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Journal of Clinical and Experimental Neuropsychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ncen19
Object-memory evaluation for prospective detection of dementia in normal functioning elderly: Predictive and normative data a
a
a
Paula A. Fuld , David M. Masur , Alan D. Blau , a
Howard Crystal & Miriam K. Aronson
a
a
Albert Einstein College of Medicine , Published online: 04 Jan 2008.
To cite this article: Paula A. Fuld , David M. Masur , Alan D. Blau , Howard Crystal & Miriam K. Aronson (1990) Object-memory evaluation for prospective detection of dementia in normal functioning elderly: Predictive and normative data, Journal of Clinical and Experimental Neuropsychology, 12:4, 520-528, DOI: 10.1080/01688639008400998 To link to this article: http://dx.doi.org/10.1080/01688639008400998
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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Journal of Clinicat and Experimental Neuropsychology 1990, Vol. 12, NO.4, pp. 520-528
0168-8634/90/1204-05u)$3.00 Q Swets L Zeitlinger
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
Object-Memory Evaluation for Prospective Detection of Dementia in Normal Functioning Elderly: Predictive and Normative Data* Paula A. Fuld, David M. Masur, Alan D. Blau. Howard Crystal, and Miriam K. Aronson Albert Einstein College of Medicine
ABSTRACT In a prospective study of dementia in initially normal functioning elderly, a brief form of the Fuld Object- Memory Evaluation (OM) was administered to 474cognitively normal community-residing volunteers aged 75-85at baseline and annually thereafter. Seventy-two subjects later became demented. Memory test data from the last annual evaluation before cognitive change was noted were available for 56. Although the entire population recalled 7.28 (SO = 1.33) of the 10 objects on Trial 1 of the test at baseline, these 56 subjects recalled only 5.96 (SO = 1.85). When recall of 6 or fewer objects was used as a predictor, the OM test identified 32 of the 56 who subsequently became demented. Compared to an estimated base rate of 15% for dementia, the predictive value of a positive test (PV+) was 39%. and that of a negative test (PV-) was 89%. With a cutoff of 5 or fewer items recalled, the PV+ rose to 59% and the PV-was 94%. Although the OM test was only moderately sensitive to incipient dementia (.57), it was fairly specific (34). and lowering the cutoff to 5 increased the specificity to .96. Memory testing would therefore seem to hold promise as a predictor of dementia in cognitively normal elderly,
Several studies recently have suggested the possibility of preclinical identification of elderly individuals likely to become demented (Berg et al., 1984; Branconnier, Cole, Spera. & DeVitt, 1982; Eslinger, Damasio, Benton, & Van Allen, 1985; Storandt et al., 1984). Given the prominence of memory impairment in the clinical picture of Alzheimer-type dementia (ATD) (Coblentz et al., 1973; Sim & Sussman, 1962), it is not surprising that these studies all found memory test scores to be among the best predictors of further cognitive decline in demented individuals. None of these studies were prospective in nature and did not predict
* This research was supported in part by NINCDS Grant #5P01 NS19234-04. Address correspondence to Dr. Paula A. Fuld, Clinical and Consulting Associates, 5435 Balboa Blvd. #208. Enckro, CA 91316,USA. Accepted for publication: July 26, 1989.
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
PREDICTING DEMENTIA
521
the development of dementia in specific individuals who were functioning normally and who had not yet come to clinical attention for dementia evaluation. In a study of individuals aged 75 to 85 who were considered normal when tested, Fuld, Dickson, Crystal, and Aronson (1987) found a remarkably high correlation (-.83) between subjects’ performance on the Fuld Object-Memory Evaluation (Fuld, 1980; 1981) and the number of primitive senile plaques later seen in their brains after death. This correlation suggested that the prospective detection of dementia in individuals might be possible. The present study investigated prospectively the preclinical detection of dementia in elderly individuals who had normal mental status a t baseline. The study demonstrates that the Fuld Object-Memory Evaluation has substantial predictive (and discriminative) validity for this purpose and also presents new normative data for the 75-85-year-old age group. A parallel study (Masur, Fuld, Blau, Crystal, & Aronson, 1990) shows that the Selective Reminding test (Buschke & Fuld, 1974) has approximately equivalent characteristics, although this test is most useful in different clinical and research situations from the Fuld Object-Memory Evaluation (OM). METHOD Memory testing for the present studies was done in the context of a prospective study of risk-factors in the development of dementia (Katzman et al., 1989).
