical trial of prednisone showed no benefit, and signifi-
cant side effects were observed (Aisen, Davis, et al., 2000). An early NSAID trial demon-
strated borderline benefit in the presence of significant side effects with indomethacin
(Rogers, Kirby, et al., 1993). A more recent study found no benefit for the NSAID
diclofenac in combination with misoprostol and reported nearly a 50% withdrawal rate
(Scharf, Mander, et al., 1999). Similarly, a multicenter trial of naproxen showed no bene-
fit in patients with AD (Aisen, Schafer, et al., 2003). Although selective COX-2 inhibitors
have reasonable CNS penetrability, two well-designed, year-long, multicenter trials of
these agents have not demonstrated efficacy in the treatment of AD (Aisen, Schafer, et al.,
2003; Reines, Block, et al., 2004).
It is possible that the effect observed with NSAIDs in epidemiological studies is not
due to anti-inflammatory properties but rather to a reduction of Aβ formation. Recently,
Weggen, Eriksen, et al. (2001) reported that ibuprofen and indomethacen reduced the
amyloidagenic Aβ42 formation in cell cultures. Naproxen and COX-2 inhibitors did not
have the same effect (Weggen et al., 2001). The authors postulate that this effect may
come from subtle mediation of secretase activity. Taken together, the present state of
knowledge provides no data to support the use of anti-inflammatory agents for the treat-
ment of AD, and the known side effect profile suggests that the risks may be consider-
TABLE 19.6. Clinical Trials for Anti-Inflammatory Agents
Primary Secondary
Aisen et al. Probable AD 138 ITT Randomized, 1 year 22 20–10 Prednisone ADAS-Cog CDR-SB, BDRS,
(2000) double-blind, mg/day HAM-D, BPRS
placebo-
controlled, two-
group parallel,
multicenter trial
Rogers et al. Mild to 44 OC Randomized, 6 months 36 100–150 Indomethican MMSE, ADAS-

(1993) moderate double-blind, mg/day Cog, BNT, TK
AD placebo-
controlled trial
Scharf et al. AD 41 ITT Randomized, 25 weeks 34 50 mg Diclofenac & ADAS-Cog, MMSE, IADL,
(1999) double-blind, diclofenac, misoprostol GDS, CGI PSMS
placebo- 200 mg
442
controlled trial (D/M)
misoprostol
Aisen, Schafer, Mild to 351 ITT Randomized, 1 year 24 220 mg Naproxen ADAS-Cog CDR-SB, NPI,
et al. (2003) moderate double-blind, 2x/day QOL-AD
AD placebo-
controlled,
parallel group
trial
Aisen, Schafer, Mild to 351 ITT Randomized, 1 year 24 25 mg/day Rofecoxib ADAS-Cog CDR-SB, NPI,
et al. (2003) moderate double-blind, QOL-AD
AD placebo-
controlled,
parallel group
trial
(continued)
Primary Secondary
Reines et al. Possible or 692 ITT Randomized, 1 year 25 25 mg/day Rofecoxib ADAS-Cog, MMSE, CDR,
(2004) probable AD double-blind, CIBIC-Plus ADCS-ADL
placebo-
controlled,
parallel group
trial
Note. AD, Alzheimer’s disease; ITT, intent-to-treat; OC, observed cases; outcome measures: ADAS-Cog, Alzheimer’s Disease Assessment Scale—Cognitive subscale (Mohs et al., 1997;
Rosen et al., 1984); ADCS-ADL, Alzheimer’s Disease Cooperative Study—Activities of Daily Living (Galasko et al., 1997); BDRS, Blessed Dementia Rating Scale (Blessed et al., 1968);
443
BNT, Boston Naming Test (Kaplan et al., 1976); BPRS, Brief Psychiatric Rating Scale (Overall & Graham, 1962); CDR, Clinical Dementia Rating (Hughes et al., 1982); CDR-SB, Clinical
Dementia Rating—Sum of Boxes (Berg, 1988); CGI-C, Clinical Global Impression of Change (Guy, 1976); GDS, Global Deterioration Scale (Reisberg et al., 1982); CIBIC-Plus, Clinician’s
Interview-Based Impression of Change Plus Caregiver Input (Knopman et al., 1994); HAM-D, Hamilton Depression Rating Scale (Hamilton, 1960); IADL, Instrumental Activities of Daily
Living (Lawton & Brody, 1969); MMSE, Mini-Mental State Examination (Folstein et al., 1975); NPI, Neuropsychiatric Inventory (Cummings et al., 1994); PSMS, Physical Self Mainte-
nance Scale (Lawton & Brody, 1969); QOL-AD, Quality of Life—Alzheimer’s Disease (Logsdon et al., 2002); TK, Token Test (De Renzi & Vignolo, 1962; Spreen & Benton, 1969).
able, particularly in an elderly population. Interest in these agents for the prevention of
AD has led to several secondary and primary prevention trials.
Demonstrating primary prevention with anti-inflammatory agents has also proved
challenging. A primary prevention trial, the Alzheimer Disease Anti-Inflammatory Preven-
tion Trial (ADAPT), is a multicenter trial that suspended treatment in December 2004. The
ADAPT study is based on observational data (Martin, Meinert, et al., 2002) and explores
reduction of incident dementia and mitigation of cognitive decline as the primary outcome
measures. The study enrolled 2,625 individuals, ages 70 years and older, with a family his-
tory of AD in a first-degree relative and examined two anti-inflammatory agents, the con-
ventional NSAID, naproxen sodium (220 mg twice a day), and the selective COX-2 inhibi-
tor celecoxib (200 mg twice a day) and planned to follow subjects for 7 years. The trial was
stopped early due to a finding of increased risk of heart attack in subjects taking celecoxib in
an unrelated cancer study. In an analysis of adverse events, the investigators of the ADAPT
trial did not find increased risk in those randomized to Celecoxib; however, they did find an
increased risk of heart attacks and strokes in the subjects taking naproxen compared to
those on placebo. Another primary prevention trial for aspirin, the ASPREE trial (Aspirin in
Reducing Events in the Elderly), has begun to follow 15,000 study participants, ages 70
years and older, for 5 years (Nelson, Reid, et al., 2003).
Other Nutritional Supplements

