Self‐ and Informant Report of Financial Abilities in Patients with Alzheimer's Disease: Reliable and Valid?

OBJECTIVES: To evaluate the consistency, stability, and accuracy of reports by patients with Alzheimer's disease (AD) and their caregivers regarding the patients' premorbid and current financial abilities. DESIGN: Consistency of reports was assessed within patient/caregiver dyads and within control/control informant dyads. Stability of reports over a 1-month interval was assessed for each group: patients with AD, caregivers, controls, and control informants. Accuracy of each group's reports was evaluated in reference to patients' and controls' performance on a direct psychometric measure of financial capacity. SETTING: University medical center. PARTICIPANTS: Twenty patients with AD and 20 family caregivers; 23 controls and 23 family informants. MEASUREMENTS: The Prior Financial Capacity Form (PFCF) and the Current Financial Capacity Form (CFCF) were used. Parallel versions assessed self-report (patients, controls) and informant report (caregivers, control informants) at two visits 1 month apart. Patients with AD and controls were also administered the Financial Capacity Instrument (FCI), a direct assessment of the same abilities reported on the PFCF and CFCF. RESULTS: Patients with AD reported that they had more-intact current abilities than their caregivers reported. Patients with AD and their caregivers showed lower levels of stability over time on the PFCF and CFCF than did controls and their informants. Half of the patients with AD overestimated their current abilities relative to their FCI performance, whereas caregivers demonstrated both underestimation and overestimation errors. Controls and informants evidenced high levels of consistency, stability, and accuracy in PFCF and CFCF ratings. CONCLUSION: Patients with AD overestimate their financial abilities in comparison with the reports of their family caregivers. Both patients and caregivers' reports of patients' financial abilities showed limited stability and validity. The reliability and accuracy of self- and informant reports of financial abilities may be compromised in the context of dementia and caregiving, underscoring the need for direct assessment methods to augment self- and informant report in assessing functional decline in dementia.     

Longitudinal course of behavioral problems during Alzheimer's disease: linear versus curvilinear patterns of decline

BACKGROUND: Patients with Alzheimer's Disease (AD) are commonly assumed to experience a linear decline in behavioral functioning that parallels progressive cognitive decline. However, some researchers have suggested that specific behavioral problems either decline at different rates or improve in late dementia. METHODS: The present analyses examined 150 AD patients at an initial assessment, 61 of whom were also evaluated annually on two additional occasions. Measures of cognitive impairment and behavioral problems were obtained. RESULTS: Cross-sectional results indicated curvilinear associations between dementia severity and certain behavioral problems (forgetful behaviors, and emotional and impulsive behaviors). Longitudinal analyses further indicated trends for curvilinear rates of behavioral disturbance across time, with some problem areas showing improvement as AD progresses through the most severe stages. CONCLUSIONS: Even though Alzheimer's disease is a progressive dementia characterized by increasing cognitive deterioration, it appears to be inaccurate to expect behavioral functioning to show the same linear decline across time.     

Assessment of cognitive, psychiatric, and behavioral disturbances in patients with dementia: the Neurobehavioral Rating Scale.

OBJECTIVE: To assess the validity of the Neurobehavioral Rating Scale (NRS) in patients with Alzheimer's disease (AD) or multi-infarct dementia (MID) and to characterize the cognitive, psychiatric, and behavioral disturbances that occur in these patients. DESIGN: Cross-sectional evaluation. SETTING: West Los Angeles VAMC Geropsychiatry Inpatient Unit, Neurobehavior Inpatient Unit, and Dementia Clinic; UCLA Alzheimer's Disease Clinic. PATIENTS: Convenience sample of 61 patients with AD and 22 patients with MID. MAIN OUTCOME MEASURE: The NRS, a 27-item observer-rated instrument that measures cognitive, psychiatric, and behavioral disturbances. RESULTS: The NRS demonstrated content and convergent validity in this patient group. Principal components analysis of the NRS ratings identified a six-factor solution, and each factor contained clinically related symptoms. The factors were Cognition/Insight, Agitation/Disinhibition, Behavioral Retardation, Anxiety/Depression, Verbal Output Disturbance, and Psychosis. Among the patients with AD, agitation, disinhibition, hostility, poor insight, poor motivation, suspiciousness, and delusions were more severe in patients with more advanced dementia. Depressive symptoms occurred with equal severity in patients with mild and advanced dementia, but depressed mood was more severe in patients with earlier age of onset of AD. CONCLUSION: The NRS is a useful instrument for structured assessment of a broad range of cognitive, psychiatric, and behavioral disturbances in patients with dementia.     

