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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
.pdf
61
Measures of Cognitive Ability
Points
Where are we:
country;
republic;
city;
floor;
address
0–1
0–1
0–1
0–1
0–1
memorization
Name 3 items, spending 1 sleep each. Then ask the patient to name all
3 items. Repeat the names of objects until the patient remembers them
0–3
Attention and calculation
Ask to add 7 consecutively to the proposed figure. Stop at the 5th answer.
You can ask to name the letters in reverse order in the word “pen”
1–5
Memory
Ask to name 3 items discussed in paragraph 3, scoring 1 point for each
correct answer
0–3
Speech
Show the watch and pen and ask the patient to name these items.
0–2
Ask to repeat after you: “no way”, “if”, “and”, “or”, “but” (only
1 attempt — 1 point)
0–1
Run the command: “Take a sheet of paper in your right hand, fold it in
half and put it on the floor”
0–3
Invite the patient to read and execute the command “Close your eyes”
0–1
Ask the patient to come up with and write a sentence on a blank sheet of
paper (it must contain a subject and a predicate and make sense, the
correctness of grammar and punctuation is not taken into account)
0–1
Enlarge the drawing below so that the side of the pentagon is 1–5 cm and
ask the patient to copy it (1 point if all corners and sides are reproduced
and the intersecting sides form a square)
0–1
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Test for speech activity in determining
the degree of dementia
The subjects are asked to name as many names of plants or animals
as possible (semantically mediated associations) and words starting with a
certain letter, for example “l” (phonetically mediated associations) in
1 minute. Normally, in 1 minute, most elderly people with secondary and
higher education name from 15 to 22 plants and from 12 to 16 words
starting with “l”. The naming of less than 12 semantically mediated
associations and less than 10 phonetically mediated associations usually
indicates a pronounced cognitive dysfunction (Kushnir G.M. — Doctor of
Medical Sciences, Professor, Savchuk E.A. — Candidate of Medical
Sciences, Samokhvalova V. V. — c.m.s.)
Wechsler symbol-digit test
The modern recognition of disorders of cognitive function and the
ability to understand and reproduce digital designations, to assess the
exhaustion of attention and the stability of the graphic reproduction of
symbolic images, is facilitated by the Wechsler symbol-numeric test. The
test is evaluated taking into account the correctness of filling in the
standard protocol and the time required for it.
Grade
1
2
3
Ĵ
4
5
∩
6
7
8
9
63
2 1 3 7 2 4 8 1 5 4 2 1 3 2 1 4 2 3 5 2 3 1 4 6 3
1 5 4 2 7 6 3 5 7 2 8 5 4 6 3 7 2 8 1 9 5 8 4 7 3
6 2 5 1 9 2 8 3 7 4 6 5 9 4 8 3 7 2 6 1 5 4 6 3 7
9 2 8 1 7 9 4 6 8 5 9 7 1 8 5 2 9 4 8 6 3 7 9 8
Within 90 seconds, enter the symbols corresponding to the numbers
located in each cell into the empty cells with the maximum possible speed.
A sample of filling in the cells is given in the top row, it can be constantly
referred to. The first 3 cells during the briefing are filled in by the person
leading the study. The subject fills in 7 subsequent cells under control for
the purpose of training. After that, the stopwatch is turned on, and the next
cells (without gaps, from left to right) are filled in by the subject himself.
The number of cells correctly filled within 90 s is counted. This number is
the result of a test that is associated with the preservation of cognitive
function.
Clock drawing test
An easy-to-use and accurate clock drawing test is often used to study
the degree of change in cognitive impairment in dementia. It can be carried
out if there are suspicions of an incipient dementia syndrome. The
simplicity and unusually high information content of this test, including
for mild dementia, makes it one of the most commonly used tools for
diagnosing this clinical syndrome.
64
The test is carried out as follows. The patient is given a clean sheet of
unlined paper and a pencil. The doctor says: “Please draw a round clock
with numbers on the dial and so that the hands of the clock show fifteen
minutes to two.”
The patient must independently draw a circle, put all 12 numbers in
the correct places and draw arrows pointing to the correct positions.
Normally, this task is never difficult.
