Methods - University of Edinburgh



I think, therefore I forget- using experimental simulation of dementia to understand functional cognitive disorders. Laura McWhirter* (Clinical Research Fellow and Honorary Consultant Psychiatrist)Brendan Sargent (Medical Student)Craig Ritchie (Professor of Psychiatry of Ageing)Jon Stone (Professor of Neurology)Alan Carson (Professor of Neuropsychiatry)Centre for Clinical Brain Sciences, University of Edinburgh* corresponding authorWord count: 3478 (including abstract)Abstract word count: 250Tables: 2Figures: 2References: 38ABSTRACTBackgroundSymptoms of functional neurological disorder have traditionally been thought to depend, in part, on patients’ ideas about symptoms rather than on the rules of pathophysiology. The possibility that functional cognitive symptoms might similarly reflect ideas of dementia has not been explored. We aimed to assess beliefs, through performance, about symptoms of dementia in healthy non-medical adults with the intention of identifying potential markers of functional cognitive disorders. MethodsHealthy volunteers were asked to simulate symptoms of mild dementia during testing with the MoCA, coin-in-hand forced-choice test, short digit span trials, Luria 3-step test and interlocking finger test. Family history of dementia was recorded. ResultsIn 50 participants aged 18-27, simulating dementia, mean MoCA score was 16 (SD 5.5, range 5 – 26). Delayed recall was the most frequently failed item (100%) and cube drawing least frequently failed (42%). 26% failed forward three-digit span and 36% failed reverse two-digit span. On the coin-in-hand test, 32% scored at or below chance level. Inconsistent response patterns were common. ConclusionsCognitively healthy young adults simulating mild dementia perform similarly to older adults with mild dementia, demonstrating beliefs that dementia is associated with significant global impairment, including attention, motor function, and letter vigilance, but preservation of cube drawing. Inconsistent response patterns were common. Contrary to expectation, family history of dementia did not influence performance. Two and three digit span showed particular promise as a bedside test for simulation. Further investigation will establish whether similar patterns of results are produced in individuals with functional cognitive symptoms.Introduction The last 10 years has seen a drive to diagnose diseases causing dementia at the earliest clinical and even preclinical stages. However, in those presenting to memory clinics with mild complaints or mild impairment, biomarker specificity is low and aetiologies heterogeneous ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1159/000439258","ISSN":"1660-2862","PMID":"26560503","abstract":"BACKGROUND Determination of Alzheimer's disease (AD) by cerebrospinal fluid (CSF) biomarkers - 42-amino-acid amyloid-β (Aβ42), total tau and phosphorylated tau (p-tau) - has demonstrated high validity for detecting AD neuropathological changes. However, their prognostic utility to predict the onset of dementia in predementia subjects is still questioned. We aimed to study the prospective clinical evolution of a group of subjects with subjective cognitive decline (SCD) or mild cognitive impairment (MCI) and to determine the prognostic capacity of AD CSF biomarkers. METHODS 149 subjects with MCI or SCD, not meeting dementia criteria, underwent a prospective clinical, neuropsychological and CSF biomarker study. Patients were initially classified as SCD or MCI following internationally accepted criteria. CSF sampling was obtained and analysed following consensus protocols. Neuropsychological and clinical evaluations were conducted at the follow-up. Statistical analysis considering the final clinical diagnosis, regression analysis to define risk factors and survival curves for progression were made. RESULTS 72.4% of subjects (83% MCI and 27% SCD) with a pathological CSF ratio (Aβ42/p-tau) met criteria for dementia during the 5-year follow-up versus 18.7% of subjects from the group with a normal ratio. The pathological CSF ratio was a powerful marker of risk for AD dementia (OR 27.1; 95% CI 10.3-71.2). Kaplan-Meier survival curves showed that only 15% of subjects with a pathological CSF ratio remained free of AD dementia at 5 years of follow-up. All subjects who reverted to normal cognition presented a normal CSF profile at baseline. CONCLUSION An abnormal AD CSF biomarker profile in predementia subjects is a powerful predictor of cognitive and/or functional decline in the medium term.","author":[{"dropping-particle":"","family":"Sierra-Rio","given":"Alba","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Balasa","given":"Mircea","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Olives","given":"Jaume","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Antonell","given":"Anna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Iranzo","given":"Alex","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Castellví","given":"Magda","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bosch","given":"Beatriz","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Grau-Rivera","given":"Oriol","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fernandez-Villullas","given":"Guadalupe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rami","given":"Lorena","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lladó","given":"Albert","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sánchez-Valle","given":"Raquel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Molinuevo","given":"José Luis","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Neuro-degenerative diseases","id":"ITEM-1","issue":"1-2","issued":{"date-parts":[["2016"]]},"note":"310818\n\n\nAB42/p-tau ratio was measured at baseline in 149 patients with MCI or SCD who were then followed up over 5 years. 58 (38.9%) had a pathological AB42:p-tau ratio, 47 of the MCI subjects and 11 of the SCD subjects. Of those with a pathological CSF ratio, 72.4% of subjects (83% of those with MCI and 27% with SCD) developed AD dementia during the follow-up period. The absolute number of SCD individuals progressing to dementia over 5 years however was only 3 (5.4%).","page":"69-76","title":"Cerebrospinal Fluid Biomarkers Predict Clinical Evolution in Patients with Subjective Cognitive Decline and Mild Cognitive Impairment.","type":"article-journal","volume":"16"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"","ISSN":"1387-2877","abstract":"Background: Limited information is available on short-term prognosis of Alzheimer's disease (AD) biomarkers in cerebrospinal fluid (CSF) in addition to routine diagnostic workup. Objective: This study aims to investigate the added prognostic value of AD CSF biomarkers. Methods: In a prospective cohort study, clinical experts predicted cognitive and functional symptoms in 114 memory clinic patients by assessing comprehensive routine diagnostic test information (patient history, and physical, neurological, psychiatric, neuropsychological, and MRI examinations), without and with CSF biomarkers. The reference standard was the 'observed clinically relevant decline' using baseline and 1- and 2-year follow-up information. Results: Decline over a 2-year period was observed in 51 of all participants (3 in SMC, 48 in MCI, 90 in mild dementia). In the total sample, the accuracy of predicted decline did not differ significantly between routine assessment without (79 correctly predicted) and with (74 correctly predicted) CSF biomarkers. Subgroup analyses revealed 25 (83) correct predictions in SMC, 30 (68) in MCI, and 35 (88) in dementia without the use of CSF; and 21 (70), 27 (61), and 36 (90), respectively, with the use of CSF in addition to the routine assessment. Conclusion: AD CSF biomarkers did not increase accuracy of 2-year prognosis of cognitive and functional decline when added to routine diagnostic workup. This suggests that the standard diagnostic workup without CSF biomarkers allows fairly accurate predictions for the short-term course of symptoms. Routine AD biomarkers in CSF have limited prognostic value over 2 years in persons with a suspected cognitive disorder.Copyright ? 2016 - IOS Press and the authors. All rights reserved.","author":[{"dropping-particle":"","family":"Handels","given":"R L H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Joore","given":"M A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vos","given":"S J B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Aalten","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ramakers","given":"I H G B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rikkert","given":"M O","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Scheltens","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jansen","given":"W J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Visser","given":"P J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Berckel","given":"B M N","non-dropping-particle":"Van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Domburg","given":"P","non-dropping-particle":"Van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Smid","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hoff","given":"E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hoogmoed","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bouwman","given":"F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Claassen","given":"Jurgen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Leentjens","given":"A F G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wolfs","given":"C A G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Severens","given":"J L","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Alzheimer's Disease","id":"ITEM-2","issue":"3","issued":{"date-parts":[["2016"]]},"note":"200918\n\nOut of 304 patients from 4 Dutch university memory clinics referred for assessment of suspected cognitive disorder, 114 eligible participants (mean age 67.3+-8.6) with MMSE scores &gt;20 were assessed at baseline, 1 and 2 year follow-up. \nClinical assessment with CSF biomarker information was compared to that without CSF biomarker information and the predicted course of symptoms compared with follow-up data. \n30 (26%) had subjective memory complaints, 44 (39%) mild cognitive impairment, and 40 (35%) mild dementia. \n\nAssessment with CSF biomarkers did not add prognostic value. In the total sample, the specificity was lower (54% compared with 63%) but sensitivity essentially the same (95% compared with 93%) for routine assessment with CSF biomarkers. This drop in specificity afforded by the addition of CSF biomarker information was greatest in the subjective memory complaint group. In summary, the rate of 'false positives' in the SMC and MCI groups increased with inclusion of biomarkers.","page":"875-885","publisher-place":"Maastricht","title":"Added Prognostic Value of Cerebrospinal Fluid Biomarkers in Predicting Decline in Memory Clinic Patients in a Prospective Cohort","type":"article-journal","volume":"52"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"","ISSN":"1664-5464","abstract":"Background/Aims: In the quest for prevention or treatment, there is a need to find early markers for preclinical dementia. This study observed memory clinic patients with subjective cognitive impairment (SCI) and normal cognitive function at baseline. The primary aim was to address SCI as a potential risk factor for cognitive decline. The secondary aim was to address a potential relation between (1) baseline cerebrospinal fluid biomarkers and (2) a decline in memory performance over the first 2 years of follow-up, with a possible cognitive decline after 6 years. Methods: Eighty-one patients (mean age 61 years) were recruited from university memory clinics and followed up for 6 years. Results: Eighty-six percent of the cohort remained cognitively stable or improved, 9% developed mild cognitive impairment, and only 5% (n = 4) developed dementia. Regression analysis revealed that low levels of Abeta42 at baseline and memory decline during the first 2 years predicted dementia. When combined, these variables were associated with a 50% risk of developing dementia. Conclusions: Cognitive stability for 86% of the cohort suggests that SCI is predominantly a benign condition with regard to neuropathology. The low number of individuals who developed dementia limits the generalizability of the results and discussion of progression factors.Copyright ? 2017 The Author(s).","author":[{"dropping-particle":"","family":"Hessen","given":"E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eckerstrom","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nordlund","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Selseth Almdahl","given":"I","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stalhammar","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bjerke","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eckerstrom","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gothlin","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fladby","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Reinvang","given":"I","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Dementia and Geriatric Cognitive Disorders Extra","id":"ITEM-3","issue":"1","issued":{"date-parts":[["2017"]]},"note":"310818\n\n6 year follow-up of a smaller group of 81 patients with subjective cognitive impairment from this study found 86% cognitively stable or improved; 9% had developed mild cognitive impairment and 5% (n=4) dementia. The authors conclude that SCI is 'predominantly a benign condition with regard to neuropathology.'","page":"1-14","title":"Subjective cognitive impairment is a predominantly benign condition in memory clinic patients followed for 6 years: The Gothenburg-oslo MCI Study","type":"article-journal","volume":"7"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"","ISSN":"0002-0729","abstract":"Subjective cognitive complaints (SCC) are currently considered to be a core feature of mild cognitive impairment (MCI). Yet the implications of including or excluding subjective complaints has not been previously considered. The key questions are how many healthy people complain of SCC compared to those with MCI? How is the epidemiology of MCI affected by the requirement for SCC? How is the prognosis of MCI influenced by SCC? and how should SCC be defined and measured? Findings to date suggest that subjective complaints are one of many variables that comprise risk in individuals with MCI. Individuals who do not have subjective complaints and might not qualify under current definitions of MCI may still have a disorder that is of clinical significance. Despite a close association, SCC may be neither necessary nor sufficient for a diagnosis of either MCI or dementia.","author":[{"dropping-particle":"","family":"Mitchell","given":"Alex J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Age and Ageing","id":"ITEM-4","issue":"5","issued":{"date-parts":[["2008"]]},"page":"497-499","publisher":"Oxford University Press","title":"Is it time to separate subjective cognitive complaints from the diagnosis of mild cognitive