Measurement of Allostatic Load in Caregivers of Older Hispanic People With Alzheimer Disease and Related Disorders.

BACKGROUND: Allostatic load (AL) has been studied in the context of biomarkers that may be affected by environmental and contextual stressors, including social determinants of health. The specific stressor studied here is the provision of caregiving to older persons with Alzheimer disease and related disorders. The aims were to examine the factor structure of stress and nonstress biomarkers, different methods for calculating AL, and the relationship of AL with other variables. METHODS: Latent variable models were used to examine biomarkers. Regression analyses were performed with the outcomes: AL calculated as percentile-based and clinically-based for both stress and nonstress components. The sample was 187 Hispanic caregivers to individuals with dementia. RESULTS: The results of the confirmatory factor analyses (CFAs) suggested defining 2 factors: nonstress and stress-related. Performance was better for the CFA results and the associations with covariates when stress and nonstress components were examined separately. Despite some limitations, this is one of the first studies of biomarkers in Hispanic caregivers to patients with dementia. It was possible to explain almost 30% of the variance in the nonstress AL component. CONCLUSION: It may be important to differentiate among biomarkers indicative of cardiovascular, metabolic, and immune response as contrasted with the more stress-related biomarkers.

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living.

Importance: Resident-to-resident aggression in assisted living facilities can result in physical and psychological harm, but its prevalence is unknown. Objective: To estimate the prevalence of resident-to-resident aggression, including physical, verbal, and sexual, among residents in assisted living facilities. Design, Setting, and Participants: This study used cross-sectional, observational data from a clinical trial, in which residents of assisted living facilities were monitored for events over a 1-month period. All residents of 14 large facilities randomly selected from 2 geographic locations (N = 1067), except those receiving hospice care (n = 11), were invited to participate; 93 died or moved prior to enrollment. There were 33 family and resident refusals; 930 residents were enrolled. Data were collected between May 30, 2018, and August 11, 2022. Main Outcomes and Measures: The data are from a clinical trial testing the effectiveness of an intervention to reduce resident-to-resident aggression. In addition, the study was designed to assess prevalence using the Time 1 (baseline) data, using a probability sample of facilities to allow for this analysis. Resident-to-resident aggression was identified using a mixed-method, case-finding strategy involving 6 sources: (1) cognitively capable resident reports regarding 22 possible events, (2) direct care staff report, (3) staff member reports collected from event-reporting forms, (4) research assistant observation of events in real time, (5) facility accident or incident reports, and (6) resident records. Results: The prevalence of resident-to-resident aggression among the 930 participants (mean [SD] age, 88.0 [7.2] years; 738 women [79.4%]) during the past month was estimated to be 15.2% (141 of 930 residents; 95% CI, 12.1%-18.8%). The most common forms of aggression included verbal (11.2% [104 of 930 residents; 95% CI, 8.8%-14.2%]), physical (41 of 930 residents; 4.4% [95% CI, 3.1%-6.3%]), sexual (0.8% [7 of 930 residents; 95% CI, 0.4%-1.6%]), and other (70 of 930 residents; 7.5% [95% CI, 5.5%-10.2%]). These categories are not mutually exclusive as residents could be involved with more than 1 type of aggressive behavior. Conclusions and Relevance: In this cross-sectional, observational prevalence study, resident-to-resident aggression in assisted living facilities was highly prevalent. Verbal aggression was the most common form, and physical aggression also occurred frequently. The effects of resident-to-resident aggression can be both morbid and mortal; therefore, intervention research is needed to prevent it and to treat it when it occurs.

The use of subjective cognitive complaints for detecting mild cognitive impairment in older adults across cultural and linguistic groups: A comparison of the Cognitive Function Instrument to the Montreal Cognitive Assessment.

