Charlson Comorbidity Index, inappropriate medication use and cognitive impairment : Bermuda Triangle.

BACKGROUND: The aim is to evaluate the association between the Charlson Comorbidity Index (CCI), polypharmacy, inappropriate medication use and cognitive impairment in long-term care facility patients. METHODS: A cross-sectional study including 105 long-term care facility residents was performed. The Charlson Comorbidity Index (CCI) was used. Inappropriate drug use (IDU) was defined according to the STOPP (Screening Tool of Older People's Prescriptions) criteria. Univariate analysis to identify variables associated with patient outcome related with cognitive impairment was investigated with χ2, Pearson correlation, Fisher exact, and Mann-Whitney U test where appropriate. For the multivariate analysis, the possible factors identified with univariate analysis were further entered into logistic regression analysis. RESULTS: A significant difference was found between gender, CCI and cognitive impairment (p = 0.038, p = 0.01). While every one point increment in the CCI increases the risk of cognitive impairment 3.1 fold (95% CI = 1.8-5.4, p < 0.001), hypertension increases the risk 12 fold (95% CI = 2.5-67.8, p = 0.002). While the correlation between Mini-Mental Status Examination (MMSE) score and polypharmacy is significant (p = 0.015), the correlation between MMSE and IDU was insignificant (p = 0.739). The association of urogenital system drugs and dementia was significant (p = 0.044). CONCLUSIONS: Comorbidities, especially hypertension and old age, are risk factors for cognitive impairment. Polypharmacy correlates with MMSE and is considered a risk factor for cognitive impairment. Inappropriate medication use is high among long-term care facility residents. More studies on large cohorts are needed regarding optimal drug prescription and detection of specific drugs that may have an impact on cognitive performance.

A Multi-institutional Prospective Observational Study of Stereotactic Radiosurgery for Patients With Multiple Brain Metastases (JLGK0901 Study Update): Irradiation-related Complications and Long-term Maintenance of Mini-Mental State Examination Scores.

PURPOSE: The JLGK0901 study showed the noninferiority of stereotactic radiosurgery (SRS) alone as initial treatment of 5 to 10 brain metastases (BMs) compared with 2 to 4 BMs in terms of overall survival and most secondary endpoints (Lancet Oncol 2014;15:387-95). However, observation periods were not long enough to allow confirmation of the long-term safety of SRS alone in patients with 5 to 10 BMs. METHODS AND MATERIALS: This was a prospective observational study of Gamma Knife SRS-treated patients with 1 to 10 newly diagnosed BMs enrolled at 23 facilities between March 1, 2009, and February 15, 2012. RESULTS: The 1194 eligible patients were categorized into the following groups: group A, 1 tumor (n=455); group B, 2 to 4 tumors (n=531); and group C, 5 to 10 tumors (n=208). Cumulative rates of Mini-Mental State Examination (MMSE) score maintenance (MMSE score decrease <3 from baseline) determined with a competing risk analysis of groups A, B, and C were 93%, 91%, and 92%, respectively, at the 12th month after SRS; 91%, 89%, and 91%, respectively, at the 24th month; 89%, 88%, and 89%, respectively, at the 36th month; and 87%, 86%, and 89%, respectively, at the 48th month (hazard ratio [HR] of group A vs group B, 0.719; 95% confidence interval [CI], 0.437-1.172; P=.18; HR of group B vs group C, 1.280; 95% CI, 0.696-2.508; P=.43). During observations ranging from 0.3 to 67.5 months (median, 12.0 months; interquartile range, 5.8-26.5 months), as of December 2014, 145 patients (12.1%) had SRS-induced complications. Cumulative complication incidences by competing risk analysis for groups A, B, and C were 7%, 8%, and 6%, respectively, at the 12th month after SRS; 10%, 11%, and 11%, respectively, at the 24th month; 11%, 11%, and 12%, respectively, at the 36th month; and 12%, 12%, and 13%, respectively, at the 48th month (HR of group A vs group B, 0.850; 95% CI, 0.592-1.220; P=.38; HR of group B vs group C, 1.052; 95% CI, 0.666-1.662, P=.83). Leukoencephalopathy occurred in 12 of the 1074 patients (1.1%) with follow-up magnetic resonance imaging and was detected after salvage whole-brain radiation therapy in 11 of these 12 patients. In these 11 patients, leukoencephalopathy was detected by magnetic resonance imaging 5.2 to 21.2 months (median, 11.0 months; interquartile range, 7.0-14.4 months) after whole-brain radiation therapy. CONCLUSIONS: Neither MMSE score maintenance nor post-SRS complication incidence differed among groups A, B, and C. This longer-term follow-up study further supports the already-reported noninferiority hypothesis of SRS alone for patients with 5 to 10 BMs versus 2 to 4 BMs.

