Impact of Mild Behavioral Impairment on Longitudinal Changes in Cognition.

BACKGROUND: To examine cross-sectional differences and longitudinal changes in cognitive performance based on the presence of mild behavioral impairment (MBI) among older adults who are cognitively healthy or have mild cognitive impairment (MCI). METHODS: Secondary data analysis of participants (n = 17 291) who were cognitively healthy (n = 11 771) or diagnosed with MCI (n = 5 520) from the National Alzheimer's Coordinating Center database. Overall, 24.7% of the sample met the criteria for MBI. Cognition was examined through a neuropsychological battery that assessed attention, episodic memory, executive function, language, visuospatial ability, and processing speed. RESULTS: Older adults with MBI, regardless of whether they were cognitively healthy or diagnosed with MCI, performed significantly worse at baseline on tasks for attention, episodic memory, executive function, language, and processing speed and exhibited greater longitudinal declines on tasks of attention, episodic memory, language, and processing speed. Cognitively healthy older adults with MBI performed significantly worse than those who were cognitively healthy without MBI on tasks of visuospatial ability at baseline and on tasks of processing speed across time. Older adults with MCI and MBI performed significantly worse than those with only MCI on executive function at baseline and visuospatial ability and processing speed tasks across time. CONCLUSIONS: This study found evidence that MBI is related to poorer cognitive performance cross-sectionally and longitudinally. Additionally, those with MBI and MCI performed worse across multiple tasks of cognition both cross-sectionally and across time. These results provide support for MBI being uniquely associated with different aspects of cognition.

Mild behavioral impairment as a predictor of cognitive functioning in older adults.

OBJECTIVE: To assess the influence of mild behavioral impairment (MBI) on the cognitive performance of older adults who are cognitively healthy or have mild cognitive impairment (MCI). METHODS: Secondary data analysis of a sample (n = 497) of older adults from the Florida Alzheimer's Disease Research Center who were either cognitively healthy (n = 285) or diagnosed with MCI (n = 212). Over half of the sample (n = 255) met the operationalized diagnostic criteria for MBI. Cognitive domains of executive function, attention, short-term memory, and episodic memory were assessed using a battery of neuropsychological tests. RESULTS: Older adults with MBI performed worse on tasks of executive function, attention, and episodic memory compared to those without MBI. A significant interaction revealed that persons with MBI and MCI performed worse on tasks of episodic memory compared to individuals with only MCI, but no significant differences were found in performance in cognitively healthy older adults with or without MBI on this cognitive domain. As expected, cognitively healthy older adults performed better than individuals with MCI on every domain of cognition. CONCLUSIONS: The present study found evidence that independent of cognitive status, individuals with MBI performed worse on tests of executive function, attention, and episodic memory than individuals without MBI. Additionally, those with MCI and MBI perform significantly worse on episodic memory tasks than individuals with only MCI. These results provide support for a unique cognitive phenotype associated with MBI and highlight the necessity for assessing both cognitive and behavioral symptoms.

Neuropsychiatric symptoms as a distinguishing factor between memory diagnoses.

OBJECTIVES: To determine whether neuropsychiatric symptoms (NPS) are able to differentiate those with mild cognitive impairment (MCI) and dementia from persons who are cognitively healthy. METHODS: Multinomial and binary logistic regressions were used to assess secondary data of a sample (n = 613) of older adults with NPS. Analyses evaluated the ability to differentiate between diagnoses, as well as the influence of these symptoms for individuals with amnestic MCI (MCI-A), non-amnestic MCI (MCI-NA), and dementia compared with those who are cognitively healthy. RESULTS: Persons with MCI were more likely to have anxiety, apathy, and appetite changes compared with cognitively healthy individuals. Persons with dementia were more likely to have aberrant motor behaviors, anxiety, apathy, appetite changes, and delusions compared with those who were cognitively healthy. Individuals with any type of cognitive impairment were more likely to have anxiety, apathy, appetite changes, and delusions. Specifically, anxiety, apathy, appetite changes, and disinhibition were predictors of MCI-A; agitation and apathy were predictors of MCI-NA; and aberrant motor behaviors, anxiety, apathy, appetite changes, and delusions were predictors of dementia. Finally, nighttime behavior disorders were less likely in individuals with dementia. CONCLUSIONS: The present study's results demonstrate that specific NPS are differentially represented among types of cognitive impairment and establish the predictive value for one of these cognitive impairment diagnoses.