Several approaches to cognitive enhancement have been suggested in the nutritional liter-
ature, although few randomized controlled trials are available to assess their efficacy. The
following is a sample of potential leads. Though far from comprehensive, it illustrates
how leads might be identified and demonstrates the need to conduct well-controlled clini-
cal trials in order to confirm these signals.
Omega-3 fatty acids, the long-chain polyunsaturated fatty acids found in plant and
marine sources, have been studied for their beneficial value in a number of contexts. They
have been shown to reduce hypertension, coronary artery disease, reduce risk of cardiac
arrest, and decrease triglyceride levels (Freeman, 2000). Additionally, they have been
shown to have neuroprotective effects in lab studies (Calon, Lim, et al., 2004; Kimura,
Saito, et al., 2002).
Docosahexaenoic acid (DHA) is the n-3 polyunsaturated fatty acid that is a compo-
nent of membrane phospholipids in the brain. An epidemiological study of 815 partici-
pants in the Chicago Health and Aging Project showed that subjects who consumed one
or more fish meals per week had a 60% reduced risk of AD (Morris, Evans, et al., 2003).
Persons with the highest intake of total n-3 polyunsaturated fatty acids had an inverse as-
sociation with AD compared to those in the group that consumed the lowest (RR = 0.4,
95% CI = 0.1–0.9). In an evaluation of DHA specifically, the reduced risk was similar
(RR = 0.3, 95% CI = 0.1–0.9). Thus far, there has been one small treatment trial of
omega-3 fatty acids for dementia. In this trial, a total of 20 patients with mild to moder-
ate dementia were randomized to receive 0.72 g of DHA daily for 1 year. Significant dif-
ferences between groups were shown on the Hasegawa Dementia scale at 3 and 6 months
but not at 12 months (p < .05). Patients taking DHA also showed significant improve-
ment on the MMSE at 6 months but not 12 months (p < .05). Currently, a clinical trial
for fish oil and alpha lipoic acid use to treat AD is recruiting patients. This randomized,
placebo-controlled, phase I and II trial anticipates an enrollment of 39 patients and will
continue for 1 year.
The polyphenol resveratrol (3,5,4’-trihydroxy-trans-stilbene) is a sirtuin-activating
compound; this compound stimulates the catalytic activity of yeast and human sirtuins
and prolong lifespan of yeast (Cohen, Miller, et al., 2004; Howitz, Bitterman, et al.,
2003; Wood, Rogina, et al., 2004). It is derived from plants and is found in highest levels
in red wine and the skin of red grapes (Vitis vinifera). This compound may be responsible
for the “French paradox”—epidemiological data demonstrating an inverse correlation
between red wine consumption and incidences of cardiovascular disease and of dementia.
A small randomized clinical trial using a combination of agents, among which resveria-
trol was the most prominent, was reported in abstract form, demonstrating benefit in
comparison to a placebo control (Blass & Gordon, 2004).
Taken together, these types of agents offer the possibility for treatment of cognitive loss
with potentially safe substances. However, there are many challenges to demonstrating
efficacy with these drugs. First, the specific active agent is difficult to identify and is based
on many suppositions. Second, there is little known about what dose would reasonably
affect cognitive behavior and what the side effect profile of that specific dose might be.
Finally, the commercial availability of an apparently safe agent can make it difficult to
generate enthusiasm for clinical trials among patient communities, who may opt for using
what appears to be a benign treatment.
SUMMARY AND CONCLUSIONS
It is currently recognized that approved and effective treatments exist for AD. It is also
recognized that current options are not entirely satisfactory, in that the benefits are small
and brief in this degenerative condition. Further the need to maximize cognitive function
throughout the lifespan is acknowledged by both young and old. In a society with grow-
ing technological demands, even minimal loss of cognitive capacity can create significant
functional disability. These forces, along with the aging of the global population, raises
awareness and motivates efforts to find interventions to reverse and prevent cognitive loss
and dementia. To move these efforts forward will require greater knowledge of the
pathophysiology of dementia across the entire disease spectrum as well as early cognitive
losses occurring with normal brain aging. The methodology to conduct reliable clinical
trials is well established, and clinicians and scientists must work to ensure public under-
standing and commitment to participating in the clinical trials needed to provide the con-
vincing evidence of efficacy. Only through this partnership will the public health issue be
addressed.
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Index
“A-B-C’s of Behavior African American 158–159, 169, 174t–

Change” process, 355– Acculturation Scale, 206 175t, 177, 178t, 179t–
356, 376 African Americans 180, 185–187, 188–189,
Acculturation, 205–206 dementia in, 4 268–270
Activities of daily living instrumentation issues and, genetic inheritance of, 20–
(ADLs) 203–212, 207t, 200t, 21, 63–64
Alzheimer’s disease and, 210f heterogeneity in, 21
263 testing and, 200t–201, 203– neuropsychological profile
behavioral symptoms and, 205 of, 59–63, 61f
369t Age, as a risk factor for onset of, 18
depression and, 249 dementia, 44–45 overview, 5, 57–59, 78–79
feedback and, 229–232 Age of onset, 57, 90 Parkinson’s disease and, 91,
functional status and, 159– Age-related cognitive decline, 93
160, 170 33. See also Cognitive presentations of, 57–68,
interpersonal issues and, functioning 61f, 65t, 66t, 370
372 Aggression, 369t, 370, 375t, prevention of, 416, 435–
methods of assessing, 162– 380–381, 388t 438, 439t–440t, 441,
164 Aging-associated cognitive 442t–443t, 444–445
overview, 134, 160– decline, 35, 61 relative decline and, 19
161 Aging, normal. See Normal risk factors for, 44–47
primary progressive aphasia aging statistics regarding, 56, 57
and, 316 Agitation, 337–338, 369t, studies of functional change
studies of, 165–171 375t, 387t in, 167–171
treatment and, 268, 296, Agnosia, 14 treatment and, 7, 182, 232,
373–374, 386t, 415 Akinesia, 90, 93 245, 261, 262–264,
Activity level, 251 Alarms, use of, 338–339 294–295, 394–402,
Adaptation, 408 Alcohol dementia, 96–97 414–415, 420–423,
Adjustment, 409 Alcohol use, 111, 112, 360 432–435, 445
Adult Reading Test, 31t Alternative communication Alzheimer’s Disease Anti-
Affective symptoms strategies, 324–325 Inflammatory Prevention
assessment of, 350–352, Alzheimer’s disease Trial (ADAPT), 444
351t, 371–372 across ethnic groups, 201– Alzheimer’s Disease
case examples of, 254, 256, 203 Assessment Scale (ADAS),
257, 278, 279 assessing for, 13, 17, 30 416, 417t
dementia and, 71t, 350 depression-related cognitive Alzheimer’s Disease
treatment and, 248–250, dysfunction and, 113 Cooperative Study—
352–353, 354–360, education and, 208–209 Activities of Daily Living
360–361 functional status and, 9, (ADCS-ADL), 416, 418t
457
458 Index
Alzheimer’s Disease Related deficit disorder, 65 presentations of, 15

