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Balestrino M, Brugnolo A, Girtler N, Pardini M, Rizzetto C, Alì PA, Cocito L, Schiavetti I. Cognitive impairment assessment through handwriting (COGITAT) score: a novel tool that predicts cognitive state from handwriting for forensic and clinical applications. Front Psychol 2024; 15:1275315. [PMID: 38605845 PMCID: PMC11007210 DOI: 10.3389/fpsyg.2024.1275315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/26/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction Handwriting deteriorates proportionally to the writer's cognitive state. Such knowledge is of special importance in the case of a contested will, where dementia of the testator is claimed, but medical records are often insufficient to decide what the testator's cognitive state really was. By contrast, if the will is handwritten, handwriting analysis allows us to gauge the testator's cognitive state at the precise moment when he/she was writing the will. However, quantitative methods are needed to precisely evaluate whether the writer's cognitive state was normal or not. We aim to provide a test that quantifies handwriting deterioration to gauge a writer's cognitive state. Methods We consecutively enrolled patients who came for the evaluation of cognitive impairment at the Outpatient Clinic for Cognitive Impairment of the Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI) of the University of Genoa, Italy. Additionally, we enrolled their caregivers. We asked them to write a short text by hand, and we administered the Mini Mental State Examination (MMSE). Then, we investigated which handwriting parameters correlated with cognitive state as gauged by the MMSE. Results Our study found that a single score, which we called the COGnitive Impairment Through hAndwriTing (COGITAT) score, reliably allows us to predict the writer's cognitive state. Conclusion The COGITAT score may be a valuable tool to gage the cognitive state of the author of a manuscript. This score may be especially useful in contested handwritten wills, where clinical examination of the writer is precluded.
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Affiliation(s)
- Maurizio Balestrino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Brugnolo
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicola Girtler
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Pardini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cristiano Rizzetto
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Paolo Alessandro Alì
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Leonardo Cocito
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Irene Schiavetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Preti AN, Diana L, Castaldo R, Pischedda F, Difonzo T, Fumagalli G, Arighi A, Sartori G, Zago S, Bolognini N. Does cognitive decline influence signing? Aging Clin Exp Res 2023; 35:2685-2691. [PMID: 37661205 PMCID: PMC10627958 DOI: 10.1007/s40520-023-02523-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/28/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE The study explored the change in handwritten signature in neurodegenerative diseases by using of a rater-based approach. METHODS Four independent observers were required to compare a pair of signatures (on average, 5 years elapsed between the two signatures) made by 103 patients (mean age 72 years) with Alzheimer's disease (AD) or frontotemporal dementia (FTD) and by 31 healthy participants (HC; mean age 73 years), judging their change according to a 0-1 rating scale (0 = similar or 1 = different). If a signature change was detected, the rater had also to report which signature features (spatial layout, omitted/added/switched letters or names, shape of letter, pen-flow) changed on the same 0-1 scale. For the AD and FTD groups, one signature was collected prior to the diagnosis of dementia, the other subsequent. RESULTS A signature change was reported by raters in 36% of AD patients, 44% of FTD, and 17% of HC, with significant differences between both clinical groups and HC (vs. AD, p = .01; vs. FTD, p = .001). There was not a distinctive marker of the signature change (i.e., feature change) in patients with dementia. Moreover, the signature changes in neurological patients were unrelated to their clinical and demographic characteristics (age, sex, education, time elapsed between the two signatures, Mini-mental State Examination score). CONCLUSION The findings suggest a resistance of handwritten signature in neurodegenerative diseases and in physiological aging, also suggesting that the signature may be an unreliable indicator of the cognitive status in AD and FTD, at least if subjectively evaluated.
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Affiliation(s)
- Alice Naomi Preti
- School of Medicine and Surgery, PhD Program in Neuroscience, University of Milano-Bicocca, Monza, Italy.
| | - Lorenzo Diana
- Neuropsychology Laboratory, Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Rita Castaldo
- Neurology Unit, Foundation IRCCS Ca' Granda Hospital Maggiore Policlinico, Milan, Italy
| | - Francesca Pischedda
- Neuropsychology Laboratory, Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Teresa Difonzo
- Neurology Unit, Foundation IRCCS Ca' Granda Hospital Maggiore Policlinico, Milan, Italy
| | - Giorgio Fumagalli
- Center for Mind/Brain Sciences-CIMeC, University of Trento, Rovereto, Italy
| | - Andrea Arighi
- Neurology Unit, Foundation IRCCS Ca' Granda Hospital Maggiore Policlinico, Milan, Italy
| | - Giuseppe Sartori
- Department of General Psychology, University of Padova, Padua, Italy
| | - Stefano Zago
- Neurology Unit, Foundation IRCCS Ca' Granda Hospital Maggiore Policlinico, Milan, Italy.
