IPA Bulletin
Recent Advances

Wendy Moyle - Australia

Anxiety and Dementia
This cross-sectional study recruited 148 people from 19 US assisted living facilities. 124 (84%) participants were female with an average age of 86.2 yrs and a mean MMSE of 15.52. 25% had depressive symptoms. A low to moderate level of anxiety was found in this sample. However, prevalence rates for anxiety were 11% and 18% as measured by the RAID and CAS, respectively. In addition, one or more symptoms of anxiety were exhibited for 49% and 48% of the sample, as measured by the RAID and CAS, respectively. The authors were unable to conclude if the findings were consistent with previous studies as there were no comparable studies that used dementia specific scales for measuring anxiety.

Neville & Teri. Anxiety, anxiety symptoms, and associations among older people with dementia in assisted-living facilities. Int J Mental Hlth Nrs 2011, 20, 195-201.

Clinical Evaluation of Dementia
This study conducted in Sweden aimed to develop a new test of cognitive performance in people with moderate to severe dementia. Furthermore, the authors aimed to develop a scale that indicates both functional cognitive performance and over-learned knowledge. The scale developed was called the Clinical Evaluation of Moderate-to-Severe Dementia and this title was shortened to a Swedish acronym: KUD. The KUD consists of 15 items. Reliability and validity was established with a sample of 220 people with a broad range of stages of dementia. The KUD was validated against the MMSE with the correlation between the KUD and MSSE (<20) being strong (r = 0.80). Reliable assessment of cognitive performance was established in people with a MMSE score of less than 12. The authors argue that the KUD is complementary to the MMSE, rather than a replacement. The authors conclude the KUD may be useful to measure the effects of interventions, in particular in a population of people who might not be able to complete other cognitive tests.

Ericsson et al. KUD – a scale for clinical evaluation of moderate-to-severe dementia. J Clin Nrs 2011, 20, 1542-1552.

NEECHAM Confusion Scale
This Scandinavian study aimed to assess the validity and predictive value of the NEECHAM Confusion Scale. 149 patients aged >65, following orthopaedic surgery for hip fracture were observed daily using DSM-IV criteria for delirium. Participants mean age was 82.2 and the majority were women (76%). Patients who upon admission were delirious or had an MMSE of < 11 points were excluded from the study. The NEECHAM Confusion Scale was administered at admission and prior to discharge. At admission, 37 participants (25%) scored less than 25 on the NEECHAM, therefore indicative of delirium according to this scale, although they were not considered to have delirium according to DSM-IV criteria. The results show that the NEECHAM scale identified more people with delirium than the DSM-IV criteria. The incidence of DSM-IV related delirium during hospitalisation was 24%. A logistic regression analysis showed that participants scoring 25-26 points on the NEECHAM had nearly a threefold risk of developing DSM-IV delirium. Those patients who scored below 25 points on the NEECHAM Confusion Scale had a 12 times higher risk of developing delirium, as per DSM-IV criteria. The predictive value of the NEECHAM scale using logistic regression found for each one-point drop in the NEECHAM score on admission, the risk of developing DSM-IV delirium increased by 42%.
The authors concluded that the lower the NEECHAM score, the higher the risk of developing DSM-IV delirium.

Sorensen Duppils & Johansson. Predictive value and validation of the NEECHAM Confusion Scale using DSM-IV criteria for delirium as gold standard. Int J Older People Nrs, 6, 133-142.


Mark Rapoport - Canada
Research and Practice: Depression, Cognitive Impairment and the Physical Environment.

Environmental Influences-MR
Environment clearly does matter in the prevalence and course of mental illness in later life. Recent studies have shown associations between the physical environment and neuropsychiatric symptoms in assisted living facilities, between depressive symptoms and the mixture of retail buildings within residential neighborhoods, and between heavy smoking and the later development of dementia in a community sample. A study in a large emergency department setting demonstrated the transience of depressive symptoms and cognitive deficits among older patients being assessed, when followed up as little as 2 weeks later.

Researchers from Johns Hopkins School of Medicine conducted a cohort study of 326 residents in assisted living from 21 different facilities. Objective ratings were taken of the physical facilities, and participants were assessed with the Neuropsychiatric Inventory (NPI), and falls were recorded. The physical aspects of the facilities which were measured using a standardized and validated tool on a scale from 0-30, with higher scores representing better physical environment. The average physical environment score was 16.4 (SD 4.4), and was significantly related to both the NPI score and fall risk. Residents without dementia were more affected by the environment than those without. A two-factor solution was found via factor analysis: Dignity (including room autonomy, privacy, call buttons, phones, “homelikeness”, hallway length, and light even-ness) and Sensory (visual and tactile stimulation, maintenance, handrails and cleanliness). A Dignity subscore accounted for 13.9% of the variance in NPI scores. With many geriatric psychiatrists practicing in suboptimal physical settings, this study highlights the role the physical environment on symptoms. It remains to be seen whether an intervention to change the environment would have an impact on neuropsychiatric status.

Bicket, M.C. et al. The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents. Int J Ger Psychiatry 2010; 25: 1044-1054.

Researchers in Perth, Australia examined the relationship between Geriatric Depression Scores (GDS) and aspects of the environment in a sample of 5,218 men, of whom 5.7% showed scores of 7 or greater on the GDS (the cut-off used for “significant” depressive symptoms). Residential density and walkability were not associated with depressive symptoms, but there was an increase in depressive symptoms associated with a high “land use mix” OR 1.37 (95% CI 1.02-1.84). A high “land use mix” meant that there was a high level of different uses for the given land where the participant lived, ie. retail, residential, offices, community services, and entertainment/recreation. In a multivariate analysis, they found that the mix of residential with retail space was particularly associated with depressive symptoms (OR 1.46, 95% CI 1.11-1.90). This association remained once age, education, and perceived social support were controlled for. This finding was counter-intuitive, but the authors postulated that factors such as large parking lots and more visitor traffic may have led to less comfortable experiences for these men. The study raises important questions on the topic of community design in older residential neighborhoods.

