Psychometric properties of the Mini-Mental State Examination in patients with acquired brain injury in Turkey

Neuropsychological Function in Traumatic Brain Injury and the Influence of Chronic Pain

Cognitive dysfunction, pain, and psychological morbidity all present unique challenges to those living with traumatic brain injury (TBI). In this study we examined (a) the impact of pain across domains of attention, memory, and executive function, and (b) the relationships between pain and depression, anxiety, and post-traumatic stress disorder (PTSD) in persons with chronic TBI. Our sample included 86 participants with a TBI and chronic pain (n = 26), patients with TBI and no chronic pain (n = 23), and a pain-free control group without TBI (n = 37). Participants visited the laboratory and completed a comprehensive battery of neuropsychological tests as part of a structured interview. Multivariate analysis of covariance using education as a covariate, failed to detect a significant group difference for neuropsychological composite scores of attention, memory, and executive function (p = .165). A follow-up analysis using multiple one-way analysis of variance (ANOVA) was conducted for individual measures of executive function. Post-hoc testing indicated that those in both TBI groups preformed significantly worse on measures of semantic fluency when compared to controls (p < 0.001, ηρ2 = .16). Additionally, multiple ANOVAs indicated that those with TBI and pain scored significantly worse across all psychological assessments (p < .001). We also found significant associations between measures of pain and most psychological symptoms. A follow-up stepwise linear regression among those in the TBI pain group indicated that post concussive complaints, pain severity, and neuropathic pain symptoms differentially contributed to symptoms of depression, anxiety, and PTSD. These findings suggest deficits in verbal fluency among those living with chronic TBI, with results also reinforcing the multidimensional nature of pain and its psychological significance in this population.

Multidimensional pain phenotypes after Traumatic Brain Injury

More than 50% of individuals develop chronic pain following traumatic brain injury (TBI). Research suggests that a significant portion of post-TBI chronic pain conditions is neuropathic in nature, yet the relationship between neuropathic pain, psychological distress, and somatosensory function following TBI is not fully understood. This study evaluated neuropathic pain symptoms, psychological and somatosensory function, and psychosocial factors in individuals with TBI (TBI, N = 38). A two-step cluster analysis was used to identify phenotypes based on the Neuropathic Pain Symptom Inventory and Beck's Anxiety Inventory scores. Phenotypes were then compared on pain characteristics, psychological and somatosensory function, and psychosocial factors. Our analyses resulted in two different neuropathic pain phenotypes: (1) Moderate neuropathic pain severity and anxiety scores (MNP-AS, N = 11); and (2) mild or no neuropathic pain symptoms and anxiety scores (LNP-AS, N = 27). Furthermore, the MNP-AS group exhibited greater depression, PTSD, pain severity, and affective distress scores than the LNP-AS group. In addition, thermal somatosensory function (difference between thermal pain and perception thresholds) was significantly lower in the MNP-AS compared to the LNP-AS group. Our findings suggest that neuropathic pain symptoms are relatively common after TBI and are not only associated with greater psychosocial distress but also with abnormal function of central pain processing pathways.

Comparison of content and psychometric properties for assessment tools used for brain tumor patients: a scoping review

AIMS

To determine the most frequently utilized functional status assessment instruments for patients with brain tumors, compare their contents, using the International Classification of Functioning, Disability and Health (ICF), and their psychometric properties.

METHODS

A scoping review was conducted to explore possible assessment instruments and summarize the evidence. A systematic literature search was performed for identification of the frequently used functional assessment tool in clinical trials in PubMed, ScienceDirect, and ProQuest databases. The content of most used instruments was linked to the ICF categories. The psychometric qualities of these assessment tools were systematically searched and analyzed.

RESULTS

Nine most used assessment tools in clinical trials were identified. The most frequently used assessment instrument is the Karnofsky Performance Scale, which is developed for a general assessment of oncological patients. Out of four self-assessment tools, two were disease-specific (EORTC QLQ-BN20 and FACT-Br), EORTC QLQ-C30 has been shown good psychometric properties in patients with brain tumors as well as in patients with various oncological diseases, similar to the SF-36, it is used in patients with brain tumors as well as in patients with various diseases. The Functional Independence Measure and the Barthel Index were two objective assessment tools that described functioning, but two were neuropsychological tests (MMSE and Trial Making Test). Two hundred eighty-three meaningful concepts were identified and linked to 102 most relevant second-level categories covering all components of the ICF. Forty-nine studies reporting psychometric properties of those nine assessment tools were identified, indicating good reliability and validity for all the instruments.

