A multicenter intervention to improve ambulatory care handoffs at the end of residency

BACKGROUND

Graduating residents transition their continuity clinic patients to junior colleagues every year, creating a vulnerable transition period for about 1 million patients nationally.

OBJECTIVE

We examined a standardized, electronic template for handing off high-risk ambulatory patients by outgoing residents from 7 residencies within a large health care system, and compared handoff quantity and provider satisfaction for handoffs with and without that template.

METHODS

Residents graduating in 2011 from 5 internal medicine, 1 family medicine, and 1 internal medicine-pediatrics residency programs in 1 health care system were randomized to a new electronic handoff process with a standardized intervention template or a free-text handoff. Expert reviewers independently evaluated all handoff notes, and providers were surveyed after follow-up appointments regarding use, helpfulness, and overall satisfaction with the handoffs.

RESULTS

Fifty-two of 79 residents (66%) participated, performing 278 handoffs. Eighty-four patients (30%, 17 of 57) failed to follow up within the study period. For patients who followed up, providers read 61% (101 of 165) of the handoffs at the time of the visit. No significant difference existed between groups in the satisfaction of the follow up provider or the quality measure of the handoffs in our process. Expert agreement on which features make the handoff "helpful" was fair (κ  =  0.34).

CONCLUSIONS

A standardized template did not improve handoff quantity or satisfaction compared with a free-text handoff. Practical handoff programs can be instituted into diverse residencies within a short time frame, with most residents taking part in creating the handoff formats.

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers

BACKGROUND

It is unclear why systematic training in end-of-residency clinic handoffs is not universal.

PURPOSES

We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation.

METHODS

We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems.

RESULTS

Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04).

CONCLUSIONS

Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.

Multiple choice questions can be designed or revised to challenge learners' critical thinking

Multiple choice (MC) questions from a graduate physiology course were evaluated by cognitive-psychology (but not physiology) experts, and analyzed statistically, in order to test the independence of content expertise and cognitive complexity ratings of MC items. Integration of higher order thinking into MC exams is important, but widely known to be challenging-perhaps especially when content experts must think like novices. Expertise in the domain (content) may actually impede the creation of higher-complexity items. Three cognitive psychology experts independently rated cognitive complexity for 252 multiple-choice physiology items using a six-level cognitive complexity matrix that was synthesized from the literature. Rasch modeling estimated item difficulties. The complexity ratings and difficulty estimates were then analyzed together to determine the relative contributions (and independence) of complexity and difficulty to the likelihood of correct answers on each item. Cognitive complexity was found to be statistically independent of difficulty estimates for 88 % of items. Using the complexity matrix, modifications were identified to increase some item complexities by one level, without affecting the item's difficulty. Cognitive complexity can effectively be rated by non-content experts. The six-level complexity matrix, if applied by faculty peer groups trained in cognitive complexity and without domain-specific expertise, could lead to improvements in the complexity targeted with item writing and revision. Targeting higher order thinking with MC questions can be achieved without changing item difficulties or other test characteristics, but this may be less likely if the content expert is left to assess items within their domain of expertise.

Detecting When "Quality of Life" Has Been "Enhanced": Estimating Change in Quality of Life Ratings

OBJECTIVE

To demonstrate challenges in the estimation of change in quality of life (QOL).

METHODS

Data were taken from a completed clinical trial with negative results. Responses to 13 QOL items were obtained 12 months apart from 258 persons with Alzheimer's disease (AD) participating in a randomized, placebo-controlled clinical trial with two treatment arms. Two analyses to estimate whether "change" in QOL occurred over 12 months are described. A simple difference (later - earlier) was calculated from total scores (standard approach). A Qualified Change algorithm (novel approach) was applied to each item: differences in ratings were classified as either: improved, worsened, stayed poor, or stayed "positive" (fair, good, excellent). The strengths of evidence supporting a claim that "QOL changed", derived from the two analyses, were compared by considering plausible alternative explanations for, and interpretations of, results obtained under each approach.

RESULTS

Total score approach: QOL total scores decreased, on average, in the two treatment (both -1.0, p < 0.05), but not the placebo (=-0.59, p > 0.3) groups. Qualified change approach: Roughly 60% of all change in QOL items was worsening in every arm; 17% - 42% of all subjects experienced change in each item.