Suicidality and the Onset of Homelessness: Evidence for a Temporal Association From VHA Treatment Records.

OBJECTIVE: This study examined the temporal sequencing of a first-recorded episode of homelessness and treatment for suicidal ideation or attempt. METHODS: Data were from the U.S. Department of Veterans Affairs Corporate Data Warehouse and contained medical records of service use dates and associated ICD codes for care provided by the Veterans Health Administration. The analysis examined treatment for suicidality before and after a first record of homelessness ("onset") among 152,519 veterans. The second analysis examined the rate of treatment for suicidality among 156,288 veterans with any indication of homelessness. The third analysis examined the rate of homelessness among 145,770 veterans with indication of suicidality. RESULTS: Among newly homeless veterans, treatment for suicidality peaked just before onset of homelessness. Thirteen percent of homeless veterans had evidence of suicidality. Twenty-nine percent of veterans with evidence of suicidality appeared to have concurrent homelessness. CONCLUSIONS: Homelessness should be considered a primary risk factor for suicidality.

Mortality and Cause of Death in Younger Homeless Veterans.

OBJECTIVES: Increased mortality has been documented in older homeless veterans. This retrospective study examined mortality and cause of death in a cohort of young and middle-aged homeless veterans. METHODS: We examined US Department of Veterans Affairs records on homelessness and health care for 2000-2003 and identified 23 898 homeless living veterans and 65 198 non-homeless living veterans aged 30-54. We used National Death Index records to determine survival status. We compared survival rates and causes of death for the 2 groups during a 10-year follow-up period. RESULTS: A greater percentage of homeless veterans (3905/23 898, 16.3%) than non-homeless veterans (4143/65 198, 6.1%) died during the follow-up period, with a hazard ratio for risk of death of 2.9. The mean age at death (52.3 years) for homeless veterans was approximately 1 year younger than that of non-homeless veterans (53.2 years). Most deaths among homeless veterans (3431/3905, 87.9%) and non-homeless veterans (3725/4143, 89.9%) were attributed to 7 cause-of-death categories in the International Classification of Diseases, 10th Revision (cardiovascular system; neoplasm; external cause; digestive system; respiratory system; infectious disease; and endocrine, nutritional, and metabolic diseases). Death by violence was rare but was associated with a significantly higher risk among homeless veterans than among non-homeless veterans (suicide hazard ratio = 2.7; homicide hazard ratio = 7.6). CONCLUSIONS: Younger and middle-aged homeless veterans had higher mortality rates than those of their non-homeless veteran peers. Our results indicate that homelessness substantially increases mortality risk in veterans throughout the adult age range. Health assessment would be valuable for assessing the mortality risk among homeless veterans regardless of age.

Predictors of Mortality in Older Homeless Veterans.

OBJECTIVES: In this analysis of a cohort of older homeless veterans, we examined psychosocial, health, housing, and employment characteristics to identify predictors of mortality. METHOD: Our sample of 3,620 older veterans entered Veteran Affairs homeless programs in years 2000-2003. Fifteen variables from a structured interview described this sample and served as predictors. National Death Index data for years 2000-2011 were used to ascertain death. Survival table analyses were conducted to estimate and plot cumulative survival functions. To determine predictors and estimate hazard functions, Cox proportional hazards regression analysis was conducted. RESULTS: Five variables (presence of a serious health issue, hospitalization for alcohol abuse, alcohol dependency, unemployment for 3 years, and age 60+) were associated with increased risk of death; three (non-White, drug dependency, and dental problems) were associated with reduced risk. A risk score, based on total unit-weighted risk for all eight predictors, was used to identify three groups that were found to differ significantly in mortality. CONCLUSIONS: These analyses underline the jeopardy faced by older homeless veterans in terms of early death. We were able to identify several variables associated with mortality; more importantly, we were able to show that a risk score based on status for these variables was significantly related to survival.