impairment?","type":"article-journal","volume":"37"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"10.1111/j.1600-0447.2008.01326.x","ISBN":"1600-0447","ISSN":"0001690X","PMID":"19236314","abstract":"OBJECTIVE: To quantify the risk of developing dementia in those with mild cognitive impairment (MCI). METHOD: Meta-analysis of inception cohort studies. RESULTS: Forty-one robust cohort studies were identified. To avoid heterogeneity clinical studies, population studies and clinical trials were analysed separately. Using Mayo defined MCI at baseline and adjusting for sample size, the cumulative proportion who progressed to dementia, to Alzheimer's disease (AD) and to vascular dementia (VaD) was 39.2%, 33.6% and 6.2%, respectively in specialist settings and 21.9%, 28.9% and 5.2%, respectively in population studies. The adjusted annual conversion rate (ACR) from Mayo defined MCI to dementia, AD and VaD was 9.6%, 8.1% and 1.9%, respectively in specialist clinical settings and 4.9%, 6.8% and 1.6% in community studies. Figures from non-Mayo defined MCI and clinical trials are also reported. CONCLUSION: The ACR is approximately 5-10% and most people with MCI will not progress to dementia even after 10 years of follow-up.","author":[{"dropping-particle":"","family":"Mitchell","given":"A. J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shiri-Feshki","given":"M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Acta Psychiatrica Scandinavica","id":"ITEM-5","issue":"4","issued":{"date-parts":[["2009","4","1"]]},"note":"250119\n\nA meta-analysis of 41 cohort studies found less than half of individuals with MCI progress to dementia within 10 years of follow-up.","page":"252-265","publisher":"John Wiley & Sons, Ltd (10.1111)","title":"Rate of progression of mild cognitive impairment to dementia - Meta-analysis of 41 robust inception cohort studies","type":"article-journal","volume":"119"},"uris":[""]}],"mendeley":{"formattedCitation":"^1–5","plainTextFormattedCitation":"1–5","previouslyFormattedCitation":"^1–5"},"properties":{"noteIndex":0},"schema":""}1–5. It is likely that a significant proportion who do not ultimately receive a diagnosis of dementia have Functional Cognitive Disorders: that is, conditions where cognitive symptoms are present and associated with distress and disability, but which are caused by functional disturbances of attention, abnormal metacognitive beliefs, alongside other functional neurological symptoms, or as a result of psychiatric illness ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"Cognitive symptoms such as poor memory and concentration represent a common cause of morbidity among patients presenting to general practitioners and may result in referral for a neurological opinion. In many cases, these symptoms do not relate to an underlying neurological disease or dementia. In this article we present a personal perspective on the differential diagnosis of cognitive symptoms in the neurology clinic, especially as this applies to patients who seek advice about memory problems but have no neurological disease process. These overlapping categories include the following 'functional' categories: 1) cognitive symptoms as part of anxiety or depression; 2) \"normal\" cognitive symptoms that become the focus of attention; 3) isolated functional cognitive disorder in which symptoms are outwith 'normal' but not explained by anxiety; 4) health anxiety about dementia; 5) cognitive symptoms as part of another functional disorder; and 6) retrograde dissociative (psychogenic) amnesia. Other 'non-dementia' diagnoses to consider in addition are 1) cognitive symptoms secondary to prescribed medication or substance misuse; 2) diseases other than dementia causing cognitive disorders; 3) patients who appear to have functional cognitive symptoms but then go on to develop dementia/another neurological disease; and finally 4) exaggeration/malingering. We discuss previous attempts to classify the problem of functional cognitive symptoms, the importance of making a positive diagnosis for the patient, and the need for large cohort studies to better define and manage this large group of patients.","author":[{"dropping-particle":"","family":"Stone","given":"Jon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pal","given":"Suvankar","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Blackburn","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Reuber","given":"Markus","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Thekkumpurath","given":"Parvez","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carson","given":"Alan","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Alzheimer's Disease","id":"ITEM-1","issue":"S1","issued":{"date-parts":[["2015"]]},"note":"091018\n\nStone et al propose that those who present with cognitive symptoms not due to neurological disease, defined as Functional Cognitive Disorders generally fall into a range of overlapping categories: caused by anxiety or depression, 'normal' symptoms that become the focus of attention, an isolated functional cognitive disorder (neither normal nor caused by anxiety), occuring as part of another functional disorder, and retrograde (dissociative) amnesia. The authors note important other diagnoses to consider including prodromal dementia, symptoms caused by drugs, and exaggeration or malingering.","page":"S5-S17","title":"Functional (Psychogenic) Cognitive Disorders: A Perspective from the Neurology Clinic","type":"article-journal","volume":"48"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1093/bmb/ldu029","ISSN":"1471-8391","PMID":"25274571","abstract":"INTRODUCTION OR BACKGROUND: Memory problems are a very common reason for presenting to primary care. There is a need for better treatments for dementia. Increased government and media interest may result in greater number seeking help for memory problems, which may not reduce the dementia gap but rather increase numbers seen who do not have dementia. This review highlights the issues around the diagnostic criteria and terminology used for people with memory complaints. SOURCES OF DATA: A comprehensive literature search using PubMed using keywords for articles on subjective memory decline (SMD)/impairment/complaints, subjective cognitive decline (SCD), mild cognitive impairment (MCI) and functional memory disorder (FMD). AREAS OF AGREEMENT: There is a need for early accurate detection of dementia syndromes so that trials of new treatments can begin earlier on the disease process. AREAS OF CONTROVERSY: Diagnostic criteria and terminology used for disorders of memory including SCD, MCI and FMD. GROWING POINTS: This article reviews SCD and whether this can be used to predict Alzheimer's disease. The review also discusses the terminology used for non-progressive memory problems and the long-term outcomes for this patient group. AREAS TIMELY FOR DEVELOPING RESEARCH: The accurate distinction of premorbid dementia syndromes from benign non-progressive memory problems. Studies of treatment options for people with benign non-progressive memory problems and longer-term follow-up to determine which patients develop chronic problems.","author":[{"dropping-particle":"","family":"Blackburn","given":"Daniel J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wakefield","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shanks","given":"Michael F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Harkness","given":"Kirsty","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Reuber","given":"Markus","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Venneri","given":"Annalena","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British medical bulletin","id":"ITEM-2","issue":"1","issued":{"date-parts":[["2014","12","1"]]},"page":"71-81","title":"Memory difficulties are not always a sign of incipient dementia: a review of the possible causes of loss of memory efficiency.","type":"article-journal","volume":"112"},"uris":[""]}],"mendeley":{"formattedCitation":"^6,7","plainTextFormattedCitation":"6,7","previouslyFormattedCitation":"^6,7"},"properties":{"noteIndex":0},"schema":""}6,7. Subjective report of memory impairment generally correlates poorly with performance on cognitive tests, and performance on cognitive screening tests is unpredictable in those with functional disorders: some patients achieve normal scores, but some score very poorly, especially in tests of memory, attention and executive functionADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/jnnp-2017-317823","ISSN":"1468-330X","PMID":"29735513","abstract":"BACKGROUND Functional cognitive disorder (FCD) describes cognitive dysfunction in the absence of an organic cause. It is increasingly prevalent in healthcare settings yet its key neuropsychological features have not been reported in large patient cohorts. We hypothesised that cognitive profiles in fibromyalgia (FM), chronic fatigue syndrome (CFS) and functional neurological disorders (FNDs) would provide a template for characterising FCD. METHODS We conducted a systematic review of studies with cognition-related outcomes in FM, CFS and FND. RESULTS We selected 52 studies on FM, 95 on CFS and 39 on FND. We found a general discordance between high rates of subjective cognitive symptoms, including forgetfulness, distractibility and word-finding difficulties, and inconsistent objective neuropsychological deficits. Objective deficits were reported, including poor selective and divided attention, slow information processing and vulnerability to distraction. In some studies, cognitive performance was inversely correlated with pain, exertion and fatigue. Performance validity testing demonstrated poor effort in only a minority of subjects, and patients with CFS showed a heightened perception of effort. DISCUSSION The cognitive profiles of FM, CFS and non-cognitive FND are similar to the proposed features of FCD, suggesting common mechanistic underpinnings. Similar findings have been reported in patients with mild traumatic brain injury and whiplash. We hypothesise that pain, fatigue and excessive interoceptive monitoring produce a decrease in externally directed attention. This increases susceptibility to distraction and slows information processing, interfering with cognitive function, in particular multitasking. Routine cognitive processes are experienced as unduly effortful. This may reflect a switch from an automatic to a less efficient controlled or explicit cognitive mode, a mechanism that has also been proposed for impaired motor control in FND. These experiences might then be overinterpreted due to memory perfectionism and heightened self-monitoring of cognitive performance.","author":[{"dropping-particle":"","family":"Teodoro","given":"Tiago","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Edwards","given":"Mark J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Isaacs","given":"Jeremy D","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of neurology, neurosurgery, and psychiatry","id":"ITEM-1","issue":"12","issued":{"date-parts":[["2018","5","7"]]},"note":"Performance validity tests: generally don't show poor effort, especially when patients seeking compensation or disability benefits are excluded.\n\nOverall: impairments of selective and divided attention but not attention generally.\n\nSlow information processing.\n\nHeightened perception of cognitive effort.\n\nSome working memory problems in FMD/NEA suggesting vulnerability to distraction. \n\nCoexisting psychopathology is not robustly associated with cognitive difficulties.","page":"1308-1319","title":"A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: systematic review","type":"article-journal","volume":"89"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8. Although cognitive screening tests are now heavily used in the diagnosis of dementia and in defining mild cognitive impairment (MCI), the specificity remains unacceptably low. A 2009 review of 41 robust longitudinal cohort studies found that fewer than half of those receiving a description of MCI (described on the basis of memory symptoms and mild impairment on screening tests) progress to dementia even after 10 years of follow up ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1600-0447.2008.01326.x","ISBN":"1600-0447","ISSN":"0001690X","PMID":"19236314","abstract":"OBJECTIVE: To quantify the risk of developing dementia in those with mild cognitive impairment (MCI). METHOD: Meta-analysis of inception cohort studies. RESULTS: Forty-one robust cohort studies were identified. To avoid heterogeneity clinical studies, population studies and clinical trials were analysed separately. Using Mayo defined MCI at baseline and adjusting for sample size, the cumulative proportion who progressed to dementia, to Alzheimer's disease (AD) and to vascular dementia (VaD) was 39.2%, 33.6% and 6.2%, respectively in specialist settings and 21.9%, 28.9% and 5.2%, respectively in population studies. The adjusted annual conversion rate (ACR) from Mayo defined MCI to dementia, AD and VaD was 9.6%, 8.1% and 1.9%, respectively in specialist clinical settings and 4.9%, 6.8% and 1.6% in community studies. Figures from non-Mayo defined MCI and clinical trials are also reported. CONCLUSION: The ACR is approximately 5-10% and most people with MCI will not progress to dementia even after 10 years of follow-up.","author":[{"dropping-particle":"","family":"Mitchell","given":"A. J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shiri-Feshki","given":"M.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Acta Psychiatrica Scandinavica","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2009","4","1"]]},"note":"250119\n\nA meta-analysis of 41 cohort studies found less than half of individuals with MCI progress to dementia within 10 years of follow-up.","page":"252-265","publisher":"John Wiley & Sons, Ltd (10.1111)","title":"Rate of progression of mild cognitive impairment to dementia - Meta-analysis of 41 robust inception cohort studies","type":"article-journal","volume":"119"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵","plainTextFormattedCitation":"5","previouslyFormattedCitation":"⁵"},"properties":{"noteIndex":0},"schema":""}5. Over-reliance on cognitive screening tests brings a risk of misdiagnoses and associated iatrogenic harm, and we expect misdiagnoses to become a more pressing problem as preclinical Alzheimer disease profiles are increasingly identified in younger people. It has been traditionally taught that the symptoms of functional neurological disorders are, in part, dependent on the patient’s ideas about the symptoms rather than anatomical and pathophysiological rules ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.jns.2017.08.3248","ISSN":"18785883","abstract":"Introduction Symptoms and signs of functional (psychogenic) motor and sensory disorder are often said to be dependent on the patients’ idea of what symptoms should be, rather than anatomy and physiology. This hypothesis has however rarely been tested. Materials and methods Inspired by a brief experiment carried out in 1919 by neurologist Arthur Hurst we aimed to assess the views of healthy non-medical adults towards paralysis and numbness and their response to tests for functional disorders when asked to pretend to have motor and sensory symptoms. Results When subjects were asked to pretend they had a paralysed arm 80% thought there would be sensory loss. Of these 60% thought it would have a circumferential (functional) distribution at the wrist, elbow or shoulder. Hoover's sign of functional weakness was only positive in 75% of patients pretending to have leg paralysis with 23% maintaining weakness of hip extension in the feigned weak leg, a rare finding in neurological practice. 