The Rey 15-item recognition trial: a technique to enhance sensitivity of the Rey 15-item memorization test

Numerous publications on the Rey 15-item Memorization Test have cited limitations primarily in test sensitivity, as well as to some extent in specificity. In the current study, 49 patients with suspect effort, 36 neuropsychology clinic patients not in litigation or attempting to secure disability, 33 learning disabled college students, and 60 normal controls were administered the Rey Test in standard format followed by a recognition trial. A free recall score <9 was found to have excellent specificity (97-100%), although sensitivity was modest (47%). However, use of a combined recall and recognition score (i.e., free recall + [recognition - false positives] <20) substantially increased sensitivity (71%) while maintaining high specificity (> or=92%).     

Performance validity in older adults: Observed versus predicted false positive rates in relation to number of tests administered

Introduction: This study examined false positive rates on embedded performance validity tests (PVTs) in older adults grouped by cognitive status.

Method: The research design involved secondary analysis of data from the National Alzheimer’s Coordinating Center database. Participants (N = 22,688) were grouped by cognitive status: normal (n = 10,319), impaired (n = 1,194), amnestic or nonamnestic mild cognitive impairment (MCI; n = 5,414), and dementia (n = 5,761). Neuropsychological data were used to derive 5 PVTs.

Results: False positive rates on individual PVTs ranged from 3.3 to 26.3% with several embedded PVTs showing acceptable specificity across groups. The proportion of participants failing two or more PVTs varied by cognitive status: normal (1.9%), impaired (6.6%), MCI (13.2%), and dementia (52.8%). Comparison of observed and predicted false positive rates at different specificity levels (.85 or .90) demonstrated significant differences in all comparisons. In normal and impaired groups, predicted rates were higher than observed rates. In the MCI group, predicted and observed comparisons varied: Predicted rates were higher with specificity at .85 and lower with specificity at .90. In the dementia group, predicted rates underestimated observed rates.

Conclusions: Despite elevated false positives in conditions involving severe cognitive compromise, several measures retain acceptable specificity regardless of cognitive status. Predicted false positive rates based on the number of PVTs administered were not observed empirically. These findings do not support the utility of simulated data in predicting false positive rates in older adults.     

Performance of Older Depressed Patients on Two Cognitive Malingering Tests: False Positive Rates for the Rey 15-item Memorization and Dot Counting Tests

To our knowledge, no investigations have been undertaken to determine whether depression impacts performance on two commonly used tests to detect malingering of cognitive symptoms, the Rey 15-item Memorization Test and the Rey Dot Counting Test. This is a critical issue because of the high rate of depressive symptoms in patients with neurological conditions. It was hypothesized that depressed individuals, especially those with more severe depression, might be at risk for failing the tests, because these patients exhibit mild deficits in mental speed, visual perceptual/spatial skills, and visual memory, abilities required for successful completion of the malingering tests. However, examination of test performance in 64 older participants with major depression generally revealed very low false positive rates for most test scores, and severity of depression was unrelated to test scores. These results add to accumulating data supporting the validity of these cognitive malingering tests by documenting few false positive identifications.     

Performance of older adults on tests of cognitive estimation

This study provides performance data for older adults on two existing tests of cognitive estimation ability (Cognitive Estimation Test [CET] and Temporal Judgement Test [TJT]) and a novel set of estimation questions (n-EQ) that make reference to familiar, everyday objects. It explores the relations between each of the three tests of estimation and verbal intelligence. The sample comprises 101 adults aged 55 years and over. Neither n-EQ nor TJT scores were associated with verbal IQ, but scores on the more established CET were. As well as providing performance data for older adults, this study confirms the limitations of existing measures of cognitive estimation. It is proposed that the novel questions devised for this study show promise as an assessment tool, and warrant further validation.     

Attempted suicide in older depressed patients: effect of cognitive functioning.