INTRODUCTION: This pilot study aims to explore the psychometric properties of the Cognitive Function Instrument (CFI) as a measure of subjective cognitive complaints (SCC) and its performance in distinguishing mild cognitive impairment (MCI) from normal control (NC) compared to an objective cognitive screen (Montreal Cognitive Assessment [MoCA]). METHODS: One hundred ninety-four community-dwelling non-demented older adults with racial/ethnic diversity were included. Unidimensionality and internal consistency of the CFI were examined using factor analysis, Cronbach's alpha, and McDonald's omega. Logistic regression models and receiver operating characteristic (ROC) analysis were used to examine the performance of CFI. RESULTS: The CFI demonstrated adequate internal consistency; however, the fit for a unidimensional model was suboptimal. The CFI distinguished MCI from NC alone or in combination with MoCA. ROC analysis showed comparable performance of the CFI and the MoCA. DISCUSSION: Our findings support the use of CFI as a brief and easy-to-use screen to detect MCI in culturally/linguistically diverse older adults. HIGHLIGHT: What is the key scientific question or problem of central interest of the paper? Subjective cognitive complaints (SCCs) are considered the earliest sign of dementia in older adults. However, it is unclear if SCC are equivalent in different cultures. The Cognitive Function Instrument (CFI) is a 14-item measure of SCC. This study provides pilot data suggesting that CFI is sensitive for detecting mild cognitive impairment in a cohort of older adults with racial/ethnic diversity. Comparing performance, CFI demonstrates comparable sensitivity to the Montreal Cognitive Assessment, an objective cognitive screening test. Overall, SCC may provide a non-invasive, easy-to-use method to flag possible cognitive impairment in both research and clinical settings.

The 32-Item Multilingual Naming Test: Cultural and Linguistic Biases in Monolingual Chinese-Speaking Older Adults.

OBJECTIVES: This study describes the performance of the Multilingual Naming Test (MINT) by Chinese American older adults who are monolingual Chinese speakers. An attempt was also made to identify items that could introduce bias and warrant attention in future investigation. METHODS: The MINT was administered to 67 monolingual Chinese older adults as part of the standard dementia evaluation at the Alzheimer's Disease Research Center (ADRC) at the Icahn School of Medicine at Mount Sinai (ISMMS), New York, USA. A diagnosis of normal cognition (n = 38), mild cognitive impairment (n = 12), and dementia (n = 17) was assigned to all participants at clinical consensus conferences using criterion sheets developed at the ADRC at ISMMS. RESULTS: MINT scores were negatively correlated with age and positively correlated with education, showing sensitivity to demographic factors. One item, butterfly, showed no variations in responses across diagnostic groups. Inclusion of responses from different regions of China changed the answers from "incorrect" to "correct" on 20 items. The last five items, porthole, anvil, mortar, pestle, and axle, yielded a high nonresponse rate, with more than 70% of participants responding with "I don't know." Four items, funnel, witch, seesaw, and wig, were not ordered with respect to item difficulty in the Chinese language. Two items, gauge and witch, were identified as culturally biased for the monolingual group. CONCLUSIONS: Our study highlights the cultural and linguistic differences that might influence the test performance. Future studies are needed to revise the MINT using more universally recognized items of similar word frequency across different cultural and linguistic groups.

Examination of the Measurement Equivalence of the Functional Assessment in Acute Care MCAT (FAMCAT) Mobility Item Bank Using Differential Item Functioning Analyses.

