Can the 'head-turning sign' be a clinical marker of Alzheimer's disease?

"Don't know" sign: description and evaluation of its diagnostic accuracy for cognitive impairment

OBJECTIVES

Patients in neurology clinics are sometimes not aware of the reason for the consultation, and we have called this circumstance the "Don't know" sign (DKS). Our objective was to define this new sign and its modalities and to evaluate its prevalence and its diagnostic accuracy for cognitive impairment (CI) in comparison to other observation-based signs.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional prospective study included all new outpatients evaluated by the authors at neurology consultation.

MEASUREMENTS

We recorded observation-based signs. The Global Deterioration Scale (GDS) was used to assess the cognitive status of patients, based on clinical history, caregiver interview, and cognitive test results. We analyzed the prevalence and the diagnostic accuracy for CI of DKS, "head turning sign," "attending with," verbal repetition, and combinations, calculating sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

We enrolled 673 consecutive patients (62% female) with a mean ± SD age of 59.3 ± 20.2 years. DKS was positive in 94 patients (14%) and was strongly associated with GDS score. DKS had a Se of 0.41, Sp of 0.98, PPV of 0.89, and NPV of 0.79 for CI diagnosis. The presence of at least two positive observation signs yielded a Se of 0.50, Sp of 0.97, PPV of 0.86, and NPV of 0.81.

CONCLUSIONS

DKS is frequently observed in neurology outpatients. It has low sensitivity but high specificity and PPV for CI diagnosis. It does not require additional consultation time, and its use can be recommended in combination with other observation-based signs.

Suspecting dementia: canaries, chameleons and zebras

The early and accurate diagnosis of dementia is more important than ever before but remains challenging. Dementia is increasingly the business of neurologists and, with ageing populations worldwide, will become even more so in future. Here we outline a practical, symptom-led, bedside approach to suspecting dementia and its likely diagnosis, inspired by clinical experience and based on recognition of characteristic syndromic patterns. We show how clinical intuition reflects underlying signature profiles of brain involvement by the diseases that cause dementia and suggest next steps that can be taken to define the diagnosis. We propose 'canaries' that provide an early warning signal of emerging dementia and highlight the 'chameleons' that disguise or mimic this, as well as the 'zebras' that herald a rare (and sometimes curable) diagnostic opportunity.

"Sometimes it feels like thinking in syrup" - the experience of losing sense of self in those with young onset dementia

Purpose: To explore and describe the experience of people having young-onset dementia.Methods: This was a qualitative study that used semi-structured interviews to collect data from nine persons with young-onset dementia (aged 47-65; five men and four women). Data were collected in the spring of 2018. All interviews were conducted at the participants' choice and in their own homes by one interviewer. The collected data were analysed using the six-stage process of reflexive thematic analysis model.Results: The analysis revealed three themes: Dementia causing loss of control over oneself; becoming a burden to the family while sense of self disappears; and fearing a humiliating future.Conclusions: The experience of having and living with young onset dementia affected the persons' thoughts and memory and was experienced through the persons' loss of personality and sense of self. Thoughts about the future were associated with fear, and the risk of changing their personalities to something different from the one which they had experienced as humiliating throughout most of their lives.

The utility of simple questions to evaluate cognitive impairment

Objectives

As the population of patients with cognitive decline grows, physicians and caregivers need brief screening tools. Comprehensive neurocognitive batteries require special training and time for evaluation. We focused on accessibility and compared the diagnostic power of several easy questions.

Design

“Attended With” (AW) and “Head-Turning Sign” (HTS) factors and participants’ replies to following questions were recorded: “Do you feel that you have more difficulties in your daily life than you used to?”, [no consciousness (C-) or consciousness+ (C+)], “Could you tell me about your daily pleasures or pastimes?” [no pleasure (P-) or pleasure + (P+)], “What are notable current/recent news/topics?” [no news (N-) or news+ (N+)].

Setting

This took place in our Memory Clinic between May 2016 and July 2019.

Participants

We enrolled 162 consecutive cases (44 cognitive normal (CN), 55 amnestic mild cognitive impairment (aMCI), and 48 Alzheimer’s disease (AD)).

Measurements

The sensitivity and specificity of each battery were calculated, and on account of those numbers, the population attributable risk percent % (PAR%) of (AW and HTS+), (C- and P-), (C- and N-), (P- and N-) as analysis of combination of questions, respectively, were calculated.

