Associations among measures of awareness of cognitive deficits in dementia

BACKGROUND

Awareness of deficits is a complex phenomenon. In this study, we examined the relationships among various measures of awareness of cognitive deficits in dementia, and investigated the unique association between clinician ratings and alternative approaches to assessing awareness.

METHODS

Participants included 108 patients with very mild (n = 50) or mild (n = 58) dementia. Awareness of cognitive difficulties was assessed by clinician ratings, informant ratings, patients' reports of cognitive difficulties, discrepancies between patients' and informants' reports of cognitive difficulties, and patients' perceptions of performance on neuropsychological tests. Correlational analyses were used to assess associations among these measures of awareness, and ordinal logistic regression was used to examine the unique relationship between clinician ratings of awareness and the other approaches.

RESULTS

All measures of awareness were significantly correlated with one another. Coefficients ranged from 0.26 to -0.64. Patients categorized as unaware by either clinicians or informants reported fewer cognitive difficulties. Of the awareness measures evaluated, clinician ratings had the strongest correlation with measures of global cognition. In the regression analysis, only informant global ratings and patients' reports of cognitive difficulties were significantly associated with clinician ratings. The model's classification accuracy was satisfactory for patients in the "intact awareness" and "severe unawareness" categories, but not for those in the "mild unawareness" category.

CONCLUSIONS

Although measures of awareness likely share overlapping variance, they are not interchangeable. Each potentially elucidates unique aspects of the complex phenomenon of awareness, with clinician assessment being the most suited for ambiguous cases. When clinician assessment is not feasible, informant rating (but not patient-informant discrepancy) would be a valid substitute.

Criterion validity of the financial skills subscale of the direct assessment of functional status scale

Among the severely mentally ill, some individuals with schizophrenia or schizoaffective disorder can manage their finances independently, while others depend upon a court-appointed guardian or a representative payee. The present study examined the criterion validity of the financial skills subscale of the Direct Assessment of Functional Status (DAFS) scale in classifying those who manage their finances independently from those who do not. Scores on the financial skills subscale of the DAFS scale of 25 severely mentally ill outpatients without a guardian/payee were compared to scores of 24 severely mentally ill outpatients with a guardian/payee; 25 non-mentally ill participants served as controls. Logistic regression analyses, Bayesian statistics, and Receiver Operating Characteristic analyses revealed moderate classification accuracy in a sample with mild cognitive impairment. These analyses were also conducted on Mini-Mental State Examination (MMSE) scores and revealed generally lower accuracy than the DAFS financial skills subscale. The DAFS financial skills subscale can inform the clinician's opinion about the financial capacity of the severely mentally ill.

Neurocognitive predictors of financial capacity across the dementia spectrum: Normal aging, mild cognitive impairment, and Alzheimer's disease

Financial capacity is a complex instrumental activity of daily living critical to independent functioning of older adults and sensitive to impairment in patients with amnestic mild cognitive impairment (MCI) and Alzheimer's disease (AD). However, little is known about the neurocognitive basis of financial impairment in dementia. We developed cognitive models of financial capacity in cognitively healthy older adults (n = 85) and patients with MCI (n = 113) and mild AD (n = 43). All participants were administered the Financial Capacity Instrument (FCI) and a neuropsychological test battery. Univariate correlation and multiple regression procedures were used to develop cognitive models of overall FCI performance across groups. The control model (R2 = .38) comprised (in order of entry) written arithmetic skills, delayed story recall, and simple visuomotor sequencing. The MCI model (R2 = .69) comprised written arithmetic skills, visuomotor sequencing and set alternation, and race. The AD model (R2 = .65) comprised written arithmetic skills, simple visuomotor sequencing, and immediate story recall. Written arithmetic skills (WRAT-3 Arithmetic) was the primary predictor across models, accounting for 27% (control model), 46% (AD model), and 55% (MCI model) of variance. Executive function and verbal memory were secondary model predictors. The results offer insight into the cognitive basis of financial capacity across the dementia spectrum of cognitive aging, MCI, and AD.