OBJECTIVE: To assess differential item functioning (DIF) in an item pool measuring the mobility of hospitalized patients across educational, age, and sex groups. DESIGN: Measurement evaluation cohort study. Content experts generated DIF hypotheses to guide the interpretation. The graded response item response theory (IRT) model was used. Primary DIF tests were Wald statistics; sensitivity analyses were conducted using the IRT ordinal logistic regression procedure. Magnitude and impact were evaluated by examining group differences in expected item and scale score functions. SETTING: Hospital-based rehabilitation. PARTICIPANTS: Hospitalized patients (N=2216). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A total of 111 self-reported mobility items. RESULTS: Two linking items among those used to set the metric across forms evidenced DIF for sex and age: "difficulty climbing stairs step-over-step without a handrail (alternating feet)" and "difficulty climbing 3-5 steps without a handrail." Conditional on the mobility state, the items were more difficult for women and older people (aged ≥65y). An additional 18 items were identified with DIF. Items with both high DIF magnitude and hypotheses related to age were difficulty "crossing road at a 4-lane traffic light with curbs," "jumping/landing on one leg," "strenuous activities," and "descending 3-5 steps with no handrail." Although DIF of higher magnitude was observed for several items, the scale-level effect was relatively small and the exposure rate for the most problematic items was low (0.35, 0.27, and 0.20). CONCLUSIONS: This was the first study to evaluate measurement equivalence of the hospital-based rehabilitation mobility item bank. Although 20 items evidenced high magnitude DIF, 5 of which were related to stairs, the scale-level effect was minimal; however, it is recommended that such items be avoided in the development of short-form measures. No items with salient DIF were removed from calibrations, supporting the use of the item bank across groups differing in education, age, and sex. The bank may thus be useful to assist clinical assessment and decision-making regarding risk for specific mobility restrictions at discharge as well as identifying mobility-related functions targeted for postdischarge interventions. Additionally, with the goal of avoiding long and burdensome assessments for patients and clinical staff, these results could be informative for those using the item bank to construct short forms.

Challenges in Measuring Applied Cognition: Measurement Properties and Equivalence of the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT) Applied Cognition Item Bank.

OBJECTIVE: To present challenges in assessment of applied cognition and the results of differential item functioning (DIF) analyses used to inform the development of a computerized adaptive test (CAT). DESIGN: Measurement evaluation cohort study. DIF analyses of 107 items were conducted across educational, age, and sex groups. DIF hypotheses informed the evaluation of the results. SETTING: Hospital-based rehabilitation from a single hospital system. PARTICIPANTS: A total of 2216 hospitalized patients (N=2216). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Applied cognition item pool from multiple sources. RESULTS: Many items were hypothesized to show DIF, particularly for age. Information was moderately high in the lower (cognitive disability) tail of the distribution, but some items were not informative. Reliability estimates were high (>0.89) across all studied groups, regardless of estimation method. There were 35 items with DIF of high magnitude and 19 with accompanying supportive hypotheses. CONCLUSIONS: A key clinical tool in inpatient rehabilitation medicine is assessment of applied functional cognitive ability to inform patient-centered rehabilitation strategies to improve function. This was the first study to evaluate measurement equivalence of the applied cognition item pool across large samples of hospitalized patients. Although about one-third of the item pool evidenced DIF or low discrimination, results supported placement of most items into the bank and its use across groups differing in education, age, and sex. Six items were classified with salient DIF, defined as consistent DIF of high magnitude and or impact, with confirmatory directional DIF hypotheses, generated by content experts. These were recommended for adjustment or removal from the bank; 4 were deleted from the bank and 2 had lowered CAT exposure (administration frequency) rates. Many items hypothesized to show DIF contained content measuring constructs other than applied cognition such as physical frailty, perceptual difficulties, or skills reflective of greater educational attainment. Challenges in measurement of this construct are discussed.

Improving the Delivery of Function-Directed Care During Acute Hospitalizations: Methods to Develop and Validate the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT).

OBJECTIVE: To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans. DESIGN: This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics. SETTING: A large (2000-bed) Midwestern Medical Center. PARTICIPANTS: The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization. CONCLUSIONS: The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

Evaluation of the measurement properties of the Perceived Stress Scale (PSS) in Hispanic caregivers to patients with Alzheimer's disease and related disorders.