Increased Mortality Among Older Veterans Admitted to VA Homelessness Programs.

OBJECTIVE: National Death Index data were examined to describe mortality patterns among older veterans who are homeless. METHODS: Homelessness and health care records from the U.S. Department of Veterans Affairs were used to identify old (ages 55-59) and older (ages ≥60) veterans who were (N=4,475) or were not (N=20,071) homeless. Survival functions and causes of death of the two samples over an 11-year follow-up period were compared. RESULTS: Substantially more veterans who were homeless (34.9%) died compared with the control sample (18.2%). Veterans who were homeless were approximately 2.5 years younger at time of death compared with the control sample. Older veterans who were homeless had the lowest survival rate (58%). No disease category appeared to be critical in reducing survival time. Suicide was twice as frequent in the homeless (.4%) versus the control (.2%) sample. CONCLUSIONS: Older veterans who were homeless experienced excess mortality and increased suicide risk.

Health risk factors and differences in outcomes between younger and older veterans using VA transitional housing.

OBJECTIVE: This study examined age-related differences in general medical and mental health risk factors for veterans participating in the U.S. Department of Veterans Affairs (VA) Grant Per Diem (GPD) transitional supportive housing program. The subpopulation of older homeless veterans is growing, and little is known about the implications of this fact for health care providers and for supportive programs intended to meet homeless veterans' needs. METHODS: Data were obtained from the VA records of all veterans (N=40,820) who used the GPD program during fiscal years 2003 to 2009. Unconditional adjusted and unadjusted odds ratios for general medical and psychiatric characteristics were calculated and were the primary study focus. Significant predictors of homeless program completion assessed from univariate models were then evaluated in multivariate models. RESULTS: Younger (<55) and older (≥55) homeless veterans reported an equal number of days homeless before enrollment. Younger veterans averaged 19 fewer days in GPD. Older veterans had more general medical problems and approximately $500 more in program costs. CONCLUSIONS: Findings from this study indicate that older homeless veterans are at increased risk of serious medical problems. This group is especially vulnerable to experiencing negative consequences related to homelessness. Addressing these complex needs will allow the VA to provide enhanced care to older homeless veterans.

Verbal fluency patterns in mild cognitive impairment and Alzheimer's disease.

BACKGROUND/AIMS: Verbal fluency patterns can assist in differential diagnosis during neuropsychological assessment and identify individuals at risk for developing Alzheimer's disease (AD). While evidence suggests that subjects with AD perform worse on category fluency than letter fluency tasks, the pattern in mild cognitive impairment (MCI) is less well known. METHODS: Performance on the Controlled Oral Word Association Test (COWAT) and Animal fluency was compared in control, amnestic MCI, non-amnestic MCI, and AD groups. The sample included 136 participants matched for age, education, and gender. RESULTS: Both MCI groups performed similarly with a category > letter fluency pattern rather than a category < letter fluency pattern typically observed in AD. The pattern in MCI, albeit relatively more impaired than in controls, was more similar to healthy controls who exhibited a category > letter fluency pattern. CONCLUSION: MCI using a category < letter fluency pattern may not represent AD; however, future research requires longitudinal studies of pattern analysis.

Perceptions of homelessness in older homeless veterans, VA homeless program staff liaisons, and housing intervention providers.