Psychobehavioral disorders in severe dementia

Behavioral and psychological symptoms of dementia (BPSD) are not included in the diagnostic criteria for dementia or in the assessment tools for grading its severity. However, they constitute a major part of the caregivers' burden and the main cause for institutionalization. They are, for one part, the direct consequence of the brain lesions, but, for another part, they result from the psychological reactions of the patients to their cognitive deficits or their relational difficulties with their family or carers. Despite speech disorder and mind disruption, patients with severe dementia still have a psychic and relational life, which is expressed through BPSD. Many BPSD are of short duration and can be improved by a better understanding, psychological and behavioral approach. However, psychotropic drugs are often useful or necessary, but, due to the frailty of the patients with severe dementia, their use should be very cautious.     

The CAMDEX: a standardized instrument for the diagnosis of mental disorder in the elderly: a replication with a US sample

The Cambridge Mental Disorders of the Elderly Examination (CAMDEX) was developed by Roth, et al (1986) to assist in the early diagnosis and measurement of dementia in the elderly. In this study the CAMDEX was administered to a mixed group of independently diagnosed elderly psychiatric patients and control subjects in the United States. The CAMDEX was found to have a high interrater reliability with a mixed group of clinicians of varying backgrounds. The diagnostic scales and the cognitive section of the CAMDEX demonstrated considerable promise in distinguishing between independently diagnosed populations of depressed, demented, and normal subjects. The results suggest comparability between samples of subjects in England and the US, and that the CAMDEX is a promising instrument for use in both research and clinical settings.     

Accuracy of self-reported depression in persons with dementia

OBJECTIVES: To investigate the reliability and validity of self-reported depression in demented elderly patients. DESIGN: This is the first study to combine the use of multiple depression criteria with dementia and depression control groups. SETTING: Houston Veterans Affairs nursing home and geropsychiatric inpatient unit and outpatient clinic, Baylor College of Medicine's Alzheimer's Disease Research Center. PARTICIPANTS: The total sample included 121 volunteer participants, their informants, and their clinicians, forming four diagnostic groups (27 controls, 37 dementia only, 28 depression only, 29 dementia and depression). MEASUREMENTS: Scales assessing depression, deficit awareness, physical illness, functional disability, caregiver burden, and severity of cognitive impairment were used. RESULTS: Analyses of variance using informant- and clinician-rated depression categories found main effects on patient-reported depression scores for deficit awareness and depression diagnosis but not for dementia diagnosis. Chi-square analyses revealed that demented and depressed patients underreported depression at similarly high rates compared with clinician and informant reports. Regression analyses revealed that deficit awareness accounted for significant variance in self-reported depression accuracy, whereas clinician- or informant-rated depression, severity of cognitive impairment, physical disability, functional status, and caregiver burden were not significant. CONCLUSION: The results of this investigation suggest that the presence of dementia per se does not predict inaccurate depression self-reports. Deficit awareness, which covaries with dementia, appears to account for the majority of the variance in self-report accuracy. These findings were stable across informant- and clinician-rated depression criteria and multiple analyses.     

Neuropsychological assessment of the severely impaired elderly patient

Although a number of standard scales exist for the assessment of the mildly to moderately demented patient, measurement of cognitive decline needs to be extended beyond this stage and into the range of functioning characteristic of the severely impaired individual. To do this, assessment techniques need to be developed which take into account the specific behavioral and cognitive deficits seen in severe dementia. Until such techniques are developed. a full and adequate account of the natural history of cognitive decline in AD is not possible. We have introduced a new assessment device, the Severe Impairment Battery, which evaluates a range of cognitive functioning in patients who are unable to complete standard neuropsychological tests. Preliminary results with this test are encouraging and suggest that, contrary to popular belief, many severely cognitively impaired patients are testable if appropriate techniques and strategies are applied.     

Measuring Illness Behavior in Patients With Systemic Sclerosis

Objective

Illness behaviors (cognitive, affective, and behavioral reactions) among individuals with systemic sclerosis (SSc; scleroderma) are of clinical concern due to relationships between these behaviors and physical and mental quality of life, such as pain and symptoms of depression. Self‐report measures with good psychometric properties can aid in the accurate assessment of illness behavior. The Illness Behavior Questionnaire (IBQ) was designed to measure abnormal illness behaviors; however, despite its longstanding use, there is disagreement regarding its subscales. The goal of the present study was to evaluate the validity of the IBQ in a cohort of patients with SSc.

Methods

Patients with SSc (n = 278) completed the IBQ at enrollment into the Genetics Versus Environment in Scleroderma Outcome Study. Structural validity of previously derived factor solutions was investigated using confirmatory factor analysis. Exploratory factor analysis was utilized to derive SSc‐specific subscales.

Results

None of the previously derived structural models were supported for SSc patients. Exploratory factor analysis supported an SSc‐specific factor structure with 5 subscales. Validity analyses suggested that the subscales were generally independent of disease severity, but were correlated with other health outcomes (i.e., fatigue, pain, disability, social support, and mental health).

Conclusion

The proposed subscales are recommended for use in SSc, and can be utilized to capture illness behavior that may be of clinical concern.     

Modified Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening test for dementia for Thai elderly

A potential test for early detection of dementia in the elderly is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which is based on information from the informant for the elderly about the changes of the elderly in everyday cognitive functioning associated with dementia. The present study aimed to modify and assess the reliability and validity of the modified IQCODE consisting of 32 items. The study consisted of two methods of assessing dementia: DSMIV diagnosis carried out by clinicians, and informants responding to the IQCODE. The subjects were 200 pairs of elderly subjects and their informants who visited the Geriatric Clinic, Ramathibodi Hospital. The optimal cutoff score on the modified IQCODE was 3.42, with 90% sensitivity and 95% specificity. The positive predictive values, negative predictive values, and accuracy were 0.94, 0.90, and 0.92, respectively. The IQCODE items had high internal consistency. The IQCODE associated with the elderly person's age, but not with their gender and educational level; nor were they associated with the demographic characteristics of the informant. Therefore, the IQCODE could be used as an alternative screening test for dementia in Thailand with acceptable sensitivity and specificity. This tool may be useful for dementia screening in the community and the geriatric clinic for early detection of disease.     

Cognitive functioning in spousal caregivers of dementia patients: findings from the prospective MAASBED study

BACKGROUND: Spousal caregivers are usually of the same age as the dementia patient and therefore at risk of age-related cognitive decline. Suboptimal cognitive functioning in caregivers may have profound implications. METHODS: Fifty-four spousal caregivers of dementia patients from the Memory Clinic of the Academic Hospital Maastricht and the Regional Institute for Community Mental Health Care in the Netherlands were compared with 108 non-caregiving controls. Data were collected on patient and caregiver characteristics and caregiver cognitive functioning. Repeated measures statistical analyses were carried out to investigate the relationship between caregiver cognitive functioning at baseline and patient behavioural problems and caregiver competence during 1 year of follow-up. RESULTS: Caregivers performed significantly worse on several cognitive domains compared with control subjects. Low performance on a verbal memory task was related to a decrease in caregiver subjective competence and an increase in patient hyperactivity. CONCLUSION: The results indicate that screening for cognitive impairment of spousal caregivers may be helpful, because suboptimal cognitive functioning may affect the ability to provide adequate care.     

Factors associated with inconsistent diagnosis of dementia between physicians and neuropsychologists

OBJECTIVE: To explore reasons for discrepancy in the diagnosis of cognitive impairment between physicians and neuropsychologists. DESIGN: Retrospective analysis of national survey data. SETTING: Canadian Study of Health and Aging Phase 1, a national survey of community-dwelling and institutionalized older Canadians. PARTICIPANTS: 1879 subjects who completed all components of a clinical examination. MEASUREMENTS: Data available to both disciplines (demographic data, functional status, Modified Mini-Mental State (3MS), schedule H of the Cambridge Mental Disorders of the Elderly Examination (CAMDEX)), results of the physician's history and physical examination, and results of a psychometric test battery. Subjects were classified as No Cognitive Impairment, Cognitive Impairment Not Dementia (CIND), and Dementia, the latter according to the criteria of the Diagnostic and Statistical Manual, 3rd Ed., Revised. Preliminary diagnoses by physicians and neuropsychologists were compared. RESULTS: In univariate modeling, higher education increased consistency. Lower scores on the 3MS, depression reported in the CAMDEX, focal neurological signs, and all neuropsychological variables decreased agreement. In multivariate modeling, higher education and identification of long-term memory impairment by the neuropsychologist increased agreement; lower scores on the 3MS, depression reported on the CAMDEX, and identification of short-term memory impairment or constructional impairment led to disagreement. When the category of CIND was removed, kappa for agreement increased from 0.51 to 0.92. CONCLUSIONS: Physicians and neuropsychologists have different, complementary approaches to the diagnosis of dementia, and a consensus approach should be used. The category of CIND requires elucidation. Identification of dementia in subjects with depression or low education is difficult, and new strategies are required.     

The Mexican Cognitive Aging Ancillary Study (Mex-Cog): Study Design and Methods

ObjectiveDescribe the protocol sample and instruments of the Cognitive Aging Ancillary Study in Mexico (Mex-Cog). The study performs an in-depth cognitive assessment in a subsample of older adults of the ongoing Mexican Health and Aging Study (MHAS). The Mex-Cog is part of the Harmonized Cognitive Assessment Protocol (HCAP) design to facilitate cross-national comparisons of the prevalence and trends of dementia in aging populations around the world, funded by the National Institute on Aging (NIA).MethodsThe study protocol consists of a cognitive assessment instrument for the target subject and an informant questionnaire. All cognitive measures were selected and adapted by a team of experts from different ongoing studies following criteria to warrant reliable and comparable cognitive instruments. The informant questionnaire is from the 10/66 Dementia Study in Mexico.ResultsA total of 2,265 subjects aged 55-104 years participated, representing a 70% response rate. Validity analyses showed the adequacy of the content validity, proper quality-control procedures that sustained data integrity, high reliability, and internal structure.ConclusionsThe Mex-Cog study provides in-depth cognitive data that enhances the study of cognitive aging in two ways. First, linking to MHAS longitudinal data on cognition, health, genetics, biomarkers, economic resources, health care, family arrangements, and psychosocial factors expands the scope of information on cognitive impairment and dementia among Mexican adults. Second, harmonization with other similar studies around the globe promotes cross-national studies on cognition with comparable data. Mex-Cog data is publicly available at no cost to researchers.     

Informant ratings of cognitive decline of elderly people: relationship to longitudinal change on cognitive tests

Formal assessment of cognitive decline with cognitive tests can be difficult, requiring either two measurement points or a comparison of 'hold' with 'don't hold' tests. Informant-based assessment provides an alternative approach because informants can adopt a longitudinal perspective and directly rate cognitive change. A study was carried out to assess the validity of informant ratings collected by means of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). A community sample of 500 subjects aged 74 or over underwent four cognitive tests on two occasions 3½ years apart. On the second occasion, informants filled out the IQCODE. Subjects rated as having moderate or severe decline were found to have greater change on the cognitive tests. These findings support the validity of informant ratings of cognitive decline.     

Lay person-based screening for early detection of Alzheimer's disease: development and validation of an instrument

Symptoms of cognitive impairment reported to telephone interviewers by caregivers of 272 patients were analyzed with respect to research diagnoses of dementia. All patients received neuropsychological evaluation for establishing the research diagnoses. A data mining program that used machine learning algorithms produced an optimized binary decision tree for differentiating patient groups according to all available information. The results of this analysis were used to help four dementia experts create a dementia screening instrument amenable to application and scoring by nonclinical personnel. The validity of the resulting instrument was then evaluated in an independent sample of 103 patients administered neuropsychological testing within the previous 60 days. The psychometric properties of the empirically derived scale and its performance for discriminating control from probable or possible Alzheimer's patients indicate strong potential for use as a dementia screener for the general population.     

