Psychometric properties of an informant personality questionnaire (the HAP) in a sample of older adults in the Netherlands and Belgium

Personality assessment in nursing home residents with mental and physical multimorbidity: two informant perspectives

OBJECTIVES

In older patients with mental and physical multimorbidity (MPM), personality assessment is highly complex. Our aim was to examine personality traits in this population using the Hetero-Anamnestic Personality questionnaire (HAP), and to compare the premorbid perspective of patients' relatives (HAP) with the present-time perspective of nursing staff (HAP-t).

DESIGN

Cross-sectional.

SETTING

Dutch gerontopsychiatric nursing home (GP-NH) units.

PARTICIPANTS

Totally, 142 GP-NH residents with MPM (excluding dementia).

MEASUREMENTS

NH norm data of the HAP were used to identify clinically relevant premorbid traits. Linear mixed models estimated the differences between HAP and HAP-t trait scores (0-10). Agreement was quantified by intraclass correlation coefficients (ICCs). All HAP-HAP-t analyses were corrected for response tendency (RT) scores (-10-10).

RESULTS

78.4% of the patients had at least one premorbid maladaptive trait, and 62.2% had two or more. Most prevalent were: "disorderly" (30.3%), "unpredictable/impulsive" (29.1%) and "vulnerable" (27.3%) behavior. The RT of relatives appeared significantly more positive than that of nursing staff (+1.8, 95% CI 0.6-2.9, p = 0.002). After RT correction, the traits "vulnerable", "perfectionist" and "unpredictable/impulsive" behavior scored higher on the HAP than HAP-t (respectively +1.2, 95% CI 0.6-1.7, p < 0.001; +2.1, 95% CI 1.3-2.8, p < 0.001; +0.6, 95% CI 0.1-1.1, p = 0.013), while "rigid" behavior scored lower (-0.7, 95% CI -1.3 to -0.03, p = 0.042). Adjusted ICCs ranged from 0.15 to 0.58.

CONCLUSIONS

Our study shows high percentages of premorbid maladaptive personality traits, which calls for attention on personality assessment in MPM NH residents. Results also indicate that the HAP and HAP-t questionnaires should not be used interchangeably for this patient group in clinical practice.

Personality traits and personality problems in Korsakoff syndrome patients

Personality research is of relevance because it provides insights into the psychological strengths and vulnerabilities of a person. Korsakoff's syndrome (KS) is a severe neuropsychiatric disorder following acute thiamine deficiency, usually as a consequence of alcohol-use disorders. Research on personality traits of KS patients is currently limited. The aim of the current exploratory study was therefore to examine the personality traits and problems of KS patients. We assessed self-reported and informant-reported personality traits and problems in institutionalized KS patients (n = 30). Results indicate that the psychotic personality organization was more frequently present in KS patients compared to a psychiatric reference population, leading to increased vulnerability for the development of severe psychiatric issues. Informants observed more premorbid and current cluster B ("emotional") and C ("anxious") personality behavior in comparison to the general population. Also, rigid- and socially avoidant behavior in KS patients was observed to increase over the years. They also observed personality problems such as emotional-, unpredictable-, dramatic-, anxious and fearful behavior in the present and in the past. KS patients reported themselves as healthy individuals, indicating a lack of self-awareness. We recommend training programs for the medical team focussed on psycho-education and supportive interventions for patients with complex personality problems concomitant to KS.

Assessment of Personality Disorders in Older Adults. A Practice Guide

Assessment of personality disorders (PDs) in older adults is a nuanced trade of its own. The aim of this practice guide is to illustrate gerontological assessment challenges using 3 case vignettes. We argue that it is important to pay extra attention to the influence of cognitive and medical (somatic) disorders on personality functioning in older adults during personality assessment. We also note that information provided by informants contributes added value to personality assessment. Personality assessment should be sufficiently age-specific to prevent overdiagnosis or underdiagnosis in older adults. Furthermore, given the reduced psychological or somatic capacity of some older adults, phased or sequential personality assessment is recommended. This should be focused on the assessment questions to be answered, for example starting with short general screening of personality functioning, followed by more in-depth exploration. Personality assessment should be kept as brief and simple as possible in terms of formulation of the items.