The authors explored cognitive functioning and suicidal behavior in older depressed patients. Inpatients age 50 years or older (N=103) with major depression, 45 of whom had attempted suicide, were evaluated within 1 week of their hospital admission. Measures of suicidal behavior included suicide attempter status, the Suicide Intent Scale (SIS), ratings of method used (violent/nonviolent), and seriousness of injuries sustained (lethality). The Mini-Mental State Exam (MMSE) score measured cognitive impairment; covariates were age, gender, and living arrangement. The MMSE score was not associated with suicide attempter status, but for attempters, MMSE score showed a positive association with SIS score, but not method or lethality. Findings suggest that although cognitive disturbance may be associated with less-deliberate acts among older depressed suicide attempters, it does not appear to influence the potential lethality of their behavior.     

A tail of two sides: Artificially doubled false positive rates in neuroimaging due to the sidedness choice with t‐tests

One‐sided t‐tests are widely used in neuroimaging data analysis. While such a test may be applicable when investigating specific regions and prior information about directionality is present, we argue here that it is often mis‐applied, with severe consequences for false positive rate (FPR) control. Conceptually, a pair of one‐sided t‐tests conducted in tandem (e.g., to test separately for both positive and negative effects), effectively amounts to a two‐sided t‐test. However, replacing the two‐sided test with a pair of one‐sided tests without multiple comparisons correction essentially doubles the intended FPR of statements made about the same study; that is, the actual family‐wise error (FWE) of results at the whole brain level would be 10% instead of the 5% intended by the researcher. Therefore, we strongly recommend that, unless otherwise explicitly justified, two‐sided t‐tests be applied instead of two simultaneous one‐sided t‐tests.     

Two-year follow-up of bibliotherapy and individual cognitive therapy for depressed older adults

This study examined the stability of treatment gains after receiving either cognitive bibliotherapy or individual cognitive psychotherapy for depression in older adults. A 2-year follow-up of 23 participants from Floyd, Scogin, McKendree-Smith, Floyd, and Rokke (2004) was conducted by comparing pre-and posttreatment scores with follow-up scores on the Hamilton Rating Scale for Depression (HRSD) and the Geriatric Depression Scale (GDS). Results indicated that treatment gains from baseline to the 2-year follow-up period were maintained on the HRSD and GDS, and there was not a significant decline from posttreatment to follow-up. There were no significant differences between the treatments on the GDS or HRSD at the 2-year follow-up; however, bibliotherapy participants had significantly more recurrences of depression during the follow-up period.     

A review of the Boston Naming Test and multiple-occasion normative data for older adults on 15-item versions

The literature reveals numerous versions of the Boston Naming Test (BNT) but normative data for very old people are scarce. Using four shortened versions of the BNT we produced normative data and examined naming ability longitudinally in a population-based sample of community dwelling elderly people. Our initial sample comprised 803 people with an average age of 76 years (range 65-93) who were examined twice, 2 years apart. A sub-sample of 326 people were followed-up 6 years later and re-examined. Results indicated that age and education level, but not gender, affected naming ability.     

The Henry-Heilbronner Index: a 15-item empirically derived MMPI-2 subscale for identifying probable malingering in personal injury litigants and disability claimants

A new 15-item MMPI-2 subscale, the Henry-Heilbronner Index (HHI), representing a "pseudosomatic factor," was empirically derived from both the 43-item Lees-Haley Fake Bad Scale (FBS) and the 17-item Shaw and Matthews' Pseudoneurologic Scale (PNS). The HHI was superior to both the FBS and PNS in identification of symptom exaggeration in personal injury litigants and disability claimants compared to non-litigating head-injured controls. Logistic regression analyses revealed that a cutscore of > or = 8 on the HHI was associated with good specificity (89%) and sensitivity (80%). These results suggest that the HHI may be useful in identifying personal injury litigants and disability claimants who exaggerate, overreport, or malinger physical symptoms on the MMPI-2 related to their current health and/or litigation status.     