Disorders Association driving ability and, 186 psychological distress and,
(ADRDA), 30 geriatric neuropsychological 394
Alzheimer’s Disease-Related assessment and, 11 treatment and, 7, 373–374,
Quality of Life, 419t, 420 Lewy body dementia and, 375t, 376–377f, 378f,
Amyloid angiopathy, 63 74, 77 379–383, 384t–385t,
Amyloid plaque, 432 Parkinson’s disease and, 76– 386t–388t, 389, 401
Anosognosia, 246–248 77 triggers of, 369–373, 370t
Anti-inflammatory agents, Attention deficit disorder, 65 Behavioral treatment, 352–
441, 442t–443t, 444. See Auditory cueing systems, 353, 354–360, 360–361.
also Pharmacotherapy 338–339 See also Treatment
Antianxiety medication, 117. Augmentative communication Benign aging, 28–29, 29–33t,
See also Pharmacotherapy strategies, 324–325 31t, 32f, 33
Anticonvulsants, 118. See Aural comprehension, 58 Beta-carotene, 436, 437. See
also Pharmacotherapy Autonomy, 176, 229–232, also Pharmacotherapy
Antidepressant medication, 379, 386t Bias, 148–149
114, 116–117. See also Autopsy confirmation of AD Blessed Dementia Rating Scale
Pharmacotherapy pathology, 202 (BDRS), 167–168
Antiepileptic drugs, 118. See Boston Naming Test, 31t,
also Pharmacotherapy 136
B
Antihistamines, 118–119. See Boundary conditions
also Pharmacotherapy Back to the Drawing Board normative studies of aging
Antihypertensives, 117–118. treatment program, 324 and, 34f–37f, 36, 38t,
See also Pharmacotherapy Bathing, 370, 372 39f, 40–42
Antioxidants, 436–437. See Behavior Observation Record overview, 47
also Pharmacotherapy (BOR), 376, 377f Brain trauma, 19, 45–46, 73,
Anxiety Behavior Tracking Log (BTL), 97–98, 160
behaviors and, 349, 398 376, 378f Brain tumor, 73
frontotemporal dementia Behavioral Dyscontrol Scale
and, 71t (BDS), 143–144, 169
overview, 350 Behavioral group therapy, C
treatment and, 117, 354– 403–404. See also Group Canadian Study of Health
360, 357–358 therapy and Aging (CSHA), 36, 61
Anxiety disorders, 91 Behavioral observations, 17, Capacity, assessment of, 171–
Apathy, 71t, 72, 77, 244 227 177, 178t, 179t–180,
Aphasia, 14, 58, 94, 175. See Behavioral Pathology in 181t, 182–189
also Primary progressive Alzheimer’s Disease Scale Capacity to Consent to
aphasia (BEHAVE-AD), 375t, Treatment Instrument
Apolipoprotein E (apoE), 20, 418t, 420 (CCTI), 173–175t, 174t
46, 63–64, 110, 327–328 Behavioral Rating Scale for Cardiovascular conditions,
APP gene, 46–47 Geriatric Patients, Care 437, 433–434
Apraxia, 14, 58–59 Dependency subscale, Caretaker Obstreperous
Arthritis, 9–10. See also 419t, 420 Behavior Rating
Motor function Behavioral symptoms Assessment Scale
impairment Alzheimer’s disease and, 58, (COBRA), 375t
Asian/Pacific Islanders, 200t– 398 Carotenoids, 436. See also
201 depression and, 249 Pharmacotherapy
Aspirin, 437. See also external memory aids and, Central nervous system
Pharmacotherapy 337–338 dysfunction, 244
Assessment, 374 frontotemporal dementia CERAD battery, 9, 13, 60,
Assessment reports, 226–227 and, 70, 71t, 72 201
Attendant data, 20–21 impact of, 368–369 Cerebrospinal fluid, 105
Attention overview, 349, 367–368, Cerebrovascular events, 73,
cognitive aging and, 28–29 369t, 389–390 94, 117–118
Index 459
Characteristic signs, 15–16 overview, 158–160, 165– Compensatory methods. See

