Digital Methods for Performing Daily Tasks Among Older Adults: An Initial Report of Frequency of Use and Perceived Utility

OBJECTIVE

Digital technologies permit new ways of performing instrumental activities of daily living (iADLs) for older adults, but these approaches are not usually considered in existing iADL measures. The current study investigated how a sample of older adults report using digital versus analog approaches for iADLs.

METHOD

248 older adults completed the Digital and Analog Daily Activities Survey, a newly developed measure of how an individual performs financial, navigation, medication, and other iADLs.

RESULTS

The majority of participants reported regularly using digital methods for some iADLs, such as paying bills (67.7%) and using GPS (67.7%). Low digital adopters were older than high adopters (F(2, 245) = 12.24, p < .001), but otherwise the groups did not differ in terms of gender, years of education, or history of neurological disorders. Participants who used digital methods relatively more than analog methods reported greater levels of satisfaction with their approach and fewer daily errors.

CONCLUSIONS

Many older adults have adopted digital technologies for supporting daily tasks, which suggests limitations to the validity of current iADL assessments. By capitalizing on existing habits and enriching environments with new technologies, there are opportunities to promote technological reserve in older adults in a manner that sustains daily functioning.

The Technology in Caring Questionnaire: Development and Psychometric Properties

OBJECTIVE

We developed the Technology in Caring Questionnaire (TCQ) to assess the use of technology-based strategies by dementia caregivers.

METHODS

One hundred caregivers completed a survey that included TCQ items along with measures of technology proficiency and patient and caregiver-centered outcomes.

RESULTS

The final 34-item TCQ scale had adequate to excellent internal consistency (raw Cronbach alpha = 0.75; standardized Cronbach alpha = 0.95; Guttman lambda-6 = 0.97). TCQ scores demonstrated modest convergent associations with scores from measures of smartphone ( r = 0.265, P < 0.01) and computer proficiency ( r = 0.230, P < 0.05) but a strong association with overall technology experience scores ( r = 0.578, P < 0.001). Elevated TCQ scores were associated with reduced informant-reported cognitive symptoms ( B = -0.003, P < 0.05), increased ability of caregivers to find support and information ( B = 0.03, P < 0.001), and increased direct care strain ( B = 0.03, P < 0.05), after controlling for dementia severity and demographics.

CONCLUSION

The TCQ has good psychometric properties for the assessment of technology-based care strategies among dementia caregivers. Findings imply that the use of technologies may aid in symptom management and finding support and information but may also increase caregiver strain.

Internet-Enabled Behaviors in Older Adults During the Pandemic: Patterns of Use, Psychosocial Impacts, and Plans for Continued Utilization

In response to social distancing measures during the COVID-19 pandemic, there was a need to increase the frequency of internet enabled behaviors (IEBs). To date, little is known about how the pandemic impacted IEBs in older adults, a population that has historically been linked to lower digital literacy and utilization. We administered an online survey between April and July 2021 to 298 adults who were over age 50 (mean age = 73 years; 93.5% non-Hispanic white; 94% smart phone owners; 83.5% retired). Older adults self-reported IEBs for social, shopping, medical, and leisure activities during the pandemic, plans for continued use of these behaviors, and completed measures of psychosocial functioning. 66.8% of respondents reported an overall increase in IEBs during the pandemic, most notably for online meeting attendance. More frequent online meeting use was associated with less depression (r = -0.12, p = .04) and less loneliness (r = -0.14, p = .02). With regard to plans for continued use, 82.5% of the sample reported at least one IEB (M = 2.18, SD = 1.65) that they increased during the pandemic and planned to maintain over time (e.g., online shopping for household goods). Plans for continued use were more likely in participants who used IEBs more overall during the pandemic (r = 0.56, p < .001), and who frequently sought technical support on search engines (r = 0.22, p < .001), or online video sites (r = 0.16, p = .006). In summary, IEBs during the pandemic were associated with favorable psychosocial functioning and expectations for continued use in this sample of predominantly white older adults who had some baseline technological familiarity.

The impact of technology-based compensatory behaviors on subjective cognitive decline in older adults with a family history of dementia

The current study examined whether greater use of technology to help with daily tasks is associated with less subjective cognitive decline (SCD), especially in individuals with a family history of Alzheimer's disease (AD). Individuals over the age of 50 (n = 102; age range 50-85) completed surveys about their digital and analog approaches to daily tasks, physical activity, and SCD. Participants with and without family histories of AD were matched on age, education, sex, and family history of AD using the R package MatchIt. There was no main effect of technology-based behavioral strategies on SCD (p = 0.259). However, a family history of AD moderated the association between technology use and SCD even when controlling for another protective lifestyle factor, physical activity. In individuals with a family history of AD, more reliance on technology-based behavioral strategies was associated with less SCD (p = 0.018), but this relationship was not significant in individuals without family history of AD (p = 0.511). Our findings suggest that technology-based behavioral strategies are associated with less SCD in individuals with a family history of AD, independent of another protective lifestyle factor. Future recommendations provided by healthcare providers to address SCD in cognitively unimpaired older adults might include focusing on technological assistance.

Recent Advances in Neuropsychological Test Interpretation for Clinical Practice

Much attention in the field of clinical neuropsychology has focused on adapting to the modern healthcare environment by advancing telehealth and promoting technological innovation in assessment. Perhaps as important (but less discussed) are advances in the development and interpretation of normative neuropsychological test data. These techniques can yield improvement in diagnostic decision-making and treatment planning with little additional cost. Brooks and colleagues (Can Psychol 50: 196-209, 2009) eloquently summarized best practices in normative data creation and interpretation, providing a practical overview of norm development, measurement error, the base rates of low scores, and methods for assessing change. Since the publication of this seminal work, there have been several important advances in research on development and interpretation of normative neuropsychological test data, which may be less familiar to the practicing clinician. Specifically, we provide a review of the literature on regression-based normed scores, item response theory, multivariate base rates, summary/factor scores, cognitive intraindividual variability, and measuring change over time. For each topic, we include (1) an overview of the method, (2) a rapid review of the recent literature, (3) a relevant case example, and (4) a discussion of limitations and controversies. Our goal was to provide a primer for use of normative neuropsychological test data in neuropsychological practice.

Computer use: a protective factor for cognition in aging and HIV disease?

BACKGROUND

Modifiable lifestyle factors such as engagement with technology may be beneficial to cognition in older adults, but we know little about these relationships in older persons with chronic medical conditions.

AIMS

The current study examined the association between computer use frequency and cognition in younger and older adults with and without HIV disease.