Interdisciplinary research strategies in geriatric psychiatry--studies and results in dementia and depressed patients

Eighty-one patients (mean age: 66 +/- 9 years) who had been in gerontopsychiatric in-patient care were included in the study. As well as physical, psychiatric and neurological examinations, EEG, brain CT scanning and the determination of the Ischemic Scale were performed, in order to confirm the clinical diagnosis of dementia of Alzheimer type (DAT), dementia of vascular type (DVT) or multi-infarct dementia (MID), and depression in old age, as based on the DSM III criteria. A comprehensive psychological test battery was administered, to one section of the subjects. Our results indicate that EEG and Ischemic Score can differentiate patients with DAT and DVT to a satisfactory degree, whereas CT findings and psychometric assessment were apt to confirm the overall diagnosis of dementia (DAT/DVT) and depression. Patients with dementia showed memory impairment to a greater extent than depressive patients, as could be proved by a memory test (Syndrom-Kurztest). However, a dementia screening test (Information-Memory-Concentration Test) could more accurately differentiate dementia and depression. The application of a comprehensive psychometric testing procedure did not prove to be an effective diagnostic tool in the assessment of various stages of dementia. Short dementia tests and rating scales seem to be appropriate to distinguish depression from dementia, especially in cases of mild to moderate dementia. In patients with very mild and insignificant organic brain disturbances these screening methods fall short of diagnostic validity. Beyond this, there is a current need for assessment instruments in the evaluation of alterations in personality and affectivity, such as are seen in depression.     

Development of the Risk Appraisal Measure: A Brief Screen to Identify Risk Areas and Guide Interventions for Dementia Caregivers

OBJECTIVES: To develop and validate a brief screening measure for use in research, healthcare, and community settings to systematically assess well-being and identify needed areas of support for caregivers of patients with dementia.
DESIGN: This study used data from Resources for Enhancing Alzheimer's Caregiver Health (REACH II), a multisite randomized clinical trial of a behavioral intervention designed to improve the quality of life of caregivers in multiple domains.
SETTING: REACH II.
PARTICIPANTS: Two hundred twelve Hispanic, 211 black, and 219 white family caregivers providing in-home care to patients with dementia.
MEASUREMENT: Based on conceptual and psychometric analyses, a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors. The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program.
RESULTS: The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups. Concurrent validity was also demonstrated for the measure.
CONCLUSION: The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research, clinical, and community settings to guide, prioritize, and target needed areas of support for caregivers of patients with dementia.     

Underrecognition of preexisting cognitive impairment by physicians in older ICU patients

OBJECTIVES: Cognitive impairment increases with age, as do many serious illnesses requiring intensive care. Little is known, however, about physician recognition of preexisting cognitive impairment in the ICU and which patient factors may play a role in physician recognition. DESIGN: Cross-sectional comparative study. SETTING: Urban university teaching hospital. PARTICIPANTS: A total of 165 patients aged > or =65 years who were admitted to the medical ICU. MEASUREMENTS: Two previously validated proxy measures of cognitive impairment, the modified Blessed dementia rating scale and the informant questionnaire on cognitive decline in the elderly. Physician interviews and medical record abstraction were used to evaluate the recognition of cognitive impairment. RESULTS: The prevalence of preexisting cognitive impairment in the ICU was 37%. Attending physicians were unaware of the preexisting cognitive impairment in 53% of cases, and intern physicians were unaware in 59% of cases. The recognition of preexisting cognitive impairment increased as the severity of the cognitive impairment increased. Two independent risk factors were identified that were significantly associated with the increased recognition of preexisting cognitive impairment (ie, impairment in activities of daily living or being admitted to the ICU from a nursing home). If both were present, preexisting cognitive impairment was 13 times more likely to be recognized. CONCLUSIONS: A substantial number of older ICU patients have preexisting cognitive impairment on admission to the ICU, and ICU physicians caring for these patients are unaware of this cognitive impairment in the majority of cases. Future research is needed to identify outcomes related to preexisting cognitive impairment and to improve its recognition.     

Beginnende Demenz und Fahreignung

The legal framework and the essentials in traffic and transport psychology and statistics were described in part 1. Safe driving depends on different sensory and mental processes interacting in a complicated manner. Physiological changes and—even more importantly—a variety of diseases result in impaired performance in these functional areas. Moderate to severe dementia certainly means that the person is no longer fit to drive, whereas driving ability may be maintained in mild dementia for some time. There are different approaches and assessment tools, but a single test that could, on its own, answer the question whether a patient with mild dementia is fit to drive does not exist. Driving ability is not only determined by cognitive function. Further assessment of possible risk factors and overall functioning is necessary. If dementia is diagnosed, then the question of fitness to drive must be promptly discussed with the patient because during the course of dementia driving ability will inevitably be lost. The conclusion of the assessment of driving ability must not be pronounced like a verdict, the physician should rather counsel and support the patient and his family on the difficult road towards driving cessation.