Luria’s three-step test: what is it and what does it tell … · Title Faculty of Medicine...
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Title
Faculty of Medicine KhonKaen University, Thailand2011
Presenter: Pongsatorn Paholpak M.D.
Luria’s three-step test: what is it and what does it tell us?
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Clinical Epidemiology Course: Critical Appraisal
Module: How to read the clinical journal
Objective: To be able to critically appraise the medical research articles.
Title: Luria’s three-step test: what is it and what does it tell us?
Authors: Myron F. Weiner, Linda S. Hynan, Heidi Rossetti and Jed Falkowski1
Journal: International Psychogeriatrics. 2011 May 4:1-5.
Presenter: Pongsatorn Paholpak, MD.
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Content
Page
1. Clinical scenario 3 2. Background and Rationale 4 3. Selection of the article 6 4. Summary of article 8 5. Materials and methods 9 6. Result 10 7. Discussion 12 8. Conclusion 12 9. Clinical appraisal 13
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Clinical Scenario 56 years old male, an early-retired teacher, visited our psychiatric outpatient department for cognitive follow after he was diagnosed with “senile forgetfulness” since 3 months ago. At this visit, even though he is able to perform other hand praxis tests, he cannot do Luria three steps test. Then he asks the question that “Is this from my normal aging process or any disorder?” Question: Can we use Luria three steps test to distinguish between demented patients and normal cognitive people?
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Back ground and rationale In the past decade, with rapid development of medical sciences and health care systems, our senile populations have increased significantly. Dementia is one among the most burdened and devastated neurodegenerative diseases which affect these old ages people primarily. Developing country in Asia may found 3 times rising of dementia prevalence1. Currently, Alzheimer’s disease leads all causes of dementia and is followed by mixed dementia, vascular dementia and frontotemporal lobe dementia respectively2. With deteriorative natural courses of dementia, these groups of patients will slowly suffer from mild cognitive impairment in the beginning. Then it will progress to significant daily activities disability after 3-10 years. Finally these demented patients will develop behavioral problems and they will be totally depended on caregivers. Making diagnosis of dementia and its spectrum is very challenging. Since the goal standard is only brain autopsy. Currently we use either DSM-IV-tr3 or NINCDS-ADRA4 criteria to establish diagnosis with good sensitivity and specificity. But these diagnosis criteria require us to evaluate patients extensively with full neuropsychological test which take a lot of time. Thus MMSE5, CDR6 and many others screening tools were developed for practical feasibility. Still, these tests require 15-45 minutes in clinical setting to be completed, that make these tests become not practical, especially, in crowded outpatient clinical setting.
Luria three steps test7, imitating 3 hand sequencing gestures, is very easy to instruct and it require only 1-2 minutes. It was first introduced by Aleksandr Luria, a Russian Psychologist, in 1970. It was studied in traumatic brain injury patients extensively. Together with other motor task, Luria-Nebraska neuropsychological test could distinguish between brain damaged patients and psychiatric patients. This motor sequencing test, technically, also elicit frontal lobe and parietal lobe functions which firstly be affected by frontotemporal dementia8. However, previous study found deficit in Luria test from Alzheimer’s dementia patient more frequent than frontotemporal dementia patients9. Thus, we need further studies which will bring us to truly understanding about its validity and application in neurocognitive sciences.
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References
1. Kukull WA. The growing global burden of dementia. Lancet neurology 2006;5:199-200. 2. Mathers C, Fat DM, Boerma JT, World Health O. The global burden of disease : 2004 update. Geneva, Switzerland: World Health Organization, 2008. 3. American Psychiatric A, American Psychiatric Association. Task Force on D-I. Diagnostic and statistical manual of mental disorders : DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000. 4. Blacker D, Albert MS, Bassett SS, Go RC, Harrell LE, Folstein MF. Reliability and validity of NINCDS-ADRDA criteria for Alzheimer's disease. The National Institute of Mental Health Genetics Initiative. Archives of neurology 1994;51:1198-1204. 5. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. Journal of psychiatric research 1975;12:189-198. 6. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993;43:2412-2414. 7. Luria AR. Higher cortical functions in man. New York: Basic Books : Consultants Bureau, 1980. 8. Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology 2000;55:1621-1626. 9. Lipton AM, Ohman KA, Womack KB, Hynan LS, Ninman ET, Lacritz LH. Subscores of the FAB differentiate frontotemporal lobar degeneration from AD. Neurology 2005;65:726-731.
