Southwestern Assessment of Processing Speed (SWAPS): A new brief test with demographically-corrected norms in an ethnically and educationally diverse population.

Objective. Neuropsychological measures of processing speed have long been used as sensitive indices of cognitive functioning. Most of these commonly used tests are proprietary, and there is a need for brief, freely available tools that can be used in diverse clinical and research settings. The Southwestern Assessment of Processing Speed (SWAPS) is a 60-second digit-symbol transcription task developed as a brief alternative to commercially available coding tests. Demographically-corrected normative data are presented along with reliability and sensitivity/specificity values in older adults with and without cognitive impairment.Method. SWAPS data from 915 healthy aging individuals (NC) and 858 subjects with clinical diagnoses of mild cognitive impairment (MCI; n = 430) and Alzheimer's disease clinical syndrome (ADCS; n = 428) were obtained from the Texas Alzheimer's Research and Care Consortium (TARCC). TARCC participants represent ethnically and educationally diverse community-dwelling individuals age 50+.Results. SWAPS scores showed the expected associations with age, sex, and education, and the interaction between age and education were significant predictors of SWAPS scores. Test-retest reliability in NC was good, and the SWAPS distinguished impaired and non-impaired groups with adequate to excellent sensitivity and specificity for the primary analyses, with optimal cut-off points provided. Raw score- to uncorrected normalized T-scores and demographically-corrected SWAPS T-scores using regression-based norms are presented along with scoring programs for the calculation of each.Conclusions. The SWAPS is a brief, free, easily administered test with demographically-corrected regression-based norms and promising utility for detection of cognitive impairment and efficient assessment of processing speed.

Differences in quality of life in patients with cutaneous lupus erythematosus with varying income levels.

BACKGROUND: Cutaneous lupus erythematosus (CLE) is an autoimmune photosensitive skin condition. The impact of income on quality of life has been incompletely characterized in CLE. OBJECTIVES: We aimed to assess how annual income affects quality of life among CLE patients. METHODS: In this cross-sectional study of 238 patients with CLE, relationships between predictor variables including annual income and each SKINDEX-29 + 3 subdomain were identified using univariate and multivariable analyses. In addition, answers to individual SKINDEX-29 + 3 questions were compared across income groups. Clinical factors in patients making less than <10,000 USD (N = 85) with worse SKINDEX-29 + 3 scores were also identified by univariate and multivariable analyses. RESULTS: Patients making <10,000 USD annually experienced worse quality of life across multiple SKINDEX-29 + 3 subdomains (p < 0.05). These patients specifically experienced poorer quality of life relating to social isolation and self-consciousness. (p < 0.001). Among those making <10,000 USD, predictors for worse quality of life included females, smokers, and those with higher skin disease activity were identified (p < 0.05).Limitations: This is a single center study. Income was also self-reported and could not be verified. CONCLUSIONS: Lower income is related to poorer quality of life in patients with CLE. Specifically, patients experience limitations regarding social isolation and self-consciousness.

Detection of Mild Cognitive Impairment Among Community-Dwelling African Americans Using the Montreal Cognitive Assessment.

