Reliability of routine clinical instruments for the assessment of Alzheimer's disease administered by telephone

Measurement properties of outcome measures used in neurological telerehabilitation: A systematic review using COSMIN checklist

OBJECTIVE

To summarize the measurement properties (reliability, validity, and responsiveness) and the clinical utility of measurement tools used in telerehabilitation in individuals with neurological conditions.

DESIGN

Systematic review.

SUBJECTS

Individuals with neurological conditions.

INTERVENTION

Not applicable.

MAIN MEASURES

The methodological quality of the studies using the COSMIN Risk of Bias Checklist, the quality of the measurement properties using the criteria for good measurement properties, and the clinical utility of the measurements using the Tyson & Connell scale.

RESULTS

From the 22,188 identified studies, 47 were included. Forty-three measurement tools were identified. The main modes of administration were telephone and videoconference. Studies involved mostly individuals with stroke, multiple sclerosis, and Alzheimer's disease. Criterion validity and reliability were the most investigated measurement properties. None of the tools had their responsiveness investigated. Twenty-two measurement tools have at least one measurement property evaluated as "sufficient" in a study with appropriate methodological quality ("very good" or "adequate"). Nineteen measurement tools showed adequate clinical utility. Eight measurement tools, investigated in individuals with stroke, spinal cord injury or Alzheimer's disease, all administered by telephone, were recommended.

CONCLUSION

The present results can be used to assist in choosing appropriate measurement tools, both in research and clinical practice, during telerehabilitation in individuals with neurological conditions. Measurement error, content validity, structural validity, and responsiveness need to be further investigated. In addition, the measurement properties of tools used in telerehabilitation in other neurological conditions, such as Huntington's disease, should also be investigated.

REGISTRATION NUMBER

CRD42021257662.

Validation study of the Persian version of behavioral pathology in Alzheimer's Disease Rating scale (BEHAVE-AD) and the empirical BHAVE-AD (E-BEHAVE-AD)

INTRODUCTION

Behavioral and psychological symptoms of dementia (BPSD) are observed in more than 90% of patients with Alzheimer's disease (AD). BPSDs are remediable if detected early and managed appropriately. Behavioral Pathology in Alzheimer's disease Rating Scale (BEHAVE-AD) and Empirical BEHAVE-AD (E-BEHAVE-AD) were designed to identify BPSD. The aim of this study is to validate and prepare BEHAVE-AD and E-BEHAVE-AD in Persian language for clinical and research applications.

METHOD

120 patients were selected through a combination of intentional and convenience sampling. All participants should fulfill the NINCDS-ADRDA Work Group criteria for a clinical diagnosis of Alzheimer's disease. Functional Assessment Staging Tool (FAST) was used to determine the rate of AD progression. All patients were evaluated using the BEHAVE-AD and E-BEHAVE-AD questionnaires, as well as the Persian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Mini-Mental State Examination (MMSE). The Content Validity Index (CVI) is determined based on the compatibility of the Persian and the original version of the two scales according to the opinion of expert panels. Correlation of MMSE with BEHAVE-AD and E-BEHAVE-AD as well as the BPSD pattern on AD progression continuum by FAST were considered as indices of construct validity. Concurrent validity was estimated by correlating NPI-Q scores with BEHAVE-AD and E-BEHAVE-AD scores. For both scales, interrater reliability was extracted as a reliability index.

RESULTS

Pearson correlation coefficients for the BEHAVE-AD scale were as follows: with NPI-Q (r = 0.77, p-value <0.01), with MMSE (r = -0.34, p-value <0.01), indicating concurrent and construct validity, respectively. The result for E-BEHAVE-AD was as follows: with NPI-Q-total (r = 0.59, p-value <0.01), and with MMSE (r = 0.31, p-value <0. 01). BEHAVE-AD and E-BEHAVE-AD scores increased in parallel with AD severity according to FAST, but not on the most severe AD stage. The area under the curve was estimated to be 0.84 (p-value <0.001) for BEHAVE-AD and 0.78 (p-value <0.001) for E-BEHAVE-AD. Correlation between BEHAVE-AD and E-BEHAVE-AD scores ranged from 0.45 to 0.63. The inter-rater reliability index ranged from 0.88 to 0.99 for BEHAVE-AD and from 0.74 to 0.95 for E-BEHAVE-AD.

CONCLUSIONS

The Persian version of BEHAVE-AD and E-BEHAVE-AD is valid and reliable for the assessment of BPSD in patients with AD.

Diagnostic test accuracy of remote, multidomain cognitive assessment (telephone and video call) for dementia

BACKGROUND

Remote cognitive assessments are increasingly needed to assist in the detection of cognitive disorders, but the diagnostic accuracy of telephone- and video-based cognitive screening remains unclear.