OBJECTIVES: The Perceived Stress Scale (PSS) is the most widely used measure of perceived stress; however, minimal psychometric evaluation has been performed among Hispanic respondents, and even less among Hispanic caregivers to persons with Alzheimer's disease and related disorders (ADRDs). DESIGN: Secondary data analysis. SETTING: New York City, NY, USA. PARTICIPANTS: A sample of 453 community dwelling Hispanic caregivers to patients with ADRD. MEASUREMENTS: Latent variable models were used to evaluate the PSS. Exploratory and confirmatory factor analyses were used to examine unidimensionality. Differential item functioning (DIF) was examined for age, education, and language using the graded item response model. RESULTS: The factor and bifactor analyses results supported essential unidimensionality of the item set; however, positively worded items were observed using response item theory to be less informative than the negatively worded items. Reliability estimates were high. Salient DIF was not observed for age, education, or language of interview using the primary DIF detection method. Sensitivity analyses using a second DIF detection method identified uniform language-DIF for the item, "In the last month, how often have you felt that you were on top of things?" However, the non-compensatory DIF value was below the threshold considered salient. CONCLUSIONS: In summary, the 10-item PSS performed well in a sample of English- and Spanish-speaking Hispanic caregivers to patients with ADRD. Very little DIF, and none of high magnitude and impact, was observed. However, the negatively worded items, perhaps because they are more directly reflective of stress, were more informative. In the context of a short-form measure or computerized adaptive test, more informative items are those that would be selected for inclusion.

Evaluation of measurement equivalence of the Family Satisfaction with the End-of-Life Care (FAMCARE): Tests of differential item functioning between Hispanic and non-Hispanic White caregivers.

OBJECTIVE: Although the psychometric properties of the Family Satisfaction with End-of-Life Care measure have been examined in diverse settings internationally; little evidence exists regarding measurement equivalence in Hispanic caregivers. The aim was to examine the psychometric properties of a short-form of the FAMCARE in Hispanics using latent variable models and place information on differential item functioning (DIF) in an existing family satisfaction item bank. METHOD: The graded form of the item response theory model was used for the analyses of DIF; sensitivity analyses were performed using a latent variable logistic regression approach. Exploratory and confirmatory factor analyses to examine dimensionality were performed within each subgroup studied. The sample included 1,834 respondents: 317 Hispanic and 1,517 non-Hispanic White caregivers of patients with Alzheimer's disease and cancer, respectively. RESULTS: There was strong support for essential unidimensionality for both Hispanic and non-Hispanic White subgroups. Modest DIF of low magnitude and impact was observed; flagged items related to information sharing. Only 1 item was flagged with significant DIF by both a primary and sensitivity method after correction for multiple comparisons: "The way the family is included in treatment and care decisions." This item was more discriminating for the non-Hispanic, White responders than for the Hispanic subsample, and was also a more severe indicator at some levels of the trait; the Hispanic respondents located at higher satisfaction levels were more likely than White non-Hispanic respondents to report satisfaction. SIGNIFICANCE OF RESULTS: The magnitude of DIF was below the salience threshold for all items. Evidence supported the measurement equivalence and use for cross-cultural comparisons of the short-form FAMCARE among Hispanic caregivers, including those interviewed in Spanish.

Psychometric Properties of a Spanish-Language Version of a Short-Form FAMCARE: Applications to Caregivers of Patients With Alzheimer's Disease and Related Dementias.

Although family satisfaction is recognized as a critical indicator of quality care for persons with serious illness, Spanish-language measures are limited. The study aims were to develop a Spanish translation of the short-form Family Satisfaction With End-of-Life Care (FAMCARE), investigate its psychometric properties in Hispanic caregivers to patients with Alzheimer's disease and related dementias (ADRD; N = 317; 209 interviewed in Spanish), and add parameters to an existing item bank. Based on factor analyses, the measure was found to be essentially unidimensional. Reliabilities from a graded item response theory model were high; the average estimate was 0.93 for the total and Spanish-language subsample. Discrimination parameters were high, and the model fit adequate. This is the first study to examine the performance of the short-form FAMCARE measure among Hispanics and caregivers to patients with ADRD. The short-form measure can be recommended for Hispanics and caregivers to patients with ADRD.

Methodological approaches to the analyses of elder abuse screening measures: Application of latent variable measurement modeling to the WC-RAPS.

