A new perspective on proxy report: Investigating implicit processes of understanding through patient-proxy congruence

Measuring the reliability of proxy respondents in behavioural assessments: an open question

BACKGROUND

In behavioural assessment, information can be gathered from internally referenced self-reports or from proxy informants.

AIMS

This study aimed to fine-tune a brief but reliable method for evaluating the proxy accuracy in cases where responses obtained from adult and older adults' patient cannot be considered reliable.

METHODS

We generated a set of items reflecting both overt and covert behaviours related to the basic instrumental activities of daily living. The psychometric properties of the content, factorial, and criterium validity of these items were then checked. The Proxy Reliability Questionnaire-ProRe was created. We tested the frequency of "I don't know" responses as a measure of proxy reliability in a sample of healthy older adults and their proxies, and in a second sample of proxy respondents who answered questions about their parents.

RESULTS

As expected, response precision was lower for items characterizing covert behaviours; items about covert compared to overt behaviours generated more "I don't know" answers. Proxies provided less "I don't know" responses when evaluating the parent, they claimed they knew better. Moreover, we tried to validate our approach using response confidence. Encouragingly, these results also showed differences in the expected direction in confidence between overt and covert behaviours.

CONCLUSIONS

The present study encourages clinicians/researchers to how well the proxy the patient know each other, the tendency of proxies to exhibit, for example, response bias when responding to questions about patients' covert behaviours, and more importantly, the reliability of informants in providing a clinical assessment of neurocognitive diseases associated with aging.

Association Between Proxy- or Self-Reported Cognitive Decline and Cognitive Performance in Memory Clinic Visitors

BACKGROUND

It is uncertain whether self- and proxy-reported cognitive decline in older adults reflect an actual objective cognitive dysfunction in the clinical sense, and if these are predictive for developing dementia.

OBJECTIVE

The aim of the present study is to investigate the cross-sectional and longitudinal relation between subjective cognitive decline and objective cognitive performance, depressive symptoms, and to determine the predictive value for development of dementia.

METHODS

We included 405 patients without dementia at first visit from the Maastricht memory clinic participating in a longitudinal cohort study. Subjective cognitive decline was measured using a self- and proxy-report questionnaire. All patients underwent a standardized neuropsychological assessment. Follow-up assessments were performed yearly for three consecutive years, and once after five years.

RESULTS

Subjective cognitive decline was associated with lower cognitive performance and more depressive symptoms. When comparing self- (n = 342, 84%) and proxy-reported decline (n = 110, 27%), it was shown that proxy reports were associated with a more widespread pattern of lower cognitive performance. In participants without cognitive impairment proxy-reported decline was not associated with depressive symptoms. In contrast, self-reported decline was associated with a stable course of depressive symptoms at follow-up. Proxy-reported cognitive decline (HR = 1.76, 95% CI = 1.12- 2.78), and mutual complaints (HR = 1.73, CI:1.09- 2.76) predicted incident dementia while self-reported decline did not reach statistical significance (HR = 1.26, 95% CI = 0.65- 2.43).

CONCLUSION

Proxy-reported cognitive decline was consistently associated with lower cognitive performance and conversion to dementia over 5 years. Self-reported cognitive decline in patients without cognitive impairment might indicate underlying depressive symptoms and thus deserve clinical attention as well.

Toward mindfulness in quality-of-life research: perspectives on how to avoid rigor becoming rigidity

Background

The field of quality-of-life (QOL) research has matured into a discipline with scientific rigor, sophisticated methods, and guidelines. While this maturation is laudable and needed, it can result in a limiting rigidity. We aim to highlight examples of practices that are based on shared research values and principles that, when dogmatically applied, may limit the potential impact of QOL research.

Methods

By juxtaposing rigorous standards with their rigid application for different stages of the research cycle, we suggest more balanced approaches.

Results

Rigidity in cultivating a research question relates to constraining our thinking, leading to ‘safe’ research focusing on small variations of similar studies. Rigidity in operationalizing key constructs focuses on problems with validation practices that hinder further innovations, the use of static questionnaires when a more flexible approach is needed, dismissing rarely endorsed items that are clinically relevant, use of insensitive generic measures when specific measures are required, and a rigid emphasis on short questionnaires. Rigidity in data analysis relates to an undue emphasis on delineating primary and secondary outcomes and an unquestioned insistence on reducing Type 1 errors regardless of the research context. Rigidity in research infrastructure focuses on the unquestioned validity of patient input on scientific matters, and increasingly rigid guidelines and checklists that end up driving grant applications.

Discussion

It is hoped that this overview will lead to a reconsideration of a more flexible application of research principles while retaining scientific rigor.