PURPOSE: To understand the needs and challenges encountered by older homeless veterans. METHODS: We conducted six focus groups of older veterans, two focus groups, and one semi-structured interview of VA staff liaisons, and two focus groups and one semi-structured interview of housing intervention providers. RESULTS: Major themes for older veterans: 1) negative homelessness experience; 2) benefits of the structured transitional housing program; 3) importance of peer outreach; and 4) need for age-tailored job placement programs. Major themes for VA staff liaison/housing intervention providers: 1) belief that the transitional housing program has made a positive change; 2) need for individualized criteria to address the unique needs of veterans; 3) distinct differences between older and younger homeless veterans; 4) outreach services; 5) permanent housing issues; and 6) coordination of services. DISCUSSION: Compared with younger veterans, older veterans have less social support, greater employment and health challenges, and, perhaps greater motivation to change.

Evaluating the impact of dental care on housing intervention program outcomes among homeless veterans.

OBJECTIVES: In this retrospective longitudinal cohort study, we examined the impact of dental care on outcomes among homeless veterans discharged from a Department of Veterans Affairs (VA) transitional housing intervention program. METHODS: Our sample consisted of 9870 veterans who were admitted into a VA homeless intervention program during 2008 and 2009, 4482 of whom received dental care during treatment and 5388 of whom did not. Primary outcomes of interest were program completion, employment or stable financial status on discharge, and transition to permanent housing. We calculated descriptive statistics and compared the 2 study groups with respect to demographic characteristics, medical and psychiatric history (including alcohol and substance use), work and financial support, and treatment outcomes. RESULTS: Veterans who received dental care were 30% more likely than those who did not to complete the program, 14% more likely to be employed or financially stable, and 15% more likely to have obtained residential housing. CONCLUSIONS: Provision of dental care has a substantial positive impact on outcomes among homeless veterans participating in housing intervention programs. This suggests that homeless programs need to weigh the benefits and cost of dental care in program planning and implementation.

Use of outpatient mental health services by homeless veterans after hurricanes.

Little is known about the impact of hurricanes on people who are homeless at the time a disaster occurs. Although researchers have extensively studied the psychosocial consequences of disaster produced homelessness on the general population, efforts focused on understanding how homeless people fare have been limited to a few media reports and the gray literature. In the event of a hurricane, homeless veterans may be at increased risk for negative outcomes because of their cumulative vulnerabilities. Health care statistics consistently document that homeless veterans experience higher rates of medical, emotional, substance abuse, legal, and financial problems compared with the general population. This study used the 2004 to 2006 Veterans Health Administration (VHA) Outpatient Medical Dataset to examine the effects of hurricanes on use of outpatient mental health services by homeless veterans. Homeless veterans residing in hurricane-affected counties were significantly more likely to participate in group psychotherapy (32.4% vs. 13.4%, p < .002), but less likely to participate in individual 30-40-min sessions with medical evaluations (3.5% vs. 17.3%, p < .001). The study findings have implications for homeless programs and the provision of VHA mental health services to homeless veterans postdisaster.

Cognitive change checklist: psychometric characteristics in community-dwelling older adults.

OBJECTIVE: To extend the psychometric study of the Cognitive Change Checklist (3CL) by examining the reliability, factor structure, and external correlates of 3CL informant and self-report ratings in community-dwelling adults. We also conducted receiver operating characteristic analyses examining rating scores from this normative sample with those of clinical samples. DESIGN: Scale reliability and validity study. SETTING: Community sites. PARTICIPANTS: Six hundred seventy-nine older adults. RESULTS: The pattern of scale relationships within and across versions, and the failure to find associations with age and education, were consistent with findings in clinic samples reported previously. Factor analysis replicated the four-factor structure of the informant ratings. All informant version scales significantly discriminated amnestic mild cognitive impairment cases and patients with mild dementia from normals. CONCLUSION: These findings provide support for the use of the checklist as a clinical tool to facilitate identification of cases of mild cognitive impairment and early dementia.

Further issues in determining the readability of self-report items: comment on McHugh and Behar (2009).

