Megan E. O'Connell

Age Corrections and Dementia Classification Accuracy

In contrast to expectations, demographic corrections to reduce biases against those of advanced age or few years of education does not universally improve diagnostic classification accuracy. Age corrections may be particularly problematic because age is also a risk factor for a dementia diagnosis. We found that simulating increased risk for dementia based on demographic variables, such as age, reduced the overall classification accuracy for demographically corrected simulated scores relative to the raw, uncorrected test scores. In clinical data with a small magnitude of association between age and dementia diagnosis, we found equivalent overall classification accuracy for demographically corrected and raw test scores. Regardless of the overall classification accuracy results, cutoff comparisons (16th and 9th percentiles) in clinical and simulated data demonstrated that for the most part, the sensitivity of raw scores was higher than the sensitivity of demographically corrected scores, but the specificity of scores corrected with normative data was superior.

The 12-Item Buschke Memory Test: Appropriate for Use Across Levels of Impairment

Monitoring cognitive functions as older adults move from independent to assisted living is of utmost importance with respect to care planning. To this end, we examined the utility of a 12-item, free and cued recall, selective reminding, memory task for assessing persons across levels of functioning. Using cross-sectional data from the Canadian Study of Health and Aging, it was observed that the 12-item Buschke memory test was well tolerated by participants regardless of their level of impairment. Further, various measures from the memory task differentiated among participants with different levels of impairment: Individuals living in the community performed better than those in institutions; individuals with no or mild functional impairment performed better than individuals with moderate or severe functional impairments; individuals with mild dementia performed better than those with moderate to severe dementia. Normative data are provided for this easily administered and well-tolerated memory measure.

Simultaneous temporal trends in dementia incidence and prevalence, 2005–2013: a population-based retrospective cohort study in Saskatchewan, Canada

BACKGROUND Original studies published over the last decade regarding time trends in dementia report mixed results. The aims of the present study were to use linked administrative health data for the province of Saskatchewan for the period 2005/2006 to 2012/2013 to: (1) examine simultaneous temporal trends in annual age- and sex-specific dementia incidence and prevalence among individuals aged 45 and older, and (2) stratify the changes in incidence over time by database of identification. METHODS Using a population-based retrospective cohort study design, data were extracted from seven provincial administrative health databases linked by a unique anonymized identification number. Individuals 45 years and older at first identification of dementia between April 1, 2005 and March 31, 2013 were included, based on case definition criteria met within any one of four administrative health databases (hospital, physician, prescription drug, and long-term care). RESULTS Between 2005/2006 and 2012/2013, the 12-month age-standardized incidence rate of dementia declined significantly by 11.07% and the 12-month age-standardized prevalence increased significantly by 30.54%. The number of incident cases decreased from 3,389 to 3,270 and the number of prevalent cases increased from 8,795 to 13,012. Incidence rate reductions were observed in every database of identification. CONCLUSIONS We observed a simultaneous trend of decreasing incidence and increasing prevalence of dementia over a relatively short 8-year time period from 2005/2006 to 2012/2013. These trends indicate that the average survival time of dementia is lengthening. Continued observation of these time trends is warranted given the short study period.

Prevalence and Covariates of Elevated Depressive Symptoms in Rural Memory Clinic Patients with Mild Cognitive Impairment or Dementia

Background/Aims: To estimate the prevalence, severity, and covariates of depressive symptoms in rural memory clinic patients diagnosed with either mild cognitive impairment (MCI) or dementia. Methods: In a cross-sectional study of 216 rural individuals who attended an interdisciplinary memory clinic between March 2004 and July 2012, 51 patients were diagnosed with MCI and 165 with either dementia due to Alzheimers disease (AD) or non-AD dementia. The Center for Epidemiologic Studies of Depression Scale (CES-D) was used to estimate the severity and prevalence of clinically elevated depressive symptomatology. Results: The prevalence of elevated depressive symptoms was 51.0% in the MCI patients and 30.9% in the dementia patients. Depressive symptoms were more severe in the MCI patients than in the dementia patients. Elevated depressive symptoms were statistically associated with younger age for the MCI group, with lower self-rated memory for the dementia group, and with increased alcohol use and lower quality of life ratings for all patients. In the logistic regression models, elevated depressive symptoms remained negatively associated with self-rated memory and quality of life for the patients with dementia, but significant bivariate associations did not persist in the MCI group. Conclusions: The high prevalence and severity of depressive symptoms among rural memory clinic patients diagnosed with either MCI or dementia warrant continued investigation.