Results

AW had high sensitivity, 87.4, 95.8% (CN vs aMCI + AD, CN + aMCI vs AD) but the sensitivity of HTS was only 46.4, 57.7%, and HTS showed high specificity, 100.0, 71.8%. C- had high sensitivity, 80.6, 87.5%, whereas P- and N- had high specificity, both 83.9% in CN vs aMCI + AD, 88.1% and 75.9% in CN + aMCI vs AD, respectively. In combination analysis, the PAR% of (C- and N-) were as high as (AW and HTS+).

Conclusions

The combination of (C- and N-) is as powerful as (AW and HTS+) in screening AD. Our findings provide novel insights for screening utility of brief questions “Consciousness of Impairment” and “Recent News.”

Triple Test Plus Rapid Cognitive Screening Test: A Combination of Clinical Signs and A Tool for Cognitive Assessment in Older Adults

Less time-consuming, easy-to-apply and more reliable cognitive screening tests are essential for use in primary care. The aim of this study was to investigate the diagnostic value of the Turkish version of the Rapid Cognitive Screen (RCS-T) and Triple Test individually and the combination of RCS-T with each sign and Triple Test to screen elderly patients for cognitive impairment (CI). A total of 357 outpatients aged 60 or older, who underwent comprehensive geriatric assessment, were included in the study. Presence or absence of attended alone sign (AAS), head-turning sign, and applause sign was investigated. The mean age of the patients was 74.29 ± 7.46. Of those, 61 patients (28 men, 33 women) had Alzheimer’s disease (AD), 59 patients had mild cognitive impairment (MCI) (29 men, 30 women), and 237 (80 men, 157 women) were cognitively robust. The sensitivity of the combination of RCS-T and negative for AAS for CI, AD and MCI is 0.79, 0.86 and 0.61, respectively; the specificity was 0.92, 0.93 and 0.92, respectively; and the positive and negative predictive values revealed good diagnostic accuracy. The combination of RCS-T and negative for AAS is a simple, effective and rapid way to identify possible CI in older adults.

Factors affecting sensitivity and specificity of head-turning sign in the studies

We read with interest the comment by Williamson and Larner on our recent study titled "Attended With and Head-Turning Sign can be clinical markers of cognitive impairment in older adults" (Soysal et al., 2017). After the authors read the study, they re-examined their data according to the presence of Attended With (AW) and Head-Turning Sign (HTS), and compared their results with ours (Larner, 2014). Then, they found that while the sensitivity, specificity, positive predictive value, and negative predictive value of AW in detecting cognitive impairment were similar to ours, HTS had lower sensitivity (80.95% vs. 65.0%) and higher specificity (64.7% vs. 95.0%) than our results (Larner, 2014; Soysal et al., 2017). We think that some methodological and cultural differences may explain these discrepancies between the two.

Are saving appearance responses typical communication patterns in Alzheimer's disease?

INTRODUCTION

To keep up appearances, people with dementia sometimes pretend to know the correct answer, as seen during administration of neuropsychological tests such as the Mini-Mental State Examination (MMSE). These saving appearance responses (SARs) of people with dementia often lead to caregivers and/or medical staff underestimating the severity of dementia and impede proper early initiation of treatment. However, most descriptions of SARs are based on empirical knowledge of clinicians. In this study, we investigated whether SARs are typical communication patterns in people with Alzheimer's disease (AD), compared with mild cognitive impairment (MCI) or dementia with Lewy bodies (DLB).

METHODS

The participants were 107 outpatients with AD, 16 with mixed AD with cerebrovascular dementia, 55 with MCI, and 30 with DLB. We assessed the occurrence of SARs during the MMSE. The relationships between the SARs and AD were examined by the χ2 test and logistic regression analysis.

RESULTS

People with AD who showed SARs were 57.9%, whereas those with MCI were 18.2% and DLB were 20.0% (P with Bonferroni correction < 0.05). Although there were significant differences in some variables in each group of diagnosis, logistic regression analysis showed that people with AD were more likely to show SARs than those with MCI (Odds ratio = 3.48, 95% Confidential Interval = 1.18-10.28) and DLB (Odds ratio = 4.24, 95% Confidential Interval = 1.50-12.01), even after controlling for sex, estimated disease duration, MMSE, and frontal assessment battery scores.

CONCLUSION

The occurrence of SARs could be found most frequently in people with AD. Clinicians should develop a respectful attitude toward dementia patients with SARs because SARs imply conflicted feelings about questions that patients cannot answer correctly.