20% of subjects managed to continue having their feigned tremor during the entrainment test. 52% of subjects thought there was asymmetry of a tuning fork across their forehead even when no prior instruction had been given. Conclusions The study confirmed Hurst's finding that non-medical people generally expect sensory loss to go along with paralysis, especially if the examiner suggests it. When present, it usually conforms to functional patterns of sensory loss. Clinical tests for functional and motor disorders appear to behave somewhat differently in patients asked to pretend to have symptoms suggesting that larger more detailed studies would be worthwhile.","author":[{"dropping-particle":"","family":"Stone","given":"Jon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mutch","given":"Jennifer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Giannokous","given":"Denis","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hoeritzauer","given":"Ingrid","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carson","given":"Alan","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of the Neurological Sciences","id":"ITEM-1","issue":"August","issued":{"date-parts":[["2017"]]},"page":"188-191","title":"Hurst revisited: Are symptoms and signs of functional motor and sensory disorders “dependent on idea”?","type":"article-journal","volume":"381"},"uris":[""]}],"mendeley":{"formattedCitation":"⁹","plainTextFormattedCitation":"9","previouslyFormattedCitation":"⁹"},"properties":{"noteIndex":0},"schema":""}9. Similarities have been observed between simulated and functional paralysis, for example, suggesting to us not that patients with functional disorder are feigning but rather that symptoms in both cases may depend on ‘top-down’ predictions that the brain makes about motor and sensory experience, which in the case of a functional disorder are involuntary. Experimental simulation – asking a healthy subject to mimic the symptoms of a disease – can give a more detailed insight into that subject’s ideas and beliefs about those symptoms than is possible through interview or questionnaire. Ideas and beliefs about symptoms of dementia may be similar in healthy individuals to in those with functional cognitive disorders; or they may be different. Experimental simulation may be a useful route in which to access these beliefs in order to further investigate how different belief profiles might relate to the experience of cognitive symptoms, and may also suggest avenues for investigation in developing more accurate diagnostic profiles for functional cognitive disorders. This study therefore aimed to compare performance in easily available cognitive screening tests in young adults simulating mild dementia with normative data, in order to better understand what young adults believe the symptoms of dementia to look like. We hypothesised that simulating individuals would perform as if impaired, but less severely than those with dementia, and that they would present with different patterns of impairment. MethodsParticipants were recruited via peer networks and social media. Inclusion criteria were: age over 16 and able to speak and read English. Individuals were excluded if they had a pre-existing neurological disorder or had received any education or training in medicine, healthcare, or clinical neuroscience at college or university level. Educational level and family history of neurological disease was recorded. Participants were asked to complete a panel of cognitive tests ‘as if you have mild dementia due to Alzheimer’s disease’; a script was used to standardise examiner suggestion (Appendix 1). The assessment included a brief interview and the Montreal Cognitive Assessment (MoCA), with response times for each item measured using a stopwatch. The Luria 3-step test, interlocking fingers test, and examination of gait and tandem (heel-to-toe) gait were included due to increasing recognition of the diagnostic utility of motor symptoms in dementia ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1532-5415.2005.53221.x","ISSN":"00028614","author":[{"dropping-particle":"","family":"Nasreddine","given":"Ziad S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Phillips","given":"Natalie A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bedirian","given":"Valerie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Charbonneau","given":"Simon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Whitehead","given":"Victor","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Collin","given":"Isabelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cummings","given":"Jeffrey L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chertkow","given":"Howard","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of the American Geriatrics Society","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2005","4","1"]]},"page":"695-699","title":"The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment","type":"article-journal","volume":"53"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1136/JNNP.74.4.530","ISSN":"0022-3050","PMID":"12640084","abstract":"This study sought to determine the utility of an interlocking finger task in screening for parietal lobe dysfunction. The ability of 69 patients to imitate a standardised set of four interlocking finger figures was compared with concurrent performance on formal neurocognitive tests. Poor interlocking finger test scores correlated most highly with standard measures of parietal lobe dysfunction. In addition, an analytical model of parietal dysfunction indicated the interlocking finger test was similar to, if not better than, standard tests of parietal lobe dysfunction. Attempts to imitate these figures should serve as a fast and simple screen of parietal lobe dysfunction.","author":[{"dropping-particle":"","family":"Moo","given":"L R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Slotnick","given":"S D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tesoro","given":"M A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zee","given":"D S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hart","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of neurology, neurosurgery, and psychiatry","id":"ITEM-2","issue":"4","issued":{"date-parts":[["2003","4","1"]]},"page":"530-2","publisher":"BMJ Publishing Group Ltd","title":"Interlocking finger test: a bedside screen for parietal lobe dysfunction.","type":"article-journal","volume":"74"},"uris":[""]},{"id":"ITEM-3","itemData":{"ISSN":"0028-3878","abstract":"OBJECTIVES The aim of this study was to (1) document rates of routine examination of the motor system among physicians attending to patients with cognitive complaints and (2) to design and validate a tool for screening for motor signs in patients with cognitive presentations. BACKGROUND Identification of abnormal motor signs is essential for accurate diagnoses of dementia syndromes. Routine motor examination is often perceived as time-consuming and daunting for non-neurologists. In clinical situations where patients with cognitive complaints do not undergo routine neurological examinations, a brief screening tool for motor signs might improve dementia diagnoses. METHODS An online survey was used to evaluate rates of neurological motor examination among physicians attending patients with cognitive problems. The Edinburgh Motor Assessment Scale (EMAS) was designed as a brief screening tool for motor signs in cognitive patients. The scale is comprised of extrapyramidal, amyotrophic, cerebellar and complex movements sub-scales. Normative data were generated using a cohort of healthy controls. Consecutive patients attending a tertiary cognitive clinic were screened for motor signs using the EMAS. RESULTS The online survey, which included 281 physicians from 30 countries, suggested that rates of routine motor examination in patients presenting with cognitive symptoms are highly variable (30-80[ percnt]) depending on physician sub-speciality. To date, the EMAS has been undertaken in 51 healthy controls and 135 patients with a mean age of 63.0 (SD=8.2, range 39-79) and 62.0 (SD=8.3, range 35-85, p=0.475) respectively. Median time to complete the EMAS was 6.1 minutes. Inter-rater reliability was high (intraclass correlation coefficient=0.894 n=20). An abnormal EMAS score was observed in 52[percnt] patients. We describe the predictive value of specific motor patterns in differentiating dementia syndromes. CONCLUSION Our findings to date suggest that the EMAS is a useful screening tool for motor signs in patients presenting with cognitive symptoms.","author":[{"dropping-particle":"","family":"Elamin","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bennett","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Symonds","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pal","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abrahams","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Parra","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bak","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""}],"collection-title":"67th American Academy of Neurology Annual Meeting, AAN 2015. Washington, DC United States.","container-title":"Neurology","id":"ITEM-3","issue":"SUPPL. 14","issued":{"date-parts":[["2015"]]},"publisher":"Lippincott Williams and Wilkins","publisher-place":"M. Elamin","title":"Introducing a brief screening a tool for motor signs in patients with dementia","type":"article-journal","volume":"84"},"uris":[""]},{"id":"ITEM-4","itemData":{"author":[{"dropping-particle":"","family":"Bak","given":"Thomas H","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Neurology, Neurosurgery & Psychiatry","id":"ITEM-4","issue":"11","issued":{"date-parts":[["2016","6","3"]]},"page":"1157","title":"Why patients with dementia need a motor examination","type":"article-journal","volume":"87"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"10.1136/","author":[{"dropping-particle":"","family":"Ahmed","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Baker","given":"I","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Thompson","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"J Neurol Neurosurg Psychiatry","id":"ITEM-5","issued":{"date-parts":[["2016"]]},"page":"1158-1162","title":"Utility of testing for apraxia and associated features in dementia","type":"article-journal","volume":"87"},"uris":[""]}],"mendeley":{"formattedCitation":"^10–14","plainTextFormattedCitation":"10–14","previouslyFormattedCitation":"^10–14"},"properties":{"noteIndex":0},"schema":""}10–14. The coin-in-hand tests and short digit span trials were included in an attempt to quantify effort or intention to fail ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/JNNP.57.3.385","PMID":"8158200","author":[{"dropping-particle":"","family":"Kapur","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of neurology, neurosurgery, and psychiatry","id":"ITEM-1","issue":"3","issued":{"date-parts":[["1994","3","1"]]},"page":"385-6","publisher":"BMJ Publishing Group Ltd","title":"The coin-in-the-hand test: a new \"bed-side\" test for the detection of malingering in patients with suspected memory disorder.","type":"article-journal","volume":"57"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁵","plainTextFormattedCitation":"15","previouslyFormattedCitation":"¹⁵"},"properties":{"noteIndex":0},"schema":""}15. The following procedure was used for the coin-in-hand test: the examiner showed the participant a two-pence coin in the palm of one hand, closed both hands into fists and asked the participant to close their eyes and count aloud backwards from 10; the participant was then asked to open their eyes and indicate which hand the coin was in; 10 trials were completed, the coin appearing in each hand an equal number of times. Any unusual behaviours during testing were noted. Data were analysed using R (version 3.5.2), and with group comparisons performed using independent 2-group t-test for continuous and Pearson’s chi-square for dichotomous data; distribution was assessed for normality (Shapiro Wilks). The study received University of Edinburgh ethical approval. Results50 subjects were recruited: 25 female and 25 male, mean age 22 (range 18-27). 78% were current university students (66% undergraduate and 12% postgraduate), 18% university graduates, and 4% neither students nor graduates. In response to the question ‘Please could you tell me what you think someone with mild or early stage dementia might experience? What symptoms might they have?’ (Table 1): 49/50 participants listed memory problems, of whom 25 specified preferential impairment of ‘short-term’ memory and 12 impairment of both ‘short-term’ and ‘long-term’ memory. Failure to recognise familiar people or faces was the most commonly reported specific memory symptom (20), followed by losing things (7), repetitive conversation (5), forgetting items like keys and shopping lists (5), forgetting tasks whilst undertaking them (4) (for example, going into a room and forgetting what you went in for), and lack of awareness of current affairs (2). Two described relative preservation of memories with emotional content. 17/50 listed ‘confusion’, 14 listed disorientation to place, getting lost, problems with spatial awareness or navigation and three disorientation in time. Ten participants listed distress or agitation: including ‘fear’, irritation and frustration’, ‘frustration’, ‘feeling insecure’ and ‘anxiety’. Eight listed motor impairment: including ‘loss of dexterity’, ‘slow movement and bad imbalance’, ‘lacking co-ordination’, ‘balance problems, falling’, ‘slower motor skills’, and ‘slightly restricted mobility’; in contrast, three specifically stated they would expect no motor impairment or physical symptoms. Six described changes in behaviour: ‘angry’, ‘strange behaviour’, ‘short and irritable’, ‘expressionless’, ‘slight personality change’, ‘saying things that are out of character or socially unacceptable’, ‘reduced social interaction’; six listed speech changes, including ‘difficulty speaking / difficulty forming sentences’, ‘disorganised speech’, ‘mixing words up’, ‘slurred words’ and ‘slow speech’. Five listed affective symptoms including ‘sadness’, ‘negative mood’, ‘not a full range of emotions’, and another ‘absence of drive and motivation’. Five listed problems performing simple tasks, one of whom stated that a person with dementia might sustain a greater number of accidental injuries such as burns or cuts from cooking. Three included higher-order problems: ‘loss of critical reasoning’, ‘problems with decision making’, ‘difficulty problem solving’. Two listed ‘short attention span’. Symptoms mentioned once only included: confabulation (‘constructing false memories’); ‘paranoia’ and auditory and visual hallucinations (‘speaking to self / seeing things’); slow processing speed; lack of insight (‘denial of symptoms’); neglect of self, household and pets; ‘reminiscing’; ‘removal from reality’; ‘tiredness’; and ‘headaches’.Mean MOCA score was 16 (±5.5, range 5 – 26, maximum potential score 30) (Table 2). The items with most errors were: delayed recall of five items (100%, with 72% recalling two or fewer items), letter vigilance (86%), digit span (5 digits) (82%), clock-drawing (82%), and sentence repetition (80%). The items with fewest errors were cube drawing (42%) and serial sevens (54%). 