CONCLUSION

Nine most frequently utilized functional status assessment instruments for patients with brain tumors represent all components of the ICF and have good psychometric properties. However, the choice of the tool depends on the clinical question posed and the aim of its use.

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review

Cognitive assessment is a cornerstone of geriatric care. Cognitive impairment has the potential to significantly impact multiple phases of a person's cancer care experience. Accurately identifying this vulnerability is a challenge for many cancer care clinicians, thus the use of validated cognitive assessment tools are recommended. As international cancer guidelines for older adults recommend Geriatric Assessment (GA) which includes an evaluation of cognition, clinicians need to be familiar with the overall interpretation of the commonly used cognitive assessment tools. This rapid review investigated the cognitive assessment tools that were most frequently recommended by Geriatric Oncology guidelines: Blessed Orientation-Memory-Concentration test (BOMC), Clock Drawing Test (CDT), Mini-Cog, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Short Portable Mental Status Questionnaire (SPMSQ). A detailed appraisal of the strengths and limitations of each tool was conducted, with a focus on practical aspects of implementing cognitive assessment tools into real-world clinical settings. Finally, recommendations on choosing an assessment tool and the additional considerations beyond screening are discussed.

The prevalence and determinants of inappropriate sexual behaviour in people with acquired brain injury in nursing homes

AIMS

Establishing the prevalence of inappropriate sexual behaviour, concurrent challenging behaviours and the determinants of inappropriate sexual behaviour among patients with acquired brain injury ≤65 years of age in Dutch nursing homes.

DESIGN

Cross-sectional, observational study in acquired brain injury special care units spreads throughout the country.

METHODS

Nursing homes were recruited through the national expertise network for patients with severe acquired brain injury, regional brain injury teams and by searching the Internet. Patient characteristics were collected through digital questionnaires. Inappropriate sexual behaviour was assessed with the St. Andrews Sexual Behaviour Assessment, concurrent challenging behaviours with the NeuroPsychiatric Inventory-Nursing Home Version and the Cohen-Mansfield Agitation Inventory, cognition with the Mini-Mental State Examination and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and inappropriate sexual behaviour were examined using multilevel multivariate linear regression model analyses. Data collection started in June 2017 and ended in April 2019.

RESULTS

Of the 118 included patients, 38.1% had one or more inappropriate sexual behaviours. Verbal comments (30.1%) and non-contact behaviour (24.8%) were the most prevalent types of inappropriate sexual behaviour. Less severe behaviours were more common than more severe behaviours. The most frequent concurrent challenging behaviours were agitation, aggression and hyperactivity. Physical aggression was associated with more inappropriate sexual behaviour. Being married and pain were associated with less inappropriate sexual behaviour.

CONCLUSION

Inappropriate sexual behaviour is prevalent in patients with acquired brain injury ≤65 years of age residing in nursing homes.

IMPACT

Inappropriate sexual behaviour may have impact not only on the patients themselves but also on nursing staff. Insight into the magnitude, severity, course and concurrent challenging behaviours, sexuality and quality of life could give direction to the kind of interventions and education that is needed. The ultimate goal is to develop appropriate care for this vulnerable group of patients, specifically psychosocial interventions and appropriate use of psychotropic drugs.

Prevalence and characteristics of neuropsychiatric symptoms, quality of life and psychotropics in people with acquired brain injury in long-term care

Aim

Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes.

Design

Cross‐sectional, observational study among patients aged 18–≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes.

Methods

According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory‐Nursing Home version, the Cohen–Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini‐Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020.

Discussion

Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS.

Impact

Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long‐term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.

Analyzing differential item functioning of the Nottingham Health Profile by Mixed Rasch Model

Objectives

This study aims to evaluate whether items in the Turkish version of the Nottingham Health Profile (NHP) function differently according to age, sex, and duration of pain using the Mixed Rasch Model (MRM).

Patients and methods

The NHP data of patients with low back pain from a previous study was analyzed. To analyze differential item functioning (DIF) within the items of the NHP, the MRM was used. Age, sex, and duration of pain were considered factors which could cause DIF. The most powerful factor to define latent classes derived from the MRM was estimated using the Rasch tree method.

