Ricardo Salazar

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.

Neuropsychiatric symptoms in community‐dwelling Mexican‐Americans: results from the Hispanic Established Population for Epidemiological Study of the Elderly (HEPESE) study

The Neuropsychiatric Inventory (NPI) is a well‐established measure of psychopathology and frequently used in dementia studies. Little is known about its psychometric characteristics at a population level, particularly among Hispanics. We report the frequency of NPI symptoms in a community‐dwelling older Mexican‐American (MA) population cohort and the degree of symptom‐related distress experienced by participant informants.

Neuropsychiatric symptoms in community-dwelling Mexican-Americans

The Neuropsychiatric Inventory (NPI) is a well‐established measure of psychopathology and frequently used in dementia studies. Little is known about its psychometric characteristics at a population level, particularly among Hispanics. We report the frequency of NPI symptoms in a community‐dwelling older Mexican‐American (MA) population cohort and the degree of symptom‐related distress experienced by participant informants.

Telephone Screening for Mild Cognitive Impairment in Hispanics Using the Alzheimer’s Questionnaire

Background/Study Context: There is a need for a simple and reliable screening test to detect individuals with mild cognitive impairment (MCI). The authors analyzed the relationship between performance of the Alzheimer’s Questionnaire (AQ), an informant-rated measure of dementia-related behaviors, relative to the Telephone Interview for Cognitive Status—modified (TICS-m), Memory Impairment Scale—telephone version (MIS-t), and the Telephone Executive Assessment (TEXAS) as predictors of MCI. Methods: Comparative cross-sectional design, with data collected from participants in the Texas Alzheimer’s Research and Care Consortium’s (TARCC) San Antonio site. One-hundred percent of our sample was Hispanic. The San Antonio subset of TARCC sample is highly enriched with Mexican Americans (MAs). Fifty-five percent of the interviews were conducted in Spanish. Of the 184 persons enrolled, 124 were normal controls (NCs), and 60 participants had MCI. MCI status and Clinical Dementia Rating Scale Sum of Boxes (CDR-SOB) were determined through clinical consensus and performed blind to telephone assessments. Controlling for age, gender, education, and language of interview, the association between telephone measures and CDR-SOB was evaluated by multivariate regression. Results: AQ scores were not affected by education, gender, and language of interview, but subject’s age did show a positive correlation with informant AQ ratings. The AQ predicted CDR-SOB independently of the cognitive measures, adding variance above and beyond demographics. The TICS-m and the TEXAS appear to have additive value in improving the detection of cognitively impaired patients. The MIS-t failed to contribute significantly to CDR-SOB, independent of the other measures. Conclusion: The AQ may have utility as a culture-fair telephone screening for MCI. The AQ was able to modestly distinguish MCI from NCs. The TEXAS adds variance to a model of dementia severity independent of the AQ, suggesting that the latter may weakly assess that cognitive domain (executive control function). On the other hand, the AQ attenuates the MIS-t effect. This suggests a prominent AQ bias in favor of detecting memory impairment. Additional studies are required to determine if the AQ can distinguish between amnestic and dysexecutive MCI subtypes, or between MCI and Alzheimer’s disease in Hispanics.

Difficult Encounters with Psychiatric Patients: A South Texas Psychiatry Practice-based Research Network (PBRN) Study

Purpose: To examine the prevalence of difficult psychiatrist-patient interactions of 20 psychiatrists in the South Texas Psychiatric practice-based research network, determine what characteristics were associated with “difficult” patients, and compare findings with previous studies in primary care. Methods: During a 2-month observational study, psychiatrists collected patient information on setting, demographics, diagnoses, and medications and rated the patients using the Difficult Doctor-Patient Relationship Questionnaire, which had previously been used and validated in the primary care setting. Results: A total of 905 valid data cards were collected. Difficult patients were identified in 15% of the sample. Diagnoses of schizophrenia, alcohol/substance abuse, and personality disorder were associated with difficulty. Psychiatrists least burdened by difficult patients were older and in a solo practice and worked 51 to 55 hours per week. Conclusions: This cross-sectional study demonstrates that psychiatrists encounter difficult patients at a rate (15%) similar to that of primary care physicians. Mentoring programs and structured treatment interventions for the most difficult patient groups may assist all physicians who treat psychiatric patients, whether in specialty, family medicine, or other primary care settings.

