Assessing Cognition Aims of this resource This presentation provides an overview of the assessment of cognition and has been designed for postgraduates and PhD students Summary of contents ID: 911189
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Slide1
10th September 2014, v1.0 draft
Assessing Cognition
Slide2Aims of this resourceThis presentation provides an overview of the assessment of cognition, and has been designed for post-graduates and PhD students.
Slide3Summary of contentsDiscussion of different reasons for assessing cognition – perspective of society/groups and of individuals, with examples:
Understanding relationships between
cortico
-subcortical circuitry, neuromodulators, and behaviour
Study gene by environment interactions
Identify and treat cognitive problems across a multitude of disorders
Occupational uses: impact of sleep deprivation in military personal; enhancing cognition in sleep-deprived doctors
Individual level: early detection of dementia
Consideration of what would make an ‘ideal’ set of cognitive tests
Pros and cons of different methods of cognitive assessment (clinician rated versus self-report; pen & paper versus computerized)
Introduction to the CANTAB method of cognitive assessment, exemplified with the CANTAB ADHD battery
Slide4Why assess cognition? Cognitive assessment refers to the objective measurement
of distinct cognitive abilities, such as working memory, inhibition, cognitive flexibility, and executive planning
Cognitive functioning is
critical for day-to-day life
, governing our thoughts and actions
Reasons for assessing cognition can be considered from different vantage points:
Perspective of
society (and of groups)Perspective of the individual
Slide5Why assess cognition? Perspective of society
Understand key aspects of human and animal behavior, and how this arises from distinct circuits and neurotransmitters in the brain
1
1
Arnsten et al., Bio Psych, 2011
neuromodulators
Slide6Why assess cognition? Perspective of society
Understand how genetic and environmental factors can influence brain function across the lifespan
Genetic factors
Gene variants
Gene expression
Environmental factors
e.g.
Stress
Trauma
Inflammation
Diet and drug use
Slide7Why assess cognition? Perspective of society
Example: studies have identified negative effect of maternal smoking on subsequent cognitive abilities in infancy / early childhood, which can be influenced by genes
1
Genetic factor
Environmental factor
Maternal smoking
1
Morales et al.,
Int
J
Epidem
, 2009
GSTM1 polymorphism (codes for enzyme involved in breakdown of tobacco by-products)
Maternal smoking in women with a defective form of GSTM1 gene polymorphism was associated with worse cognition in children, when assessed four years after birth.
Slide8Why assess cognition? Perspective of society
Example: the
A
polipoprotein
E4 gene (APOE4) is involved in lipid metabolism and is widely studied as a risk factor for cognitive decline in older age (including dementia)
1
Genetic factor
Environmental factor
Cortisol level (stress axis)
1
Lee et al., Am J Psych, 2008
APOE4 gene
Higher levels of cortisol were associated with worse cognition in community dwelling older adults; however, this relationship was particularly strong in individuals with
at
least one
APOE4 allele
Slide9Why assess cognition? Perspective of society
Cognitive assessment is invaluable for understanding the role of brain dysfunction across a multitude of disorders/syndromes
Examples of conditions in which cognitive impairment can occur:
These impairments represent
key treatment targets
1
Alzheimer's
disease
Mild
cognitive impairment
Depression
ADHD
Schizophrenia
PainSleep disordersDown's syndromeParkinson's diseaseDiabetesTraumatic brain injurySubstance abuseCancerHuntington's diseaseEpilepsyAutismFragile XBipolar disorderMultiple sclerosisImpulse-control
disordersAllergic diseasesGenetic disordersCardiovascular diseaseEating disordersObesityRespiratory disorders