METHODS

Participants included 110 older persons with HIV (pwHIV; age ≥ 50 years), 84 younger pwHIV (age ≤ 40 years), 76 older HIV-, and 66 younger HIV- adults who completed a comprehensive medical, psychiatric, and cognitive research assessment. Demographically adjusted scores were derived from a well-validated clinical battery of performance-based neuropsychological tests. Participants also completed self-reported measures of cognitive symptoms in daily life and the Brief Computer Use and Anxiety Questionnaire (BCUAQ).

RESULTS

Older age was associated with less frequent computer use among persons with and without HIV disease. More frequent computer use was strongly and independently related to better cognitive performance, particularly in higher order domains (e.g., episodic memory and executive functions) and among the older seronegative adults. A small, univariable correlation between more frequent computer use and fewer cognitive symptoms in daily life was observed in the full sample, but that relationship was better explained by computer-related anxiety and HIV/age study group.

DISCUSSION

These findings add to the existing literature that suggests regular engagement with digital technologies may have a beneficial impact on cognitive functioning, consistent with the technological reserve hypothesis.

Technology use and subjective cognitive concerns in older adults

OBJECTIVES

How technology impacts the day to day cognitive functioning of older adults is a matter of some debate. On the one hand, the use of technologies such as smartphones and social media, may lead to more subjective cognitive concerns (SCC) by promoting distractibility and reliance on devices to perform memory tasks. However, continued digital engagement in older adults may also be related to better cognitive functioning. Given these competing viewpoints, our study evaluated if frequency of digital device use was associated with greater or less subjective cognitive concerns.

METHOD

Participants were 219 adults over the age of 65 (mean age =75 years) who had internet access. Measures assessing frequency of digital device use along with SCC were administered. Hierarchical multiple regression was used to gage association between frequency of device use and SCC, controlling for relevant demographic and lifestyle factors.

RESULTS

Increased frequency of digital device use was associated with less SCC, over and above the influence of demographic factors, across cognitive (but especially in executive) domains. This effect was observed for general device usage, with no statistically significant associations were observed between texting/video call, social media use and SCC.

DISCUSSION

Results were broadly consistent with the technological reserve hypothesis in that digital engagement was associated with better experienced cognitive functioning in older adults. While device use may contribute to distractibility in certain cases, the current results add to a burgeoning literature that digital engagement may be a protective factor for cognitive changes with age.

From pleasure to punding: Distinct patterns of anhedonia and impulsivity linked to motivational disturbances in Parkinson disease

INTRODUCTION

Apathy and impulse control disorders (ICD) are common comorbid motivational syndromes in Parkinson disease (PD). This study aimed to determine if patients with these motivational disturbances exhibit different patterns of anhedonia and trait impulsivity.

METHODS

Sixty-four non-demented patients with PD completed questionnaires assessing apathy and ICD symptoms, which were used to classify participants into one of the following groups: apathy only, ICD only, both, and neither. Participants also completed multidimensional measures of anhedonia and trait impulsivity, which were compared across groups defined by motivational status.

RESULTS

Individuals with both apathy and ICD had significantly greater symptoms of positive and negative urgency than all other groups and had significantly greater consummatory anhedonia and lack of premeditation and perseverance than those with ICD only and neither. Patients with apathy only also reported significantly greater anticipatory anhedonia than those with ICD only and the neither group. There were no significant between-group differences in sensation seeking.

CONCLUSION

Distinct patterns of impulsivity and anhedonia characterize unique behavioral phenotypes of motivational disturbances in PD and may reflect important differences in the underlying neurobiological mechanisms. Clinicians should be aware that motivational disturbances may be more severe in cases where apathy co-occurs with one or more ICD.HIGHLIGHTSHighlights are mandatory for all submissions except letters. They consist of a short collection of bullet points that convey the core findings of the article and should be submitted in a separate file in the online submission system. Please use "Highlights" in the file name and include 3-5 bullet points (maximum 85 characters, including spaces, per bullet point). See https://www.elsevier.com/highlights for examples.

Correspondence of the Boston Naming Test and Multilingual Naming Test in identifying naming impairments in a geriatric cognitive disorders clinic

Confrontation naming measures are commonly used for both diagnostic and clinical research purposes in populations of known or suspected neurodegenerative disorders. The Boston Naming Test (BNT) is the most widely used measure of confrontation naming but has been criticized for outdated and culturally biased content. A new naming measure, the Multilingual Naming Test (MiNT), has been developed that may address these limitations, but research regarding its validity and diagnostic performance relative to existing instruments is limited. The current study examined how the BNT and MiNT performed in a sample of older adults evaluated in an interprofessional memory disorders clinic. Eighty-six individuals (50.0% women) met the inclusion criteria and were included in the study. The average age of participants was 74.2 years (SD = 7.7), and the average education was 16.7 years (SD = 2.5). Most participants were non-Hispanic White (94.2%), and the remaining participants were Hispanic or Black. All participants completed a comprehensive evaluation in English and were administered both the BNT and the MiNT. The strength of agreement as indexed by CCC (.67) was modest for the sample as a whole. Eighty-seven-point five percent classification agreement for impaired vs. normal naming performance was obtained. Eleven cases showed disagreement between BNT and MiNT classification of impairment, with seven of these being borderline score cases. Overall, the results suggest that the MiNT performs similarly at the identification of naming impairments as the BNT, though performance may diverge across different diagnostic groups and may be influenced by age.

Online vs Face-to-Face Administration of Impulse Control Disorder Questionnaires in Parkinson Disease: Does Method Matter?

Background:

Social desirability bias, the tendency to underreport undesirable behaviors, may be one reason patients with Parkinson disease (PD) underreport symptoms of impulse control disorders (ICDs).

Methods:

We compared rates of ICD endorsement on questionnaires administered face-to-face and online in 60 patients with mild to moderate idiopathic PD. Participants also completed a self-report measure of social desirability.

Results:

We found significantly higher prevalence of any ICD based on online (56.7%) versus in-person (33.3%) administration. Significantly higher endorsement of items related to hypersexuality in men, and compulsive eating and buying in women were found with online administration. Social desirability bias was positively correlated with ICD symptom endorsement across all items and subscales.

Conclusion:

Results highlight the importance of social context/setting and the need for sensitivity and discretion when screening for ICD symptoms. While a higher level of symptom endorsement does not necessarily imply a greater level of accuracy, more work is needed to determine which method of administration is most accurate for clinical and research practice.