OBJECTIVES

To assess the test accuracy of any multidomain cognitive test delivered remotely for the diagnosis of any form of dementia. To assess for potential differences in cognitive test scoring when using a remote platform, and where a remote screener was compared to the equivalent face-to-face test.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, LILACS, and ClinicalTrials.gov (www.

CLINICALTRIALS

gov/) databases on 2 June 2021. We performed forward and backward searching of included citations.

SELECTION CRITERIA

We included cross-sectional studies, where a remote, multidomain assessment was administered alongside a clinical diagnosis of dementia or equivalent face-to-face test.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data; a third review author moderated disagreements. Our primary analysis was the accuracy of remote assessments against a clinical diagnosis of dementia. Where data were available, we reported test accuracy as sensitivity and specificity. We did not perform quantitative meta-analysis as there were too few studies at individual test level. For those studies comparing remote versus in-person use of an equivalent screening test, if data allowed, we described correlations, reliability, differences in scores and the proportion classified as having cognitive impairment for each test.

MAIN RESULTS

The review contains 31 studies (19 differing tests, 3075 participants), of which seven studies (six telephone, one video call, 756 participants) were relevant to our primary objective of describing test accuracy against a clinical diagnosis of dementia. All studies were at unclear or high risk of bias in at least one domain, but were low risk in applicability to the review question. Overall, sensitivity of remote tools varied with values between 26% and 100%, and specificity between 65% and 100%, with no clearly superior test. Across the 24 papers comparing equivalent remote and in-person tests (14 telephone, 10 video call), agreement between tests was good, but rarely perfect (correlation coefficient range: 0.48 to 0.98).

AUTHORS' CONCLUSIONS

Despite the common and increasing use of remote cognitive assessment, supporting evidence on test accuracy is limited. Available data do not allow us to suggest a preferred test. Remote testing is complex, and this is reflected in the heterogeneity seen in tests used, their application, and their analysis. More research is needed to describe accuracy of contemporary approaches to remote cognitive assessment. While data comparing remote and in-person use of a test were reassuring, thresholds and scoring rules derived from in-person testing may not be applicable when the equivalent test is adapted for remote use.

Delusion and Delirium in Neurodegenerative Disorders: An Overlooked Relationship?

Delusions are part of the neuropsychiatric symptoms that patients suffering from neurodegenerative conditions frequently develop at some point of the disease course and are associated with an increased risk of cognitive and functional decline. Delirium is a syndrome characterized by acute onset of deficits in attention, awareness, and cognition that fluctuate in severity over a short time period. Delusions and delirium are frequently observed in the context of neurodegeneration, and their presence can easily mislead clinicians toward a misdiagnosis of psychiatric disorder further delaying the proper treatment. Risk factors for developing delusion and delirium in neurodegenerative conditions have been investigated separately while the possible interplay between these two conditions has not been explored so far. With this study, we aim to achieve a more comprehensive picture of the relationship between delusions and delirium in neurodegeneration by analyzing prevalence and subtypes of delusions in different neurodegenerative disorders; providing an overview of clinical tools to assess delusions in neurodegenerative patients and how delusions are covered by delirium assessment tools and discussing the possible common pathophysiology mechanisms between delusion and delirium in neurodegenerative patients. A more extensive characterization of the relationship between delusions and delirium may help to understand whether delusions may constitute a risk factor for delirium and may ameliorate the management of both conditions in patients with neurodegenerative disorders.

Comparison of Instrumental Activities of Daily Living assessment by face-to-face or telephone interviews: a randomized, crossover study

Background

The functional autonomy assessment is essential to manage patients with a neurodegenerative disease, but its evaluation is not always possible during a consultation. To optimize ambulatory autonomy assessment, we compared the Lawton Instrumental Activities of Daily Living (IADL) questionnaire collected by telephone and face-to-face interviews.

Methods

A randomized, crossover study was carried out among patients attending a memory clinic (MC). The IADL questionnaire was collected for patients during telephone and face-to-face interviews between nurses and patients’ caregivers. The agreement between the two methods was measured using the proportion of participants giving the same response, Cohen’s kappa, intraclass correlation (ICC) coefficient, and Bland and Altman method. The associations between patients’ characteristics, events occurring between the two assessments, and agreement were assessed.