While several elder abuse screens exist, few measure risk and none target long-term support services. The aims were to examine the psychometric properties of the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS), comparing approaches to modeling self-reported risk and abuse in relation to reported Adult Protective Services contacts. METHODS: The sample (n = 7,035), admissions to managed long-term care (79%) and short-term rehabilitation (20%), was primarily (66%) female, with mean age 77.6 (SD = 9.10); 7% each were African American and Latino and 12% Asian. Latent variable models were used to examine measurement properties of six indicators of abuse and five of risk. RESULTS: Good model fit and stable subscale measurement models were observed across analyses. Reliability was >0.80 across methods, and concurrent criterion validity estimates were as expected. CONCLUSION: Evidence supported the reliability and concurrent criterion validity of the risk and abuse subscales in an ethnically diverse cohort.

Assessment of financial decision making: an informant scale.

Older adults with cognitive impairment are a population at great risk for financial exploitation. At-risk older adults often have difficulty reporting on their own financial abilities. Collecting information from trusted others is vital for professionals investigating the financial exploitation older adults. There are few reliable, valid, and standardized informant-report measures of financial capacity, and none that assess decisional abilities for an ongoing, real-world financial transaction. The present study sought to examine the psychometric properties of a new informant-report scale of financial decisional abilities in older adults. One hundred fifty participants were recruited to complete the Family and Friends and Interview regarding a known older adult's financial decisional abilities. A factor analysis identified two subscales. The full scale had adequate sensitivity and specificity to detect an informant's current concerns regarding financial exploitation. The Family and Friends Scale is a useful tool for collecting informant-report regarding an older adult's ability to make financial transactions.

Development of a Short-Form of the Medication Management Test: Evaluation of Dimensionality, Reliability, Information and Measurement Equivalence Using Latent Variable Models.

BACKGROUND AND PURPOSE: The Medication Management Test (MMT) measures higher cognitive functioning. The aim of the analyses presented was to reduce assessment burden by developing a short-form version, and describe its psychometric properties. METHODS: Factor analyses, item response theory (IRT), and differential item functioning (DIF) were performed to examine the dimensionality, reliability information, and measurement equivalence. RESULTS: The ratio of the first two extracted eigenvalues from the exploratory principal component analysis was 7.62, indicating essential unidimensionality. Although one item "needs prompting for pill regime" evidenced DIF above the threshold for education and race/ethnicity, the magnitude was relatively small and the impact minimal. IRT-based reliability estimates were high (>0.80) across all subgroups. CONCLUSIONS: Because medication management is an important task associated with independent living, it is critical to assess whether medications can be self-administered safely.

Conceptual and Empirical Approaches to Financial Decision-making by Older Adults: Results from a Financial Decision-making Rating Scale.

OBJECTIVES: The objectives of this study were threefold: (1) to empirically test the conceptual model proposed by the Lichtenberg Financial Decision-making Rating Scale (LFDRS); (2) to examine the psychometric properties of the LFDRS contextual factors in financial decision-making by investigating both the reliability and convergent validity of the subscales and total scale, and (3) extending previous work on the scale through the collection of normative data on financial decision-making. METHODS: A convenience sample of 200 independent function and community dwelling older adults underwent cognitive and financial management testing and were interviewed using the LFDRS. Confirmatory factor analysis, internal consistency measures, and hierarchical regression were used in a sample of 200 community-dwelling older adults, all of whom were making or had recently made a significant financial decision. RESULTS: Results confirmed the scale's reliability and supported the conceptual model. Convergent validity analyses indicate that as hypothesized, cognition is a significant predictor of risk scores. Financial management scores, however, were not predictive of decision-making risk scores. CONCLUSIONS: The psychometric properties of the LFDRS support the scale's use as it was proposed. CLINICAL IMPLICATIONS: The LFDRS instructions and scale are provided for clinicians to use in financial capacity assessments.

Reliability and Validity of the Lichtenberg Financial Decision Screening Scale.

