Beverly N. Jones

Incidence and Prevalence of Dementia in the Cardiovascular Health Study

Objectives: To estimate the incidence and prevalence of dementia, Alzheimers disease (AD), and vascular dementia (VaD) in the Cardiovascular Health Study (CHS) cohort.

The Women’s Health Initiative Memory Study (WHIMS): A Trial of the Effect of Estrogen Therapy in Preventing and Slowing the Progression of Dementia

Evidence from animal, human cross-sectional, case-control, and prospective studies indicate that hormone replacement therapy (HRT) is a promising treatment to delay the onset of symptoms of dementia. The Womens Health Initiative Memory Study (WHIMS) is the first double-masked, randomized, placebo-controlled, long-term clinical trial designed to test the hypothesis that HRT reduces the incidence of all-cause dementia in women aged 65 and older. WHIMS, an ancillary study to the Womens Health Initiative (WHI) funded by the National Institutes of Health, will recruit a subgroup of women aged 65 and older from among those enrolling in the HRT trial of the WHI. The WHI clinical centers and 10 affiliated satellites plan to enroll approximately 8300 women into WHIMS over a 2-year period. Participants will be followed annually for 6 years, receiving cognitive assessments via the Modified Mini-Mental State (3MS) Examination. Women who screen positively for cognitive impairment on the basis of an educational and age-adjusted 3MS cutpoint proceed to more extensive neuropsychological testing and neurologic evaluation. Each woman suspected to have dementia then undergoes a series of laboratory tests that confirm the clinical diagnosis and classify the type of dementia. WHIMS is designed to provide more than 80% statistical power to detect a 40% reduction in the rate of all-cause dementia, an effect that could have profound public health implications for older womens health and functioning.

Neuropsychological characteristics of mild cognitive impairment subgroups

Objective: To describe the neuropsychological characteristics of mild cognitive impairment (MCI) subgroups identified in the Cardiovascular Health Study (CHS) cognition study. Methods: MCI was classified as MCI-amnestic type (MCI-AT): patients with documented memory deficits but otherwise normal cognitive function; and MCI-multiple cognitive deficits type (MCI-MCDT): impairment of at least one cognitive domain (not including memory), or one abnormal test in at least two other domains, but who had not crossed the dementia threshold. The MCI subjects did not have systemic, neurological, or psychiatric disorders likely to affect cognition. Results: MCI-AT (n = 10) had worse verbal and non-verbal memory performance than MCI-MCDT (n = 28) or normal controls (n = 374). By contrast, MCI-MCDT had worse language, psychomotor speed, fine motor control, and visuoconstructional function than MCI-AT or normal controls. MCI-MCDT subjects had memory deficits, though they were less pronounced than in MCI-AT. Of the MCI-MCDT cases, 22 (78.5%) had memory deficits, and 6 (21.5%) did not. MCI-MCDT with memory disorders had more language deficits than MCI-MCDT without memory disorders. By contrast, MCI-MCDT without memory deficits had more fine motor control deficits than MCI-MCDT with memory deficits. Conclusions: The most frequent form of MCI was the MCI-MCDT with memory deficits. However, the identification of memory impaired MCI groups did not reflect the true prevalence of MCI in a population, as 16% of all MCI cases and 21.5% of the MCI-MCDT cases did not have memory impairment. Study of idiopathic amnestic and non-amnestic forms of MCI is essential for an understanding of the aetiology of MCI.