Results

Among the 292 patients (means ± SD age 81.5 ± 7, MMSE 19.6 ± 6, 39.7% with major neurocognitive disorders) analyzed, the proportion of agreement between the two modes was 89.4% for the total IADL score. Weighted kappa coefficient was 0.66 and ICC score was 0.91 for total IADL score. The mean difference between the IADL score by telephone or face-to-face was 0.32. Overall, 96.9% of measures lay within the 95% limits of agreement. The occurrence of fall was less likely associated with the probability to lie within the 95% limits of agreement (OR = 0.07 [0.02–0.27]).

Conclusion

The administration of IADL by telephone with the caregiver appears to be an acceptable method of assessment for MC patients compared to face-to-face interview. The events such as falls which could occur in a time close to the evaluation should be reported.

Study registration

ClinicalTrials.gov, NCT02654574. Retrospectively registered: 13 January 2016

Rethinking Psychosis in Dementia: An Analysis of Antecedents and Explanations

An in-depth analysis of qualitative data regarding antecedents, consequences, and descriptions of delusions of persons with dementia (PwD) provided by family caregivers is presented. Three broad classifications of reasons given behind types of delusions are included, namely environmental factors, personal factors, and dementia, with dementia being the most prominent factor. We observed an overlap between known cognitive symptoms of dementia and the characteristics of the reported "delusions" in dementia. It therefore appears that what is often classified as a delusion of a seemingly psychotic nature is in fact the PwD's disorientation combined with an attempt to fill in gaps caused by cognitive deficiencies.

Association of Antioxidant Supplement Use and Dementia in the Prevention of Alzheimer's Disease by Vitamin E and Selenium Trial (PREADViSE)

Importance

Oxidative stress is an established dementia pathway, but it is unknown if the use of antioxidant supplements can prevent dementia.

Objective

To determine if antioxidant supplements (vitamin E or selenium) used alone or in combination can prevent dementia in asymptomatic older men.

Design, Setting, and Participants

The Prevention of Alzheimer's Disease by Vitamin E and Selenium (PREADViSE) trial began as a double-blind randomized clinical trial in May 2002, which transformed into a cohort study from September 2009 to May 2015. The PREADViSE trial was ancillary to the Selenium and Vitamin E Cancer Prevention Trial (SELECT), a randomized clinical trial of the same antioxidant supplements for preventing prostate cancer, which closed in 2009 owing to findings from a futility analysis. The PREADViSE trial recruited 7540 men, of whom 3786 continued into the cohort study. Participants were at least 60 years old at study entry and were enrolled at 130 SELECT sites, and Cox proportional hazards models were used in a modified intent-to-treat analysis to compare hazard rates among the study arms.

Interventions

Participants were randomized to vitamin E, selenium, vitamin E and selenium, or placebo. While taking study supplements, enrolled men visited their SELECT site and were evaluated for dementia using a 2-stage screen. During the cohort study, men were contacted by telephone and assessed using an enhanced 2-stage cognitive screen. In both phases, men were encouraged to visit their physician if the screen results indicated possible cognitive impairment.

Main Outcomes and Measures

Dementia case ascertainment relied on a consensus review of the cognitive screens and medical records for men with suspected dementia who visited their physician for an evaluation or by review of all available information, including a functional assessment screen.

Results

The mean (SD) baseline age of the 7540 participants was 67.5 (5.3) years, with 3936 (52.2%) reporting a college education or better, 754 (10.0%) reporting black race, and 505 (6.7%) reporting Hispanic ethnicity. Dementia incidence (325 of 7338 men [4.4%]) was not different among the 4 study arms. A Cox model, which adjusted incidence for participant demographic information and baseline self-reported comorbidities, yielded hazard ratios of 0.88 (95% CI, 0.64-1.20) for vitamin E, 0.83 (0.60-1.13) for selenium, and 1.00 (0.75-1.35) for the combination compared with placebo.

Conclusions and Relevance

Neither supplement prevented dementia. To our knowledge, this is the first study to investigate the long-term association of antioxidant supplement use and dementia incidence among asymptomatic men.

Lead exposure and rate of change in cognitive function in older women

BACKGROUND

Higher long-term cumulative lead exposure predicts faster cognitive decline in older men, but evidence of an association in women is lacking.

OBJECTIVE

To determine if there is an association between lead exposure and cognitive decline in women.

METHODS

This study considers a sample of 584 women from the Nurses' Health Study who live in or near Boston, Massachusetts. We quantified lead exposure using biomarkers of lead exposure assessed in 1993-2004 and evaluated cognitive decline by repeated performance on a telephone battery of cognitive tests primarily assessing learning, memory, executive function, and attention completed in 1995-2008. All cognitive test scores were z-transformed for use in analyses. We used linear mixed models with random effects to quantify the association between each lead biomarker and change in cognition overall and on each individual test.