Cross-Ethnic Differences in the Severity of Neuropsychiatric Symptoms in Persons With Mild Cognitive Impairment and Alzheimer's Disease.

In this cross-sectional study, we examined the neuropsychiatric profile of mild cognitive impairment (MCI) and Alzheimers disease (AD) using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Data were available on 875 controls, 339 MCI cases, and 975 AD participants. Surprisingly, differences in neuropsychiatric symptom (NPS) severity by ethnicity in subjects with AD, but not with MCI, were found. More so, in Hispanics with AD, a higher frequency in most of the individual NPI-Q symptom items of the scale was observed, except for apathy. After adjustment for clinical features, some individual NPI-Q symptoms also showed an association with Hispanic ethnicity in the control group that nearly reached statistical significance. There may be cross-ethnic differences in the neuropsychiatric presentation of AD in Hispanics versus non-Hispanic whites. Future studies are needed to clarify the etiology of these differences, and to assess the need for ethnicity-specific treatment and care-giving interventions.

Neuropsychiatric symptoms in community-dwelling Mexican-Americans: Results from the Hispanic EPESE Study

Background: The Neuropsychiatric Inventory (NPI) is a well-established measure of psychopathology in dementia studies. Little is known about its psychometric properties at the population level and secondly in Hispanics. We report the prevalence and distribution of the behavioral domains of the scale in a community dwelling Mexican American elderly population and make a cross-cultural comparison from what has been already reported in the literature. Methods: A total of n1⁄4 1078 Mexican Americans age 80 and over, were administered the NPI as part of the seventh wave of the Hispanic Established Population for Epidemiological Study (HEPESE) conducted from 2010 to 2011. Demographic and descriptive statistics were calculated using Statistical Analysis System version 9 for windows. Rates were calculated for each subdomain of the NPI as well as “intensity” (frequency severity) for some specific problem behaviors. Results: Demographic characteristics were as follows: Age in years, mean: 86 64(range 80-102), gender(65% were women). 925 informants rated -NPI domains; 74% of the informants were women with a mean age in years of 56 612.5(range 6693). Rates of the behavioral symptoms by subdomains were: delusions(10%), hallucinations(8%), agitation/aggression(32%, of which 48% were in the moderate to severe range of severity), dysphoria/depression(29%, of which 44% were in the moderate to severe range of severity), anxiety(16%), euphoria/elation(5%), apathy/indifference (20%), Disinhibition(12%), irritability/lability(26%), Aberrant motor behaviors(12%), nighttime behavioral disturbances(19%), and appetite/eating disturbances(19%). Of the 294(32%) informants that reported distress from agitation/aggressive behavior, 49(17%) reported moderate distress,19 (6%) severe and 2(0.7%) extreme or very severe distress. Conclusions: A large percentage (>50%) of community dwelling Mexican American elderly display problem behaviors at similar rates to Alzheimer‘s Disease(AD) cases(Levy et al., 2006), being the most common symptoms in the domains of agitation/aggression, follow by mood, nighttime behavioral and appetite disturbances. We hypothesize that a fraction of these elders with behavioral disturbances have undiagnosed neuropsychiatric syndromes including AD. A pattern of high percentage for mood and low percentage for psychotic symptoms is interestingly observed. These findings have diagnostic, prognostic, and therapeutic implications. Neuropsychiatric disorders maybe the initial clinical presentation of dementing disorders, appearing before cognitive alterations and nesting the onset of the brain disease.

Delirium in an Obese Woman with Intellectual Disability

A32-year-old woman with a history of severe intellectual disability was brought to the hospital by emergency medical services after being found unconscious on the bathroom floor by her parents. In the weeks prior to her admission, the patient had experienced numerous falls. Her Glasgow Coma Scale score in the emergency department was 9. She had a temperature of 87°F and a heart rate of approximately 50 beats per minute, indicative of severe hypothermia and bradycardia, respectively. Abnormal laboratory findings upon admission included a thyroid-stimulating hormone level of 68.3 uIU/mL and a potassium level of 3.1 mmol/L, as well as evidence of a urinary tract infection (UTI). Computed tomography without contrast of the head showed no acute intracranial or structural abnormalities. The patient was admitted to the intensive care unit for further care and monitoring. Endocrinology was