A New Bedside Test of Cognition for Patients with HIV Infection

Cognitive impairment is a frequent complication of human immunodeficiency virus (HIV) infection [1-3]. The nomenclature and criteria for the classification of cognitive impairment in patients with HIV infection are being developed [4, 5]. The cognitive impairment associated with HIV infection includes slowed mentation, poor concentration, and impaired psychomotor speed [6-9]. Tests of focused attention and speed of performance are most sensitive to HIV-related cognitive changes [10], as they are to subcortical dementia [1, 2, 11, 12]. Primary caretakers need methods of screening for cognitive impairment in patients with HIV infection or the acquired immunodeficiency syndrome (AIDS) [13], because detailed psychological evaluation is expensive and time consuming. The ideal screening test would identify patients for whom further neuropsychological testing of a comprehensive nature could be helpful. One of us (ELT) developed the Mental Alternation Test, which is modeled on the Trailmaking Test. We predicted that this test, which involves timed performance of a sequencing and category-switching task, would be sensitive to HIV-related cognitive impairment. Our goal was to determine if the Mental Alternation Test could be used at the bedside to quickly identify patients who had abnormal performance on both the MMSE and the Trailmaking Test, part B. Methods Patients Consecutive inpatients admitted to the Osler 8 AIDS service at Johns Hopkins Hospital during a 2-month period were asked to participate in the study. Seven outpatients from the Johns Hopkins Moore Clinic were also tested. Patients who were in acute distress, recovering from surgery or invasive procedures, or terminally ill were excluded. Patients were only tested if they were alert and judged not to be delirious. Sixty-two patients completed the testing. Approximately 40 patients were excluded by the ward research coordinator because they were seriously ill; these patients were more likely to be delirious or moribund, or both, than were those who participated. Approximately five patients declined to participate; these patients did not differ systematically from the participants. Testing The Mini-Mental State Exam (MMSE) is a brief screening test of cognition that measures orientation, memory, concentration, language, and praxis [14]. The Trailmaking Test, parts A and B [15], requires persons to draw a line connecting circles in a specified sequence. Part A assesses psychomotor speed and sequencing ability; part B assesses the ability to switch between two categories. The Mental Alternation Test requires alternation between numbers and letters. Patients were told that the researchers were interested in testing their thinking and memory, that they might find some questions difficult and others easy, and that their best effort would be appreciated. Patients are asked to count to 20, say the alphabet, and then alternate between the numbers and letters in the following fashion: 1-A, 2-B, 3-C . Progressing from the most recent number or letter to the next letter or number in the sequence is one alternation. The number of correct alternations in 30 seconds, discounting any errors, determines the score. The maximum score is 52 points. The MMSE was administered first, followed by either the Trailmaking Test or the Mental Alternation Test, the order being alternated between successive patients to control for any learning effect. Patients were tested in the late morning or early afternoon, usually at 10 a.m. or 2 p.m. The tests were administered by a psychiatrist and an internist to the first 25 patients and by the internist to the remaining participants. The MMSE required between 5 and 10 minutes for administration; the Trailmaking Test, parts A and B, required from 7 to 15 minutes, whereas the Mental Alternation Test was administered in less than 1 minute. Data Analysis To determine the relation between the performance on the Mental Alternation Test and the better standardized tests, we calculated correlation coefficients among scores on the MMSE; the Trailmaking Test, part B; and the Mental Alternation Test. To find the utility of using performance on the Mental Alternation Test to predict cognitive impairment as measured by scores on the MMSE and the Trailmaking Test, part B, we calculated the sensitivity and specificity of various Mental Alternation Test cutoff values in identifying abnormal performance on the MMSE and the Trailmaking Test, part B, based on population norms [16, 17]. A chi-square analysis was done to determine the likelihood that patients with an abnormal Mental Alternation Test score would have abnormal scores on the MMSE and the Trailmaking Test, part B. A general linear model analysis of the MMSE score was conducted to determine whether the Mental Alternation Test score was a significant source of variance when age, sex, educational level, intravenous drug use, homosexual activity, and performance on the