Subjects Subjects in this study were volunteers, aged 75-85 (M= 79.3), who initially made no more than eight errors on the Blessed mental status test (Blessed, Tomlinson, & Roth, 1968) and were considered normal, following the criteria suggested by Fuld (1 978). They received annual neuropsychological and neurological examinations, including appropriate blood tests. A CT scan and an EEG were also done when subjects were suspected of having had a change in mental status from the previous evaluation (for this purpose, a change was defined as an increase of 4 or more points on the Blessed mental status test). Subjects who evidenced significant declines in cognitive as well as social functioning received a research diagnosis of dementia based on DSM-111-R criteria (APA, 1987). Those subjects who could be classified as having probable Alzheimer-Type Dementia received that diagnosis according to the criteria explicated by McKhann et al. (1984). Subjects were predominantly Caucasian, had a modal education o f 7-9 years, and were slightly above average in intelligence. About half were native-born and the rest were predominantly of eastern European origin. Two-thirds were female. These and other demographic characteristics are summarized in Table 1. (A more detailed description of the subjects is available in Katzman et al., 1989). For the purpose of the present studies, the subjects were divided into two groups. The normal group consisted of individuals who did not change during the study (n=418). In the subsequently demented group were individuals who ultimately received research diagnoses of dementia and for whom memory test scores were available for at least one testing occasion before any change had been noted (n=56). This testing occasion had occurred an average of 489 days before the date of diagnosis (range 234-728 days). Subjects were tested individually by examiners experienced in evaluating aged and/or dementing individuals.
522
PAULA A. FULD ET AL.
Table 1. Demographic Characteristics of Subject Samples Who Received Object Memory Test (Numbers Reflect Percent of Sample) Normal (Baseline n=418)
Subsequently Demented (n=56)
64.5% 35.5
67.2% 32.8
Race White Black and Other
90.4 9.6
93.1 6.9
Place of Birth Europe England and Ireland USA
42.8 6.2 45.6
52.6 8.8 31.6
Other
5.4
7.0
Religion Jewish Catholic Protestant Other
57.7 24.9 14.2 3.2
62.2 29.3 7.0 1.7
Education Less than 9 10 - 12 Greater than 12 Other
53.0 23.8 19.4 3.8
66.1 16.1 14.3 3.5
Mean Age (Yrs.)
79.3 (3.05)
82.1 (3.16)(*)
Sex
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
Female Male
(*)
Age at time of preclinical test, which occurred an average of 1.3 years before diagnosis, but often occurred sometime after baseline evaluation.
Measures As part of the annual neuropsychological evaluation, each subject was given an abbreviated version of the Fuld Object-Memory Evaluation (OM). Administration followed the directions in the test manual (Fuld, 1980; 1981). except that only two 1earningJrecall trials were given. The second trial included multiple-choice recognition testing for any items the subject had not recalled on that trial. This provided scores for each of the two recalls, as well as a score on combined recall-plus-recognition for Trial 2.
Procedure The abbreviated OM uses a modification of the Selective Reminding Procedure (Buschke. 1973) in which 10 common objects are presented in a bag for tactile naming, followed by visual naming, if necessary, to guarantee stimulus-processing. After each object is named,
523
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
PREDICTING DEMENTIA
60 s of distraction is introduced by having the subject say given names (same gender as subject) as quickly as possible. This is followed by 60 s during which the subject attempts to recall all 10 objects, (Recall 1) with encouragement to keep trying even when recall becomes difficult. After this, the subject is reminded verbally of each item s h e omitted and is distracted again, before the final delayed recall (Recall 2) and recognition task. For the present study, the second distraction period was 10 min of continued structured interviewing. To determine what cutoff scores should be used for predictive value analysis, data were examined from 112 subjects in the original sample who had made no more than two errors on the Blessed test for each of two consecutive years. These subjects recalled an average of 7.68 of the 10 common objects on Trial 1 of the OM (SO = 1.08), with none of these stable, unimpaired subjects having recalled fewer than six objects. Based upon this data, we chose to look at the utility of the OM test for the prediction of dementia assuming a cutoff of six objects recalled. We also employed a more stringent cutoff of five objects in order to provide a broader comparison of test sensitivity and specificity. These were obtained by tallying the number of cognitively normal subjects who fell above and below the assigned cutoff scores, and comparing this to the distribution observed with the subjects who eventually became demented, Table 2 illustrates the distribution of both groups of subjects as a function of the cutoff scores. The a priori predictive value of the abbrievated OM Test was calculated through the use of Bayesian analysis (Branconnier et al., 1982; Stilson, 1966). Positive predictive value (PV+) is the probability of having a dementia if the OM test score falls below the cutoff score. Negative predictive value (PV-) represents the probability of the absence of dementia given a test score that is above the cutoff. The predictive value analyses were carried out assuming a base rate of 15 percent for the prevalence of dementia in this population (Katchaturian, 1985).