Negative Aging Stereotypes Impair Performance on Brief Cognitive Tests Used to Screen for Predementia.

OBJECTIVES: There is today ample evidence that negative aging stereotypes impair healthy older adults' performance on cognitive tasks. Here, we tested whether these stereotypes also decrease performance during the screening for predementia on short cognitive tests widely used in primary care. METHOD: An experiment was conducted on 80 healthy older adults taking the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) under Threat or Reduced-threat condition. RESULTS: Stereotype threat significantly impaired older adults' performance on both tests, resulting in 40% of older adults meeting the screening criteria for predementia, compared with 10% in Reduced-threat condition (MMSE and MoCA averaged). DISCUSSION: Our research highlights the influence of aging stereotypes on short cognitive tests used to screen for predementia. It is of critical importance that physicians provide a threat-free testing environment. Further research should clarify whether this socially induced bias may also operate in secondary care by generating false positives.

Cognitive performance of primary open-angle glaucoma and normal-tension glaucoma patients / Desempenho cognitivo em pacientes com glaucoma primário de ângulo aberto e glaucoma de pressão normal

ABSTRACT Purpose: To assess cognitive performance differences among primary open-angle glaucoma (POAG) patients, normal-tension glaucoma (NTG) patients, and healthy control (C) subjects. Methods: A total of 60 participants (20 POAG, 20 NTG, and 20 C subjects) were included in this study. A detailed ophthalmologic examination was performed on all participants. A spectral domain-optical coherence tomography (SD-OCT) system was used to measure the ganglion cell-inner plexiform layer (GC-IPL) and retinal nerve fiber layer (RNFL) thicknesses. To assess the cognitive performance of all participants, detailed neurological examinations, including the mini-mental state examination (MMSE), were performed by the same neurologist. Results: There were no significant differences among the groups in terms of age (p =0.348) or gender (p =0.935). The mean RNFL thicknesses were significantly different among the groups (85.2 ± 14.7, 76.8 ± 10.3, and 91.4 ± 7.7 µm in the POAG, NTG, and C subjects, respectively; p <0.001). The mean GC-IPL thicknesses were 77.5 ± 9.7 µm in the POAG group, 73.4 ± 7.8 µm in the NTG group, and 78.8 ± 3.8 µm in the C group. Differences among the groups were not statistically significant (p =0.085). MMSE scores were 26.1 ± 1.4, 25.7 ± 2.3, and 28.8 ± 0.9 in the POAG, NTG, and C groups, respectively. There were significant differences among the three groups (p <0.001). Specifically, there were significant differences between the NTG and C groups (p <0.001), and between the POAG and C groups (p =0.001). There was no significant difference between the POAG and NTG groups (p =0.595). Conclusions: There appear to be similar risk factors in glaucoma and neurodegenerative disorders that cause deterioration in cognitive performance. Comparing the low MMSE scores of the POAG and NTG patients with the scores of healthy C participants supports our hypothesis. Consequently, it is recommended that a neurologist should also examine glaucoma patients.