If errors occur, they are quantified on a 10-point scale:
10 — points — the norm, a circle is drawn, the numbers are in the
right places, the arrows show the set time;
9 points — minor inaccuracies in the location of the arrows;
8 points — more noticeable errors in the location of the arrows;
7 points — the hands show a completely wrong time;
6 points — the arrows do not perform their function (for example,
the right time is circled);
5 points — incorrect arrangement of numbers on the dial: they follow
in reverse order (counterclockwise) or the distance between the numbers is
not the same;
4 points — the integrity of the watch is lost, some of the numbers are
missing or located outside the circle;
3 points — the numbers and the dial are no longer related to each
other;
2 points — the patient's activity shows that he is trying to follow the
instructions, but to no avail;
1 point — the patient makes no attempts to follow the instructions.
Schulte test
It is carried out using a special table in which the numbers are
arranged in random order from 1 to 25. The doctor marks the time spent by
the patient to find the numbers with a stopwatch.
65
21
12 7 1
20 6 15
17 3 18
19 4 8
25
13
24 2 22
10 5 9
14
11
23
16
Normally, the execution time of the Schulte test is 25–30 seconds.
Battery frontal dysfunction
(Frontal Assessment Batter — FAB)
1. Conceptualization. The patient is asked: “What do an apple and a
pear have in common?” The answer that contains a categorical
generalization (“It's a fruit”) is considered correct. If the patient finds it
difficult or gives a different answer, he is told the correct answer. Then
they ask: “What do a coat and a jacket have in common?” ... “What is
common between a table and a chair?”. Each categorical generalization is
worth 1 point. The maximum score in this test is 3, the minimum is 0.
2. Fluency of speech. They are asked to close their eyes and for a
minute say words starting with the letter “s”. In this case, proper names are
not counted. Result: more than 9 words per minute — 3 points, from 7 to
9 — 2 points, from 4 to 6 — 1 point, 3 or less — 0 points.
3. Dynamic praxis. The patient is invited to repeat a series of three
movements after the doctor with one hand: fist (placed horizontally,
parallel to the table surface) — rib (the brush is placed vertically on the
medial edge) — palm (the brush is placed horizontally, palm down). At the
first presentation of the three series described above, the patient only
follows the doctor, at the second presentation of the three series, he repeats
the movements of the doctor, and finally, he does the next two times three
series on his own. When self-fulfilling tips to the patient are unacceptable.
Result: correct execution of nine series of movements — 3 points, six
series — 2 points, three series (together with the doctor) — 1 point.
66
4. Simple reaction of choice. The instruction is given: “Now I will
check your attention. We will tap out the rhythm. If I hit once, you must
hit twice in a row. If I strike twice in a row, you must strike only once.”
The following rhythm is tapped out: 1-1-2-1-2-2-2-1-1-2. Evaluation of the
result: correct execution — 3 points, no more than 2 errors — 2 points,
many errors — 1 point, complete copying of the doctor's rhythm —
0 points.
5. Complicated choice reaction. The instruction is given: “Now if
I strike once, you must do nothing. If I strike twice in a row, you must
strike only once.” The rhythm is tapped: 1-1-2-1-2-2-2-1-1-2. Evaluation
of the result is similar to paragraph 4.
6. Study of grasping reflexes. The patient sits, he is asked to put his
hands on his knees with palms up and check the grasping reflex. The
absence of a grasping reflex is estimated at 3 points. If the patient asks if
he should grab, a score of 2 is given. If the patient grabs, he is instructed
not to, and the grasping reflex is retested. If the reflex is absent during the
re-examination, 1 is assigned, otherwise — 0 points.
Evaluation of results: 17–18 — normal, 12–16 — mild cognitive
impairment, 11 points or less — frontal dementia.
Clinical Dementia Rating Scale
(eng. Clinical dementia rating)
0 points — no violations
0–5 points — “doubtful” dementia
Memory: persistent minor forgetfulness, incomplete recall of past
events, “benign forgetfulness”
Orientation: fully orientated, but there may be inaccuracies in naming
the date
Thinking: slight difficulty in solving problems, analyzing similarities
and differences
Interaction in society: minor difficulties
Household behavior and hobbies: minor difficulties
67
Self-service: no violations
1 point — mild dementia
Memory: greater forgetfulness of current events that interferes with
daily life
Orientation: not completely oriented in time, but always correctly
names the place; at the same time, there may be difficulties in selforientation on the ground
Thinking: moderate difficulty in solving problems, analyzing
similarities and differences that do not affect everyday life
Interaction in society: independence is lost, however, it is possible to
perform certain social functions. On a superficial acquaintance, violations
may not be obvious
Behavior at home and hobbies: mild but distinct domestic
difficulties, loss of interest in complex activities
Self Service: Needs Reminders
2 points — moderate dementia
Memory: severe forgetfulness, current events do not remain in
memory, only memories of the most significant events of life are preserved
Orientation: disoriented in time, not fully oriented in place
Thinking: Marked difficulty in solving problems and analyzing
similarities and differences that have a negative impact on daily activities
Interaction in society: independence is lost outside one's home, but
can enter into social interaction under the control of others
Household behavior and hobbies: extreme limitation of interest,
ability to perform only the simplest activities
Self care: Needs help with dressing, hygiene, natural bowel
movements
3 points — severe dementia
Memory: fragmentary memories of life Orientation: focused only on
self
Thinking: solving intellectual problems is impossible
Social interaction: Impairment prevents social interaction outside
one's home
68
Behavior at home and hobbies: unable to perform household duties
Self care: constantly in need of care; frequent incontinence.
For studying the presence, degree and structure of symptoms of
depression, it is recommended to use the full geriatric depression scale
(Geriatrics Depression Scale-30, abbr. GDS-30). The test is used to screen
for the diagnosis of the presence and degree of dysthymia, depression in
elderly and senile people (table 4).
Table 4
CES-D Depression Self-Questionnaire
1. I'm nervous about things that didn't
bother me before.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
2. I don't enjoy food, I have a poor
appetite.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
3. Despite the help of friends and
family members, I cannot get rid of the
feeling of longing.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
4. It seems to me that I am no worse
than others
0 Most of the time
1 Much of the time
2 Sometimes
3 Very rarely or never
5. I find it difficult to concentrate on
what I have to do.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
6. I feel overwhelmed
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
7. Everything I do requires extra effort
from me.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
8. I hope for a good future
0 Most of the time
1 Much of the time
2 Sometimes
3 Very rarely or never
69
9. It seems to me that life has turned
out unsuccessfully.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
10. I experience anxiety, fears
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
11. I have a bad night's sleep.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
12. I feel like a happy person
0 Most of the time
1 Much of the time
2 Sometimes
3 Very rarely or never
13. It seems that I began to talk less
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
14. Feeling lonely bothers me.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
15. People around me are unfriendly
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
16. Life gives me pleasure
0 Most of the time
1 Much of the time
2 Sometimes
3 Very rarely or never
17. I can cry easily
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
18. I feel sad, spleen
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
19. It seems to me that people do not
like me.
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
20. I do not have the strength and
desire to start doing something
0 Very rarely or never
1 Sometimes
2 Much of the time
3 Most of the time
The test was based on studies of depression in later life, which
showed a high risk of suicide due to increased depression. This test can be
used to assess depressive symptoms in patients with mild or moderate
cognitive deficits. Indicators on the geriatric depression scale correlate
with the scales for assessing the degree of depression A. Beck (abbr. BDI),
70
M. Hamilton (abbr. HDRS) and W. Zung Depression Rating Scale (abbr.
Zung SDS) (table 5). If the patient scores 19 or more points, then with very
high certainty we can talk about the presence of a depressive disorder. A
score from 19 to 26 corresponds to mild depression, from 27 to 36 —
moderate depression. If the patient scores 37 or more points, this indicates
that he has severe depression.
Table 5
Hamilton Scale (HDRS)
Row
number
Symptoms of depression
1
Depressive mood (depression, hopelessness, helplessness, feeling of low
worth)
0 = no;
1 = expression of said feeling only when asked directly;
2 = speaks out in complaints spontaneously;
3 = determined not by verbal expression, but by observation: facial
expressions, posture, voice, tearfulness;
4 = Patient only expresses these feelings both spontaneously and nonverbally.
2
Guilt
0 = not available;
1 = self-deprecation; believes he let others down;
2 = self-guilt or agonizing thoughts about past mistakes or sins;
3 = present illness is regarded as a punishment; delusional ideas of
guilt;
4 = verbal hallucinations of accusing and condemning content and/or
visual hallucinations of threatening content.
3
Suicidal Intentions
0 = not available;
1 = feeling that life is not worth living,
2 = desire for death or any thoughts about the possibility of one's own
death;
3 = suicidal statements or gestures;
4 = suicidal attempts (any serious attempt is scored as a “4”)
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