RESULTS

Consideration of individual tests showed greater cognitive decline with increased tibia lead concentrations, a measure of long-term cumulative exposure, for story memory and category fluency. The estimated excess annual decline in overall cognitive test z-score per SD increase in tibia bone lead concentration was suggestive, although the confidence intervals included the null (0.024 standard units, 95% confidence interval: -0.053, 0.004 - an additional decline in function equivalent to being 0.33 years older). We found little support for associations between cognitive decline and patella or blood lead, which provide integrated measures of exposure over shorter timeframes.

CONCLUSIONS

Long-term cumulative lead exposure may be weakly associated with faster cognitive decline in community-dwelling women, at least in some cognitive domains.

The meanings of delusions in dementia: a preliminary study

One of the common symptoms of dementia is delusions. Due to a biological conceptualization of the behaviors represented as delusions, these are classified as psychotic symptoms. This is a qualitative and quantitative study aiming to describe the delusions experienced by older persons with dementia and the context of occurrence, and to elucidate their etiology. Participants were 74 nursing home residents aged 65 and over, diagnosed with dementia, from nine nursing homes in Israel. Participants with delusions were found to have significantly more difficulties in performing ADLs, and poorer vision and hearing. Based on assessment using the BEHAVE-AD, six categories of delusions were examined: 1. One's house is not one's home, 2. Theft, 3. Danger, 4. Abandonment, 5. Misidentification, and 6. Other non-paranoid. Common themes appeared across delusions including reality, disorientation, re-experience of past events, loneliness and insecurity, boredom, and trigger. Current results suggest that delusions may not represent psychotic symptoms for most participants, because they sometimes represented reality, or were neither firm nor incontrovertible. Thus, utilizing the term delusion relegates the person's behavior to the domain of severe psychiatric phenomena and precludes understanding its true meaning.

Recommended measures for the assessment of behavioral disturbances associated with dementia

OBJECTIVE

The study reviewed all the published instruments used for the assessment, diagnosis, screening, and outcomes monitoring/evaluation of behavioral disturbances associated with dementia (BDAD) to recommend a set of psychometrically valid measures for clinicians and researchers to use, across a range of different practice settings.

METHODS

The study involved a broad scoping search, followed by a series of in-depth literature reviews on 29 instruments using scientific literature databases (MEDLINE, PsycINFO, CINAHL, and the Cochrane Library) and various national, international government, and government agency websites and professional organization websites. External consultations from measurement, clinical and research experts in dementia care, consumer representatives, and policy/decision makers, were sought in selecting the best instruments and in making the final recommendations.

FINDINGS

Key attributes and psychometric properties of a short list of five instruments were measured against prespecified criteria. The Neuropsychiatry Inventory (NPI) and the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) were rated as the best measures for assessment of behavioral disturbances, followed by the Consortium to Establish a Registry for Alzheimer's Disease-Behavior Rating Scale for Dementia (CERAD-BRSD), the Dementia Behavior Disturbance Scale, and the Neurobehavioral Rating Scale.

CONCLUSION

The use of valid and standardized outcome measures for the assessment of BDAD is critical for epidemiological studies, prevention, early intervention and treatment of dementia conditions, and funding for relevant healthcare services. The review recommends the NPI and BEHAVE-AD as the most appropriate measures for both clinical and research, whereas the CERAD-BRSD is suited better for research. The review was designed for the Australian context; however, the findings are applicable in other developed countries.

Functional, global and cognitive decline correlates to accumulation of Alzheimer's pathology in MCI and AD

BACKGROUND

Cognitive, global and functional instruments have been extensively investigated for correlations with neuropathological changes such as neurofibrillary tangles (NFTs), plaques, and synapse loss in the brain.

OBJECTIVE

Our objective is to correlate the functional, global and cognitive decline assessed clinically with the neuropathological changes observed in a large prospectively characterized cohort of mild cognitive impairment (MCI) and Alzheimer's disease (AD).

METHODS

We examined 150 subjects (16 MCI and 134 AD) that were prospectively assessed and longitudinally followed to autopsy. MCI subjects clinically met Petersen criteria for single or multi-domain amnestic MCI. AD subjects clinically met NINCDS-ADRDA criteria for probable or possible AD. All subjects received the Functional Assessment Staging (FAST), the Global Deterioration Scale (GDS), and the Mini Mental State Examination (MMSE) ante-mortem. Plaque and tangle counts were gathered for hippocampus, entorhinal cortex, frontal, temporal and parietal cortices. Braak staging was performed as well.

RESULTS

The GDS, FAST and MMSE correlated with plaque counts in all regions. The GDS, FAST and MMSE correlated with tangle counts in in all regions. The three instruments also correlated with the Braak score. The MMSE and GDS correlate better than the FAST in most regions.

