Current Literature In Clinical Science
Do We Know What We Think We Know? Reconciling Subjective Complaints and Objective Cognitive Testing in Older Adults With Epilepsy
Subjective Cognitive Complaints Versus Objective Neuropsychological Performance in Older Adults With Epilepsy. Galioto R, Blum AS, Tremont G. Epilepsy Behav 2015;51:48–52. DOI: 10.1016/j.yebeh.2015.06.035.
Memory complaints are common among older adults with epilepsy (OAE), though discrepancy between subjective complaints and objective performance often exists. This study examined how accurately OAE and their informants reported on the participant’s cognitive difficulties by comparing ratings of everyday cognition to objective performance. Thirty-seven OAE and 27 older adult controls completed a brief battery of neuropsychological tests, the Beck Depression Inventory, and the Cognitive Difficulties Scale (CDS). Each participant had an informant who completed the CDS. Older adults with epilepsy performed worse than controls on cognitive testing and reported more subjective cognitive complaints. Neither participant- nor informant-reported cognitive complaints were related to performance on any of the neuropsychological tests for either the group with epilepsy or control group, but both were related to greater depressive symptoms. Results suggest that subjective report of cognitive problems by both OAE and their informants may not reliably reflect the extent to which these problems exist.
Commentary Subjective cognitive complaints are a frequent concern of patients in the epilepsy clinic. Patients frequently report poor concentration, worsening memory, language difficulties, and inability to complete tasks. Oftentimes, however, these complaints are minimized or even ignored as we move on to more measurable variables: frequency of seizures, seizure duration, seizure type, medication compliance, and other clinical facts. Cognitive symptoms may be related to so many different factors converging in our patients: aging, recurrent seizures, medications, depression, and poor sleep quality, among others; this poses a challenge to address them individually or act on them all together. It would be of great help to know how to better address cognitive complaints in the clinic and ideally establish how these complaints correlate with measurable psychometric deficits, which could help us make treatment decisions that would improve our patients’ quality of life. The relationship between subjective cognitive complaints and objective cognitive deficits has been addressed in other populations. Longitudinal studies of cognitively intact individuals have found that subjective memory complaints predict a higher risk for future cognitive impairment and Alzheimer Epilepsy Currents, Vol. 16, No. 4 (July/August) 2016 pp. 230–231 © American Epilepsy Society
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disease brain pathology (1, 2). This calls for neurologists to actively ask and monitor subjective cognitive complaints in all older adults. Galioto et al. compared the neuropsychologic performance of older adults with epilepsy (OAE) and older adults with mild cognitive impairment (MCI) and found that the two groups have similar cognitive deficits, except for worse delayed memory and less awareness of cognitive deficits in the group with MCI (3). Patients with epilepsy frequently report subjective cognitive complaints even when seizures are controlled, and these complaints best correlate with the use of polypharmacy and the patient’s psychologic profile (4). In patients with temporal lobe epilepsy, in whom we strongly rely on neuropsychologic data of cognitive functions to make surgical decisions, only the subjective reports related to language functions are of lateralizing value when compared with objective cognitive performance; all other neuropsychologic domains evaluated do not correlate with cognitive complaints reported by patients. In contrast, the measures related to psychologic and emotional functioning are predictive of cognitive symptom reports (5) across all tested domains. A similar trend is observed when self-reported and informantreported cognitive concerns are compared with objective cognitive deficits; repeatedly, the presence of psychiatric or psychologic factors such as depression, anxiety (6, 7), or psychologic stress (8) are the main risk factors associated with subjective reports of cognitive deficits. In this article, Galioto et al. compared the subjective reports of cognitive difficulties of OAE and their informants
Do We Know What We Think We Know?
