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      T I T L E     L i n k s
1 Prevalence estimates of cognitive impairment and the association between cognitive impairment and affective symptoms among a probability sample of community-residing Latino elders.
2 Modelling the decline pattern in functional measures from a prevalent cohort study
3 Cognitive impairment among SCU and non-SCU residents in the United States: Prevalence estimates from the national institute on aging collaborative studies of special care units for Alzheimer’s disease.
4 Prevalence estimates of cognitive impairment in medical model adult day health care programs
5 Methodological issues in cognitive assessment and their impact on outcome measurement
6 Reporting source bias in estimating prevalence of cognitive impairment
7 Measurement choices in multi-site studies of outcomes in dementia
8 Measurement of older chronic care populations
9 Cognitive assessment measures for chronic care populations
10 Latent structure methods for estimating item bias, item validity and prevalence using cognitive and other geriatric screening measures
11 Measurement issues in chronic care populations: Dementia special care
12 Overview of methodological issues in gerontological and geriatric measurement.
13 Screening scales for dementia: Towards reconciliation of conflicting cross-cultural findings
14 The ESAI: A self-administered screening test for cognitive impairment in the elderly

Methodological challenges in cognitive assessment in elder, ethnically diverse and chronic care populations.

This set of references focuses on methodological issues in assessing cognition among older, ethnically diverse populations.  Seminal and more current work related to cognitive screening measures are abstracted. Included are articles applying traditional psychometric approaches to examine cognitive measures across demographic subgroups. Also included are articles related to methods for estimating prevalence and modeling longitudinal outcomes among individuals with dementing illness. The original publication abstract is included for most of the references.

 

    

RamRrez, M, Teresi, J, Holmes, D, Martinez, V, Lantigua, R. Prevalence estimates of cognitive impairment and the association between cognitive impairment and affective symptoms among a probability sample of community-residing Latino elders. 2006 (under review) 

Objectives: This article presents prevalence estimates of cognitive impairment among a      probability sample of community residing Latino elders in the South Bronx section of New York City. A profile of those individuals with cognitive impairment is provided, and   the association between cognitive impairment and depressive symptomatology is examined. Methods: A prevalence survey was conducted among a community sample of 205 Latino elders in New York City, drawn from the Medicare Beneficiary tape files   maintained by the Health Care Financing Administration (now CMS). Results: The prevalence ratio for cognitive impairment using scale cut scores was 12%; the latent class estimate was .15, (standard error=.025; 95% C.I.=.10-.21).  Individuals with cognitive impairment were older, had lower levels of education, income and acculturation, and reported higher levels of depressive symptomatology. Discussion: The importance of improved screening and detection methods for identifying cognitive and affective disorders, particularly among members of ethnic and low income minorities is discussed.   [PUBLICATION ABSTRACT]  

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Liu X, Teresi JA, Waternaux C. Modelling the decline pattern in functional measures from a prevalent cohort study. Statistics in Medicine, 2000, Vol. 19, pp. 1593-1606

In studying decline among cognitively impaired people, a prevalent cohort study design is commonly used to account for entry into the study at different levels of impairment.  The data set typically consists of many short series of repeated measurements collected over time.  However, the time origin, such as time of disease/impairment onset, is often uncertain.  In order to model non-linear decline patterns in functional test scores and associated risk factors with such data, we propose two approaches as alternatives to Liu et al. One approach models change over adjacent visits with varying time intervals.  The second models the change since baseline using a random effect for heterogeneity of change.  We used these two approaches to examine the decline in cognitive test scores among special care unit (SCU) and non-SCU residents at the New York sites of the National Institute on Aging (NIA) collaborative studies of special dementia care.  The analyses suggest that, controlling for several covariates, SCU residents experienced more rapid cognitive decline than did non-SCU residents.  The relative advantages and disadvantages of the two models are discussed.  [PUBLICATION ABSTRACT]

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Teresi JA, Morris JN, Mattis S, Reisberg B. Cognitive impairment among SCU and non-SCU residents in the United States: Prevalence estimates from the national institute on aging collaborative studies of special care units for Alzheimer’s disease. Research and Practice in Alzheimer’s Disease, 2000, Vol. 4, pp. 117-138

Data from a sample of approximately 1,200 residents of Special Care Units (SCUs) and 1,400 of non-SCUs from nine of ten studies funded under the NIA initiative on collaborative studies of Special Care Units for Alzheimer’s Disease, were used to estimate the prevalence of cognitive impairment.  Because most nursing home residents live in non-SCUs, the estimates from the non-SCU sample are closest to what would be observed in the general nursing home population, and serve as a comparison for estimates from the SCU sample.  Using data from a 7-state study, from the total non-SCU sample and from the New York prevalent cohort sample, it is estimated that 32% to 34% had communication impairment; 44% to 53% were in the last two stages of dementing illness (Global Deterioration Scale (GDS) stages 6 and 7); 34% to 40% had severe stage cognitive impairment (Minimum Data Set (MDS) Cognitive Performance Scale (CPS) stages 4, 5, 6); 29% to 34% were not testable on neuropsychological tests and 89% to 93% evidenced neuropsychological impairment (47% to 48% severe) on the NIA Research Mattis Dementia Rating Scale (RMDRS).  In contrast, examination of the data from SCUs profiled a much more severely cognitively impaired individual. On average, two thirds (about 65%) were communication impaired; 68% to 85% were in the late-stages of dementing illness; 56% to 61% had severe stage cognitive impairment and 46% to 53% were not testable on neuropsychological tests.  All (100%) were neuropsychologically impaired on the Total RMDRS; 78% to 85% were severely impaired. It is noted that different prevalence estimates are produced using different sources, e.g., neuropsychological measures, screening tests, global staging methods and administrative data. [PUBLICATION ABSTRACT] 

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Teresi JA, Holmes D, Koren MJ, Dichter E, Ramirez M, Fairchild S. Prevalence estimates of cognitive impairment in medical model adult day health care programs. Social Psychiatry and Psychiatric Epidemiology, 1998, Vol. 33, pp. 283-290

Despite an increasing emphasis on adult day health care (ADHC) programs as alternatives to institutional care for persons with dementia, little research based on direct assessment of clients= cognitive status has been conducted in such settings.  The goal of this analysis was to estimate the prevalence of cognitive impairment among ADHC clients using commonly used screening measures.  Age-adjusted and non-age-adjusted prevalence estimates of cognitive impairment in New York State ADHC programs were developed using a probability sample of 336 clients.  Estimates were made using traditional cutting scores on standard cognitive screening measures, such as the Mini-Mental State Examination (MMSE), as well as latent class analyses applied to the same item sets.  Average prevalence estimates of cognitive impairment were 55% across age cohorts and 60% for persons aged 65 and over.  The MMSE yielded a prevalence estimate of 58% across age cohorts and 63% for those aged 65 and over.  Using a more conservative cut score, the estimate for the MMSE was 33%; latent class estimates of moderate to severe impairment indicate that approximately 30% of the ADHC clients had cognitive impairment suggestive of probable or definite dementia.   Different scales and methods of measurement yielded widely varying prevalence estimates. Latent class methods may yield more stable estimates than traditional cut scores. [PUBLICATION ABSTRACT]

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Teresi JA, Holmes D. Methodological issues in cognitive assessment and their impact on outcome measurement. Alzheimer Disease and Associated Disorders, 1997, Vol. 11, Suppl. 6, pp. 146-155

Assessment of cognitive impairment in chronic care populations is complicated by several factors that may interfere with the assessment process: physical frailty and disability; comorbid conditions such as depression; and decrements in vision, hearing, speech, and general communication.  Moreover, cognitive impairment itself affects assessment of outcome domains such as depression, behavior, and function, thus contributing to several sources of measurement bias.  Sources of bias are discussed in the context of findings from the literature relating individual and cognitive factors to outcome measurement.  Recommendations for further methodological research are provided. [PUBLICATION ABSTRACT]

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Teresi JA, Holmes D. Reporting source bias in estimating prevalence of cognitive impairment. Journal of Clinical Epidemiology, 1997, Vol. 50, No. 2, pp.175-184

Reporting source bias was examined using cognitive data from a probability sample of adult day health care (ADHC) clients.  Data were obtained from four sources: client, family, staff, and chart. These data suggest that prevalence estimates are influenced by the reporting source and method of assessment, with chart diagnoses yielding the least convergent estimates.  Examination of agreement summary statistics and bias indices show that both staff and family underreport prevalence of cognitive impairment, but that more bias is associated with staff than is with family sources.  Such bias should be considered in studies of prevalence estimation of cognitive impairment. [PUBLICATION ABSTRACT]

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Smyth KA, Ferris SH, Fox P, Heyman A,  Holmes D, Morris JN, Phillips CD, Schulz R, Teresi JA, Whitehouse PJ. Measurement choices in multi-site studies of outcomes in dementia.    Alzheimer Disease and Associated Disorders. An International Journal, 1997, Vol.11, Suppl. 6,  pp.30-44       

This paper summarizes the measurement choices made by selected current or recently completed multi-site projects with a common emphasis on measuring outcomes in dementia.  Information on number of items and scoring, reason(s) for selecting the measure, and reliability and validity of the measure (either citations providing this information or a report of pertinent unpublished findings) is presented for eight domains: cognition, behavioral symptoms, physical health status, physical functioning and self-care abilities, quality of life, family/staff caregiver outcomes, service use, and cost.  We found considerable reliance on the published literature as a guide to measurement choice, motivated largely by measures’ superior psychometric properties, their ubiquity in the literature, and/or their brevity or ease of use.  There is still evidence of “starting from scratch” in some domains, however.  To the extent that these projects reflect the state of the art in dementia-relevant outcomes research, we conclude that comparison of outcomes across studies will continue to be problematic.  However, as long as dissemination of methodological as well as substantive findings continues to characterize outcome studies in dementia, there is hope that a more congruent view of how to assess key outcomes in dementia will emerge. [PUBLICATION ABSTRACT]