The ecological validity of the Uniform Data Set 3.0 neuropsychological battery in individuals with mild cognitive impairment and dementia

Objective: Ecological validity refers to the ability of neuropsychological measures to predict real world performance. Questions remain as to the ecological validity of commonly used measures, particularly regarding their relationships to global versus specific activities of daily living among those with neurodegenerative disease. We explored these issues through the lens of the Uniform Data Set 3.0 Neuropsychological battery (UDS3NB) in individuals with mild cognitive impairment and dementia. Method: UDS3NB and informant rated Functional Activities Questionnaire scales were evaluated from 2,253 individuals with mild cognitive impairment and dementia. Ordinal regression equations were used to explore the relationships of demographic and cognitive variables with overall and specific instrumental activities of daily living. Results: Delayed recall for visual and verbal material, and performance on trail making tests were consistent predictors of global and specific functions. Specific skills (i.e. naming or figure copy) showed differential relationships with specific activities, while phonemic fluency was not related to any particular activity. Conclusions: Measures in the UDS3NB predicted activities of daily living in individuals with MCI and dementia, providing initial support for the ecological validity of these tests. Specifically, measures that tap core deficits of Alzheimer's disease, such as delayed recall and sequencing/shifting, are consistent predictors of performance in daily tasks.

Using smartphone technology to improve prospective memory functioning: A randomized controlled trial

BACKGROUND

A decline in the ability to perform daily intentions-known as prospective memory-is a key driver of everyday functional impairment in dementia. In the absence of effective pharmacological treatments, there is a need for developing, testing, and optimizing behavioral interventions that can bolster daily prospective memory functioning. We investigated the feasibility and efficacy of smartphone-based strategies for prospective memory in persons with cognitive impairment.

METHODS

Fifty-two older adults (74.79 ± 7.20 years) meeting diagnostic criteria for mild cognitive impairment or mild dementia were enrolled in a 4-week randomized controlled trial. Participants were trained to use a digital voice recorder app or a reminder app to off-load prospective memory intentions. Prospective memory was assessed using experimenter-assigned tasks (e.g., call the laboratory on assigned days), standardized questionnaires, and structured interviews. Secondary dependent measures included days of phone and app usage, acceptability ratings, quality of life, and independent activities of daily living.

RESULTS

Participant ratings indicated that the intervention was acceptable and feasible. Furthermore, after the four-week intervention, participants reported improvements in daily prospective memory functioning on standardized questionnaires (p < 0.001, η_p²  = 0.285) and the structured interview (p < 0.001, d = 1.75). Participants performed relatively well on experimenter-assigned prospective memory tasks (51.7% ± 27.8%), with performance levels favoring the reminder app in Week 1, but reversing to favor the digital recorder app in Week 4 (p = 0.010, η_p²  = 0.079). Correlational analyses indicated that greater usage of the digital recorder or reminder app was associated with better prospective memory performance and greater improvements in instrumental activities of daily living (completed by care partners), even when controlling for condition, age, baseline cognitive functioning, and baseline smartphone experience.

CONCLUSIONS

Older adults with cognitive disorders can learn smartphone-based memory strategies and doing so benefits prospective memory functioning and independence.

An initial exploration of the convergent and ecological validity of the UDS 3.0 neuropsychological battery in Parkinson's Disease

OBJECTIVE

The Uniform Data Set 3.0 neuropsychological battery (UDS3NB) is well developed for research with Alzheimer's disease and related dementias, and may serve as a common set of measures of cognitive decline across neurodegenerative diseases. However, the battery has not been formally assessed in persons with Parkinson's disease (PD). The current research provides initial information on the convergent and ecological validity of the UDS3NB in individuals with PD.

METHODS

Participants included 75 individuals diagnosed with PD from the Arizona Study of Aging and Neurodegenerative Disorders. Clinical dementia ratings, administered independently from the cognitive measures, identified individuals as having normal cognition (n = 38), Mild Cognitive Impairment (MCI; n = 25) and dementia (n = 12). UDS3NB measures were compared between these groups, and correlations between UDS3NB measures, gold standard neuropsychological measures, and informant rated activities of daily living ability (ADL) were evaluated.

RESULTS

At the group-level, UDS3NB scores followed the expected pattern with higher scores in participants with PD but no cognitive diagnosis and lower in those with dementia; scores in the MCI group were between these extremes. Convergent validity was suggested by moderate correlations between UDS specific measures (i.e., Craft story) and measures such as the RAVLT. Ecological validity was suggested by statistically significant correlations between UDS3NB performance and caregiver ratings of ADLs, with speed and executive functioning measures (Trailmaking A; r = -.51, p < .01; Trailmaking B; r = -.51, p < .01) most strongly related to reported daily functioning.

CONCLUSIONS

Findings provide initial support for the convergent and ecological validity of the UDS3NB in individuals with PD. Implications and future directions for this battery are discussed.

Apathy and actions- another consideration when theorizing about embodied nature of language in Parkinson's disease

Objectives Individuals with Parkinson's disease (PD) have difficulty processing actions or verbs relative to nouns. Verb difficulties are thought to represent the coupling of language and motor networks. However, those with PD also frequently experience apathy. The overlap between apathy and action language difficulties is to date unexplored. Furthermore, whether verb/action fluency difficulty represents verb degradation (semantic/conceptual) or a selective lexical retrieval difficulty has not been determined. Methods In the current study, 20 individuals with PD without dementia completed cued action (verb) and animal (noun) fluency tasks in addition to assessments of apathy, cognition, and motor functioning. Results Individuals who exhibited impairments on action and animal fluency improved around 50% with the provision of cueing. The degree to which action fluency improved with cueing was correlated with behavioral/initiation apathy (r_s=.56) as well as motor dysfunction (r_s=-.57), while no similar relationship was found between those factors and nouns. Conclusions These findings suggest that impaired retrieval of actions and nouns are present in PD, but may have different underlying neuropsychological underpinnings. This provides preliminary support for grounded cognition models, which suggest the brain organizes information around motor, perceptual, and other networks. MESH terms Parkinson Disease, Neurocognitive Disorders, Apathy, Language Disorders, Neuropsychological Tests, Cognition.

Emerging topics in dementia care and services

BACKGROUND

The National Institute on Aging (NIA), in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act (NAPA), convened a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series. This review article summarizes three areas of emerging science that are likely to grow in importance given advances in measurement, technologies, and diagnostic tests that were presented at the Summit.

RESULTS

Dr. Cassel discussed novel ethical considerations that have resulted from scientific advances that have enabled early diagnosis of pre-clinical dementia. Dr. Monin then summarized issues regarding emotional experiences in persons with dementia and their caregivers and care partners, including the protective impact of positive emotion and heterogeneity of differences in emotion by dementia type and individual characteristics that affect emotional processes with disease progression. Finally, Dr. Jared Benge provided an overview of the role of technologies in buffering the impact of cognitive change on real-world functioning and their utility in safety and monitoring of function and treatment adherence, facilitating communication and transportation, and increasing access to specialists in underserved or remote areas.

