Development and content validation of the Multifactoral assessment of perceived social support (MAPSS), a brief, patient-reported measure of social support for use in HIV care.

Low perceived social support (SS) negatively impacts health outcomes. We developed a measure of perceived SS for use in HIV care. We sought and categorized legacy items, selecting strongest items within categories. We elicited SS concepts from patients in English/Spanish, coded transcripts to match item pool content, and developed new items for salient unrepresented content. In focus groups, patients prioritized highly-matched items. We conducted cognitive interviews on high-priority items, and validity testing on final items against two legacy measures. From interviews (n = 32), we matched the following concepts: sense of belonging/inclusion; communication; emotional support; feeling accepted by others as a person; companionship; and practical support. We identified a new concept: support from friends/family in remaining healthy. Focus groups (n = 23) prioritized emotional support, communication, and support to remain healthy. Cognitive interviews (n = 30) found items were well-understood. The final 8-item measure performed well with patients (n = 708), with good construct validity. We used an Item Response Theory program to create a 3-item Short Form version of the measure, which captures 96% of patients indicating low social support. We developed the Multifactoral Assessment of Perceived Social Support (MAPSS) and Short Form (MAPSS-SF); brief, clinically relevant, sufficiently unidimensional measures of SS for use in HIV care.

Health literacy, sociodemographic factors, and cognitive training in the active study of older adults.

OBJECTIVE: Health literacy is critical for understanding information from health-care providers and correct use of medications and includes the capacity to filter other information in navigating health care systems. Older adults with low health literacy exhibit more chronic health conditions, worse physical functioning, and poorer mental health. This study examined the relationship between sociodemographic variables and health literacy, and the impact of cognitive training on change in health literacy over 10 years in older adults. METHODS: Participants (N = 2,802) aged 65 years and older completed assessments, including reading and numeracy health literacy items, as part of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. We evaluated baseline sociodemographic variables and change in health literacy over a 10-year period in individuals exposed to cognitive training in reasoning, processing speed, memory, or a no-contact control condition. RESULTS: Age, sex, race, education level, and general cognitive functioning at baseline were all associated with baseline health literacy in older adults. Predictors of change in health literacy over the 10-year follow-up were age, race, education level, general cognitive functioning, and neighborhood income; disparities in health literacy because of race attenuated over time, while the effect of age increased over time. Health literacy was generally stable across the ACTIVE intervention groups over 10 years. CONCLUSIONS: The present study showed important disparities in health literacy level and change over 10 years. Cognitive training did not significantly impact health literacy, suggesting that alternative approaches are needed to reduce the disparities.

Health Problems Precede Traumatic Brain Injury in Older Adults.

OBJECTIVES: To evaluate whether indices of preinjury health and functioning are associated with risk of incident traumatic brain injury (TBI) with loss of consciousness (LOC) and to evaluate health-related factors associated with mortality in individuals with incident TBI. DESIGN: Prospective community cohort study. SETTING: Group Health, Seattle, Washington. PARTICIPANTS: Individuals aged 65 and older with no self-reported prior TBI with LOC (N = 3,363) were enrolled and followed every 2 years for an average of 7.5 years (range 0-18 years). MEASUREMENTS: Weibull survival models were used to evaluate baseline and time-varying predictors of incident TBI with LOC, including measures of depression, activities of daily living (ADLs), cerebrovascular disease, and disease comorbidity. RESULTS: In an adjusted multivariate model, baseline depression symptoms as measured according to Center for Epidemiologic Studies Depression Scale (CES-D) score (hazard ratio (HR) for 4 points = 1.23, 95% confidence interval (CI) = 1.02-1.49, P = .03) and baseline activity of daily living (ADL) impairment (HR = 2.37, 95% CI = 1.24-4.53, P = .009) were associated with incident TBI. In a model that included time-dependent covariates, cerebrovascular disease at the previous visit (HR = 2.28, 95% CI = 1.37-3.78, P < .001), CES-D score the previous visit (HR for 4 points = 1.23, 95% CI = 1.02-1.49, P < .04) and baseline ADL impairment (HR 2.14, 95% CI = 1.11-4.13, P = .02) predicted incident TBI. Of factors considered, cerebrovascular disease and ADL impairment were associated with earlier mortality in participants with incident TBI with LOC. CONCLUSION: Indices of health, mood, and functional status predict incident TBI with LOC in older adults. These findings may have implications for injury prevention and postinjury clinical management.