OBJECTIVE: Issues regarding the readability of self-report assessment instruments, methods for establishing the reading ability level of respondents, and guidelines for development of scales designed for marginal readers have been inconsistently addressed in the literature. A recent study by McHugh and Behar (2009) provided new findings relevant to these issues. McHugh and Behar calculated indices of readability separately for the instructions and the item sets of 105 self-report measures of anxiety and depression. Results revealed substantial variability in readability among the measures, with most measures being written at or above the mean reading grade level in the United States. These results were consistent with those reported previously by Schinka and Borum (1993, 1994) in analyses of the readability of commonly used self-report psychopathology and personality inventories. In their discussion, McHugh and Behar addressed implications of their findings for clinical assessment and for scale development. METHOD: I expand on their comments by addressing the failure to consider vocabulary difficulty, a major shortcoming of readability indices that examine only text complexity. I demonstrate how vocabulary difficulty influences readability and discuss additional considerations and possible solutions for addressing the gap between scale readability and the reading skill level of the self-report respondent. RESULTS AND CONCLUSION: The work of McHugh and Behar clearly demonstrates that the issues of reading ability that arise in collecting self-report data are neither simple nor straightforward. Comments are offered to focus attention on the problems identified by their work. These problems will require additional effort on the part of researchers and clinicians in order to obtain reliable, valid estimates of clinical status.

An investigation of PreMCI: subtypes and longitudinal outcomes.

BACKGROUND/AIMS: To investigate the clinical features and rates of progression of conditions that are not considered to be normal, but do not fulfill criteria for mild cognitive impairment (MCI). METHODS: We longitudinally evaluated 269 elderly subjects who did not meet formal criteria for MCI at baseline but had: (1) a clinical history suggesting MCI without neuropsychological deficits (PreMCI-Clinical); or (2) neuropsychological deficits on one or more memory measures in conjunction with a negative clinical examination (amnestic PreMCI-NP) or were normal on both neuropsychological and clinical examination. RESULTS: The rate of progression to MCI or dementia over an average of 2- to 3 years was 3.7% for no cognitive impairment subjects, whereas it was significantly greater for all PreMCI subtypes (22.0% for PreMCI-Clinical, 38.9% for amnestic PreMCI-NP subjects with two or more memory impairments). Among PreMCI subjects as a whole, lower baseline scores on object memory and category fluency tests were the best predictors of progression to MCI or dementia. Cardiovascular risk factors, Parkinsonian symptoms, and hippocampal atrophy were not associated with progression. CONCLUSION: Distinct PreMCI subtypes defined on the basis of clinical and neuropsychological evaluations were found to have distinct characteristics, but both subtypes demonstrated elevated risk for progression to MCI or dementia. Despite the lack of evidence of clinical impairment, subjects with neuropsychological deficits in two memory domains were particularly at increased risk for progression of their deficits.

Suicidal behavior in a national sample of older homeless veterans.

OBJECTIVES: We examined self-reported suicidal behavior of older homeless veterans to establish frequencies and predictors of recent suicidal behaviors, and their impact on transitional housing interventions. METHODS: We analyzed the records of a national sample of 10,111 veterans who participated in a transition housing program over a 6-year period, ending in 2008. RESULTS: Approximately 12% of homeless veterans reported suicidal ideation before program admission; 3% reported a suicide attempt in the 30 days before program admission. Older homeless veterans exhibiting suicidal behavior had histories of high rates of psychiatric disorders and substance abuse. Regression analyses showed that self-report of depression was the primary correlate of suicidal behavior. Suicidal behavior before program entry did not predict intervention outcomes, such as program completion, housing outcome, and employment. CONCLUSIONS: Suicidal behavior was prevalent in older homeless veterans and was associated with a history of psychiatric disorder and substance abuse. Self-reported depression was associated with these behaviors at the time of housing intervention. Despite the association with poor mental health history, suicidal behavior in older homeless veterans did not impact outcomes of transitional housing interventions.

Assessment of cognition in early dementia.