CONCLUSIONS

Accumulation of neuropathology appears to correlate with functional, global, and cognitive decline as people progress from MCI through AD.

A systematic review of the reliability of screening for cognitive impairment in older adults by use of standardised assessment tools administered via the telephone

We conducted a systematic review to identify the extent to which the process of screening for cognitive impairment in older adults has been validated for administration by telephone. A search of electronic databases and a handsearch of relevant journals and reference lists were carried out for studies published between 1966 and 2008. The database search identified 411 studies and handsearching found another seven. Fourteen studies were finally identified as relevant to the review: three concerned a modified telephone version of the Mini-Mental State Examination (MMSE); five concerned the Telephone Interview for Cognitive Status; one study tested a telephone-administered Short Portable Mental Status Questionnaire; four studies tested the validity of newly developed tools; and the remaining study considered the Confusion Assessment Method as a means of diagnosing delirium. The quality of the reference standard varied among the papers reviewed. The limited number of high quality studies with suitable reference standards makes it difficult to recommend a specific tool which should be used to assess the cognition of older adults by telephone. In advance of further studies, the 22-item MMSE is simple to administer and was shown to correlate well with the face-to-face MMSE. It appears to be a useful technique for telephone screening for cognitive impairment or delirium, if used in conjunction with the Delirium Symptom Interview.

Repetitive thinking as a psychological cognitive style in midlife is associated with lower risk for dementia three decades later

AIMS

To examine the association of a reported tendency toward repetitive thinking (RT) in midlife when confronting difficulties in family and work settings with dementia many years later.

METHODS

A tendency toward RT was assessed in approximately 9,000 male participants in the Israeli Ischemic Heart Disease study in 1965. The subjects were categorized according to their tendency toward RT in familial and work settings as: 1 = always forget; 2 = tend to forget; 3 = tend to think repetitively, and 4 = usually think repetitively. Dementia was assessed over 3 decades later in 1,889 participants among 2,604 survivors of the original cohort.

RESULTS

The prevalence rates of dementia were 24, 19, 15 and 14% in the 4 groups of tendency toward RT in stressful work situations with superiors (p for trend < 0.0002), respectively. The prevalence rates of dementia were 21, 18, 14 and 14% in the 4 groups of tendency toward RT in familial situations (p for trend < 0.004), respectively. These associations held after multivariate analysis.

CONCLUSIONS

The tendency toward RT when confronting distress is associated with a lower risk for dementia. Future studies should assess possible mechanisms and potentials for intervention and modification.

The Memory and Aging Telephone Screen: development and preliminary validation

BACKGROUND

Telephone interviews are widely used in geriatric settings to identify eligible research participants and to perform brief follow-up assessments of cognition. This article reports on the development and validation of the Memory and Aging Telephone Screen (MATS), a structured interview for older adults with mild cognitive impairment and/or significant memory complaints. We also developed three alternate forms of the MATS objective memory test to reduce practice effects engendered by multiple administrations.

METHODS

Participants were enrolled in a longitudinal study that included 120 older adults with amnestic mild cognitive impairment, subjective cognitive complaints but without deficit on neuropsychological tests, and demographically matched healthy controls. An additional 15 patients with mild probable Alzheimer's disease completed the alternative forms study. All participants received the original MATS version, and a subset (n = 90) later received two of three alternate forms.

RESULTS

The MATS was sensitive to group differences, and the alternate forms were equivalent. MATS objective memory test scores showed adequate stability during a period of 1 year and were moderately correlated with scores on a widely used list-learning test (California Verbal Learning Test, Second Edition).

CONCLUSIONS

The MATS, a repeatable telephone screen that includes objective and subjective memory assessments, is useful for detecting individuals in the preclinical and early stages of dementia. Results encourage use of the MATS as a reliable and valid cognitive screening tool in research and clinical settings. Longitudinal assessments are being performed to investigate the predictive validity of the MATS for cognitive progression in mild cognitive impairment.

