Joni Vander Bilt

Reliability and validity of the Panic Disorder Severity scale: replication and extension

UNLABELLED The Panic Disorder Severity Scale (PDSS) is a recently developed seven-item instrument to rate overall severity of Panic Disorder. The scale has previously shown good psychometric properties in a sample of Panic Disorder patients with no more than mild agoraphobia. The purpose of this paper is to confirm reliability and validity, to provide an estimate of a cut-score discriminating the presence or absence of current DSM-IV Panic Disorder, and to determine the factor structure of the instrument. PROCEDURES 104 psychiatric outpatients, including 54 with current Panic Disorder, underwent structured diagnostic assessment and the PDSS interview. The PDSS was repeated within 3-17 days. RESULTS we confirmed reliability and validity of the instrument and found a one-factor solution fit the data. A cut-off score of eight identifies patients with current panic with a sensitivity of 83.3%, and a specificity of 64%. CONCLUSION the PDSS is a simple, reliable instrument for use in Panic Disorder studies. A cut-score of eight may be useful as a tool to screen patients in settings such as primary care, for diagnosis-level symptoms.

Outcomes of mild cognitive impairment by definition: a population study.

BACKGROUND Mild cognitive impairment (MCI) has been defined in several ways. OBJECTIVE To determine the 1-year outcomes of MCI by different definitions at the population level. DESIGN Inception cohort with 1-year follow-up. Participants were classified as having MCI using the following definitions operationalized for this study: amnestic MCI by Mayo criteria, expanded MCI by International Working Group criteria, Clinical Dementia Rating (CDR) = 0.5, and a purely cognitive classification into amnestic and nonamnestic MCI. SETTING General community. PARTICIPANTS Stratified random population-based sample of 1982 individuals 65 years and older. MAIN OUTCOME MEASURES For each MCI definition, there were 3 possible outcomes: worsening (progression to dementia [CDR ≥ 1] or severe cognitive impairment), improvement (reversion to CDR = 0 or normal cognition), and stability (unchanged CDR or cognitive status). RESULTS Regardless of MCI definition, over 1 year, a small proportion of participants progressed to CDR > 1 (range, 0%-3%) or severe cognitive impairment (0%-20%) at rates higher than their cognitively normal peers. Somewhat larger proportions of participants improved or reverted to normal (6%-53%). Most participants remained stable (29%-92%). Where definitions focused on memory impairment and on multiple cognitive domains, higher proportions progressed and lower proportions reverted on the CDR. CONCLUSIONS As ascertained by several operational definitions, MCI is a heterogeneous entity at the population level but progresses to dementia at rates higher than in normal elderly individuals. Proportions of participants progressing to dementia are lower and proportions reverting to normal are higher than in clinical populations. Memory impairments and impairments in multiple domains lead to greater progression and lesser improvement. Research criteria may benefit from validation at the community level before incorporation into clinical practice.

Exercise level and cognitive decline: The MoVIES project

Growing evidence suggests that physical exercise may be protective against cognitive impairment and decline. A prospective study of a representative rural community sample (N = 1,146) aged 65+ years examined self-reported exercise habits and measured global cognitive function using the Mini-Mental State Examination (MMSE). A composite variable “exercise level” combining type, frequency, and duration of exercise was created with three levels: “high exercise” (aerobic exercise of ≥ 30 minute duration ≥ 3 times a week), “low exercise” (all other exercise groups), and “no exercise.” Cognitive decline was defined as being in the 90th percentile of decline in this cohort, ie, declining by 3 or more MMSE points during the 2-year interval between two assessments. In a multiple regression model, high exercise level at the baseline assessment was negatively associated with, ie, was protective against, being in the group with the greatest amount of decline at the follow-up assessment, after adjusting for likely confounders (odds ratio = 0.39; 95% confidence interval, 0.19, 0.78). When high exercise was redefined using frequency as ≥ 5 days per week as the threshold, as per the Surgeon General’s guidelines, both low exercise and high exercise were negatively associated with cognitive decline. Exercise may have implications for prevention of cognitive decline.

How much do depressive symptoms affect cognition at the population level? The Monongahela-Youghiogheny Healthy Aging Team (MYHAT) study

To examine the impact of subjective depressive symptoms on objective performance on tests of several cognitive domains, in a community‐based sample of older adults.

Effects of age, gender, education and race on two tests of language ability in community-based older adults

BACKGROUND Neuropsychological tests, including tests of language ability, are frequently used to differentiate normal from pathological cognitive aging. However, language can be particularly difficult to assess in a standardized manner in cross-cultural studies and in patients from different educational and cultural backgrounds. This study examined the effects of age, gender, education and race on performance of two language tests: the animal fluency task (AFT) and the Indiana University Token Test (IUTT). We report population-based normative data on these tests from two combined ethnically divergent, cognitively normal, representative population samples of older adults. METHODS Participants aged > or =65 years from the Monongahela-Youghiogheny Healthy Aging Team (MYHAT) and from the Indianapolis Study of Health and Aging (ISHA) were selected based on (1) a Clinical Dementia Rating (CDR) score of 0; (2) non-missing baseline language test data; and (3) race self-reported as African-American or white. The combined sample (n = 1885) was 28.1% African-American. Multivariate ordinal logistic regression was used to model the effects of demographic characteristics on test scores. RESULTS On both language tests, better performance was significantly associated with higher education, younger age, and white race. On the IUTT, better performance was also associated with female gender. We found no significant interactions between age and sex, and between race and education. CONCLUSIONS Age and education are more potent variables than are race and gender influencing performance on these language tests. Demographically stratified normative tables for these measures can be used to guide test interpretation and aid clinical diagnosis of impaired cognition.