Awareness of deficits in financial abilities in patients with mild cognitive impairment: going beyond self-informant discrepancy

OBJECTIVE

Self and informant reports of functional abilities are weighted heavily in diagnostic decision making regarding mild cognitive impairment (MCI). However, it is unclear whether patients with MCI are fully aware and provide reliable estimates of their functional status. In this study, the authors used three different approaches to examine accuracy of self-report of financial abilities among patients with MCI.

DESIGN

Cross-sectional, case-comparison group study.

SETTING

University medical center.

PARTICIPANTS

Seventy-four patients with MCI and their informants, and 73 cognitively healthy older adults and their informants.

MEASUREMENTS

The authors compared MCI patients' report of their financial abilities with their performance on an objective measure of financial capacity. The authors also compared informant reports of patients' abilities with patients' objective test performance, and informant reports with patients' self-report.

RESULTS

The authors found that the discrepancy between self-report and objective performance was higher among MCI patients compared with the cognitively healthy older adults on the financial domains of Checkbook Management, Bank Statement Management, and Bill Payment, and on overall financial capacity. The authors also found that MCI patients with poorer global cognition overestimated their financial abilities whereas those with higher depressive symptoms underestimated their financial abilities. Overall, MCI patients were better at estimating their financial abilities than their informants.

CONCLUSIONS

Patients with MCI are not fully aware of deficits in their financial abilities. Both cognitive impairment and depression impact MCI patients' self-reported functioning. In addition, MCI informants misestimate patients' financial abilities. This raises concerns about the widespread use of informant report as the gold standard against which to evaluate patient self-report of functioning.

Schizotypal traits impact upon executive working memory and aspects of IQ

Previous inconsistent findings concerning a link between working memory dysfunction and negative aspects of non-clinical schizotypy have been interpreted to cast doubt on the continuity model of 'negative psychosis-proneness'. This study employed the Letter-Number-Sequencing (LNS) task and the Trail-Making Test to assess more demanding, executive working memory. A secondary concern was to rule out possible mediating effects of familial schizophrenia. It was hypothesised that executive working memory impairment would be associated primarily with negative rather than positive schizotypy even in the absence of familial schizophrenia. Matrix reasoning controlled for IQ. In 87 university-student participants with no known family history of schizophrenia, lower LNS scores were associated with higher levels of negative and positive schizotypy traits. Counter to expectations, matrix reasoning scores were also associated with schizotypy, primarily the cognitive/perceptual traits. Results were similar when participants with a known family history of schizophrenia (10) were included (N=97). Findings support the view that impairment of executive working memory (indexed by LNS) is a reliable cognitive marker for negative (and perhaps also positive) schizophrenia vulnerability, independent of familial schizophrenia, and provide the first indication that some facets of IQ (e.g. inductive reasoning) might also be compromised in non-clinical schizotypy.

Declining financial capacity in patients with mild Alzheimer disease: a one-year longitudinal study

OBJECTIVE

The objective of this study was to investigate change over time in financial abilities in patients with mild Alzheimer disease (AD).

METHODS

The authors conducted a prospective 1-year longitudinal study at a large southern U.S. metropolitan-area medical school university. Participants included healthy older adults (N=63) and patients with mild AD (N=55). The authors conducted a standardized performance measure of financial capacity. Performance was assessed on 18 financial tasks, nine domains of financial activity, and overall financial capacity. Capacity outcomes classifications (capable, marginally capable, or incapable) for domains and overall performance were made using cut scores referenced to comparison group performance.

RESULTS

At baseline, patients with mild AD performed significantly below healthy older adults on 16 of 18 tasks, on all nine domains, and on overall financial capacity. At one-year follow up, comparison group performance was stable on all variables. In contrast, patients with mild AD showed substantial declines in overall financial capacity, on eight of nine domains, and on 12 of 18 tasks. Similarly, the proportion of the mild AD group classified as marginally capable and incapable increased substantially over one year for the two overall scores and for five financial domains.

