An itemized approach to assessing behavioral and psychological symptoms in dementia.

In an effort to obtain more detailed clinical information regarding behavioral and psychology symptoms in dementia, we submitted an existing, comprehensive measure of behavioral and psychology symptoms in dementia (Neuropsychiatric Inventory) to an alternate itemized scoring system. One hundred twenty-four caregivers of patients with dementia (mean Mini-Mental State Examination=22.6) rated the frequency of individual symptoms across all domains of the measure. Internal reliability and factor structures for all domains were analyzed to assess the stability of this scoring approach. Internal consistency alphas for each domain ranged from .57 to .91. Alpha reliability for the total inventory was .96. Results indicate an itemized approach to assessing behavioral and psychological symptoms in dementia among patients with mild-to-moderate dementia can be reliable, has the power to capture multiple features of neuropsychiatric symptoms, and can produce a rich neurobehavioral profile adding valuable information to the diagnosis and treatment of these patients.

Syntactic comprehension deficits are associated with MRI white matter alterations in dementia.

Comprehension difficulties associated with periventricular and deep white matter alterations (WMA) in mild dementia were investigated using portions of the Boston Diagnostic Aphasia Examination (BDAE) Complex Ideation subtest and Syntax subtests. Mild dementia participants were grouped according to the extent of their WMA as observed on magnetic resonance imaging (mild WMA n = 45 vs. moderate to severe WMA n = 52). Correlation and regression analyses also were performed to examine the link between WMA and comprehension abilities, as well as the link between comprehension abilities and neuropsychological measures of executive functioning, language, episodic memory, and overall dementia severity. Results showed that the WMA groups differed on the BDAE-Syntax subtests, with the severe WMA group demonstrating more impairment. Correlation and regression analyses including the entire sample also demonstrated that the extent of WMA was significantly linked to Syntax test scores but not Complex Ideation scores. Regression analyses including neuropsychological measures showed that the BDAE-Complex Ideation score was marginally predicted by only overall dementia severity, whereas the BDAE-Syntax scores were significantly predicted by independent measures of working memory/executive functioning. In conclusion, greater subcortical WMA and executive deficits are associated with greater difficulties in syntactic comprehension in individuals with mild dementia.

The influence of personal familiarity on object naming, knowledge, and use in dementia.

Reports of semantic dementia patients have shown more accurate identification and use for personal objects than unfamiliar analogs of the same objects (e.g., personal comb versus experimenter's comb) [Bozeat, S., Lambon Ralph, M. A., Patterson, K., & Hodges, J. R. (2002). The influence of personal familiarity and context on object use in semantic dementia. Neurocase, 8, 127-134; Snowden, J. S., Griffiths, H., & Neary, D. (1994). Semantic dementia: Autobiographical contribution to preservation of meaning. Cognitive Neuropsychology, 11, 265-288]. Despite potential clinical implications, the personal object advantage has not been explored in various dementia populations. Sixteen mild to moderate dementia patients were tested with 12-15 of their personal objects and laboratory analog objects. Four tasks were administered: Naming, Gesture, Semantic/Script Generation, and Personal Object Decision (i.e., Is this yours?). Although 25% of the sample performed at chance in identifying personal objects as their own, participants generated more specific information (t=2.3, p=.03) and more accurate gestures (t=2.4, p=.03) for personal objects. Thus, the personal object advantage was observed for script/semantic knowledge and movement sequences, and should be considered in residential planning for various dementia patients.

Construct and concurrent validity of the Dementia Rating Scale-2 Alternate Form.

The Dementia Rating Scale-2: Alternate Form (DRS-2: AF) was developed by Schmidt (2004) for use in serial neuropsychological assessments with the original DRS-2 (Jurica, Leitten, & Mattis, 2001). Results from two preliminary validation studies of the DRS-2: AF are presented here. In Study 1, the DRS-2: AF and four additional neuropsychological measures were administered to 49 healthy, community-dwelling participants without dementia; convergent and discriminant correlational analyses provide evidence for the construct validity of four DRS-2: AF subscales (Attention, Initiation/ Perseveration, Conceptualization, Memory). In Study 2, the DRS-2: AF and Mini-Mental State Examination (MMSE) were administered to a sample of 65 residents living in a continuing care retirement community (30 residents with dementia, 35 residents without dementia) to demonstrate the construct and concurrent validity of the DRS-2: AF Total Score. A strong correlation was found between the MMSE and DRS-2: AF Total Score. When DRS-2: AF Total Scores were subjected to a discriminant function analysis, Total Scores accurately classified 61 of the 65 participants into the appropriate patient group (dementia vs. comparison). The results of these preliminary validation studies are robust, and suggest that the DRS-2: AF may be a useful measure when serial assessments with the DRS-2 are needed.