OBJECTIVE: To establish a cut score for the Montreal Cognitive Assessment (MoCA) that distinguishes mild cognitive impairment (MCI) from normal cognition (NC) in a community-based African American (AA) sample. METHODS: A total of 135 AA participants, from a larger aging study, diagnosed MCI (n = 90) or NC (n = 45) via consensus diagnosis using clinical history, Clinical Dementia Rating score, and comprehensive neuropsychological testing. Logistic regression models utilized sex, education, age, and MoCA score to predict MCI versus NC. Receiver operating characteristic (ROC) curve analysis determined a cut score to distinguish MCI from NC based on optimal sensitivity, specificity, diagnostic accuracy, and greatest perpendicular distance above the identity line. ROC results were compared with previously published MoCA cut scores. RESULTS: The MCI group was slightly older (MMCI = 64.76[5.87], MNC = 62.33[6.76]; p = .033) and less educated (MMCI = 13.07[2.37], MNC = 14.36[2.51]; p = .004) and had lower MoCA scores (MMCI=21.26[3.85], MNC = 25.47[2.13]; p < .001) than the NC group. Demographics were non-significant in regression models. The area under the curve (AUC) was significant (MoCA = .83, p < .01) and an optimal cut score of <24 maximized sensitivity (72%), specificity (84%), and provided 76% diagnostic accuracy. In comparison, the traditional cut score of <26 had higher sensitivity (84%), similar accuracy (76%), but much lower specificity (58%). CONCLUSIONS: This study provides a MoCA cut score to help differentiate persons with MCI from NC in a community-dwelling AA sample. A cut score of <24 reduces the likelihood of misclassifying normal AA individuals as impaired than the traditional cut score. This study underscores the importance of culturally appropriate norms to optimize the utility of commonly used cognitive screening measures.

Validity of Teleneuropsychological Assessment in Older Patients with Cognitive Disorders.

OBJECTIVE: The feasibility and reliability of neuropsychological assessment at a distance have been demonstrated, but the validity of this testing medium has not been adequately demonstrated. The purpose of this study was to determine the ability of video teleconferencing administration of neuropsychological measures (teleneuropsychology) in discriminating cognitively impaired from non-impaired groups of older adults. It was predicted that measures administered via video teleconference would distinguish groups and that the magnitude of differences between impaired and non-impaired groups would be similar to group differences achieved in traditional administration. METHODS: The sample consisted of 197 older subjects, separated into two groups, with and without cognitive impairment. The cognitive impairment group included 78 individuals with clinical diagnoses of mild cognitive impairment or Alzheimer's disease. All participants completed counterbalanced neuropsychological testing using alternate test forms in both a teleneuropsychology and a traditional face-to-face (FTF) administration condition. Tests were selected based upon their common use in dementia evaluations, brevity, and assessment of multiple cognitive domains. Results from FTF and teleneuropsychology test conditions were compared using individual repeated measures ANCOVA, controlling for age, education, gender, and depression scores. RESULTS: All ANCOVA models revealed significant main effects of group and a non-significant interaction between group and administration condition. All ANCOVA models revealed non-significant main effects for administration condition, except category fluency. CONCLUSIONS: Results derived from teleneuropsychologically administered tests can distinguish between cognitively impaired and non-impaired individuals similar to traditional FTF assessment. This adds to the growing teleneuropsychology literature by supporting the validity of remote assessments in aging populations.

Montreal Cognitive Assessment Performance among Community-Dwelling African Americans.

OBJECTIVE: To report descriptive and normative data for the Montreal Cognitive Assessment (MoCA) in a population-based African American sample. METHOD: The MoCA was administered to 1,419 African American participants (mean age 49.89 years, range 18-75, 64% female). After excluding those with subjective cognitive complaints (n = 301), normative data were generated by education and overlapping age ranges (n = 1,118). Pearson correlations and analysis of variance were used to examine the relationship to demographic variables, and frequency of missed items was reviewed. RESULTS: Total MoCA scores (mean 22.3, SD 3.9) were lower than previously published normative data derived from an elderly Caucasian Canadian population with 80% falling below the suggested cutoff (<26) for impairment. Several MoCA items were missed by a large portion of the sample, including cube drawing (72%), delayed free recall (66% <4/5 words), sentence repetition (63%), and abstraction items (45%). CONCLUSION: This is the first study to examine normative performance on the MoCA specific to community-dwelling African Americans. Findings suggest that certain aspects of this measure and previously established cutoff scores may not be well-suited for some populations.

Changes in Montreal Cognitive Assessment Scores Over Time.

