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Introduction
Populational aging is a world-scale phenomenon. The elderly is the fastest-growing segment in Brazil, it is estimated by the Brazilian Institute of Statistics and Geography (IBGE) that this segment will reach 41.5 million by 2030 (Campos, & Borges, 2015). It has been projected, according to WHO data, that Brazil’s elderly population is going to be the 6th largest worldwide (Felix, 2007). According to the World Health Organization (OMS, n.d.), the population over 60 years of age is growing at a rate of about 3% per year and is growing faster than all younger age groups. In addition to the known changes in metabolism due to age, cognition may also change along with aging, with impacts on perception, attention, memory, and reasoning. Such changes may occur due to natural aging and changes in the frontal lobe circuits, which tend to appear precociously in comparison to other regions of the brain (Fuentes et al., 2014). Such changes, thus, are highly related to the executive functions (EF), mainly related to the frontal lobes of the brain, being also implicated in neurodegenerative processes including dementia (Nobrega, 2014). An accurate assessment and differential diagnosis are highly important to promote interventions and preserve the patient’s quality of life. Neuropsychological assessment (NA), the process that aims to investigate the relationship between cognitive functions and the central nervous system, promotes a better understanding of the cognitive changes possibly resulting from brain injuries and dysfunctions (Hamdan et al., 2011). As an efficient method to assist the diagnostic process and monitor the progression of numerous clinical conditions, particularly dementia, NA is known to contribute to a higher quality of life (Hamdan & Ramos, 2016). It is necessary to note that the term “dementia” encompasses different clinical conditions that are characterized by intellectual impairment that directly interferes with the patient’s routine (Hamdan & Ramos, 2016). It is more prevalent among older adults, with some estimates indicating that the incidence of dementia may triple in the next 40 years (Hebert et al., 2013). An increase from 4.7 million people affected in the United States in 2010 to 13.8 million in 2050 is projected (Hebert et al., 2013). Thus, it is urgently necessary to understand the demands and peculiarities of this population in order to meet their needs in a coherent and adapted way, which is also important for NA. According to the Psychological Test Assessment System (SATEPSI – Brazil, 159 tests are approved for application in the country (as of April 18th, 2021), which evaluate multiple psychological and neuropsychological aspects, and also vary in application and correction norms. However, out of the 159 approved tests, only six are recovered when the target population (“Público-alvo”) criteria of the searching mechanism are set for the elderly (“idosos”; as of April 18th, 2021), although it is known that others also have normative data of this population, such as WASI (Wechsler’s Brief Intelligence Scale). The tests in question are Online Alternating Attention Test (AOL), Beck’s Depression Inventory-II (BDI-II), d2 Test-Revised (d2-R), Rey Auditory Verbal Learning Test (RAVLT), Benton Visual Retention Test (BVRT), Wisconsin Card Sorting Test (WCST). Out of these tests, RAVLT is used to assess verbal memory, WCST is used to assess executive functioning, two are used to assess attention (AOL and d2-R), BDI-II is used to assess the level of depression symptoms and BVRT is used to assess visual memory, visual perception, and visuoconstructives praxis. Considering the worldwide population aging and the assessment resources available for NA, it is necessary to understand how NA is carried out internationally to improve it in an ecological and suitable manner, especially regarding the elderly. The present study, thus, aims to provide a list of the most oftenly used psychological and neuropsychological instruments internationally and the most important cognitive aspects in the context of the NA of elderly populations.