Trailmaking Test, parts A and B, were included in the model. A single examiner (KSH) administered the Mental Alternation Test twice in the same day to a series of 20 patients to determine test-retest reliability. Two investigators (BNJ, KSH) independently scored a tape recording of 15 persons performing the Mental Alternation Test, and inter-rater reliability was calculated. Results Patient characteristics are shown in Table 1. The Mental Alternation Test scores ranged from 0 to 35 (mean SD, 16.8 8.5). Scores on the MMSE ranged from 12 to 30 (mean, 25.0 4.0). Scores on the Trailmaking Test, part A, ranged from 20 to 300 s (mean, 72.8 68.8 s). The mean score on the Trailmaking Test, part B, was 238 199 s; scores ranged from 50 to 600 s (10 patients unable to complete the test were assigned a null value of 600 s). The Mental Alternation Test score correlated significantly at the P < 0.001 level with the MMSE score (r = 0.68); the Trailmaking Test, part A, score (r = 0.53);and the Trailmaking Test, part B, score (r = 0.54).A scatterplot of Mental Alternation Test scores and MMSE scores is shown in Figure 1. Table 1. Patient Characteristics* Figure 1. Scatterplot of Mini-Mental State Exam (MMSE) scores versus Mental Alternation Test scores. A general linear model for variation fitted with covariants showed only the Trailmaking Test, part B, and the Mental Alternation Test to be significant covariates at the P < 0.05 significance level. These two covariants accounted for 61% of the total variation in the MMSE score. Reliability as measured by test-retest correlation gave a Pearson correlation coefficient of 0.80. The Pearson correlation coefficient for inter-rater reliability was 0.85. Using cutoff scores of 15/14 on the Mental Alternation Test to divide performance into normal and abnormal, we found that agreement between raters was high (, 0.84). A receiver operating curve is a graphic presentation of one tests sensitivity and false-positive rate (1 specificity) along a range of thresholds or cutoff scores for identifying a case, that is, abnormality as defined by some other measure [18, 19]. In our study, a case was defined as a patient with an abnormal MMSE or Trailmaking Test score. Having established a significant correlation between the Mental Alternation Test and the MMSE and Trailmaking Test, we then wished to know how to use the new test of cognition to identify such cases (that is, what constituted normal and abnormal Mental Alternation Test scores). The MMSE scores were recoded as normal if 24 or above and abnormal if lower based on established norms [16]. Trailmaking Test, part B, scores were recoded as abnormal if greater than 140 s, a value 2 standard deviations above the average score for an age-appropriate sample [18]. The appropriateness of different cutoff values for defining the abnormal Mental Alternation score was determined by calculating the sensitivity and specificity of each cut-off score for identifying cases with abnormal scores on the MMSE and Trailmaking Test, part B. The most appropriate value will have a position on the receiver operating curve in the uppermost left-hand corner, corresponding to a high sensitivity and low false-positive rate (high specificity). A Mental Alternation Test cutoff score of 15 yielded the best results for the MMSE (sensitivity, 95% [95% CI, 90% to 100%]; specificity, 79% [CI, 69% to 89%]) (Figure 2, Table 2) and for the Trailmaking test, part B (sensitivity, 78% [CI, 68% to 88%]; specificity, 93% [CI, 90% to 100%]). Patients making fewer than 15 alternations in 30 seconds were significantly more likely to have abnormal scores on the MMSE (P < 0.0001) and the Trailmaking test, part B (P < 0.0001). Table 2. Sensitivity and Specificity of Various Cutoff Scores for the Mental Alternation Test To Detect Abnormal MMSE Score Figure 2. Receiver operating curve. Discussion The Mental Alternation Test is a verbal test of cognition that can be easily and quickly administered to patients at risk for cognitive impairment. The Mental Alternation Test had high sensitivity and specificity for abnormal performance on the MMSE and the Trailmaking Test, part B; patients making fewer than 15 correct alternations in 30 seconds were significantly more likely to have an abnormal MMSE score. Most participants in this study were inpatients, many of whom had advanced-stage AIDS. They had several potential causes for cognitive impairment, many of which are shared with the general hospital population. The success of the Mental Alternation Test in this population suggests it may also be useful in the general hospital population. The impairments detected in our study participants cannot be assumed to be caused by HIV infection alone, and the utility of the Mental Alternation Test in ambulatory, asymptomatic persons cannot be determined from our study. However, our sample included persons who scored normally on the MMSE, indicating that not all persons in our sample had gross cognitive impairment as detectable by th