Results

The two-class mixture version of the nominal response model was identified as the best fitting model for the physical mobility, sleep, and social isolation sections. For the physical mobility dimension, some items showed DIF by age and for the social isolation dimension some items showed DIF by sex. For the sleep dimension, latent classes were unable to be explained by age, sex, and duration of pain. Items in other dimensions of the NHP were DIF-free and no items showed DIF according to age, sex, and duration of pain.

Conclusion

The results of this study may shed light on explaining the different response behavior of patients on the items of the NHP. Age and sex were found to be variables affecting item responses of NHP. Contrary to expectations, duration of pain did not cause DIF for any item. From the perspective of DIF, it can be concluded that NHP scale is a robust scale in terms of validity.

Can kinesio tape be used as an ankle training method in the rehabilitation of the stroke patients?

OBJECTIVE

To investigate the effects of the kinesio tape application to the tibialis anterior on rehabilitation outcomes of the stroke patients.

DESIGN AND SETTING

Twenty patients with stroke were allocated into two groups: the first group of ten patients was assigned to receive kinesio tape in addition to the conventional rehabilitation program while a second group of 10 patients was assigned to receive a conventional rehabilitation program only.

MAIN OUTCOME MEASURES

The clinical variables and health-related quality of life (HRQoL) were evaluated at baseline and at the end of the forth week.

RESULTS

The present study showed that kinesio tape application to the tibialis anterior has significant effects on motor recovery of the lower extremity, spasticity, ambulation capacity, HRQoL and gait compared to the control group and baseline.

CONCLUSIONS

The results of this study suggest that kinesio tape can be used as an ankle training method.

The impact of lower extremity pain conditions on clinical variables and health-related quality of life in patients with stroke

BACKGROUND

The presence of lower extremity pain may be associated with poorer motor recovery, impaired activities of daily living (ADL), reduced quality of life, and disability in patients with stroke.

OBJECTIVE

The aims of the study were to describe the characteristics of lower extremity pain conditions and to evaluate the impact of lower extremity pain on clinical variables, and health-related quality of life in patients with stroke.

METHODS

One hundred and eighty-five patients with stroke who have self-reported pain in the lower extremity were included in the study. Lower extremity pain characteristics of stroke survivors including etiology, intensity, onset time, frequency, aggravating factors, relieving factors, site, and location of pain were evaluated and recorded. The Brunnstrom motor recovery scale, the functional ambulation category, the mini-mental state examination, the star cancellation test, the beck depression inventory, the Barthel Index, and the Short Form-36 Questionnaire (SF-36) were used.

RESULTS

The causes of lower extremity pain were diagnosed as osteoarthritis (51.1%), central neuropathic pain (28.7%), mixed pain (10.3%), low back pain associated with leg pain (8.6%), greater trochanteric pain syndrome (5.2%), prior hip fracture (2.4%), heterotopic ossification (2%), developmental hip luxation (1%), hallux valgus (0.5%), and malignancy (0.5%). The intensity of lower extremity pain was a significant predictor of cognitive functions, ADL, depression, and all SF-36 subscales except emotional role and vitality. The duration of lower extremity pain was a significant predictor of depression and lower extremity spasticity.

CONCLUSIONS

Since lower extremity pain conditions have a significant important influence on clinical variables and health-related quality of life in stroke survivors, early identification and appropriate treatment of the lower extremity pain conditions should be carried out in order to reduce the level of disability in stroke patients.

The value of neurocognitive testing for acute outcomes after mild traumatic brain injury

BACKGROUND

Traditionally, neurocognitive testing is performed weeks to months after head injury and is mostly performed on patients who continue to have symptoms or difficulties. In this study, we sought to determine whether these tests, when administered acutely, could assist in predicting short-term outcomes after acute traumatic brain injury (TBI).

METHODS

This is an IRB-approved prospective study of adult patients who came to the emergency department of our Level-1 trauma center with TBI. Patients were enrolled prospectively after providing written informed consent and underwent three separate neurocognitive tests: the Galveston Orientation Amnesia Test (GOAT) the Rivermead Post-Concussion Survey Questionnaire (RPCSQ) and the Mini Mental Status Examination (MMSE).