Chicago Health and Aging 171 also External memory
Project, 444 Parkinson’s disease and, 93 aids
Cholesterol levels, 434–435 rate and course of changes Alzheimer’s disease and,
Cholinergic therapies, 78, in, 18–19 264
421–422. See also sleep-disordered breathing case examples of, 254, 256,
Pharmacotherapy and, 115 257, 278, 279
Circumlocution, 58 test selection and, 13 intervention planning and,
Classical conditioning, 283 testamentary capacity and, 250–251
Clinical Assessment Scales for 183–184 Competency
the Elderly (CASE), 15 thiamine deficiency and, assessment of, 171–177,
Clinical Dementia Rating 111 178t, 179t–180, 181t,
Scale (CDR), 35, 416 treatment and, 244–245, 182–189, 230
Clinical Dementia Rating— 399–400 overview, 6–7
Sum of Boxes, 417t vascular dementia and, 94 Computed tomography (CT),
Clinical Global Impression of vitamin B12 deficiency and, 20, 67, 95, 203
Change (CGI), 416, 417t 109–110, 109–110 Concentration, 113, 370
Clinician’s Interview-Based Cognitive impairment no Conditioning, 283
Impression of Change plus dementia (CIND), 36, 61, Confusion, 16
Caregiver Input (CIBIC- 95, 97 Consent capacity, 172–175t,
Plus), 416, 417t Cognitive rehabilitation 174t
Cognition-focused therapy, cognitive training programs Consortium to Establish a
294 and, 295–297 Registry for Alzheimer’s
Cognitive aging functional tasks and, 268– Disease (CERAD), 35,
benign change and, 33 270 139, 143–144, 201
malignant change and, 34f– overview, 261, 265–267t, Construct validity of a
37f, 38t, 39f, 40–42 267–268, 270–271, measure, 146
normative studies of, 29– 294–295, 301, 311 Constructional tasks, 59, 76–
33t, 31t, 32f research regarding, 302t– 77, 186
overview, 27–29, 28f 310t Continuous norming method,
studies of functional change Cognitive reserve, 209 139–140
in, 165–166 Cognitive testing, ethnicity Continuous positive airway
Cognitive-behavioral group and, 203–205 pressure (CPAP), 115–
therapy, 403–404. See Cognitive training programs 116
also Group therapy in broad-based programs, Controlled Oral Word
Cognitive continuum, 37f 300–301 Association Test, 31t,
Cognitive functioning cognitive rehabilitation and, 169–170
Alzheimer’s disease and, 58, 295–297 Coping skills, 3, 397, 398,
60 in group work, 297–299 405
behavioral observations of, 17 overview, 253, 301, 302t– Cornell–Brown Scale for
benign aging and, 33 310t, 311 Quality of Life in
case examples of, 254 pharmacotherapy and, 299– Dementia (CBS), 419t,
depression and, 112–114, 249 300 420
genetic inheritance and, 20 Cohen-Mansfield Agitation Cornell Scale for Depression
head trauma and, 98 Inventory (CMAI), 375t, in Dementia, 351t, 352,
hypothyroidism and, 107– 419t, 420 375t
108 Communication, 324–325, Cortical atrophy, 317
Lewy body dementia and, 74 397 Corticobasal degeneration,
medication effects on, 116– Communication notebook, 77–78
119 324 Corticosubthalamic
normal aging and, 17–18 Community Screening connections, 91
normal-pressure Interview for Dementia Course of changes in patient,
hydrocephalus and, (CSI-D), 201–202 18–19, 90, 93, 94, 98
105–106 Comorbidity, 78–79, 350 Crystallized abilities, 17–18
460 Index
Cultural issues Dementia pugilistica, 97–98 Diagnositc and Statistical

instrumentation issues and, Dementia Quality of Life Manual of Mental
203–212, 207t, 200t, instrument, 419t, 420 Disorders (DSM), 14–15
210f Dementia syndrome of Direct Assessment of
overview, 198–201, 200t, depression. See Functional Status Scale,
212–214 Depression-related 266–267t
rates of AD and dementia cognitive dysfunction Disability Assessment for
and, 201–203 Dementia Voice Group Dementia scale (DAD),
Psychotherapy Project, 416, 418t
D 407 Disruptive Behavior Rating
Dependency, 372 Scale (DBRS), 375t
DATATOP study, 437 Depression Docosahexaenoic acid
Decision-making capacity, assessment of, 3, 17, 375t (DHA), 444. See also
172–175t, 174t behavioral presentations of, Pharmacotherapy
Declarative knowledge, 96 15, 349, 376, 398 Donepezil. See also
Declarative memory, 282– diagnosing Alzheimer’s Pharmacotherapy
283. See also Memory disease and, 67 overview, 421, 424t
Delusions, 71t, 182 frontotemporal dementia PDD and LBD and, 429,
Dementia. See also Treatable and, 71t 430t
causes of dementia intervention planning and, vascular dementia and,
across ethnic groups, 4, 244, 248–250 424–425, 427t
201–203 overview, 350 Dopamine levels, 90–91
affective disturbances in, Parkinson’s disease and, 91 Driving ability, 6, 184–188,
350 treatment and, 7, 232, 354– 230–231
assessment of, 6, 13, 416, 360, 356–357, 403–404 DSM-IV, 159
417t–419t, 419–420 vascular dementia and, 95 Duke Established Populations
behavioral presentations of, Depression-related cognitive for Epidemiological
15, 349, 369t dysfunction, 112–114, 121t Studies of the Elderly, 201
diagnostic criteria of, 14–15 Developmental history, 65 Dysarthria, 93, 94
driving ability and, 230– DHA, 444. See also Dysthymia, 3, 248–250
231 Pharmacotherapy
education and, 208–209 Diagnosis, clinical
E
functioning and, 158–159, Alzheimer’s disease, 30, 64–
160–165 68, 65t, 66t Education
heterogeneity in, 21 on the assessment report, 229 diagnosing Alzheimer’s
mild cognitive impairment criteria of, 14–15 disease and, 65
and, 43f–44 feedback and, 233 ethnicity and, 200t, 206–
overview, 18–19, 44–47 financial capacity and, 176 211, 207t, 210f, 213
pharmacotherapy and, 7, frontotemporal dementia, geriatric neuropsychological
423–425, 426t–427t, 70, 71t, 72–73 assessment and, 12
437–429, 430t, 431–432 functional status and, 159 instrumentation issues,
research regarding, 34f–37f, geriatric neuropsychological ethnicity and, 203–204
38t, 39f, 40–42, 167– assessment and, 6 premorbid functioning
171 group psychotherapy and, estimations and, 16–17
testamentary capacity and, 400–401 Emotional factors, 17, 95,
182 intervention planning and, 248–250, 371–372. See
treatment and, 293, 353– 245 also Affective symptoms
354 mild cognitive impairment Empathy, 71t
vascular dementia and, 95 and, 166 Encoding, 41, 334–336
Dementia Behavior PD-D and LBD and, 75–78 Engagement, 396–397
Disturbance Scale (DBD), using normative standards, Environmental exposures, 74–
375t 137–138 75, 201, 250, 353–354, 377
Dementia lacking distinctive vascular dementia and, 94– Environmental factors, 372–
histology, 318 95 373
Index 461
Episodic memory, 41, 58, 61– for sensory memory and Functional disability
62, 183. See also Memory registration deficits, framework, 164
Errorless learning, 263–264, 338–340 Functional imaging, 20, 67–
283, 284, 285 training in, 340–342 68, 73
Estrogen, 435–436. See also Extrapyramidal symptoms Functional Living Skills
Pharmacotherapy (EPS), 19, 93 Assessment, 263
Ethnicity Functional neuroanatomy, 14
acculturation and, 205–206 Functional status
F
cognitive testing and, 203– Alzheimer’s disease and,
205 Face–Name Association Test 263
overview, 198–201, 200t, (FNAT), 266–267t assessment of, 6–7, 11,
212–214 Family history, 68, 73, 91–92 162–164
rates of AD and dementia Family medical history, 19 dementia and, 68, 160–165
across, 201–203 Family of the patient, 223– depression and, 249
Executive functions 224 external memory aids and,
Alzheimer’s disease and, 59, Feedback, 223, 223–224, 337–338
59–60, 62 224–232, 232–235, 262 overview, 6, 158–160, 165,
cognitive aging and, 28– Financial capacity, 175–177, 367–368, 369t
29 178t, 179t–180, 181t studies of, 165–171
dementia and, 14 Financial Capacity treatment and, 268–270,
depression-related cognitive Instrument, 177, 180, 296
dysfunction and, 113 181t vision problems and, 8
driving ability and, 186 Flavenoids, 436, 438. See
frontotemporal dementia also Pharmacotherapy
Fluorodeoxyglucon positron G
and, 70, 72
geriatric neuropsychological emission tomography Gait disorder, 93
assessment and, 11 (FDG-PET), 67. See also Gait disturbances, 105
group psychotherapy and, Functional imaging Galantamine, 422, 424t,
400 Folic acid, 433–434 426t, 427t. See also
Lewy body dementia and, Forgetfulness. See Memory Pharmacotherapy
77 impairment Gender, 45, 211
medical decision-making Frontal lobe dementias, 15, Genetic inheritance
capacity and, 175 17, 19, 161, 169 Alzheimer’s disease and,
neuropsychological profile Frontotemporal dementias 63–64, 68
of, 169–171 diagnosis of, 70, 71t, 72–73 frontotemporal dementia
Parkinson’s disease and, 76– genetic inheritance and, 20, and, 69–70, 73
77, 92 69–70 interpretation of, 20–21
relative decline and, 19 pharmacotherapy and, 431 Lewy body dementia, 74–75
Expanding rehearsal method, presentations of, 68–70, normal aging and, 18
262–264 71t, 72–73, 370 Parkinson’s disease, 74–75
Expressive language, 11, 58, risk factors for, 46 primary progressive aphasia
59–60, 62, 68 statistics regarding, 56, 68– and, 327–328
External memory aids. See 69 as a risk factor for
also Compensatory Frontotemporal lobar dementia, 46–47
methods degeneration, 316 Geriatric Depression Scale
for long-term memory and Functional Activities (GDS), 15
retrieval deficits, 336– Questionnaire (FAQ), 416 Gerstmann’s syndrome, 16
337 Functional assessment Ginkgo biloba, 438, 439t–
for memory encoding Alzheimer’s disease and, 440t. See also
deficits, 334–336 64–66, 65t Pharmacotherapy
to modify behavior and of competencies, 171–177, Ginkgo Evaluation of
support functioning, 178t, 179t–180, 181t, Memory (GEM) study,
337–338 182–189 438
overview, 333–334 overview, 158–160, 189 Global cognition, 167–169
462 Index
Global Deterioration Scale Hormone replacement geriatric neuropsychological