Telemedicine Use and the Reduction of Psychiatric Admissions from a Long-Term Care Facility

Copper Ridge is a long-term care facility that provides care for persons with dementia and their families from early diagnosis to end of life. A low-cost videoconferencing system was employed in the development of a comprehensive, integrated continuum of care for Copper Ridge residents by bridging long-term care with inpatient psychiatric care at Johns Hopkins Hospital. In this article, we discuss the Copper Ridge/Johns Hopkins telemedicine project and how its operation appears to have brought about a reduction in psychiatric admissions. Telemedicine projects using inexpensive technology over standard telephone lines can be successfully used in long-term care settings. (J Geriatr Psychiatry Neurol 2001; 14:76-79).

Baseline experience with Modified Mini Mental State Exam: The Women's Health Initiative Memory Study (WHIMS)

The Modified Mini Mental State Exam (3MS) is widely used for screening global cognitive functioning, however little is known about its performance in clinical trials. We report the distribution of 3MS scores among women enrolled in the Womens Health Initiative Memory Study (WHIMS) and describe differences in these scores associated with age, education, and ethnicity. The 3MS exams were administered to 7,480 women aged 65-80 who had volunteered for and were eligible for a clinical trial on postmenopausal hormone therapy. General linear models were used to describe demographic differences among scores. Factor analysis was used to characterize the correlational structure of exam subscales. The distribution of 3MS scores at baseline was compressed in WHIMS compared to population-based data. Mean 3MS scores (overall 95.1) tended to decrease with age and increase with education, however these associations varied among ethnic groups ( p < 0.0001) even after adjustment for health, physical disability and occupation attainment. Four factors accounted for 37% of the total variance. Each varied with education and ethnicity; the two most prominent factors also varied with age. Despite relatively narrow distributions in WHIMS, baseline 3MS scores retained associations with age and education. These associations varied among ethnic groups, so that care must be taken in comparing data across populations.

Telemedicine and Geriatric Psychiatry: Directions for Future Research and Policy:

The use of telecommunications to provide mental health services at a distance has grown rapidly in the past 10 years. The overall experience has been positive, but evaluations and reliability studies have been preliminary A funda mental question of what constitutes adequate technology for telepsychiatry remains unanswered. As technology and equipment capability change rapidly, a more important question may be what clinical decisions and behavioral observations are required to produce high standards of distance mental health care. Geriatric patients may have sensory impairments and unique aspects to their psychiatric problems that can make telemental health assess ments more challenging. It is not clear what model of telepsychiatry constitutes the best practice for geriatric psychiatry. Future research and program evaluations should address these questions to guide the use of tele psychiatry in productive directions. (J Geriatr Psychiatry Neurol 2001; 14:59-62).

Subtypes of mild cognitive impairment in older postmenopausal women: the Women's Health Initiative Memory Study.

Mild cognitive impairment (MCI) is a transitional state between normal cognitive functioning and dementia. A proposed MCI typology classifies individuals by the type and extent of cognitive impairment, yet few studies have characterized or compared these subtypes. Four hundred forty-seven women 65 years of age and older from the Womens Health Initiative Memory Study were classified into the 4 MCI subgroups and a “no impairment” group and compared on clinical, sociodemographic, and health variables. A cognitive deficit in at least 1 domain was present in 82.1% of participants, with most (74.3%) having deficits in multiple cognitive domains. Only 4.3% had an isolated memory deficit, whereas 21.3% had an isolated nonmemory deficit. Of the 112 women who met all MCI criteria examined, the most common subtype was amnestic multidomain MCI (42.8%), followed by nonamnestic multiple domain MCI (26.7%), nonamnestic single domain (24.1%), and amnestic single domain MCI (6.3%). Subtypes were similar with respect to education, health status, smoking, depression, and prestudy and onstudy use of hormone therapy. Despite the attention it receives in the literature, amnestic MCI is the least common type highlighting the importance of identifying and characterizing other nonamnestic and multidomain subtypes. Further research is needed on the epidemiology of MCI subtypes, clinical and biologic differences between them, and rates for conversion to dementia.

Depression coexisting with dementia: Evaluation and Treatment

Depression and dementia are the most common syndromes of geriatric psychiatry. Although emphasis is often placed on distinguishing the two, patients frequently have both disorders. Treating the complications of irreversible dementia, while unaltering the underlying disease process, can result in significant functional improvement in affected patients.

Service Use and Financial Performance in a Replication Program on Adult Day Centers

The authors describe results from Partners in Caregiving: The Dementia Services Program, and present information on service utilization and financial performance among a group of 48 adult day centers across the United States from 1992 to 1996. Centers, with nonrandom assignment, received either grant support (average value: