Replicating a Meta-Analysis: The Search for the Optimal Word Choice Test Cutoff Continues.

This study was designed to expand on a recent meta-analysis that identified ≤42 as the optimal cutoff on the Word Choice Test (WCT). We examined the base rate of failure and the classification accuracy of various WCT cutoffs in four independent clinical samples (N = 252) against various psychometrically defined criterion groups. WCT ≤ 47 achieved acceptable combinations of specificity (.86-.89) at .49 to .54 sensitivity. Lowering the cutoff to ≤45 improved specificity (.91-.98) at a reasonable cost to sensitivity (.39-.50). Making the cutoff even more conservative (≤42) disproportionately sacrificed sensitivity (.30-.38) for specificity (.98-1.00), while still classifying 26.7% of patients with genuine and severe deficits as non-credible. Critical item (.23-.45 sensitivity at .89-1.00 specificity) and time-to-completion cutoffs (.48-.71 sensitivity at .87-.96 specificity) were effective alternative/complementary detection methods. Although WCT ≤ 45 produced the best overall classification accuracy, scores in the 43 to 47 range provide comparable objective psychometric evidence of non-credible responding. Results question the need for designating a single cutoff as "optimal," given the heterogeneity of signal detection environments in which individual assessors operate. As meta-analyses often fail to replicate, ongoing research is needed on the classification accuracy of various WCT cutoffs.

Delirium as a Presenting Symptom of COVID-19.

BACKGROUND: Delirium is a common neurologic manifestation of coronavirus disease 2019 (COVID-19) in older adults who present to the emergency department (ED). OBJECTIVE: To investigate clinical characteristics associated with delirium as a presenting symptom of COVID-19 in older adults and develop a logistic regression to predict the likelihood of delirium. METHOD: We compared clinical characteristics in an age- and gender-matched sample of 68 delirious individuals with 68 nondelirious individuals (Mage = 78) who presented to the ED with COVID-19. RESULTS: The delirious group was more likely to have neurologic, psychiatric, and cardiovascular comorbidities; a prior history of delirium; and deliriogenic medications in their medication list. They were less likely to present with respiratory symptoms and more likely to present with sepsis, hypoxia, higher heart rate, and higher sodium. The delirious group had higher mortality (51%) than the nondelirious group (32%). Delirium developed within an average of 2 days of initial COVID-19 symptom onset, with symptom onset to ED within an average of 4 days and symptom onset to death within an average of 11 days. Logistic regression based on five delirium predictors correctly predicted 80% of those with delirium (75% sensitivity at 86% specificity). CONCLUSION: Our results are largely consistent with prior studies and suggest that delirium is a common, early occurring, and lethal manifestation of COVID-19 in older adults presenting to the ED, in most cases causing acute on chronic neurocognitive dysfunction strongly influenced by inflammatory and hypoxic-ischemic mechanisms.

Critical Item Analysis Enhances the Classification Accuracy of the Logical Memory Recognition Trial as a Performance Validity Indicator.

OBJECTIVE: : Replicate previous research on Logical Memory Recognition (LMRecog) and perform a critical item analysis. METHOD: : Performance validity was psychometrically operationalized in a mixed clinical sample of 213 adults. Classification of the LMRecog and nine critical items (CR-9) was computed. RESULTS: : LMRecog ≤20 produced a good combination of sensitivity (.30-.35) and specificity (.89-.90). CR-9 ≥5 and ≥6 had comparable classification accuracy. CR-9 ≥5 increased sensitivity by 4% over LMRecog ≤20; CR-9 ≥6 increased specificity by 6-8% over LMRecog ≤20; CR-9 ≥7 increased specificity by 8-15%. CONCLUSIONS: : Critical item analysis enhances the classification accuracy of the optimal LMRecog cutoff (≤20).

Predictors of survival in older adults hospitalized with COVID-19.

OBJECTIVE: This study was designed to investigate clinical characteristics associated with mortality and predictors of survival in older adults hospitalized with COVID-19 with a focus on neurological comorbidities and presenting neurological manifestations. METHODS: We compared clinical characteristics in an age- and gender-matched sample of 75 deceased and 75 recovered patients (MAge = 78) hospitalized with COVID-19 and developed a logistic regression to predict likelihood of survival. RESULTS: Deceased patients were more like to have dementia, altered mental status (AMS), acute respiratory distress syndrome (ARDS), sepsis, mechanical ventilation, and balance difficulties; higher heart rate, respiratory rate, blood urea nitrogen, creatinine, and absolute neutrophils; lower oxygen saturation and absolute lymphocytes; and shorter length of hospitalization. Logistic regression based on three mortality predictors (ARDS, AMS, and length of hospitalization) correctly predicted 87% of the outcome (89% sensitivity at 85% specificity). CONCLUSIONS: Dementia and AMS were strong predictors of death in older adults hospitalized with COVID-19. Our findings add to the rapidly growing neurology of COVID-19 literature and underscore the importance of early recognition and the incorporation of a mental status examination into the medical assessment of COVID-19.