(GDS), 416, 417t therapy, 435–435. See assessment and, 7–8
Goals also Pharmacotherapy overview, 242–251, 258
behavioral symptoms and, Hypertension, 117–118 Interventions. See also Spaced
382 Hypnotics, 117. See also retrieval technique;
case examples of, 252, 255, Pharmacotherapy Treatment
257, 278, 279 Hypochondriasis, 71t affective disturbances and,
of spaced retrieval Hypokinesia, 90 354–360
technique, 277–278, Hypothyroidism, 107–108, Alzheimer’s disease and,
280–281t 120t 262–264, 270–271
treatment and, 242–243, behavioral symptoms and,
251, 355 I 373–374, 375t, 376–
Graduate Record 377f, 378f, 389–390
Examination, 142, 211 Implicit memory, 282–283. dementia and, 293
Group psychotherapy, 394– See also Memory overview, 4, 5–6, 285–288
402, 406–407, 407–410 Impulsivity, 72, 369t, 388t Interview for Deterioration in
Group therapy. See also Information processing, 28– Daily Living Activities in
Treatment 29, 59, 186 Dementia (IDDD), 416,
case examples of, 407– Insight 418t
410 case examples of, 253–254,
cognitive training programs 255–256, 257, 278, 279
intervention planning and, L
and, 297–299
eclectic approaches to, 406– 246–248 Language impairments. See
407 spaced retrieval technique also Primary progressive
modifications to consider, and, 283 aphasia
402–403 Instrumental activities of Alzheimer’s disease and, 62
overview, 7 daily living (IADLs) cognitive aging and, 28–29
cognitive training programs driving ability and, 186
research regarding, 403–
and, 296 frontotemporal dementia
406
depression and, 249 and, 72–73
driving ability as, 184 overview, 6
H feedback and, 229–232 Parkinson’s disease and, 92
Hallucinations, 15, 78, 182 functional status and, 159– primary progressive aphasia
Halstead–Reitan 160 and, 316–317, 318–319,
Neuropsychological methods of assessing, 162– 319–325
Battery (HRB), 12, 141, 164 treatment and, 245, 328t,
205–206 overview, 160, 161–162 400
Hamilton Depression Rating studies of, 165–171 wandering and, 370
Scale (HDRS), 356–357 Integrated model for Language issues, 211–212
Head trauma, 19, 45–46, 73, intervention, 241 Learning disabilities, 65
97–98 Intelligence, 18, 59 Legal issues, 7, 176, 180,
Healthcare triangle model, Interpersonal issues 182–184
287 behavioral symptoms and, Lewy body dementia
Hearing loss, 9 371–372, 377 behavioral presentations of,
Heart failure, 111 feedback and, 234–235 15
Herbicide exposure, 75 group psychotherapy and, diagnosis of, 75–78
Heterogeneity, 21 395–396, 409 genetic inheritance of, 74–
Higher-order Intervention planning. See 75
conceptualization, 62 also Treatment plan Parkinson’s disease and, 93
Hispanics, 200t–201, 203– behavioral symptoms and, pharmacotherapy and, 437–
205, 205–206 379–383, 384t–385t, 429, 430t, 431–432
Historical data, 18–19, 227. 386t–388t presentations of, 73–78, 75t
See also Medical history case examples of, 252–258, statistics regarding, 56
Homocysteine, 433–434 252f, 253f Lifestyle factors, 74–75
Index 463
Lipids, 434–435 depression-related cognitive financial capacity and, 180,