CONCLUSIONS

National policy initiatives, supported by strong advocacy and increased federal investments, have accelerated the pace of scientific inquiry and innovation related to dementia care and services but have raised some new concerns regarding ethics, disparities, and attending to individual needs, capabilities, and preferences.

Preserving prospective memory in daily life: A systematic review and meta-analysis of mnemonic strategy, cognitive training, external memory aid, and combination interventions

OBJECTIVE

To preserve or improve independent functioning in older adults and those with neurocognitive impairments, researchers and clinicians need to address prospective memory deficits. To be effective, prospective memory interventions must restore (or circumvent) the underlying attention and memory mechanisms that are impaired by aging, brain injury, and neurodegeneration. We evaluated two decades of prospective memory interventions for efficacy, time/resource costs, and ecological validity.

METHOD

We systematically reviewed 73 prospective memory intervention studies of middle- to older-aged healthy adults and clinical groups (N = 3,749). We also rated the ecological validity of each study's prospective memory assessment/task using a newly developed scale. When possible (72% of studies), we estimated effect sizes using random-effects models and Hedges' g.

RESULTS

We identified four categories of prospective memory interventions, including mnemonic strategy, cognitive training, external memory aid, and combination interventions. Mnemonic strategy (g = .450) and cognitive training (g = .538) interventions demonstrated efficacy. Combination interventions showed mixed results (g = .254), underscoring that "more is not always better." External memory aids demonstrated very positive outcomes (g = .805), though often with small-sample, case-series designs. Prospective memory assessments had high ecological validity in external memory aid studies (84%), but not in mnemonic strategy (14%), cognitive training (20%), or combination intervention (50%) studies, p < .001, ηp2 = .33.

CONCLUSIONS

Everyday prospective memory can be meaningfully improved, perhaps particularly with external memory aids, but larger trials are required to optimize treatments, increase adherence, and broaden implementation in daily life. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

How impaired is too impaired? Exploring futile neuropsychological test patterns as a function of dementia severity and cognitive screening scores

Some older adults cannot meaningfully participate in the testing portion of a neuropsychological evaluation due to significant cognitive impairments. There are limited empirical data on this topic. Thus, the current study sought to provide an operational definition for a futile testing profile and examine cognitive severity status and cognitive screening scores as predictors of testing futility at both baseline and first follow-up evaluations. We analysed data from 9,263 older adults from the National Alzheimer's Coordinating Center Uniform Data Set. Futile testing profiles occurred rarely at baseline (7.40%). There was a strong relationship between cognitive severity status and the prevalence of futile testing profiles, χ² (4) = 3559.77, p < .001. Over 90% of individuals with severe dementia were unable to participate meaningfully in testing. Severity range on the Montreal Cognitive Assessment (MoCA) also demonstrated a strong relationship with testing futility, χ² (3) = 3962.35, p < .001. The rate of futile testing profiles was similar at follow-up (7.90%). There was a strong association between baseline dementia severity and likelihood of demonstrating a futile testing profile at follow-up, χ² (4) = 1513.40, p < .001. Over 90% of individuals with severe dementia, who were initially able to participate meaningfully testing, no longer could at follow-up. Similarly, there was a strong relationship between baseline MoCA score band and likelihood of demonstrating a futile testing profile at follow-up, χ² (3) = 1627.37, p < .001. Results can help to guide decisions about optimizing use of limited neuropsychological assessment resources.

Abstract P178: Rapid Improvement in Timely tPA Administration With Initiation of Telestroke in a Predominantly Rural Catchment Area

Introduction: In acute ischemic stroke (AIS) treatment, reduction in tPA Door-To-Needle time (DTN) by 15 minutes improves functional outcomes. Telestroke has demonstrated timely tPA administration over several years of implementation. However, telestroke care in the rural setting is less well characterized, and many telestroke studies have only shown improvement in DTN over longer periods. We evaluated reduction in DTN over a 6 month period after implementing an internal telestroke process in a rural spoke-hub model in central Texas.

Methods: Data was abstracted from local databases from 6 months before and 6 months after initiation of telestroke at each center over years 2017-2019. Patients who presented to the emergency room at 1 of 5 spokes in central Texas with AIS symptoms were included, 393 pre-telestroke and 362 post. Patients who did not receive tPA were excluded. Patients with documented delay such as initial tPA refusal, further imaging or management of acute comorbidities were also excluded, leaving 80 cases, 33 pre-telestroke and 47 post. Chi-square analyses for changes in DTN were used. T-test analysis was used for continuous variables. Primary outcome assessed reduction in DTN with secondary outcome of number of tPA administrations.

Results: Total stroke volume did not increase over the study period [average per site pre-telestroke 78.6 (SD 58.1) and post-telestroke 72.4 (SD 45.7)] ( t (4)=0.91, p =0.42). Attainment of <45 minute DTN improved from 18.2% pre- to 48.9% post-telestroke ( p = 0.01), and <60 minute DTN improved from 36.3% to 80.1% ( p <0.0001). Total tPA volume at each site increased over the period, with a moderate effect size though not statistically significant (average per site of 6.6 administrations pre-telestroke to 9.4 post-telestroke, t (4)=-1.72, p =0.16, d=-0 .77)

Conclusions: Telestroke within a rural catchment area in central Texas resulted in significant reduction in DTN within 6 months of implementation. This study showed that successful telestroke processes can be implemented in a relatively short time period even in the rural setting. Further investigation of telestroke at rural stroke centers is needed to improve access and quality of care.

Neuropsychological Equivalence of the Clinical Diagnosis of Mild Cognitive Impairment in the National Alzheimer's Coordinating Center Uniform Data Set and Alzheimer's Disease Neuroimaging Initiative

INTRODUCTION

Our understanding of Alzheimer's disease may be improved by harmonizing data from large cohort studies of older adults. Differences in the way clinical conditions, like mild cognitive impairment (MCI), are diagnosed may lead to variability among participants that share the same diagnostic label. This variability presents a challenge for cohort harmonization and may lead to inconsistency in research findings. Little research to date has explored the equivalence of the diagnostic label of MCI across 2 of the largest and most influential cohort studies in the USA: the National Alzheimer's Coordinating Center (NACC) and the Alzheimer's Disease Neuroimaging Initiative (ADNI).

METHODS

Participants with MCI due to presumed Alzheimer's disease from the NACC Uniform Data Set (n = 789) and ADNI (n = 131) were compared on demographic, psychological, and functional variables, as well as on an abbreviated neuropsychological battery common to the 2 data sets.

RESULTS

Though similar in terms of age, education, and functional status, the NACC sample was more diverse (17.4% non-White participants vs. 7.6% in ADNI; χ2 = 7.923, p = 0.005) and tended to perform worse on some cognitive tests. In particular, participants diagnosed with MCI in NACC were more likely to have clinically significant impairments on language measures (26.36-31.18%) than MCI participants in ADNI (16.03-19.85%).

