Jason E. Schillerstrom

Depression, disability and intermediate pathways: a review of longitudinal studies in elders.

Cross-sectional studies demonstrate depression is associated with disability in elders. These studies also report that disability in depressed elders is associated with greater medical illness burden, cognitive impairment, and behavioral changes. Only longitudinal studies, however, can determine the impact of depression and its comorbidities on functional decline. This review summarizes the findings of 20 longitudinal studies examining the relationship between baseline or incident depression and functional decline. However, the mediational effects of potential risk factors identified by cross-sectional studies cannot be derived from the current literature. We propose a mediational effects model for future longitudinal studies, incorporating measures sensitive to both mood symptoms and the medical, cognitive, and behavioral comorbidities of depression to better understand the impact of each on functional decline and to focus future clinical interventions.

Psychopharmacological Treatment for Cognitive Impairment in Survivors of Traumatic Brain Injury: A Critical Review

Traumatic brain injury (TBI) is a growing national health issue that commonly results in clinically significant cognitive impairments. This article reviews and evaluates the many proposed psychopharmacological treatments for TBI-related cognitive impairment. A literature review was utilized to focus on stimulant and nonstimulant dopamine enhancing agents, acetylcholinesterase inhibitors, antidepressant agents, mood stabilizers, antipsychotics, and benzodiazepines. The most consistent evidence supports the use of dopamine enhancing medications. However, other medications such as acetylcholinesterase inhibitors and antidepressant agents may help select subgroups. A need remains for well designed, sufficiently powered studies that incorporate functionally relevant neuropsychological outcome measures.

Documented combat‐related mental health problems in military noncombatants

Although combat-related posttraumatic stress disorder (PTSD) has been documented for military combatants, little is known about PTSD in noncombatants. Active-duty U.S. Air Force noncombatants (N = 5,367) completed a Post-Deployment Health Assessment upon return from combat zones in Iraq (n = 4,408) or a noncombat zone in Qatar (n = 959). Those deployed to Iraq were significantly more likely to report exposure to someone who was wounded or killed (20.8% vs. 6.3%), feeling in great danger of being killed at some point during deployment (18.9% vs. 3.5%), symptoms of PTSD (4.1% vs. 0.7%), and symptoms of major depression (9.9% vs. 5.4%). These findings suggest that deployment to a war zone is associated with increased mental health problems, even for noncombatants.

Informing Evidence-Based Practice: A Review of Research Analyzing Adult Protective Services Data

The mission of Adult Protective Services (APS) is to protect older and vulnerable adults from abuse, neglect, and exploitation. The complexity of APS cases and the potential for life-changing interventions point to the need for research that examines and evaluates APS practices. A literature review identified 50 studies published during a 16-year period that used APS agencies, clients, data, or resources to test hypotheses regarding elder abuse. The analysis revealed promising efforts toward knowledge development about elder mistreatment and self-neglect. This article provides an overview of salient findings, notes the scarcity of studies that analyze the effectiveness of APS, and highlights the need for additional research. Lessons learned are described, and APS practitioners and researchers are urged to work collaboratively to develop key practice-related questions about APS processes and outcomes that can be tested with appropriate research methodologies.

Executive Function in Self-Neglecting Adult Protective Services Referrals Compared With Elder Psychiatric Outpatients

OBJECTIVE Psychometric performance, with an emphasis on executive function, was compared between adult protective services (APS) clients referred for a decision-making capacity consultation and elders seen in an outpatient geriatric psychiatry clinic. METHODS The authors performed a retrospective medical records review extracting general, executive, and visuospatial cognitive performance and depression symptom burden in APS referrals (N = 63) and geriatric psychiatry outpatients (N = 58). RESULTS After adjusting for age and education, APS clients had worse mean executive performance as measured by the Executive Interview (24.3 [SD 6.4] versus 17.3 [SD 7.6], F[1, 87] 15.7, p <0.001) and CLOX1 (7.4 [SD 4.0] versus 9.3 [SD 4.2], F[1, 92] 4.79, p = 0.03). There were no differences in visuospatial or general cognitive abilities. The self-neglect subgroup had worse cognitive performance on each measure than other APS referrals. CONCLUSIONS Compared with routine geriatric psychiatry patients, APS referrals are more likely to be executively impaired but less depressed. General cognitive screens do not distinguish these two groups.

Executive clock drawing correlates with performance-based functional status in people with combat-related mild traumatic brain injury and comorbid posttraumatic stress disorder

Executive Clock Drawing Tasks (CLOX parts 1 and 2) can predict functional impairment. This study determined the correlation between CLOX and other psychometric screening instruments with the Structured Assessment of Independent Living Skills (SAILS)-defined performance-based functional status in people with combat-related mild traumatic brain injury (TBI) and comorbid posttraumatic stress disorder (PTSD). We hypothesized that CLOX would correlate significantly with functional performance. This prospective, cross-sectional study design determined the correlation between a structured neuropsychological battery and functional status assessment. We calculated Pearson correlation coefficients between neuropsychological instruments and functional status scores. We entered neuropsychological measures correlating p < 0.1 with functional status into a linear regression model to determine independent contributions. Fifteen Operation Iraqi Freedom veterans participated. Only CLOX1 correlated significantly with functional competency and efficiency. Only mean CLOX1 scores were significantly lower in those scoring below the median for SAILS competency and in those scoring above the median for SAILS efficiency. CLOX1 contributed significant variance to functional status independent of mood or anxiety symptoms and was not affected by age or time since injury. Executive dysfunction per the brief, easily administered CLOX1 is sensitive to functional status following combat-related mild TBI, independent of PTSD anxiety with or without depression.