The scarcity of empirically validated assessment instruments continues to impede the work of professionals in a number of fields, including medicine, finance, and estate planning; adult protective services; and criminal justice-and, more importantly, it impedes their ability to effectively assist and, in some case, protect their clients. Other professionals (e.g. legal, financial, medical, mental health services) are in a position to prevent financial exploitation and would benefit from access to new instruments. The Lichtenberg Financial Decision Screening Scale (LFDSS) was introduced in 2016, along with evidence for its convergent validity (Lichtenberg et al., 2016). Using a sample of 213 participants, this study investigated the internal consistency of the LFDSS and its criterion validity based on ratings by professionals using the scale. Results demonstrate that the LFDSS has excellent internal consistency and clinical utility properties. This paper provides support for use of the LFDSS as a reliable and valid instrument. The LFDSS and instructions for its use are included in the article, along with information about online tools and support.

Item response theory analysis of the Lichtenberg Financial Decision Screening Scale.

The focus of these analyses was to examine the psychometric properties of the Lichtenberg Financial Decision Screening Scale (LFDSS). The purpose of the screen was to evaluate the decisional abilities and vulnerability to exploitation of older adults. Adults aged 60 and over were interviewed by social, legal, financial, or health services professionals who underwent in-person training on the administration and scoring of the scale. Professionals provided a rating of the decision-making abilities of the older adult. The analytic sample included 213 individuals with an average age of 76.9 (SD = 10.1). The majority (57%) were female. Data were analyzed using item response theory (IRT) methodology. The results supported the unidimensionality of the item set. Several IRT models were tested. Ten ordinal and binary items evidenced a slightly higher reliability estimate (0.85) than other versions and better coverage in terms of the range of reliable measurement across the continuum of financial incapacity.

Methodological issues in measuring subjective well-being and quality-of-life: Applications to assessment of affect in older, chronically and cognitively impaired, ethnically diverse groups using the Feeling Tone Questionnaire.

Quality of life assessment includes measurement of positive affect. Methods artifacts associated with positively and negatively worded items can manifest as negative items loading on a second factor, despite the conceptual view that the items are measuring one underlying latent construct. Negatively worded items may elicit biased responses. Additionally, item-level response bias across ethnically diverse groups may compromise group comparisons. The aim was to illustrate methodological approaches to examining method factors and measurement equivalence in an affect measure with 9 positively and 7 negatively worded items: The Feeling Tone Questionnaire (FTQ). The sample included 4,960 non-Hispanic White, 1,144 non-Hispanic Black, and 517 Hispanic community and institutional residents receiving long-term supportive services. The mean age was 82 (s.d.=11.0); 73% were female. Two thirds were cognitively impaired. Methods effects were assessed using confirmatory factor analyses (CFA), and reliability with McDonald's omega and item response theory (IRT) generated estimates. Measurement equivalence was examined using IRT-based Wald tests. Methods effects associated with negatively worded items were observed; these provided little IRT information, and as a composite evidenced lower reliability. Both 13 and 9 item positive affect scales performed well in terms of model fit, reliability, IRT information, and evidenced little differential item functioning of high magnitude or impact. Both CFA and IRT approaches provided complementary methodological information about scale performance. The 9-item affect scale based on the FTQ can be recommended as a brief quality-of-life measure among frail and cognitively impaired individuals in palliative and long-term care settings.

Measurement Equivalence of the Patient Reported Outcomes Measurement Information System® (PROMIS®) Anxiety Short Forms in Ethnically Diverse Groups.