Cluster failure revisited: Impact of first level design and physiological noise on cluster false positive rates

Methodological research rarely generates a broad interest, yet our work on the validity of cluster inference methods for functional magnetic resonance imaging (fMRI) created intense discussion on both the minutia of our approach and its implications for the discipline. In the present work, we take on various critiques of our work and further explore the limitations of our original work. We address issues about the particular event‐related designs we used, considering multiple event types and randomization of events between subjects. We consider the lack of validity found with one‐sample permutation (sign flipping) tests, investigating a number of approaches to improve the false positive control of this widely used procedure. We found that the combination of a two‐sided test and cleaning the data using ICA FIX resulted in nominal false positive rates for all data sets, meaning that data cleaning is not only important for resting state fMRI, but also for task fMRI. Finally, we discuss the implications of our work on the fMRI literature as a whole, estimating that at least 10% of the fMRI studies have used the most problematic cluster inference method (p = .01 cluster defining threshold), and how individual studies can be interpreted in light of our findings. These additional results underscore our original conclusions, on the importance of data sharing and thorough evaluation of statistical methods on realistic null data.     

Caring for depressed and suicidal older patients: a survey of physicians and nurse practitioners

OBJECTIVE: This study sought to describe patterns of mental health care for depressed and suicidal geriatric patients by primary care physicians (MDs) and nurse practitioners (NPs). METHODS: A probability sample of 300 Illinois MDs from the AMA Physician Masterfile and a national sample of 595 NPs from the American Academy of Nurse Practitioners were surveyed. Sixty-three percent of MDs and 61 percent of NPs responded regarding their approaches to assessing, treating, and referring older adult patients who were depressed or suicidal. Respondents rated their confidence in assessing and treating depression and suicidality and identified barriers to mental health treatment in a primary care setting. RESULTS: Both similarities and differences were found among MDs and NPs in their patterns of managing depressed and suicidal older adults. NPs used more varied approaches in assessing, treating, and referring their geriatric patients with mental health problems. MDs relied more heavily on psychotropic medications for the treatment of depression and on psychiatrists when referring suicidal older patients. NPs were more likely than MDs to note lack of training and referral resources as barriers to treating depression of older patients. NPs rated their training in geriatric mental health more favorably than MDs. CONCLUSIONS: In terms of assessment of depression, preferred treatment approaches, the use of referral resources, and perceived barriers to mental health care, there appears to be a greater orientation towards a psychosocial approach among NPs. Primary care MDs and NPs often have different perspectives that in combination could enhance the mental health care of geriatric patients.     

Thyroid function, depressed mood, and cognitive performance in older individuals: the Maastricht Aging Study

The hypothesis was tested that thyroid function, as indicated by serum thyroid-stimulating hormone (TSH) level, is associated with cognitive performance in a healthy aging population. In a random sample of 120 participants recruited from the Maastricht Aging Study (MAAS), aged between 49 and 71 years, we assessed TSH level, mood state (Symptom Check List, subscale depression), and three domains of cognitive function: verbal memory, general sensorimotor speed, and complex flexibility. After correction for age, sex, and educational level, a negative association between TSH and memory function was apparent: higher levels of TSH predicted lower levels of memory performance. Exclusion of individuals with TSH levels suspect for thyroid disorder (n=2) or who were on thyroid replacement (n=3) attenuated this association. Furthermore, additional control for mood status reduced the association below the significance level. No interaction between age and TSH on cognition was found, which indicated that the TSH-memory association was independent of age group level. We conclude that the association between TSH level and memory performance was small and dependent on mood status and the presence of (possible) thyroid disease in this relatively healthy population based sample. Prospective studies are needed to address the role of thyroid function in age-related cognitive decline.     

Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment

Objectives: The aim of this population-based study was to investigate the usefulness of the Geriatric Depression Scale 15-item version (GDS-15) to assess depressive symptoms among very old people with differing levels of cognitive function.

Methods: The 834 participants were aged 85 and over. Feasibility of GDS-15 was evaluated as the proportion of people who completed the scale. Concurrent criterion validity was evaluated by calculating correlations between GDS-15 and Philadelphia Geriatric Center Morale Scale (PGCMS). PGCMS measures psychological wellbeing which is closely related with depressive symptoms. Correlations were calculated within groups according to cognitive function assessed with Mini-Mental State Examination (MMSE); 0–4, 5–9, 10–14, 15–19, 20–24, 25–27, and 28–30, using Pearson's two-sided correlation and compared using Fisher r-to-z transformation. Internal consistency of the GDS-15 was evaluated by calculating Cronbach's α in each group.