16 (32%) made at least one perseveration in verbal fluency. We also noted some perseverative responses during delayed recall: ‘feet’ (when previously produced in letter fluency) and ‘clock’; and some semantic errors such as ‘rose’ for daisy. Median total summed response time for the whole MocA was 7 minutes 57 seconds with an unusually wide range (5 minutes 13 seconds - 14 minutes 12 seconds, IQR 2 minutes 4 seconds.) Data from digit span testing was particularly interesting in relation to what might be expected in mild dementia. 58% of subjects failed a forward digit span of four digits, and 26% a forward digit span of three digits. On the coin-in-hand test, 12 (24%) scored at and four (8%) below, the level expected by chance (Figure 1). Three subjects (6%) including two of those scoring 10/10 were observed to circumvent the requirement to recall the coin’s location during the test by pointing to the correct hand whilst they had their eyes closed. Four struggled or failed to count backwards from ten. 9 (18%) achieved all three steps of the Luria three-step test and 17 (34%) did not manage the first step, the remaining 24 (48%) managing one or two steps (Figure 2). 15 (30%) copied all four interlocking finger positions, 23 (46%) three, 10 (20%) two; one subject copied only one and another failed to copy any of the hand positions.We noted several inconsistent patterns of response. 15 successfully achieved 5/5 in subtraction of serial sevens from 100 but failed to repeat a digit span of five, of whom six also failed a reverse digit span of two digits. Of the 29 subjects who failed forward digit span of four digits, 16 (55%) passed cube drawing, 10 (34%) passed serial sevens and four (14%) achieved full marks for orientation. Of the 15 scoring 4/4 on Interlocking Fingers, 11 (73%) did not successfully complete the Clock Drawing task. Similarly, of the nine participants scoring 3/3 on the Clock Drawing task, five (56%) were unable to copy all four finger positions. Gait appeared normal in 26 (52%) and abnormal in 24 (48%): five were unusually slow and one very quick, 16 appeared unsteady, and 17 failed to manage or lost their balance during tandem gait. Ten in whom gait otherwise appeared normal appeared to have difficulty remembering or following instructions during examination of gait.There were no significant differences in total or individual item scores between the 24 participants who reported a family history of dementia (all grandparents) and in the 26 who did not. On the clock-drawing task, individuals with a family history were faster than those without (42.3 seconds vs. 54.7 seconds, p=0.02 (95%CI 1.48,23.3); there were no other significant differences in response time.DiscussionAttention and beliefs are widely recognised as important elements in the aetiology of functional neurological disorders ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/brain/aws129","author":[{"dropping-particle":"","family":"Edwards","given":"M J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Adams","given":"R A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Parees","given":"I","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Friston","given":"K J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Brain","id":"ITEM-1","issue":"11","issued":{"date-parts":[["2012","11","20"]]},"page":"3495-3512","title":"A Bayesian account of 'hysteria'","type":"article-journal","volume":"135"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.neubiorev.2017.01.015","ISSN":"01497634","PMID":"28108416","author":[{"dropping-particle":"","family":"Bergh","given":"Oliver","non-dropping-particle":"Van den","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Witth?ft","given":"Michael","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Petersen","given":"Sibylle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"Richard J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Neuoscience & Biobehavioral reviews","id":"ITEM-2","issued":{"date-parts":[["2017"]]},"page":"185-203","publisher":"Elsevier Ltd","title":"Symptoms and the body: Taking the inferential leap","type":"article-journal","volume":"74"},"uris":[""]}],"mendeley":{"formattedCitation":"^16,17","plainTextFormattedCitation":"16,17","previouslyFormattedCitation":"^16,17"},"properties":{"noteIndex":0},"schema":""}16,17. In the Bayesian paradigm described by Edwards et al, prior beliefs about movement, typically not held in awareness, exert a top-down influence on sensorimotor processing to produce and maintain symptoms of functional motor disorder ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/brain/aws129","author":[{"dropping-particle":"","family":"Edwards","given":"M J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Adams","given":"R A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Parees","given":"I","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Friston","given":"K J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Brain","id":"ITEM-1","issue":"11","issued":{"date-parts":[["2012","11","20"]]},"page":"3495-3512","title":"A Bayesian account of 'hysteria'","type":"article-journal","volume":"135"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁶","plainTextFormattedCitation":"16","previouslyFormattedCitation":"¹⁶"},"properties":{"noteIndex":0},"schema":""}16. Experimental simulation has previously demonstrated similarity between simulated and functional paralysis, both groups also demonstrating sensory loss, in patterns (for example, circumferential) that are less common in structural lesions ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.jns.2017.08.3248","ISSN":"18785883","abstract":"Introduction Symptoms and signs of functional (psychogenic) motor and sensory disorder are often said to be dependent on the patients’ idea of what symptoms should be, rather than anatomy and physiology. This hypothesis has however rarely been tested. Materials and methods Inspired by a brief experiment carried out in 1919 by neurologist Arthur Hurst we aimed to assess the views of healthy non-medical adults towards paralysis and numbness and their response to tests for functional disorders when asked to pretend to have motor and sensory symptoms. Results When subjects were asked to pretend they had a paralysed arm 80% thought there would be sensory loss. Of these 60% thought it would have a circumferential (functional) distribution at the wrist, elbow or shoulder. Hoover's sign of functional weakness was only positive in 75% of patients pretending to have leg paralysis with 23% maintaining weakness of hip extension in the feigned weak leg, a rare finding in neurological practice. 20% of subjects managed to continue having their feigned tremor during the entrainment test. 52% of subjects thought there was asymmetry of a tuning fork across their forehead even when no prior instruction had been given. Conclusions The study confirmed Hurst's finding that non-medical people generally expect sensory loss to go along with paralysis, especially if the examiner suggests it. When present, it usually conforms to functional patterns of sensory loss. Clinical tests for functional and motor disorders appear to behave somewhat differently in patients asked to pretend to have symptoms suggesting that larger more detailed studies would be worthwhile.","author":[{"dropping-particle":"","family":"Stone","given":"Jon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mutch","given":"Jennifer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Giannokous","given":"Denis","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hoeritzauer","given":"Ingrid","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carson","given":"Alan","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of the Neurological Sciences","id":"ITEM-1","issue":"August","issued":{"date-parts":[["2017"]]},"page":"188-191","title":"Hurst revisited: Are symptoms and signs of functional motor and sensory disorders “dependent on idea”?","type":"article-journal","volume":"381"},"uris":[""]},{"id":"ITEM-2","itemData":{"ISBN":"459483976","author":[{"dropping-particle":"","family":"Hurst","given":"Arthur F","non-dropping-particle":"","parse-names":false,"suffix":""}],"edition":"1","id":"ITEM-2","issued":{"date-parts":[["1920","1","1"]]},"number-of-pages":"131","publisher":"Frowde, Hodder & Stoughton","publisher-place":"London","title":"The psychology of the special senses and their functional disorders","type":"book"},"uris":[""]}],"mendeley":{"formattedCitation":"^9,18","plainTextFormattedCitation":"9,18","previouslyFormattedCitation":"^9,18"},"properties":{"noteIndex":0},"schema":""}9,18. It might therefore be similarly expected that individuals simulating dementia might demonstrate prior beliefs about dementia which are more characteristic of functional cognitive disorders than of dementia. This study aimed to access prior beliefs about dementia in healthy individuals by asking them to simulate symptoms of mild dementia, with the purpose of clarifying those ideas and identifying behaviours with potential utility in the diagnosis of functional cognitive disorders. This cognitively healthy and highly educated group of young adults, asked to simulate mild dementia, scored similarly to individuals with mild Alzheimer’s disease in the original normative data, with a mean score of 16 and 90% falling below the 23/30 cutoff ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1532-5415.2005.53221.x","ISSN":"00028614","author":[{"dropping-particle":"","family":"Nasreddine","given":"Ziad S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Phillips","given":"Natalie A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bedirian","given":"Valerie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Charbonneau","given":"Simon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Whitehead","given":"Victor","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Collin","given":"Isabelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cummings","given":"Jeffrey L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chertkow","given":"Howard","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of the American Geriatrics Society","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2005","4","1"]]},"page":"695-699","title":"The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment","type":"article-journal","volume":"53"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"","ISSN":"1873-5843","abstract":"Objective: To report descriptive and normative data for the Montreal Cognitive Assessment (MoCA) in a population-based African American sample., Method: The MoCA was administered to 1,419 African American participants (mean age 49.89 years, range 18-75, 64% female). After excluding those with subjective cognitive complaints (n = 301), normative data were generated by education and overlapping age ranges (n = 1,118). Pearson correlations and analysis of variance were used to examine the relationship to demographic variables, and frequency of missed items was reviewed., Results: Total MoCA scores (mean 22.3, SD 3.9) were lower than previously published normative data derived from an elderly Caucasian Canadian population with 80% falling below the suggested cutoff (<26) for impairment. Several MoCA items were missed by a large portion of the sample, including cube drawing (72%), delayed free recall (66% <4/5 words), sentence repetition (63%), and abstraction items (45%)., Conclusion: This is the first study to examine normative performance on the MoCA specific to community-dwelling African Americans. Findings suggest that certain aspects of this measure and previously established cutoff scores may not be well-suited for some populations.Copyright ? The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@.","author":[{"dropping-particle":"","family":"Rossetti","given":"Heidi C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lacritz","given":"Laura H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hynan","given":"Linda S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cullum","given":"C Munro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wright","given":"Aaron","non-dropping-particle":"Van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Weiner","given":"Myron F","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Archives of clinical neuropsychology","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2017"]]},"page":"238-244","title":"Montreal Cognitive Assessment Performance among Community-Dwelling African Americans.","type":"article-journal","volume":"32"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1080/13825585.2015.1041449","author":[{"dropping-particle":"","family":"Malek-Ahmadi","given":"Michael","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Powell","given":"Jessica J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Belden","given":"Christine M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Evans","given":"Linda","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Coon","given":"David W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nieri","given":"Walter","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Aging, Neuropsychology, and Cognition","id":"ITEM-3","issue":"6","issued":{"date-parts":[["2015"]]},"note":"160119\n\nOf 205 participants mean age 84.6(SD 7.88), the mean MoCA score was 25.03 (SD 3.06), with 43% of the sample scoring below the 26 cutoff.","page":"755-761","title":"Age-and education-adjusted normative data for the Montreal Cognitive Assessment (MoCA) in older adults age 70-99","type":"article-journal","volume":"22"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.3233/JAD-170203","ISSN":"1875-8908","PMID":"28697562","abstract":"BACKGROUND The Montreal Cognitive Assessment (MoCA) has a high sensitivity for detecting cognitive dysfunction. Swedish normative data does not exist and international norms are often derived from populations where cognitive impairment has not been screened for and not been thoroughly assessed to exclude subjects with dementia or mild cognitive impairment. OBJECTIVE To establish norms for MoCA and develop a regression-based norm calculator based on a large, well-examined cohort. METHODS MoCA was administered on 860 randomly selected elderly people from a population-based cohort from the EPIC study. Cognitive dysfunction was screened for and further assessed at a memory clinic. After excluding cognitively impaired participants, normative data was derived from 758 people, aged 65-85. RESULTS MoCA cut-offs (-1 to -2 standard deviations) for