Development and assessment of a composite score for memory in the Alzheimer's Disease Neuroimaging Initiative (ADNI).

We sought to develop and evaluate a composite memory score from the neuropsychological battery used in the Alzheimer's Disease (AD) Neuroimaging Initiative (ADNI). We used modern psychometric approaches to analyze longitudinal Rey Auditory Verbal Learning Test (RAVLT, 2 versions), AD Assessment Schedule - Cognition (ADAS-Cog, 3 versions), Mini-Mental State Examination (MMSE), and Logical Memory data to develop ADNI-Mem, a composite memory score. We compared RAVLT and ADAS-Cog versions, and compared ADNI-Mem to RAVLT recall sum scores, four ADAS-Cog-derived scores, the MMSE, and the Clinical Dementia Rating Sum of Boxes. We evaluated rates of decline in normal cognition, mild cognitive impairment (MCI), and AD, ability to predict conversion from MCI to AD, strength of association with selected imaging parameters, and ability to differentiate rates of decline between participants with and without AD cerebrospinal fluid (CSF) signatures. The second version of the RAVLT was harder than the first. The ADAS-Cog versions were of similar difficulty. ADNI-Mem was slightly better at detecting change than total RAVLT recall scores. It was as good as or better than all of the other scores at predicting conversion from MCI to AD. It was associated with all our selected imaging parameters for people with MCI and AD. Participants with MCI with an AD CSF signature had somewhat more rapid decline than did those without. This paper illustrates appropriate methods for addressing the different versions of word lists, and demonstrates the additional power to be gleaned with a psychometrically sound composite memory score.

The Alzheimer's Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus): an expansion of the ADAS-Cog to improve responsiveness in MCI.

BACKGROUND: The Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-Cog) is widely used in AD, but may be less responsive to change when used in people with mild cognitive impairment (MCI). METHODS: Participants from the Alzheimer's Disease Neuroimaging Initiative were administered a neuropsychological battery and 1.5 T MRI scans over 2-3 years. Informants were queried regarding functional impairments. Some participants had lumbar punctures to obtain cerebrospinal fluid (CSF). We added executive functioning (EF) and functional ability (FA) items to the ADAS-Cog to generate candidate augmented measures. We calibrated these candidates using baseline data (n = 811) and selected the best candidate that added EF items alone and that added EF and FA items. We selected candidates based on their responsiveness over three years in a training sample of participants with MCI (n = 160). We compared traditional ADAS-Cog scores with the two candidates based on their responsiveness in a validation sample of participants with MCI (n = 234), ability to predict conversion to dementia (n = 394), strength of association with baseline MRI (n = 394) and CSF biomarkers (n = 193). RESULTS: The selected EF candidate added category fluency (ADAS Plus EF), and the selected EF and FA candidate added category fluency, Digit Symbol, Trail Making, and five items from the Functional Assessment Questionnaire (ADAS Plus EF&FA). The ADAS Plus EF& FA performed as well as or better than traditional ADAS-Cog scores. CONCLUSION: Adding EF and FA items to the ADAS-Cog may improve responsiveness among people with MCI without impairing validity.

A life course model of cognitive activities, socioeconomic status, education, reading ability, and cognition.

OBJECTIVES: To cross-sectionally quantify the contribution of proxy measures of cognitive reserve reflective of the lifespan, such as education, socioeconomic status (SES), reading ability, and cognitive activities, in explaining late-life cognition. DESIGN: Prospective observational cohort study of aging. SETTING: Retirement communities across the Chicago metropolitan area. PARTICIPANTS: Nine hundred fifty-one older adults free of clinical dementia in the Rush Memory and Aging Project (aged 79 ± 8, 74% female). MEASUREMENTS: Baseline data on multiple life course factors included early-, mid-, and late-life participation in cognitive activities; early-life and adult SES; education; and reading ability (National Adult Reading Test; NART). Path analysis quantified direct and indirect standardized effects of life course factors on global cognition and five cognitive domains (episodic memory, semantic memory, working memory, visuospatial ability, perceptual speed). RESULTS: Adjusting for age, sex, and race, education had the strongest association with global cognition, episodic memory, semantic memory, and visuospatial ability, whereas NART (followed by education) had the strongest association with working memory. Late-life cognitive activities had the strongest association with perceptual speed, followed by education. CONCLUSIONS: These cross-sectional findings suggest that education and reading ability are the most-robust proxy measures of cognitive reserve in relation to late-life cognition. Additional research leveraging path analysis is warranted to better understand how these life course factors, reflecting the latent construct of cognitive reserve, affect abnormal cognitive aging.

lordif: An R Package for Detecting Differential Item Functioning Using Iterative Hybrid Ordinal Logistic Regression/Item Response Theory and Monte Carlo Simulations.