Listening skills, 233 dysfunction and, 113 181t
Literacy genetic inheritance and, 46– functioning and, 159
ethnicity and, 200t, 206– 47 normative standards and,
211, 207t, 210f, 213 insight and, 247 144
geriatric neuropsychological literacy and, 210f–211 overview, 5, 34f–37f, 38t,
assessment and, 10 normal-pressure 39f, 40–42, 47, 78–79,
premorbid functioning hydrocephalus and, 106 98
estimations and, 16–17 Parkinson’s disease and, 92 pharmacotherapy and, 415,
treatment and, 328t procedural, 161, 262–263, 431–432
264, 282–283 prevention of AD and,
spaced retrieval technique 416
M
and, 262, 282–283 studies of functional change
Magnetic resonance imaging testamentary capacity and, in, 166–167
(MRI), 20, 67, 95, 203 183 Milieu therapy, 300–301
Malignant aging treatment and, 297–299, Mini-Mental State
normative studies of, 29– 333–334, 399–400 Examination (MMSE)
33t, 31t, 32f visual, 110 Alzheimer’s disease and,
overview, 28–29, 34f–37f, vitamin B12 deficiency and, 62
38t, 39f, 40–42 110 cognitive rehabilitation and,
ManorCare, 287–288 wandering and, 370 266, 296
Mayo Cognitive Factor Scores Wernicke-Korsakoff ethnicity and, 203, 204–
(MCFS), 30, 32t–33t syndrome and, 112 205
Mayo Older African Memory aids global cognition and, 167–
American Normative book, 336–338, 357 169
Studies (MOAANS), 30– notebook, 269–270, 334– mild cognitive impairment
32f, 31t, 36 335 and, 166
Mayo Older Americans wallet, 336–337 normative standards and,
Normative Studies Memory decline, 10, 19 136, 142, 147
(MOANS), 30–32f, 31t, Memory encoding deficits, overview, 13, 416, 417t
36, 145 334–336 Mission statement of a
McGill Pain Questionnaire, Memory impairment facility or organization,
376 Alzheimer’s disease and, 287
Medical decision-making 57–58, 59–60 Mixed dementia, 415. See
capacity, 172–175, 174t frontotemporal dementia also Dementia
Medical history, 18–19, 66t– and, 68, 72 Mood, evaluation of, 3
67, 73. See also Historical Lewy body dementia and, Motivation
data 77 assessment and, 11
Medication effects, 18–19, overview, 41 case examples of, 252, 255,
116–119. See also Parkinson’s disease and, 76 257, 278, 279
Pharmacotherapy presentations of, 16 intervention planning and,
Memantine, 423, 424t, 425, Mental processing speed, 28– 243–244
426t, 437. See also 29 Motor function impairment
Pharmacotherapy Metabolic dysregulation, 18– assessment and, 9–
Memory 19 10
activities of daily living Metastic illness, 73 diagnosis of Parkinson’s
(ADLs) and, 161 Method of loci, 246 disease and, 75–76
aging and, 28–29, 33, 34 Micrographia, 90 relative decline and, 19
Alzheimer’s disease and, Mild cognitive impairment vascular dementia and, 93,
262–264 Alzheimer’s disease and, 94, 95
assessment of, 11, 170 60–61 Multiple-domain MCI, 42,
cognitive impairment and, cultural issues and, 213 43f–44
36, 40–41 dementia and, 43f–44 Muscular rigidity, 90
dementia and, 14, 95–96 evolution of, 42–43 Mutism, 71t, 72
464 Index
N Nimodipine, 426t, 437. See Occupational functioning, 14

