Relationship between measures of dementia severity and observation of daily life functioning as measured with the Assessment of Motor and Process Skills (AMPS)

Establishing the Predictive Validity of the Assessment of Motor and Process Skills for Driving Performance Outcomes

IMPORTANCE

Although the Assessment of Motor and Process Skills (AMPS) is an excellent tool for evaluating the functional performance of instrumental activities of daily living (IADLs), a limited number of studies have used the AMPS for decisions regarding the IADL of fitness to drive and community mobility.

OBJECTIVE

To determine the specificity and sensitivity of the AMPS as a tool for determining a person's fitness to drive.

DESIGN

Cross-sectional observational design.

SETTING

Three driving rehabilitation programs in three states.

PARTICIPANTS

Participants were 388 community-living adults (M age = 68.74 yr, SD = 11.53); 196 adults were recruited before completing a comprehensive driving evaluation, and 192 were recruited in two other studies of older drivers.

OUTCOME AND MEASURES

AMPS and results of comprehensive driving evaluation or on-road assessment.

RESULTS

Using a logistical regression, AMPS Motor and Process Skills scores yielded a sensitivity of 84.6% and a specificity of 88.8%. The odds ratio of the AMPS Motor Skills score was .347; for the AMPS Process Skills score, it was .014. Using cross-validations, the model with AMPS Motor and Process scores produced a cross-validation area under the curve of .918, with sensitivity and specificity of 84.6% and 88.4%, respectively, and a probability greater than .334 was used for predicting a fail or drive-with-restriction evaluation.

CONCLUSIONS AND RELEVANCE

The AMPS Motor and Process Skills scores revealed significant differences between those who failed or had driving restrictions and with those who passed the driving evaluation, which supported the AMPS as an effective tool for predicting fitness to drive. Plain-Language Summary: This study demonstrates how the Assessment of Motor and Process Skills (AMPS), as a top-down occupational therapy assessment tool, can be used to differentiate between medically at-risk drivers who are likely to pass a comprehensive driving evaluation and those who are likely to fail or need restrictions. AMPS will assist occupational therapy practitioners in determining who is most appropriate to receive driving rehabilitation services and/or when to refer a person for a comprehensive driving evaluation.

Development and content validity of the cognition in daily life scale (CDL)

Cognitive impairment can negatively influence daily functioning. Current cognitive measures are essential for diagnosing cognitive impairment, but findings on these tests do not always represent the level of cognitive functioning in daily life. Therefore, this study aimed to design a structured measurement instrument to observe and rate the impact of cognitive impairment in daily life, named the cognition in daily life scale for persons with cognitive problems (CDL). In this paper we describe the development, expected usability, and psychometric properties (content and face validity) of the instrument. The CDL was established through three consecutive development phases: (1) item selection, (2) item categorization and comparison, and (3) item revision and manual construction. Subsequently, a panel of eleven international experts rated the relevance of the selected items and provided comments on the expected usability and face validity. Content validity was estimated with the content validity index, based on which four items were removed. The experts' comments led to minor adjustments of the manual, domains, and formulation of the maintained items. The final instrument consists of 65 items describing behaviour that relies on cognitive functions within six domains. Future research should focus on evaluating the construct validity and reliability of the CDL.

Diagnostic criteria for apathy in neurocognitive disorders

INTRODUCTION

Apathy is common in neurocognitive disorders (NCD) but NCD-specific diagnostic criteria are needed.

METHODS

The International Society for CNS Clinical Trials Methodology Apathy Work Group convened an expert group and sought input from academia, health-care, industry, and regulatory bodies. A modified Delphi methodology was followed, and included an extensive literature review, two surveys, and two meetings at international conferences, culminating in a consensus meeting in 2019.

RESULTS

The final criteria reached consensus with more than 80% agreement on all parts and included: limited to people with NCD; symptoms persistent or frequently recurrent over at least 4 weeks, a change from the patient's usual behavior, and including one of the following: diminished initiative, diminished interest, or diminished emotional expression/responsiveness; causing significant functional impairment and not exclusively explained by other etiologies.

DISCUSSION

These criteria provide a framework for defining apathy as a unique clinical construct in NCD for diagnosis and further research.