Trajectories of cognitive function in late life in the United States: demographic and socioeconomic predictors

This study used mixed-effects modeling of data from a national sample of 6,476 US adults born before 1924, who were tested 5 times between 1993 and 2002 on word recall, serial 7's, and other mental status items to determine demographic and socioeconomic predictors of trajectories of cognitive function in older Americans. Mean decline with aging in total cognition score (range, 0-35; standard deviation, 6.00) was 4.1 (0.68 standard deviations) per decade (95% confidence interval: 3.8, 4.4) and in recall score (range, 0-20; standard deviation, 3.84) was 2.3 (0.60 standard deviations) per decade (95% confidence interval: 2.1, 2.5). Older cohorts (compared with younger cohorts), women (compared with men), widows/widowers, and those never married (both compared with married individuals) declined faster, and non-Hispanic blacks (compared with non-Hispanic whites) and those in the bottom income quintile (compared with the top quintile) declined slower. Race and income differences in rates of decline were not sufficient to offset larger differences in baseline cognition scores. Educational level was not associated with rate of decline in cognition scores. The authors concluded that ethnic and socioeconomic disparities in cognitive function in older Americans arise primarily from differences in peak cognitive performance achieved earlier in the life course and less from declines in later life.

A review of telephone-administered screening tests for dementia diagnosis

Dementia screening measures serve an important role in epidemiological research, clinical trials, identifying patients for more comprehensive assessment, and monitoring progression. Telephone-administered measures allow increased flexibility. Although there are several extant telephone-administered measures that offer the promise of efficient detection of cognitive impairment, research evidence supporting their use is limited. We review telephone-based cognitive screening instruments for detecting dementia or mild cognitive impairment, critically review the evidence for their validity, and make recommendations for future research directions. Most measures reviewed do a good job of classifying patients as likely to have dementia or likely to be neurologically healthy. However, with sensitivity values ranging from 38% to 100% and specificity values ranging from 79% to 100%, there is considerable variability in the measures available. Future validation studies should reflect the populations most likely to benefit from a telephone-based measure, namely community-dwelling elderly who have not yet been identified as being cognitively impaired.

Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study

Background

Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain).

Methods

Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability.

Results

Base-line differences in functional capacity – significantly lower in the intervention group (RR: 1.52 95%CI: 1.05–2.21; p = 0.0016) – disappeared at six months (RR: 1.31 95%CI: 0.87–1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77–59.34 vs. 60.50 95%CI: 53.63–67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67–57.92 vs. 66.26 95%CI: 60.66–71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22–10.62 vs. 3.24 95%CI: 1.37–5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89–10.92 vs.11.30 95%CI: 9.10–14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32–17.43; range: 0–21, vs. 14.65 95%CI: 13.61–15.68; p = 0,001).

Conclusion

A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction.

Trial registration

ISRCTN44054549

Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study

BACKGROUND

Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain).

METHODS

Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability.

RESULTS

Base-line differences in functional capacity - significantly lower in the intervention group (RR: 1.52 95%CI: 1.05-2.21; p = 0.0016) - disappeared at six months (RR: 1.31 95%CI: 0.87-1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77-59.34 vs. 60.50 95%CI: 53.63-67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67-57.92 vs. 66.26 95%CI: 60.66-71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22-10.62 vs. 3.24 95%CI: 1.37-5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89-10.92 vs.11.30 95%CI: 9.10-14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32-17.43; range: 0-21, vs. 14.65 95%CI: 13.61-15.68; p = 0,001).

CONCLUSION

A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction.

TRIAL REGISTRATION

ISRCTN44054549.

Functional ability correlates with cognitive impairment in Parkinson's disease and Alzheimer's disease

BACKGROUND/AIMS

Previously we have shown that functional declines in Parkinson's disease (PD) and Alzheimer's disease (AD) correlate to global measures of cognitive decline. We now determine if the correlation between cognitive impairment and functional ability in PD is similar to that in AD using individual cognitive measures.

METHODS

93 PD subjects and 124 AD/MCI subjects underwent the Functional Assessment Staging (FAST), the Global Deterioration Scale (GDS), and a neuropsychological battery.

RESULTS

In PD subjects, the FAST and GDS correlated significantly with Rey Auditory Verbal Learning Test (AVLT), Controlled Oral Word Association (COWA), Animal Fluency, and Stroop but not with Clock Draw or Judgment Line Orientation (JLO). In AD/MCI subjects, FAST and GDS correlated with all neuropsychological components except Stroop. In the AD/MCI group, the UPDRS significantly correlated with the FAST, GDS, MMSE, and all neuropsychological parameters except the Stroop. In the PD group, the motor UPDRS significantly correlated significantly with FAST, GDS, MMSE and all neuropsychological parameters except Digit Span, Stroop, Clock Draw and JLO.

CONCLUSIONS

Similar to AD, functional decline in PD correlates with multiple measures of cognitive impairment. Some differences between PD and AD may be explained by the influence of motor disability and declines in visuospatial function in PD.