DISCUSSION

The current findings suggest important differences in cognitive performances between 2 large MCI cohorts, likely reflective of differences in diagnostic criteria used in these 2 studies, as well as differences in sample compositions. Such diagnostic heterogeneity may make harmonizing data across these cohorts challenging. However, application of shared psychometric criteria across studies may lead to closer equivalence of MCI groups. Such approaches could pave the way for cohort harmonization and enable "big data" analytic approaches to understanding Alzhei-mer's to be developed.

An Initial Empirical Operationalization of the Earliest Stages of the Alzheimer's Continuum

PURPOSE

The Alzheimer's Continuum (AC) includes 2 preclinical stages defined by subjective cognitive complaints, transitional cognitive declines, and neurobehavioral symptoms. Operationalization of these stages is necessary for them to be applied in research.

METHODS

Cognitively normal individuals with known amyloid biomarker status were selected from the National Alzheimer's Coordinating Center Uniform Data Set. Participants and their caregivers provided information on subjective cognitive complaints, neurobehavioral features, and objective cognitive functioning.

PATIENTS

The sample included 101 amyloid positive (A+) and 447 amyloid negative (A-) individuals.

RESULTS

Rates of subjective cognitive complaints (A+: 34.90%, A-: 29.90%) and neurobehavioral symptoms (A+: 22.40%, A-: 22.40%) did not significantly differ between A+/- individuals. However, the frequency of transitional cognitive decline was significantly higher among A+ (38.00%) than A- participants (24.90%). We explored various empirical definitions for defining the early stages of the AC among A+ participants. Rates of classification into AC stage 1 versus AC stage 2 varied depending on the number of symptoms required: 57.40% versus 42.60% (1 symptom), 28.70% versus 71.30% (2 symptoms), and 6.90% versus 93.10% (all 3 symptoms).

CONCLUSION

The presence of 2 of the proposed symptom classes to separate AC stage 2 from stage 1 seems to provide a good empirical balance.

Factors affecting time between symptom onset and emergency department arrival in stroke patients

Background and purpose

Delays in seeking care compromise diagnosis, treatment options, and outcomes in ischemic strokes. This study identified factors associated with time between stroke symptom onset and emergency department (ED) arrival at a private nonprofit medical center serving a large rural catchment area in central Texas, with the goal of identifying symptomatic, demographic, and historical factors that might influence seeking care.

Methods

Demographic and clinical data from a large tertiary care center's Get With The Guidelines (GWTG) database were evaluated in 1874 patients presenting to the ED with a diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, subarachnoid hemorrhage, or ischemic stroke. The dependent variable was time between discovery of stroke symptoms and presentation at the hospital (time-to-ED). Factors entered into regression models predicting time-to-ED within 4 h or categorical time-to-ED.

Results

The average time from symptom onset to presentation was 15.0 h (sd = 23.2), with 43.6% of the sample presenting within 4 h of symptom onset. Results suggested that female gender (Odds Ratio [OR] = 0.70; 95% Confidence Interval [CI] 0.23–0.74), drug abuse (OR = 0.41; CI 0.23–0.74), and diabetes were significantly associated with longer time to presentation.

Conclusions

A combination of demographics, stroke severity, timing, and health history contributes to delays in presenting for treatment for ischemic stroke. Stroke education concentrating on symptom recognition may benefit from a special focus on high-risk individuals as highlighted in this study.

•

Patients that had stroke symptoms occurring during the daytime were more likely to present within 4h of symptom onset.

•

Females and younger patients were more likely to arrive after 4h of symptom onset.

•

Comorbid conditions such as diabetes and substance abuse were associated with delayed presentation times.

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Other comorbid conditions such as hypertension or dyslipidemia were not associated with decreased time of presentation.

Development and Preliminary Validation of Standardized Regression-Based Change Scores as Measures of Transitional Cognitive Decline

OBJECTIVE

An increasing focus in Alzheimer's disease and aging research is to identify transitional cognitive decline. One means of indexing change over time in serial cognitive evaluations is to calculate standardized regression-based (SRB) change indices. This paper includes the development and preliminary validation of SRB indices for the Uniform Data Set 3.0 Neuropsychological Battery, as well as base rate data to aid in their interpretation.

METHOD

The sample included 1,341 cognitively intact older adults with serial assessments over 0.5-2 years in the National Alzheimer's Coordinating Center Database. SRB change scores were calculated in half of the sample and then validated in the other half of the sample. Base rates of SRB decline were evaluated at z-score cut-points, corresponding to two-tailed p-values of .20 (z = -1.282), .10 (z = -1.645), and .05 (z = -1.96). We examined convergent associations of SRB indices for each cognitive measure with each other as well as concurrent associations of SRB indices with clinical dementia rating sum of box scores (CDR-SB).

RESULTS

SRB equations were able to significantly predict the selected cognitive variables. The base rate of at least one significant SRB decline across the entire battery ranged from 26.70% to 58.10%. SRB indices for cognitive measures demonstrated theoretically expected significant positive associations with each other. Additionally, CDR-SB impairment was associated with an increasing number of significantly declined test scores.

CONCLUSIONS

This paper provides preliminary validation of SRB indices in a large sample, and we present a user-friendly tool for calculating SRB values.

Using multivariate base rates of low scores to understand early cognitive declines on the uniform data set 3.0 Neuropsychological Battery

OBJECTIVE

Low neuropsychological test scores are commonly observed even in cognitively healthy older adults. For batteries designed to assess for and track cognitive decline in older adults, documenting the multivariate base rates (MBRs) of low scores is important to differentiate expected from abnormal low score patterns. Additionally, it is important for our understanding of mild cognitive impairment and preclinical declines to and determine how such score patterns predict future clinical states.

METHOD

The current study utilized Uniform Data Set Neuropsychological Battery 3.0 (UDS3NB) data for 5,870 English-speaking, older adult participants from the National Alzheimer's Coordinating Center from 39 Alzheimer's disease Research Centers from March 2015 to December 2018. MBRs of low scores were identified for 2,608 cognitively healthy participants that had completed all cognitive measures. The association of abnormal MBR patterns with subsequent conversion to mild cognitive impairment and dementia were explored.

RESULTS

Depending on the operationalization of "low" score, the MBR of demographically adjusted scores ranged from 1.40 to 79.2%. Posttest probabilities using MBR methods to predict dementia status at 2-year follow up ranged from .06 to .33, while posttest probabilities for conversion to mild cognitive impairment (MCI) ranged from .12-.32.