Towards the concept of disease-modifier in post-stroke or vascular cognitive impairment: a consensus report

BACKGROUND

Vascular cognitive impairment (VCI) is a complex spectrum encompassing post-stroke cognitive impairment (PSCI) and small vessel disease-related cognitive impairment. Despite the growing health, social, and economic burden of VCI, to date, no specific treatment is available, prompting the introduction of the concept of a disease modifier.

CONSENSUS AND SUGGESTIONS

Within this clinical spectrum, VCI and PSCI remain advancing conditions as neurodegenerative diseases with progression of both vascular and degenerative lesions accounting for cognitive decline. Disease-modifying strategies should integrate both pharmacological and non-pharmacological multimodal approaches, with pleiotropic effects targeting (1) endothelial and brain-blood barrier dysfunction; (2) neuronal death and axonal loss; (3) cerebral plasticity and compensatory mechanisms; and (4) degenerative-related protein misfolding. Moreover, pharmacological and non-pharmacological treatment in PSCI or VCI requires valid study designs clearly stating the definition of basic methodological issues, such as the instruments that should be used to measure eventual changes, the biomarker-based stratification of participants to be investigated, and statistical tests, as well as the inclusion and exclusion criteria that should be applied.

CONCLUSION

A consensus emerged to propose the development of a disease-modifying strategy in VCI and PSCI based on pleiotropic pharmacological and non-pharmacological approaches.

Skill clusters of ability to manage everyday technology among people with and without cognitive impairment, dementia and acquired brain injury

BACKGROUND

In order to develop supporting interventions for people demonstrating problems ET use, a detailed level of description of strengths and deficits is needed.

AIMS

To explore clusters of specific performance skill required when using ET, and to evaluate if and in what way such clusters are associated with age, gender, diagnosis, and types of ETs managed.

MATERIALS AND METHODS

A secondary analysis of 661 data records from 203 heterogeneous samples of participants using the Management of Everyday Technology Assessment (META) was used. Ward's method and a hierarchical tree cluster analysis were used to determine and define the skill clusters.

RESULTS

Four distinct clusters of performance skill item profiles were found, across the 661 data records. These were then, based on each individuals' cluster profiles in managing ET, categorized into two groups. The two groups were associated with, diagnosis and type of ETs managed.

CONCLUSIONS AND SIGNIFICANCE

The findings support a more dyadic person-ET approach in evaluation of ET management. The information from the skill clusters can be used to develop targeted intervention guides for occupational therapy and healthcare.

Apathy associated with neurocognitive disorders: Recent progress and future directions

INTRODUCTION

Apathy is common in neurocognitive disorders (NCDs) such as Alzheimer's disease and mild cognitive impairment. Although the definition of apathy is inconsistent in the literature, apathy is primarily defined as a loss of motivation and decreased interest in daily activities.

METHODS

The Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) Neuropsychiatric Syndromes Professional Interest Area (NPS-PIA) Apathy workgroup reviewed the latest research regarding apathy in NCDs.

RESULTS

Progress has recently been made in three areas relevant to apathy: (1) phenomenology, including the use of diagnostic criteria and novel instruments for measurement, (2) neurobiology, including neuroimaging, neuropathological and biomarker correlates, and (3) interventions, including pharmacologic, nonpharmacologic, and noninvasive neuromodulatory approaches.

DISCUSSION

Recent progress confirms that apathy has a significant impact on those with major NCD and those with mild NCDs. As such, it is an important target for research and intervention.

Collecting Information for Rating Global Assessment of Functioning (GAF): Sources of Information and Methods for Information Collection

INTRODUCTION

Global Assessment of Functioning (GAF) is an assessment instrument that is known worldwide. It is widely used for rating the severity of illness. Results from evaluations in psychiatry should characterize the patients. Rating of GAF is based on collected information. The aim of the study is to identify the factors involved in collecting information that is relevant for rating GAF, and gaps in knowledge where it is likely that further development would play a role for improved scoring.

METHODS

A literature search was conducted with a combination of thorough hand search and search in the bibliographic databases PubMed, PsycINFO, Google Scholar, and Campbell Collaboration Library of Systematic Reviews.