CONCLUSIONS

Totalling the subjective QOL item ratings collapses over items, and suggests a potentially misleading "overall" level of change (or no change, as in the placebo arm). Leaving the items as individual components of "quality" of life they were intended to capture, and qualifying the direction and amount of change in each, suggests that at least 17% of any group experienced change on every item, with 60% of all observed change being worsening.

DISCUSSION

Summarizing QOL item ratings as a total "score" collapses over the face-valid, multi-dimensional components of the construct "quality of life". Qualified Change provides robust evidence of changes to QOL or "enhancements of" life quality.

Current Practice in End-of-Residency Handoffs: A Survey of Internal Medicine-Pediatrics Program Directors

BACKGROUND

End-of-residency outpatient handoffs affect at least 1 million patients per year, yet there is no consensus on best practices.

OBJECTIVE

To explore the use of formal systems for end-of-residency clinic handoffs in internal medicine-pediatrics residency (Med-Peds) programs, and their associated categorical internal medicine and pediatrics programs.

METHODS

We surveyed Med-Peds program directors about their programs' system for handing off ambulatory continuity patients.

RESULTS

Our response rate was 85% (67 of 79 programs). Thirty-one programs (46%) reported having a system for end-of-residency handoffs. Of the 30 that offered detailed information, 22 (73%) formally introduced the program to residents, 12 (40%) standardized the handoff, and 14 (47%) used multiple methods for information exchange, with the electronic health record and oral transfer of information (15 of 30, 50%) the most common. Six programs (20%) indicated they did not offer residents protected time to complete end-of-residency handoffs, and 13 programs (43%) did not identify a specific postgraduate year level for residents to whom patients were handed off. Programs were more likely to have a system for end-of-residency handoffs if another categorical program at their institution also had one (P < .001).

CONCLUSIONS

Fewer than half of responding Med-Peds programs have outpatient handoff systems in place. Inclusion of end-of-residency handoff information in the electronic health record may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.

Using the Guttman scale to define and estimate measurement error in items over time: the case of cognitive decline and the meaning of "points lost"

We used a Guttman model to represent responses to test items over time as an approximation of what is often referred to as "points lost" in studies of cognitive decline or interventions. To capture this meaning of "point loss", over four successive assessments, we assumed that once an item is incorrect, it cannot be correct at a later visit. If the loss of a point represents actual decline, then failure of an item to fit the Guttman model over time can be considered measurement error. This representation and definition of measurement error also permits testing the hypotheses that measurement error is constant for items in a test, and that error is independent of "true score", which are two key consequences of the definition of "measurement error"--and thereby, reliability--under Classical Test Theory. We tested the hypotheses by fitting our model to, and comparing our results from, four consecutive annual evaluations in three groups of elderly persons: a) cognitively normal (NC, N = 149); b) diagnosed with possible or probable AD (N = 78); and c) cognitively normal initially and a later diagnosis of AD (converters, N = 133). Of 16 items that converged, error-free measurement of "cognitive loss" was observed for 10 items in NC, eight in converters, and two in AD. We found that measurement error, as we defined it, was inconsistent over time and across cognitive functioning levels, violating the theory underlying reliability and other psychometric characteristics, and key regression assumptions.

Intra-individual variability in Alzheimer's disease and cognitive aging: definitions, context, and effect sizes

BACKGROUND/AIMS

To explore different definitions of intra-individual variability (IIV) to summarize performance on commonly utilized cognitive tests (Mini Mental State Exam; Clock Drawing Test); compare them and their potential to differentiate clinically-defined populations; and to examine their utility in predicting clinical change in individuals from the Alzheimer's Disease Neuroimaging Initiative (ADNI).

METHODS

Sample statistics were computed from ADNI cohorts with no cognitive diagnosis, a diagnosis of mild cognitive impairment (MCI), and a diagnosis of possible or probable Alzheimer's disease (AD). Nine different definitions of IIV were computed for each sample, and standardized effect sizes (Cohen's d) were computed for each of these definitions in 500 simulated replicates using scores on the Mini Mental State Exam and Clock Drawing Test. IIV was computed based on test items separately ('within test' IIV) and the two tests together ('across test' IIV). The best performing definition was then used to compute IIV for a third test, the Alzheimer's Disease Assessment Scale-Cognitive, and the simulations and effect sizes were again computed. All effect size estimates based on simulated data were compared to those computed based on the total scores in the observed data. Association between total score and IIV summaries of the tests and the Clinician's Dementia Rating were estimated to test the utility of IIV in predicting clinically meaningful changes in the cohorts over 12- and 24-month intervals.