also Pharmacotherapy Oklahoma Premorbid
Naming tasks
NITE-AD trial, 359–360 Intelligence Estimate-3
Alzheimer’s disease and, Nondeclarative memory, 282– (OPIE-3), 16
59–60 283. See also Memory Omega-3 fatty acids, 444. See
Lewy body dementia and, 77 Nonspecific focal atrophy, also Pharmacotherapy
Parkinson’s disease and, 76 318 Operant conditioning, 283
primary progressive aphasia Nonsteroidal anti- Orientation, 11, 370
and, 319–320 inflammatory drugs, 441, Orientation and Memory
semantic dementia and, 72– 442t–443t, 444. See also Notebook, 269–270, 334–
73 Pharmacotherapy 335. See also External
treatment and, 320–322 Nonverbal communication, memory aids
National Institute of 324–325 Outpatient therapy groups,
Neurological and Normal aging 402. See also Group
Communicative Disorders cognitive aging and, 28f psychotherapy
and Stroke (NINCDS), 30 compared to Alzheimer’s Overlapping cell tables
Native Americans, 200t–201, disease, 58 method, 139–140
201–202 education and, 209
Nervous system, 17–18, 370– interpretation of the
371 P
neuropsychological data
Neuroanatomy, functional, 14 and, 17–18 Paranoia, 369t, 388t
Neurobiology, 63 overview, 47 Parkinson’s disease
Neurocognitive assessment, research regarding, 29–33t, diagnosis of, 75–78
64–66, 65t 31t, 32f functioning and, 169
Neuroimaging, 20 studies of functional change genetic inheritance of, 74–75
Neuropathology, 78 in, 165–166 memory and, 42
Neuropsychiatric Inventory Normal-pressure overview, 90–93
(NPI), 15, 351t, 352, hydrocephalus, 16, 105– pharmacotherapy and, 420,
418t, 419–420 107, 120t 437–429, 430t, 431–432
Neuropsychological Normative standards presentations of, 15, 16,
evaluation, 64–66, 65t, 73–78, 75t
cultural issues and, 212–
73, 244–246 relative decline and, 19
213
Neuropsychological profiles statistics regarding, 56
development of, 138–145,
alcohol dementia, 97 141t Parkinson’s disease dementia,
Alzheimer’s disease, 59–63, geriatric neuropsychological 437–429, 430t, 431–432
61f assessment and, 11–12 Pathognomonic signs, 15–16
behavioral symptoms and, language issues and, 212 Performance-based
369–371 assessments, 163–164
nature and purpose of,
case examples of, 253–254, 134–138 Peripheral neuropathy, 9–10,
255–256, 257, 278, 279 overview, 133–134, 150–151 111. See also Motor
driving ability and, 186– serial assessments and, 148– function impairment
187 150 Periventricular shunt
functional status and, 169– uses of, 145–148 procedure, 106–107
171 Northwestern Naming Personality change, 68, 72,
group psychotherapy and, Battery, 319 244
399–400 Nutritional supplements, Pesticide exposure, 75
head trauma and, 98 444–445. See also Pharmacotherapy. See also
intervention planning and, Pharmacotherapy Medication effects
245–246 Alzheimer’s disease and,
Lewy body dementia, 77–78 414–415, 420–423, 424t
Parkinson’s disease, 76–77, O behavioral symptoms and,
92–93 Obstructive sleep apnea, 114– 376, 389
vascular dementia and, 95– 116 cognitive training programs
96 Occupational background, 16 and, 299–300
Index 465
dementia and, 423–425, language deficits and, 318– Recognition memory, 76. See
426t–427t, 437–429, 319 also Memory
430t, 431–432 overview, 72, 315–318, Recruitment, normative
depression-related cognitive 327f, 328t studies and, 144–145
dysfunction and, 114 treatment of, 319–325 Referral question, 11,
Lewy body dementia and, Priming, 282–283 227
76 Problem solving, 17–18, 170 Registration deficits, 338–
new approaches to, 432–435 Procedural memory, 161, 340
overview, 7, 445 262–263, 264, 282–283. Regression to the mean, 149
regulatory approval process See also Memory Rehabilitation, 4, 294–295
and, 415–416 Procedural motor learning, Reinforcement of behaviors,
Physical Self Maintenance 262–263, 264, 269 373, 380–381, 381–382
Scale, 418t, 419 Procedural Object–Memory Reisberg Global Deterioration
Pick’s disease, 70 Evaluation (POME), 266– Scale, 36
Pittsburgh Agitation Scale, 267t Relationships, 409–410
375t Progesterone, 435. See also Relative decline, 19
Pleasant Events Schedule— Pharmacotherapy Reliable change indices, 149–
AD (PES-AD), 375t Progressive supranuclear 150
Polyphenol resveratrol, 445. palsy, 73, 77, 77–78 Reminder cards, 335–336
See also Pharmacotherapy Pseudodementia, 112, 249 Reminiscence groups, 405–
Positron emission Psychodynamic group 406. See also Group
tomography (PET), 20, psychotherapy, 404–405. therapy
67–68, 73, 95, 317 See also Group therapy Retrieval tasks, 41, 336–
Postoperative cognitive Psycholinguistic Assessment 337
dysfunction, 19 of Language Skills, 319 Reversible causes of dementia
PREADVISE study, 437 Psychological factors, 67, depression-related cognitive
Premorbid function, 11, 14, 371–372, 394 dysfunction, 112–114
16–17 Psychomotor speed, 113, hypothyroidism and, 107–
Presenilin 1 gene, 46–47, 63, 118, 170 108
69 Public health issues, 57, 140– medication effects, 116–
Presenilin 2 gene, 46–47 142, 141t, 224, 396 119
Presentation of patient normal-pressure
Alzheimer’s disease, 57–68, hydrocephalus and,
61f, 65t, 66t
Q 105–107
frontotemporal dementia, Quality of life, 3, 249, 420 overview, 103–105, 119,
68–70, 71t, 72–73 Quality of Life—Alzheimer’s 120t–122t, 123
historical data and, 18–19 Disease scale, 419t, 420 sleep-disordered breathing,
Lewy body dementia, 73– 114–116
78, 75t statistics regarding, 103–
R
overview, 16–19, 56 104
Parkinson’s disease, 73–78, Race, 198–201, 200t, 211, thiamine deficiency, 111–
75t 212–214. See also 112
Prevention of Alzheimer’s Cultural issues vitamin B12 deficiency and,
disease, 416, 435–438, Rapid eye movement sleep 108–111
439t–440t, 441, 442t– disorders, 76 Revised Memory and
443t, 444–445 Rapport, 11, 232–233 Behavior Checklist, 351t,
Primary caregiver, 234–235 Rate of changes in patient, 352
Primary hypothyroidism, 19 18–19, 62–63, 209 Right–left disorientation,
Primary progressive aphasia. Reality orientation model, 16
See also Aphasia; 404–405, 406 Rivastigmine, 421–422, 424t,
Frontotemporal dementia Reasoning ability, 62 425, 426t, 430t. See also
case examples of, 325–327 Recall memory, 76. See also Pharmacotherapy
intervention planning and, Memory Ryden Aggression Scale
245 Receptive language, 11, 58, 175 (RAS), 375t
466 Index
S Structural imaging, 20, 67 hypothyroidism and, 108