RESULTS

Collection of information for rating GAF depends on two fundamental factors: the sources of information and the methods for information collection. Sources of information are patients, informants, health personnel, medical records, letters of referral and police records about violence and substance abuse. Methods for information collection include the many different types of interview - unstructured, semi-structured, structured, interviews for Axis I and II disorders, semistructured interviews for rating GAF, and interviews of informants - as well as instruments for rating symptoms and functioning, and observation. The different sources of information, and methods for collection, frequently result in inconsistencies in the information collected. The variation in collected information, and lack of a generally accepted algorithm for combining collected information, is likely to be important for rated GAF values, but there is a fundamental lack of knowledge about the degree of importance.

CONCLUSIONS

Research to improve GAF has not reached a high level. Rated GAF values are likely to be influenced by both the sources of information used and the methods employed for information collection, but the lack of research-based information about these influences is fundamental. Further development of GAF is feasible and proposals for this are presented.

The Suitability of the Montreal Cognitive Assessment as a Screening Tool to Identify People with Dysfunction in Occupational Performance after Mild Stroke

Introduction:

Cognitive deficits are an important determinant for experiencing limitations in occupational performance after stroke. It is important to recognize these deficits, and their impact on daily activities, at an early stage so people can get the support they need. The non-challenging environment of a hospital hampers this recognition, making it difficult for occupational therapists to select which patients should be assessed extensively, and which not. This study aims to explore the Montreal Cognitive Assessment as a screening tool by investigating its relationship with occupational performance in patients with mild stroke.

Method:

Twenty-nine people with mild stroke were recruited for this cross-sectional study. Scores on the Montreal Cognitive Assessment and Assessment of Motor and Process Skills were compared and correlations were calculated.

Findings:

The Montreal Cognitive Assessment cut-off did not identify those who might experience problems in daily functioning after mild stroke. A moderate correlation was found between scores on the Montreal Cognitive Assessment and the Assessment of Motor and Process Skills process scores.

Conclusion:

The Montreal Cognitive Assessment cannot be used as a screening tool to identify problems in occupational performance after mild stroke.

A 52 month follow-up of functional decline in nursing home residents - degree of dementia contributes

Background

Few have studied how personal activities of daily living (P-ADL) develop over time in nursing home residents with dementia. Thus, the aim was to study variables associated with the development of P-ADL functioning over a 52-month follow-up period, with a particular focus on the importance of the degree of dementia.

Method

In all, 932 nursing home residents with dementia (Clinical Dementia Rating–CDR- Scale ≥1) were included in a longitudinal study with four assessments of P-ADL functioning during 52 months. P-ADL was measured using the Lawton and Brody’s Physical Self-Maintenance Scale. Degree of dementia (CDR), neuropsychiatric symptoms and use of psychotropic medication were assessed at the same four time points. Demographic information and information about physical health was included at baseline. Linear regression models for longitudinal data were estimated.

Results

Follow-up time was positively associated with a decline in P-ADL functioning. Degree of dementia at baseline was associated with a decline in P-ADL functioning over time. The association between degree of dementia and P-ADL functioning was strongest at baseline, and then flattened over time. A higher level of neuropsychiatric symptoms such as agitation and apathy and no use of anxiolytics and antidementia medication were associated with a decline in P-ADL functioning at four time points. Higher physical co-morbidity at baseline was associated with a decline in P-ADL functioning.

Conclusion

P-ADL functioning in nursing home patients with dementia worsened over time. The worsening was associated with more severe dementia, higher physical comorbidity, agitation, apathy and no use of anxiolytics and antidementia medication. Clinicians should pay attention to these variables (associates) in order to help the nursing home residents with dementia to maintain their level of functioning for as long as possible.

Validation of the NOSCA - nurses' observation scale of cognitive abilities

AIMS AND OBJECTIVES

To examine the psychometric properties of the Nurses' Observation Scale for Cognitive Abilities.

BACKGROUND

Nurses' Observation Scale for Cognitive Abilities is a behavioural rating scale comprising eight subscales that represent different cognitive domains. It is based on observations during contact between nurse and patient.

DESIGN

Observational study.

METHODS

A total of 50 patients from two geriatric wards in acute care hospitals participated in this study. Reliability was examined via internal consistency and inter-rater reliability. Construct validity of the Nurses' Observation Scale for Cognitive Abilities and its subscales were explored by means of convergent and divergent validity and post hoc analyses for group differences.