RESULTS

ES estimates differed substantially depending on the definition of IIV and the test(s) on which IIV was based. IIV (coefficient of variation) summaries of MMSE and Clock-Drawing performed similarly to their total scores, the ADAS total performed better than its IIV summary.

CONCLUSION

IIV can be computed within (items) or across (totals) items on commonly-utilized cognitive tests, and may provide a useful additional summary measure of neuropsychological test performance.

Independent contributions of neural and "higher-order" deficits to symptoms in Alzheimer's disease: a latent variable modeling approach

BACKGROUND

Analytic models of Alzheimer's disease (AD) tend to focus on one type of symptom and assume implicitly that no measurement error is present. These tendencies render changes in symptom domains difficult to model mathematically, although latent variable methods can accommodate both multiple symptom domains and error. This study formulated and compared underlying (latent) factor structures representing previously reported dependence and independence of symptoms of cognitive decline, functional impairment, and behavioral disturbance in AD.

METHODS

In confirmatory factor analyses of data from 2 cohorts of AD patients, 2 levels of latent variables were conceptualized. One general neurologic factor represented disease, and symptom factors represented cognition, function, and behavior. Two "null" models had either a single factor or 3 symptom factors. Two 2-level models treated the general factor as underlying both the observed variables and the symptom factors or treated the symptom factors as explaining variability in the observed variables after taking the general factor into account ("residualized").

RESULTS/CONCLUSIONS

The residualized model fit the data in both cohorts significantly better than the other models, and relations in this model between some observed and latent variables were different across cohorts. Neither cohort supported a single factor model; both cohorts independently supported a residualized model that may permit differentiation of symptom- from disease-modifying effects of treatment.

Incidence of atypical handedness in epilepsy and its association with clinical factors

The incidence of atypical handedness (left-handedness and ambidexterity) in patients with epilepsy, particularly its association with major clinical factors, is not well established. We evaluated a full range of clinical variables in 478 patients with epilepsy from the United States and Korea. With the Edinburgh Handedness Inventory, handedness was established as both a categorical variable (right-handed, left-handed, ambidextrous) and a continuous variable. Seizures were classified as complex or simple partial, primary generalized, or generalized tonic-clonic. The relationship between handedness and a range of clinical findings was explored. The overall incidence of atypical handedness in our patients was higher than in the general population (13.6%) and significantly higher in the U.S. patient group (17.6%) than in the Korean patients (8.8%). Handedness was not associated with sex; age; seizure type; age at onset; type, side, or site of EEG or brain imaging abnormalities; family history of seizures; refractory epilepsy; or history of epilepsy surgery.

Agreement in cognitive and clinical assessments in Alzheimer's disease

AIMS

To estimate agreement among scores on three common assessments of cognitive function.

METHOD

Baseline responses on the Alzheimer's Disease Assessment Scale - Cognitive, Clinical Dementia Rating, and the Mini-Mental State Examination were obtained from two clinical trials (n = 138 and n = 351). A graphical method of examining agreement, the means-difference or Bland-Altman plot, was followed by Levene's test of the equality of variance corrected for multiple comparison within each sample.

RESULTS

70-78% of variability was shared by one factor, suggesting that all three instruments reflect cognitive impairment. However, agreement among tests was significantly worse for individuals with greater-than-average, relative to individuals with less-than-average, cognitive impairment.

CONCLUSIONS

Worse agreement between tests, as a function of increasing cognitive impairment, implies that interpretation of these tests and selection of coprimary cognitive impairment outcomes may depend on impairment level.