Anxiety disorders/stressStroke
1
e.g. Chamberlain et al., Bio Psych, 2011
Slide10Why assess cognition? Perspective of society
Cognitive assessment is widely used in
occupational
contexts
“Psychometric Testing” to screen potential employees
Use of “
cognitive rehabilitation” and “cognitive (re)training
” e.g. in children with special educational needs, in people with Traumatic Brain Injury (TBI)Explore the impact of environmental factors on cognitive function, and safety, in sensitive occupations (e.g. military, truck drivers, doctors)
Slide11Why assess cognition? Perspective of society
1
Lopez et al., J App Res Mem Cog, 2008
Example: impact of sleep deprivation on cognition in US Air Force Pilots
1
Sleep deprivation was associated with a variety of cognitive deficits, shown here in relation to deterioration in sustained attention
more attentional
lapses
s
leep
deprivation
begins
1pm 4pm 7pm 10pm 1am 4am 7am 10am 1pm 4pm
Slide12Why assess cognition? Perspective of society
Cognitive assessment allows measurement of effects of
interventions
This includes both unwanted effects:
psychomotor slowing, impaired attention, impaired ability to undertake goal-directed planning (important: e.g. driving abilities)
a
nd desired effects:
cognitive enhancement, remediation of cognitive deficitsThese effects may be unexpected
Slide13Why assess cognition? Perspective of society
Example: synergistic effect of benzodiazepine and antipsychotic medication on reaction time slowing
1
1
Internal
Camcog
data
d
eterioration
equivalent to BAC>0.05%
equivalent to BAC>0.1%
Reaction Times
Combination of benzodiazepine and antipsychotic medication had a synergistic unwanted effect on reaction times in volunteers
The combination was equivalent to being over the drink-driving limit in virtually all jurisdictions, in terms of effects on cognition
BAC = B
lood
alcohol
concentration
Slide14Why assess cognition?
Perspective of
society
1
Sugden et al., Ann
Surg
, 2012
Example: effect of
modafinil
on cognition in sleep-deprived doctors
1
Modafinil
improved the ability of sleep-deprived doctors to solve difficult trials on an executive planning task (p<0.05)
s
lower problem
solving
Slide15Why assess cognition?
Individual level
Cognitive assessment also has many applications at the level of the
individual person
An individual’s performance can be compared to normative data
Clinicians and researchers can quantify to what extent an individual’s cognition is impaired (or better than expected), in which domains, and to what extent
Objective quantification of cognitive impairments can inform early
detection, diagnosis, and treatment
Slide16Why assess cognition? Individual level
Example: early detection of memory problems requiring further investigation in General Practice
Patient undertakes brief assessment using medical device in GP surgery
One-page report generated for GP
Software indicates where further medical investigations are needed; and reassures where no problems were detected
Slide17Characteristics of an ‘ideal’ set of cognitive tests
Capture the spectrum of different cognitive functions and separate them
Good psychometric properties
Reliability (consistency, test-retest)
Validity (face, content, discriminant)
Sensitive
:
able to maximize detection of cognitive impairments in disorders/syndromes; and effects of interventionsTranslational: can be directly related to neural circuitry and neurochemical
systems
Respected
by scientific community
Availability of a large normative database
Slide18Methods of cognitive assessment: pros and cons
Clinician-rated (or supervised)
cognitive assessment refers to trained individuals assessing cognition by asking questions/tasks of patients, or overseeing the testing process
For example,
Mini Mental State Examination (MMSE)
, widely used in clinical practice as a broad composite measure of cognition, and to detect possible dementia
1
e.g. “What year is it?”