RESULTS

Cronbach's αs of the total Nurses' Observation Scale for Cognitive Abilities and its subscales were 0·98 and 0·66-0·93, respectively. The item-total correlations were satisfactory (overall > 0·4). The intra-class coefficients were good (37 of 39 items > 0·4). The convergent validity of the Nurses' Observation Scale for Cognitive Abilities against cognitive ratings (MMSE, NOSGER) and severity of dementia (Clinical Dementia Rating) demonstrated satisfactory correlations (0·59-0·70, p < 0·01), except for IQCODE (0·30, p > 0·05). The divergent validity of the Nurses' Observation Scale for Cognitive Abilities against depressive symptoms was low (0·12, p > 0·05). The construct validity of the Nurses' Observation Scale for Cognitive Abilities subscales against 13 specific neuropsychological tests showed correlations varying from poor to fair (0·18-0·74; 10 of 13 correlations p < 0·05).

CONCLUSIONS

Validity and reliability of the total Nurses' Observation Scale for Cognitive Abilities are excellent. The correlations between the Nurses' Observation Scale for Cognitive Abilities subscales and standard neuropsychological tests were moderate. More conclusive results may be found if the Nurses' Observation Scale for Cognitive Abilities subscales were to be validated using more ecologically valid tests and in a patient population with less cognitive impairment.

RELEVANCE TO CLINICAL PRACTICE

Use of the Nurses' Observation Scale for Cognitive Abilities yields standardised, reliable and valid information about patient's cognitive behaviour in daily practice. The Nurses' Observation Scale for Cognitive Abilities aids in tailoring nursing interventions to patients' specific cognitive needs. We advocate the implementation of the Nurses' Observation Scale for Cognitive Abilities both in research and at geriatric units in acute care hospitals.

Everyday action impairment in Parkinson's disease dementia

This study examined everyday action impairment in participants with Parkinson's disease dementia (PDD) by comparison with participants with Parkinson's disease-no dementia (PD) or Alzheimer's disease (AD) and in reference to a neuropsychological model. Participants with PDD (n = 20), PD (n = 20), or AD (n = 20) were administered performance-based measures of everyday functioning that allowed for the quantification of overall performance and error types. Also, caregiver ratings of functional independence were obtained. On performance-based tests, the PDD group exhibited greater functional impairment than the PD group but comparable overall impairment relative to the AD group. Error patterns did not differ between PDD and PD participants but the PDD group demonstrated a higher proportion of commission errors and lower proportion of omission errors relative to the AD group. Hierarchical regression analyses showed omission errors were significantly predicted by neuropsychological measures of episodic memory, whereas commission errors were predicted by both measures of general dementia severity (MMSE) and executive control. Everyday action impairment in PDD differs quantitatively from PD but qualitatively from AD and may be characterized by a relatively high proportion of commission errors-an error type associated with executive control deficits. (JINS, 2012, 18, 1-12).

Comparing day care at green care farms and at regular day care facilities with regard to their effects on functional performance of community-dwelling older people with dementia

Day care at green care farms (GCFs) is a new care modality for community-dwelling older people with dementia. In view of the more physical and normal daily life activities available at GCFs than at RDCFs, we investigated whether functional decline differed between subjects from both day care settings. In this observational cohort study, primary caregivers of 47 subjects from GCFs and 41 subjects from RDCFs rated the subjects’ functional performance three times during one year. They also provided information on the subjects’ diseases and medication use. Generally, no significant change over time in functional performance, the number of diseases and the number of medications was observed, and no differences in these rates of change were found between subjects from both day care settings. This study suggests that GCFs are not more effective in maintaining functional performance or slowing down its decline in community-dwelling older people with dementia than RDCFs.

Noninvasive brain stimulation in Alzheimer's disease: systematic review and perspectives for the future

BACKGROUND

A number of studies have applied transcranial magnetic stimulation (TMS) to physiologically characterize Alzheimer's disease (AD) and to monitor effects of pharmacological agents, while others have begun to therapeutically use TMS and transcranial direct current stimulation (tDCS) to improve cognitive function in AD. These applications are still very early in development, but offer the opportunity of learning from them for future development.