Executive control function in psychiatric and medical illness.

Executive Control Function (ECF) is the ability to plan, sequence, and monitor one’s behavior in order to accomplish a given goal while simultaneously exercising cognitive flexibility to adapt to changing task requirements. Multiple studies demonstrate that ECF predicts functional outcome, level of care required, and work potential for both well and ill populations. However, clinicians often do not routinely assess ECF during mental status evaluations because of the perceived lack of practical bedside tests. This review article discusses the major neuropsychological measures used to probe for impairment, with special emphasis on those that are easily administered at the patient’s bedside. The current literature on executive dysfunction in psychiatric and medical illness is reviewed. The neuroanatomy and neurochemistry of ECF is also reviewed, with emphasis on structural dysfunction in specific illnesses. Finally, various treatment options, both pharmacological and psychotherapeutic, are discussed.

Prospective Evaluation of Pretreatment Executive Cognitive Impairment and Depression in Patients Referred for Radiotherapy

PURPOSE Cancer patients are at risk of cognitive impairment and depression. We sought to ascertain the prevalence of executive, visuospatial, memory, and general cognitive performance deficits before radiotherapy in a radiation oncology clinic referral population and correlate the neurocognitive measures with the depression symptom burden. METHODS AND MATERIALS A total of 122 sequential patients referred for radiotherapy evaluation were administered a test battery composed of the Executive Interview (EXIT25), Executive Clock Drawing Task (CLOX1 and CLOX2), Mini Mental State Examination (MMSE), Memory Impairment Screen (MIS), and Geriatric Depression Scale (GDS). The mean age +/- standard deviation was 58 +/- 17 years. Of 122 patients, 24 (20%) had been referred for breast cancer, 21 (17%) for gastrointestinal cancer, 17 (14%) for genitourinary disease, and 8 (7%) for brain lesions; the rest were a variety of tumor sites. The cognitive performance among the tumor cohorts was compared using Bonferroni-corrected analysis of variance and Tukey-Kramer tests. Pearson correlation coefficients were determined between each cognitive instrument and the GDS. RESULTS Of the 122 patients, 52 (43%) exhibited a detectable executive cognition decrement on one or more test measures. Five percent had poor memory performance (MIS), 18% had poor visuospatial performance (CLOX2), and 13% had poor global cognition (MMSE). Patients with brain tumors performed substantially worse on the EXIT25. No between-group differences were found for CLOX1, CLOX2, MIS, or GDS performance. The EXIT25 scores correlated significantly with the GDS scores (r = 0.26, p = 0.005). CONCLUSIONS The results of this study have shown that patients referred for radiotherapy exhibit cognitive impairment profiles comparable to those observed in acutely ill medical inpatients. Executive control impairment appears more prevalent than global cognitive deficits, visuospatial impairment, or depression.

Clock drawing phenotypes in community-dwelling African Americans and Caucasians: Results from the University of Alabama at Birmingham study of aging

Background: Two dementia patterns have been described: ‘type 1’ dementia is characterized by executive function impairment and posterior cortical impairment, and ‘type 2’ dementia is characterized by executive impairment and relatively preserved posterior cortical function. The Executive Clock Drawing Task (CLOX) has been used to discriminate between type 1, type 2, and normal cognitive phenotypes. The aim of this study was to describe the prevalence of these phenotypes in community-dwelling African American and Caucasian elders. Methods: 433 African Americans and 477 Caucasians over the age of 65 were recruited. Executive function was assessed using CLOX1, a command-directed clock drawing task. Posterior cortical impairment was assessed using CLOX2, a clock copy task. CLOX scores were combined to estimate the prevalence of type 1 phenotype (those with poor CLOX1 and CLOX2 performance) versus type 2 phenotype (those with only poor CLOX1 performance). Results: 351 (39%) subjects had poor executive performance. Three hundred (33%) subjects had a type 1 phenotype and this pattern was 2.5 times more common among African Americans than Caucasians. One hundred and thirty-seven (15%) subjects had a type 2 phenotype with no significant difference between African Americans and Caucasians. African American ethnicity was independently associated with poor CLOX1 performance after adjusting for sociodemographic factors, posterior cortical function, and global cognition. CLOX2 performance was not associated with ethnicity. Conclusion: The prevalence of poor executive performance in community-dwelling elders is high. African Americans were more likely to have a type 1 phenotype and these ethnic differences were not explained by sociodemographic variables alone.

Neuropsychological Correlates of Performance Based Functional Status in Elder Adult Protective Services Referrals for Capacity Assessments

We have previously described high rates of executive function impairment in clients referred by Adult Protective Services (APS) to geriatric psychiatry for decision-making capacity assessments. The purpose of this study was to determine the independent relationship between neuropsychological screening instruments, particularly instruments sensitive to executive function, and performance-based functional tasks in elder referrals. Our retrospective medical review (n = 75/157 referrals completed all neuropsychological and functional assessments) revealed that only the Executive Interview (EXIT25) contributed independent variance to money management performance (R2 = 0.29, p < 0.001), telephone use ability (R2 = 0.39, p < 0.001), and summed performance (R2 = 0.45, p < 0.001). Executive instruments may specifically inform decision-making capacity assessments.