Results: In total, 651 (78%) of the 834 participants completed the GDS-15. For the two MMSE-groups with scores of <10, the proportion who completed GDS-15 were 1% and 42%, respectively, compared to 65–95% in the MMSE-groups with scores of ≥10. Cronbach's α in each MMSE-group ranged from 0.636 (MMSE 28–30) to 0.821 (MMSE 5–9). The level of correlation between GDS-15 and PGCMS did not significantly differ between MMSE-groups with scores of 5–27 compared to the MMSE-group with scores of 28–30.

Conclusions: The GDS-15 seems to have an overall usefulness to assess depressive symptoms among very old people with an MMSE score of 10 or more. More studies are needed to strengthen the validity of GDS-15 among older people with MMSE scores of 10–14. For older people with MMSE scores lower than 10, there is a need to develop and validate other measurements.     

Empirical derivation of a new MMPI-2 scale for identifying probable malingering in personal injury litigants and disability claimants: the 15-item Malingered Mood Disorder Scale (MMDS)

A new 15-item MMPI-2 subscale, the Malingered Mood Disorder Scale (MMDS), was empirically derived from the original 32-item Malingered Depression Scale (MDS) of Steffan, Clopton, and Morgan (2003). The MMDS was superior to the original MDS in identification of symptom exaggeration in personal injury litigants and disability claimants compared to non-litigating head-injured controls. Logistic regression revealed that a cut score of > or = 7 on the MMDS produced good specificity (93.4%) with an associated sensitivity of 54.8%. An MMDS score of > or = 8 was associated with 100% positive predictive power, i.e., no false positive errors. These results suggest that the MMDS may be useful in identifying personal injury litigants and disability claimants who exaggerate emotional disturbance on the MMPI-2.     

Effects of acute tryptophan depletion on mood and cognitive functioning in older recovered depressed subjects.

OBJECTIVE: Previous studies show that acute tryptophan depletion (ATD), by administration of an amino acid drink lacking tryptophan, can produce clinically significant depressive symptoms in subjects who have recovered from major depression. This is more likely in female patients who have had suicidal ideation, recurrent depression, and treatment with specific serotonin reuptake inhibitors. These risk factors are frequent in older recovered depressed people. The authors investigated the effects of ATD on mood and cognitive functioning in this group. METHODS: Sixteen recovered depressed (RD) subjects and 17 healthy-comparison subjects, over 60 years old, participated in a double-blind, placebo-controlled, crossover study involving administration of a tryptophan-depleting and a placebo drink. Mood ratings scales were administered at baseline and at 4 and 7 hours post-drink on each test day. A battery of neuropsychological tests, including the modified Mini-Mental State Examination (MMSE) was administered between 4 and 6 hours post-drink. RESULTS: Depletion of plasma free tryptophan was 71% at 4 and 7 hours after the active drink. There was no evidence of mood change at any time in either group. On the MMSE, however, the ATD/RD group showed a significant decrease compared with placebo. CONCLUSIONS: There was no evidence of mood disturbance during ATD in any subject. This may imply less sensitivity to acute disturbance of the 5HT system than in younger recovered patients.     

Effects of pharmacological therapy on gait and cognitive function in depressed patients

OBJECTIVE: To investigate the relationship among affective status, cognitive function, and gait in depressed patients and to evaluate the effects of treatment of depression on gait and cognitive function. METHODS: Nineteen patients recently diagnosed with clinical depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) were recruited from a psychiatric outpatient clinic. Evaluation included the Hamilton Depression Rating Scale (HAM-D), the Mini-Mental State Examination, a computerized neuropsychological battery (Mindstreams, NeuroTrax Corp, New York, NY), and Barthel's Index of Instrumental Activities of Daily Living. Temporal parameters of gait were quantified using a stopwatch and force-sensitive insoles. All assessments were performed at baseline and after approximately 10 weeks of treatment with antidepressants. RESULTS: The patients' mean age was 68.6 +/- 9.1 years (15 women). Therapy significantly (P < 0.001) improved the affective state (HAM-D scores). There were small but significant improvements in gait speed (P = 0.033), stride time variability (P = 0.036), and gait asymmetry (P = 0.038). With the exception of the hand-eye coordination index, all tested cognitive domains also improved significantly. Baseline depression scores correlated with changes in depression: patients with higher HAM-D scores at baseline had more significant improvement in their affect (P < 0.001). Changes in HAM-D were not significantly correlated with changes in gait or changes on computerized tests of cognitive function (P > 0.10). CONCLUSIONS: Depressive symptoms are associated with gait and cognitive impairment. Moreover, the present results suggest that these domains improve in response to antidepressant medication.     

Deterministic learning and attempted suicide among older depressed individuals: cognitive assessment using the Wisconsin Card Sorting Task

BackgroundLate-life suicide is an under-investigated public health problem. Among the putative vulnerabilities for this complex multifactorial behaviour are deficits in cognitive control, an ability to integrate and prioritize multiple cognitive processes in order to flexibly adapt behaviour and meet situational demands. We investigated cognitive control during rule learning in a complex and changing environment in older individuals with suicide attempts of varying lethality.MethodNinety-three participants over the age of 60 (30 healthy controls, 29 depressed never suicidal, 20 low-lethality suicide attempters, 14 high-lethality suicide attempters) underwent structured clinical and cognitive assessments. Participants then completed the Wisconsin Card Sorting Test (WCST), a well-studied task of cognitive control during rule learning.ResultsHigh-lethality attempters demonstrated a pattern of deficits involving poor conceptual reasoning, perseverative errors and total errors. Compared to low-lethality attempters and healthy controls, high-lethality attempters demonstrated poor conceptual reasoning, as well as increased rates of perseverative errors and total errors. Compared to non-suicidal depressed participants, high-lethality attempters also made more conceptual errors.ConclusionHigh-lethality suicide attempts among older people are associated with impaired cognitive control during rule learning as detected by the WCST. Our data suggest that impairment in cognitive control during rule learning may represent a vulnerability distinct from the impulsive diathesis, typically manifesting in young, low-lethality attempters. This vulnerability may contribute to the high incidence of serious or, often, fatal suicidal acts in old age.     

Validation of short screening tests for depression and cognitive impairment in older medically ill inpatients

OBJECTIVE: To investigate the criterion validity of the four-item Geriatric Depression Scale (GDS4) and the six-item Orientation-Memory-Concentration-test (OMC) against longer widely used screening instruments. METHOD: Participants were 153 patients (aged 65 or over) admitted to four acute medical wards of a northern UK town. The validity of the GDS4 was determined using the 30-item geriatric depression scale (GDS30) as the comparator; the validity of the OMC was determined using the standardised mini-mental state examination (MMSE) as the comparator. For both screens, the area under receiver operating characteristic (ROC) curve was calculated in addition to the number of true and false positives and the sensitivity and specificity for various cut-off points. RESULTS: The area under ROC curve was 0.80 for the GDS4 and 0.90 for the OMC. Using a cut-off of 0/1, the GDS4 correctly classified 78.2% of participants, using the GDS30 as the standard. This cut-off gave a sensitivity of 90.1% and specificity of 55.3%. With a cut-off of 1/2 the GDS4 correctly classified 76.8% of participants and had sensitivity and specificity of 78% and 74.5% respectively. The GDS4 and GDS30 were highly correlated (rho=0.63, p < 0.0005). A cut-off of 10/11 on the OMC gave optimum performance. With this cut-off, it correctly classified 85.9% of participants, and had 85.6% sensitivity and 86.8% specificity. There was a significant correlation between the OMC and the SMMSE (rho = -0.827, p < 0.0005). CONCLUSION: The GDS4 and OMC appear to be useful instruments for screening for depression and cognitive impairment among older medical inpatients.