Methodology
An Integrative Literature Review was carried out to identify the knowledge gaps about the theme of NA in the elderly. This method consists of gathering and systematizing results on a given topic, which systematically allows the synthesis of multiple published studies and general conclusions on the subject (Souza et al., 2010). The following filters were used: articles published in scientific journals in the field of research “Psychology”; published from 2016 up to the day the search was done (May 23rd, 2020). No language filters were added. PubMed, Scopus, and Scielo databases were chosen, with the following keywords: “Neuropsychological Assessment” AND “elderly” AND “test”. The inclusion criteria demandad articles to: be published in scientific journals; to include data collection in a clinical context; to employ neuropsychological instruments; to specifically focus the elderly (60+ years of age); to focus on NA. The criteria excluded articles that: did not collect data; did not use neuropsychological instruments; did not focus on the elderly; were focused on other fields, such as traffic psychology; sought the standardization of tests in a specific language or specific population; focused neuroimaging exams. The examination of the selected articles was initially focused on the abstracts and titles, being the included articles posteriorly evaluated according to their full texts in order to apply the inclusion and exclusion criteria. Tables of all the employed instruments and their frequency of use were elaborated. The state of the instrument regarding SATEPSI’s position was assessed by searching for the instrument’s name on two databases (on April 18th, 2021): the complete list of psychological tests (“Lista completa”; <https://satepsi.cfp.org.br/lista_teste_completa.cfm>) and the complementary list of instruments that are not of exclusive to psychologists (“Instrumentos Não Privativos”; <https://satepsi.cfp.org.br/testesNaoPrivativos.cfm>). The search was conducted using fragments of the instrument’s name, its initials, and the full name, both in English and in Portuguese, when possible. Qualitative searching was employed for subtests, since a subtest might be approved as part of a collection of subtests, such as cases listed in Table 2. This study did not intend to include standardizations and normative samples that were not yet listed by SATEPSI.
Results
Initially, 978 studies were retrieved from the three databases using the overcited keywords. Scopus granted 803 findings, while PubMed granted 147 and Scielo, 28. After applying the first filters (articles published in scientific journals since 2016 in the field of Psychology), 125 articles were retrieved from Scopus, 54 from PubMed, and four from Scielo. The second filter restrained the search for articles that were labeled as “open access”, granting 28 articles from Scopus, 23 from PubMed, and four from Scielo, totaling 55 papers. After the examination of titles and abstracts, four duplicates were excluded. With the full reading of the articles, 14 were excluded since the studies involved the standardization of tests in certain languages or specific to certain types of assessment, such as traffic psychology. In addition, some studies covered the adult population lower than 60 years of age or did not use neuropsychological instruments, resulting in the final number of 37 articles that met the inclusion criteria. The selection process is described in Figure 1.
Neuropsychological instruments
The final list displays the articles in descending order of the year of publication, which is described in Figure 2. Fifty-seven instruments were used to assess different cognitive aspects, including batteries, subtests, scales, and tasks. To facilitate the understanding of the most frequently used instruments, an instrument frequency list, described in Figure 3, was elaborated in ascending order, from the most frequently used to the less frequently used, including, out of parsimony, only instruments used in at least three different studies, which totaled a list of 17 instruments involved in NA. Also listed in Figure 3 is the information regarding SATEPSI’s position (or lack of an evaluation) on the instrument.
It was observed that the most frequently used instruments, which were employed more than 15 times among the reviewed articles, were the Trail Making Test (TMT A-B), Mini-Mental State Examination (MMSE), Digit Span Forward and Backward (DS), Verbal Fluency (VF) and Boston Naming Test (BNT). Out of the most frequently used, BNT did not present SATEPSI’s approval. This factor can make the adequate comparison between the samples a difficult process, since the results could be biased due to socioeconomic characteristics of the population, although normative samples and testing norms that are not listed by SATEPSI do exist, such as the BNT adaptation published by Miotto et al. (2010). This review did not intend to verify standardization studies not listed by SATEPSI. Out of the less frequently used instruments shown in Figure 3 (employed in three different studies), it was observed that (as of April 18th, 2021), BVRT and blocks subtest from WAIS-III were recommended for usage. The search for CAVLT granted no results from SATEPSI. In sum, five out of the 15 most frequently observed instruments are recommended by SATEPSI.