RESUMO Objetivos: Avaliar as diferenças de desempenho cognitivo entre pacientes com glaucoma primário de ângulo aberto (POAG), glaucoma de pressão normal (NTG) e controle de indivíduos saudáveis (C). Métodos: Um total de 60 pessoas (20 POAG, 20 NTG e 20 indivíduos saudáveis) foram incluídos neste estudo. Um exame oftalmológico detalhado foi realizado em todos os participantes. Um sistema de tomografia de coerência óptica de domínio espectral (SD-OCT) foi utilizado para medir as espessuras da camada de células ganglionares plexiforme interna (GC-IPL) e da camada de fibras nervosas da retina (RNFL). Para avaliar o desempenho cognitivo de todos os participantes, foi realizado pelo mesmo neurologista um exame neurológico detalhado, incluindo mini-exame do estado mental (MMSE). Resultados: Não houve diferenças significativas entre os grupos em termos de idade (p=0,348) e sexo (p=0,935). Espessuras médias da RNFL foram significativamente diferentes, sendo 85,2 ± 14,7, 76,8 ± 10,3 e 91,4 ± 7,7 µm nos grupos POAG, NTG e controles, respectivamente (p<0,001). As espessuras médias da GC-IPL observadas foram 77.5 ± 9.7 μm no grupo POAG, 73,4 ± 7,8 µm no grupo NTG e 78,8 ± 3,8 µm nos controlos. As diferenças entre os grupos não foram estatisticamente significantes (p=0,085). Graduações do MMSE foram 26,1 ± 1,4, 25,7 ± 2,3 e 28,8 ± 0,9 nos grupos POAG, NTG e controles, respectivamente. Houve diferenças significativas entre os três grupos (p<0,001). Houve diferença significativa entre NTG e saudáveis (p<0,001). Houve diferença significativa entre POAG e saudáveis (p=0,001). Não houve diferença significativa entre o POAG e NTG (p=0,595). Conclusões: Parecem haver fatores de risco semelhantes no glaucoma e nos distúrbios neurodegenerativos que causam deterioração no desempenho cognitivo. Comparando a baixa graduação do MMSE de pacientes com POAG e NTG com controles saudáveis referenda nossa hipótese. Consequentemente recomenda-se que um neurologista também examine os pacientes de glaucoma.

Cognitive function and 10 year mortality in an 85 year-old community-dwelling population.

The relationship between mortality and impaired cognitive function has not been thoroughly investigated in a very elderly community-dwelling population, and little is known about the association of disease-specific mortality with Mini-Mental State Examination (MMSE) subscale scores. Here we evaluated these data in Japanese community-dwelling elderly. In 2003, 85 year-olds (n=207) were enrolled; 205 completed the MMSE for cognitive function and were followed-up for 10 years, during which time 120 participants died, 70 survived, and 17 were lost to follow-up. Thirty-eight deaths were due to cardiovascular disease, 22 to senility, 21 to respiratory disease, and 16 to cancer. All-cause mortality decreased by 4.3% with a 1-point increase in the global MMSE score without adjustment, and it decreased by 6.3% with adjustment for both sex and length of education. Cardiovascular mortality decreased by 7.6% and senility mortality decreased by 9.2% with a 1-point increase in the global MMSE score with adjustment for sex and education. No association was found between respiratory diseases or cancer mortality and global MMSE score. All-cause mortality also decreased with increases in MMSE subscale scores for time orientation, place orientation, delayed recall, naming objects, and listening and obeying. Cardiovascular mortality was also associated with the MMSE subscale of naming objects, and senility mortality was associated with the subscales of time orientation and place orientation. Thus, we found that impaired cognitive function determined by global MMSE score and some MMSE subscale scores were independent predictors of all-cause mortality or mortality due to cardiovascular disease or senility in 85 year-olds.

Processing speed in the aging process: screening criteria for the Spanish Quick Test of Cognitive Speed.

A Quick Test of Cognitive Speed was administered to 357 participants without cognitive impairment, aged 18 to 85 years, to explore the effects of age on processing speed variables in Spanish speakers and to provide normative data for the test adapted to this population. Results were consistent with previous findings: correlations between age and naming times were high and statistically significant. Linear regression indicated that cognitive processing speed on this test slows 2 to 4 sec. per decade, depending on the task. Normalized data were provided. The findings concur with several studies that have linked age-cognitive impairment with slowing processing speed. This study attempted to assess the importance of this relation, as information processing speed could be considered a measure of cognitive impairment in everyday clinical screening evaluations.

Faster cognitive decline in elders without dementia and decreased risk of cancer mortality: NEDICES Study.