CONCLUSIONS

The data confirm that abnormal cognitive test scores are common among cognitively normal older adults. Using MBR criteria may improve our understanding of MCI. They may also be used to enrich clinical trial selection processes through recruitment of at-risk individuals. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Rapid communication: Preliminary validation of a telephone adapted Montreal Cognitive Assessment for the identification of mild cognitive impairment in Parkinson's disease

Objective: In the current pandemic, tele-screening of neuropsychological status has become a necessity. Instruments developed for telephone screening are not as well validated as traditional neuropsychological measures. Therefore, the current study presents preliminary validation of a telephone version of the Montreal Cognitive Assessment (T-MoCA) in individuals with Parkinson's disease (PD).Method: Twenty-one persons with PD completed the T-MoCA along with a traditional neuropsychological battery. Diagnostic accuracy for the presence of PD-related mild cognitive impairment (MCI) and correlations with traditional neuropsychological measures are reported.Results: Individuals with MCI (n = 9) scored lower than individuals without cognitive impairment (17.56 vs. 19.50; t = -2.28, p = .03, d = -1.00). Diagnostic accuracy for MCI ranged from 76% to 81%, with sensitivity ranging from 0.56 to 0.67 and specificity ranging from 0.92 to 1.00. Correlations of T-MoCA derived scores with traditional neuropsychological measures were quite modest, with the exception of the memory impairment scale.Conclusions: This rapid communication presents preliminary validation of the T-MoCA for use in individuals with PD. Caveats and implications for practical use in the current pandemic are discussed.

The Uniform Dataset 3.0 Neuropsychological Battery: Factor Structure, Invariance Testing, and Demographically Adjusted Factor Score Calculation

OBJECTIVE

The goals of this study were to (1) specify the factor structure of the Uniform Dataset 3.0 neuropsychological battery (UDS3NB) in cognitively unimpaired older adults, (2) establish measurement invariance for this model, and (3) create a normative calculator for factor scores.

METHODS

Data from 2520 cognitively intact older adults were submitted to confirmatory factor analyses and invariance testing across sex, age, and education. Additionally, a subsample of this dataset was used to examine invariance over time using 1-year follow-up data (n = 1061). With the establishment of metric invariance of the UDS3NB measures, factor scores could be extracted uniformly for the entire normative sample. Finally, a calculator was created for deriving demographically adjusted factor scores.

RESULTS

A higher order model of cognition yielded the best fit to the data χ2(47) = 385.18, p < .001, comparative fit index = .962, Tucker-Lewis Index = .947, root mean square error of approximation = .054, and standardized root mean residual = .036. This model included a higher order general cognitive abilities factor, as well as lower order processing speed/executive, visual, attention, language, and memory factors. Age, sex, and education were significantly associated with factor score performance, evidencing a need for demographic correction when interpreting factor scores. A user-friendly Excel calculator was created to accomplish this goal and is available in the online supplementary materials.

CONCLUSIONS

The UDS3NB is best characterized by a higher order factor structure. Factor scores demonstrate at least metric invariance across time and demographic groups. Methods for calculating these factors scores are provided.

Normative Data for Derived Measures and Discrepancy Scores for the Uniform Data Set 3.0 Neuropsychological Battery

OBJECTIVE

The Uniform Data Set 3.0 (UDS 3.0) neuropsychological battery is a recently published battery intended for clinical research with older adult populations. While normative data for the core measures has been published, several additional discrepancy and derived scores can also be calculated. We present normative data for Trail Making Test (TMT) A & B discrepancy and ratio scores, semantic and phonemic fluency discrepancy scores, Craft Story percent retention score, Benson Figure percent retention score, difference between verbal and visual percent retention, and an error index.

METHOD

Cross-Sectional data from 1803 English speaking, cognitively normal control participants were obtained from the NACC central data repository.

RESULTS

Descriptive information for derived indices is presented. Demographic variables, most commonly age, demonstrated small but significant associations with the measures. Regression values were used to create a normative calculator, made available in a downloadable supplement. Statistically abnormal values (i.e., raw scores corresponding to the 5th, 10th, 90th, and 95th percentiles) were calculated to assist in practical application of normative findings to individual cases. Preliminary validity of the indices are demonstrated by a case study and group comparisons between a sample of individuals with Alzheimer's (N = 81) and Dementia with Lewy Bodies (DLB; N = 100).

CONCLUSIONS

Clinically useful normative data of such derived indices from the UDS 3.0 neuropsychological battery are presented to help researchers and clinicians interpret these scores, accounting for demographic factors. Preliminary validity data is presented as well along with limitations and future directions.

Functional neurological symptoms masquerading as Wernicke encephalopathy following bariatric surgery

Wernicke encephalopathy (WE), caused by thiamine deficiency, is classically associated with alcoholism but is increasingly recognized among patients who have undergone bariatric surgery. As with other neurocognitive conditions, alternative explanations for symptoms, such as psychiatric, neurological, and motivational factors, must be considered before arriving at a diagnosis of WE. We present a patient after sleeve gastrectomy who was presumed to have WE; after detailed neuropsychological assessment, the condition was better conceptualized as a conversion disorder. The case illustrates the heretofore unrecognized role of bariatric surgery in the development of functional symptoms and demonstrates the importance of neuropsychological assessment in detecting functional symptoms.

Quantitative and qualitative features of executive dysfunction in frontotemporal and Alzheimer's dementia

Behavioral variant fronto-temporal degeneration (bvFTD) is typically distinguished from Alzheimer's disease (AD) by early, prominent dysexecutive findings, in addition to other clinical features. However, differences in executive functioning between these groups are not consistently found. The current study sought to investigate quantitative and qualitative differences in executive functioning between those with bvFTD and AD in a large sample, while controlling for dementia severity and demographic variables. Secondary data analyses were completed on a subset of cases from the National Alzheimer's Coordinating Center collected from 36 Alzheimer's Disease Research Centers and consisting of 1,577 individuals with AD and 406 individuals with bvFTD. Groups were compared on 1) ability to complete three commonly administered executive tasks (letter fluency, Trail Making Test Part B [TMTB], and digits backward); 2) quantitative test performance; and 3) errors on these tasks. Findings suggested that individuals with bvFTD were less likely to complete letter fluency, χ²(2) = 178.62, p < .001, and number span tasks, χ²(1) = 11.49, p < .001), whereas individuals with AD were less likely to complete TMTB, χ²(2) = 460.38, p < .001. Individuals with bvFTD performed more poorly on letter fluency, F(1) = 28.06, p = .013, but there were not group differences in TMTB lines per second or number span backwards. Errors generally did not differentiate the diagnostic groups. In summary, there is substantial overlap in executive dysfunction between those with bvFTD and AD, though individuals with bvFTD tend to demonstrate worse letter fluency performance.