RBANS Embedded Measures of Suboptimal Effort in Dementia: Effort Scale Has a Lower Failure Rate than the Effort Index

The importance of evaluating effort in neuropsychological assessments has been widely acknowledged, but measuring effort in the context of dementia remains challenging due to the impact of dementia severity on effort measure scores. Two embedded measures have been developed for the repeatable battery for the assessment of neuropsychological status (RBANS; Randolph, C., Tierney, M. C., Mohr, E., & Chase, T. N. (1998). The repeatable battery for the assessment of neuropsychological status (RBANS): Preliminary clinical validity. Journal of Clinical and Experimental Neuropsychology, 20 (3), 310-319): the Effort Index (EI; Silverberg, N. D., Wertheimer, J. C., & Fichtenberg, N. L. (2007). An effort index for the repeatable battery for the assessment of neuropsychological status (RBANS). Clinical Neuropsychologist, 21 (5), 841-854) and the Effort Scale (ES; Novitski, J., Steele, S., Karantzoulis, S., & Randolph, C. (2012). The repeatable battery for the assessment of neuropsychological status effort scale. Archives of Clinical Neuropsychology, 27 (2), 190-195). We explored failure rates on these effort measures in a non-litigating mixed dementia sample (N = 145). Failure rate on the EI was high (48%) and associated with dementia severity. In contrast, failure on the ES was 14% but differed based on type of dementia. ES failure was low (4%) when dementia was due to Alzheimer disease (AD), but high (31%) for non-AD dementias. These data raise concerns about use of the RBANS embedded effort measures in dementia evaluations.

Demographic corrections appear to compromise classification accuracy for severely skewed cognitive tests.

Demographic corrections for cognitive tests should improve classification accuracy by reducing age or education biases, but empirical support has been equivocal. Using a simulation procedure, we show that creating moderate or extreme skewness in cognitive tests compromises the classification accuracy of demographic corrections, findings that appear replicated within clinical data for the few neuropsychological test scores with an extreme degree of skew. For most neuropsychological tests, the dementia classification accuracy of raw and demographically corrected scores was equivalent. These findings suggest that the dementia classification accuracy of demographic corrections is robust to slight degrees of skew (i.e., skewness <1.5).

Evolution of a community-based participatory approach in a rural and remote dementia care research program.

Background: Community–based participatory research (CBPR) approaches are valuable strategies for addressing complex health and social problems and powerful tools to support effective transformation of social and health policy to better meet the needs of diverse stakeholders.Objectives: Since 1997, our team has utilized CBPR approaches to improve health service delivery for persons with dementia and their caregivers in rural and remote settings. We describe the evolution of our approach, including benefits, challenges, and lessons learned over the last 15 years.Methods: A multistage approach initiated an ongoing CBPR research program in rural dementia care and shaped its direction based on stakeholders’ recommendation to prioritize both community and facility–based care. Strategies to develop and foster collaborative partnerships have included travel to rural and remote regions, province–wide community meetings, stakeholder workshops, creation of a Decision–Maker Advisory Council to provide ongoing direction to the overall program, development of diverse project–specific advisory groups, and a highly successful and much anticipated annual knowledge exchange and team–building event.Lessons Learned: Partnering with stakeholders in the full research process has enhanced the research quality, relevance, application, and sustainability. These benefits have supported the team’s evolution from a relatively traditional focus to an integrated approach guiding all aspects of our research.Conclusions: Developing and sustaining the full range of stakeholder and decision–maker partnerships is resource–and time–intensive, but our experience shows that community–based participatory strategies are highly suited to health services research that is designed to support sustainable service delivery improvements.