OBJECTIVE: To assess whether faster cognitive decline in elders without dementia is associated with decreased risk of cancer mortality. METHODS: In this population-based, prospective study of 2,627 people without dementia aged 65 years and older (Neurological Disorders in Central Spain), a 37-item version of the Mini-Mental State Examination (37-MMSE) was administered at 2 visits (baseline and follow-up, approximately 3 years later). We divided change in 37-MMSE into tertiles (lower tertile ≥ 2 point improvement in score, higher tertile ≥ 2 point decline in score). Community-dwelling elders were followed for a median of 12.9 years, after which the death certificates of those who died were examined. RESULTS: A total of 1,003 (38.2%) died, including 339 (33.8%) deaths among participants who were in the higher tertile of 37-MMSE change and 664 (66.2%) deaths among those in the remaining tertiles. Cancer was reported significantly less often in those in the higher tertile of MMSE change (20.6%) than in those in the remaining tertiles (28.6%): in an unadjusted Cox model, hazard ratio for cancer mortality in participants within the higher tertile = 0.75 (p = 0.04) compared with the participants within the remaining tertiles. In a Cox model that adjusted for a variety of demographic factors and comorbidities, hazard ratio for cancer mortality in participants within the higher tertile = 0.70 (p = 0.01). CONCLUSION: In this population-based, prospective study of community-dwelling elders without dementia, faster cognitive decline was associated with a decreased risk of cancer mortality. Further studies are required to elucidate this inverse association in elders without dementia.

Acceptance of and attitudes towards Alzheimer's disease screening in elderly German adults.

BACKGROUND: Considering the discussion on implementing routine dementia screening in Germany, the objective of the current study was to validate the German version of the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire and to determine the acceptance of Alzheimer's disease screening in elderly German adults. METHODS: The German version of the PRISM-PC was administered to a subsample of participants who attended the Berlin Aging Study II (n = 506). The questionnaire was validated by exploratory as well as confirmatory factor analysis. RESULTS: Regarding acceptance of Alzheimer's disease screening (Section B) a single factor structure fitted best. In terms of attitudes regarding Alzheimer's disease (Section D), a hierarchical factor structure was modeled with the higher-order factor "Harms" covering the domains "Family Burden," "Dependence," "Emotional Suffering," "Stigma," and "Medical Care" on the one hand and the domain "Future Planning" on the other hand. Internal consistency of the different scales reached from α = 0.67 to α = 0.94. Overall, 71.2% of the participants indicated that they wanted to be screened for Alzheimer's disease on a regular basis. CONCLUSIONS: This study suggests that acceptance can reliably be assessed with the section "Acceptance of Alzheimer's disease screenings" of the German PRISM-PC questionnaire. Furthermore, the majority of elderly German adults would like to be screened for Alzheimer's disease regularly, which might be an effective starting point in order to implement routine dementia screenings. As the sample is a convenience sample of (relatively) healthy older adults, generalizability of these results is limited.

Cognitive approaches to early Alzheimer's disease diagnosis.

In this article, cognitive measures in the screening of individuals at risk for Alzheimer disease (AD) are reviewed. Use of cognitive tasks in identifying clinical cases of AD is considered, as well as methods for detecting those in the prodromal stages of the disease, including cognitive screening instruments. Traditional assessments, such as the mini-mental state examination, as well as contemporary computerized screening instruments, are examined. Areas of cognition for investigation in the detection of prodromal AD are recommended. The prospects for general cognitive screening are reviewed, and more engaging technologies to tests individuals at risk for developing AD are recommended.

The association between social stress and global cognitive function in a population-based study: the European Prospective Investigation into Cancer (EPIC)-Norfolk study.

