Linking Rivermead Post Concussion Symptoms Questionnaire (RPQ) and Sport Concussion Assessment Tool (SCAT) scores with item response theory.

OBJECTIVE: Despite the public health burden of traumatic brain injury (TBI) across broader society, most TBI studies have been isolated to a distinct subpopulation. The TBI research literature is fragmented further because often studies of distinct populations have used different assessment procedures and instruments. Addressing calls to harmonize the literature will require tools to link data collected from different instruments that measure the same construct, such as civilian mild traumatic brain injury (mTBI) and sports concussion symptom inventories. METHOD: We used item response theory (IRT) to link scores from the Rivermead Post Concussion Symptoms Questionnaire (RPQ) and the Sport Concussion Assessment Tool (SCAT) symptom checklist, widely used instruments for assessing civilian and sport-related mTBI symptoms, respectively. The sample included data from n = 397 patients who suffered a sports-related concussion, civilian mTBI, orthopedic injury control, or non-athlete control and completed the SCAT and/or RPQ. RESULTS: The results of several analyses supported sufficient unidimensionality to treat the RPQ + SCAT combined item set as measuring a single construct. Fixed-parameter IRT was used to create a cross-walk table that maps RPQ total scores to SCAT symptom severity scores. Linked and observed scores were highly correlated (r = .92). Standard errors of the IRT scores were slightly higher for civilian mTBI patients and orthopedic controls, particularly for RPQ scores linked from the SCAT. CONCLUSION: By linking the RPQ to the SCAT we facilitated efforts to effectively combine samples and harmonize data relating to mTBI.

A Statistical Consideration Regarding the Threshold of the Psychopathy Checklist-Revised.

The Psychopathy Checklist-Revised (PCL-R; Hare, 2003 ) is one of the most commonly used measures of psychopathy. Scores range from 0 to 40, and legal and mental health professionals sometimes rely on a cut score or threshold to classify individuals as psychopaths. This practice, among other things, assumes that all items contribute equally to the overall raw score. Results from an item response theory analysis (Bolt, Hare, Vitale, & Newman, 2004 ), however, indicate that PCL-R items differ in the amount of information they can provide about psychopathy. We examined the consequences of these item differences for using a cut score, detailing the consequences for a previously applied cut score of 30 as an example. Results indicated that there were more than 8.5 million different response combinations that equaled 30 and more than 14.2 million that equaled 30 or more. This raw score, like others, corresponded to a broad range of PCL-R-defined psychopathy, indicating that applying cut scores on this measure results in imprecise quantifications of psychopathy. We show that by using the item parameters along with an individual's particular scores on the PCL-R items, it is possible to arrive at a more precise understanding of an individual's level of psychopathy on this instrument.

Examining DSM criteria for trichotillomania in a dimensional framework: implications for DSM-5 and diagnostic practice.

BACKGROUND: Diagnosis of trichotillomania (TTM) requires meeting several criteria that aim to embody the core pathology of the disorder. These criteria are traditionally interpreted monothetically, in that they are all equally necessary for diagnosis. Alternatively, a dimensional conceptualization of psychopathology allows for examination of the relatedness of each criterion to the TTM latent continuum. OBJECTIVES: First, to examine the ability of recently removed criteria (B and C) to identify the latent dimensions of TTM psychopathology, such that they discriminate between individuals with low and high degrees of hair pulling severity. Second, to determine the impact of removing criteria B and C on the information content of remaining diagnostic criteria. Third, to determine the psychometric properties of remaining TTM diagnostic criteria that remain largely unchanged in DSM-5; that is, whether they measure distinct or overlapping levels of TTM psychopathology. Fourth, to determine whether information content derived from diagnostic criteria aid in the prediction of disease trajectory (i.e., can relapse propensity be predicted from criteria endorsement patterns). METHOD: Statistics derived from item response theory were used to examine diagnostic criteria endorsement in 91 adults with TTM who underwent psychotherapy. RESULTS: The removal of two criteria in DSM-5 and psychometric validity of remaining criteria was supported. Additionally, individual trait parameters were used to predict treatment progress, uncovering predictive power where none previously existed. CONCLUSIONS: Diagnostic criteria for TTM should be examined in dimensional models, which allow for nuanced and sensitive measurement of core symptomology in treatment contexts.