Analytic methods for factors, dimensions and endpoints in clinical trials for Alzheimer's disease

Alzheimer's disease (AD) is a complex disease process, so finding a single biomarker to track in clinical trials has proven difficult. This paper describes and contrasts statistical methods that might be used with biomarkers in clinical trials for AD, highlighting their differences, limitations and interpretations. The first method is traditional regression, within which one dependent variable, the Best Empirically Supported Indicator (BESI), must be identified. In this approach one biomarker (e.g., the ratio of tau to Abeta42 from CSF) is the indicator for an individual's disease status, and change in that status. The second approach is an exploratory factor analysis (EFA) to consolidate a multitude of candidate dependent variables into a sample-dependent, mathematically-optimized smaller set of 'factors'. The third method is latent variable (LV) modeling of multiple indicators of an entity (e.g., "disease burden"). The LV approach can yield a complex 'dependent variable', the Best Measurement Model Indicator (BMMI). A measurement model represents an entity that several dependent variables reflect or measure, and so can include many 'dependent variables', and estimate their relative contributions to the underlying entity. The selection of a single BESI is an artifact of regression that limits the investigator's ability to utilize all relevant variables representing the entity of interest. EFA results in sample-specific combination of biomarkers that might not generalize to a new sample - and fit of the EFA results cannot be tested. Latent variable methods can be useful to construct powerful, efficient statistical models that optimally combine diverse biomarkers into a single, multidimensional dependent variable that can generalize across samples when they are theory-driven and not sample-dependent. This paper shows that EFA can work to uncover underlying structure, but that it does not always yield solutions that 'fit' the data. It is not recommended as a method to build BMMIs, which will be useful in establishing diagnostic criteria, creating and evaluating benchmarks, and monitoring progression in clinical trials.

A Mastery Rubric: guiding curriculum design, admissions and development of course objectives

This article describes a 'Mastery Rubric' (MR) used to design both the curriculum and the assessments in a new two-year certificate programme intended to train physicians in clinical research skills. The MR for clinical research skills is built around a set of core research skills: critical review of literature; articulation of research objective; development of research design; development of analysis plan; implementation of the study; implementation of the analysis plan and presentation of results. Four distinct levels of performance are described for each skill: beginning, novice, competent and proficient. This rubric outlines and provides a path to mastery of the clinical research skills the certificate programme was designed and funded to target. Using the rubric to design the curriculum ensures that courses will provide instruction in key domains, promotes assessment that demonstrates development in the target skills and knowledge, and encourages reflection and cognitive self-monitoring in the students. It is a flexible, criterion-referenced definition of 'success' for students as well as the programme itself. The criteria are characterised in terms of the skills, habits of mind and organisational principles that can foster excellence in clinical research, but the approach can be generalised.

Towards the integration of medical informatics education for clinicians into the medical curriculum

In the context of an existing first year, one-semester mandatory course of medical informatics (MI) for medical students, we tested an interactive teaching approach in parallel with the traditional academic program. After six semesters (at the beginning of the clinical stage) we collected feedback from the former students in the two parallel programs (with anonymous questionnaires comprising both subjectively-rated items and open-ended questions). We conclude that an introductory course on information and communication technology and information skills can be useful at the beginning of the medical curriculum, while an interactive, problem-based-learning-type MI course should be included during the clinical stage. Early development of these skills, and their use/utility across the curriculum, are important aspects of integrating MI education into clinical training.

Oral gabapentin for the treatment of postoperative pain after photorefractive keratectomy

PURPOSE

To evaluate oral gabapentin for postoperative pain after photorefractive keratectomy (PRK).

DESIGN

Prospective, nonrandomized clinical trial.

METHODS

In additional to a standard regimen of topical antibiotics, topical steroids, and topical tetracaine as required, all PRK patients at our laser vision center were treated after surgery for pain for a two-month period with Percocet (oxycodone/acetaminophen) [Endo Pharmaceuticals; Chadds Ford, Pennsylvania, USA] 5 mg/325 mg as required for three days (control group). Patients completed a pain assessment survey using a faces pain scale (from zero through 6) on the evening of surgery and each subsequent morning and evening until postoperative day 3. A successive cohort of patients received Neurontin (gabapentin) [Pfizer, New York, New York, USA] 300 mg thrice daily (first dose administered two hours or more before the procedure) as an oral pain medication for three days, and the same survey data were collected.

RESULTS

Data were collected on 141 patients in each cohort. Successful pain management score (defined as faces zero through 2 on the scale) differences did not reach statistical significance between the two cohorts except on the morning of the second postoperative day, when gabapentin was superior. On all postoperative days, patients in the oxycodone/acetaminophen cohort used significantly less tetracaine eye drops as required. The percent of patients rating overall pain experience as better than expected was 35% and 36%, those rating pain experience as about what was expected was 50% and 49%, and those rating pain experience as worse than expected was 15% and 15% in the oxycodone/acetaminophen and gabapentin cohorts, respectively.