Better tools for assessing cognitive impairment in the early stages of Alzheimer's disease (AD) are required to enable diagnosis of the disease before substantial neurodegeneration has taken place and to allow detection of subtle changes in the early stages of progression of the disease. The National Institute on Aging and the Alzheimer's Association convened a meeting to discuss state of the art methods for cognitive assessment, including computerized batteries, as well as new approaches in the pipeline. Speakers described research using novel tests of object recognition, spatial navigation, attentional control, semantic memory, semantic interference, prospective memory, false memory and executive function as among the tools that could provide earlier identification of individuals with AD. In addition to early detection, there is a need for assessments that reflect real-world situations in order to better assess functional disability. It is especially important to develop assessment tools that are useful in ethnically, culturally and linguistically diverse populations as well as in individuals with neurodegenerative disease other than AD.

Requiring sobriety at program entry: impact on outcomes in supported transitional housing for homeless veterans.

OBJECTIVE: An important distinction in models of housing for the homeless is whether programs that require abstinence prior to program admission produce better outcomes than unrestricted programs. Data from a large transitional housing program were used to compare client characteristics of and outcomes from programs requiring abstinence at admission and programs not requiring abstinence. METHODS: The U.S. Department of Veterans Affairs (VA) Northeast Program Evaluation Center provided records of individuals who were admitted into, and discharged from, the VA Grant and Per Diem program in 2003-2005. Records contained information from intake interviews, program discharge information, and descriptions of provider characteristics. Analyses were based on 3,188 veteran records, 1,250 from programs requiring sobriety at admission and 1,938 from programs without a sobriety requirement. Group differences were examined with t tests and chi square analyses; predictors of program outcome were determined with logistic regression. RESULTS: Individuals using drugs or alcohol at program admission had more problematic histories, as indicated by several general health and mental health variables, and shorter program stays. There were significant differences between groups in the frequency of program completion, recidivism for homelessness, and employment on program discharge, but effect sizes for these analyses were uniformly small and of questionable importance. Regression analyses did not find meaningful support for the importance of sobriety on program entry on any of the outcome measures. CONCLUSIONS: The results add evidence to the small body of literature supporting the position that sobriety on program entry is not a critical variable in determining outcomes for individuals in transitional housing programs.

Use of informants to identify mild cognitive impairment in older adults.

Extensive research supports the use of informant ratings in diagnosing dementia. In comparison, far fewer studies have examined the use of informant ratings in identifying mild cognitive impairment (MCI), a state that occurs as healthy older adults make the gradual transition to dementia. A review of available studies that have examined discrepancies between MCI patient and informant reports has for the most part demonstrated that informant ratings reveal greater loss of everyday functional ability and cognitive competency. Additionally, current findings support a significantly greater association of informant ratings with objective measures of patient cognitive performance and characteristics of underlying dementing processes. Structured measures used to examine the diagnostic efficacy of informant ratings in identifying cases of MCI are reviewed. Two recently developed instruments seem especially promising, but further validation efforts will be required before they can be considered to meet standards for clinical use.

Use of mental health services by nursing home residents after hurricanes.

OBJECTIVE: A growing body of research supports the value of mental health intervention to treat people affected by disasters. This study used a mixed-methods approach to evaluate pre- and posthurricane mental health service use in Florida nursing homes. METHODS: A questionnaire was administered to 258 directors of nursing, administrators, and owners of nursing homes, representing two-thirds of Florida's counties, to identify residents' mental health needs and service use. In four subsequent focus group meetings with 22 nursing home administrators, underlying factors influencing residents' use of services were evaluated. RESULTS: Although most nursing homes provided some type of mental health care during normal operations, disaster-related mental health services were not routinely provided to residents. Receiving facilities were more likely than evacuating facilities to provide treatment to evacuated residents. CONCLUSIONS: Nursing home staff should be trained to deliver disaster-related mental health intervention and in procedures for making referrals for follow-up evaluation and formal intervention.