The enduring impact of maladaptive personality traits on relationship quality and health in later life.

Over the past 5 years, the St. Louis Personality and Aging Network (SPAN) has been collecting data on personality in later life with an emphasis on maladaptive personality, social integration, and health outcomes in a representative sample of 1,630 adults aged 55-64 living in the St. Louis area. This program has confirmed the importance of considering both the normal range of personality and in particular the role of maladaptive traits in order to understand individuals' relationships, life events, and health outcomes. In the current article, we discuss the explanatory benefits of considering maladaptive traits or traits associated with personality disorders when discussing the role of personality in social and health outcomes, with an emphasis on adults in middle to later life, and integrate these findings into the greater literature.

An examination of younger and older adults' age preferences.

Research suggests that how people feel about aging can contribute to their later physical, cognitive, and mental health. In two studies, we examined younger (ages 18-30) and older adults' (ages 61-70) views about aging by asking them to rate the extent to which they would find it desirable to be various ages between 0 and 120. Participants also indicated both their ideal age (the age at which they would most like to be) and their subjective age (how old they generally feel). Consistent with the previous studies, younger adults' ideal age was significantly younger than older adults' ideal age. Younger adults' subjective age was slightly older than their chronological age, whereas older adults' subjective age was slightly younger than their chronological age. Of interest was the finding that, for older adults, their desirability ratings of various ages gradually decreased after age 35. In contrast, younger adults' desirability ratings decreased precipitously after age 20 and remained low from age 45 through age 90. Results suggest that older adults view middle to later life in a more nuanced manner than younger adults, who viewed middle and later life as being undesirable and homogenous. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Data-driven characterization of traumatic brain injury severity from clinical, neuroimaging, and blood-based indicators.

The conventional clinical approach to characterizing traumatic brain injuries (TBIs) as mild, moderate, or severe using the Glasgow Coma Scale (GCS) total score has well-known limitations, prompting calls for more sophisticated strategies to characterize TBI. Here, we use item response theory (IRT) to develop a novel method for quantifying TBI severity that incorporates neuroimaging and blood-based biomarkers along with clinical measures. Within the multicenter Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study sample (N = 2545), we show that a set of 23 clinical, head computed tomography (CT), and blood-based biomarker variables familiar to clinicians and researchers index a common latent continuum of TBI severity. We illustrate how IRT can be used to identify the relative value of these features to estimate an individual's position along the TBI severity continuum. Finally, we show that TBI severity scores generated using this novel IRT-based method incrementally predict functional outcome over classic clinical (mild, moderate, severe) or International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) classification methods. Our findings directly inform ongoing international efforts to refine and deploy new pragmatic, empirically-supported strategies for characterizing TBI, while illustrating a strategy that may be useful to evolve staging systems for other diseases.

Low-Performing Students Confidently Overpredict Their Grade Performance throughout the Semester.

When asked to predict how they will perform on an upcoming exam, students are often poorly calibrated, typically in the direction of overpredicting their performance. Research shows that low-performing students' calibration tends to remain poor across multiple tests over the course of a semester. We tested whether these students remain confident in these erroneously high grade predictions across the semester or whether their confidence wanes, suggesting some degree of metacognitive awareness. In two studies, students made grade predictions prior to taking four in-class exams and then rated their level of confidence in their predictions. Results from both studies showed that miscalibration and confidence remained stable across tests, suggesting that low-performing students continued to believe that they would perform well on upcoming exams despite prior evidence to the contrary.

Reducing Surgical Complications in Spine Patients Through a Medication Management Support Program.