This is the first study of the measurement equivalence of the Patient Reported Outcomes Measurement Information System® (PROMIS®) Anxiety short forms in a large ethnically diverse sample. The psychometric properties and differential item functioning (DIF) were examined across different racial/ethnic, educational, age, gender and language groups. METHODS: These data are from individuals selected from cancer registries in the United States. For the analyses of race/ethnicity the reference group was non-Hispanic Whites (n = 2,263), the studied groups were non-Hispanic Blacks (n = 1,117), Hispanics (n = 1,043) and Asians/Pacific Islanders (n = 907). Within the Hispanic subsample, there were 335 interviews conducted in Spanish and 703 in English. The 11 anxiety items were from the PROMIS emotional disturbance item bank. DIF hypotheses were generated by content experts who rated whether or not they expected DIF to be present, and the direction of the DIF with respect to several comparison groups. The primary method used for DIF detection was the Wald test for examination of group differences in item response theory (IRT) item parameters accompanied by magnitude measures. Expected item scores were examined as measures of magnitude. The method used for quantification of the difference in the average expected item scores was the non-compensatory DIF (NCDIF) index. DIF impact was examined using expected scale score functions. Additionally, precision and reliabilities were examined using several methods. RESULTS: Although not hypothesized to show DIF for Asians/Pacific Islanders, every item evidenced DIF by at least one method. Two items showed DIF of higher magnitude for Asians/Pacific Islanders vs. Whites: "Many situations made me worry" and "I felt anxious". However, the magnitude of DIF was small and the NCDIF statistics were not above threshold. The impact of DIF was negligible. For education, six items were identified with consistent DIF across methods: fearful, anxious, worried, hard to focus, uneasy and tense. However, the NCDIF was not above threshold and the impact of DIF on the scale was trivial. No items showed high magnitude DIF for gender. Two items showed slightly higher magnitude for age (although not above the cutoff): worried and fearful. The scale level impact was trivial. Only one item showed DIF with the Wald test after the Bonferroni correction for the language comparisons: "I felt fearful". Two additional items were flagged in sensitivity analyses after Bonferroni correction, anxious and many situations made me worry. The latter item also showed DIF of higher magnitude, with an NCDIF value (0.144) above threshold. Individual impact was relatively small. CONCLUSIONS: Although many items from the PROMIS short form anxiety measures were flagged with DIF, item level magnitude was low and scale level DIF impact was minimal; however, three items: anxious, worried and many situations made me worry might be singled out for further study. It is concluded that the PROMIS Anxiety short form evidenced good psychometric properties, was relatively invariant across the groups studied, and performed well among ethnically diverse subgroups of Blacks, Hispanic, White non-Hispanic and Asians/Pacific Islanders. In general more research with the Asians/Pacific Islanders group is needed. Further study of subgroups within these broad categories is recommended.

Measurement Equivalence of the Patient Reported Outcomes Measurement Information System® (PROMIS®) Pain Interference Short Form Items: Application to Ethnically Diverse Cancer and Palliative Care Populations.

Reducing the response burden of standardized pain measures is desirable, particularly for individuals who are frail or live with chronic illness, e.g., those suffering from cancer and those in palliative care. The Patient Reported Outcome Measurement Information System® (PROMIS®) project addressed this issue with the provision of computerized adaptive tests (CAT) and short form measures that can be used clinically and in research. Although there has been substantial evaluation of PROMIS item banks, little is known about the performance of PROMIS short forms, particularly in ethnically diverse groups. Reviewed in this article are findings related to the differential item functioning (DIF) and reliability of the PROMIS pain interference short forms across diverse sociodemographic groups. METHODS: DIF hypotheses were generated for the PROMIS short form pain interference items. Initial analyses tested item response theory (IRT) model assumptions of unidimensionality and local independence. Dimensionality was evaluated using factor analytic methods; local dependence (LD) was tested using IRT-based LD indices. Wald tests were used to examine group differences in IRT parameters, and to test DIF hypotheses. A second DIF-detection method used in sensitivity analyses was based on ordinal logistic regression with a latent IRT-derived conditioning variable. Magnitude and impact of DIF were investigated, and reliability and item and scale information statistics were estimated. RESULTS: The reliability of the short form item set was excellent. However, there were a few items with high local dependency, which affected the estimation of the final discrimination parameters. As a result, the item, "How much did pain interfere with enjoyment of social activities?" was excluded in the DIF analyses for all subgroup comparisons. No items were hypothesized to show DIF for race and ethnicity; however, five items showed DIF after adjustment for multiple comparisons in both primary and sensitivity analyses: ability to concentrate, enjoyment of recreational activities, tasks away from home, participation in social activities, and socializing with others. The magnitude of DIF was small and the impact negligible. Three items were consistently identified with DIF for education: enjoyment of life, ability to concentrate, and enjoyment of recreational activities. No item showed DIF above the magnitude threshold and the impact of DIF on the overall measure was minimal. No item showed gender DIF after correction for multiple comparisons in the primary analyses. Four items showed consistent age DIF: enjoyment of life, ability to concentrate, day to day activities, and enjoyment of recreational activities, none with primary magnitude values above threshold. Conditional on the pain state, Spanish speakers were hypothesized to report less pain interference on one item, enjoyment of life. The DIF findings confirmed the hypothesis; however, the magnitude was small. Using an arbitrary cutoff point of theta (θ) ≥ 1.0 to classify respondents with acute pain interference, the highest number of changes were for the education groups analyses. There were 231 respondents (4% of the total sample) who changed from the designation of no acute pain interference to acute interference after the DIF adjustment. There was no change in the designations for race/ethnic subgroups, and a small number of changes for respondents aged 65 to 84. CONCLUSIONS: Although significant DIF was observed after correction for multiple comparisons, all DIF was of low magnitude and impact. However, some individual-level impact was observed for low education groups. Reliability estimates were high. Thus, the PROMIS short form pain items examined in this ethnically diverse sample performed relatively well; although one item was problematic and removed from the analyses. It is concluded that the majority of the PROMIS pain interference short form items can be recommended for use among ethnically diverse groups, including those in palliative care and with cancer and chronic illness.