Synergistic Effects of Reserve and Adaptive Personality in Multiple Sclerosis

OBJECTIVES

Cognitive reserve moderates the effects of gray matter (GM) atrophy on cognitive function in neurological disease. Broadly speaking, Reserve explains how persons maintain function in the face of cerebral injury in cognitive and other functional domains (e.g., physical, social). Personality, as operationalized by the Five Factor Model (FFM), is also implicated as a moderator of this relationship. It is conceivable that these protective mechanisms are related. Prior studies suggest links between Reserve and personality, but the degree to which these constructs overlap and buffer the clinical effects of neuropathology is unclear.

METHODS

We evaluated Reserve and FFM traits-Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness-in a cohort of 67 multiple sclerosis (MS) patients. We also examined the extent to which FFM traits and aspects of Reserve interact in predicting cognitive processing speed.

RESULTS

Retrospectively reported educational/occupational achievement was associated with higher Openness, and childhood social engagement was associated with higher Extraversion, Agreeableness, and Conscientiousness. Current involvement in exercise activities and social activities was associated with Extraversion, current involvement in hobbies was associated with Neuroticism, and current receptive behaviors were associated with Agreeableness and Conscientiousness. When tested as predictors, Conscientiousness and childhood enrichment activities interacted in predicting cognitive processing speed after accounting for age, disease duration, disability, and GM volume.

CONCLUSIONS

Childhood enrichment activities and Conscientiousness have a synergistic effect on cognitive processing speed. Current findings have implications for using psychological interventions to foster both Reserve and adaptive personality characteristics to stave off clinical symptoms in MS. (JINS, 2016, 22, 920-927).

Reserve and Reserve-building activities research: key challenges and future directions

Background

The concept of Cognitive Reserve has great appeal and has led to an interesting and important body of research. We believe, however, that it is unnecessarily limited by ‘habits’ of measurement, nomenclature, and intra-disciplinary thinking.

Main body

A broader, more comprehensive way of conceptualizing Reserve is proposed that invokes a broader measurement approach, nomenclature that uses specific terms embedded in a theoretical model, and crosses disciplines.

Conclusion

Building on this comprehensive conceptualization, we will discuss fruitful directions for future research.

Reserve-related activities and MRI metrics in multiple sclerosis patients and healthy controls: an observational study

BACKGROUND

To examine whether past and current reserve-related activities make the brain less susceptible to MS pathology (i.e., lesions or disease-related atrophy).

METHODS

This secondary analysis of a cohort study included 276 healthy controls (HC), and 65 clinically isolated syndrome (CIS), 352 relapsing-remitting MS (RR) and 109 secondary- progressive MS (SPMS) patients. Past reserve-related activities comprised educational and occupational attainment. Current reserve-related activities comprised strenuous and non-strenuous activities. MRI was performed on 3 T scanner. Regression and non-parametric analysis examined relationships between MRI metrics and reserve-related activities.

RESULTS

Multivariate models (HC as referent) revealed significant interactions in predicting strenuous reserve-related activities with chronic lesion burden (for CIS), brain- (for RR & SPMS), subcortical- (for CIS, RR, & SPMS) and amygdala- (for RR) volumes. Maximal Lifetime Brain Growth was higher for RR patients who engaged in running before and after diagnosis, rather than only before or never. Residual Brain Volume was higher in RR patients who did weights-exercise before and after diagnosis, as compared to only before.

CONCLUSIONS

Reserve-related activities are related to brain health cross-sectionally in all MS subgroups, and longitudinally in RR patients. Consistent with reserve theory, RR patients who maintained strenuous activities had higher Maximal Lifetime Brain Growth and Residual Brain Volume. The study's limitations are discussed, including the potential for recall bias and design limitations that preclude causal inference.

Reserve-building activities in multiple sclerosis patients and healthy controls: a descriptive study

BACKGROUND

Cognitive reserve has been implicated as a possible protective factor in multiple sclerosis (MS) but to date no study has compared reserve-building activities across disease course or to healthy controls. This study aims to describe differences in reserve-building activities across the MS disease course and healthy controls.

METHODS

Secondary analysis of a cross-sectional cohort study that included 276 healthy controls, and subjects with clinically isolated syndrome (CIS; n = 67), relapsing-remitting MS (RRMS; n = 358) and secondary progressive MS (PMS; n = 109). Past reserve-building activities were operationalized as occupational attainment and education. Current activities comprised 6 strenuous and 6 non-strenuous activities, including 5 reserve-building activities and television-watching. Multivariate Analysis of Variance models examined group differences in past and current activities, after adjusting for covariates.

RESULTS

There were group differences in past and current reserve-building activities. SPMS patients had lower past reserve-building activities than healthy controls. All forms of MS engaged in fewer strenuous current reserve-building pursuits than healthy controls. RRMS read less than healthy controls. SPMS engaged in fewer job-related non-strenuous activities. All MS groups watched more television than healthy controls.

CONCLUSIONS

MS patients show significantly fewer past and present reserve-building activities. Although it is difficult to establish causality without future prospective studies, lifestyle-modifying interventions should prioritize expanding MS patients' repertoire of strenuous and non-strenuous activities.