Clinical Correlates of Awareness for Balance, Function, and Memory: Evidence for the Modality Specificity of Awareness

Awareness in dementia is increasingly recognized not only as multifactorial, but also as domain specific. We demonstrate differential clinical correlates for awareness of daily function, awareness of memory, and the novel exploration of awareness of balance. Awareness of function was higher for participants with mild cognitive impairment (aMCI and non-aMCI) than for those with dementia (due to Alzheimer disease; AD and non-AD), whereas awareness of memory was higher for both non-aMCI and non-AD dementia patients than for those with aMCI or AD. Balance awareness did not differ based on diagnostic subgroup. Awareness of function was associated with instrumental activities of daily living and caregiver burden. In contrast, awareness of balance was associated with fall history, balance confidence, and instrumental activities of daily living. Clinical correlates of awareness of memory depended on diagnostic group: associations held with neuropsychological variables for non-AD dementia, but for patients with AD dementia, depression and instrumental activities of daily living were clinical correlates of memory awareness. Together, these data provide support for the hypothesis that awareness and dementia are not unitary and are, instead, modality specific.

The Telehealth Satisfaction Scale: Reliability, Validity, and Satisfaction with Telehealth in a Rural Memory Clinic Population

INTRODUCTION Patient satisfaction is a key aspect of quality of care and can inform continuous quality improvement. Of the few studies that have reported on patient satisfaction with telehealth in programs aimed at individuals with memory problems, none has reported on the psychometric properties of the user satisfaction scales used. MATERIALS AND METHODS We evaluated the construct validity and internal consistency reliability of the Telehealth Satisfaction Scale (TeSS), a 10-item scale adapted for use in a rural and remote memory clinic (RRMC). The RRMC is a one-stop interprofessional clinic for rural and remote seniors with suspected dementia, located in a tertiary-care hospital. Telehealth videoconferencing is used for preclinic assessment and for follow-up. Patients and caregivers completed the TeSS after each telehealth appointment. With data from 223 patients, exploratory factor analysis was conducted using the principal components analysis extraction method. RESULTS The eigenvalue for the first factor (5.2) was greater than 1 and much larger than the second eigenvalue (0.92), supporting a one-factor solution that was confirmed by the scree plot. The total variance explained by factor 1 was 52.1%. Factor loadings (range, 0.54-0.84) were above recommended cutoffs. The TeSS items demonstrated high internal consistency reliability (Cronbachs alpha=0.90). Satisfaction scores on the TeSS items ranged from 3.43 to 3.72 on a 4-point Likert scale, indicating high satisfaction with telehealth. CONCLUSIONS The study findings demonstrate high user satisfaction with telehealth in a rural memory clinic and the sound psychometric properties of the TeSS in this population.

Trajectories of Depressive Symptomatology in Rural Memory Clinic Patients between Baseline Diagnosis and 1-Year Follow-Up

Background/Aims: To investigate the prevalence and trajectories of depressive symptomatology at 1-year follow-up, and the severity of depressive symptoms, by dementia diagnostic group, as well as to determine the predictors of depressive symptomatology at 1-year follow-up. Methods: In rural and remote patients of an interdisciplinary memory clinic between 2004 and 2014, 144 patients diagnosed with no cognitive impairment (NCI), mild cognitive impairment, dementia due to Alzheimers disease (AD), or non-AD dementia completed the Center for Epidemiologic Studies of Depression Scale to assess depressive symptomatology at both time points. Results: Among patients with data at both time points, persistence of depressive symptomatology at follow-up occurred in 22.2%, remission in 17.4%, incidence in 13.2%, and absence in 47.2%. The prevalence of depressive symptomatology at baseline and persistence at follow-up were significantly greater in the NCI group than in the other diagnostic groups, but there were no differences in severity. Depressive symptomatology at follow-up was independently associated with depressive symptomatology, lower independence in activities of daily living, and lower self-rating of memory at baseline, as well as with decreased independence in activities of daily living between time points. Conclusion: Future studies should further examine short-term postdiagnostic trajectories in depressive symptomatology in multiple dementia diagnostic groups to inform prognoses and treatment decisions.