cognitive impairment ranged from <25 to <21 for the lowest educated and <26 to <24 for the highest educated, depending on age group. Significant predictors for MoCA score were age, sex and level of education. CONCLUSION We present detailed normative MoCA data and cut-offs according to the DSM-5 criteria for cognitive impairment based on a large population-based cohort of elderly individuals, screened and thoroughly investigated to rule out cognitive impairment. Level of education, sex, and age should be taken in account when evaluating MoCA score, which is facilitated by our online regression-based calculator that provide percentile and z-score for a subject's MoCA score.","author":[{"dropping-particle":"","family":"Borland","given":"Emma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"N?gga","given":"Katarina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nilsson","given":"Peter M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Minthon","given":"Lennart","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nilsson","given":"Erik D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Palmqvist","given":"Sebastian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Alzheimer's disease","id":"ITEM-4","issue":"3","issued":{"date-parts":[["2017"]]},"note":"160119\n\nIn normative data from a cohort of 758 people (those with MCI and dementia excluded) aged 65-78 (mean age 73) the mean MoCA score was 26.0 (SD 2.3), with 37.3% scoring below the cut-off. Most points were lost on delayed recall (mean score 62% available points), fluency (69%) and abstraction (85%).","page":"893-901","title":"The Montreal Cognitive Assessment: Normative Data from a Large Swedish Population-Based Cohort.","type":"article-journal","volume":"59"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"","ISSN":"978-1-4471-2451-1 (Paperback); 978-1-4471-2452-8 (PDF)","abstract":"The Montreal Cognitive Assessment (MoCA) is a cognitive screening instrument developed to detect mild cognitive impairment (MCI). It is a simple 10 minute paper and pencil test that assesses multiple cognitive domains including memory, language, executive functions, visuospatial skills, calculation, abstraction, attention, concentration, and orientation. Its validity has been established to detect mild cognitive impairment in patients with Alzheimer's disease and other pathologies in cognitively impaired subjects who scored in the normal range on the Mini-Mental State Examination (MMSE). MoCA's sensitivity and specificity to detect subjects with MCI due to Alzheimer's disease and distinguish them from healthy controls are excellent. MoCA is also sensitive to detect cognitive impairment in cerebrovascular disease and Parkinson's disease, Huntington's disease, brain tumors, systemic lupus erythematosus, substance use disorders, idiopathic rapid eye movement sleep behaviour disorder, obstructive sleep apnoea, risk of falling, rehabilitation outcome, and epilepsy. There are several features in MoCA's design that likely explain its superior sensitivity for detecting MCI. The MoCA's memory testing involves more words, fewer learning trials, and a longer delay before recall than the MMSE. Executive functions, higher-level language abilities, and complex visuospatial processing can also be mildly impaired in MCI participants of various etiologies and are assessed by the MoCA with more numerous and demanding tasks than the MMSE. MoCA was developed in a memory clinic setting and normed in a highly educated population. Norms in lesser educated, community based, multi-cultural samples will hopefully be available to help first line healthcare providers better assess subjects presenting with cognitive complaints. The MoCA is freely accessible for clinical and educational purposes (), and is available in 36 languages and dialects. (PsycINFO Database Record (c) 2017 APA, all rights reserved)","author":[{"dropping-particle":"","family":"Julayanont","given":"Parunyou","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Phillips","given":"Natalie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chertkow","given":"Howard","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nasreddine","given":"Ziad S","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Cognitive screening instruments: A practical approach.","editor":[{"dropping-particle":"","family":"Larner","given":"Andrew J","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-5","issued":{"date-parts":[["2017"]]},"page":"139-195","publisher":"Springer","title":"Montreal Cognitive Assessment (MoCA): Concept and clinical review.","type":"chapter"},"uris":[""]}],"mendeley":{"formattedCitation":"^10,19–22","plainTextFormattedCitation":"10,19–22","previouslyFormattedCitation":"^10,19–22"},"properties":{"noteIndex":0},"schema":""}10,19–22. We were surprised by the severity of apparent impairment displayed, expecting more subtle deficits. In previous studies of simulated ‘mental disorder’ and of cognitive impairment due to brain injury, simulators (particularly student simulators) have produced milder impairments than disease controls ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"18 normal Ss were asked to simulate mental disorder, following which each was submitted to a standardized psychiatric examination. The results were contrasted with those of a normal nonsimulating group, a group of patients with organic dementia, and a group exhibiting pseudodementia. In relation to the number and quality of errors made, certain differences are demonstrable. The pertinent world literature is discussed on the basis of a 65-item bibliography. (PsycINFO Database Record (c) 2016 APA, all rights reserved)","author":[{"dropping-particle":"","family":"Anderson","given":"E W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Trethowan","given":"W H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kenna","given":"J C","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Acta Psychiatrica et Neurologica","id":"ITEM-1","issued":{"date-parts":[["1959"]]},"page":"42","title":"An experimental investigation of simulation and pseudo-dementia.","type":"article-journal","volume":"34, Suppl."},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1076/clin.15.2.171.1891","ISBN":"419)861±4458","ISSN":"1744-4144","author":[{"dropping-particle":"","family":"Haines","given":"Mary E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Norris","given":"Margaret P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Clinical Neuropsychologist","id":"ITEM-2","issue":"2","issued":{"date-parts":[["2001"]]},"note":"important to read","page":"171-182","title":"Comparing Student and Patient Simulated Malingerers Performance on Standard Neuropsychological Measures to Detect Feigned Cognitive Deficits","type":"article-journal","volume":"15"},"uris":[""]}],"mendeley":{"formattedCitation":"^23,24","plainTextFormattedCitation":"23,24","previouslyFormattedCitation":"^23,24"},"properties":{"noteIndex":0},"schema":""}23,24. However, the overall level and scope of impairment demonstrated by this cohort of simulating subjects reflected the overall impression suggested by their verbal descriptions of mild dementia. Although most identified memory impairment as a key symptom, more often dementia was described as a syndrome of global impairments even at an early stage; motor, speech, emotional and behavioural symptoms were relatively over-represented in our subjects’ reports of expected symptoms, whereas lack of insight – prevalent in dementia – was only included in the report of one subject, suggesting either that lack of insight is not recognised to be important or that it is assumed to be so common as to not be worthy of mention ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s11910-016-0684-z","ISSN":"1528-4042","author":[{"dropping-particle":"","family":"Wilson","given":"Robert S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sytsma","given":"Joel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barnes","given":"Lisa L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Boyle","given":"Patricia A","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Current Neurology and Neuroscience Reports","id":"ITEM-1","issue":"9","issued":{"date-parts":[["2016"]]},"page":"77","title":"Anosognosia in Dementia","type":"article-journal","volume":"16"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁵","plainTextFormattedCitation":"25","previouslyFormattedCitation":"²⁵"},"properties":{"noteIndex":0},"schema":""}25. In those with functional cognitive disorder, the former seems more likely, given the frequent observation of memory catastrophisation, in which the patient is acutely aware of their deficits whereas others are not. Our first observation, therefore, is that healthy young adults perceive even mild dementia as a condition of significant rather than subtle impairment. Although total scores were similar, patterns of apparent impairment differed in several important ways from norms for both dementia and cognitively healthy populations. In normative data, individuals with Alzheimer’s Dementia and MCI have been reported to perform worst on trail-making, clock drawing, naming, delayed recall, phonemic fluency, abstraction, and orientation ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1532-5415.2005.53221.x","ISSN":"00028614","author":[{"dropping-particle":"","family":"Nasreddine","given":"Ziad S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Phillips","given":"Natalie A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bedirian","given":"Valerie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Charbonneau","given":"Simon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Whitehead","given":"Victor","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Collin","given":"Isabelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cummings","given":"Jeffrey L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chertkow","given":"Howard","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of the American Geriatrics Society","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2005","4","1"]]},"page":"695-699","title":"The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment","type":"article-journal","volume":"53"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁰","plainTextFormattedCitation":"10","previouslyFormattedCitation":"¹⁰"},"properties":{"noteIndex":0},"schema":""}10. This group of adults simulating dementia performed worst on delayed recall (100%), letter vigilance (86%), clock-drawing (82%), forward digit span (82%), repetition (80%), fluency (78%) and trail-making (72%); letter vigilance (a task involving sustained attention and response inhibition) therefore being more impaired than might be expected in mild dementia. A cognitively healthy cohort of 73 year olds lost most points for delayed recall (mean score 3.1±1.3), fluency (0.7±0.5), and abstraction (1.7±0.6) ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3233/JAD-170203","ISSN":"1875-8908","PMID":"28697562","abstract":"BACKGROUND The Montreal Cognitive Assessment (MoCA) has a high sensitivity for detecting cognitive dysfunction. Swedish normative data does not exist and international norms are often derived from populations where cognitive impairment has not been screened for and not been thoroughly assessed to exclude subjects with dementia or mild cognitive impairment. OBJECTIVE To establish norms for MoCA and develop a regression-based norm calculator based on a large, well-examined cohort. METHODS MoCA was administered on 860 randomly selected elderly people from a population-based cohort from the EPIC study. Cognitive dysfunction was screened for and further assessed at a memory clinic. After excluding cognitively impaired participants, normative data was derived from 758 people, aged 65-85. RESULTS MoCA cut-offs (-1 to -2 standard deviations) for cognitive impairment ranged from <25 to <21 for the lowest educated and <26 to <24 for the highest educated, depending on age group. Significant predictors for MoCA score were age, sex and level of education. CONCLUSION We present detailed normative MoCA data and cut-offs according to the DSM-5 criteria for cognitive impairment based on a large population-based cohort of elderly individuals, screened and thoroughly investigated to rule out cognitive impairment. Level of education, sex, and age should be taken in account when evaluating MoCA score, which is facilitated by our online regression-based calculator that provide percentile and z-score for a subject's MoCA score.","author":[{"dropping-particle":"","family":"Borland","given":"Emma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"N?gga","given":"Katarina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nilsson","given":"Peter M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Minthon","given":"Lennart","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nilsson","given":"Erik D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Palmqvist","given":"Sebastian","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Alzheimer's disease","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2017"]]},"note":"160119\n\nIn normative data from a cohort of 758 people (those with MCI and dementia excluded) aged 65-78 (mean age 73) the mean MoCA score was 26.0 (SD 2.3), with 37.3% scoring below the cut-off. Most points were lost on delayed recall (mean score 62% available points), fluency (69%) and abstraction (85%).","page":"893-901","title":"The Montreal Cognitive Assessment: Normative Data from a Large Swedish Population-Based Cohort.","type":"article-journal","volume":"59"},"uris":[""]}],"mendeley":{"formattedCitation":"²¹","plainTextFormattedCitation":"21","previouslyFormattedCitation":"²¹"},"properties":{"noteIndex":0},"schema":""}21. Our simulating subjects scored worse than healthy controls in all of these measures: delayed recall (2, IQR 2), fluency (0.22±0.41) and abstraction (1.24±0.71). In another population-based sample the items with the most frequent errors were cube drawing (59%) and delayed recall (56%) ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1212/WNL.0b013e318230208a","ISSN":"0028-3878","PMID":"21917776","abstract":"OBJECTIVE To provide normative and descriptive data for the Montreal Cognitive Assessment (MoCA) in a large, ethnically diverse sample. METHODS The MoCA was administered to 2,653 ethnically diverse subjects as part of a population-based study of cardiovascular disease (mean age 50.30 years, range 18-85; Caucasian 34%, African American 52%, Hispanic 11%, other 2%). Normative data were generated by age and education. Pearson correlations and analysis of variance were used to examine relationship to demographic variables. Frequency of missed items was also reviewed. RESULTS Total scores were lower than previously published normative data (mean 23.4, SD 4.0), with 66% falling below the suggested cutoff (<26) for impairment. Most frequently missed items included the cube drawing (59%), delayed free recall (56%; <4/5 words), sentence repetition (55%), placement of clock hands (43%), abstraction items (40%), and verbal fluency (38%; <11 words in 1 minute). Normative data stratified by age and education were