Locus coeruleus neurofibrillary degeneration in aging, mild cognitive impairment and early Alzheimer's disease

Neurofibrillary degeneration in the nucleus basalis and a loss of its cortical cholinergic projections are prominent components of the neuropathology in Alzheimer's disease (AD). The AD brain is also associated with a degeneration of the noradrenergic projections arising from the nucleus locus coeruleus (LC), but the time course of this lesion is poorly understood. To determine whether the LC displays neurofibrillary abnormalities early in the course of events leading to AD, we examined tissue specimens from seven cognitively normal controls and five subjects at the stages of mild cognitively impairment (MCI) or early AD. Tyrosine hydroxylase immunochemistry was used as a marker of LC neurons while AT8 immunolabeling visualized abnormal tau associated with neurofibrillary tangles and their precursors. Thioflavine-S was used as a marker for fully developed tangles. We found that AT8-positive labeling and thioflavine-S positive tangles were present in both groups of specimens. However, the percentage of neurons containing each of these markers was significantly higher in the cognitively impaired group. The MMSE scores displayed a negative correlation with both markers of cytopathology. These results indicate that cytopathology in the LC is an early event in the age-MCI-AD continuum and that it may be listed among the numerous factors that mediate the emergence of the cognitive changes leading to dementia.

Stigmatization in Alzheimer's disease research on African American elders

Stigmatization in research sustains the spread of the silent epidemic of Alzheimer's disease (AD) in African American populations. Researchers use stereotypes and inappropriate assumptions to select a paradigm to examine the symptoms of AD. This paradigm fails to encompass the symptoms as manifested by African American elders. Yet, stigmatization can be minimized by recognizing the genetic heterogeneity of the symptoms within the general population, especially those manifested by African American elders. Thus, researchers can utilize pioneering genetic analyses to identify other paradigms critical in the assessment and proactive treatment of the symptoms of AD needed for this vulnerable population.

Is the functional decline of Parkinson's disease similar to the functional decline of Alzheimer's disease?

Since many Parkinson's disease (PD) subjects develop dementia, we determined whether the correlation between functional and cognitive decline seen in Alzheimer's disease (AD) is seen in PD. Seventy-five PD subjects with and without dementia and 103 AD/MCI subjects underwent the Functional Assessment Staging (FAST), the Global Deterioration Scale (GDS), the UPDRS motor portion, and the MMSE. In AD/MCI subjects, changes in FAST and GDS scores correlated with MMSE (rho=-0.814, P<0.001; rho=-0.840, P<0.001, respectively). In PD subjects, the FAST and GDS also correlated with MMSE (rho=-0.675, P<0.001; rho=-0.647, P<0.001, respectively). The UPDRS correlated with the GDS and FAST more closely in PD than in AD. Similar to AD, functional declines in PD correlates with cognitive decline and may be influenced by motor disability in PD.

Telemedicine and neurosciences

It is well known that in most countries there is a perennial shortage of specialists in neurosciences. The available neurologists and neurosurgeons are clustered in the metropolitan, urban areas. Those living in suburban and rural areas may have limited or no access to neurological care. Concurrently, there has been an unprecedented growth in information and communication technology (ICT). In this article, the author will demonstrate how the practice of neurosciences will change, with increasing use of telemedicine and ICT. In addition to presenting the author's personal experience, the literature on telemedicine in neurosciences is reviewed.

Validation of a Brief Screen for Cognitive Impairment (BSCI) Administered by Telephone for Use in the Medicare Population

The aim of this research was to examine the validity of a brief screen for cognitive impairment (BSCI) consisting of three questions administered by telephone (delayed recall, frequency of help with planning trips for errands, and frequency of help remembering to take medications). The study design was an age and gender matched case-control study. Seventy managed care members, 35 with dementia (cases) and 35 without dementia (controls), were assessed using BSCI embedded within a longer health assessment questionnaire commonly used in Medicare-managed care. A number of measures were used to examine validity of BSCI, including comparisons of the differences between cases and controls in BSCI scores, comparisons of the correlations between patient scores on BSCI and the Mini Mental Status Exam (MMSE, a common screening test for dementia) and the Alzheimer's Disease Assessment Scale (ADAS, a common dementia assessment test), and comparisons of the areas under the receiver operating characteristic (ROC) curves for the three instruments. BSCI scores for cases and controls were significantly different, as were their scores for the MMSE and ADAS. Scores on BSCI were significantly correlated with scores for the MMSE and ADAS using both the Kendall's tau-b and Spearman rank-order correlation; correlations ranged from 0.654 between BSCI and ADAS to -0.83 for the correlation between BSCI and the MMSE (p < 0.001 for both). The areas under the ROC curves ranged from 0.94 to 0.96 for the three tests, meaning that they were equally accurate in discriminating between demented and nondemented patients. BSCI, a brief telephone screen for cognitive impairment due to dementia, discriminates between demented patients and normal controls as well as two standard tests of dementia, and may be considered a valid screen for dementia. Compared to existing screening tests, it has the additional advantages of extreme brevity, and ease of administration and scoring by lay interviewers via telephone. The use of brief screening instruments for dementia, such as the one validated here, will be increasingly important for the effective management of dementia and other chronic diseases where dementia is a coexisting condition.