Table 2. Number of Subjects Above and Below the Cut-off scores for Each Measure of Object-Memory Evaluation Nondemented (n=418)* Subsequently Demented (n=56) Number Above Cutoff Score Cutoff
Measure RECALL 1 RECALL 2 RECALL 1 RECALL 2 RECALL + RECOG.
*
26 1 6 55 1 5
59
353 360 400 374 388
Number Below Cutoff
Number Above Cutoff
Number Below Cutoff
65 29 18 15 0
24 34 36 40 44
32 20 20 14 9
Subjects who eventually became demented were removed for the purposes of predictive value analysis.
524
PAULA A. FULD ET AL.
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
RESULTS
Norms for the Abbreviated Fuld Object-Memory Evaluation Normative data for the abbreviated form of the OM is presented in Table 3. This is based on test scores obtained at initial entry into the study and thus includes data from all subjects in the original sample. These 474 75- to 85-year-old subjects, on the average, recalled 7.28 objects on the first trial (SD = 1.32) and 7.74 (SD = 1.37) on the second. They recalled 3r recognized virtually all 10 objects. Intrusions into recall could not be analyzed for this study because of limitations in coding done during the initial phase of the study. The discriminative validity of the OM test was examined by looking at the ability of the test to distinguish normal from dementing individuals at the time of diagnosis. Recall 1 demonstrated a sensitivity of .86, and a specificity of 32, thus indicating that one trial of recall on the OM Test is capable of discritninating between normal functioning and very early dementia in better than 8 out of 10 cases. The reliability of the longer version of the OM test has been reported elsewhere (Fuld. Muramoto, Blau, Westbrook, & Katzman, 1988) and was not investigated in the present study. However, the reliability of the single trial version is adequate to support the validity data presented here. As Table 3 shows, individuals who later became demented performed significantly less well on each OM measure, although in practical terms, differences were not dramatic (e.g. typical recall of 5 or 6, rather than 7 objects on the first trial). Thus, those individuals who later became demented typically recalled only 5.96 items on the first trial (SD=l.85, t=6.70, p
Journal of Clinical and Experimental Neuropsychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ncen19
Object-memory evaluation for prospective detection of dementia in normal functioning elderly: Predictive and normative data a
a
a
Paula A. Fuld , David M. Masur , Alan D. Blau , a
Howard Crystal & Miriam K. Aronson
a
a
Albert Einstein College of Medicine , Published online: 04 Jan 2008.
To cite this article: Paula A. Fuld , David M. Masur , Alan D. Blau , Howard Crystal & Miriam K. Aronson (1990) Object-memory evaluation for prospective detection of dementia in normal functioning elderly: Predictive and normative data, Journal of Clinical and Experimental Neuropsychology, 12:4, 520-528, DOI: 10.1080/01688639008400998 To link to this article: http://dx.doi.org/10.1080/01688639008400998
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Clinicat and Experimental Neuropsychology 1990, Vol. 12, NO.4, pp. 520-528
0168-8634/90/1204-05u)$3.00 Q Swets L Zeitlinger
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
Object-Memory Evaluation for Prospective Detection of Dementia in Normal Functioning Elderly: Predictive and Normative Data* Paula A. Fuld, David M. Masur, Alan D. Blau. Howard Crystal, and Miriam K. Aronson Albert Einstein College of Medicine
ABSTRACT In a prospective study of dementia in initially normal functioning elderly, a brief form of the Fuld Object- Memory Evaluation (OM) was administered to 474cognitively normal community-residing volunteers aged 75-85at baseline and annually thereafter. Seventy-two subjects later became demented. Memory test data from the last annual evaluation before cognitive change was noted were available for 56. Although the entire population recalled 7.28 (SO = 1.33) of the 10 objects on Trial 1 of the test at baseline, these 56 subjects recalled only 5.96 (SO = 1.85). When recall of 6 or fewer objects was used as a predictor, the OM test identified 32 of the 56 who subsequently became demented. Compared to an estimated base rate of 15% for dementia, the predictive value of a positive test (PV+) was 39%. and that of a negative test (PV-) was 89%. With a cutoff of 5 or fewer items recalled, the PV+ rose to 59% and the PV-was 94%. Although the OM test was only moderately sensitive to incipient dementia (.57), it was fairly specific (34). and lowering the cutoff to 5 increased the specificity to .96. Memory testing would therefore seem to hold promise as a predictor of dementia in cognitively normal elderly,
Several studies recently have suggested the possibility of preclinical identification of elderly individuals likely to become demented (Berg et al., 1984; Branconnier, Cole, Spera. & DeVitt, 1982; Eslinger, Damasio, Benton, & Van Allen, 1985; Storandt et al., 1984). Given the prominence of memory impairment in the clinical picture of Alzheimer-type dementia (ATD) (Coblentz et al., 1973; Sim & Sussman, 1962), it is not surprising that these studies all found memory test scores to be among the best predictors of further cognitive decline in demented individuals. None of these studies were prospective in nature and did not predict
* This research was supported in part by NINCDS Grant #5P01 NS19234-04. Address correspondence to Dr. Paula A. Fuld, Clinical and Consulting Associates, 5435 Balboa Blvd. #208. Enckro, CA 91316,USA. Accepted for publication: July 26, 1989.