derived. CONCLUSION These findings highlight the need for population-based norms for the MoCA and use of caution when applying established cut scores, particularly given the high failure rate on certain items. Demographic factors must be considered when interpreting this measure.","author":[{"dropping-particle":"","family":"Rossetti","given":"H C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lacritz","given":"L H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cullum","given":"C M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Weiner","given":"M F","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Neurology","id":"ITEM-1","issue":"13","issued":{"date-parts":[["2011","9","27"]]},"note":"160119\n\nIn 2653 subjects (mean age 50), total scores were mean 23.4 (SD 4.0). Most frequently missed items were cube drawing (59%), delayed free recall (56% &lt;4/5), sentence repetition (55%), placement of clock hands (43%), abstraction (40%) and verbal fluency (38%). The mean score for &lt;35 year olds (n = 207) was 25.16 (3.08).","page":"1272-1275","title":"Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample","type":"article-journal","volume":"77"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁶","plainTextFormattedCitation":"26","previouslyFormattedCitation":"²⁶"},"properties":{"noteIndex":0},"schema":""}26. Cube drawing was comparatively preserved in our simulating group, 44% making errors, whereas 100% failed delayed recall. It seems that these simulating adults do not perform with an exaggerated pattern of normal failures, nor do they perform similarly to those of individuals with mild dementia. The degree of effort applied during cognitive testing significantly influences performance but is notoriously difficult to define and measure. Some validity tests are so straightforward that they should be completed without difficulty even in the presence of significant impairment. Others use a ‘forced choice’ paradigm, on the basis that scoring less than chance indicates intention to fail: arguably a completely different concept to that of effort by degree of intention to perform to capacity. The coin-in-hand test meets both criteria, and is easy to perform in clinic without special equipment ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/JNNP.57.3.385","PMID":"8158200","author":[{"dropping-particle":"","family":"Kapur","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of neurology, neurosurgery, and psychiatry","id":"ITEM-1","issue":"3","issued":{"date-parts":[["1994","3","1"]]},"page":"385-6","publisher":"BMJ Publishing Group Ltd","title":"The coin-in-the-hand test: a new \"bed-side\" test for the detection of malingering in patients with suspected memory disorder.","type":"article-journal","volume":"57"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁵","plainTextFormattedCitation":"15","previouslyFormattedCitation":"¹⁵"},"properties":{"noteIndex":0},"schema":""}15. In this study, subjects simulating dementia performed poorly on the coin-in-hand test, 84% scoring 7/10 or less, although only 8% scored below the level expected by chance. We have reservations about the utility of these tests in the memory clinic. Critically, individuals with dementia also sometimes fail effort tests. In a study of six validity tests 5/22 individuals with moderate to severe dementia failed (scoring 7/10 or less) the coin-in-hand test (although the number scoring at or less than chance is not reported); 16/22 (7/20 with mild dementia) failed the Medical Symptom Validity Test and 16/22 failed the Rey 15 item test ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1080/13607863.2010.508770","ISSN":"1360-7863","abstract":"Objectives: Performance on neuropsychological tests can be influenced by non-cognitive factors, including deliberate underperformance, stress, the need to fulfil a sick role, depression, un-cooperativeness, fatigue and unhappiness with the evaluative situation. Tests to detect suboptimal effort are becoming widely used in clinical practice and are based on their reported insensitivity to cognitive dysfunction. A diagnosis of dementia has life-changing implications for an individual of working age. It is therefore crucial that clinicians can be confident they have obtained a valid estimate of current cognitive functioning. This study aimed to establish whether mood or cognitive functioning adversely influenced performance on symptom validity tests (SVTs) in individuals with working age dementia, who were judged to be using full effort. Method: Forty-two participants with dementia diagnosed before the age of 65 completed measures of emotional and cognitive functioning and six SVTs. Results: There were no si...","author":[{"dropping-particle":"","family":"Rudman","given":"Natalie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oyebode","given":"Jan R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"Chris A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bentham","given":"Peter","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Aging & Mental Health","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2011","1","5"]]},"note":"180119\n\nSubjects with dementia may score differently in effort tests than those with head injury or neurological patients [check refs]. \n\n6 SVTs trialled in patients with mild dementia and with moderate/severe dementia. \n\nRey-15 and TOMM most sensitive to 'genuine memory impairments seen in dementia'\n\nDot counting (times) was passed by every participant, therefore 100% specific (no false positives). Coin in hand was the next most specific at 88.1%, Dot counting (error score) 78.6%, TOMM 64.3%, Rey-15 54.8%, MSVT 45.2% and NV-MSVT 33.3%. \n\nImpairment of recent memory, calculation and attention predicted poor performance on the coin in hand test.","page":"47-57","publisher":"Routledge","title":"An investigation into the validity of effort tests in a working age dementia population","type":"article-journal","volume":"15"},"uris":["",""]}],"mendeley":{"formattedCitation":"²⁷","plainTextFormattedCitation":"27","previouslyFormattedCitation":"²⁷"},"properties":{"noteIndex":0},"schema":""}27. So, although a cutoff score of 7/10 on the coin-in-hand test would correctly identify 84% of our simulating patients, this could not be relied on in a clinical context to exclude other causes of cognitive impairment. Moreover, interpretation of validity test performance in non-simulating, non-litigating patients with functional neurological disorders is complex: in some individuals, the interference from pathologically excessive effort, and anxiety, might disrupt normally automatic cognitive processes in order to produce results suggesting, paradoxically, a lack of effort. In normative WAIS (Wechsler Adult Intelligence Scale) digit span data, individuals with memory impairment, including due to Alzheimer’s dementia or vascular dementia, traumatic brain injury, Korsakoff’s syndrome, and temporal lobectomy, generally scored between five and eight on forward digit span; 4.1%, of all clinical groups and 10.5% with Alzheimer’s disease scored a maximum of four and 2.6% of the Alzheimer’s disease group scored a maximum of three; young adults aged 20-24 scored a mean of 6.8±1.3, reducing gradually over age to a mean of 5.7±1.0 in those aged 85-89 ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0887-6177(01)00176-7","ISSN":"0887-6177","abstract":"In several studies, suppressed Digit Span performance has been proposed as a potential marker for deliberately poor performance in a neuropsychological evaluation. The purpose of this study was to document Digit Span performance patterns in the Wechsler Adult Intelligence Scale—Third Edition (WAIS-III; Wechsler, 1997) standardization sample and selected clinical groups. Base rate tables were generated for the Digit Span scaled score, longest span forward, longest span backward, and the Vocabulary–Digit Span difference score. Cut-off scores for suspecting negative response bias were proposed, and clinical case examples were used to illustrate these scores.","author":[{"dropping-particle":"","family":"Iverson","given":"Grant L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tulsky","given":"David S","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Archives of Clinical Neuropsychology","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2003","1","1"]]},"page":"1-9","title":"Detecting malingering on the WAIS-III: Unusual Digit Span performance patterns in the normal population and in clinical groups","type":"article-journal","volume":"18"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁸","plainTextFormattedCitation":"28","previouslyFormattedCitation":"²⁸"},"properties":{"noteIndex":0},"schema":""}28. In a study of 18 individuals with Alzheimer’s dementia, 18 with vascular dementia and 26 controls, neither Alzheimer’s nor vascular dementia were associated with impaired performance on forward digit span (mean scores around 5.5 in both groups), although both dementia groups were impaired on backward digit span compared with controls ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"This study aimed to explore verbal and spatial memory spans in Alzheimer's (AD) and multi-infarct (MID) demented patients. For this purpose, we administered the forward and backward versions of the Digit Span and of the Corsi test to 18 AD, 18 MID and 26 controls. Results revealed a normal forward verbal span but reduced backward verbal and forward and backward spatial spans in both demented groups. These data are discussed in the light of the Working Memory model. It is argued that the normal verbal forward span is sustained by a normally functioning Articulatory Loop. The deficient processing resources of the Central Executive, on the other side, are responsible for the reduced extension of the other memory spans. The possible anatomical substrate of short-term memory impairment in dementia, as well as alternative interpretations of memory span performance in demented patients are discussed.","author":[{"dropping-particle":"","family":"Carlesimo","given":"GA","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fadd","given":"L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lorusso","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Caltagirone","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Acta Neurologica Scandinavica","id":"ITEM-1","issued":{"date-parts":[["1994"]]},"page":"132-138","title":"Verbal and spatial memory spans in Alzheimer's and multi-infarct dementia","type":"article-journal","volume":"89"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁹","plainTextFormattedCitation":"29","previouslyFormattedCitation":"²⁹"},"properties":{"noteIndex":0},"schema":""}29. Reliable digit span (summed maximum forward and backwards span measured using the WAIS) has been used in attempts to measure effort ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISBN":"9781483216867","abstract":"Alcoholic Korsakoff's Syndrome. Cover image; Title page; Table of Contents; Copyright; Dedication; Preface; Acknowledgments; Chapter 1: Clinical Symptoms, Neuropathology, and Etiology; Publisher Summary; NEUROPATHOLOGY; ETIOLOGY; Chapter 2: The Original Memory Model; Publisher Summary; FUNCTIONAL DIFFERENCES AMONG LONG-TERM MEMORY, SHORT-TERM MEMORY, AND SENSORY MEMORY; SHORT-TERM-LONG-TERM-MEMORY PARADIGMS FREQUENTLY USED IN AMNESIA RESEARCH; Chapter 3: Long-Term Memory; Publisher Summary; PAIRED-ASSOCIATE LEARNING; SERIAL LEARNING; REMOTE MEMORY; SEMANTIC MEMORY; MOTOR MEMORY; Chapter 4: Short-Term Memory. Publisher SummaryRECENCY IN SERIAL LEARNING; DISTRACTOR TASK RECALL; RATE OF RETRIEVAL FROM SHORT-TERM MEMORY; SENSORY MEMORY; SHORT-TERM MOTOR MEMORY; Chapter 5: Encoding Deficits; Publisher Summary; Chapter 6: Depth of Encoding and Visuoperceptive Deficits; Publisher Summary; ANALYSES OF THE ALCOHOLIC KORSAKOFF PATIENT'S DEFICITS ON THE DIGIT-SYMBOL TEST; LIMITED ENCODING AND THE ALCOHOLIC KORSAKOFF PATIENT'S DEFICITS IN FACE PERCEPTION; Chapter 7: Alternative Theories Of Amnesia; Publisher Summary; CONSOLIDATION; RETRIEVAL-INTERFERENCE THEORY; CONTEXTUAL THEORY. OTHER THEORETICAL APPROACHESTHEORETICAL CONCLUSIONS; Chapter 8: Are All Amnesics Alike?; Publisher Summary; MEMORY DISORDERS OF POSTENCEPHALITIC PATIENTS; INDIVIDUAL CASE STUDIES; COMPARISONS OF ALCOHOLIC KORSAKOFF AND DEMENTING PATIENTS; Chapter 9: Sensory Capacities; Publisher Summary; Chapter 10: Memory and Cognitive Disorders of Chronic Alcoholics; Publisher Summary; References; Subject Index.","author":[{"dropping-particle":"","family":"Butters","given":"Nelson.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cermak","given":"Laird S.","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["1980"]]},"number-of-pages":"305","publisher":"Academic Press","publisher-place":"New York","title":"Alcoholic Korsakoff's Syndrome : an Information-Processing Approach to Amnesia.","type":"book"},"uris":["",""]},{"id":"ITEM-2","itemData":{"DOI":"10.1037/1040-3590.6.3.218","abstract":"A large sample of chronic postconcussive patients with and without overt malingering signs was compared with objectively brain-injured patients on common episodic memory and malingered amnesia measures. Probable malingerers and traumatically brain-injured subjects were not differ-entiated on popular episodic recall tests. In contrast, probable malingerers performed poorly on the Rey 15-Item, Rey Word Recognition List, Reliable Digit Span, Portland Digit Recognition Test, and Rey Auditory Verbal Learning Test recognition trial. These findings validated both commonly cited malingering measures and newly introduced methods of classifying malingering in real-world clini-cal samples. The base rate for malingering in chronically complaining mild head injury patients may be much larger than previously assumed.","author":[{"dropping-particle":"","family":"Greiffenstein","given":"Manfred F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Baker","given":"W John","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gola","given":"Thomas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Psychological Assessment","id":"ITEM-2","issue":"3","issued":{"date-parts":[["1994"]]},"note":"160119\n\nReliable digit span - summed maximum forward and backward span, as measured using the WAIS, with a cutoff of 7/8 - was described as effective in detecting 'probable malingering' by Grieffenstein, although individuals with conduction aphasia or anxiety can also score poorly.","page":"218-224","title":"Validation of Malingered Amnesia Measures With a Large Clinical Sample","type":"article-journal","volume":"6"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1177/1073191102009003009","ISBN":"1073-1911","ISSN":"1073-1911","PMID":"12216787","abstract":"This study assessed the effectiveness of Greiffenstein’s Reliable Digit Span (RDS) score for the detection of malingered neurocognitive dysfunction. Participants were 54 traumatic brain injury patients referred for neuropsychological evaluation. Twenty-four met the Slick, Sherman, and Iverson criteria for at least probable malingered neurocognitive dysfunction. The control group was composed of 30 patients without external incentive and who thus did not meet