Triple test, a diagnostic observation, can detect cognitive impairment in older adults

BACKGROUND

A simple, quick, and efficient screening tool for detecting mild cognitive impairment (MCI) and Alzheimer's disease (AD) is essential, especially in the primary care setting. In this study, we examined the neuropsychological profiles of elderly patients and aimed to assess the diagnostic value of the triple test, comprised of the attended alone sign (AAS), head-turning sign, and applause sign (AS), for detecting MCI and AD.

METHOD

Comprehensive geriatric assessment was performed in 354 elderly outpatients, and the presence or absence of AS, AAS and HTS was investigated.

RESULTS

Of the 354 patients, 93 patients were considered to be cognitively impaired (MCI: 30; AD: 63); the remaining 261 were cognitively healthy. Relative to those without AS, patients with AS had significantly lower scores on the Mini-Mental State Examination, the clock-drawing test, Instrumental Activities of Daily Living Scale, and Basic Activities of Daily Living Scale (P < 0.001, for each). Similar significant differences were found between patients who were positive and negative for the HTS (P < 0.001) and between those who attended the clinic alone and those who were accompanied (P < 0.001). The sensitivity of the triple test for identifying cognitively impairment (CI), MCI, and AD was 0.61, 0.30, and 0.72, respectively; the specificity was 0.85, 0.68, and 0.83, respectively; and the positive and negative predictive values were 0.69, 0.09, and 0.59, respectively, and 0.79, 0.90, and 0.89, respectively.

CONCLUSIONS

The present study suggests that the triple test is a simple, quick, and efficient screening tool for detecting cognitive impairment, and the results may reflect deterioration in patients' activities of daily living. Additionally, it could be advantageous in clinical practice because educational level does not affect the test outcome. Therefore, it may be an appropriate test to screen for cognitive impairment in the elderly, both as a bedside diagnostic test and in daily clinical practice, especially in the primary care setting.

Identifying patterns of communication in patients attending memory clinics: a systematic review of observations and signs with potential diagnostic utility

BACKGROUND

Subjective cognitive complaints are commonly encountered in primary care and often result in memory clinic referral. However, meta-analyses have shown that such concerns do not consistently correspond to objective memory impairment or predict future dementia. Memory clinic referrals are increasing, with greater proportions of patients attending who do not have dementia. Studies of interaction during memory clinic assessments have identified conversational profiles that can differentiate between dementia and functional disorders of memory. To date, studies exploring communication patterns for the purpose of diagnosis have not been reviewed. Such profiles could reduce unnecessary investigations in patients without dementia.

AIM

To identify and collate signs and observable features of communication, which could clinically differentiate between dementia and functional disorders of memory.

DESIGN AND SETTING

This was a systematic review and synthesis of evidence from studies with heterogeneous methodologies.

METHOD

A qualitative, narrative description and typical memory clinic assessment were employed as a framework.

RESULTS

Sixteen studies met the criteria for selection. Two overarching themes emerged: 1) observable clues to incapacity and cognitive impairment during routine assessment and interaction, and 2) strategies and accounts for loss of abilities in people with dementia.

CONCLUSION

Whether the patient attends with a companion, how they participate, give autobiographical history, demonstrate working memory, and make qualitative observations during routine cognitive testing are all useful in building a diagnostic picture. Future studies should explore these phenomena in larger populations, over longer periods, include dementia subtypes, and develop robust definitions of functional memory disorders to facilitate comparison.

Attended With and Head-Turning Sign can be clinical markers of cognitive impairment in older adults

BACKGROUND

Comprehensive neurocognitive assessment may not be performed in clinical practice, as it takes too much time and requires special training. Development of easily applicable, time-saving, and cost effective screening methods has allowed identifying the individuals that require further evaluation. The aim of present study was to assess the diagnostic value of the Attended With (AW) and Head-Turning Sign (HTS) for screening cognitive impairment (CI).

METHODS

Comprehensive geriatric assessment was performed in 529 elderly outpatients, and the presence or absence of AW and HTS was investigated in them all.

RESULTS

Of the 529 patients, of whom the mean age was 75.67 ± 8.29 years, 126 patients were considered as CI (102 dementia, 24 mild CI). The patients with positive AW had significantly lower scores on Mini-Mental State Examination, Cognitive State Test, and Montreal Cognitive Assessment, and activities of daily living compared to AW (-) patients (p < 0.001). Similar significant findings were obtained in the patients with positive and negative HTS (p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of AW in detecting CI were 92%, 37%, 31.4%, and 93.7%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of HTS were 80%, 64%, 41.8%, and 91.5%, respectively. The area under the receiver-operating characteristics curve was 0.90 for AW and 0.82 for HTS.