STUDY DESIGN: A hospital-wide medication management program was implemented to ensure that high-risk patients would systematically pause antiplatelet and anticoagulant medications. We analyzed complications before and during the implementation of this program. OBJECTIVE: The goal of the study was to determine if a medication management support program was effective for reducing perioperative complications, including hemorrhage, myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis. DATA AND METHODS: Using data from the National Surgical Quality Improvement Program database, we examined the presence of 5 complications before and during the implementation of a medication management support program. There were 9732 patients in the clinic population who underwent elective spine surgery between 2011 and 2020 and were included in this analysis. Of those 9732 patients, 7205 had surgery before the introduction of the program, whereas 2527 had surgery at some point after the program was introduced. We conducted a series of Pearson's χ 2 tests to determine the relative frequencies of the complications before and during the program. RESULTS: Results showed that during the implementation of the program, patients were relatively less likely to experience hemorrhage (3.16% vs. 1.11%; P <0.001). The reductions in thrombotic complications were clinically significant: myocardial infarction (0.12% vs. 0.00%), stroke (0.10% vs. 0.04%), pulmonary embolism (0.33% vs. 0.28%), and deep vein thrombosis (0.36% vs. 0.28%). These P values ranged from P =0.08 for myocardial infarction to P =0.67 for pulmonary embolism. CONCLUSIONS: The use of this medication management support program appears effective for reducing the need for blood transfusions and thrombotic complications. While promising, the results should be interpreted with caution as we do not know whether this type of program will be effective for other hospital systems.

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

Gaining precision on the Alzheimer's Disease Assessment Scale-cognitive: a comparison of item response theory-based scores and total scores.

BACKGROUND: The Alzheimer's Disease Assessment Scale-cognitive (ADAS-cog) is a commonly used measure for assessing cognitive dysfunction in patients with Alzheimer's disease (AD). The measure has 11 subscales, each of which captures an important aspect of cognitive dysfunction in AD. Traditional scoring of the ADAS-cog involves adding up the scores from the subscales without regarding their varying difficulty or their strength of relationship to AD-associated cognitive dysfunction. The present article analyzes problems associated with this approach and offers solutions for gaining measurement precision by modeling how the subscales function. METHODS: We analyzed data collected at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Clinic from 1240 patients diagnosed with varying degrees of dementia. Item response theory was used to determine the relationship between total scores on the ADAS-cog and the underlying level of cognitive dysfunction reflected by the scores. RESULTS: Results revealed that each total score corresponded to a spectrum of cognitive dysfunction, indicating that total scores were relatively imprecise indicators of underlying cognitive dysfunction. Furthermore, it was common for two individuals with the same total score to have significantly different degrees of cognitive dysfunction. CONCLUSIONS: These findings suggest that item response theory scoring of the ADAS-cog may measure cognitive dysfunction more precisely than a total score method.

How Do Scores on the Functional Status Examination (FSE) Correspond to Scores on the Glasgow Outcome Scale-Extended (GOSE)?

This study was designed to determine how raw scores correspond between two alternative measures of functional recovery from traumatic brain injury (TBI), the Functional Status Examination (FSE) and the Glasgow Outcome Scale-Extended (GOSE). Using data from 357 persons with moderate-severe TBI who participated in a large clinical trial, we performed item response theory analysis to characterize the relationship between functional ability measured by the FSE and GOSE at 6 months post-injury. Results revealed that raw scores for the FSE and GOSE can be linked, and a table is provided to translate scores from one instrument to the other. For example, a FSE score of 7 (on its 0-21 scale, where higher scores reflect more impairment) is equivalent to a GOSE score of 6 (where GOSE is scaled on an 8-point scale, with higher scores reflecting less impairment). These results allow clinicians or researchers who have a score for a person on one instrument to cross-reference it to a score on the other instrument. Importantly, this enables researchers to combine data sets where some persons only completed the GOSE and some only the FSE. In addition, an investigator could save participant time by eliminating one instrument from a battery of tests, yet still retain a score on that instrument for each participant. More broadly, the findings help anchor scores from these two instruments to the broader continuum of injury-related functional limitations.

Improving the Precision of the Glasgow Outcome Scale-Extended Using Item Response Theory: A TRACK-TBI Study.

The Glasgow Outcome Scale-Extended (GOSE) is a functional outcome measure intended to place individuals with traumatic brain injury (TBI) into one of eight broad levels of injury-related disability. This simplicity is not always optimal, particularly when more granular assessment of individuals' injury recovery is desired. The GOSE, however, is customarily assessed using a multi-question interview that contains richer information than is reflected in the GOSE score. Using data from the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study (N = 1544), we used item response theory (IRT) to evaluate whether rescoring the GOSE using IRT, which posits that a continuous latent variable (disability) underlies responses, can yield a more precise index of injury-related functional limitations. We fit IRT models to GOSE interview responses collected at three months post-injury. Each participant's level of functional limitation was estimated from the model (GOSE-IRT) and comparisons were made between IRT-based and standard (GOSE-Ordinal) scores. The IRT scoring resulted in 141 possible scores (vs. 7 GOSE-Ordinal scores in this sample of individuals with GOSE scores ranging between 2 and 8). Moreover, GOSE-IRT scores were significantly more strongly associated with measures of TBI-related symptoms, psychological symptoms, and quality of life. Our findings demonstrate that rescoring the GOSE interview using IRT yields more granular, meaningful measurement of injury-related functional limitations, while adding no additional respondent or examiner burden. This technique may have utility for many applications, such as clinical trials aiming to detect small treatment effects, and small-scale studies that need to maximize statistical efficiency.

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.

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.

Personality disorders in later life: questions about the measurement, course, and impact of disorders.

Lifespan perspectives have played a crucial role in shaping our understanding of many forms of psychopathology. Unfortunately, little attention has been given to personality disorders in middle adulthood and later life. Several issues are responsible for this deficiency, including difficulty applying the diagnostic criteria for personality disorders to older people and challenges in identifying appropriate samples of older participants. The goal of this review is to explore the benefits of considering older adults in the study of personality disorders. Later life offers a unique opportunity for investigators to consider links between personality pathology and consequential outcomes in people's lives. Many domains are relevant, including health, longevity, social adjustment, marital relationships, and the experience of major life events. We review each domain and consider ways in which the study of middle-aged and older adults challenges researchers to evaluate how personality disorders in general are defined and measured.

Is there a difference between simultaneous or staged decompressions for combined cervical and lumbar stenosis?

STUDY DESIGN: We evaluated 43 patients diagnosed with tandem spinal stenosis (TSS) from 1999 to 2005 in an academic hospital. OBJECTIVE: The purpose of this study is to compare outcomes after simultaneous decompression of the cervical and lumbar spine versus staged operations. SUMMARY OF BACKGROUND DATA: TSS is a rare degenerative disease affecting multiple spinal levels with limited research describing operative management. METHODS: Of our patients, 21 underwent simultaneous decompression of both the cervical and lumbar spine and 22 underwent staged decompression of the cervical spine followed by the lumbar spine at a later date. Medical records were reviewed for patient demographics, type and duration of symptoms, operative time, combined blood loss, cervical myelopathy modified Japan Orthopaedic Association Score, Oswestry Disability Index (ODI), major and minor complications, and average length of follow up. Each category was evaluated by Pearson correlations and unpaired Student t tests. RESULTS: With a mean follow-up of 7 years, both groups improved in JOA and ODI without a significant difference between the 2 operative groups in terms of major or minor complications, JOA, or ODI. Independent of the surgical algorithm, age above 68 years, estimated blood loss ≥400 mL, and operative time ≥150 minutes significantly increased the number of complications. CONCLUSIONS: These results indicate that TSS can be effectively managed by either surgical intervention, simultaneous, or staged decompressions. However, patient age, blood loss, and operative time do significantly impact outcomes. Therefore, operative management should be tailored to the patient's age and the option which will limit blood loss and operative time, whether that is by simultaneous or staged procedures.

Suicidal ideation across race in a justice-involved sample: An item response theory approach.

OBJECTIVES: Compared to community samples, rates of suicide are much higher in forensic and correctional settings, yet limited research has focused on the development and improvement of suicide assessment methods used in such contexts. Moreover, despite evidence that suicide assessment varies across Caucasians and African Americans, to our knowledge this important issue has received little attention within higher risk correctional samples. We used Item Response Theory and Differential Item Functioning analyses to address this gap within the literature. METHOD: Specifically, we examined the psychometric properties of the Suicidal Ideation scale of the Personality Assessment Inventory (Morey, 2007) in a large sample of justice-involved individuals. RESULTS: Caucasians report greater suicidal ideation compared to African American participants on average. However, after controlling for mean differences, Caucasians and African Americans differentially endorsed symptoms of suicidal ideation. If the level of suicidal ideation is held constant across racial categories, Caucasians underreported suicidal ideation relative to African Americans. CONCLUSION: Results suggest a nuanced picture of suicidal ideation across racial categories that can be informed by Item Response Theory approaches to scale construction and refinement.

Functional Status Examination Yields Higher Measurement Precision than the Glasgow Outcome Scale-Extended after Moderate-to-Severe Traumatic Brain Injury.

A limited evidence base supports the Functional Status Examination (FSE) as superior to the more commonly used Glasgow Outcome Scale-Extended (GOSE) for precisely characterizing injury-related functional limitations. The aim of this study was to use modern psychometric tools to test the hypothesis that the FSE is more precise than the GOSE in characterizing individual differences in functional limitations after moderate-to-severe traumatic brain injury (TBI). Secondarily, we sought to confirm that the type of interviewee (patient, significant other) does not affect the test performance of the FSE. Using data from 357 individuals with TBI who participated in the Magnesium Sulfate clinical trial and had six-month outcome data, we performed item response theory (IRT) analyses comparing the FSE and GOSE at six months post-injury. Results showed that the FSE yielded higher measurement precision (IRT test information) than the GOSE across most of the disability severity spectrum. The GOSE yielded more information than the FSE at a very high level of disability, because of the GOSE's assignment of a unique score for individuals who are in a vegetative state. Finally, the FSE showed no evidence of differential item functioning by interviewee, indicating it is appropriate to interview either persons with TBI or significant others and combine data across respondents as is typically done. The findings support the FSE as a viable and oftentimes advantageous substitute for the GOSE in clinical trials and translational studies of TBI.

Hallucinations and Delusions Signal Alzheimer's Associated Cognitive Dysfunction More Strongly Compared to Other Neuropsychiatric Symptoms.

OBJECTIVES: Neuropsychiatric symptoms (NPS) are common among individuals with dementia of the Alzheimer's type (DAT). We sought to characterize which NPS more purely relate to cognitive dysfunction in DAT, relative to other NPS. METHOD: Demographic, neurocognitive, neuroimaging, and NPS data were mined from the Alzheimer's Disease Neuroimaging Initiative database (n = 906). Using factor analysis, we analyzed the degree to which individual NPS were associated with DAT-associated cognitive dysfunction. We also employed item response theory to graphically depict the ability of individual NPS to index DAT-associated cognitive dysfunction across a continuum ranging from cognitively normal to mild DAT. RESULTS: Psychotic symptoms (hallucinations and delusions) were more strongly related to the continuum of DAT-associated cognitive dysfunction than other NPS, with the strength of the relationship peaking at high levels of disease severity. Psychotic symptoms also negatively correlated with brain volume and did not relate to the presence of vision problems. Aberrant motor behavior and apathy had relatively smaller associations with DAT-associated cognitive dysfunction, while other NPS showed minimal associations. DISCUSSION: Psychotic symptoms most strongly indexed DAT-associated cognitive dysfunction, whereas other NPS, such as depression and anxiety, were not as precisely related to the DAT-associated cognitive dysfunction.

Functional Status Examination Yields Higher Measurement Precision of Functional Limitations after Traumatic Injury than the Glasgow Outcome Scale-Extended: A Preliminary Study.

The Glasgow Outcome Scale-Extended (GOSE) is one of the most widely used measures of functional limitations after traumatic brain injury (TBI), and is the primary outcome measure used in clinical trials of acute TBI treatment. However, the GOSE appears insensitive to the full spectrum of TBI-related functional limitations, which may limit its potential to capture treatment effects or correlate with other variables that impact outcome. The Functional Status Examination (FSE) was designed to improve on the assessment of injury-related functional limitations using a standardized assessment and wider possible score range. The aim of this pilot study was to employ item response theory (IRT) to test the hypothesis that the FSE yields more precise estimation of functional outcome than the GOSE. Traumatically injured patients (n = 100, 77 TBI, 23 orthopedic injuries) were interviewed at 3 months post-injury using both the GOSE and FSE structured interviews. IRT was used to quantify and compare the tests' information functions, which reflect the degree to which each instrument precisely measures functional limitations across the severity spectrum. Findings were consistent with predictions: the FSE yielded stronger measurement of functional limitations (i.e., higher test information) across a wider range of severity than the GOSE, whether scoring the GOSE from all interview items or using the traditional GOSE overall score. Although the FSE appears to be a promising alternative measure to the GOSE, further research is needed to cross-validate these findings in a larger sample and understand how to best deploy it in clinical and translational research.