METHODS

We performed a systematic search of all studies using noninvasive stimulation in AD and reviewed all 29 identified articles. Twenty-four focused on measures of motor cortical reactivity and (local) plasticity and functional connectivity, with eight of these studies assessing also effects of pharmacological agents. Five studies focused on the enhancement of cognitive function in AD.

RESULTS

Short-latency afferent inhibition (SAI) and resting motor threshold are significantly reduced in AD patients as compared to healthy elders. Results on other measures of cortical reactivity, e.g. intracortical inhibition (ICI), are more divergent. Acetylcholine-esterase inhibitors and dopaminergic drugs may increase SAI and ICI in AD. Motor cortical plasticity and connectivity are impaired in AD. TMS/tDCS can induce acute and short-duration beneficial effects on cognitive function, but the therapeutic clinical significance in AD is unclear. Safety of TMS/tDCS is supported by studies to date.

CONCLUSIONS

TMS/tDCS appears safe in AD, but longer-term risks have been insufficiently considered. TMS holds promise as a physiologic biomarker in AD to identify therapeutic targets and monitor pharmacologic effects. In addition, TMS/tDCS may have therapeutic utility in AD, though the evidence is still very preliminary and cautious interpretation is warranted.

Development of the Nurses' Observation Scale for Cognitive Abilities (NOSCA)

Background. To assess a patient's cognitive functioning is an important issue because nurses tailor their nursing interventions to the patient's cognitive abilities. Although some observation scales exist concerning one or more cognitive domains, so far, no scale has been available which assesses cognitive functioning in a comprehensive way. Objectives. To develop an observation scale with an accepted level of content validity and which assesses elderly patients' cognitive functioning in a comprehensive way. Methods. Delphi technique, a multidisciplinary panel developed the scale by consensus through four Delphi rounds (>70% agreement). The International Classification of Functioning/ICF was used as theoretical framework. Results. After the first two Delphi rounds, the panel reached consensus about 8 cognitive domains and 17 sub domains. After two other rounds, 39 items were selected, divided over 8 domains and 17 sub domains. Discussion. The Nurses' Observation Scale Cognitive Abilities (NOSCA) was successfully designed. The content validity of the scale is high because the scale sufficiently represents the concept of cognitive functioning: the experts reached a consensus of 70% or higher on all domains and items included; and no domains or items were lacking. As a next step, the psychometric qualities of the NOSCA will have to be tested.

Assessment of memory function: the relation between daily observation and neuropsychological test performance

BACKGROUND

The aim of the study was to explore the value of a daily observation scale in the assessment of patients' memory function by nurses on a geriatric ward.

METHODS

An observational study of 50 geriatric inpatients was carried out. The relationship between the memory items of the Nurses' Behavioral Rating Scale for Geriatric Inpatients (GIP) and four types of neuropsychological memory tests was examined: visual paired-associate learning (Visual Association Test, VAT), word-list learning (Eight Word Test, 8WT from the Amsterdam Dementia Screening, ADS), and the subtests Route Recall and Story Recall from the Rivermead Behavioural Memory Test (RBMT). Correlations with the overall measures assessing level of dementia such as the Mini-mental State Examination (MMSE), Clinical Dementia Rating scale (CDR) and the 15-item Geriatric Depression Scale (GDS-15) were examined as well.

RESULTS

The Pearson's correlation coefficients between GIP and the four memory tests were between 0.45 and 0.71 (p < 0.01). The GIP correlations with the MMSE and CDR were 0.63 and 0.46, respectively (p < 0.01). No significant correlation was found with the GDS-15. Statistically significant differences in GIP memory scores between patients with dementia and non-demented patients were found (p < 0.01).

CONCLUSIONS

Results indicate that an observation scale of memory function may have value for providing information about the underlying memory impairment. The results of nurses' observations may be used in triage contributing to the diagnostic process by selecting patients requiring further neuropsychological assessment.

Effectiveness of an individualized functional training program on affective disturbances and functional skills in mild and moderate dementia--a randomized control trial

OBJECTIVES

We reported the findings of a randomized controlled trial (RCT) to examine the effects of an individualized functional enhancement program (FEP) on functional skills and mood symptoms in mild and moderate dementia.