RESULTS

A lower GOAT score was significantly associated with hospitalization (P = 0.0212) and the development of post-concussion syndrome (P = 0.0081) at late follow-up. A higher RPCSQ score was significantly associated with hospital admission (P = 0.0098), re-admission within 30 days of discharge (P = 0.0431) and evidence of post-concussion syndrome (PCS) at early follow-up (P = 0.0004). A higher MMSE score was significantly associated with not being admitted to the hospital (P = 0.0002) and not returning to the emergency department (ED) within 72 hours of discharge (P = 0.0078). Lower MMSE was also significantly associated with bleeding or a fracture on the brain CT (P = 0.0431).

CONCLUSIONS

While neurocognitive testing is not commonly performed in the ED in the setting of acute head injury, it is both feasible and appears to have value in predicting hospital admission and PCS. These data are especially important in terms of helping patients understand what to expect, thus, aiding in their recovery.

Mood Instability and Irritability as Core Symptoms of Major Depression: An Exploration Using Rasch Analysis

BACKGROUND

Mood instability (MI) and irritability are related to depression but are not considered core symptoms. Instruments typically code clusters of symptoms that are used to define syndromic depression, but the place of MI and irritability has been under-investigated. Whether they are core symptoms can be examined using Rasch analysis.

METHOD

We used the UK Psychiatric Morbidity Survey 2000 data (n = 8,338) to determine whether the nine ICD/DSM symptoms, plus MI and irritability, constitute a valid depression scale. Rasch analysis was used, a method concerned with ensuring that items constitute a robust scale and tests whether the count of symptoms reflects an underlying interval-level measure. Two random samples of 500 were drawn, serving as calibration and validation samples. As part of the analysis, we examined whether the candidate symptoms were unidimensional, followed a Guttman pattern, were locally independent, invariant with respect to age and sex, and reliably distinguished different levels of depression severity.

RESULTS

A subset of five symptoms (sad, no interest, sleep, cognition, suicidal ideas) together with mood instability and irritability satisfactorily fits the Rasch model. However, these seven symptoms do not separate clinically depressed persons from the rest of the population with adequate reliability (Cronbach α = 0.58; Person Separation Index = 0.35), but could serve as a basis for scale development. Likewise, the original nine DSM depression symptoms failed to achieve satisfactory reliability (Cronbach α = 0.67; Person Separation Index = 0.51).

LIMITATIONS

The time frame over which symptoms were experienced varied, and some required recall over the last year. Symptoms other than those examined here might also be core depression symptoms.

CONCLUSION

Mood instability and irritability are candidate core symptoms of the depressive syndrome and should be part of its clinical assessment.

Assessing the invariance of a culturally competent multi-lingual unmet needs survey for immigrant and Australian-born cancer patients: a Rasch analysis

PURPOSE

The purpose of this study was to assess the invariance of a culturally competent multi-lingual unmet needs survey.

METHODS

A cross-sectional study was conducted among immigrants of Arabic-, Chinese- and Greek-speaking backgrounds, and Anglo-Australian-born controls, recruited through Cancer Registries (n = 591) and oncology clinics (n = 900). The survey included four subscales, with newly developed items addressing unmet need in culturally competent health information and patient support (CCHIPS), and items adapted from existing questionnaires addressing physical and daily living (PDL), sexuality (SEX) and survivorship (SURV) unmet need. The survey was translated into Arabic, Chinese and Greek. Rasch analysis was carried out on the four domains.

RESULTS

Whilst many items were mistargeted to less prevalent areas of unmet need, causing substantial floor effects in person estimates, reliability indices were acceptable. The CCHIPS domain showed differential item functioning (DIF) for cultural background and language, and the PDL domain showed DIF for treatment phase and gender. The results for SEX and SURV domains were limited by floor effects and missing responses. All domains showed adequate fit to the model after DIF was resolved and a small number of items were deleted.

CONCLUSIONS

The study highlights the intricacies in designing a culturally competent survey that can be applied to culturally and linguistically diverse groups across different treatment contexts. Overall, the results demonstrate that this survey is somewhat invariant with respect to these factors. Future refinements are suggested to enhance the survey's cultural competence and general validity.

Determinants of change in stroke-specific quality of life after distributed constraint-induced therapy

OBJECTIVE

We identified the predictive factors of change in quality of life (QOL) after a distributed form of constraint-induced therapy (dCIT) among stroke survivors.

METHOD

Seventy-four participants were treated with dCIT. We identified eight potential determinants of change: age, gender, side of lesion, time since stroke, cognitive status, motor impairment of the upper extremity, activities of daily living (ADLs), and instrumental ADLs (IADLs). The Stroke-Specific Quality of Life Scale (SS-QOL) was used to assess QOL.

