Janine Stein

Longitudinal Predictors of Institutionalization in Old Age.

Objective To investigate time-dependent predictors of institutionalization in old age using a longitudinal approach. Methods In a representative survey of the German general population aged 75 years and older predictors of institutionalization were observed every 1.5 years over six waves. Conditional fixed-effects logistic regressions (with 201 individuals and 960 observations) were performed to estimate the effects of marital status, depression, dementia, and physical impairments (mobility, hearing and visual impairments) on the risk of admission to old-age home or nursing home. By exploiting the longitudinal data structure using panel econometric models, we were able to control for unobserved heterogeneity such as genetic predisposition and personality traits. Results The probability of institutionalization increased significantly with occurrence of widowhood, depression, dementia, as well as walking and hearing impairments. In particular, the occurrence of widowhood (OR = 78.3), dementia (OR = 154.1) and substantial mobility impairment (OR = 36.7) were strongly associated with institutionalization. Conclusion Findings underline the strong influence of loss of spouse as well as dementia on institutionalization. This is relevant as the number of old people (a) living alone and (b) suffering from dementia is expected to increase rapidly in the next decades. Consequently, it is supposed that the demand for institutionalization among the elderly will increase considerably. Practitioners as well as policy makers should be aware of these upcoming challenges.

Assessing cognitive changes in the elderly: Reliable Change Indices for the Mini‐Mental State Examination

Stein J, Luppa M, Maier W, Wagner M, Wolfsgruber S, Scherer M, Köhler M, Eisele M, Weyerer S, Werle J, Bickel H, Mösch E, Wiese B, Prokein J, Pentzek M, Fuchs A, Leicht H, König H‐H, Riedel‐Heller SG for the AgeCoDe Study Group. Assessing cognitive changes in the elderly: Reliable Change Indices for the Mini‐Mental State Examination.

The Assessment of Changes in Cognitive Functioning: Reliable Change Indices for Neuropsychological Instruments in the Elderly - A Systematic Review

Background/Aims: The determination of meaningful cognitive change over time is essential for the diagnosis of dementia in the elderly. Reliable change indices (RCIs) represent a suitable methodology to assess clinically significant cognitive change. The purpose of this paper is to provide a systematic review of RCI scores in elderly persons for neuropsychological tests currently available. Methods: A comprehensive literature search was conducted. Longitudinal studies dealing with the assessment of RCIs for cognitive instruments and cognitively healthy older participants were reviewed. Quality of studies was determined using a standardized system of evaluating methodical quality. Results: A total of 11 studies met the inclusion criteria; half of the studies rated highly for methodical quality. RCI scores were summarized for a number of neuropsychological instruments. Conclusion: RCIs have important implications regarding the interpretation of change in test scores in older adults. Further assessment and standardization is needed for many neuropsychological instruments.

The CERAD Neuropsychological Assessment Battery Total Score Detects and Predicts Alzheimer Disease Dementia with High Diagnostic Accuracy

OBJECTIVES To establish the diagnostic accuracy of the Total Score of the Consortium to Establish a Registry for Alzheimers Disease neuropsychological assessment battery (CERAD-NP) both for cross-sectional discrimination of Alzheimer disease (AD) dementia and short-term prediction of incident AD dementia. DESIGN Longitudinal cohort study with two assessments at a 1.5-year interval. SETTING Primary care sample randomly recruited via medical record registries. PARTICIPANTS As part of the German Study on Ageing, Cognition, and Dementia (AgeCoDe), a sample of elderly individuals (N = 1,606; mean age: 84 years) was assessed. MEASUREMENTS Subjects were assessed with the CERAD-NP and followed up for 18 months (97.6% follow-up rate). Logistic regression and receiver-operating-characteristic (ROC) curve analysis were used to compare the diagnostic accuracy of the CERAD-NP Total Score (CTS) with that of single CERAD-NP scores and the Mini-Mental-State-Examination (MMSE) score. RESULTS ROC curve analysis resulted in excellent (area under the curve [AUC]: 0.97) cross-sectional discrimination between non-AD and AD dementia subjects. Prediction of incident AD dementia with the CTS was also very good (AUC: 0.89), and was significantly better than prediction based on the MMSE. CONCLUSIONS The cross-sectional results confirm that the CTS is a highly accurate diagnostic tool for detecting AD dementia in elderly primary care patients. In addition, we provide evidence that the CTS is also accurate for the prediction of incident AD dementia. These findings further support the validity of the CTS as an index of overall cognitive functioning for detection and prediction of AD dementia.

Predictors of Institutionalisation in Incident Dementia – Results of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study)

Background/Aims: In the past few decades, a number of studies investigated risk factors of nursing home placement (NHP) in dementia patients. The aim of the study was to investigate risk factors of NHP in incident dementia cases, considering characteristics at the time of the dementia diagnosis. Methods: 254 incident dementia cases from a German general practice sample aged 75 years and older which were assessed every 1.5 years over 4 waves were included. A Cox proportional hazard regression model was used to determine predictors of NHP. Kaplan-Meier survival curves were used to evaluate the time until NHP. Results: Of the 254 incident dementia cases, 77 (30%) were institutionalised over the study course. The mean time until NHP was 4.1 years. Significant characteristics of NHP at the time of the dementia diagnosis were marital status (being single or widowed), higher severity of cognitive impairment and mobility impairment. Conclusion: Marital status seems to play adecisive role in NHP. Early initiation of support of sufferers may ensure remaining in the familiar surroundings as long as possible.