BACKGROUND: Stress is thought to exert both positive and negative effects on cognition, but the precise cognitive effects of social stress and individuals' response to stress remain unclear. We aimed to investigate the association between different measures of social stress and cognitive function in a middle- to older-aged population using data from the European Prospective Investigation into Cancer (EPIC)-Norfolk study. METHOD: Participants completed a comprehensive assessment of lifetime social adversity between 1993 and 1997 and the short form of the Mini Mental State Examination (SF-MMSE), an assessment of global cognitive function, during the third health check between 2004 and 2011 (a median of 10.5 years later). A low MMSE score was defined as a score in the bottom quartile (20-26). RESULTS: Completed MMSE scores and stress measures were available for 5129 participants aged 48-90 years. Participants who reported that their lives had been more stressful over the previous 10 years were significantly more likely to have low MMSE scores [odds ratio (OR) 1.14, 95% confidence interval (CI) 1.04-1.24 per unit increase in perceived stress], independently of sociodemographic factors, physical and emotional health. The effects were restricted to the highest level of stress and the association was stronger among participants with a lower educational level. Adaptation following life event experiences also seemed to be associated with MMSE scores after adjusting for sociodemographic factors, but the association was attenuated with further adjustment. CONCLUSIONS: In this generally high-functioning population, individuals' interpretations and responses to stressful events, rather than the events themselves, were associated with cognitive function.

Use of the MC-FAQ and MMSE-FAQ in cognitive screening of older African Americans, Hispanic Americans, and European Americans.

OBJECTIVE: The purpose of this study was to examine the performance of the Mini-Cog-Functional Activities Questionnaire (MC-FAQ) and the Mini-Mental State Examination-Functional Activities Questionnaire (MMSE-FAQ) in cognitive screening of a multiethnic sample of older adults. DESIGN: This is a descriptive psychometric study. SETTING: Cognitive screening was done in senior centers, at health fairs, and within the nine participating memory disorder centers in the State of Florida. PARTICIPANTS: African American, Hispanic American, and European American older adults who participated in this screening were matched on gender, age within 3 years and education within 3 years yielding a sample of 225. MEASUREMENTS: The MC-FAQ is a combination of the Mini-Cog and Functional Activities Questionnaire. The MMSE-FAQ combines the MMSE with the FAQ. The Geriatric Depression Scale was used to assess depressive symptoms. RESULTS: African Americans reported significantly less depressive symptoms (F[2, 217] = 10.31, p <0.001) and European Americans had significantly higher mean MMSE scores than the other two groups (F[2, 222] = 3.33, p = 0.037). Participants did not differ by ethnic group on the MC-FAQ or MMSE-FAQ classifications of normal, mild cognitive impairment, or dementia. Age, years of education, and depressive symptoms were significant predictors of MC-FAQ and MMSE-FAQ classifications. CONCLUSIONS: The results suggest that these combinations of screening measures may have less culture bias than the MMSE alone. Sensitivity and specificity should be evaluated in these groups with confirmatory neurological and psychiatric diagnosis.

The reliability and validity of the mini-mental state examination in the elderly Croatian population.

AIM: The aim of this study was standardization and validation of the Mini-Mental State Examination (MMSE) in the general Croatian aging population. METHODS: Three-hundred and forty-four participants underwent the MMSE test, 217 cognitively healthy subjects without neurological and psychiatric disorders and 127 patients with mild cognitive impairment (MCI) or dementia. RESULTS: The optimal cutoff point for screening of the general Croatian population (cognitively healthy vs. MCI and dementia) is 26/27; in the Croatian population aged ≥65 years, the cutoff point is 24/25, whereas for screening of highly educated persons (≥14 years of education) aged ≥65 years a higher cutoff point should be used (26/27). CONCLUSIONS: MMSE results when standardized and validated in a certain population might better contribute to recognition of the individuals at risk that should be directed to dementia outpatient clinics.

Reliability and validity of A Quick Test of Cognitive Speed for detecting early-stage dementia in elderly Japanese.