“What is this?” [point to object]
“Please copy this figure”
Clinician-rated versus self-rated
1
Folstein et al., J Psych Res, 1975
Takes about 10 minutes to complete
Measures orientation, registration, short-term memory, and language
Scores (maximum 30):
25-30 normal
21-24 mild impairment
10-20 moderate impairment
<10 severe impairment
Slide19Methods of cognitive assessment: pros and consSelf-rated cognitive assessment refers to individuals doing tests themselves, typically following written instructions, such as from their own homes or over the Internet
For example, the
Self-Administered
Geocognitive
Examination (
SAGE)
, designed to detect signs of dementia
1 e.g. “What is today’s date?” “Name the following pictures” “Copy this picture”
Clinician-rated versus self-rated
1
Scharre et al.,
Alz
Dis
Assoc
Dis, 2010
Takes about 15-20 minutes to complete
Four pages long
Measures various cognitive functions
Score (maximum 22)
<17 suggests cognitive impairment
Slide20Methods of cognitive assessment: pros and consClinician-rated (or supervised) assessment
- Greater objectivity
- Greater control over testing environment and test administration
- Less ‘statistical noise’ and superior data control
But,
- Requires training - Potential inconvenience (supervisor and person being assessed together at the same site)Self-rated assessment - Convenience (can be done from home) - No need to train and employ testers But, - Limited control over testing environment and test administration
- Difficult to quantify or record various confounding factors
Clinician-rated versus self-rated
Slide21Methods of cognitive assessment: pros and consCognitive assessment initially relied on pen/paper tests, before the advent of computer technology
Computerized assessment is now the gold standard, with potential
advantages:
- Objectively tease apart distinct cognitive abilities
- Automated data collection and processing; quality control
- Accuracy (such as in measurement of response latencies) - Can be made less reliant on complex motor skill; special interface technology - Translational: neuroimaging, animal models
Pen/Paper versus Computerized assessment
Slide22Computerized assessment: CANTAB
Comprehensively captures all important cognitive domains
Established validation including excellent psychometric properties
Proven
sensitivity to drug
and disease effects
where cognition is a factor
Comprehensively validated by
>30
years of global
translational research, and >1300 peer-reviewed papers
Used
in over
700 academic research
institutions
worldwide
E
xtensive
normative and clinical
data
Slide23Psychomotor speed
Attention
Memory
Social cognition
Executive function
Reaction
Time
Visual Information Processing
Paired Associates Learning
Spatial Working Memory
Compulsivity
Emotion Recognition
Verbal Recall
Alzheimer's disease
Depression
ADHD
Schizophrenia
Abuse Liability
Parkinson's disease
Pain
Sleep
Down’s syndrome
Multiple sclerosis
Cardiovascular disease
Huntington’s disease
Traumatic brain injury
Autism
Cancer
Validated touchscreen tests
Measuring effects across cognitive domains
Applied to research of disorders and syndromes
Drug
Safety
Drug
Efficacy
Slide24Stop Signal Task
Verbal Recall / Recognition Memory
Reaction
Time Task
Delayed Matching to Sample
Paired Associates Learning
Spatial Working Memory
Stockings of Cambridge
Attention Switching Task
Pattern or Spatial Recognition Memory
Affective Go/No-go
Emotion Recognition Test
Rapid Visual Information Processing
CANTAB Cognitive Tests and Brain Regions
Slide25CANTAB
Cantab
detects effects in smaller
sample sizes over shorter periods of time (large effect sizes versus placebo for drug manipulations, even in healthy volunteers)
1
The
high
sensitivity,
and established validation of Cantab enables research that is lower
cost and
lower risk for your academic research
Cantab is sensitive to the discovery of effects that other tests would miss
2
1
Turner et al.,
Psychopharm
, 2003;
Deakin
et al.,
Psychopharm
, 2004;
2
Greig et al.,
Curr
Alz
Res, 2005
Slide26CANTAB
The translational bridge from pre-clinical research increases chance of success with grant applications, and maximises the scientific impact of your research
2
Enables you to pinpoint cognitive deficits in syndromes/disorders,
and
effects of drug manipulations and interventions (high precision)
1
Computerized, language-independent delivery enables
easy deployment, and maximises
signal-to-noise
3
1
Chamberlain et al., Bio Psych, 2011;
2
Robbins et al.,
Neurosci
Biobehav
Rev, 2013;
3
e.g.
Yurko
-Mauro et al., 2010;
Shiina
et al., 2010
Slide27CANTAB
Core
Cognitive Battery
Research
key aspects of cognitive performance using computerized tests that have proven sensitivity to pharmacological
manipulation
Dementia
Battery
For
measuring the severity of impairment in patients with prodromal Alzheimer’s disease and those functioning within the dementia
range
Schizophrenia Battery
Accurately research cognitive effects in schizophrenia and related
syndromes
ADHD
Battery
Reliably
study the cognitive effects in conditions characterized by excessive impulsivity and the inability to control
behaviors
Depression
Battery
For
research into cognitive impairment associated with depression (including treatment resistant depression) and related mood disorders during acute mood episodes and periods of
remission
Or create your own test combination
Tailored packages
Slide28Example: CANTAB ADHD Battery
Fast
, reliable and highly sensitive,
the CANTAB ADHD Battery allows
accurate quantification of
cognitive problems in ADHD, and effects of interventions
Attention / reaction time
Rapid Visual Information Processing (RVP)
Spatial Working Memory (SWM)
Executive
Function
Response Control
Stop Signal Task
(SST)
Slide29CANTAB ADHD Battery
Impairment (Cohen’s D) in
ADHD v Controls
1
From Chamberlain et al., Bio Psych, 2011; and
Gau
& Huang, Psych Med, 2014; see also Fried et al.,
Journ Atten Disorders, 2012;
2
Dowson et al.,
Acta
Psych
Scand
, 2010; Lipszyc & Schachar, J Int Neuropsych Soc, 2010 greater impairmentMaximize
scope for detecting cognitive benefits of intervention, and enrich samples, with large baseline deficits in ADHD1
significant clinicalimpairmentCANTAB discriminates the cognitive profile of ADHD from other conditions including2 -Anxiety/Depression -Personality Disorder -Conduct Disorder
Sensitive to cognitive impairments
Slide30CANTAB ADHD Battery
1
Tseng &
Gau
, J Child
Psychol
and Psych, 2013;
2Clark et al., J Child Psychol and Psych, 2002; Kofler et al., J Abnorm Child Psychol, 2011 CANTAB predicts day-to-day function in ADHD
1,2
. In path modelling, CANTAB SWM significantly mediated the relationship between ADHD and social problems
1
Cognitive impairment in ADHD contributes to functional impairment across multiple areas (including academic, work, and social domains)
2
ADHDExecutive Dysfunction
Social Problems
p<0.01p<0.01
Functionally relevant
Slide31CANTAB ADHD Battery
1
Aron et al., Nat
Neurosci
, 2003; see also Aron et al., Trends Cog
Sci
, 2014;
2Chamberlain et al., Bio Psych, 2009; 3Shang et al., Psych Med, 2013CANTAB SST detects the effects of ADHD medications on brain function, even following a single dose2
CANTAB SST is sensitive to frontal lobe damage, especially to the right inferior frontal
gyrus
(correlation p<0.001)
1
40
0
100
450
Volume of damage (cm
3
)
Stop Signal Reaction Time (SST)
w
orse inhibitory
control
more cortex damage
Enhanced brain activation in the right inferior frontal
gyrus
following
atomoxetine
treatment, detected using CANTAB
2
CANTAB performance correlates with structural and functional brain abnormalities in ADHD, such as with disorganized white matter tracts
3
Translational
Slide32CANTAB ADHD Battery
CASE STUDY:
CANTAB SWM showed dose-dependent improvement from single-dose methylphenidate treatment in N=26 patients with ADHD
1
1
Bedard et al., J Am Child
Adolesc
Psych, 2004
2
Chamberlain et al., Bio Psych, 2007
better inhibitory
control
CASE STUDY:
CANTAB SST detected cognitive benefits of
atomoxetine
(selective norepinephrine reuptake inhibitor) following just a single-dose in N=22 patients with ADHD
2
Stop Signal Reaction Time
(SST)
*
p
< 0.05
Errors (SWM)
better
working
memory
higher dose
*
p
< 0.05 significant linear
reduction in errors with increasing methylphenidate dose
Sensitive to cognitive enhancing effects of interventions
Slide33Cambridge Cognition LtdTunbridge Court
Bottisham
Cambridge,
CB25
9TU
UK
Call
+44 1223 810700Email research@camcog.com
Get further information
www.cantab.com/research
Download resources
www.cantab.com/ignitionSearch the research library www.cantab.com/biblography