Development and Preliminary Evaluation of a Rapid Screening Tool for Detecting Borderline Personality Disorder in People Aged over 60 Years

OBJECTIVES

Screening and diagnostic instruments for Borderline Personality Disorder (BPD) are not validated in people aged over 60. We report a pilot study examining the sensitivity and specificity of a de-novo screening instrument in older adults.

METHODS

The BPD-OA screening tool incorporates DSM 5 and literature describing the expression of BPD in older adults. This study was conducted using a case control design. The Diagnostic Interview for Borderlines-Revised (DIB-R) and the McLean Screening Instrument for BPD (MSI-BPD) were used as comparators. Comprehensive assessment by psychiatric teams determined participants to be (i) BPD-positive (n = 22) or (ii) BPD-negative (gender matched; n = 21).

RESULTS

The BPD-OA was the most sensitive instrument for discriminating older adult BPD from non-BPD participants (sensitivity = 0.82). No significant relationship was found between the BPD-OA score and age in BPD-diagnosed participants (r = -0.181, n = 21, p = .432). Participant age explained 3.2% of the variance in BPD-OA scores. Of the 21 BPD-negative participants, eight false positives experienced prominent mood disorders (specificity = 0.62).

CONCLUSIONS

The BPD-OA screening tool is clearly superior to instruments validated for use in younger people. Further refinement and evaluation will enhance its sensitivity and specificity.

CLINICAL IMPLICATIONS

Detection of BPD in older adult care settings will improve outcomes for patients, families, and staff through better understanding and appropriate management and treatment strategies.

Age-neutrality of the SCID-II: Differential Item Functioning in Younger Outpatients (Aged 20-45) and Older Outpatients (Aged 65+)

OBJECTIVES

Measurements are often developed for the assessment of personality disorders (PDs) in younger adults and seldom evaluated on the applicability in older adults. Remarkably, research has not yet been conducted into age-group appropriateness of the gold standard for the assessment of PDs, known as Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). Therefore, the current study empirically investigated the age-neutrality of the PDs assessed by the SCID-II.

METHODS

Age-neutrality was examined in 84 younger adults (aged 20-45 years) and 68 older adults (aged 65-85) by Differential Item Functioning (DIF). The impact of DIF on scale level was further examined using Differential Test Functioning analyzes to examine the impact of the amount of DIF variance in the items on scale level.

RESULTS

Overall, the great majority, 95.8% of the categorically measured items and 87.5% of the dimensionally measured items, was endorsed in the same way by younger adults and older adults with equal scores on the PD scale. Subsequent analyzes revealed no large DTF for PD scales.

CONCLUSIONS

Overall the SCID-II in an outpatient population is age-neutral for both categorically and dimensionally scored PD scales.

CLINICAL IMPLICATIONS

The SCID-II can be used for the assessment of PDs in older adults.

Feasibility of the Cognitive Model for Behavioral Interventions in Older Adults with Behavioral and Psychological Symptoms of Dementia

Objectives: The purpose of this study was to develop an individually tailored, non-pharmacological treatment model, the Cognitive Model for Behavioral Interventions (CoMBI), for patients with Behavioral and Psychological Symptoms of Dementia (BPSD) and comorbid maladaptive personality traits (CMPT), and to explore its feasibility and effectiveness.Methods: CoMBI was developed and implemented in two geriatric psychiatric inpatient wards in the Netherlands. In this single-group pretest-posttest, feasibility study, 40 patients with BPSD and CMPT (M = 73.8, SD = 8.5) were treated with CoMBI. BPSD and CMPT were assessed using informant-based questionnaires. Wilcoxon signed-rank tests and effect size calculations were conducted to determine differences.Results: Wilcoxon signed-rank tests demonstrated a significant decrease of BPSD with medium (r = 0.45) to large (r = 0.56) effect sizes. CoMBI demonstrated high acceptability and compliance by health-care professionals and family members.Conclusions: CoMBI is a feasible treatment model for challenging behavior in patients with BPSD and CMPT. CoMBI is associated with a significant decrease in challenging behaviors regardless of etiology.Clinical implications: Focusing on personality and associated core needs could have a key role in the non-pharmacological treatment of the elderly with BPSD.