Mild Cognitive Deficits and Everyday Functioning Among Older Adults in the Community: The Monongahela-Youghiogheny Healthy Aging Team Study

OBJECTIVE : A key component of successful aging is the ability to independently perform instrumental activities of daily living (IADL). We examined the ability to perform multiple IADL tasks in relation to mild cognitive impairment (MCI) defined on purely neuropsychological grounds. DESIGN : Cross-sectional study. SETTING : Population-based cohort in southwestern Pennsylvania. PARTICIPANTS : One thousand seven hundred thirty-seven community-dwelling adults age 65 years and older. MEASUREMENTS : Classification of MCI based on performance with reference to norms in the cognitive domains of memory, language, attention, executive, and visuospatial functions. The ability to perform seven IADL tasks (traveling, shopping, preparing meals, doing housework, taking medications, handling personal finances, and using the telephone) as assessed by the Older Americans Resources and Services scale. RESULTS : Those with cognitively defined MCI were more likely to be dependent in at least one IADL task, as well as in each individual IADL task, than cognitively normal participants. Better memory and executive functioning were associated with lower odds of IADL dependence in MCI. Across the subtypes of MCI, those with the multiple-domain amnestic subtype were most likely to be dependent in all IADL tasks, with better executive functioning associated with lower risk of dependence in select IADL tasks in this group. CONCLUSIONS : Mild impairment in cognition is associated with difficulty performing IADL tasks at the population level. Understanding these associations may help improve prediction of the outcomes of MCI. It may also allow appropriate targeting of cognitive interventions in MCI to potentially help preserve functional independence.

Engagement in Reading and Hobbies and Risk of Incident Dementia: The MoVIES Project

Objective: To examine whether there is an association between engagement in reading and hobbies and dementia risk in late life. Methods: A total of 942 members of a population-based, prospective cohort study were followed biennially to identify incident dementia cases. Cox proportional hazards models were used to estimate the risk of dementia in relation to baseline total number of activities and time commitment to reading and hobbies. Results: A lower risk for dementia was found for a greater number of activities and for a high (about 1 hour each day) compared with low (less than 30 minutes each day) weekly time commitment to hobbies, independent of covariates. Only the protective effect of hobbies remained after methods were used to minimize bias due to potential preclinical dementia. Conclusion: Engaging in hobbies for 1 or more hours every day might be protective against dementia in late life.

Discrepancies in Information Provided to Primary Care Physicians by Patients With and Without Dementia: The Steel Valley Seniors Survey

OBJECTIVE The objective of this study was to examine associations between discrepancies in health information provided to primary care providers and severity of impairment in older patients with and without dementia. METHODS This study included brief assessment and medical record review of 1,107 patients with a mean (standard deviation) age of 76.3 (6.6) years (range: 65-100 years) in seven small-town primary care practices. In 358 patients, detailed in-home assessment included demographics; dementia by Clinical Dementia Rating (CDR) scale; and frequencies of memory complaints, falls, and inadvertent medication nonadherence determined from medical records and standardized in-home research assessments. Main outcome variables were trends in discrepancies between chart reviews and research assessments. Main explanatory variable was CDR box total scores. RESULTS Proportions of patients reporting memory complaints and falls, and evidence of inadvertent nonadherence, in the charts and by research assessment increased with CDR. Discrepancies between medical record and research assessment, were also associated with CDR, showing linear trends for memory complaints and inadvertent nonadherence and a quadratic trend for falls. CONCLUSION Memory complaints, falls, and inadvertent medication nonadherence increase with dementia severity. The levels of discrepancy between information patients provided to their physicians and information they provided in response to detailed, standardized assessments, also varied with dementia severity. Physicians should be alert to the possibility of receiving unreliable health information from even mildly demented patients, whether or not dementia has been detected.

Sustained Benzodiazepine Use in a Community Sample of Older Adults

OBJECTIVES: To identify factors associated with sustained benzodiazepine use in older adults.

The association between congestive heart failure and cognitive performance in a primary care population of elderly adults: the Steel Valley Seniors Survey.

BACKGROUND Evidence suggests an association between congestive heart failure (CHF) and cognitive function, particularly in heart transplant patients and patients hospitalized for CHF. We examined the association between CHF and cognitive performance in stable outpatients recruited from primary care. METHODS This is a cross-sectional secondary data analysis of the Steel Valley Seniors Survey, an epidemiological study of elderly primary care outpatients. Participants aged >/= 65 years were recruited in primary care clinics. The study cohort (n = 354) is a subgroup, composed of subjects with Mini-mental State Examination score < 25, and a random sample of the remaining, who underwent a baseline assessment in the home. The assessment included demographics, comorbid illnesses, depressive symptoms, functional status, a neurological examination and a neuropsychological battery. CHF is defined by self-report and/or chart review, and stable CHF as not being hospitalized in the year prior to the assessment. The associations between CHF and specific cognitive tests were examined by bivariate analysis and logistic regression, controlling for demographic variables. RESULTS Subjects with CHF performed worse on tests of visual memory [10.1 (S.D. 5.4) vs. 12.7 (S.D. 5.2), p = 0.007], Trailmaking B [0.1 (0.1) vs. 0.2 (0.1), p = 0.002], category fluency [11.1 (4.4) vs. 13.4 (4.5), p = 0.008], and clock drawing [5.6 (1.9) vs. 6.7 (1.4), p < 0.001] compared to subjects without CHF, after adjustment for relevant demographic variables. CONCLUSION CHF is associated with lower cognitive functioning in a population of patients with stable heart failure in primary care settings.