RESULTS

Right-sided lesion and onset >17 mo earlier determined greater improvement in the SS-QOL Energy domain. Onset >10 mo earlier, poorer IADL performance, and age >68 yr predicted improvement in the Family Role, Mobility, and Mood domains, respectively.

CONCLUSION

Side of lesion, time since stroke, IADL performance, and age were the most important determinants of QOL in patients receiving stroke motor rehabilitation.

Factors that Influence Functional Mobility Outcomes of Patients after Traumatic Brain Injury

Objective/Background

The consequences of traumatic brain injury (TBI) include physical, cognitive, psychological, behavioural, and emotional deficits. Prognostic factors such as age, mechanism of injury, and severity of injury assist in determining the outcome of the patient. It is believed that predictors of recovery assist both the patient as well as family members in determining the potential outcomes for the patient. The objective of this study was to identify factors that influence functional mobility outcome of patients after TBI.

Methods

This was a cross-sectional study. Participants were assessed predischarge. The Glasgow Coma Scale on admission was noted to establish the severity of the TBI. The Rivermead Mobility Index was used to establish the functional mobility outcome.

Results

The sample consisted of 60 participants of which 56 (93%) were males. The average age of the participants in the study was 28 ± 8.5 years. More than 50% of the participants were unable to walk outside and 37% were able to climb a flight of stairs without help at the time of discharge from the hospital. Younger age (p < .001), male gender (p = .001), Grade 12 education (p = .001), being self employed (p < .001), having bowel and bladder continence (p < .001), not smoking and drinking (p < .001), and having occupational therapy sessions (p = .002) had a positive impact on function after TBI.

Conclusion

Previous studies have identified a multitude of factors and this study has served to confirm factors that have a positive impact on physical function after TBI within this study group.

Improving precision in the quantification of cognition using the Montreal Cognitive Assessment and the Mini-Mental State Examination

BACKGROUND

The Montreal Cognitive Assessment (MoCA) can be used to quantify cognitive ability in older persons undergoing screening for cognitive impairment. Although highly sensitive in detecting mild cognitive impairment, its measurement precision is weakest among persons with milder forms of impairment. We sought to overcome this limitation by integrating information from the Mini-Mental State Examination (MMSE) into the calculation of cognitive ability.

METHODS

Data from 185 geriatric outpatients screened for cognitive impairment with the MoCA and the MMSE were Rasch analyzed to evaluate the extent to which the MMSE items improved measurement precision in the upper ability ranges of the population.

RESULTS

Adding information from the MMSE resulted in a 13.8% (13.3-14.3%) reduction in measurement error, with significant improvements in all quartiles of patient ability. The addition of three-word repetition and recall, copy pentagons, repeat sentence, and write sentence improved measurement of cognition in the upper levels of ability.

CONCLUSIONS

The algorithm presented here maximizes the yield of available clinical data while improving measurement of cognitive ability, which is particularly important for tracking changes over time in patients with milder levels of impairment.

Validation of a Mini-Mental State Examination (MMSE) for the Persian population: a pilot study

The objective of the study was to develop and validate a translated and culturally adapted Mini-Mental State Examination (MMSE) for the Persian-speaking population. The MMSE was translated into Persian. Two groups of neurologically intact subjects (n = 100) and subjects with Alzheimer's disease (n = 13) were studied. The difference between groups on the mean total scores of the Persian MMSE was statistically significant (control = 28.62 +/- 2.09; subjects with Alzheimer's disease = 11.77 +/- 5.66; p < .001). The cutoff score of 23 was the best cutoff score for our subjects with a sensitivity and specificity of 98% and 100%, respectively. There was a significant correlation between the Persian MMSE score and the level of education (r = .46) and with age (r = -.77). There was no significant correlation between the Persian MMSE and gender. The Persian MMSE was found to be valid for discrimination of cognitive impairment in the Persian-speaking community.

Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke

BACKGROUND

There are no reports of predictive models or predictors for quality of life (QoL) after constraint-induced therapy (CIT).

OBJECTIVE

This investigation identified predictors of change in stroke-related QoL after distributed CIT using the Chi-squared Automatic Interaction Detector (CHAID) method.

