Friday, February 27, 2015

Computerised testing and the elderly

I have recently read a thorough review of computerized testing in dementia by one of our colleagues: Nicola Gates.
Gates, N.J., Kochan, N.A. (2015). Computerized and on-line neuropsychological testing for late-life cognition and neurocognitive disorders: are we there yet? www.co-psychiatry.com, Vol 28 (2), which you can access (for a price, alas) at http://journals.lww.com/co-psychiatry/Abstract/2015/03000/Computerized_and_on_line_neuropsychological.15.aspx
It is a must-read for all of us who work in dementia, even though her conclusions are pretty much negative. It seems that there are no good tools in this area yet. Some are adapted from the military or sports psychology and don't do what we need them to do in dementia assessments. Others are computerised versions of paper-and-pencil tests, which are not comparable to the original tests, and which do not have new normative data. And, of course, the elderly, especially those with a dementing illness, are the one client group that is really the worst suited to computerised assessment: some of them have never used computers, others are wary of them, and yet others have motor and sensory problems that affect testing.

There were some tests that received reasonable billing in the article, and I reviewed them for this post. These were:

- Memory Orientation Screening Test in its iPad administration (highly comparable to the paper-and-pencil test)
This test is billed as 'neuropsychological testing administered by a computer with qualified health care professional interpretation and report'. There are 3 versions available in the app store, costing $3.79, $12.99, and $64.99, but it is not clear what the difference is between each version. After a short search I think that the difference is in the quality of output information. The test itself is a replacement for the Mini-Mental and includes: memory for 3 words, orientation questions, naming and remembering 12 common objects (called 'sequential memory' for some reason) and clock drawing. It claims 85-89% sensitivity and 76-87% specificity in screening dementia, outperforming both MMSE and Mini-Cog. So this is a nice tool, it is just pretty useless to us, being a pretty basic screening tool. Pity.

- Cognitive Assessment for Dementia (CADi) on the iPad that has large concurrent validity with the Mini-Mental and good internal consistency
This one sounded good, so I tried to download and and test it, but found only a Japanese language version in the app store. Hoping that an English version exists, I downloaded it, but had no luck. I think the authors were Japanese, and I am not sure if an English version of this test exists.
- Self-administered Cognitive Function Test (CFT) which showed good concurrent validity with paper-and-pencil tests in correlational analysis. However, there was no information on test-retest reliability, which Nicola notes is a problem in a test that is supposed to be used for self-monitoring over time.
This one can be accessed on http://cft.foodforthebrain.org/. I dutifully went through it, and was declared unlikely to have dementia. It consists of a good task of visual memory and quite clever analogues to Symbol Search and Coding. Also, it has a pre-test screen that checks facility with the use of a computer (one has to mouse-click on some targets as fast as one can). While it is a nice example of a good computerised test, it is not going to be in any way useful for our practice.
So, as to computerised tests and the elderly, we are not there yet.

The only computerised test that I do use in this group is the iPad-based Mini-Mental from the PAR (handy if you want to be meticulous with copyright compliance), but I cannot say that it is particularly good either.

I think that computerised testing of adults and children is a much better proposition, but I'll write about it this in other posts.

Cheers,
Izabela