CONCLUSIONS

We found no difference in overall subjective pain management ratings between gabapentin and oxycodone/acetaminophen for postoperative PRK pain, although gabapentin was associated with significantly more frequent use of anesthetic eye drops as required.

No cross-sectional influence of APOE epsilon4 dose on clinical tests in Alzheimer's disease

This study sought to determine if there are detectible influences on the symptoms of Alzheimer's disease (AD) from the genetic risk factor for AD, the epsilon4 allele of apolipoprotein-E (APOE). Using data from two cohorts of AD patients, a cross-sectional latent variable model of AD was tested with three symptom factors explaining variability in the observed variables after taking a general neurological factor into account. No significant influence of epsilon4 was detected. APOE's effect in AD may occur prior to clinical symptoms, or may simply be more subtle than these instruments can detect.

Promoting self-awareness and reflection through an experiential mind-body skills course for first year medical students

BACKGROUND

This research examines student evaluations of their experience and attitudes in an 11 week mind-body skills course for first year medical students.

AIMS

The aim is to understand the impact of this course on students' self-awareness, self-reflection, and self-care as part of their medical education experience.

METHODS

This study uses a qualitative content analysis approach to data analysis. The data are 492 verbatim responses from 82 students to six open-ended questions about the students' experiences and attitudes after a mind-body skills course. These questions queried students' attitudes about mind-body medicine, complementary medicine, and their future as physicians using these approaches.

RESULTS

The data revealed five central themes in students' responses: connections, self discovery, stress relief, learning, and medical education.

CONCLUSIONS

Mind-body skills groups represent an experiential approach to teaching mind-body techniques that can enable students to achieve self-awareness and self-reflection in order to engage in self-care and to gain exposure to mind-body medicine while in medical school.

Assessing and analyzing change in attitudes in the classroom

We explore three analytic methods that can be used to quantify and qualify changes in attitude and similar outcomes that may be encountered in the educational context. These methods can be used or adapted whenever the outcome of interest is change in a generally unmeasurable attribute, such as attitude. The analyses we describe focus on: (1) change in total 'attitude score'; (2) item-level changes in attitudes towards different topics; and (3) 'attitude shift' that is defined based on a qualified change algorithm. In our example data, the total-score approach gives a general index to the level of positive attitude; the item-level approach gives the median level of positive attitude and indicates items with the most positive/negative attitude (i.e., items to target in future iterations). The qualified change approach provides an objective measure of whether a shift in attitude has occurred. Each analysis is described with its advantages and disadvantages using the data from a survey of 70 preclinical first and second year medical students before and after an elective 11-week interactive seminar (22 contact hours) which introduced elements of complementary and alternative medicine (CAM) into programmed medical school training. When assessing changes that are more qualitative than quantitative, any of these methods can be employed to derive either descriptive or inferential statistics. The methods are straightforward and are appropriate when measurements are imperfect, ratings are subjective and differences are not necessarily absolute.

Use of steroid profiles in determining the cause of adrenal insufficiency

HYPOTHESIS

A cortisol response to adrenocorticotropin injection is the standard test for diagnosing adrenal insufficiency. Multiple steroid hormones can now be accurately measured by tandem mass spectrometry in a single sample. The study objective was to determine whether a steroid profile, created by simultaneous measurement of 10 steroid hormones by tandem mass spectrometry, would help determine the cause of adrenal insufficiency.

DESIGN

A 10-steroid profile was measured by tandem mass spectrometry during the performance of a standard high dose cortrosyn stimulation test. The steroids were measured at baseline, 30, and 60min following synthetic adrenocorticotropin injection. Adrenal insufficiency was defined as a peak cortisol level of less than 20microg/dL. Testing was conducted in the general clinical research center of a university medical center. Normal volunteers, patients suspected of having adrenal insufficiency, and patients with known adrenal insufficiency participated.

RESULTS

Our results showed that adrenal insufficiency of any cause was adequately diagnosed using the response of 11-deoxycortisol, dehydroepiandrosterone, or these analytes combined in a two-steroid profile. A three-steroid profile yielded a test with 100% accuracy for discriminating primary adrenal insufficiency from normal status. Primary adrenal insufficiency was well separated from secondary adrenal insufficiency using only a single aldosterone value. 11-Deoxycortisol, dehydroepiandrosterone, and a two-steroid profile each provided fair discrimination between secondary adrenal insufficiency and normal status.