Verbal fluency and digit span variables as performance validity indicators in experimentally induced malingering and real world patients with TBI.

Objective: This study was designed to examine the classification accuracy of verbal fluency (VF) measures as performance validity tests (PVT).Method: Student volunteers were assigned to the control (n = 57) or experimental malingering (n = 24) condition. An archival sample of 77 patients with TBI served as a clinical comparison.Results: Among students, FAS T-score ≤29 produced a good combination of sensitivity (.40-.42) and specificity (.89-.95). Animals T-score ≤31 had superior sensitivity (.53-.71) at .86-.93 specificity. VF tests performed similarly to commonly used PVTs embedded within Digit Span: RDS ≤7 (.54-.80 sensitivity at .93-.97 specificity) and age-corrected scaled score (ACSS) ≤6 (.54-.67 sensitivity at .94-.96 specificity). In the clinical sample, specificity was lower at liberal cutoffs [animals T-score ≤31 (.89-.91), RDS ≤7 (.86-.89) and ACSS ≤6 (.86-.96)], but comparable at conservative cutoffs [animals T-score ≤29 (.94-.96), RDS ≤6 (.95-.98) and ACSS ≤5 (.92-.96)].Conclusions: Among students, VF measures had higher signal detection performance than previously reported in clinical samples, likely due to the absence of genuine impairment. The superior classification accuracy of animal relative to letter fluency was replicated. Results suggest that existing validity cutoffs can be extended to cognitively high functioning examinees, and emphasize the importance of population-specific cutoffs.

The doubtful benefits of giving the benefit of the doubt: Lenient scoring of the spatial orientation items on the mini-Mental Status Exam increases false negative rates.

Lenient scoring of spatial orientation errors (SOE) on the Mini-Mental State Exam (MMSE) is common practice, even though it deviates from standard protocol and may compromise its diagnostic power. This study was designed to empirically evaluate the effect of lenient scoring on the MMSE's classification accuracy. Participants were 113 community dwelling older adults recruited for a research study, representing a wide range of range of neurological status from cognitively healthy to Alzheimer's disease. Clinical classification was determined by expert assessors based on multiple sources of clinical evidence. Lenient scoring significantly inflated MMSE total scores (d = .88, large effect), and suppressed failure rates (from 26% to 14%). Standard scoring produced superior overall classification accuracy (75% vs. 67%) over lenient scoring and, more importantly, increased sensitivity from .33 to .53, with minimal loss in specificity (from 1.00 to .95). SOEs are empirical markers of cognitive decline and should not be adjusted based on clinical judgment. Results indicate that diminished sensitivity to cognitive impairment is an unintended consequence of lenient scoring and argue against this practice.

The power of timing: Adding a time-to-completion cutoff to the Word Choice Test and Recognition Memory Test improves classification accuracy.

INTRODUCTION: The Recognition Memory Test (RMT) and Word Choice Test (WCT) are structurally similar, but psychometrically different. Previous research demonstrated that adding a time-to-completion cutoff improved the classification accuracy of the RMT. However, the contribution of WCT time-cutoffs to improve the detection of invalid responding has not been investigated. The present study was designed to evaluate the classification accuracy of time-to-completion on the WCT compared to the accuracy score and the RMT. METHOD: Both tests were administered to 202 adults (Mage = 45.3 years, SD = 16.8; 54.5% female) clinically referred for neuropsychological assessment in counterbalanced order as part of a larger battery of cognitive tests. RESULTS: Participants obtained lower and more variable scores on the RMT (M = 44.1, SD = 7.6) than on the WCT (M = 46.9, SD = 5.7). Similarly, they took longer to complete the recognition trial on the RMT (M = 157.2 s,SD = 71.8) than the WCT (M = 137.2 s, SD = 75.7). The optimal cutoff on the RMT (≤43) produced .60 sensitivity at .87 specificity. The optimal cutoff on the WCT (≤47) produced .57 sensitivity at .87 specificity. Time-cutoffs produced comparable classification accuracies for both RMT (≥192 s; .48 sensitivity at .88 specificity) and WCT (≥171 s; .49 sensitivity at .91 specificity). They also identified an additional 6-10% of the invalid profiles missed by accuracy score cutoffs, while maintaining good specificity (.93-.95). Functional equivalence was reached at accuracy scores ≤43 (RMT) and ≤47 (WCT) or time-to-completion ≥192 s (RMT) and ≥171 s (WCT). CONCLUSIONS: Time-to-completion cutoffs are valuable additions to both tests. They can function as independent validity indicators or enhance the sensitivity of accuracy scores without requiring additional measures or extending standard administration time.