Measurement Equivalence of the Patient Reported Outcomes Measurement Information System® (PROMIS®) Applied Cognition - General Concerns, Short Forms in Ethnically Diverse Groups.

AIMS: The goals of these analyses were to examine the psychometric properties and measurement equivalence of a self-reported cognition measure, the Patient Reported Outcome Measurement Information System® (PROMIS®) Applied Cognition - General Concerns short form. These items are also found in the PROMIS Cognitive Function (version 2) item bank. This scale consists of eight items related to subjective cognitive concerns. Differential item functioning (DIF) analyses of gender, education, race, age, and (Spanish) language were performed using an ethnically diverse sample (n = 5,477) of individuals with cancer. This is the first analysis examining DIF in this item set across ethnic and racial groups. METHODS: DIF hypotheses were derived by asking content experts to indicate whether they posited DIF for each item and to specify the direction. The principal DIF analytic model was item response theory (IRT) using the graded response model for polytomous data, with accompanying Wald tests and measures of magnitude. Sensitivity analyses were conducted using ordinal logistic regression (OLR) with a latent conditioning variable. IRT-based reliability, precision and information indices were estimated. RESULTS: DIF was identified consistently only for the item, brain not working as well as usual. After correction for multiple comparisons, this item showed significant DIF for both the primary and sensitivity analyses. Black respondents and Hispanics in comparison to White non-Hispanic respondents evidenced a lower conditional probability of endorsing the item, brain not working as well as usual. The same pattern was observed for the education grouping variable: as compared to those with a graduate degree, conditioning on overall level of subjective cognitive concerns, those with less than high school education also had a lower probability of endorsing this item. DIF was also observed for age for two items after correction for multiple comparisons for both the IRT and OLR-based models: "I have had to work really hard to pay attention or I would make a mistake" and "I have had trouble shifting back and forth between different activities that require thinking". For both items, conditional on cognitive complaints, older respondents had a higher likelihood than younger respondents of endorsing the item in the cognitive complaints direction. The magnitude and impact of DIF was minimal. The scale showed high precision along much of the subjective cognitive concerns continuum; the overall IRT-based reliability estimate for the total sample was 0.88 and the estimates for subgroups ranged from 0.87 to 0.92. CONCLUSION: Little DIF of high magnitude or impact was observed in the PROMIS Applied Cognition - General Concerns short form item set. One item, "It has seemed like my brain was not working as well as usual" might be singled out for further study. However, in general the short form item set was highly reliable, informative, and invariant across differing race/ethnic, educational, age, gender, and language groups.