Saarloos, D. et al The built environment and depression in later life: The health in men study. Am J. Geriatr Psychiatry 2011; 19:461-70.

A prospective cohort study from Finland was reported in the Archives of Internal Medicine this past winter in which more than 21,000 members of a health care system completed a survey in the 1970s and 1980s quantifying their smoking use, when they were between 50 and 60 years of age. The authors examined the relationship between smoking and later diagnosis of Alzheimer’s (AD) and vascular dementias (VaD) between 1994 and 2008. Of the sample assessed, 5367 people (25.4%) were diagnosed with dementia. Using those who never smoked as a reference group, the authors reported a doubling of risk of dementia associated with being a current smoker of 2 or more packs per day (OR 2.10, 95% CI 1.57-2.58), which was significantly greater than those who smoked 1-2 packs per day (OR 1.37, 95% CI 1.21-1.55), or lesser amounts. Being a heavy smoker of 2 or more packs per day was linked with both AD and VaD, and the relationship between smoking and dementia persisted after controlling for age, sex, education, race, marital status, BMI, diabetes, hypertension, heart disease, hyperlipidemia, and alcohol use. This important study gives emphasis to smoking as a modifiable risk factor not only for vascular disease and cancer, but also neurodegenerative disease.

Rusanen M, et al. Heavy smoking in midlife and long-term risk of Alzheimer disease and vascular dementia. Arch Intern Med 2011, 1171(4):333-9.

Researchers from Rochester, New York evaluated 1,206 older adults who visited an emergency department in a 3 month period in 2008, of whom 67% completed a second assessment by telephone 2 weeks later. Participants were assessed for depression using the Patient Health Questionnaire-9, using a cut-off of 10 or more to indicate significant depression, and the Six Item Screener was used to screen for cognitive impairment, with 2 or more errors used as the cut-off for significant impairment. At the first screening, 15% were scored in the depressive range and 9% in the cognitively impaired range. Two weeks later, 28% of those with a positive depression screen at baseline still screened positive for depression, and 12% screening positive for cognitive impairment still met criteria for cognitive impairment. Only 3% and 1% of those with negative depressive or cognitive screens at baseline screened positive at the 2 week followup. The study raises an important finding about the variability and transience of symptoms when assessed in an emergency department setting.

Shah, M.N. et al Depression and cognitive impairment in older adult emergency department patients: changes over 2 weeks. JAGS, 2011, 59(2): 321-6.

Cognitive Impairment – Subjective and Objective - MR
The role of subjective cognitive impairment in predicting decline over time has been controversial, and a recent cross-sectional study suggests that subjective cognitive impairment is linked closer to emotional symptoms and personality variables than to objective cognitive deficits. A recent study systematically addressed the use of tools for screening and case finding in various settings, providing more specific guidance into selection of measures for detecting objective cognitive impairment, and raising a call for more research into this area.

A large-scale cross-sectional study of 827 community-dwelling older adults without dementia was conducted in Sydney, Australia. Participants completed a Memory Complaint Questionnaire (MAC-Q) by telephone, and then had an in-person assessment with a research psychologist who administered neuropsychological testing, and asked them to complete scales of depression and anxiety in person. The NEO-Five Factor Inventory personality measure was completed by participants at home and mailed back. Subjective memory complaints by participants on the MAC-Q was not significantly related to objective impairment status (categorized based on the objective neuropsychological testing), but there were significant, although weak, associations between subjective cognitive complaints with depression and anxiety ratings, as well as higher neuroticism and lower conscientiousness. It is particularly notable that 89.5% of participants endorsed at least one subjective memory complaint. The authors caution against the use of subjective cognitive complaints as a criterion for “Mild Cognitive Impairment” given the high prevalence and lack of relationship with objective deficits. On the basis of this study, it will be important for measures of affective symptoms and personality to be incorporated into prospective studies of subjective cognitive impairment to avoid confounding the study of it’s relationship to later decline.

Slavin, M. et al Prevalence and predictors of “subjective cognitive complaints” in the Sydney Memory and Ageing Study. Am J Geriatr Psychiatry 2010; 18(8): 701-710.

Two investigators from Leicester, UK conducted a systematic review and meta-analysis of multi-domain tests for detecting dementia, and only studies with tools that took no longer than the MMSE to administer were selected. Out of 784 potential studies, 44 analyses were extracted. Twenty studies were conducted in specialist settings, ten in primary-care, and 14 in community settings, and these settings were analyzed separately. The authors emphasize that case-finding is generally measured by positive predictive value (PPV) as it is the ability of the tool to detect the condition with minimal false negatives, whereas screening is reported as the negative predictive value (NPV, or the ability to detect the diagnosis with minimal false positives), and they therefore reported recommendations for screening and case-finding separately. On the basis of their analyses, in secondary care settings, grade A recommendations were made for using the Mini-Cog and the 6-item cognitive impairment test for case-finding, and the Mini-Cog for screening. The only grade A recommendation in primary care settings was for using the Abbreviated Mental Test Score (AMTS) for case-finding. No grade A recommendations were made for screening in primary care or for screening or case-finding in community settings, revealing the limitations and shortage of rigorous literature in this area.

Mitchell, A.J. & Maladi, S. Screening and case-finding tools for the detection of dementia. Part I: Evidence based meta-analysis of multi-domain tests. Am J Geriatr Psychiatry 2010; 18(9); 759-782.



Reprinted from IPA Bulletin, Volume 28, Number 3