Discussion
Although 57 different instruments have been employed in the reviewed articles, it was observed that the most recurrent ones in the NA of the elderly were related to EF, mental screening or memory. Cognitive screening instruments such as MMSE and MoCA were used in less than half of the studies (18 articles), which can influence the test results since the participant’s previous clinical condition has not undergone any previous assessment. In addition, depression markers (such as BDI and GDS) and the subjects’ level of independence (ADL) were mentioned in only four studies, which may also interfere with the results (Ferreira et al., 2019; Tastan et al., 2019). The studies had different foci and objectives, ranging from the relationship of biomarkers and cognitive functions (Espinosa et al., 2017; Hessen et al., 2019; Liebel et al., 2017; Payton et al., 2018) to the effectiveness of administering neuropsychological tests when applied remotely (Wadsworth et al., 2016, 2017). Some studies sought to evaluate patients with some type of dementia (Ashendorf et al., 2018; Martinelli et al., 2018; Pistono et al., 2016; Zenisek et al., 2016) and others assessed the general cognition of the elderly by providing updated data for a specific population (Bourscheid et al., 2016; Giulioli et al., 2016; Ichihara-Takeda et al., 2016). One study sought to identify the cognitive tests that best predict the ability to drive in individuals with dementia (Crivelli et al., 2019) and one sought to adapt an instrument to assess low educational level populations while presenting preliminary evidence of its psychometric properties (Paula et al., 2016). Although it was possible to list the main instruments used in the assessment of the elderly, the foci variability unviabilized the comparison of the findings, being the findings also related to different contexts and populations. Considering the reviewed articles and the lack of specific articles regarding the NA of the elderly, it is necessary to interpret this data with caution, as the clinical practice might differ from the published protocols. It was observed that, although the articles are recent, the majority of the instruments have been developed a long time ago. In addition, in the case of Brazil, most of the instruments found are not recommended by SATEPSI (as of June 16th, 2020), either because the standardization is obsolete or because of the lack of a normative sample for the population (as in the case of BNT). Both in Brazil and internationally, it is necessary to assess whether the tests have been effective in evaluating the desired cognitive aspects, due to the frequent lack of standardization. It is necessary to understand whether the items have fully encompassed the elderly person’s context, as well as if the results can provide plausible ecological inference of their cognitive functioning and possible diagnosis. The assessment based on ecological instruments is characterized by the standardized form of application associated with the tasks that simulate daily situations of cognitive demand. In the case of the EF, which was a commonly assessed aspect of cognition, daily complex tasks may involve a high demand (Zimmermann et al., 2014). In this context, the adequate use of instruments can not only contribute to both the assessment and a possible rehabilitation process but can also enhance the interpretation of the results. By incorporating the patient’s daily life and characteristics, the possibility of inadequate conclusions following a NA may be decreased. Thus, it is suggested that further research is carried out with the use of instruments that are valid for the elderly. It is also important to highlight that such instruments should be elaborated with ecological aspects in mind, taking into account specific factors such as natural cognitive decline and education levels, especially if low. Such focus was clearly observed in only one of the reviewed studies (Paula et al., 2016).
Conclusion
Bearing in mind that the main objective of this work was to list the most frequently used psychological and neuropsychological tests internationally for the NA of the elderly, as well as the most frequently assessed cognitive aspects, it can be concluded that, in addition to the lack of protocols specialized for this population, the tests mainly evaluate EF, memory and global mental state. The most frequently used instruments, although classic in Neuropsychology, do not always present standardization and normative samples that are recommended by SATEPSI for their employment in Brazil. The lack of standardization and normative samples may impact the adequate inference of daily functioning and, consequently, may compromise the selection of adequate treatments. It is important to note that several instruments present different stages of standardization, some even including normative samples, while not being yet considered by SATEPSI. Although expensive, the standardization of instruments could promote higher access to health services among the elderly, both in public and private institutions, through more adequate assessments, referrals and treatment protocols. In sum, a possible protocol to assess this population could start with an assessment of the patient’s general condition, the possibility of mental disorders such as depression, and the possibility of pre-existing comorbidities, while using ecologically coherent tests for each cognitive aspect and taking into account background measures such as education and socioeconomic status.