The Relationship Between Maladaptive Personality and Social Role Impairment in Depressed Older Adults in Primary Care

Objective: Personality pathology is associated with impaired social functioning in adults, though further evidence is needed to examine the individual contributions of personality traits and processes to social functioning in depressed older adults. This study is a secondary analysis examining the relationship between maladaptive personality traits and processes and social role impairment in depressed older adults in primary care. Methods: Participants (N = 56) were 77% female and ranged in age between 55-89 (M = 66.82, SD = 8.75). Personality pathology was measured by maladaptive traits (NEO-FFI) and processes (Inventory of Interpersonal Problems; IIP-PD-15). Individual variable as well as combined predictive models of social role impairment were examined. Results: Higher neuroticism (β = 0.30, p < .05), lower agreeableness (β = -0.35 p < .001) and higher IIP-PD-15 (β = 0.28, p < .01) scores predicted greater impairment in social role functioning. A combined predictive model of neuroticism and IIP-PD-15 scores predicted unique variance in social role impairment (R² = .71). Conclusion: These results link select personality traits and interpersonal processes to social role impairment, suggesting that these are indicators of personality pathology in older adults. Clinical Implications: These findings lend preliminary support for clinical screening of personality pathology in depressed older adults utilizing both personality trait and process measures.

Screening for personality disorders in geriatric medicine outpatients

PURPOSE

Personality disorder (PD) assessment in older adults is challenging. In geriatric medicine, older adults with multi-morbidity are treated for their somatic, psychogeriatric, functional and social complaints and the presence of a PD can be a complicating factor in this treatment. Therefore, this study evaluates the diagnostic accuracy of a PD screening instrument, the Gerontological Personality disorder Scale (GPS) in a Dutch geriatric medicine population.

METHODS

Using an informant-based personality questionnaire (HAP) as a reference criterion, the psychometric properties of the GPS-informant version were assessed in a sample of N = 160 (62 male) outpatients (mean age = 81.7).

RESULTS

The internal consistency of the GPS (total score), Cronbach's alpha, was α = 0.69. And the average inter-item correlation (total score) was 0.14. The test-retest reliability was r_s = 0.68. The sensitivity and specificity for the GPS were 0.91 and 0.67, respectively. The GPS items showed predictive validity for PD status with 87.4% of predictions being accurate based on a logistic regression analysis.

CONCLUSIONS

This is the first psychometric study to use the GPS as an age-specific screening instrument for PDs in Dutch geriatric medicine outpatients. The GPS is an adequate screening tool for PDs in geriatric medicine, given the high sensitivity. The diagnostic accuracy of the GPS-informant version is fair to excellent.

Severity Indices of Personality Problems-Short Form in Old-Age Psychiatry: Reliability and Validity

The Severity Indices of Personality Problems (SIPP; Verheul et al., 2008) is a popular self-report questionnaire that measures severity of maladaptive personality functioning. Two studies demonstrated the utility of the short form (SIPP-SF) among older adults but validation in clinical settings is lacking. Therefore, we examined the psychometric properties of the SIPP-SF in a large sample of older adult Dutch outpatients (N = 124; age range = 60-85 years, M = 69.8, SD = 5.3). The SIPP-SF domains showed good to excellent internal reliability (Cronbach's α = .75-.91) and effectively discriminated between participants with and without a personality disorder, as assessed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Convergent validity of the SIPP-SF was examined with instruments for measuring personality pathology among older adults (Informant Personality questionnaire [HAP]; Gerontological Personality Disorders Scale [GPS]). The GPS generally correlated with the SIPP-SF domains in expected directions, with small to large effect sizes. For the HAP, only 1 scale correlated with all SIPP-SF domains. No associations were found between the SIPP-SF and psychiatric symptomatology as measured by the Brief Symptom Inventory (BSI). The SIPP-SF appears to be a promising instrument for assessing maladaptive personality functioning among older adult outpatients.