Medical versus nonmedical mental health referral: clinical decision-making by telephone access center staff

A database review investigated decisions of clinicians staffing a university-based telephone access center in referring new adult patients to nonpsychiatrists versus psychiatrists for initial ambulatory behavioral health care appointments. Systematically collected demographic and clinical data in a computer log of calls to highly trained care managers at the access center had limited predictive value with respect to their referral decisions. Furthermore, while 28% of the 610 study patients were initially referred to psychiatrists, billing data revealed that in-person therapists soon cross-referred at least 20% more to a psychiatrist. Care managers sent 56% of callers already taking psychotropic medications to nonpsychiatrists, 51% of whom were then cross-referred to psychiatrists. Predictive algorithms showed no potential to enhance efficiency of decisions about referral to a psychiatrist versus a nonpsychiatrist. Efforts to enhance such efficiency may not be cost-effective. It may be more fiscally efficient to assign less-experienced personnel as telephone care managers.

Applications of computer-based neuropsychological assessment

OBJECTIVES

To present current applications of computer-based neuropsychological assessment, including the assessment of sports-related concussion, symptom validity testing, and the remote administration of tests through the Internet.

PROBLEM AREAS

If computer-based assessment benefits are to become popularized, a few issues will need to be addressed: the development of psychometric data based on comparisons with long-standing empirically sound test measures; additional validation of measures by parties not involved in their commercial development; increased focus on ecological validity; exploration of the usefulness of remote data storage and automated posting to databases; and improved documentation of specific computer hardware and software used in experimental methods.

CONCLUSIONS

Beyond ease of administration and data collection, computer-based assessment offers benefits over paper-and-pencil measures in the form of millisecond timing accuracy, reliable and randomized presentation of stimuli over multiple trials and repeat administrations, and unobtrusive measurement of cognitive skills and response times during all aspects of the assessment process.

Telepsychiatry and geriatric care

The use of telecommunications--telephone, computer, videoconferencing equipment--to provide mental health services at a distance has grown rapidly. This review encompasses reports from programs that provide telepsychiatry services, including telephone- and computer- based education and support services, telephone screening for dementia, and the use of videoconferencing to provide psychiatric consultations, health education, and administrative support. The extensive experience to date supports the value of telepsychiatry. Applications in geriatric settings and research involving geriatric subjects are reviewed. Cost analyses and economic evaluations of telepsychiatry are preliminary at this time and need further refinement. There is great potential for using telecommunications to expand access to mental health services to underserved geriatric populations.

Addition of a frequency-weighted score to the Behavioral Pathology in Alzheimer's Disease Rating Scale: the BEHAVE-AD-FW: methodology and reliability

The Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) is a well-established instrument, designed to assess potentially remediable behavioral symptoms in Alzheimer's disease (AD) patients as well as to evaluate treatment outcome. It consists of 25 symptoms grouped into seven categories. Each symptom is scored on the basis of severity on a four-point scale. A knowledgeable caregiver is queried and items are scored on the basis of symptoms noted in the preceding two weeks. Reliability, construct validity and criterion validity data for the BEHAVE-AD have previously been published. Because of the significance of psychopathology in dementia, it is necessary to optimally describe and define the nature, magnitude and prevalence of behavioral symptomatology. Accordingly, a frequency component was added to each of the 25 items of the BEHAVE-AD scale. The objective of the present report is to describe this new Behavioral Pathology in Alzheimer's Disease Frequency-Weighted Severity Scale (BEHAVE-AD-FW) and to establish its inter-rater reliability. In this investigation the BEHAVE-AD-FW scale was administered to caregivers of 28 patients with either mildly impaired cognitive function or a dementia diagnosis. Two clinicians separately and independently rated the responses. Analyses determined that the intraclass correlation coefficients (ICCs) for the frequency component varied between 0.86 and 0.97 for each of the seven BEHAVE-AD categories (p(s) < 0.001). ICCs for the frequency-weighted scores (item severity score x item frequency score) ranged from 0.69 to 0.98 for the seven symptom categories (p(s) < 0.001). For the BEHAVE-AD-FW total scores, the ICC was 0.91 (P < 0.001). These results indicate that the frequency-weighted component is a reliable addition to the BEHAVE-AD scale.