Everyday action in dementia: evidence for differential deficits in Alzheimer's disease versus subcortical vascular dementia.

The relationship between dementia diagnosis and everyday action (e.g., meal preparation, grooming) is not well understood. This study examines differences between individuals diagnosed with vascular dementia (VaD; n = 25) versus Alzheimer's disease (AD; n = 23) on the Naturalistic Action Test (NAT; Schwartz et al., 2003), a performance-based measure that includes three tasks of increasing complexity. The percentage of task steps accomplished, number of errors, and performance times were recorded for each task. While the groups did not differ in dementia severity or overall impairment on the NAT, the VaD group committed more errors (3.3 vs. 1.6, p = 02). The VaD group also accomplished significantly fewer steps when salient distractor objects were present (74.0% vs. 91.3%, p < .01). Correlations between NAT variables and neuropsychological tests suggest the executive control deficits associated with VaD may contribute to specific action difficulties, such as distractor interference and inefficient, error-prone action on complex tasks. In AD, everyday action may be negatively influenced by episodic memory failures. Thus, dementia diagnosis has relevance to everyday function.

The neuropsychological profile of alcohol-related dementia suggests cortical and subcortical pathology.

The neuropathology associated with chronic alcohol abuse varies across studies, though research suggests generalized reductions in cortical and subcortical grey and white matter. Neuropsychological findings also differ within the literature. The inconsistent findings with respect to the neuropathology and neurobehavior of patients with histories of alcohol abuse may be due, at least in part, to differing nosology and the highly variable inclusion/exclusion criteria employed by researchers. Oslin et al. [Int J Geriatr Psychiatry 1998;13:203-212] have proposed and recently validated specific criteria for probable alcohol-related dementia (ARD). We were interested in comparing the neuropsychological profile of ARD patients with the neurocognitive profiles of typical cortical and subcortical dementia patients. Participants included 14 ARD patients, 15 patients diagnosed with Alzheimer's disease (AD), 13 patients diagnosed with subcortical vascular dementia (VaD), and 20 normal controls. Patient subgroups were similar with respect to age (mean = 79), education (mean = 12 years) and dementia severity (MMSE; mean = 22.1). The three dementia patient subgroups demonstrated significantly worse performance than the normal controls subgroup on all neuropsychological tests. The ARD subgroup exhibited very similar executive control deficits to VaD patients. However, the different neurocognitive profiles of the patient subgroups suggest that ARD patients may also, in fact, demonstrate some degree of amnesia given that they perform slightly worse than subcortical patients on delayed verbal free recall and recognition. Nonetheless, the ARD patients did not display as severe impairment as the AD patients on the memory tasks. No significant differences between the three patient groups were identified on language tests. In sum, we present preliminary evidence of a distinct neuropsychological profile for ARD patients that includes impairment on both executive control and memory tests. This pattern of performance suggests that long-term alcohol abuse, in comparison to AD and VaD, may be associated with both cortical and subcortical neuropathology.

Reduced ability to self-administer medication is associated with assisted living placement in a continuing care retirement community.