Screening of Autism Spectrum Disorders in Geriatric Psychiatry

Autism spectrum disorders (ASD) are difficult to detect in old age. This study examined if ASD symptoms in older adults (age > 60) can be detected with the Dutch informant personality questionnaire, (Hetero-Anamnestische Persoonlijkheidsvragenlijst, HAP) in a mental health setting. Patients with ASD (N = 40) were compared to patients with a different psychiatric diagnosis (N = 43; personality disorders excluded). The ASD group had significant higher scores on the scales 'Socially avoidant behavior', 'Rigid behavior' and 'Unpredictable and impulsive behavior'. These scales were able to discriminate between individuals with or without ASD. The HAP can thus be used as a screening instrument for ASD symptoms in elderly patients. Further research is needed to clarify what items have the best predictive validity for ASD symptoms.

Feasibility and Acceptability of the Gerontological Personality Disorders Scale (GPS) in General Practice: A Mixed Methods Study

Although the Gerontological Personality Disorders Scale (GPS) can aid in detecting personality disorders (PDs) in older adults in general practice, its availability does not guarantee its use. This study therefore aimed to examine the feasibility and acceptability of the GPS from an older adult, informant, and professional perspective. A convergent parallel mixed methods study was conducted. Qualitative data were collected through semistructured interviews with four general practitioners and four nurse practitioners and were analyzed thematically. Quantitative data were collected through a 5-item questionnaire completed by 329 older adults and 329 informants. The thematic analysis revealed five major themes regarding feasibility and acceptability according to the professionals: taboo to ask intimate questions, quite unfamiliar with these disorders, assets, PDs are a topic of interest in general practice, and preconditions. Descriptive statistics showed that most older adults and informants found the GPS items to be clearly phrased, easy to understand, and nonconfrontational or not unpleasant to answer. The GPS is a feasible and acceptable instrument for detecting PDs in older adults in general practice. Educating professionals about PDs in older adults and the GPS is important prior to its use in daily practice and might further increase its acceptability.

What do nursing home residents with mental-physical multimorbidity need and who actually knows this? A cross-sectional cohort study

OBJECTIVE

Aging societies will bring an increase in the number of long-term care residents with mental-physical multimorbidity. To optimize care for these residents, it is important to study their care needs, since unmet needs lower quality of life. To date, knowledge about care needs of residents with mental-physical multimorbidity is limited. The aim of this study was to explore (un)met care needs of residents with mental-physical multimorbidity and determinants of unmet needs.

METHODS

Cross-sectional cohort study among 141 residents with mental-physical multimorbidity without dementia living in 17 geronto-psychiatric nursing home units across the Netherlands. Data collection consisted of chart review, semi-structured interviews, (brief) neuropsychological testing, and self-report questionnaires. The Camberwell Assessment of Need for the Elderly (CANE) was used to rate (un)met care needs from residents' and nursing staff's perceptions. Descriptive and multivariate regression analyses were conducted.

RESULTS

Residents reported a mean number of 11.89 needs (SD 2.88) of which 24.2% (n = 2.88, SD 2.48) were unmet. Nursing staff indicated a mean number of 14.73 needs (SD 2.32) of which 10.8% (n = 1.59, SD 1.61) were unmet. According to the residents, most unmet needs were found in the social domain as opposed to the psychological domain as reported by the nursing staff. Different opinions between resident and nursing staff about unmet needs was most common in the areas accommodation, company, and daytime activities. Further, nearly half of the residents indicated 'no need' regarding behavior while the nursing staff supposed that the resident did require some kind of support. Depression, anxiety and less care dependency were the most important determinants of unmet needs.

CONCLUSIONS

Systematic assessment of care needs showed differences between the perspectives of resident and nursing staff. These should be the starting point of a dialogue between them about needs, wishes and expectations regarding care. This dialogue can subsequently lead to the most optimal individually tailored care plan. To achieve this, nurses with effective communication and negotiation skills, are indispensable.

Diagnostic accuracy of the Gerontological Personality Disorder Scale (GPS) in Dutch general practice

OBJECTIVE

Personality disorders (PDs) often remain unrecognized in older adults by doctors in general practice. Therefore, this study evaluated the diagnostic accuracy of a screening instrument, the Gerontological Personality Disorder Scale (GPS), in a Dutch general-practice population of older adults.