Latent variables may be useful in pain’s assessment

BackgroundUnobserved “latent” variables have the potential to minimize “measurement error” inherent to any single clinical assessment or categorical diagnosis.ObjectivesTo demonstrate the potential utility of latent variable constructs in pain’s assessment.DesignWe created two latent variables representing depressive symptom-related pain (Pd) and its residual, “somatic” pain (Ps), from survey questions.SettingThe Hispanic Established Population for Epidemiological Studies in the Elderly (H-EPESE) project, a longitudinal population-based cohort study.ParticipantsCommunity dwelling elderly Mexican-Americans in five Southwestern U.S. states. The data were collected in the 7th HEPESE wave in 2010 (N = 1,078).MeasurementsSelf-reported pain, Center for Epidemiological Studies Depression Scale (CES-D) scores, bedside cognitive performance measures, and informant-rated measures of basic and instrumental Activities of Daily Living.ResultsThe model showed excellent fit [χ2 = 20.37, DF = 12; p = 0.06; Comparative fit index (CFI) = 0.998; Root mean statistical error assessment (RMSEA) = 0.025]. Ps was most strongly indicated by self-reported pain-related physician visits (r = 0.48, p ≤0.001). Pd was most strongly indicated by self-reported pain-related sleep disturbances (r = 0.65, p <0.001). Both Pd and Ps were significantly independently associated with chronic pain (> one month), regional pain and pain summed across selected regions. Pd alone was significantly independently associated with self-rated health, life satisfaction, self-reported falls, Life-space, nursing home placement, the use of opiates, and a variety of sleep related disturbances. Ps was associated with the use of NSAIDS. Neither construct was associated with declaration of a resuscitation preference, mode of resuscitation preference declaration, or with opting for a “Do Not Resuscitate” (DNR) order.ConclusionThis analysis illustrates the potential of latent variables to parse observed data into “unbiased” constructs with unique predictive profiles. The latent constructs, by definition, are devoid of measurement error that affects any subset of their indicators. Future studies could use such phenotypes as outcome measures in clinical pain management trials or associate them with potential biomarkers using powerful parametric statistical methods.

Frequency of neuropsychiatric symptoms in Hispanics with Alzheimer's disease

Background: Previous studies show that problem behavior, as measured by the Neuropsychiatric Inventory (NPI) differentiates Mild Cognitive Impairment (MCI) from both dementia cases and normal controls. This implies a clinical and possibly a biological continuumwhich may help identify populations at risk for developing dementia. Data from the Texas Alzheimer‘s Research and Care Consortium (TARCC) may help confirm MCI as an intermediate state between normal cognitive functioning and dementia, and identify differences between MCI’s presentation in Hispanic and non-Hispanic populations. The aim of this study was t o examine moderating effects of ethnicity on the neuropsychiatric profile of MCI, and compare MCI to both normal controls and patients with Alzheimer‘s Disease (AD) in the TARCC population. Methods: Visit 1 data from n1⁄4 2189 TARCC participants [975 cases of Alzheimer‘s disease (AD), 339 Mild Cognitive Impairment (MCI) cases, and 875 normal controls (NC)] were included in the analyses. The frequency of NPI-Q affected domains and NPI-Q total scores were compared across the three groups while controlling for age, education, Mini-Mental State Exam (MMSE), Clinical Dementia Rating-Sum of Boxes (CDRSUM), and Geriatric Depression Scores (GDS). Statistical analysis using multivariate analysis of variance (MANOVA) was performed on Statistica version 10 for windows. Results: Both NPI-Q total and NPI-Q domain subscores differed significantly across the three diagnostic groups (p <0.001). Interaction analyses stratified by ethnicity identified a significant difference in the frequency of NPI-Q affected domains and total NPI-Q scores between Hispanic and Non-Hispanic subjects among AD cases only (both p 1⁄4 0.004), but not among those with NC and MCI (all p > 0.05). There were no significant cross ethnic interactions by stage of disease in gender, CDRSUM or IADL scores. Conclusions: NPI-Q has repeatedly proven to be a reliable indicator of problem behaviors. The current analysis indicates that it may also be used to stage and monitor AD progression. Ethnic differences in neuropsychiatric symptoms of subjects with AD, but not MCI, indicate that the presentation of dementia, but also possibly its etiology, may differ between these two populations. This could have significant impacts on the treatment and understanding of dementia within the Hispanic population.