This study explored the utility of the Montreal Cognitive Assessment (MoCA) in the detection of cognitive change over time in a community sample (age ranging from 58 to 77 years). The MoCA was administered twice approximately 3.5 years apart ( n = 139). Participants were classified as mild cognitive impairment (MCI) or cognitively intact at follow-up based on multidisciplinary consensus. We excluded 33 participants who endorsed cognitive complaints at baseline. The MCI group ( n = 53) showed a significant decrease in MoCA scores ( M = -1.83, p < .001, d = 0.64). When accounting for age and education, the MCI group showed a decline of 1.7 points, while cognitively intact participants remained stable. Using Reliable Change Indices established by cognitively intact group, 42% of MCI participants demonstrated a decline in MoCA scores. Results suggest that the MoCA can detect cognitive change in MCI over a 3.5-year period and preliminarily supports the utility of the MoCA as a repeatable brief cognitive screening measure.

Remote Neuropsychological Assessment in Rural American Indians with and without Cognitive Impairment.

OBJECTIVE: To determine the feasibility and reliability of a brief battery of standard neuropsychological tests administered via video teleconference (VTC) to a sample of rural American Indians compared with traditional face-to-face administration. METHODS: The sample consisted of 84 participants from the Choctaw Nation in Oklahoma, including 53 females and 31 males [M age = 64.89 (SD = 9.73), M education = 12.58 (SD = 2.35)]. Of these, 29 had a diagnosis of mild cognitive impairment or dementia, and 55 were cognitively normal. Tests included the MMSE, Clock Drawing, Digit Span Forward and Backward, Oral Trails, Hopkins Verbal Learning Test-Revised, Letter and Category Fluency, and a short form Boston Naming Test. Alternative forms of tests were administered in counterbalanced fashion in both face-to-face and VTC conditions. Intraclass correlation coefficients (ICCs) were used to compare test scores between test conditions across the entire sample. RESULTS: All ICCs were significant (p< .0001) and ranged from 0.65 (Clock Drawing) to 0.93 (Boston Naming Test), with a mean ICC of 0.82. CONCLUSION: Results add to the expanding literature supporting the feasibility and reliability of remote videoconference-based neuropsychological test administration and extend findings to American Indians.

An Abbreviated Montreal Cognitive Assessment (MoCA) for Dementia Screening.

OBJECTIVE: The Montreal Cognitive Assessment (MoCA) is a cognitive screening instrument growing in popularity, but few studies have conducted psychometric item analyses or attempted to develop abbreviated forms. We sought to derive and validate a short-form MoCA (SF-MoCA) and compare its classification accuracy to the standard MoCA and Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI), Alzheimer disease (AD), and normal aging. METHODS: 408 subjects (MCI n = 169, AD n = 87, and normal n = 152) were randomly divided into derivation and validation samples. Item analysis in the derivation sample identified most sensitive MoCA items. Receiver Operating Characteristic (ROC) analyses were used to develop cut-off scores and evaluate the classification accuracy of the SF-MoCA, standard MoCA, and MMSE. Net Reclassification Improvement (NRI) analyses and comparison of ROC curves were used to compare classification accuracy of the three measures. RESULTS: Serial subtraction (Cramer's V = .408), delayed recall (Cramer's V = .702), and orientation items (Cramer's V = .832) were included in the SF-MoCA based on largest effect sizes in item analyses. Results revealed 72.6% classification accuracy of the SF-MoCA, compared with 71.9% for the standard MoCA and 67.4% for the MMSE. Results of NRI analyses and ROC curve comparisons revealed that classification accuracy of the SF-MoCA was comparable to the standard version and generally superior to the MMSE. CONCLUSIONS: Findings suggest the SF-MoCA could be an effective brief tool in detecting cognitive impairment.

Reliability assessment and validation of the postacne hyperpigmentation index (PAHPI), a new instrument to measure postinflammatory hyperpigmentation from acne vulgaris.

BACKGROUND: There are no validated outcome measures for postinflammatory hyperpigmentation (PIH). OBJECTIVE: We sought to determine the reliability and validity of an outcome measure for PIH after acne in patients with skin of color. METHODS: A postacne hyperpigmentation index (PAHPI) was developed. Six raters scored 21 patients with PIH twice. Reliability was determined within and between raters, whereas validity was evaluated by comparing scores with severity ranking by an independent dermatologist. The pigment intensity scores were compared with the melanin index of each patient using a narrowband reflectance spectrophotometer. A quality-of-life score (Skindex-29) was also compared with PAHPI scores. RESULTS: Total PAHPI scores showed good reliability within and between raters and were valid when compared with clinical severity and melanin indices. Good correlation was achieved between the total PAHPI score and the emotion subscale of the Skindex-29. LIMITATIONS: Generalizability of results is limited to African American females. CONCLUSION: The PAHPI shows good reliability and validity when scored on patients with PIH from acne vulgaris. The PAHPI also correlates well with the emotional impact of PIH as measured by the Skindex-29. Future studies should assess the ability of the PAHPI to change with improvement of PIH from acne after treatment.

Consumer acceptability of brief videoconference-based neuropsychological assessment in older individuals with and without cognitive impairment.

Growing evidence suggests that neuropsychological assessment via videoconference shows good agreement with traditional in-person assessment. However, there are few published studies regarding patient acceptability of this methodology, particularly in individuals with cognitive impairment. In this study we sought to evaluate patient preferences and acceptability of teleneuropsychology to further shed light on the viability of this cognitive assessment medium. We examined acceptability of videoconference-based neuropsychological assessment among healthy aging individuals and in subjects with mild cognitive impairment or early stage Alzheimer disease. We found that teleneuropsychology appears to be well accepted by consumers. Our results reflected 98% satisfaction, and roughly two-thirds of participants indicated no preference between traditional face-to-face testing and examination by teleneuropsychology. Furthermore, even participants with cognitive impairment showed good acceptability of teleneuropsychological assessment. In conjunction with the preliminary data on reliability and validity from this growing literature, these results support teleneuropsychology as a viable and acceptable method for assessing cognitive functioning, and show promise for the implementation and utilization of this cognitive assessment medium in clinical and research settings.

Proof of concept: Partner-Assisted Interpersonal Psychotherapy for perinatal depression.

Although poor partner support is a key risk factor for depression in pregnant and postpartum women, partners are not generally involved in treatment beyond psychoeducation. The aim of this "proof of concept" study was to test safety, acceptability, and feasibility of Partner-Assisted Interpersonal Psychotherapy (PA-IPT), an intervention that includes the partner as an active participant throughout treatment. Women more than 12 weeks estimated gestational age and less than 12 weeks postpartum were invited to participate if they fulfilled DSM-IV criteria for Major Depressive Disorder and reported moderate symptom severity (HAM-D(17) ≥16). The open trial included eight acute-phase sessions and a 6-week follow-up assessment. Ten couples completed the acute phase treatment and nine presented for a 6-week follow-up assessment. There were no study-related adverse events, and no women had symptomatic worsening from intake to Session Eight. All partners attended all sessions, no couples dropped out of treatment, and all reported positive treatment satisfaction at the conclusion of the study. Nine of ten women (90 %) met the criteria for clinical response (HAM-D(17) = 9) at the conclusion of acute phase treatment, and eight of the nine (89 %) presenting at a 6-week follow-up assessment met criteria for symptomatic recovery. Incorporating partners in the treatment of major depressive disorders during the perinatal period is safe, acceptable, and feasible, but needs further testing in a larger population to evaluate efficacy.

A SAS(®) macro implementation of a multiple comparison post hoc test for a Kruskal-Wallis analysis.

The Kruskal-Wallis (KW) nonparametric analysis of variance is often used instead of a standard one-way ANOVA when data are from a suspected non-normal population. The KW omnibus procedure tests for some differences between groups, but provides no specific post hoc pair wise comparisons. This paper provides a SAS(®) macro implementation of a multiple comparison test based on significant Kruskal-Wallis results from the SAS NPAR1WAY procedure. The implementation is designed for up to 20 groups at a user-specified alpha significance level. A Monte-Carlo simulation compared this nonparametric procedure to commonly used parametric multiple comparison tests.

Reliability assessment and validation of the Melasma Area and Severity Index (MASI) and a new modified MASI scoring method.

BACKGROUND: The Melasma Area and Severity Index (MASI), the most commonly used outcome measure for melasma, has not been validated. OBJECTIVE: We sought to determine the reliability and validity of the MASI. METHODS: After standardized training, 6 raters independently rated 21 patients with mild to severe melasma once daily over a period of 2 days to determine intrarater and interrater reliability. Validation was performed by comparing the MASI with the melasma severity scale. The darkness component of the MASI was validated by comparing it with the difference between mexameter scores for affected versus adjacent normal-appearing skin. The area component of the MASI was validated by comparing it with the area of each section of the face determined by computer-based measurement software. RESULTS: The MASI score showed good reliability within and between raters and was found to be valid when compared with the melasma severity scale, mexameter scores, and area measurements. Homogeneity assessment by raters showed the least agreement and can be removed from the MASI score without any loss of reliability. LIMITATIONS: Patients were limited to Hispanic, African, and Asian backgrounds. CONCLUSION: The MASI is a reliable measure of melasma severity. Area of involvement and darkness are sufficient for accurate measurement of the severity of melasma and homogeneity can be eliminated.

When policy meets statistics: the very real effect that questionable statistical analysis has on limiting health care access for bariatric surgery.

HYPOTHESIS: Bariatric surgery for Medicare patients must be performed in an accredited hospital that performs at least 125 cases per year. We assessed the validity of this volume threshold and its policy implications. DESIGN: Using the 2001-2003 National Inpatient Survey, the effect of hospital volume on in-hospital mortality was statistically modeled and the effect of a 125-case per year threshold on access to bariatric surgery was calculated. We performed Monte Carlo modeling to investigate the effect random sampling has on the apparently high mortality rate for low-volume hospitals. SETTING: US inpatient hospitals. PATIENTS: Patients with hospital discharge codes indicating bariatric surgery. Main Outcome Measure In-house mortality. RESULTS: The observed in-hospital mortality distribution as a function of hospital volume was similar to the expected frequency attributable to random sampling alone. A small number of excess deaths in very low-volume facilities cause statistically significant results for volume-outcome studies. Although 74% of all bariatric surgeries are performed in high-volume centers, 73% of all hospitals currently offering these services are now classified as low volume. CONCLUSIONS: When the results of statistical analysis are used for policy determination, the consequences for patient care may be substantial. Most studies of volume-outcome relationships rely on statistical methods that tend to amplify the effects and few fully characterize their statistical models. Despite the weak evidence for a volume-outcome relationship for bariatric surgery, a 125-case per year threshold has been set for center-of-excellence status, which eliminates most hospitals currently providing these services and disproportionately restricts access for the poor and underinsured.

Feasibility of telecognitive assessment in dementia.

Videoconferencing (VC) technology has been used successfully to provide psychiatric services to patients in rural and otherwise underserved settings. VC-based diagnostic interviewing has shown good agreement with conventional face-to-face diagnosis of dementia in several investigations, but extension of this technology to neurocognitive assessment has received little attention. To this end, the authors administered a brief battery of common neuropsychological tests via VC technology (telecognitive) and traditional face-to-face methods to 14 older persons with mild cognitive impairment (MCI) and 19 persons with mild to moderate Alzheimer's disease (AD). Highly similar test scores were obtained when participants were tested in-person or via VC. Telecognitive assessment appears to be a valid means to conduct neuropsychological evaluation of older adults with cognitive impairment. Furthermore, continued development of VC technology has implications for expanding neuropsychological assessment options in under-served populations.