METHOD

The psychometric properties of the GPS patient (GPS-pv) and informant (GPS-iv) versions were assessed in a sample of 302 (144 male) patients (average age: 69.9 years) and 302 (124 male) informants (average age: 64.7 years), respectively, using an informant-based personality questionnaire (the Hetero-Anamnestische Persoonlijkheidsvragenlijst ) as a reference criterion.

RESULTS

The internal consistency (average item correlation) of the subscale and total scores of the GPS-pv and GPS-iv were .12 (HAB), .16 (BIO), and .10 (total); and .16 (HAB), .15 (BIO), and .12 (total), respectively. The test--retest reliability was strong for both the GPS-pv (rs = .56 [HAB], rs = .67 [BIO], rs = .66 [total]) and the GPS-iv (rs = .52 [HAB], rs = .65 [BIO], rs = .68 [total]) versions. The sensitivity and specificity of the GPS-pv were .83 and .27, respectively, with a cutoff score of ≥1. Raising the cutoff score to ≥2, the sensitivity dropped to .59, whereas the specificity rose to .57. For the GPS-iv, a cutoff score of ≥3 maximized the sensitivity (.78) and specificity (.65).

CONCLUSION

The diagnostic accuracy of the GPS-iv was preferable to that of the GPS-pv. This is the first psychometric study to use the GPS as an age-specific screening instrument for PDs.

Age Neutrality of Categorically and Dimensionally Measured DSM-5 Section II Personality Disorder Symptoms

Studies on the face validity of DSM-5 Section II categorical personality disorder (PD) symptoms indicate a bias against older adults. To extend these results, this article explores whether categorically and dimensionally scored PD symptoms of DSM-5 Section II, as measured in the Assessment of DSM-IV Personality Disorders (ADP-IV; Schotte & de Doncker, 1994), corroborate potential age bias across younger (aged 18-34), middle-aged (35-59 years), and older adults (aged 60-75). Differential item functioning (DIF) analyses, following a classical test theory approach, showed that 2 of the 79 symptoms were measured differently across 3 age groups when categorically assessed, and 4 when dimensionally measured. Nevertheless, subsequent differential test functioning analyses supported a low aggregated impact of DIF on the dimensional scales, justifying mean-level comparisons across age groups. Generalizability of the results is discussed in light of methodological issues concerning the research of age neutrality of PD symptoms, including the employed measurement instrument, PD symptom measurement approach, and sample and age range used to describe older adults.

Personality disorders in older adults: emerging research issues

Empirical research focusing on personality disorders (PDs) among older adults is mainly limited to studies on psychometric properties of age-specific personality tests, the age neutrality of specific items/scales, and validation of personality inventories for older adults. We identified only two treatment studies-one on dialectical behavior therapy and one on schema therapy-both with promising results among older patients despite small and heterogeneous populations. More rigorous studies incorporating age-specific adaptations are needed. Furthermore, in contrast to increasing numbers of psychometric studies, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 pays little attention to the characteristics of older adults with PDs. Moreover, the constructs "personality change due to another medical condition" and "late-onset personality disorder" warrant further research among older adults. These needs will become even more pressing given the aging society worldwide.

Personality disorders in older adults: expert opinion as a first step toward evaluating the criterion validity of an informant questionnaire (HAP)

There is a lack of validated questionnaires for screening personality disorders (PDs) in older adults (e.g. Van Alphen et al., 2012). The development of measurement instruments is hampered because the criteria of DSM-IV-TR PD are not age-neutral that might lead to over- and underdiagnosis (Balsis et al., 2007). As far as we know only three measurement instruments have been specifically developed for older adults, including the Hetero- Anamnestic Personality questionnaire (HAP; Barendse et al., 2013). However, we did not find any articles concerning the criterion validity of all ten PDs in an elderly population. In this Delphi study, a panel of experts examined two research questions: (1) To what extend are the items of the HAP age-neutral? (2) Does the HAP detect all ten specific PD's of DSM-IV-TR, based on qualitative research?