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
PREDICTING DEMENTIA
521
the development of dementia in specific individuals who were functioning normally and who had not yet come to clinical attention for dementia evaluation. In a study of individuals aged 75 to 85 who were considered normal when tested, Fuld, Dickson, Crystal, and Aronson (1987) found a remarkably high correlation (-.83) between subjects’ performance on the Fuld Object-Memory Evaluation (Fuld, 1980; 1981) and the number of primitive senile plaques later seen in their brains after death. This correlation suggested that the prospective detection of dementia in individuals might be possible. The present study investigated prospectively the preclinical detection of dementia in elderly individuals who had normal mental status a t baseline. The study demonstrates that the Fuld Object-Memory Evaluation has substantial predictive (and discriminative) validity for this purpose and also presents new normative data for the 75-85-year-old age group. A parallel study (Masur, Fuld, Blau, Crystal, & Aronson, 1990) shows that the Selective Reminding test (Buschke & Fuld, 1974) has approximately equivalent characteristics, although this test is most useful in different clinical and research situations from the Fuld Object-Memory Evaluation (OM). METHOD Memory testing for the present studies was done in the context of a prospective study of risk-factors in the development of dementia (Katzman et al., 1989).
Subjects Subjects in this study were volunteers, aged 75-85 (M= 79.3), who initially made no more than eight errors on the Blessed mental status test (Blessed, Tomlinson, & Roth, 1968) and were considered normal, following the criteria suggested by Fuld (1 978). They received annual neuropsychological and neurological examinations, including appropriate blood tests. A CT scan and an EEG were also done when subjects were suspected of having had a change in mental status from the previous evaluation (for this purpose, a change was defined as an increase of 4 or more points on the Blessed mental status test). Subjects who evidenced significant declines in cognitive as well as social functioning received a research diagnosis of dementia based on DSM-111-R criteria (APA, 1987). Those subjects who could be classified as having probable Alzheimer-Type Dementia received that diagnosis according to the criteria explicated by McKhann et al. (1984). Subjects were predominantly Caucasian, had a modal education o f 7-9 years, and were slightly above average in intelligence. About half were native-born and the rest were predominantly of eastern European origin. Two-thirds were female. These and other demographic characteristics are summarized in Table 1. (A more detailed description of the subjects is available in Katzman et al., 1989). For the purpose of the present studies, the subjects were divided into two groups. The normal group consisted of individuals who did not change during the study (n=418). In the subsequently demented group were individuals who ultimately received research diagnoses of dementia and for whom memory test scores were available for at least one testing occasion before any change had been noted (n=56). This testing occasion had occurred an average of 489 days before the date of diagnosis (range 234-728 days). Subjects were tested individually by examiners experienced in evaluating aged and/or dementing individuals.
522
PAULA A. FULD ET AL.
Table 1. Demographic Characteristics of Subject Samples Who Received Object Memory Test (Numbers Reflect Percent of Sample) Normal (Baseline n=418)
Subsequently Demented (n=56)
64.5% 35.5
67.2% 32.8
Race White Black and Other
90.4 9.6
93.1 6.9
Place of Birth Europe England and Ireland USA
42.8 6.2 45.6
52.6 8.8 31.6
Other
5.4
7.0
Religion Jewish Catholic Protestant Other
57.7 24.9 14.2 3.2
62.2 29.3 7.0 1.7
Education Less than 9 10 - 12 Greater than 12 Other
53.0 23.8 19.4 3.8
66.1 16.1 14.3 3.5
Mean Age (Yrs.)
79.3 (3.05)
82.1 (3.16)(*)
Sex
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
Female Male
(*)
Age at time of preclinical test, which occurred an average of 1.3 years before diagnosis, but often occurred sometime after baseline evaluation.