Indicators for Healthy Ageing — A Debate

Definitions of healthy ageing include survival to a specific age, being free of chronic diseases, autonomy in activities of daily living, wellbeing, good quality of life, high social participation, only mild cognitive or functional impairment, and little or no disability. The working group Epidemiology of Ageing of the German Association of Epidemiology organized a workshop in 2012 with the aim to present different indicators used in German studies and to discuss their impact on health for an ageing middle-European population. Workshop presentations focused on prevalence of chronic diseases and multimorbidity, development of healthy life expectancy at the transition to oldest-age, physical activity, assessment of cognitive capability, and functioning and disability in old age. The communication describes the results regarding specific indicators for Germany, and hereby contributes to the further development of a set of indicators for the assessment of healthy ageing.

Predictors of frailty in old age–results of a longitudinal study

ObjectivesTo investigate time-dependent predictors of frailty in old age longitudinally.DesignPopulation-based prospective cohort study.SettingElderly individuals were recruited via GP offices at six study centers in Germany. The course of frailty was observed over 1.5 years (follow up wave 4 and follow up wave 5).Participants1,602 individuals aged 80 years and older (mean age 85.4 years SD 3.2, with mean CSHA CFS 3.5 SD 1.6) at follow up wave 4.MeasurementsFrailty was assessed by using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA CFS), ranging from 1 (very fit) to 7 (severely frail).ResultsFixed effects regressions revealed that frailty increased significantly with increasing age (ß=.2) as well as the occurrence of depression (ß=.5) and dementia (ß=.8) in the total sample. Changes in marital status and comorbidity did not affect frailty. While the effects of depression and dementia were significant in women, these effects did not achieve statistical significance in men.ConclusionOur findings highlight the role of aging as well as the occurrence of dementia and depression for frailty. Specifically, in order to delay frailty in old age, developing interventional strategies to prevent depression might be a fruitful approach.

Differential Risk of Incident Alzheimer’s Disease Dementia in Stable Versus Unstable Patterns of Subjective Cognitive Decline

BACKGROUND It is unknown whether longitudinal stability versus instability in subjective cognitive decline (SCD) is a modifying factor of the association between SCD and risk of incident Alzheimers disease (AD) dementia. OBJECTIVE We tested the modifying role of temporal stability of the SCD report on AD dementia risk in cognitively normal elderly individuals. METHODS We analyzed data of 1,990 cognitively normal participants from the longitudinal AgeCoDe Study. We assessed SCD with/without associated worries both at baseline and first follow-up 18 months later. Participants were then classified either as (a) Controls (CO, with no SCD at both baseline and follow-up 1, n = 613), (b) inconsistent SCD (with SCD reported only at baseline or at follow-up 1, n = 637), (c) consistent SCD but without/or with inconsistent worries (n = 610) or (d) consistent SCD with worries (n = 130). We estimated incident AD dementia risk over up to 6 years for each group with Cox-Proportional Hazard Regression analyses adjusted for age, gender, education, ApoE4 status, and depression. RESULTS Compared to CO, inconsistent SCD was not associated with increased risk of incident AD dementia. In contrast, risk was doubled in the group of consistent SCD without/ with inconsistent worries, and almost 4-fold in the group of consistent SCD with worries. These results could be replicated when using follow-up 1 to follow-up 2 response patterns for group definition. CONCLUSION These findings suggest that longitudinal stability versus instability is an important modifying factor of the association between SCD and AD dementia risk. Worrisome SCD that is also consistently reported over time is associated with greatly increased risk of AD dementia.

The Assessment of Changes in Cognitive Functioning: Age-, Education-, and Gender-Specific Reliable Change Indices for Older Adults Tested on the CERAD-NP Battery: Results of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe)

OBJECTIVES The Consortium to Establish a Registry for Alzheimers Disease-Neuropsychological (CERAD-NP) battery represents a commonly used neuropsychological instrument to measure cognitive functioning in the elderly. This study provides normative data for changes in cognitive function that normally occur in cognitively healthy individuals to interpret changes in CERAD-NP test scores over longer time periods. DESIGN Longitudinal cohort study with three assessments at 1.5-year intervals over a period of 3 years. SETTING : Primary care medical record registry sample. PARTICIPANTS As part of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients, a sample of 1,450 cognitively healthy general practitioner patients, age 75 years and older, was assessed. MEASUREMENTS Age-, education-, and gender-specific Reliable Change Indices (RCIs) were computed for a 90% confidence interval for selected subtests of the CERAD-NP battery. RESULTS Across different age, education, and gender subgroups, changes from at least six to nine points in Verbal Fluency, four to eight points in Word List Memory, two to four points in Word List Recall, and one to four points in Word List Recognition indicated significant (i.e. reliable) changes in CERAD-NP test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated. CONCLUSIONS Smaller changes in CERAD-NP test scores can be interpreted with only high uncertainty because of probable measurement error, practice effects, and normal age-related cognitive decline. This study, for the first time, provides age-, education-, and gender-specific CERAD-NP reference values on the basis of RCI methods for the interpretation of cognitive changes in older-age groups.

Depressionsscreening am Telefon mittels der Allgemeinen Depressionsskala (ADS)

OBJECTIVE Analyses of the reliability and validity of the German version of the Center for Epidemiological Studies Depression Scale (CES-D) and the assessment of normative values. METHOD A representative sample of 868 people (German population, 18 to 94 years) was assessed via structured interviews in a telephone survey. RESULTS According to the cut-off score of 16 points, 8.5 % of the total sample (11.0 % women and 5.6 % men) showed relevant depressive symptoms. When using the cut-off score of 22 points, 3.5 % of the subjects of the total sample, 4.2 % of the women and 2.5% of the men, were classified as depressed. The analysis of the psychometric properties of the instrument such as internal consistency, test-retest reliability, construct validity and factor structure revealed moderate to good results. Percentile standard values were determined. CONCLUSION The German version of the CES-D can be described as a reliable and valid instrument for detecting depressive symptoms. The present study offers current normative data for the specific use in telephone surveys.