as well as a battery of neuropsychologic tests and the Beck Depression Inventory (BDI-II) with the ones of a healthy control group with similar demographics. OAE performed worse than controls in objective cognitive testing, and they also reported more subjective deficits; however, the personal and informant reports did not correlate with any of the objective cognitive tests. Subjective and informant cognitive reports best correlated with the severity of depressive symptoms on the BDI-II, highlighting the relation between perceived cognitive difficulties and depression in OAE. In this context, it is useful to remember that depression (prevalence rate, 20–60%) and anxiety (prevalence rate, 15–20%) are relatively frequent in patients with epilepsy (9). Both conditions are often under recognized and undertreated, and they both severely affect the quality of life of our patients. These psychiatric conditions are also seen more frequently in older adults. Five percent of adults over 65 meet criteria for major depression, while 8 to 16% have clinically significant symptoms of depression. These numbers are higher (12–30%) for institutionalized patients and are up to 50% in nursing home patients suffering chronic disease (10, 11). Depression in the elderly does not present with the typical symptoms described for younger adults or children. Older patients are unlikely to report depressed mood or sadness. Depression in the elderly is more likely to present as anhedonia, sleep disturbances, behavioral changes (anger or irritability), eating disorders, somatic complaints, and very frequently as cognitive complaints (12). Physicians and family members are less likely to recognize these symptoms as symptoms of depression. The care of older adults with depression is further complicated by the presence of multiple comorbidities, polypharmacy, and medication side effects, along with greater reluctance by the patients to discuss the symptoms or accept the diagnosis of depression. The questions at hand are: What are our OAE and their caregivers trying to tell us when they report cognitive complaints? What can we do to better address their concerns? Cognitive complaints are frequent in older adults with or without epilepsy as well as in young adults with epilepsy. As stated above, subjective cognitive complaints may be an early warning for further cognitive impairment. These complaints have to be taken seriously and investigated appropriately, including ordering formal neuropsychologic testing when appropriate. Objective neuropsychologic deficits in OAE may be related to high levels of an anti-epileptic drug, polypharmacy, or both. Accordingly, the simplification of the pharmacologic regimen and the use of the lowest effective doses should be attempted. Anhedonia and cognitive decline are frequent symptoms of depression in the elderly. Subjective cognitive complaints
have been associated with depression in elderly populations with and without epilepsy. Proactive screening of depression should be conducted in all patients with subjective cognitive complaints because it is a treatable condition frequently seen in OAE. Its successful treatment has been shown to improve the related cognitive complaints and the overall quality of life of these patients. by Adriana Bermeo-Ovalle, MD References 1. Kryscio RJ, Abner EL, Cooper GE, Fardo DW, Jicha GA, Nelson PT, Smith CD, Van Eldik LJ, Wan L, Schmitt FA. Self-reported memory complaints: Implications from a longitudinal cohort with autopsies. Neurology 2014;83:1359–1365. 2. Reisberg B, Shulman MB, Torossian C, Leng L, Zhu W. Outcome over seven years of healthy adults with and without subjective cognitive impairment. Alzheimers Dement 2010;6:11–24. 3. Galioto R, Thamilavel S, Blum AS, Tremont G. Awareness of cognitive deficits in older adults with epilepsy and mild cognitive impairment. J Clin Exp Neuropsychol 2015;37:785–793. 4. Uijl SG, Uiterwaal CS, Aldenkamp AP, Carpay JA, Doelman JC, Keizer K, Vecht CJ, de Krom MC, van Donselaar CA. A cross-sectional study of subjective complaints in patients with epilepsy who seem to be wellcontrolled with anti-epileptic drugs. Seizure 2006;15:242–248. 5. Banos JH, LaGory J, Sawrie S, Faught E, Knowlton R, Prasad A, Kuzniecky R, Martin RC. Self-report of cognitive abilities in temporal lobe epilepsy: Cognitive, psychosocial, and emotional factors. Epilepsy Behav 2004;5:575–579. 6. Samarasekera SR, Helmstaedter C, Reuber M. Cognitive impairment in adults with epilepsy: The relationship between subjective and objective assessments of cognition. Epilepsy Behav 2015;52(pt A):9–13. 7. Miller LA, Galioto R, Tremont G, Davis J, Bryant K, Roth J, LaFrance WC Jr, Blum AS. Cognitive impairment in older adults with epilepsy: Characterization and risk factor analysis. Epilepsy Behav 2016;56:113–117. 8. Caselli RJ, Chen K, Locke DE, Lee W, Roontiva A, Bandy D, Fleisher AS, Reiman EM. Subjective cognitive decline: Self and informant comparisons. Alzheimers Dement 2014;10:93–98. 9. Verrotti A, Carrozzino D, Milioni M, Minna M, Fulcheri M. Epilepsy and its main psychiatric comorbidities in adults and children. J Neurol Sci 2014;343:23–29. 10. Kanner AM, Schachter SC, Barry JJ, Hesdorffer DC, Mula M, Trimble M, Hermann B, Ettinger AE, Dunn D, Caplan R, Ryvlin P, Gilliam F, LaFrance WC Jr. Depression and epilepsy, pain and psychogenic non-epileptic seizures: Clinical and therapeutic perspectives. Epilepsy Behav 2012;24:169–181. 11. Park M, Reynolds CF III. Depression among older adults with diabetes mellitus. Clin Geriatr Med 2015;31:117–137, ix. 12. Unutzer J. Diagnosis and treatment of older adults with depression in primary care. Biol Psychiatry 2002;52:285–292.