the Slick criteria. All patients completed the digit span test as part of either the WAIS-R or WAIS-III. The RDS scores were calculated, and sensitivity, specificity, and predictive power were examined for several cutoffs. Classification accuracy for the RDS was excellent. Issues related to the clinical application of this technique are discussed.","author":[{"dropping-particle":"","family":"Mathias","given":"Charles W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Greve","given":"Kevin W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bianchini","given":"Kevin J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Houston","given":"Rebecca J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Crouch","given":"John A","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Assessment","id":"ITEM-3","issue":"3","issued":{"date-parts":[["2002"]]},"page":"301-308","title":"Dysfunction Using the Reliable Digit Span in Traumatic Brain Injury","type":"article-journal","volume":"9"},"uris":[""]}],"mendeley":{"formattedCitation":"^30–32","plainTextFormattedCitation":"30–32","previouslyFormattedCitation":"^30–32"},"properties":{"noteIndex":0},"schema":""}30–32. Although Reliable Digit Span could not be calculated here due to the simple method used to test digit span, addition of short digit span trials to those included in the MoCA enriched the examination by demonstrating exceedingly poor performance in some individuals; 26% failed a digit span of three and 36% failed reverse span of two digits, suggesting that a substantial minority of those tested believe working memory to be significantly impaired in individuals with mild dementia. Internal inconsistency is a key feature of functional neurological disorders; for example, in Hoover’s test, hip extension is weak during active movement but returns to normal with contralateral flexion against resistance. Inconsistency was also a prominent feature in these simulating young adults. Atypical performance patterns in less widely used neuropsychological tests have been described as a marker of malingering ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1076/clin.17.3.410.18089","ISSN":"1744-4144","author":[{"dropping-particle":"","family":"Larrabee","given":"Glenn J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Clinical Neuropsychologist","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2003"]]},"note":"160119\n\nreview: \npatterns of response in malingered cognitive impairment have been identified: including poor performance on recognition memory tests, poor attention and digit span relative to memory and vocabulary, and poor motor strength and speed relative to other neuropsychological functions. \nmotor speed, attention, recognition memory and problem-solving. \n\nOf 26 subjects with 'definite malingered neurocognitive dysfunction' (defined by worse-than-chance performance on the PDRT(Binder and Kelly 1991)), 50% scored &lt;7 on reliable digit span (the summed total of maximum forward and backward digit span as measured using the WAIS), compared with 6.5% of those with moderate or severe closed head injury.","page":"410-425","title":"Detection of Malingering Using Atypical Performance Patterns on Standard Neuropsychological Tests","type":"article-journal","volume":"17"},"uris":[""]}],"mendeley":{"formattedCitation":"³³","plainTextFormattedCitation":"33","previouslyFormattedCitation":"³³"},"properties":{"noteIndex":0},"schema":""}33. In our study, discrepant patterns such as poor performance in digit span relative to serial sevens (examining overlapping functions of sustained attention and working memory), and poor performance in construction tasks relative to performance in imitation of hand gestures were potential indicators of functional cognitive disorders which merit testing in larger cohorts of individuals with both neurodegenerative and functional disorders. Family history of dementia did not influence performance in this study. However, our subjects were young (mean age 22), and family history of dementia related to a grandparent in all cases. They were significantly younger than the reported mean age (54.6± 13.0 years) of people with functional cognitive disorders in a series of memory clinic patients, in whom family history was associated with increased likelihood of functional cognitive disorder.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Bharambe","given":"Viraj","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Larner","given":"A J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Neurodegenerative Disease Management","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2018"]]},"note":"091018\n\nnovember 2017 - april 2018\n\nIn 89 consecutive new referrals to a cognitive disorders clinic in Liverpool (median age 62), 38 (43%) were diagnosed with cognitive disorders (9 dementia, 26 MCI and 3 transient amnesia syndromes) and 51 (57%) with FCD. \n\nIn 89 consecutive new referrals to a cognitive disorders clinic (median age 62) a range of clinical features were assessed in association with a reference standard diagnosis. \nThe most sensitive features for FCD were SMC Likert (poor or fair), Jenkins Sleep Scale and two-question screener for mood. Highly specific features were la maladie du petit papier, positive family history, and attending alone. MACE was not helpful for distinguishing the patient groups and the authors note that patients with FCD may score below the suggested 1.5 SD below population norms.","page":"377-383","title":"Functional cognitive disorders: demographic and clinical features contribute to a positive diagnosis","type":"article-journal","volume":"8"},"uris":[""]}],"mendeley":{"formattedCitation":"³⁴","plainTextFormattedCitation":"34","previouslyFormattedCitation":"³⁴"},"properties":{"noteIndex":0},"schema":""}34 We predict that older individuals are more likely to have experience of dementia in a first degree relative, and that this might impact on beliefs about symptoms, although how this might manifest is an interesting topic for further investigation Although there may be similarities in beliefs about dementia between those with functional cognitive disorders and healthy adults, there are also likely to be differences, and these differences may be important in determining why functional cognitive symptoms develop in some people and not others. At a group level, people who develop functional neurological disorders have a greater experience of ill health and psychiatric comorbidity, and may also have different background experiences. These factors, together with general factors such as gender, educational background, and ethnicity, are likely to influence beliefs about illness. Further research using an experimental simulation paradigm in those with experiences of chronic pain or ill health, or who have experienced adverse events, might be used to further explore the relationship between beliefs and cognitive symptoms in those with functional disorders. Describing performance patterns in simulating adults and, in future, in individuals with functional cognitive disorders is an important step in improving our understanding of functional cognitive disorder phenotypes. However, overall, we suspect that raw cognitive test results will continue to have a limited reach in discriminating between neurodegenerative disease and functional cognitive disorders as preliminary clinical studies have suggestedADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Bharambe","given":"Viraj","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Larner","given":"A J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Neurodegenerative Disease Management","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2018"]]},"note":"091018\n\nnovember 2017 - april 2018\n\nIn 89 consecutive new referrals to a cognitive disorders clinic in Liverpool (median age 62), 38 (43%) were diagnosed with cognitive disorders (9 dementia, 26 MCI and 3 transient amnesia syndromes) and 51 (57%) with FCD. \n\nIn 89 consecutive new referrals to a cognitive disorders clinic (median age 62) a range of clinical features were assessed in association with a reference standard diagnosis. \nThe most sensitive features for FCD were SMC Likert (poor or fair), Jenkins Sleep Scale and two-question screener for mood. Highly specific features were la maladie du petit papier, positive family history, and attending alone. MACE was not helpful for distinguishing the patient groups and the authors note that patients with FCD may score below the suggested 1.5 SD below population norms.","page":"377-383","title":"Functional cognitive disorders: demographic and clinical features contribute to a positive diagnosis","type":"article-journal","volume":"8"},"uris":[""]}],"mendeley":{"formattedCitation":"³⁴","plainTextFormattedCitation":"34"},"properties":{"noteIndex":0},"schema":""}34. Promising work in this area has concentrated instead on linguistic and behavioural features during the clinical consultation, finding for example that individuals with functional cognitive disorders are more likely to attend clinic alone, more likely to provide detailed accounts of forgetting events, and less likely to ‘head turn’ towards an accompanying adult ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"","ISSN":"1546-4156","abstract":"As awareness of dementia as a major public health issue grows, increasing numbers of individuals with subjective memory impairment (SMI) are presenting to memory services. Many with SMI are cognitively healthy and require only reassurance. In the absence of reliable and easily available biomarkers of dementia, clinical signs may be the most effective way of differentiating cognitively healthy SMI individuals from those with underlying brain disease. Collateral history is important in the assessment of memory complaints, so patients are routinely instructed to bring a relative, friend, or a carer to clinic with them. Attending the clinic alone despite these instructions, the \"attended alone\" sign, is shown in this study to be not only a robust marker of absence of dementia but also of cognitively healthy individuals with SMI.","author":[{"dropping-particle":"","family":"Larner","given":"Andrew J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Alzheimer disease and associated disorders","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2014"]]},"note":"051018\n\nIn 726 individuals referred to a cognitive clinic over 3 years (median age 61), 232 (19%) received diagnoses of dementia or were described as having MCI and 68% were described as 'cognitively healthy'.\n\nIn 726 individuals referred to a cognitive disorder clinic, attending alone (despite instructions to bring an informant) was 100% sensitive and 40% (41-49%) specific for the absence of dementia.","page":"364-365","title":"Screening utility of the \"attended alone\" sign for subjective memory impairment","type":"article-journal","volume":"28"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1017/S1041610218000121","abstract":"We read the paper by Soysal et al. (2017) with interest as we have experience of both the Attended With (AW) and the Head-Turning Sign (HTS) in a neurology-led cognitive disorders clinic. In our studies, we focused on the \"Attended Alone\" (AA) sign as a marker of cognitive health, rather than AW as a marker of cognitive impairment. Reexamining our data (Larner, 2014), we present (Table 1) our findings for AW, rather than AA, for ease of comparison with the findings of Soysal et al. (2017). Hence, AW is a high frequency sign (66.1% of all clinic attenders in our study; 69.7% in Soysal et al. (2017)) which is sensitive but not specific for cognitive impairment (hence, high false positive rate but low false negative rate) with low positive predictive value. Our studies of HTS (see Larner, 2018 for details) encompass two patient cohorts (n = 398 in total, of whom 246 AW) for whom the combined results are shown in the table. In contrast to AW, we find HTS to be a lower frequency sign (43.1% of all those AW in our studies). In our clinic, we found that HTS is not sensitive but very specific for cognitive impairment (hence, low false positive rate but high false negative rate) with high positive predictive value (Table 1). These findings are consistent across our two patient cohorts, but contrast with the findings of Soysal et al. (2017), who found HTS to have high sensitivity and negative predictive value for cognitive impairment. The reasons for this discrepancy are not immediately apparent to us, but may possibly relate to methodological factors (HTS may be defined differently in different studies Tabuas-Pereira et al. (2016)) or cultural factors (HTS had a higher frequency in the Soysal et al. cohort, 244/369 = 66.1% of AW). Sensitivity 0.93 (0.90-0.96) 0.65 (0.58-0.73) Specificity 0.47 (0.42-0.51) 0.95 (0.90-0.99) Positive predictive value 0.45 (0.41-0.49) 0.95 (0.91-0.99) Negative predictive value 0.93 (0.90-0.97) 0.61 (0.53-0.69) Both AW and HTS have the potential advantage of being both easily observed and producing categorical data that is dichotomous. We believe that the diagnostic value of these non-canonical signs merits further examination.","author":[{"dropping-particle":"","family":"Williamson","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Larner","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"International Psychogeriatrics","id":"ITEM-2","issue":"10","issued":{"date-parts":[["2018"]]},"note":"090119\n\nNO - review of 2 other papers. Picked up a new reference (Tabuas pereira) but this only a conference abstract.","page":"1569-1569","title":"Attended with and head-turning sign can be clinical markers of cognitive impairment in older adults","type":"article-journal","volume":"20"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1097/WAD.0000000000000231","ISSN":"1546-4156","PMID":"29319602","abstract":"OBJECTIVE Specialist services for dementia are seeing an increasing number of patients. We investigated whether interactional and linguistic features in the communication behavior of patients with memory problems could help distinguish between those with problems secondary to neurological disorders (ND) and those with functional memory disorder (FMD). METHODS In part 1 of this study, a diagnostic scoring aid (DSA) was developed encouraging linguists to provide quantitative ratings for 14 interactional features. An optimal cut-off differentiating ND and FMD was established by applying the DSA to 30 initial patient-doctor memory clinic encounters. In part 2, the DSA was tested prospectively in 10 additional cases analyzed independently by 2 conversation analysts blinded to medical information. RESULTS In part 1, the median score of the DSA was +5 in ND and -5 in FMD (P<0.001). The optimal numeric DSA cut-off (+1) identified patients with ND with a sensitivity of 86.7% and a specificity of 100%. In part 2, DSA scores of rater 1 correctly predicted 10/10 and those of rater 2 predicted 9/10 diagnoses. CONCLUSIONS This study indicates that interactional and linguistic features can help distinguish between patients developing dementia and those with FMD and could aid the stratification of patients with memory problems.","author":[{"dropping-particle":"","family":"Reuber","given":"Markus","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Blackburn","given":"Daniel J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Elsey","given":"Chris","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wakefield","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ardern","given":"Kerry A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Harkness","given":"Kirsty","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Venneri","given":"Annalena","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"Danielle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shaw","given":"Chloe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Drew","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Alzheimer disease and associated disorders","id":"ITEM-3","issue":"3","issued":{"date-parts":[["2018","1","9"]]},"note":"language becomes impaired early in dementia but it is difficult to pick this up in clinic\n\nhowever conversation analysis derived interactional and linguistic observations have been helpful in distinguisng ES from NEA identifying NEA with S&amp;S of 85%\n\nthis initial validation and assessment of quanititative diagnostic scoring aid rating interactional, topical and linguistic features to attempt to discriminate ND (not VCI and DPD) from FMD(functional memory disorder as per Schmidtke but including &gt;70) - numerical cut-off derived\n\nall neuropsychological testing (same as Wakefield) and MRI\n\nGold standard: Schmidtke criteria except age cut off &lt;70","page":"197-206","title":"An Interactional Profile to Assist the Differential Diagnosis of Neurodegenerative and Functional Memory Disorders.","type":"article-journal","volume":"32"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.3399/bjgp18X694601","ISSN":"1478-5242","PMID":"29335322","abstract":"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.","author":[{"dropping-particle":"","family":"Bailey","given":"Cate","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Poole","given":"Norman","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Blackburn","given":"Daniel J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The British journal of general practice : the journal of the Royal College of General Practitioners","id":"ITEM-4","issue":"667","issued":{"date-parts":[["2018","2","15"]]},"note":"091018\n\nBailey, Poole and Blackburn (2018) collated evidence from 16 studies examining the use of communications behaviours during the memory clinic consultation. They found robust evidence for the sensitivity of the head turn sign in identifying cognitive impairment and the 'attended alone' sign in identifying cognitive 'normality', other potentially-helpful communication features were noted to be more difficult to operationalise and replicate.","page":"e123-e138","publisher":"British Journal of General Practice","title":"Identifying patterns of communication in patients attending memory clinics: a systematic review of observations and signs with potential diagnostic utility.","type":"article-journal","volume":"68"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"","ISSN":"1364-6915","abstract":"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.","author":[{"dropping-particle":"","family":"Jones","given":"Danielle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Drew","given":"Paul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Elsey","given":"Christopher","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Blackburn","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wakefield","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Harkness","given":"Kirsty","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Reuber","given":"Markus","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Aging & mental health","id":"ITEM-5","issue":"5","issued":{"date-parts":[["2016"]]},"note":"051018\n\nJones et al. analysed video and audio recordings of 25 intial consultations between neurologists and patients referred to neurology based memory clinic, proposing distinctive 'conversational profiles' in functional memory disorder and neurodegenerative disorder.\n\nFive features were identified that could contribute to a differential diagnostic conversational profile of patients presenting with dementia or FMD. These features are: 1) whether the patient is able to answer questions about personal information (for example ‘how old are you?’ or ‘where do you live?’); 2) whether they can display working memory in interaction; 3) whether they are able to respond to compound questions; 4) time taken to respond to questions; and 5) the level of detail they offer when providing an account of their memory failure experiences.\n\n\n\nOctober 2012 - August 2014\n\n16 FMD, 9 ND\n\nACER 85-99\n\nnot consecutive (don't think)","page":"500-509","publisher-place":"England","title":"Conversational assessment in memory clinic encounters: interactional profiling for differentiating dementia from functional memory disorders","type":"article-journal","volume":"20"},"uris":[""]}],"mendeley":{"formattedCitation":"^35–39","plainTextFormattedCitation":"35–39","previouslyFormattedCitation":"^35–39"},"properties":{"noteIndex":0},"schema":""}35–39. The conclusions we can draw from this study are limited by the lack of functional cognitive disorder controls. In addition, detailed enquiry was not made into the extent to which the instruction to simulate mild (rather than moderate or severe) dementia was understood, and it is possible that some subjects aimed to simulate more severe impairment than we intended. Finally, digit span was measured on the basis of single trials and not according the method used in the WAIS (Wechsler Adult Intelligence Scale - not available for general clinical use by non-psychologists), and as a result it was not possible to calculate Reliable Digit Span in order to compare directly with normative data. In summary, cognitively healthy individuals simulating dementia attain similar overall scores in cognitive screening tests as individuals with mild dementia, but with particularly poor performance on short digit span trials, relative preservation of cube drawing and abstraction, inconsistent patterns of performance and higher rates of effort test failure. Experimental simulation of cognitive impairment is a novel method of accessing beliefs about dementia with potential utility in the development of diagnostic tools for functional cognitive disorders. Financial SupportLM is funded by a University of Edinburgh Clinical Research Fellowship funded philanthropically by Baillie Gifford. Professor Jon Stone is a Chief Scientists Office NHS Research Scotland Career Researcher.DisclosuresLM has nothing to disclose. BS has nothing to disclose. CR has nothing to disclose. AC is a director of a limited personal services company that provides independent medical testimony in Court Cases on a range of neuropsychiatric topics on a 50% pursuer 50% defender basis. JS provides independent medical testimony in court cases regarding patients with functional disorders. Ethical standardsThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Table 1 – Responses of 50 healthy adults questioned about expected symptoms in mild dementiaSymptomExamples statedNumber reporting symptomMemory problems‘forgetful’, ‘memory loss’, ‘forgetting little things – appointments and jobs’, ‘forgetting if taken their pills’, ‘phone numbers’, ‘birthdays and pin numbers’49- short term > long term25- short term = long term‘gradual disintegration of long-term memories’12- failure to recognise familiar people 20- Losing things‘keys, shopping lists’, ‘keys’, ‘forgetting where they put their keys’, ‘prone to misplacing things’11- Repetitive conversation‘identical conversation on repeat’, ‘repeating the same stories’, ‘asking the same question over and over’5- Forgetting tasks whilst undertaking them‘walking into a room and forgetting what you went in there for’, ‘why they went to the shop’, ‘that they’d put the oven on’, ‘leaving things on stove’4- Unaware of current affairs / news events2- Relative preservation of emotional memories2Confusion17Distress or agitation‘fear’, irritation and frustration’, ‘frustration’, ‘feeling insecure’ and ‘anxiety’10Disorientation to place / getting lost / impaired spatial awareness / navigation14Motor symptomsincluding ‘loss of dexterity’, ‘slow movement and bad imbalance’, ‘lacking co-ordination’, ‘balance problems, falling’, ‘slower motor skills’, and ‘slightly restricted mobility’8No motor or physical symptoms(specifically stated) 2Changes in personality or behaviour‘angry’, ‘strange behaviour’, ‘short and irritable’, ‘expressionless’, ‘slight personality change’, ‘saying things that are out of character or socially unacceptable’, ‘reduced social interaction’6Speech or communication changes‘difficulty speaking / difficulty forming sentences’, ‘disorganised speech’, ‘mixing words up’, ‘slurred words’ and ‘slow speech’, ‘forget where they are in a sentence’6Changes in mood‘sadness’, ‘negative mood’, ‘not a full range of emotions’, and another listed ‘absence of drive and motivation’5Problems performing simple tasks‘forgetting how microwaves and toasters work’, ‘greater number of accidental injuries such as burns or cuts from cooking’5Problems with problem-solving, reasoning, decision-making3Disorientation to time3Short attention span3Confabulation (‘constructing false memories’); ‘paranoia’ and auditory and visual hallucinations (‘speaking to self / seeing things’); slow processing speed; lack of insight (‘denial of symptoms’); neglect of self, household and pets; ‘reminiscing’; ‘removal from reality’; ‘tiredness’; and ‘headaches’.1 eachTable 2 - MoCA and additional digit span results ItemAvailable points n (%) achieving fewer than all available marksMean score ± SD / median (IQR)Trail-making136 (72%)Cube121 (42%)Clock drawing341 (82%)1.78 ± 0.81- contour15 (10%)- numbers123 (46%)- hands133 (66%)Object naming328 (56%)2.12 ± 0.98Digit span 5141 (82%)Digit span 4*29 (58%)Digit span 3*13 (26%)Reverse digit span 3130 (60%)Reverse digit span 2*18 (36%)Letter vigilance143 (86%)Serial sevens327 (54%)2.1 ± 0.99Repetition240 (80%)0.64 ± 0 .80Fluency139 (78%)score 0.22 ± 0.41valid words 7 (4.5)Abstraction230 (60%)1.24 ± 0.71Delayed recall550 (100%)5 correctly recalled – 0 4 correctly recalled – 1 (0.5%)3 correctly recalled – 13 (26%) 2 correctly recalled – 14 (28%)1 correctly recalled – 12 (24%)0 correctly recalled – 10 (20%)2 (2)Orientation637 (74%)6 correct – 13 (26%)5 correct – 10 (20%)4 correct – 16 (32%)3 correct – 5 (10%)2 correct – 4 (8%)1 correct – 2 (4%0 correct – 0 4 (1.75)Total MoCA score3050 (100%)15.68 ± 5.53* additional digit span trials not part of MoCAFigure 1 – Coin in hand test (caption) X axis – number of trials in which side of coin (L or R) correctly identified. Y axis – number of subjects. 16 subjects scored at (12) or below (4) the level which would be expected by chance.Figure 2 - Luria 3-step test. (caption) X axis – number of steps correctly completed (1 - Series copied alongside examiner, 2 – Series repeated independently, 3 – new series successfully copied independently.) Y axis – number of subjects. ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Sierra-Rio A, Balasa M, Olives J, et al. Cerebrospinal Fluid Biomarkers Predict Clinical Evolution in Patients with Subjective Cognitive Decline and Mild Cognitive Impairment. Neurodegener Dis. 2016;16(1-2):69-76. doi:10.1159/0004392582. Handels RLH, Joore MA, Vos SJB, et al. Added Prognostic Value of Cerebrospinal Fluid Biomarkers in Predicting Decline in Memory Clinic Patients in a Prospective Cohort. J Alzheimer’s Dis. 2016;52(3):875-885. doi:. Hessen E, Eckerstrom M, Nordlund A, et al. 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Identifying patterns of communication in patients attending memory clinics: a systematic review of observations and signs with potential diagnostic utility. Br J Gen Pract. 2018;68(667):e123-e138. doi:10.3399/bjgp18X69460139. Jones D, Drew P, Elsey C, et al. Conversational assessment in memory clinic encounters: interactional profiling for differentiating dementia from functional memory disorders. Aging Ment Health. 2016;20(5):500-509. doi: 1 – script used during interview and cognitive examinationIntroduction"Hi my name is [researcher’s name], I’m undertaking a study with Dr Jon Stone, a consultant Neurologist, to find out the ideas that healthy people have about certain symptoms and illnesses. This interview willl take around 20 to 25 minutes. Is that OK?What I would like to do, is ask you some questions, ask you to do some movements and ask you to fill out a form used to test cognitive (mental) function. During this interview I would like you to imagine that you have mild dementia due to Alzheimer’s disease. Don’t worry if you’re not exactly sure how someone with dementia might respond, this research is interested in your perceptions and results will be anonymous.Do you have any questions or concerns about this? There is a consent form to show you some options and you can sign (show subject the consent form and answer any questions). If at any point you do not wish to continue with the interview or exam, please let me know.(Record subject’s basic details on consent form, assign them a volunteer number)Do you have any medical condition that affects your memory, or any condition that affects the movement of your hands or fingers? Do you or your close friends or family have any neurological disorders such as seizures, MS or a tremor? Is there any family history of dementia or other neurological conditions?Ideas about symptoms and investigationsPlease could you tell me what you think someone with mild or early stage dementia might experience? What symptoms might they have?As mentioned previously, I’d like you to imagine you have mild dementia for the rest of this interview.MoCA?I’m now going to ask you to perform this short test, I’d like you to do it pretending you have mild dementia. (Record performance and time on each individual component, follow MoCA script.)Gait If you could now walk from here to the end of the room (about 5 meters?) in a straight line, and back walking heel-to-toe please.Coin in hand testI’m now going to show you a coin in one of my hands. I’d then like you to close your eyes, count backwards from 10 and then open your eyes. Then I’d like you to tell me which of my closed hands contains the coin. We’ll repeat this ten times.LuriaI’d now like you to observe these three movements of my hand in sequence (do cut, fist, slap three times, pausing between each). Now please could you copy this sequence with me (three times)? Now could you complete the sequence on your own please (three times). This time, please could you follow another sequence (show slap, cut, fist once and then ask them to do it)?Interlocking FingersNow I’d like you to copy each of these finger movements one by one.(Show each movement, and wait for it to be copied: index and thumbs in pincers, pinkies hooked, fingers laced backwards, two fingers through split fingers.)That’s the end of the interview, thank you very much for your time. ................
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