SUBJECTS & METHODS

74 Chinese older persons with dementia were recruited into a skills training program by occupational therapists (OT). Thirty seven subjects were trained with an individualized selection of daily activities (FEP Intervention, I); 37 were trained with general occupational therapy (Control, C). The FEP comprised of twice weekly group sessions of skills training and problem solving using cognitive behavioral approach.

RESULTS

At 1 month after completion of program, both I and C subjects showed an improvement in process skills of the assessment of motor and process skills (AMPS)(paired t-tests, p < 0.05). At 4 months post-program, the I group showed a further reduction of cornell scale for depression in dementia (CSDD) scores (paired t-test, p = 0.02); Apathy improved at 1 month post-training (p = 0.04), but deteriorated at 4 months (p = 0.01). Group differences in changes of mood and functional scores were not significant (ANVOCA, p > 0.05).

CONCLUSIONS

The findings suggested a potential benefit for individualized occupational therapy. It should be tailor made with individual needs and continued for sustained effectiveness.

Association between cognition and daily life functioning in dementia subtypes

OBJECTIVE

To investigate the association between cognition and daily life functioning in dementia subtypes.

METHODS

Cross-sectional data were used from 615 patients with dementia who were referred to the Maastricht Memory Clinic of the Maastricht University Medical Centre. Pearson correlation coefficients were calculated between the Mini-Mental State Examination (MMSE; to measure cognitive status) and the Blessed Dementia Scale (BDS; to measure daily life functioning) for the following types of dementia: Alzheimer's Disease (AD, n = 442); Vascular dementia (VaD, n = 113); frontotemporal dementia (FTD, n = 18); Parkinson's dementia (PD, n = 21); and primary progressive aphasia (PPA, n = 21). One-way ANOVA was used to test differences in age, MMSE scores and BDS scores across dementia subtypes.

RESULTS

Scores on the MMSE showed strong correlation with BDS scores in cases of FTD (r = -0.80); moderate correlation in cases of AD, VaD, and PD (range r = -0.50-0.60); while no correlation was found in PPA cases.

CONCLUSIONS

The association between cognition and daily life functioning varied among dementia subtypes for AD, VaD, FTD and PD. Furthermore, the overall scores on both domains differ between dementia subtypes, indicating that different types of dementia are characterized by a specific pattern of cognitive status and daily life functioning. These findings underline the need for multidomain assessment in patients with dementia.

Classification of traumatic brain injury for targeted therapies

The heterogeneity of traumatic brain injury (TBI) is considered one of the most significant barriers to finding effective therapeutic interventions. In October, 2007, the National Institute of Neurological Disorders and Stroke, with support from the Brain Injury Association of America, the Defense and Veterans Brain Injury Center, and the National Institute of Disability and Rehabilitation Research, convened a workshop to outline the steps needed to develop a reliable, efficient and valid classification system for TBI that could be used to link specific patterns of brain and neurovascular injury with appropriate therapeutic interventions. Currently, the Glasgow Coma Scale (GCS) is the primary selection criterion for inclusion in most TBI clinical trials. While the GCS is extremely useful in the clinical management and prognosis of TBI, it does not provide specific information about the pathophysiologic mechanisms which are responsible for neurological deficits and targeted by interventions. On the premise that brain injuries with similar pathoanatomic features are likely to share common pathophysiologic mechanisms, participants proposed that a new, multidimensional classification system should be developed for TBI clinical trials. It was agreed that preclinical models were vital in establishing pathophysiologic mechanisms relevant to specific pathoanatomic types of TBI and verifying that a given therapeutic approach improves outcome in these targeted TBI types. In a clinical trial, patients with the targeted pathoanatomic injury type would be selected using an initial diagnostic entry criterion, including their severity of injury. Coexisting brain injury types would be identified and multivariate prognostic modeling used for refinement of inclusion/exclusion criteria and patient stratification. Outcome assessment would utilize endpoints relevant to the targeted injury type. Advantages and disadvantages of currently available diagnostic, monitoring, and assessment tools were discussed. Recommendations were made for enhancing the utility of available or emerging tools in order to facilitate implementation of a pathoanatomic classification approach for clinical trials.