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Do We Know What We Think We Know? Reconciling Subjective Complaints and Objective Cognitive Testing in Older Adults With Epilepsy
Subjective Cognitive Complaints Versus Objective Neuropsychological Performance in Older Adults With Epilepsy. Galioto R, Blum AS, Tremont G. Epilepsy Behav 2015;51:48–52. DOI: 10.1016/j.yebeh.2015.06.035.
Memory complaints are common among older adults with epilepsy (OAE), though discrepancy between subjective complaints and objective performance often exists. This study examined how accurately OAE and their informants reported on the participant’s cognitive difficulties by comparing ratings of everyday cognition to objective performance. Thirty-seven OAE and 27 older adult controls completed a brief battery of neuropsychological tests, the Beck Depression Inventory, and the Cognitive Difficulties Scale (CDS). Each participant had an informant who completed the CDS. Older adults with epilepsy performed worse than controls on cognitive testing and reported more subjective cognitive complaints. Neither participant- nor informant-reported cognitive complaints were related to performance on any of the neuropsychological tests for either the group with epilepsy or control group, but both were related to greater depressive symptoms. Results suggest that subjective report of cognitive problems by both OAE and their informants may not reliably reflect the extent to which these problems exist.
Commentary Subjective cognitive complaints are a frequent concern of patients in the epilepsy clinic. Patients frequently report poor concentration, worsening memory, language difficulties, and inability to complete tasks. Oftentimes, however, these complaints are minimized or even ignored as we move on to more measurable variables: frequency of seizures, seizure duration, seizure type, medication compliance, and other clinical facts. Cognitive symptoms may be related to so many different factors converging in our patients: aging, recurrent seizures, medications, depression, and poor sleep quality, among others; this poses a challenge to address them individually or act on them all together. It would be of great help to know how to better address cognitive complaints in the clinic and ideally establish how these complaints correlate with measurable psychometric deficits, which could help us make treatment decisions that would improve our patients’ quality of life. The relationship between subjective cognitive complaints and objective cognitive deficits has been addressed in other populations. Longitudinal studies of cognitively intact individuals have found that subjective memory complaints predict a higher risk for future cognitive impairment and Alzheimer Epilepsy Currents, Vol. 16, No. 4 (July/August) 2016 pp. 230–231 © American Epilepsy Society
230
disease brain pathology (1, 2). This calls for neurologists to actively ask and monitor subjective cognitive complaints in all older adults. Galioto et al. compared the neuropsychologic performance of older adults with epilepsy (OAE) and older adults with mild cognitive impairment (MCI) and found that the two groups have similar cognitive deficits, except for worse delayed memory and less awareness of cognitive deficits in the group with MCI (3). Patients with epilepsy frequently report subjective cognitive complaints even when seizures are controlled, and these complaints best correlate with the use of polypharmacy and the patient’s psychologic profile (4). In patients with temporal lobe epilepsy, in whom we strongly rely on neuropsychologic data of cognitive functions to make surgical decisions, only the subjective reports related to language functions are of lateralizing value when compared with objective cognitive performance; all other neuropsychologic domains evaluated do not correlate with cognitive complaints reported by patients. In contrast, the measures related to psychologic and emotional functioning are predictive of cognitive symptom reports (5) across all tested domains. A similar trend is observed when self-reported and informantreported cognitive concerns are compared with objective cognitive deficits; repeatedly, the presence of psychiatric or psychologic factors such as depression, anxiety (6, 7), or psychologic stress (8) are the main risk factors associated with subjective reports of cognitive deficits. In this article, Galioto et al. compared the subjective reports of cognitive difficulties of OAE and their informants
Do We Know What We Think We Know?