AIM: The aim of this study was to evaluate the reliability and validity of A Quick Test of Cognitive Speed (AQT) for detecting early-stage dementia in the elderly Japanese population. METHODS: A total of 280 clinical participants (180 with mild Alzheimer's disease, 43 with amnestic mild cognitive impairment, 32 with non-amnestic mild cognitive impairment and 25 control subjects) and 22 community-dwelling elderly individuals without dementia were recruited. The Clinical Dementia Rating, the Mini-Mental State Examination, and AQT were administered to all participants. The Neurobehavioral Cognitive Status Examination was also administered to clinical participants. RESULTS: The intraclass correlation coefficient for the test-retest reliability of colour-form naming time on AQT was 0.88 (95% CI, 0.74-0.95, P < 0.001). AQT colour-form naming time was significantly correlated with the Clinical Dementia Rating, the total score on the Mini-Mental State Examination, and the total score on the Neurobehavioral Cognitive Status Examination and most of its subscales. AQT colour-form naming time was significantly longer in elderly individuals with mild Alzheimer's disease, amnestic mild cognitive impairment, and non-amnestic mild cognitive impairment than in control subjects. The receiver operating characteristic curve analysis indicated that AQT colour-form naming time significantly distinguished subjects with early-stage dementia (mild Alzheimer's disease, amnestic mild cognitive impairment, and non-amnestic mild cognitive impairment) from controls. The area under the curve was estimated to be 0.88 (95%CI = 0.82-0.95). A cut-off of 71/72 seconds yielded the best sensitivity/specificity trade-off: sensitivity = 85% and specificity = 76%. CONCLUSIONS: AQT is a useful brief screening tool for detecting early-stage dementia in elderly Japanese individuals.

Screening utility of the Montreal Cognitive Assessment (MoCA): in place of--or as well as--the MMSE?

BACKGROUND: This aim of this study was to assess the clinical utility of the Montreal Cognitive Assessment (MoCA) as a screening instrument for cognitive impairment in patients referred to a memory clinic, alone and in combination with the Mini-Mental State Examination (MMSE). METHODS: This was a pragmatic prospective study of consecutive referrals attending a memory clinic (n = 150) over an 18-month period. Patients were diagnosed using standard clinical diagnostic criteria for dementia (DSM-IV) and mild cognitive impairment (MCI; cognitive impairment prevalence = 43%) independent of MoCA test scores. RESULTS: MoCA proved acceptable to patients and was quick and easy to use. Using the cut-offs for MoCA and MMSE specified in the index paper (≥26/30), MoCA was more sensitive than MMSE (0.97 vs 0.65) but less specific (0.60 vs 0.89), with better diagnostic accuracy (area under Receiver Operating Characteristic curve 0.91 vs 0.83). Downward adjustment of the MoCA cut-off to ≥20/30 maximized test accuracy and improved specificity (0.95) for some loss of sensitivity (0.63). Combining MoCA with the MMSE - either in series or in parallel - did not improve diagnostic utility above that with either test alone. CONCLUSIONS: In a memory clinic population, MoCA proved sensitive for the diagnosis of cognitive impairment. Use of a cut-off lower than that specified in the index study may be required to improve overall test accuracy and specificity for some loss of sensitivity in populations with a high prior probability of cognitive impairment. Combining the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) with the MMSE did not improve diagnostic utility.

Rehabilitation of older adults with hip fracture: cognitive function and walking abilities.

OBJECTIVES: To investigate the association between baseline cognitive function and the achievement of walking independence and its maintenance at 1 year in a population of older adults who underwent post-hip fracture (HF) surgery rehabilitation. DESIGN: Prospective cohort study. SETTING: Department of rehabilitation and aged care. PARTICIPANTS: Three hundred six older adults admitted for post-HF surgery rehabilitation. MEASUREMENTS: All participants aged 65 and older who were completely unable to walk on admission but able to walk before fracture were stratified according to Mini-Mental State Examination score (0-15=moderately severe or severe cognitive impairment (CI), 16-23=mild to moderate CI, ≥24=no CI). Walking ability was defined according to the corresponding Barthel Index subitem, with walking independence at discharge being defined as a score of 12 or more out of 15. Walking ability 1 year after discharge was ascertained by telephone interviews with participants or proxies. RESULTS: At discharge, 29.6% of participants with moderately severe or severe CI (n=24), 51.9% with mild to moderate CI (n=56) and 78.6% of participants without CI (n=92) were able to walk independently. Among those who achieved walking independence and were alive at 1 year, 12 participants with moderately severe or severe CI (57.1%), 31 with mild to moderate CI (57.7%) and 73 without CI (78.9%) were still capable of walking independently. CONCLUSION: Although less frequently than in individuals with better cognitive function, walking independence is achievable after HF surgery rehabilitation, and can be maintained at 1 year also in those with moderately severe or severe CI.

Screening cognitive performance with the Resident Assessment Instrument for Mental Health Cognitive Performance Scale.