Measures As part of the annual neuropsychological evaluation, each subject was given an abbreviated version of the Fuld Object-Memory Evaluation (OM). Administration followed the directions in the test manual (Fuld, 1980; 1981). except that only two 1earningJrecall trials were given. The second trial included multiple-choice recognition testing for any items the subject had not recalled on that trial. This provided scores for each of the two recalls, as well as a score on combined recall-plus-recognition for Trial 2.
Procedure The abbreviated OM uses a modification of the Selective Reminding Procedure (Buschke. 1973) in which 10 common objects are presented in a bag for tactile naming, followed by visual naming, if necessary, to guarantee stimulus-processing. After each object is named,
523
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
PREDICTING DEMENTIA
60 s of distraction is introduced by having the subject say given names (same gender as subject) as quickly as possible. This is followed by 60 s during which the subject attempts to recall all 10 objects, (Recall 1) with encouragement to keep trying even when recall becomes difficult. After this, the subject is reminded verbally of each item s h e omitted and is distracted again, before the final delayed recall (Recall 2) and recognition task. For the present study, the second distraction period was 10 min of continued structured interviewing. To determine what cutoff scores should be used for predictive value analysis, data were examined from 112 subjects in the original sample who had made no more than two errors on the Blessed test for each of two consecutive years. These subjects recalled an average of 7.68 of the 10 common objects on Trial 1 of the OM (SO = 1.08), with none of these stable, unimpaired subjects having recalled fewer than six objects. Based upon this data, we chose to look at the utility of the OM test for the prediction of dementia assuming a cutoff of six objects recalled. We also employed a more stringent cutoff of five objects in order to provide a broader comparison of test sensitivity and specificity. These were obtained by tallying the number of cognitively normal subjects who fell above and below the assigned cutoff scores, and comparing this to the distribution observed with the subjects who eventually became demented, Table 2 illustrates the distribution of both groups of subjects as a function of the cutoff scores. The a priori predictive value of the abbrievated OM Test was calculated through the use of Bayesian analysis (Branconnier et al., 1982; Stilson, 1966). Positive predictive value (PV+) is the probability of having a dementia if the OM test score falls below the cutoff score. Negative predictive value (PV-) represents the probability of the absence of dementia given a test score that is above the cutoff. The predictive value analyses were carried out assuming a base rate of 15 percent for the prevalence of dementia in this population (Katchaturian, 1985).
Table 2. Number of Subjects Above and Below the Cut-off scores for Each Measure of Object-Memory Evaluation Nondemented (n=418)* Subsequently Demented (n=56) Number Above Cutoff Score Cutoff
Measure RECALL 1 RECALL 2 RECALL 1 RECALL 2 RECALL + RECOG.
*
26 1 6 55 1 5
59
353 360 400 374 388
Number Below Cutoff
Number Above Cutoff
Number Below Cutoff
65 29 18 15 0
24 34 36 40 44
32 20 20 14 9
Subjects who eventually became demented were removed for the purposes of predictive value analysis.
524
PAULA A. FULD ET AL.
Downloaded by ["Queen's University Libraries, Kingston"] at 18:34 06 March 2015
RESULTS
Norms for the Abbreviated Fuld Object-Memory Evaluation Normative data for the abbreviated form of the OM is presented in Table 3. This is based on test scores obtained at initial entry into the study and thus includes data from all subjects in the original sample. These 474 75- to 85-year-old subjects, on the average, recalled 7.28 objects on the first trial (SD = 1.32) and 7.74 (SD = 1.37) on the second. They recalled 3r recognized virtually all 10 objects. Intrusions into recall could not be analyzed for this study because of limitations in coding done during the initial phase of the study. The discriminative validity of the OM test was examined by looking at the ability of the test to distinguish normal from dementing individuals at the time of diagnosis. Recall 1 demonstrated a sensitivity of .86, and a specificity of 32, thus indicating that one trial of recall on the OM Test is capable of discritninating between normal functioning and very early dementia in better than 8 out of 10 cases. The reliability of the longer version of the OM test has been reported elsewhere (Fuld. Muramoto, Blau, Westbrook, & Katzman, 1988) and was not investigated in the present study. However, the reliability of the single trial version is adequate to support the validity data presented here. As Table 3 shows, individuals who later became demented performed significantly less well on each OM measure, although in practical terms, differences were not dramatic (e.g. typical recall of 5 or 6, rather than 7 objects on the first trial). Thus, those individuals who later became demented typically recalled only 5.96 items on the first trial (SD=l.85, t=6.70, p