Structured Assessment of intervention planning and,
Screen for Caregiving Burden Independent Living Skills 251–253, 258
(SCB), 419t, 420 (SAILS), 169 medical decision-making
Sedatives, 117. See also Subcortical ischemic vascular capacity and, 172–175t,
Pharmacotherapy disease (SIVD), 94 174t
Seizure disorders, 118 Subjective memory, 113. See normal-pressure
Selecting assessments, 11–13 also Memory hydrocephalus and,
Semantic dementia, 72–73 Suicidal ideation, 71t 106–107
Semantic memory, 58. See Support groups, 405. See also overview, 251
also Memory Group therapy primary progressive aphasia
Sensorimotor changes, 94 Suspiciousness, 369t, 388t and, 319–325, 328t
Sensory deficits, 93, 158,
sleep-disordered breathing
338–340
T and, 115–116
Sentence production, 319–
therapeutic issues in
320, 322–323 Tacrine, 420–421, 424t. See providing feedback and,
Serial assessments, 29, 148–150 also Pharmacotherapy 232–235
Sexual behavior, 369t, 370– Telephone Interview for thiamine deficiency and,
371, 382, 388t Cognitive Status, 137 112
Single photon emission Testamentary capacity, 180,
tomography (SPECT), 67, vitamin B12 deficiency and,
182–184
73, 95, 203, 317. See also 110–111
Therapeutic alliance, 232–233
Functional imaging Treatment of underlying
Therapeutic nihilism, 284–
Sleep-disordered breathing, forms (TUF), 322–323
285, 286
114–116, 122t Treatment plan. See also
Thiamine deficiency, 111–
Sleep disorders Intervention planning
112, 121t
behavioral symptoms and,
behavioral treatment and, Traumatic brain injury, 97–
382–383
358–360 98, 160
case examples of, 252–258,
behaviors and, 349 Treatable causes of dementia
252f, 253f, 384t–385t
interventions and, 380, depression-related cognitive
creation of, 251–252
386t dysfunction, 112–114
overview, 251, 258
Lewy body dementia and, 76 hypothyroidism and, 107–
Tremors, 90
overview, 350, 369t 108
Smoking, 74–75 medication effects, 116–119
Social functioning, 14, 72, normal-pressure U
357, 395–396 hydrocephalus and, Urinary incontinence, 16,
Social support, 299 105–107 106, 369t, 379–380, 386t
Socialization, 211 overview, 103–104, 103– Useful Field of View, 187
Spaced retrieval technique 105, 119, 120t–122t,
case examples of, 278–284, 123
281t sleep-disordered breathing,
V
dissemination of, 284–288 114–116 Vaccinations, 432
external memory aids and, thiamine deficiency, 111– Vacuous speech quality, 58.
341 112 See also Expressive
goals of, 277–278 vitamin B12 deficiency and, language
limitations of, 264 108–111 Vascular dementia
overview, 262–264, 275– Treatment. See also Group Alzheimer’s disease and, 57,
277, 288–289 therapy; Interventions; 63
Spatial navigation, 58–59, Pharmacotherapy depression-related cognitive
71t affective disturbances and, dysfunction and, 113
Speech production, 19, 71t 354–360 diagnostic criteria of, 14–
Stroke, 9–10, 15–16, 94, behavioral, 352–353 15, 66t–67
322–323. See also Motor case examples of, 327 onset of, 18
function impairment feedback and, 224–232 overview, 93–96
Index 467
pharmacotherapy and, 415, Vitamin B12 deficiency, 108– Washington Heights–Inwood–

423–425, 426t–427t, 111, 120t, 433–434 Columbia Aging Project,
437 Vitamin B6, 433–434 436
statistics regarding, 94 Vitamin C, 436, 437. See also Wechsler Adult Intelligence
treatment and, 232 Pharmacotherapy Scale, 59
Visuospatial disturbances Vitamin E, 436, 437–438. See Wechsler Adult Intelligence
Alzheimer’s disease and, 58, also Pharmacotherapy Scale—3rd edition, 12,
62 Vocalization, excessive, 369t, 136, 138, 139–140, 140–
assessment of, 170 381–382 141, 142
depression-related cognitive Wernicke-Korsakoff
dysfunction and, 113 W syndrome, 96, 111, 112
Word comprehension, 72–73
driving ability and, 186, Wandering
Working memory, 58. See
188 interventions and, 337, 381,
also Memory
Lewy body dementia and, 77 387t
Parkinson’s disease and, 92– at night, 358
93 overview, 369t, 370

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GERIATRIC NEUROPSYCHOLOGY

THE GUILFORD PRESS

All rights reserved

No part of this book may be reproduced, translated, stored in

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Geriatric neuropsychology : assessment and intervention / edited by

For Patrick, Elise, and Nathan

Deborah K. Attix, PhD, completed her postdoctoral fellowship in Clinical Neuro-

Kathleen A. Welsh-Bohmer, PhD, is a Professor within the Department of Psychiatry and

Amarilis Acevedo, PhD, Department of Psychiatry and Behavioral Sciences, Miller

Center, Division of Neurology, Department of Medicine, Duke University Medical

PART I. GERIATRIC NEUROPSYCHOLOGICAL ASSESSMENT 1

SECTION A. Assessment of Common Geriatric Conditions 3

1 An Integrated Model for Geriatric Neuropsychological Assessment 5

2 Normal Aging and Mild Cognitive Impairment 27

4 Stable and Slowly Progressive Dementias 89

5 Potentially Reversible Cognitive Symptoms in Older Adults 103

SECTION B. Specific Considerations 131

6 Using Norms in Neuropsychological Assessment of the Elderly 133

7 Functional Assessment 158

8 Cultural Issues 198

PART II. GERIATRIC NEUROPSYCHOLOGICAL INTERVENTION 237

SECTION A. Cognitive Training and Compensatory Techniques 239

10 An Integrated Model for Geriatric Neuropsychological Intervention 241

11 Training of Cognitive and Functionally Relevant Skills in Mild 261

12 Spaced Retrieval: A Model for Dissemination of a Cognitive Intervention 275

13 Multitechnique Program Approaches 293

14 Language Interventions in Dementia 315

15 External Aids 333

SECTION B. Psychotherapeutic Interventions 347

16 Behavioral Treatment of Affective Disorders and Associated Symptoms 349

17 Behavioral Treatment of Impaired Functioning and Behavioral Symptoms 367

18 Group Psychotherapy Approaches for Dementia 394

19 Pharmacological and Other Treatment Strategies for Alzheimer’s Disease 414

An Integrated Model for Geriatric

APPLICATIONS OF GERIATRIC NEUROPSYCHOLOGICAL ASSESSMENT

Neuropsychological Assessment and Clinical Diagnosis

Neuropsychology and Estimation of Functional Status and Competency

Neuropsychological Assessment and Intervention Planning

Whether the purpose of neuropsychological evaluation with older adults is diagnosis,

As it relates to neuropsychological assessment, poor vision can be a confound to test

Rapport and Motivation

The clinician’s approach to selecting tests to administer in a neuropsychological evalua-

neuropsychological assessment battery can improve diagnostic specificity without com-

INTERPRETATION OF NEUROPSYCHOLOGICAL DATA

The interpretive process essentially defines the neuropsychological evaluation; it is the

Core Neuropsychological Knowledge Base

ders and Stroke–Alzheimer’s Disease Related Disorders Association [NINCDS-ADRDA];

Characteristic and Pathognomonic Signs

constellation of dysgraphia, dyscalculia, right–left disorientation, and finger agnosia,

Patient Presentation and Performance

Behavioral Observations. One source of nontest data that is nonetheless critical to

Historical Data: Clinical Presentation and Medical History

Rate and Course. Although it is important to establish a patient’s symptom onset, it

The previous section on neuropsychological interpretation reviewed key factors that

Welsh-Bohmer, K. A., & Mohs, R. C. (1997). Neuropsychological assessment of Alzheimer’s disease.

Normal Aging and