CONCLUSIONS

Financial capacity is already substantially impaired in patients with mild AD at baseline and undergoes rapid additional decline over one year. Relative to the comparison group, overall financial capacity performance in the AD group declined 10%, from approximately 80% of the comparison group performance at baseline to 70% at follow up. Financial skills showed differential rates of decline on both simple and complex tasks. Of clinical and public policy interest was the declining judgment of patients with mild AD regarding simple fraud schemes. The study supports the importance of prompt financial supervision and planning for patients newly diagnosed with AD.

Assessment of decision-making capacity in older adults: an emerging area of practice and research

The convergence of the aging of our society, the increase in blended families, and an enormous intergenerational transfer of wealth has greatly expanded the incidence and importance of capacity assessment of older adults. In this article we discuss the emergence of capacity assessment as a distinct field of study. We review research efforts in two domains: medical decision-making capacity and financial capacity. Existing research in these two areas provides a first pass at many key questions related to capacity assessment, but additional studies that replicate, extend, and improve on this research are urgently needed. An agenda for future is detailed that recommends studies of a wide range of capacity constructs, focusing on clinical markers of diminished capacity, methods to improve clinical assessment, and the many intersections of law and clinical practice.

Amnestic mild cognitive impairment: diagnostic outcomes and clinical prediction over a two-year time period

Amnestic mild cognitive impairment (MCI) has been defined as a precursor to Alzheimer's disease (AD), although it is sometimes difficult to identify which persons with MCI will eventually convert to AD. We sought to predict MCI conversion to AD over a two-year follow-up period using baseline demographic and neuropsychological test data from 49 MCI patients. Using a stepwise discriminant function analysis with Dementia Rating Scale (DRS) Initiation/Perseveration and Wechsler Memory Scale, third edition (WMS-III) Visual Reproduction Percent Retention scores, we correctly classified 85.7% of the sample as either AD converters or MCI nonconverters, with 76.9% sensitivity and 88.9% specificity. Adding race, the presence of vascular risk factors, or cholinesterase inhibitor use to the analysis did not greatly change the classification rates obtained with neuropsychological test data. Examining neuropsychological test cutoff scores revealed that DRS Initiation/Perseveration scores below 37 and Visual Reproduction Percent Retention scores below 26% correctly identified AD converters with 76.9% sensitivity and 91.7% specificity. These results demonstrate that commonly administered neuropsychological tests identify persons with MCI at baseline who are at risk for conversion to AD within 1-2 years. Such methods could aid in identifying MCI patients who might benefit from early treatment, in providing prognostic information to patients, and identifying potential clinical trial participants.

Impaired financial abilities in mild cognitive impairment: a direct assessment approach

OBJECTIVES

To assess financial capacity in patients with mild cognitive impairment (MCI) using a standardized psychometric capacity measure.

METHODS

Participants were 21 cognitively normal older controls, 21 patients with amnestic MCI, and 22 patients with mild AD. The Financial Capacity Instrument (FCI), a psychometric capacity measure consisting of 18 financial ability tests (tasks), 9 domains (activities), and 2 total scores, was administered to participants along with a battery of neuropsychological tests sensitive to dementia. Group differences were examined on the neuropsychological and financial capacity variables.

RESULTS

Relative to controls, the MCI group demonstrated impairments in episodic memory, and also semantic knowledge, executive function, written arithmetic, and spatial attention. MCI participants demonstrated impairments in FCI domains of conceptual knowledge, cash transactions, bank statement management, and bill payment, and in overall financial capacity. The control and MCI groups performed significantly better than patients with AD on most financial capacity and cognitive measures.

CONCLUSIONS

On direct assessment, patients with amnestic MCI as a group demonstrate impairments across a range of financial abilities. These impairments are mild and may only apply to a subset of patients with MCI. However, existing diagnostic criteria for MCI should be applied flexibly to include mild impairments in higher order activities of daily life such as financial capacity.