OBJECTIVE: To examine whether reduced ability to self-administer medication can accurately classify living placement (independent or assisted living) in a continuing care retirement community (CCRC). DESIGN: Convenience sample of consecutive patients seen in a medical clinic. SETTING: An outpatient medical clinic at a CCRC. PARTICIPANTS: A group of 78 consecutive patients (aged 68-98 years) scheduled for a geriatric medical evaluation between May 1, 2001, and August 31, 2001, residing in an independent (IL) or assisted living (AL) apartment. MEASUREMENTS: Ability to self-administer medication was assessed by asking residents to respond to a medication administration question based on a 5-point Likert scale. Residents were also given measures of cognitive status (MMSE), activities of daily living (ADL), and depression (GDS). Further, age of residents as well as number of falls within the previous 6 months were recorded. RESULTS: A discriminant function analysis accurately classified living placement (IL or AL) in 89.7% of the cases based on the ability of residents to self-administer medication. The additions of MMSE score, ADL performance, GDS score, number of falls, and age of the residents to the analyses did not improve the number of cases that were correctly classified. CONCLUSION: Ability to self-administer medication emerged as the main predictor of current living environment within the CCRC in the present study. These results underscore the importance of considering a resident's ability to independently manage his or her medications when placement decisions are being made within CCRCs.

Alternate-form reliability of the Dementia Rating Scale-2.

The Dementia Rating Scale-2 (DRS-2) is a frequently used assessment of cognitive status among older adults in both research and clinical practice. Despite its well-established psychometric properties, its use in serial assessments has posed limitations with regard to practice effects. The primary purpose of the present study is to provide preliminary evidence of alternate-form reliability for the DRS-2. A heterogeneous sample of 52 community-dwelling adults over age 60 with no reported diagnosis of dementia were administered the DRS-2 as well as a newly developed alternate form [DRS-2: AF; Schmidt, K. S. (2004). Dementia Rating Scale-2 Alternate Form: Manual supplement. Lutz, FL: Psychological Assessment Resources]. Our results reveal strong correlations between the two forms; further, no significant differences were found between total scale and subscale scores obtained from the two forms. Therefore, the DRS-2: AF may be a valuable assessment tool in both research and clinical arenas.

Test-retest reliability of the dementia rating scale-2: alternate form.

The purpose of this study was to examine the test-retest reliability of the newly developed Dementia Rating Scale-2: Alternate Form (DRS-2:AF) in a community-dwelling sample of older adults. Participants were administered the DRS-2:AF during two separate testing sessions; the interval between sessions was between 12 and 28 days. The stability coefficient for the Total Score was quite high (0.93), and reliability coefficients for the subscale scores ranged from adequate to high. This project provides evidence for the test-retest reliability of the DRS-2:AF. Given the need for cognitive status measures with equivalent forms, the DRS-2:AF is recommended as a reliable tool in the assessment of dementia.

Validity of the Medication Administration Test among older adults with and without dementia.

BACKGROUND: Impairments in everyday activities (ie, using the telephone, driving, managing medication) have been associated with increasing age as well as dementia severity. One of the initial functional losses among older adults both with and without dementia is impaired medication self-management skills. In fact, reduced ability to self administer medication has been identified as a significant predictor of an assisted living (AL) placement (vs an independent living [IL] placement) among older adults. We recently developed a Medication Administration Test (MAT) to aid in placement decisions regarding level of care (eg, IL, AL). OBJECTIVE: The purpose of this study was to examine the construct and concurrent validity of the MAT in a sample of older adults residing in a continuing care retirement facility. METHODS: IL and AL participants were administered the MAT along with a brief neuropsychological battery that included the Naturalistic Action Test, the Mini-Mental State Examination, and the Instrumental Activities of Daily Living scale. The construct validity of the MAT was assessed by correlating MAT scores with the other neuropsychological instruments of cognition and function. With respect to the MAT's concurrent validity, a discriminant function analysis was run to determine the classification accuracy (IL vs AL) of the newly developed MAT. RESULTS: Sixty-two white participants were included in the study (mean age, 85.56 years); 34 participants were residing in an AL setting and 28 were residing in an IL setting. Evidence for construct validity was relatively robust, as performance on the MAT was moderately correlated with scores on the Mini-Mental State Examination, the Naturalistic Action Test, and the Instrumental Activities of Daily Living scale. When MAT scores were subjected to a discriminant function analysis to assess concurrent validity, MAT performance accurately classified 79.03% of the participants into the appropriate level of care (IL or AL). CONCLUSION: This project provides preliminary evidence for the validity of the MAT when used for placement decisions within continuing care retirement communities. Given the current need for objective measures to aid in level of care decision making, the MAT may be useful in both clinical and research arenas.