Nancy A. Pachana

Development and validation of the Geriatric Anxiety Inventory

BACKGROUND Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people. METHODS We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale. RESULTS Cronbachs alpha for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test-retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%. CONCLUSIONS The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

Comparison of neuropsychological functioning in Alzheimer's disease and frontotemporal dementia

Neuropsychological changes distinguishing mild Alzheimers disease (AD) from frontotemporal dementia (FTD) have been described, but empirical verification of differential cognitive characteristics is lacking. Archival neuropsychological data on 15 FTD patients, 16 AD patients, and 16 controls were compared. Controls outperformed both patient groups on measures of verbal and nonverbal memory, executive ability, and constructional skill, with AD patients showing more widespread memory decline. No differences were found between the 3 groups in confrontation naming, recognition memory, or basic attention. Patient groups differed only in nonverbal memory, with FTD patients performing significantly better than AD patients. However, patient groups also differed in pattern of performance across executive and memory domains. Specifically, AD patients exhibited significantly greater impairment on memory than executive tasks, whereas the opposite pattern characterized the FTD group. These findings suggest that examination of relative rankings of scores across cognitive domains, in addition to interpretation of individual neuropsychological scores, may be useful in differential diagnosis of FTD versus AD.

Recurrent readmissions in medical patients: A prospective study

BACKGROUND Hospital readmissions are common and costly. A recent previous hospitalization preceding the index admission is a marker of increased risk of future readmission. OBJECTIVES To identify factors associated with an increased risk of recurrent readmission in medical patients with 2 or more hospitalizations in the past 6 months. DESIGN Prospective cohort study. SETTING Australian teaching hospital acute medical wards, February 2006-February 2007. PARTICIPANTS 142 inpatients aged ≥ 50 years with a previous hospitalization ≤ 6 months preceding the index admission. Patients from residential care, with terminal illness, or with serious cognitive or language difficulties were excluded. VARIABLES OF INTEREST Demographics, previous hospitalizations, diagnosis, comorbidities and nutritional status were recorded in hospital. Participants were assessed at home within 2 weeks of hospital discharge using validated questionnaires for cognition, literacy, activities of daily living (ADL)/instrumental activities of daily living (IADL) function, depression, anxiety, alcohol use, medication adherence, social support, and financial status. MAIN OUTCOME MEASURE Unplanned readmission to the study hospital within 6 months. RESULTS A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months. In multivariate analysis, chronic disease (adjusted odds ratio [OR] 3.4; 95% confidence interval [CI], 1.3-9.3, P = 0.002), depressive symptoms (adjusted OR, 3.0; 95% CI, 1.3-6.8, P = 0.01), and underweight (adjusted OR, 12.7; 95% CI, 2.3-70.7, P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status. CONCLUSIONS In this high-risk patient group, multiple chronic conditions are common and predict increased risk of readmission. Post-hospital interventions should consider targeting nutritional and mood status in this population.

Neural basis of confabulation

we present a case of acute alcohol-induced Korsakoff amnesia. A severe amnestic-confabulatory syndrome characterized the early clinical status. The initial neuropsychological tests demonstrated severe learning deficits plus impaired performance on many, but not all, tests of frontal lobe function. Single-photon emission CT (SPECT) at this stage showed hypoperfusion in the orbital and medial frontal regions and the medial diencephalic area. Four months later, the patients amnesia remained but there was no confabulation. Repeat neuropsychological tests confirmed an ongoing severe amnesia, but performance on the frontal lobe tests now was normal. Repeat SPECT showed a return to normal perfusion in the frontal brain areas but little improvement in the medial diencephalic region. These findings along with data from the clinical literature suggest that confabulation results from dysfunction of orbital and a medial frontal cortex.

Gender Differences in Social Network Size and Satisfaction in Adults in Their 70s

Strong social support is associated with lower mortality and morbidity and better self-rated health in later life. The aim of this study was to compare social network size and satisfaction in men (N = 2589) and women (n = 3152), aged 72—78 years. Women reported significantly larger networks (Difference 1.36, 95% CI 0.89, 1.83) than men. However, being separated, divorced or single had a significantly greater impact on men’s social networks (Difference 0.92, 95% CI 0.17, 1.68). Poor mental health and sensory impairments were associated with smaller networks and lower satisfaction with support for both men and women.

Frontotemporal dementia versus Alzheimer's disease: Differential cognitive features

Frontotemporal dementia (FTD) is a common neurodegenerative dementia that can be difficult to distinguish clinically from Alzheimers disease (AD).The differential distribution of pathology in FTD and AD predicts the presence of differential cognitive features on mental status examination. We compared 39 FTD patients with 101 AD patients on the Consortium to Establish a Registry in AD examination supplemented by cognitive areas from the Neurobehavioral Cognitive Status Examination. The FTD patients were diagnosed using noncognitive clinical and neuro-imaging criteria and were comparable to the AD patients in terms of gender, educational level, and dementia severity ratings. The FTD patients performed significantly better than the AD patients on constructions and calculations. These findings were at the lower limits of normal for older normal controls and persisted after covarying for younger age and higher Mini-Mental Status Examination scores in the FTD group. In addition to personality and neuroimaging features, relatively preserved performance of elementary drawings and calculations in FTD suggests additional features for distinguishing FTD patients from comparably demented AD patients. NEUROLOGY 1996;47: 1189-1194