Logistic regression provides a flexible framework for detecting various types of differential item functioning (DIF). Previous efforts extended the framework by using item response theory (IRT) based trait scores, and by employing an iterative process using group-specific item parameters to account for DIF in the trait scores, analogous to purification approaches used in other DIF detection frameworks. The current investigation advances the technique by developing a computational platform integrating both statistical and IRT procedures into a single program. Furthermore, a Monte Carlo simulation approach was incorporated to derive empirical criteria for various DIF statistics and effect size measures. For purposes of illustration, the procedure was applied to data from a questionnaire of anxiety symptoms for detecting DIF associated with age from the Patient-Reported Outcomes Measurement Information System.

Composite scores for executive function items: demographic heterogeneity and relationships with quantitative magnetic resonance imaging.

Accurate neuropsychological assessment of older individuals from heterogeneous backgrounds is a major challenge. Education, ethnicity, language, and age are associated with scale level differences in test scores, but item level bias might contribute to these differences. We evaluated several strategies for dealing with item and scale level demographic influences on a measure of executive abilities defined by working memory and fluency tasks. We determined the impact of differential item functioning (DIF). We compared composite scoring strategies on the basis of their relationships with volumetric magnetic resonance imaging (MRI) measures of brain structure. Participants were 791 Hispanic, white, and African American older adults. DIF had a salient impact on test scores for 9% of the sample. MRI data were available on a subset of 153 participants. Validity in comparison with structural MRI was higher after scale level adjustment for education, ethnicity/language, and gender, but item level adjustment did not have a major impact on validity. Age adjustment at the scale level had a negative impact on relationships with MRI, most likely because age adjustment removes variance related to age-associated diseases.

Rapid detection of differential item functioning in assessments of health-related quality of life: The Functional Assessment of Cancer Therapy.

REASON FOR STUDY: Differential item functioning (DIF) occurs when a test item functions differently in different groups when controlling for the level of the underlying construct measured by the test. DIF assessment is a first step in the evaluation of test bias. We sought to demonstrate a rapid hybrid approach to DIF detection by determining the presence and scale-level impact of DIF related to eight covariates in four domains measured by the Functional Assessment of Cancer Therapy (FACT). MAJOR FINDINGS: The number of items found with DIF in each domain depended on the criterion chosen to define the presence of DIF. With a few exceptions, scale-level differential functioning was similar regardless of the criteria chosen. For physical well-being, there was relevant scale-level differential functioning related only to race. For social and family well-being, there was relevant scale-level differential functioning related to each of the covariates. For emotional well-being, there was relevant scale-level differential functioning related to ethnicity, language, and race. For functional well-being, there was relevant scale-level differential functioning related to ethnicity, race, education, and self- vs. interviewer-administration. PRINCIPAL CONCLUSIONS: Our rapid hybrid approach to DIF detection may be broadly applicable in other studies of health-related quality of life.

Assessment of anxiety in dementia: an investigation into the association of different methods of measurement.

The objectives were to compare patient and caregiver ratings of anxiety for individuals with Alzheimer's disease and investigate their association with ratings of patient depression. Participants were 95 community-dwelling Alzheimer's disease patients and their caregivers. Measurements included caregiver proxy ratings: Rating Anxiety in Dementia, the NeuroPsychiatric Inventory, the Revised Memory and Behavior Problems Checklist, and the Cornell Scale for Depression in Dementia. Patient self-assessments included the Clinical Anxiety Scale (adapted) and the Geriatric Depression Scale. Correlations among anxiety measures ranged from rho = .16 to .40, whereas correlations between anxiety and depression scales ranged from rho = .03 to .66. Overlap among items across both anxiety and depression scales appeared to be the most important factor in determining these associations. Current scales for anxiety in dementia differ in their construction of symptoms and can overlap considerably with depression scales. Because of this, measures inadequately distinguish anxiety from depression in individuals with Alzheimer's disease. The measurement of anxiety in dementia needs additional refinement.