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Selection of the article
Searching
- PICO model: P = Participant: Normal cognitive and Dementia patients I = Intervention: Hand Luria test C = Comparison: O = Outcome: Diagnosis of dementia and normal cognitive
- Searching strategies: 1. First approach in Pubmed
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("Luria three step" OR "Ideomotor apraxia" OR "Hand Luria") AND ("Dementia" OR "Mild Cognitive inpairment" OR "Normal Cognitive")
2. Second approach in Scopus ("Luria three step" OR "Ideomotor apraxia" OR "Hand Luria") AND ("Dementia" OR "Mild
Cognitive inpairment" OR "Normal Cognitive") With 45 search results from Pubmed and another 45 from Scopus, I have read through their
titles and abstracts. I found that there was only one article that correlated with my question. The title of this article is “Luria’s three step test : what is it and what does it tell us?”
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Summary of the article
Title : “Luria’s three step test : what is it and what does it tell us?
Authors : Myron F. Weiner, Linda S. Hyan, Heidi Rosetti, and Jed Falkowki
Source: International Psychogeriatrics. 2011 May 4:1-5.
Objective of study : To determine if the Luria three-step test is useful for differentiating between cognitive disorders.
Study design : Retrospective case control study
Study setting : UT South western Alzheimer’sdisease research center
Population : 383 records at Alzheimer’s disease research center Inclusion criteria : 1) Alzheimer’s Dementia, Frontotemporal Dementia ,
Mild cognitive Impairments, Normal Cognitive patients 2) Paients has been tested with Luria, CDR, MMSE at least 1 time
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Materials and methods : Procedure: 1. Patient data collection - Located records of MCI, FTD, AD from patients at Alzheimer’s center FTD diagnosed by Neary et al criteria (1998) AD diagnosed by probable AD criteria of NINCDS ADRDA (McKhann 1984) MCI required cognitive task > 1 SD below normative population - Located record of NC from healthy elderly control in longitudinal cohort - Subjects had been asked for age and educational years - Subjects had been tested with Luria three steps test at least once - Subjects had been tested with CDR , MMSE to level functional impairment
- Of the 581 persons seen from 2002 to 2010, 383 were included in this analysis. The ratio of total persons seen to total persons studied in each diagnostic group was 131/143 NC, 56/64 MCI, 43/64 FTD, and 153/183 AD subjects.
2. Testing patients with Luria three steps - Patients imitate three hand motions performed by the examiner with fingers fully extended and
the patient following, the examiner places his right hand with a cutting motion on his right knee or on a table, then in a fist with the knuckles down, and then palm down with fingers extended.
- Examiner and patient then repeat this three more times. - The hand motions could be reinforced by counting from 1 to 3 along with each segment, or by
saying “cut, fist, and slap.” - Patients are then asked to repeat the movements unguided by the examiner. - A score of 0 is recorded if the patient is unable to mimic the movement or complete three
independent cycles, considering as abnormal. - The test was judged to be abnormal if the hand motions differed in type or sequence from that
of the examiner.
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3. Statistical analysis - Used SPSS version 18 - Two-way analysis of variance (ANOVA) compared diagnostic groups (NC, MCI, FTD and
AD) and Luria test (abnormal versus normal) on the measures of education and age - Bonferroni post hoc pairwise comparisons were performed if the ANOVA was found to be
significant. - χ2 was used to compare groups when the data were dichotomous - If χ2 was found to be significant, a Tukeytype multiple comparison test among proportions
was performed - Assumptions for all statistical tests were checked for violations. - Significance level for all analyses was p<0.05.
3.Results - No difference between educational levels for any of the four groups - No relationship of education to failure in performing the Luria test - FTD group was significantly younger than the other groups - NC were significantly younger than the AD group as in table 1 below
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Nonsignificant effect for poorer performance on the test with advancing age as in table 2 below Table 2
Table 3
- Table 3 showed that abnormal Luria test occurred in 2.3% of normal elderly controls, in 21.4% of those with MCI, 69.8% of those with FTD, and 54.9% of those with AD(χ2(3)=117.47, p < 0.001).
- When functional impairment; CDR = 3, 100% of the FTD and 72.2% of the AD subjects had abnormal Luria performance.
- Using a Tukey type multiple comparisons test among proportions, all groups were pairwise significantly different from other groups (p < 0.05) except AD and FTD subjects.