METHODS

A total of 58 patients with chronic stroke were treated with CIT for 2 hours daily for 3 weeks. The 7 potential predictors were age, gender, side of lesion, time since stroke, cognitive status, motor impairment of upper extremity, and activities of daily living (ADL). QoL was measured by the Stroke Impact Scale (SIS). CHAID analysis was used to examine for associations between the 7 predictors and each SIS domain. The validity of each model generated by the analysis was evaluated.

RESULTS

Daily functional performance as measured by the Functional Independence Measure (FIM) was found to determine SIS outcomes, including overall score (P = .006) and the ADL/instrumental ADL (IADL) domain (P = .004). None of the potential predictors emerged as significant predictors of the strength, memory, emotion, communication, mobility, hand function, and participation domains of SIS. The misclassification risk estimates were small, indicating good validity for the CHAID models.

CONCLUSIONS

The functional independence score of the FIM can predict the overall SIS score as well as the ADL/IADL domain of the SIS in chronic stroke patients who receive CIT, but larger databases are needed to confirm this. CHAID analysis was a useful approach for an exploratory study.

Individual capital and cognitive ageing in Guatemala

Using data from adults 50 years and older in Guatemala (N = 643), we assessed to what extent measures of individual capital-economic, social, intellectual, and biological-were associated with and account for variation in cognitive functioning, as measured by the Modified Mini-Mental Status Exam (M-MMSE). Measures of these components of individual capital are positively associated with cognitive functioning, and together with other attributes, account for 29.6 per cent of its variance. Schooling accounts for the largest unique share (5.3 per cent) of the variance, followed by household standard of living (2.0 per cent), church attendance (1.3 per cent), and z-score for height (0.9 per cent). In a setting like Guatemala-with low schooling, widespread poverty, malnutrition, and infectious disease-early life investments that increase schooling and improve nutrition may be valuable as investments to mitigate cognitive impairment in older adults and its contribution to the disease burden.

Measuring cognition in a geriatric outpatient clinic: Rasch analysis of the Montreal Cognitive Assessment

OBJECTIVE

To evaluate the psychometric properties of the Montreal Cognitive Assessment as a quantitative measure of cognitive ability.

DATA ANALYZED

A total of 222 cases extracted from a clinical database (57-91 years) of patients screened for cognitive impairment in outpatient geriatric assessment clinics.

DATA COLLECTED

Demographic information and individual item responses to Montreal Cognitive Assessment.

RESULTS

Comparison of the data with a unidimensional Rasch model indicated that the total score obtained by summing across all items yields a reliable (0.75) quantitative estimate of global cognitive ability. All items fit the model and together spanned a range of difficulty from -3.75 to +2.88 logits. Items were assessed for differential item functioning across such patient characteristics as age, education, and language spoken. We provide a table for converting Montreal Cognitive Assessment total scores onto a linearly scaled score, with guidelines for interpreting changes in Montreal Cognitive Assessment score in terms of their statistical significance.

CONCLUSIONS

The Montreal Cognitive Assessment can provide a reliable and valid quantitative estimate of cognitive ability in a geriatric cognitive disorders clinic setting.

Validation of the Middlesex Elderly Assessment of Mental State (MEAMS) as a cognitive screening test in patients with acquired brain injury in Turkey

PURPOSE

Assessment of cognitive impairment with a valid cognitive screening tool is essential in neurorehabilitation. The aim of this study was to test the reliability and validity of the Turkish-adapted version of the Middlesex Elderly Assessment of Mental State (MEAMS) among acquired brain injury patients in Turkey.

METHODS

Some 155 patients with acquired brain injury admitted for rehabilitation were assessed by the adapted version of MEAMS at admission and discharge. Reliability was tested by internal consistency, intra-class correlation coefficient (ICC) and person separation index; internal construct validity by Rasch analysis; external construct validity by associations with physical and cognitive disability (FIM); and responsiveness by Effect Size.

RESULTS

Reliability was found to be good with Cronbach's alpha of 0.82 at both admission and discharge; and likewise an ICC of 0.80. Person separation index was 0.813. Internal construct validity was good by fit of the data to the Rasch model (mean item fit -0.178; SD 1.019). Items were substantially free of differential item functioning. External construct validity was confirmed by expected associations with physical and cognitive disability. Effect size was 0.42 compared with 0.22 for cognitive FIM.

CONCLUSION

The reliability and validity of the Turkish version of MEAMS as a cognitive impairment screening tool in acquired brain injury has been demonstrated.