as well as a battery of neuropsychologic tests and the Beck Depression Inventory (BDI-II) with the ones of a healthy control group with similar demographics. OAE performed worse than controls in objective cognitive testing, and they also reported more subjective deficits; however, the personal and informant reports did not correlate with any of the objective cognitive tests. Subjective and informant cognitive reports best correlated with the severity of depressive symptoms on the BDI-II, highlighting the relation between perceived cognitive difficulties and depression in OAE. In this context, it is useful to remember that depression (prevalence rate, 20–60%) and anxiety (prevalence rate, 15–20%) are relatively frequent in patients with epilepsy (9). Both conditions are often under recognized and undertreated, and they both severely affect the quality of life of our patients. These psychiatric conditions are also seen more frequently in older adults. Five percent of adults over 65 meet criteria for major depression, while 8 to 16% have clinically significant symptoms of depression. These numbers are higher (12–30%) for institutionalized patients and are up to 50% in nursing home patients suffering chronic disease (10, 11). Depression in the elderly does not present with the typical symptoms described for younger adults or children. Older patients are unlikely to report depressed mood or sadness. Depression in the elderly is more likely to present as anhedonia, sleep disturbances, behavioral changes (anger or irritability), eating disorders, somatic complaints, and very frequently as cognitive complaints (12). Physicians and family members are less likely to recognize these symptoms as symptoms of depression. The care of older adults with depression is further complicated by the presence of multiple comorbidities, polypharmacy, and medication side effects, along with greater reluctance by the patients to discuss the symptoms or accept the diagnosis of depression. The questions at hand are: What are our OAE and their caregivers trying to tell us when they report cognitive complaints? What can we do to better address their concerns? Cognitive complaints are frequent in older adults with or without epilepsy as well as in young adults with epilepsy. As stated above, subjective cognitive complaints may be an early warning for further cognitive impairment. These complaints have to be taken seriously and investigated appropriately, including ordering formal neuropsychologic testing when appropriate. Objective neuropsychologic deficits in OAE may be related to high levels of an anti-epileptic drug, polypharmacy, or both. Accordingly, the simplification of the pharmacologic regimen and the use of the lowest effective doses should be attempted. Anhedonia and cognitive decline are frequent symptoms of depression in the elderly. Subjective cognitive complaints
have been associated with depression in elderly populations with and without epilepsy. Proactive screening of depression should be conducted in all patients with subjective cognitive complaints because it is a treatable condition frequently seen in OAE. Its successful treatment has been shown to improve the related cognitive complaints and the overall quality of life of these patients. by Adriana Bermeo-Ovalle, MD References 1. Kryscio RJ, Abner EL, Cooper GE, Fardo DW, Jicha GA, Nelson PT, Smith CD, Van Eldik LJ, Wan L, Schmitt FA. Self-reported memory complaints: Implications from a longitudinal cohort with autopsies. Neurology 2014;83:1359–1365. 2. Reisberg B, Shulman MB, Torossian C, Leng L, Zhu W. Outcome over seven years of healthy adults with and without subjective cognitive impairment. Alzheimers Dement 2010;6:11–24. 3. Galioto R, Thamilavel S, Blum AS, Tremont G. Awareness of cognitive deficits in older adults with epilepsy and mild cognitive impairment. J Clin Exp Neuropsychol 2015;37:785–793. 4. Uijl SG, Uiterwaal CS, Aldenkamp AP, Carpay JA, Doelman JC, Keizer K, Vecht CJ, de Krom MC, van Donselaar CA. A cross-sectional study of subjective complaints in patients with epilepsy who seem to be wellcontrolled with anti-epileptic drugs. Seizure 2006;15:242–248. 5. Banos JH, LaGory J, Sawrie S, Faught E, Knowlton R, Prasad A, Kuzniecky R, Martin RC. Self-report of cognitive abilities in temporal lobe epilepsy: Cognitive, psychosocial, and emotional factors. Epilepsy Behav 2004;5:575–579. 6. Samarasekera SR, Helmstaedter C, Reuber M. Cognitive impairment in adults with epilepsy: The relationship between subjective and objective assessments of cognition. Epilepsy Behav 2015;52(pt A):9–13. 7. Miller LA, Galioto R, Tremont G, Davis J, Bryant K, Roth J, LaFrance WC Jr, Blum AS. Cognitive impairment in older adults with epilepsy: Characterization and risk factor analysis. Epilepsy Behav 2016;56:113–117. 8. Caselli RJ, Chen K, Locke DE, Lee W, Roontiva A, Bandy D, Fleisher AS, Reiman EM. Subjective cognitive decline: Self and informant comparisons. Alzheimers Dement 2014;10:93–98. 9. Verrotti A, Carrozzino D, Milioni M, Minna M, Fulcheri M. Epilepsy and its main psychiatric comorbidities in adults and children. J Neurol Sci 2014;343:23–29. 10. Kanner AM, Schachter SC, Barry JJ, Hesdorffer DC, Mula M, Trimble M, Hermann B, Ettinger AE, Dunn D, Caplan R, Ryvlin P, Gilliam F, LaFrance WC Jr. Depression and epilepsy, pain and psychogenic non-epileptic seizures: Clinical and therapeutic perspectives. Epilepsy Behav 2012;24:169–181. 11. Park M, Reynolds CF III. Depression among older adults with diabetes mellitus. Clin Geriatr Med 2015;31:117–137, ix. 12. Unutzer J. Diagnosis and treatment of older adults with depression in primary care. Biol Psychiatry 2002;52:285–292.
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