- Of these eight subjects that MCI progress to AD, four (50%) had an abnormal Luria test at the first visit.
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- A small number of subjects were diagnosed with purely psychiatric disorders (11 major depression, 1 schizophrenia). Of these, only 1/12 (8%) was unable to perform the Luria test correctly.
4.Discussion - Luria test cannot distinguish between FTD and AD. - The increasing frequency of an abnormal Luria test with increasing functional impairment,
although not surprising, also makes it less useful as a differential diagnostic aid in late-stage dementia.
- Luria may be useful in distinguish psychiatric disorder from neurodegenerative disease The rarity of an
- Luria may distinguish persons with normal cognition from persons with early AD or FTD. - Unable to explain the appearance of an abnormal Luria test in persons with normal cognition,
but there is likely to be a range of praxis. - Another source of bias is that the test was not performed in exactly the same way for all
subjects - In summary, impaired performance in the Luria test can be helpful in distinguishing normal
and MCI subjects from AD and FTD, but does not differentiate between FTD and AD. - The Luria test may be useful cross-culturally because it is non-verbal and its performance is
unaffected by education and only minimally by age. We also have preliminary evidence that the Luria test may help to distinguish psychiatric from dementing illnesses, but that finding awaits further study.
3.Conclusion - In summary, impaired performance in the Luria test can be helpful in distinguishing normal
and MCI subjects from AD and FTD, but does not differentiate between FTD and AD. - The Luria test may be useful cross-culturally because it is non-verbal and its performance is
unaffected by education and only minimally by age.
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Critical appraisal of the selected article
1. Are these results valid? Was a defined, representative sample of patients assembled at a common (usually early) point in the course of their disease?
- Yes, because they include patients that range from normal cognitive to demented patient based on practical diagnosis standard. Moreover they include MCI, which is intermediate disorder that locates itself between normal cognitive and dementia. - With retrospective natural, they encountered with many bias. Firstly, they selected 383 cases from total of 581 with unknown reasons; I was convinced that there were many data loss and recall bias. They also gathered cases from their tertiary memory center, which contained highly educated patients, rather than community dwelling, where low educated samples stay. These considered being selection bias. - Without randomization, this study also contained huge load of confounding factors. They did not control other aspect which could affect Luria three step test e.g. disability, weakness, medications, sensory limitation, physical limitation (inflammation of joint)
Blind comparison with diagnosis “gold” standard? - Cannot tell. Even they use diagnosis standard for disease categorization but they did not blind standard diagnosis from Luria three steps test. They also did state about different Luria test instructors and raters, whom they did not train officially. This would risk this study to have poor internal and external reliability of the Luria test.
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Which would lead to huge amount of observer bias.
Were measurement test and rating appropriate? - I do not think so. Luria three steps test could be graded in many ways. It is not supposed to be scaled in just 0 or 1. With wide variety of test abnormality, it should be graded from 0-3 by trained observers. In addition, perseveration or other motor difficulties should be noted if clinical warranted.
2. Are these results valid? Are test characteristic presented? - Yes Sensitivity to all neurodegenerative processes - 0.492 Specificity to all neurodegenerative processes - 0.977 Positive predictive value - 0.977 Negative predictive value - 0.466 Likelihood ratio positive - 21.5 Likelihood ratio negative - 0.52 In global settings general prevalence of dementia = 10-15% In my settings prevalence around 20-25% (best guest)
My settings General setting
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3. Can I apply this valid, important evidence in caring for my patients? - Available, affordable, accurate, and precise in our setting
- Available, affordable à yes - accurate and precise à not known yet Even they proposed that this test is not influenced by educational years/culture but in our setting, Thailand, we have much lower educational years. So this warrant for further study in low educated samples.
- Our patients willing to carry out test? - Yes, according to its feasibility; very easy, very short time consuming. It should be another bed side test which we will routinely use to rule in our patient.
- Consequences of the test help our patient reach his or her goals? - Will the test results change my management strategy?
- Yes, this test can make us more comfortable to inform our patient whether they suffered from normal aging or neurodegenerative processes. Moreover, abnormal from this test alone would prompt us to further investigate patients with more sophisticated neuropsychological test.
Conclusion and resolution of the scenario Abnormal Luria three steps test is rarely found in normal cognitive population. Abnormal of this test indicates processes of significant cognitive disorders spectrum. However, we still do not know how cultures or educations affect this test outcome. This warrant further study of its usefulness in cross-cultural with low educational samples
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