CONCLUSIONS

We conclude that stimulated levels of aldosterone, 11-deoxycortisol, dehydroepiandrosterone, and a two- or three-steroid profile provided additional discrimination between states of adrenal sufficiency and insufficiency. It is proposed that a steroid profile measuring cortisol, aldosterone, 11-deoxycortisol, and dehydroepiandrosterone would potentially improve the ability to determine the cause of adrenal insufficiency.

A large-sample survey of first- and second-year medical student attitudes toward complementary and alternative medicine in the curriculum and in practice

PURPOSE

To assess attitudes toward complementary and alternative medicine (CAM) and its place in the medical school curriculum and medical practice among preclinical students at Georgetown University School of Medicine (GUSOM), Washington, DC.

METHOD

Two-hundred sixty-six first-year (n=111) and second-year (n=155) medical students rated their attitudes toward CAM and 15 CAM modalities in terms of personal use, inclusion in the curriculum, and use/utility in clinical practice.

RESULTS

Nearly all (91%) students agreed that "CAM includes ideas and methods from which Western medicine could benefit"; more than 85% agreed that "knowledge about CAM is important to me as a student/future practicing health professional"; and more than 75% felt that CAM should be included in the curriculum. Among all students, the most frequently indicated level of desired training was "sufficient to advise patients about use," for 11 of the 15 modalities. The greatest level of training was wanted for acupuncture, chiropractic, herbal medicine, and nutritional supplements. The descriptions of CAM in future clinical practice that occurred most frequently were endorsement, referral, or provision of acupuncture, biofeedback, chiropractic, herbal medicine, massage, nutritional supplements, prayer, and meditation.

CONCLUSIONS

Interest in and enthusiasm about CAM modalities was high in this sample; personal experience was much less prevalent. Students were in favor of CAM training in the curriculum to the extent that they could provide advice to patients; the largest proportions of the sample planned to endorse, refer patients for, or provide 8 of the 15 modalities surveyed in their future practice.

Modeling dimensions of choice in accepting the smallpox vaccine

OBJECTIVE

To model the dimensionality of understanding refusal to be vaccinated against smallpox.

METHOD

The Smallpox Vaccination Choice Questionnaire was administered to a convenience sample of students. Through a series of factor analyses, responses were subjected to a statistical evaluation of the underlying factor structure of potential influences on choice.

RESULTS

The analyses suggest 5 dimensions: knowledge, perceptions of risk and worry, psychological distress, general beliefs about vaccines, and age.

CONCLUSION

This model will be used to help identify targets of intervention to increase acceptance of the vaccine and satisfaction with choice.

Characterizing sleep problems in persons with Alzheimer's disease and normal elderly

We retrospectively analyzed sleep disturbance symptoms and estimated time in bed from the intake interviews of 399 healthy, non-demented elderly (NDE) and 263 persons with a diagnosis of possible (n = 53) or probable (n = 210) Alzheimer's disease (AD). Our primary objective was to identify what symptoms might underlie an individual's perception of 'sleep problems' and to determine if these were consistent within, and across, our two cohorts. We stratified each cohort according to whether or not they (or their caregiver) indicated that they had a 'sleep problem', and compared the frequency and endorsement rates of each of 21 sleep disturbance symptoms across those who did or did not endorse 'sleep problem'. For less than half of the symptoms in persons with AD, and a quarter of those in NDE, endorsement rates were significantly different depending on whether the reporter (or their sleep partner) did or did not report a sleep problem. Differences in mean frequency ratings between individuals reporting sleep problems relative to those not reporting were observed on 10 symptoms in both cohorts; six of these were the same symptom for both cohorts. When persons with subjective sleep problems in the AD and NDE cohorts were compared, only four of 21 symptoms were endorsed in one and not the other; two symptoms were significantly more frequent in one cohort than the other. Thus, within cohorts, the differences between persons with and without 'sleep problems' were relatively pronounced while the main differences in specific sleep-related symptoms between AD and NDE were not. Observed between-cohort differences appear to be driven by who is reporting, and the high prevalence of daytime sleeping in AD. Within-cohort differences reflect a clear distinction between persons with and without sleep problems, regardless of the reporter.