Dimensionality of nonmotor neurobehavioral impairments when observed in the natural contexts of ADL task performance

OBJECTIVE

To examine diverse nonmotor neurobehavioral impairments (NBIs) that impact activities of daily living (ADL) task performance and to verify if such impairments can be viewed as one dimension when evaluated in an ecologically-relevant context.

METHODS

Rasch analysis was performed on data from 206 individuals diagnosed with dementia or cerebral vascular accident (CVA) who had been scored on 50 standardized NBIs from the A-ONE Neurobehavioral Impairment scale, based on naturalistic observation of ADL task performance. Evaluation of mean square (MnSq) infit and outfit values and principal components analysis (PCA) of residuals were used to evaluate unidimensionality of the items. Two evaluations were implemented: (1) to evaluate if there is a single global dimension common for persons with either dementia or CVA, and (2) to evaluate if the 50 NBIs are unidimensional, but comprised of different diagnosis-specific global hierarchies (dementia, left CVA, and right CVA).

RESULTS

The PCA indicated that 56.8% of variance was explained by the global measure (Rasch factor) of NBIs, with 4.9% of the unexplained variance explained by the first contrast. Four items showed outfit misfit to the common hierarchy. Developing diagnosis-specific global hierarchies resulted in improved PCA results for all 3 diagnostic groups (Rasch factor = 79.2% to 85.5%; unexplained variance in first contrast = 1.7% to 3.4%) after removal of 2 to 3 misfitting items.

CONCLUSIONS

Nonmotor NBIs, when evaluated based on naturalistic performance of ADL, can be considered unidimensional, but the hierarchical structure of the dimension likely varies across diagnostic groups. Further study is needed with larger samples to verify these results.

Gender, resources across the life course, and cognitive functioning in Egypt

In this article, I evaluate the life-course determinants of cognitive functioning among 1,003 women and men aged 50 and older in Ismailia, Egypt. Three questions motivate this analysis: (1) Do older women have poorer cognitive functioning than do older men?; (2) Do cognitive resources accrued in childhood and adulthood have net positive associations with later-life cognitive functioning for women and men?; and (3) To what extent do differences in the amounts and effects of women's and men's cognitive resources account for gaps in their cognitive functioning? Compared with men, women have lower Modified-Mini Mental Status Exam (M-MMSE) scores for overall cognitive functioning. Cognitive resources in childhood and adulthood are jointly associated with the M-MMSE score. About 83% of the gender gap in mean M-MMSE scores is attributable to gaps in men's and women's attributes across the life course. Gender gaps in childhood cognitive resources-and especially schooling attainment-account for the largest share (18%) of the residual gender gap in cognitive functioning.

Cross-diagnostic validity in a generic instrument: an example from the Functional Independence Measure in Scandinavia

Background

To analyse the cross-diagnostic validity of the Functional Independence Measure (FIM™) motor items in patients with spinal cord injury, stroke and traumatic brain injury and the comparability of summed scores between these diagnoses.

Methods

Data from 471 patients on FIM™ motor items at admission (stroke 157, spinal cord injury 157 and traumatic brain injury 157), age range 11–90 years and 70 % male in nine rehabilitation facilities in Scandinavia, were fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM™ motor items was made prior to testing fit to the model. Categories were re-scored where necessary. Fit to the model was assessed initially within diagnosis and then in the pooled data. Analysis of Differential Item Functioning (DIF) was undertaken in the pooled data for the FIM™ motor scale. Comparability of sum scores between diagnoses was tested by Test Equating.

Results

The present seven category scoring system for the FIM™ motor items was found to be invalid, necessitating extensive rescoring. Despite rescoring, the item-trait interaction fit statistic was significant and two individual items showed misfit to the model, Eating and Bladder management. DIF was also found for Spinal Cord Injury, compared with the other two diagnoses. After adjustment, it was possible to make appropriate comparisons of sum scores between the three diagnoses.

Conclusion

The seven-category response function is a problem for the FIM™ instrument, and a reduction of responses might increase the validity of the instrument. Likewise, the removal of items that do not fit the underlying trait would improve the validity of the scale in these groups. Cross-diagnostic DIF is also a problem but for clinical use sum scores on group data in a generic instrument such as the FIM™ can be compared with appropriate adjustments. Thus, when planning interventions (group or individual), developing rehabilitation programs or comparing patient achievements in individual items, cross-diagnostic DIF must be taken into account.