Neuropsychological impact of white matter hyperintensities in older adults without dementia

The purpose of this study was to determine (a) if simple clinical judgements of white matter hyperintensities (WMH) on imaging are associated with measurable cognitive impacts in otherwise cognitively normal older adults, (b) if neuropsychological measures can predict those with WMH, and (c) the frequency of low cognitive scores in those with WMH on a battery of measures. Forty-four individuals judged free of other cognitive disorders despite moderate to extensive WMH were compared with 50 individuals matched on age (mean of 83), education (college educated), and gender (predominantly female). Data was obtained from the National Alzheimer's Coordinating Center database. The group with at least moderate WMH had lower scores on the Trail Making Test A, verbal fluency, and digit span. A component score derived from these measures was a significant predictor of the presence of WMH, though only correctly classified 68% of participants. Even in individuals free from other suspected conditions, clinically judged moderate to extensive WMH was associated with cognitive weaknesses for processing speed, working memory, and executive functioning. This shows that a relatively simple judgment of WMH burden is meaningfully associated with worse cognition. Implications and future directions for are discussed.

Brief Report: Knowledge of, Interest in, and Willingness to Try Behavioral Interventions in Individuals With Parkinson's Disease

Purpose/Objective • Behavioral interventions hold enormous promise for managing a variety of motor and nonmotor symptoms in Parkinson's disease (PD). Despite this, prior studies have suggested that the utilization of these interventions is relatively low. The current study seeks to understand factors that could relate to the utilization of PD behavioral strategies. Specifically, the study evaluates the self-described knowledge of, interest in, and willingness to participate in behavioral interventions in a community-dwelling sample of individuals with PD. Research Method/Design • Forty-five individuals with PD completed a survey that assessed knowledge, interest, and willingness to participate in 5 behavioral interventions: hypnosis, relaxation training, mindfulness/meditation, computerized "brain games," and counseling. In addition, participants self-reported their quality of life across several domains; these domain scores were correlated with overall ratings of interest and willingness to participate in behavioral interventions. Results • Self-reported knowledge of behavioral interventions was low, but interest and willingness to participate was moderate to high across modalities. Statistically significant correlations were noted between perceived knowledge of the techniques and interest (r = 0.29, P = .05) as well as willingness to participate (r = 0.32, P = .03) in these techniques. Interest and willingness were also correlated with self-reported bodily discomfort (r = 0.36, P = .02). Conclusions/Implications • The participants of the current sample were interested and willing to participate in behavioral interventions but had limited knowledge of the potential for these techniques to manage their symptoms. The reported high level of willingness to participate in behavioral interventions suggests that it is feasible to provide behavioral interventions in this population.

The smartphone in the memory clinic: A study of patient and care partner's utilisation habits

Smartphones have potential as cognitive aids for adults with cognitive impairments. However, little is known about how patients and their care partners utilise smartphones in their day-to-day lives. We collected self-reported smartphone utilisation data from patients referred for neuropsychological evaluations (N = 53), their care partners (N = 44), and an Amazon Mechanical Turk control sample (N = 204). Patient participants were less likely to own a smartphone than controls, with increasing age associated with less utilisation of smartphone features in all groups. Of the patients who owned smartphones, spontaneous use of cognitive aid features (e.g., reminders and calendars) occurred on only a monthly-to-weekly basis; by comparison, patients reported utilising social/general features (e.g., email and internet) on a weekly-to-daily basis. Individuals referred for geriatric cognitive disorder evaluations were less likely to own and use smartphones than individuals referred for other reasons. Care partners reported using their smartphones more frequently than control group adults, with 55% of care partners endorsing utilising their device in caring for the patient. Building upon existing smartphone use habits to increase the use of cognitive aid features may be a feasible intervention for some patients, and including care partners in such interventions is encouraged.

Alzheimer’s Disease Assessment: A Review and Illustrations Focusing on Item Response Theory Techniques

Alzheimer’s disease (AD) affects neurological, cognitive, and behavioral processes. Thus, to accurately assess this disease, researchers and clinicians need to combine and incorporate data across these domains. This presents not only distinct methodological and statistical challenges but also unique opportunities for the development and advancement of psychometric techniques. In this article, we describe relatively recent research using item response theory (IRT) that has been used to make progress in assessing the disease across its various symptomatic and pathological manifestations. We focus on applications of IRT to improve scoring, test development (including cross-validation and adaptation), and linking and calibration. We conclude by describing potential future multidimensional applications of IRT techniques that may improve the precision with which AD is measured.

Toward patient-centered outcomes for cognitive evaluations: the perspective of those affected by Parkinson's disease

OBJECTIVE

Patient-centered outcomes research is predicated on the idea that the opinions, attitudes, and preferences of patients should help inform study design and interpretation. To date, little is known about what defines patient-centered outcomes from cognitive evaluations. The current evaluation sought to explore this issue in persons with Parkinson's disease (PwPD) and their care partners (CP).

METHOD

Focus groups of 22 PwPD/CP dyads were conducted to identify potential consumer oriented endpoints from cognitive evaluations. These endpoints were utilized to create a Patient-Centered Cognitive Assessment Outcomes Scale, which was administered to a different group of 50 PwPD/CP dyads who rated the importance of each outcome and identified their top three priority outcomes.

RESULTS

Three themes emerged from the focus groups: improved knowledge, advice, and planning. Both PwPD and CP rated items in all three domains as being very important outcomes. Priorities for outcomes in both groups favored treatment planning information slightly above knowledge based outcomes.

CONCLUSIONS

The PwPD and CP identified improved knowledge, advice for daily activities, and knowledge they could use to plan for future eventualities as very important. This information can be used as a framework for future studies aimed at demonstrating patient-centered outcomes from neuropsychological evaluations. Implications for future research are discussed.

Duration of disease does not equally influence all aspects of quality of life in Parkinson's disease

Health related quality of life (HRQoL) is negatively impacted in patients suffering from Parkinson's disease (PD). For the specific components that comprise HRQoL, the relationship between clinical variables, such as disease duration, is not fully characterized. In this cross-sectional study (n=302), self-reported HRQoL on the Parkinson's Disease Questionnaire (PDQ-39) was evaluated as a global construct as well as individual subscale scores. HRQoL was compared in three groups: those within 5years of diagnosis, those within 6-10years of diagnosis, and those greater than 11years since diagnosis. Non-parametric analyses revealed lower HRQoL with increasing disease duration when assessed as a global construct. However, when subscales were evaluated, difficulties with bodily discomfort and cognitive complaints were comparable in individuals in the 1-5years and 6-10year duration groups. Exploratory regression analyses suggested disease duration does explain unique variance in some subscales, even after controlling for Hoehn and Yahr stage and neuropsychiatric features. Our findings show that HRQoL domains in PD patients are affected differentially across the duration of the disease. Clinicians and researchers may need to tailor interventions intended to improve HRQoL at different domains as the disease progresses.