CONCLUSION

AW and HTS are fast, simple, effective, and sensitive methods for detecting CI. Therefore, they can be used for older adults attending the primary care settings with memory loss. Those with positive AW or HTS can be referred to the relevant centers for detailed cognitive assessment.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia.

METHODS

A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm.

RESULTS

We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management.

CONCLUSIONS

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Conversational assessment in memory clinic encounters: interactional profiling for differentiating dementia from functional memory disorders

OBJECTIVES

In the UK dementia is under-diagnosed, there is limited access to specialist memory clinics, and many of the patients referred to such clinics are ultimately found to have functional (non-progressive) memory disorders (FMD), rather than a neurodegenerative disorder. Government initiatives on 'timely diagnosis' aim to improve the rate and quality of diagnosis for those with dementia. This study seeks to improve the screening and diagnostic process by analysing communication between clinicians and patients during initial specialist clinic visits. Establishing differential conversational profiles could help the timely differential diagnosis of memory complaints.

METHOD

This study is based on video- and audio recordings of 25 initial consultations between neurologists and patients referred to a UK memory clinic. Conversation analysis was used to explore recurrent communicative practices associated with each diagnostic group.

RESULTS

Two discrete conversational profiles began to emerge, to help differentiate between patients with dementia and functional memory complaints, based on (1) whether the patient is able to answer questions about personal information; (2) whether they can display working memory in interaction; (3) whether they are able to respond to compound questions; (4) the time taken to respond to questions; and (5) the level of detail they offer when providing an account of their memory failure experiences.

CONCLUSION

The distinctive conversational profiles observed in patients with functional memory complaints on the one hand and neurodegenerative memory conditions on the other suggest that conversational profiling can support the differential diagnosis of functional and neurodegenerative memory disorders.

The role of companions in outpatient seizure clinic interactions: A pilot study

PURPOSE

This study explored contributions that patients' companions (seizure witnesses) make to interactions in the seizure clinic and whether the nature of the companions' interactional contributions can help with the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES).

METHODS

Conversation analysis methods were used to examine video recordings and transcripts of neurologists' interactions with patients referred to a specialist seizure clinic and their companions.

RESULTS

The companions' behavior correlated with interactional features previously observed to distinguish patients with epilepsy from patients with PNES. Patients with PNES, but not those with epilepsy, tended to exhibit interactional resistance to the doctor's efforts to find out more about their seizure experiences and, thereby, encouraged greater interactional contribution from companions.

CONCLUSION

The contributions that companions make (in part, prompted by patient's interactional behavior) may provide additional diagnostic pointers in this clinical setting, and a number of candidate features that may help clinicians distinguish between epilepsy and PNES when the patient is accompanied by a seizure witness are described. However, companion contributions may limit the doctor's ability to identify linguistic and interactional features with previously demonstrated diagnostic potential in the conversational contributions made by patients themselves. To help offset potential diagnostic losses, doctors may need to explicitly discuss the role of the companion in the consultation when a seizure witness (or another companion) accompanies the patient.

Towards diagnostic conversational profiles of patients presenting with dementia or functional memory disorders to memory clinics

OBJECTIVE

This study explores whether the profile of patients' interactional behaviour in memory clinic conversations with a doctor can contribute to the clinical differentiation between functional memory disorders (FMD) and memory problems related to neurodegenerative diseases.

METHODS

Conversation Analysis of video recordings of neurologists' interactions with patients attending a specialist memory clinic. "Gold standard" diagnoses were made independently of CA findings by a multi-disciplinary team based on clinical assessment, neuropsychological testing and brain imaging.

RESULTS

Two discrete conversational profiles for patients with memory complaints emerged, including (i) who attends the clinic (i.e., whether or not patients are accompanied), and (ii) patients' responses to neurologists' questions about memory problems, such as difficulties with compound questions and providing specific and elaborated examples and frequent "I don't know" responses.

CONCLUSION

Specific communicative difficulties are characteristic of the interaction patterns of patients with a neurodegenerative pathology. Those difficulties are manifest in memory clinic interactions with neurologists, thereby helping to differentiate patients with dementia from those with FMD.

PRACTICAL IMPLICATIONS

Our findings demonstrate that conversational profiles based on patients' contributions to memory clinic encounters have diagnostic potential to assist the screening and referral process from primary care, and the diagnostic service in secondary care.