OBJECTIVE: The validity of the Cognitive Performance Scale (CPS) embedded in the Resident Assessment Instrument-Mental Health (RAI-MH) was evaluated among adult psychiatric inpatients. METHODS: The CPS is a brief measure of cognitive performance, with scores ranging from 0 (intact) to 6 (very severe impairment). The CPS scores were compared with the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) scores for 215 adult psychiatric inpatients. RESULTS: The CPS scores were significantly correlated with MMSE scores (r = -0.69, P < 0.001) and MoCA scores (r = -0.69, P < 0.001). Higher scores on the CPS were associated with greater functional impairment, older age, and a greater prevalence of dementia diagnoses than lower CPS scores. CONCLUSIONS: Pilot data show the CPS is a valid screening measure of cognitive performance among adult psychiatric inpatients. Additional research is needed to replicate our study using a larger sample with more diverse mental health conditions.

Screening for depression in post stroke patients.

BACKGROUND: depression has a significant prevalence in patients following a stroke. Studies have found rates to be between 25-54%. AIMS: Within this audit we aimed to ascertain the proportion of patients who have been identified as having depression, and explore the methods employed to identify depressed patients. We also looked to assess the number of these patients who have been treated for depression and to explore the medications used for the treatment of depression. METHODS: this audit was conducted in two phases. Initially an audit was conducted to establish the current prevalence, screening and management of depression in post-stroke patients. Following this, we introduced the PHQ-9 as a screening tool for depression and a re-audited at four months. In phase 2, All patients admitted to the stoke ward in Bedford hospital between 10/9/09 and 13/12/09 were included in the audit. Patients were screened for depression using the PHQ-9 questionnaire two weeks after admission. RESULTS: the incidence of depression within the phase one group was 28%. In 9 of these cases there was no record of mood assessment or diagnosis of depression in the medical notes. Thirteen out of 60 patients were prescribed psychotropic agents during their stay. In phase 2, Of the 18 patients screened, 10 patients (56%) scored 5 or above, which according to the scoring system of the PHQ-9 is indicative of depression. One patient scored 10 indicative of moderate depression and one patient scored 19 indicative of moderately severe depression. DISCUSSION: phase 1 of this audit revealed that there was no formal screening tool in use to identify depression in post stroke patients. Consequently we found the prevalence to be 28%. This correlates with the lower end of the rate expected within this group according to the literature. As no screening tool was being used, practice was not in accordance with the standards set by NICE guidelines. This led us to introduce the PHQ-9 screening tool in phase 2. Following this, we found the prevalence of depression had increased from 28% to 56%. CONCLUSIONS: these results highlight the importance of formal screening in order to reliably identify patients who have signs of depression.

The ADAS-cog in Alzheimer's disease clinical trials: psychometric evaluation of the sum and its parts.

BACKGROUND: The Alzheimer's Disease Assessment Scale Cognitive Behavior Section (ADAS-cog), a measure of cognitive performance, has been used widely in Alzheimer's disease trials. Its key role in clinical trials should be supported by evidence that it is both clinically meaningful and scientifically sound. Its conceptual and neuropsychological underpinnings are well-considered, but its performance as an instrument of measurement has received less attention. Objective To examine the traditional psychometric properties of the ADAS-cog in a large sample of people with Alzheimer's disease. METHODS: Data from three clinical trials of donepezil (Aricept) in mild-to-moderate Alzheimer's disease (n=1421; MMSE 10-26) were analysed at both the scale and component level. Five psychometric properties were examined using traditional psychometric methods. These methods of examination underpin upcoming Food and Drug Administration recommendations for patient rating scale evaluation. RESULTS: At the scale-level, criteria tested for data completeness, scaling assumptions (eg, component total correlations: 0.39-0.67), targeting (no floor or ceiling effects), reliability (eg, Cronbach's α: = 0.84; test-retest intraclass correlations: 0.93) and validity (correlation with MMSE: -0.63) were satisfied. At the component level, 7 of 11 ADAS-cog components had substantial ceiling effects (range 40-64%). CONCLUSIONS: Performance was satisfactory at the scale level, but most ADAS-cog components were too easy for many patients in this sample and did not reflect the expected depth and range of cognitive performance. The clinical implication of this finding is that the ADAS-cog's estimate of cognitive ability, and its potential ability to detect differences in cognitive performance under treatment, could be improved. However, because of the limitations of traditional psychometric methods, further evaluations would be desirable using additional rating scale analysis techniques to pinpoint specific improvements.

Development of the Japanese DOLOPLUS-2: a pain assessment scale for the elderly with Alzheimer's disease.

BACKGROUND: Pain assessment in non-communicative patients relies primarily on observation scales. The DOLOPLUS-2 is a behavioral pain assessment scale for the elderly with impaired verbal communication. It rates five somatic items, two psychomotor items, and three psychosocial items as indicators of pain. The aims of the present study were to develop a Japanese version of the DOLOPLUS-2 and to apply it to elderly patients with Alzheimer's disease (AD). METHODS: The translated instrument was evaluated with reference to Japanese patients with AD experiencing pain during post-surgery rehabilitation for hip fractures and who were unable to use any self-reported pain measures. After translation and back-translation, 21 registered nurses tested 'Version 1' of the pain assessment scale on three patients. The ratings of the nurses and researcher were compared and the number of matching scores determined. Semistructured interviews were conducted with the nurses and patient case studies were recorded. The results of the interviews provided the basis for the development of 'Version 2' of the scale, which was then tested with six patients and 31 nurses using the same procedures as for the testing of Version 1. RESULTS: The intraclass correlation coefficient for inter-rater reliability for the Version 2 administrators was 0.90 (P < 0.001), with a 95% confidence interval of 0.88-0.92; the degree of agreement by items (0.67-0.90) was excellent. Nurses' comments for Version 1 revealed that it was 'difficult to use' and that 'some Japanese expressions and explanations needed improvement'. In contrast, the nurses' comments on Version 2 indicated that there were no problems. Analysis of patient case studies in Version 2 indicated that pain scores were high only when the patients clearly would have had pain, such as when they started with full weight bearing. On the basis of these results, we developed a final version of the Japanese DOLOPLUS-2. CONCLUSION: The findings of the present study suggest that Version 2 of the Japanese DOLOPLUS-2 can be used reliably in clinical settings to measure the pain AD patients may be experiencing. However, the final version of the Japanese DOLOPLUS-2 needs to be validated in a larger patient cohort in future studies.

Screening and case-finding tools for the detection of dementia. Part II: evidence-based meta-analysis of single-domain tests.

AIM: To evaluate the diagnostic validity of single-domain cognitive tests for detecting dementia. These methods were defined as those that focus mainly on one domain of cognitive function such as orientation, memory, or executive function. METHODS: A meta-analysis of robust studies was conducted. There were 15 categories of single-domain methods assessed in 45 analyses, including 27 performed head-to-head against the Mini-Mental State Examination (MMSE). Thirteen studies took place in community settings, 9 in primary care, and 23 in specialist settings. RESULTS: In community settings, single-domain cognitive tests helped detect 64.2% of all dementias. In this setting, specificity (Sp) was 84.9%, positive predictive value (PPV) was 57.1%, and negative predictive value (NPV) was 88.3%. This was significantly less accurate than the MMSE itself. The optimal individual method was the memory impairment screen (MIS). In primary care, the sensitivity (Se) and specificity of single-domain tests were 69.5% and 82.5%, respectively. The PPV and NPV were 36.5% and 95.8%. Considered together, these methods were less specific but equally sensitive as the MMSE when applied in primary care. Here, the most successful methods were the selective reminding test (SRT) and clock drawing test, the latter having data from independent samples. In specialist settings, single-domain methods had a Se of 76.6%, a Sp of 81.9%, a PPV 80.8%, and a NPV 74.9%. This represented almost equivalent accuracy to the MMSE. The optimal method for specialist settings (based on accuracy alone) was the memory alteration test. CONCLUSION: Brief single-domain methods offer diagnostic performance for detection of dementia that is surprisingly close to that offered by cognitive batteries such as the MMSE. As a method of screening or as part of a diagnostic algorithm, brief single-domain tests may be an efficient first step in identifying cognitive impairment.