Adding delayed recall to the ADAS-cog improves measurement precision in mild Alzheimer's disease: Implications for predicting instrumental activities of daily living

As research increasingly focuses on preclinical stages of Alzheimer's disease (AD), instruments must be retooled to identify early cognitive markers of AD. A supplemental delayed recall subtest for the Alzheimer's Disease Assessment Scale-cognitive (ADAS-cog; Mohs, Rosen, & Davis, 1983; Rosen, Mohs, & Davis, 1984) is commonly implemented, but it is not known precisely where along the spectrum of cognitive dysfunction this subtest yields incremental information beyond what is gained from the standard ADAS-cog, or whether it can improve prediction of functional outcomes. An item response theory approach can analyze this in a psychometrically rigorous way. Seven hundred eighty-eight patients with AD or amnestic complaints or impairment completed a battery including the ADAS-cog and 2 activities of daily living measures. The delayed recall subtest slightly improved the ADAS-cog's measurement precision in the mild range of cognitive dysfunction and increased prediction of instrumental activities of daily living for individuals with subjective memory impairment.

Neurobehavioral effects of levetiracetam in patients with traumatic brain injury

Moderate to severe traumatic brain injury (TBI) is one of the leading causes of acquired epilepsy. Prophylaxis for seizures is the standard of care for individuals with moderate to severe injuries at risk for developing seizures, though relatively limited comparative data is available to guide clinicians in their choice of agents. There have however been experimental studies which demonstrate potential neuroprotective qualities of levetiracetam after TBI, and in turn there is hope that eventually such agents may improve neurobehavioral outcomes post-TBI. This mini-review summarizes the available studies and suggests areas for future studies.

Multidisciplinary cognitive-behavioral therapy training for the veterans affairs primary care setting

OBJECTIVE

Current research highlights the need to embed evidence-based psychotherapies such as cognitive-behavioral therapy (CBT) within primary care settings. Few studies have examined CBT training procedures, and no studies have examined the impact of CBT training in the primary care setting. The current study sought to describe and assess the feasibility and effectiveness of a focused CBT training program for a diverse sample of primary care mental health providers in the Department of Veterans Affairs (VA).

METHOD

A multidisciplinary group of 28 mental health clinicians from 6 VA medical centers and 15 community-based outpatient clinics received an intensive 1½-day CBT workshop, held in Houston, Texas, in May 2008, including didactic presentations, expert modeling, and small-group role plays. CBT experts also provided biweekly follow-up group telephone consultation calls for participants over 12 weeks to aid in development of CBT skills. Participant program evaluation surveys and self-reported CBT knowledge, ability, and utilization were measured preworkshop, postworkshop, and 3 months postworkshop. Analyses compared mean change scores at baseline to those at 3-month follow-up. Wilcoxon signed rank tests were completed, and Cohen d effect-size calculations were also computed.

RESULTS

Statistical analyses found that participant self-reported CBT knowledge (P < .01, effect size [ES] = 0.49) was significantly improved postworkshop and maintained at 3-month follow-up. Self-reported abilities were also improved (P = .07, ES = 0.40). The potency of the training experience appeared to be enhanced by the multimodal nature of the program.

CONCLUSION

Although challenges exist, focused and intensive training in CBT appears feasible for multidisciplinary mental health practitioners in the primary care setting.

Item response theory reveals variability of functional impairment within clinical dementia rating scale stages

BACKGROUND/AIMS

To investigate whether an item response theory (IRT) approach to measuring variations of dementia severity within Clinical Dementia Rating (CDR) stages is associated with activities of daily living (ADLs).

METHODS

IRT estimates of dementia severity within CDR stages in 1,181 patients were correlated with ADLs and analyzed.

RESULTS

IRT-determined dementia severity was significantly correlated with ADLs in three of four impaired dementia stages.

CONCLUSION

An IRT approach shows considerable advantages over traditional scoring practices of the CDR not only because it increases precision in dementia measurement, but also because it enables one to discover more precise associations with functional outcomes such as ADLs.

Greater precision when measuring dementia severity: establishing item parameters for the Clinical Dementia Rating Scale

BACKGROUND/AIMS

An item response theory (IRT)-based scoring approach to the Clinical Dementia Rating Scale (CDR) can account for the pattern of scores across the CDR items (domains) and their differential abilities to indicate dementia severity. In doing so, an IRT-based approach can provide greater precision than other CDR scoring algorithms. However, neither a good set of item parameters nor an easily digestible set of instructions needed to implement this approach is readily available.

METHODS

Participants were 1,326 patients at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Clinic.

RESULTS

The item parameters necessary for an IRT-based scoring approach were identified (a parameters ranged from 3.01 to 6.22; b parameters ranged from -2.46 to 2.07).

CONCLUSION

This study provides, and demonstrates how to easily apply, IRT-based item parameters for the CDR

Dementia staging across three different methods

BACKGROUND/AIMS

To investigate the effectiveness of an item response theory (IRT)-based approach to staging dementia.

METHODS

IRT estimates of dementia severity in 1,485 patients were used to stage dementia and then compared to dementia staging using the classic Clinical Dementia Rating Scale (CDR) algorithm and the Sum of the Boxes (SOB) approach.

RESULTS

Measurement imprecision was highest when dementia stages were determined based on the classic algorithm (48% of sample), lower when they were determined based on the SOB approach (12%), and lowest when determined using IRT-based staging (0%).

CONCLUSION

The classic CDR algorithm weights boxes largely according to clinical experience. The SOB approach weights all boxes equally. The IRT approach weights boxes according to their actual ability to identify dementia severity and therefore provides the most precise information for staging dementia.

Personality disorder diagnostic thresholds correspond to different levels of latent pathology

To meet a diagnosis for a particular personality disorder (PD), among other requirements, a person must exhibit a specified minimum number of the features outlined for that PD, otherwise referred to as the diagnostic threshold. Despite many years of research on the DSM PDs, there is little empirical basis for the chosen thresholds. The present study used mechanisms of item response theory (IRT) to link the diagnostic thresholds of six PDs to their corresponding level of latent PD pathology. Consistent with our hypothesis, analyses of the data from 41,227 participants revealed that PD diagnostic thresholds corresponded to a wide range of latent pathology. For example, the diagnostic threshold for schizoid PD corresponded to 1.54 SDs of pathology whereas the threshold for dependent PD corresponded to 2.72 SDs of pathology. The current analyses have demonstrated for the first time that the latent pathology associated with each PD threshold varies widely, and thus has quantified what others accurately have speculated. Implications and considerations for the future directions of PD classification are discussed.