Stigma, seizure frequency and quality of life : The impact of epilepsy in late adulthood

Epilepsy is one of the most common neurological disorders of late adulthood, yet little research has examined the impact of epilepsy on the quality of life of older people. Current measures of health-related quality of life (HRQOL) have been developed and used almost exclusively in adults under the age of 65. The issues, which affect HRQOL in younger adults, may differ from those which affect older adults who may have age-related physical limitations and multiple co-morbidities. This study sought to explore the HRQOL and psychosocial function of a community dwelling sample of 64 older adults with epilepsy compared with a similar, age-matched control group. An additional objective of the study was to examine the impact of perceived stigma and seizure frequency on HRQOL and psychosocial well-being. Results indicated that HRQOL and psychosocial functioning in the epilepsy group was significantly impaired relative to normal controls. A greater perception of stigma and more frequent seizures was also strongly related to poor quality of life and reduced psychosocial function. Although more than two thirds of the sample had seizure frequency of less than one per year, it was apparent that even infrequent seizures had the facility to impair HRQOL, suggesting that in older adults, the apprehension induced by even the possibility of a seizure may be sufficient to reduce HRQOL. The results have implications for the clinical management of epilepsy and suggest the need for further research in older populations.

The development and validation of two complementary measures of drivers’ hazard perception ability

Hazard perception in driving involves a number of different processes. This paper reports the development of two measures designed to separate these processes. A Hazard Perception Test was developed to measure how quickly drivers could anticipate hazards overall, incorporating detection, trajectory prediction, and hazard classification judgements. A Hazard Change Detection Task was developed to measure how quickly drivers can detect a hazard in a static image regardless of whether they consider it hazardous or not. For the Hazard Perception Test, young novices were slower than mid-age experienced drivers, consistent with differences in crash risk, and test performance correlated with scores in pre-existing Hazard Perception Tests. For drivers aged 65 and over, scores on the Hazard Perception Test declined with age and correlated with both contrast sensitivity and a Useful Field of View measure. For the Hazard Change Detection Task, novices responded quicker than the experienced drivers, contrary to crash risk trends, and test performance did not correlate with measures of overall hazard perception. However for drivers aged 65 and over, test performance declined with age and correlated with both hazard perception and Useful Field of View. Overall we concluded that there was support for the validity of the Hazard Perception Test for all ages but the Hazard Change Detection Task might only be appropriate for use with older drivers.

Development and validation of a short form of the Geriatric Anxiety Inventory – the GAI-SF

BACKGROUND Anxiety symptoms and anxiety disorders are highly prevalent among older people and are associated with considerable disability burden. While several instruments now exist to measure anxiety in older people, there is a need for a very brief self-report scale to measure anxiety symptoms in epidemiological surveys, in primary care and in acute geriatric medical settings. Accordingly, we undertook the development of such a scale, based on the Geriatric Anxiety Inventory. METHODS This is a cross-sectional study of randomly selected, community-residing, older women (N = 284; mean age 72.2 years) using receiver operating characteristic (ROC) analyses. DSM-IV diagnostic interviews were undertaken using the Mini International Diagnostic Interview, fifth edition (MINI-V). RESULTS We developed a 5-item version of the Geriatric Anxiety Inventory, which we have termed the Geriatric Anxiety Inventory - Short Form (GAI-SF). We found that a score of three or greater was optimal for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in this community sample. At this cut-point, sensitivity was 75%, specificity was 87%, and 86% of participants were correctly classified. GAI-SF score was not related to age, MMSE score, level of education or perceived income adequacy. Internal consistency was high (Cronbachs α = 0.81) and concurrent validity against the State-Trait Anxiety Inventory was good (rs = 0.48, p < 0.001). CONCLUSIONS The GAI-SF is a short form of the Geriatric Anxiety Inventory, which we recommend for use in epidemiological studies. It may also be useful in primary care and acute geriatric medical settings.

Dysprosodic speech following basal ganglia insult: Toward a conceptual framework for the study of the cerebral representation of prosody.

Progress in understanding brain/behavior relationships in adult-acquired dysprosody has led to models of cortical hemispheric representation of prosodic processing based on functional (linguistic vs affective) or physical (timing vs pitch) parameters. These explanatory perspectives have not been reconciled, and also a number of neurobehavior syndromes that include dysprosody among their neurological signs have not yet been integrated. In addition to expanding the functional perspective on prosody, some of these syndromes have implicated a significant role of subcortical nuclei in prosodic competence. In this article, two patients with acquired dysprosodic speech following damage to basal ganglia nuclei were evaluated using behavioral, acoustic, cognitive, and radiographic approaches. Selective quantitative measures were performed on each individuals performance to provide detailed verification and clarification of clinical observations, and to test hypotheses regarding prosodic function. These studies, combined with a review of related clinical research findings, exemplify the value of a broader perspective on the neurobehavioral dysfunction underlying acquired adult dysprosodic speech, and lead to a new, proposed conceptual framework for the cerebral representation of prosody.