| | - Nadia Bolognini
- Neuropsychology Laboratory, Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
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Fernandes CP, Montalvo G, Caligiuri M, Pertsinakis M, Guimarães J. Handwriting Changes in Alzheimer's Disease: A Systematic Review. J Alzheimers Dis 2023; 96:1-11. [PMID: 37718808 DOI: 10.3233/jad-230438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Handwriting is a complex process involving fine motor skills, kinesthetic components, and several cognitive domains, often impaired by Alzheimer's disease (AD). OBJECTIVE Provide a systematic review of handwriting changes in AD, highlighting the effects on motor, visuospatial and linguistic features, and to identify new research topics. METHODS A search was conducted on PubMed, Scopus, and Web of Science to identify studies on AD and handwriting. The review followed PRISMA norms and analyzed 91 articles after screening and final selection. RESULTS Handwriting is impaired at all levels of the motor-cognitive hierarchy in AD, particularly in text, with higher preservation of signatures. Visuospatial and linguistic features were more affected. Established findings for motor features included higher variability in AD signatures, higher in-air/on-surface time ratio and longer duration in text, longer start time/reaction time, and lower fluency. There were conflicting findings for pressure and velocity in motor features, as well as size, legibility, and pen lifts in general features. For linguistic features, findings were contradictory for error patterns, as well as the association between agraphia and severity of cognitive deficits. CONCLUSIONS Further re-evaluation studies are needed to clarify the divergent results on motor, general, and linguistic features. There is also a lack of research on the influence of AD on signatures and the effect of AD variants on handwriting. Such research would have an impact on clinical management (e.g., for early detection and patient follow-up using handwriting tasks), or forensic examination aimed at signatory identification.
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Affiliation(s)
- Carina Pereira Fernandes
- NCForenses Institute, Porto, Portugal
- Instituto Universitario de Investigación en Ciencias Policiales (IUICP), Universidad de Alcalá, Alcalá de Henares, Spain
| | - Gemma Montalvo
- Instituto Universitario de Investigación en Ciencias Policiales (IUICP), Universidad de Alcalá, Alcalá de Henares, Spain
- Universidad de Alcalá, Departamento de Química Analítica, Química Física e Ingeniería Química, Alcalá de Henares, Spain
| | - Michael Caligiuri
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Michael Pertsinakis
- Ingeniería Química, Alcalá de Henares, Spain
- City Unity College, Athens, Greece
| | - Joana Guimarães
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
- MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
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Online Handwriting, Signature and Touch Dynamics: Tasks and Potential Applications in the Field of Security and Health. Cognit Comput 2021. [DOI: 10.1007/s12559-021-09938-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Zago S, Bolognini N. Neuropsychological autopsy of testamentary capacity: Methodology and issues in the elderly. APPLIED NEUROPSYCHOLOGY-ADULT 2020; 29:570-583. [PMID: 32687452 DOI: 10.1080/23279095.2020.1791869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The forensic assessment of testamentary capacity is a topical issue given the prevalence of dementia illnesses and the increase in the complexity of modern financial and family structures. Although a contemporaneous assessment would be desirable, the majority of situations require a retrospective assessment of the mental state a deceased individual. Neuropsychologists, independently or as part of a board of consultants, are, therefore, frequently requested to give an expert opinion of the competence of cognitively impaired elderly testators.This paper offers a guide for carrying out a neuropsychological autopsy, namely the process of posthumous evaluation, for determining testamentary capacity. Taking into account the recent literature on the assessment of testamentary capacity, we propose a three-phase procedure for carrying out the neuropsychological autopsy in the forensic context. The neuropsychological autopsy of testamentary capacity is based on the meticulous, chronologically structured evaluation of any medical documents, available psychometric data, along with the critical examination of any source of information about the cognitive level of functioning of the deceased person at the time of the will.
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Affiliation(s)
- Stefano Zago
- U.O.C. di Neurologia, IRCCS Fondazione Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Nadia Bolognini
- Dipartimento di Psicologia, Università degli Studi Milano-Bicocca di Milano, Milano, Italy.,Neuropsychological Laboratory, IRCCS Istituto Auxologico Italiano, Milano, Italy
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Dynamic Handwriting Analysis for Neurodegenerative Disease Assessment: A Literary Review. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9214666] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Studying the effects of neurodegeneration on handwriting has emerged as an interdisciplinary research topic and has attracted considerable interest from psychologists to neuroscientists and from physicians to computer scientists. The complexity of handwriting, in fact, appears to be sensitive to age-related impairments in cognitive functioning; thus, analyzing handwriting in elderly people may facilitate the diagnosis and monitoring of these impairments. A large body of knowledge has been collected in the last thirty years thanks to the advent of new technologies which allow researchers to investigate not only the static characteristics of handwriting but also especially the dynamic aspects of the handwriting process. The present paper aims at providing an overview of the most relevant literature investigating the application of dynamic handwriting analysis in neurodegenerative disease assessment. The focus, in particular, is on Parkinon’s disease (PD) and Alzheimer’s disease (AD), as the two most widespread neurodegenerative disorders. More specifically, the studies taken into account are grouped in accordance with three main research questions: disease insight, disease monitoring, and disease diagnosis. The net result is that dynamic handwriting analysis is a powerful, noninvasive, and low-cost tool for real-time diagnosis and follow-up of PD and AD. In conclusion of the paper, open issues still demanding further research are highlighted.
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An Experimental Protocol to Support Cognitive Impairment Diagnosis by using Handwriting Analysis. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.procs.2018.10.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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