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Teresi JA, Lawton MP, Holmes D, Ory M. Measurement of older chronic care populations. Journal of Mental Health and Aging, 1996, Vol. 2, No. 3, pp. 147-148

This two-part special issue of the Journal of Mental and Aging contains reviews of measures that can be used in chronic care settings among individuals whose assessment is complicated because of factors, such as frailty, perceptual and communication problems, and advanced cognitive impairment. [PUBLICATION ABSTRACT]

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Teresi JA, Evans DA. Cognitive assessment measures for chronic care populations. Journal of Mental Health and Aging, 1996, Vol. 2, No. 3, pp.151-174

Assessment of cognitive impairment in chronic care populations is complicated by noncognitive factors, such as physical, perceptual, and communication disorders. Measures reviewed in this article have been developed for use or are widely used with such populations.  These include measures for use exclusively among those with advanced cognitive impairment and communication disorder as well as measures that can be used across a broader spectrum of impairment.  Four approaches to measurement are described: direct assessment, observation, informant, and chart-based data reporting.  Discussion deals with the need for more longitudinal investigations to compare these approaches, coupled with a better blend of the theoretical and the operational definition of cognitive constructs measured using these approaches. [PUBLICATION ABSTRACT]

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Teresi JA, Golden R. Latent structure methods for estimating item bias, item validity and prevalence using cognitive and other geriatric screening measures. Alzheimer Disease and Associated Disorders, 1994, Vol. 8, Suppl. 1, pp. S291-S298

Screening measures often are used to assess chronic care population, frequently in large multisite or multicenter studies.  They are used to estimate prevalence in epidemiological surveys, identify risk factors for disease, identify cases and noncases for research purposes, and target clinical, programmatic, and pharmacological interventions.  For example, screening measures can be useful in identifying nursing home residents who might benefit from different types of dementia-specific special care.  The cost of misclassification error varies according to use.  A typical problem in screening is the high cost of false positives, persons who subsequently receive elaborate laboratory diagnostic measures based on erroneous screening results, or those allocated to additional and costly health services who can equally benefit from regular care.  On the other hand, missing cases of certain types of illness can result in death or significant morbidity or excess disability.  Those not identified might miss out on care that can be therapeutic.  Thus, methods of minimizing misclassification errors are critical.  This article presents some examples of the effects of item bias and discusses some models that can be used to maximize unbiased classifications.  An unbiased indicator is one that behaves in the same manner (defined later) and is inferred to be measuring the same underlying attribute across comparison subgroups, and has the same valid-positive and false-positive rates (the same sensitivities and specificities) for each subgroup.   [PUBLICATION ABSTRACT]

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Teresi JA, Lawton MP, Ory M, Holmes D. Measurement issues in chronic care populations: Dementia special care. Alzheimer Disease and Associated Disorders, 1994, Vol. 8, Suppl. 1, pp. S144-S183

This article reviews possible measurement problems in conducting research involving individuals with dementia and presents conceptual issues related to measurement of different domains and constructs as they relate to dementia care.  Evaluation of dementia special care units (SCUs) poses special measurement problems that can affect the ability to determine the effectiveness of different types of care.  Poor measurement will reduce the chances of detecting an intervention effect, if one exists.  Paramount among these measurement problems are difficulties in assessing persons with severe cognitive deficits and problems in defining and measuring parameters of specialized care.  Because little measurement research has been conducted with persons with dementia or in dementia SCUs, this article will draw heavily on what is known about measurement issues in other chronic care populations. [PUBLICATION ABSTRACT]

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Teresi JA, Holmes D. Overview of methodological issues in gerontological and geriatric measurement. Annual Review of Gerontology and Geriatric: Focus on Assessment Techniques, 1994, Springer, Vol. 14, pp. 1-22

This chapter provides an overview of methodological issues raised by different authors with respect to constructs and measures presented in this volume. While some measurement problems (e.g., response bias) may apply to specific age cohorts, we argue that many measurement problems are not necessarily a function of the age cohort assessed, but of the varying distributions, rates, or ratios of the underlying attribute when measured across different samples of elderly, ranging from the normal well to the chronically impaired.  Thus, although the focus of this review is on assessment of older persons, the concepts presented and the statistical problems and methods discussed are relevant to the entire age spectrum. [PUBLICATION ABSTRACT]  

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Gurland B, Wilder DE, Cross P, Teresi JA, Barrett V. Screening scales for dementia: Towards reconciliation of conflicting cross-cultural findings. International Journal of Geriatric Psychiatry, 1992, Vol. 7, pp. 105-113

A compendium instrument of five widely used dementia screening scales was applied to +550 subjects 65 years and older.  Black, Hispanic and white groups were approximately equal in size.  Recruitment was designed to produce an uneven and unknown mix of dementia cases and normals among these groups.  A complex challenge to assessment and classification was thus contrived, approximating key aspects of the problem posed to cross-cultural epidemiology.  The published scoring systems of these dementia screens gave drastically conflicting results for absolute and culturally relative rates of cognitive impairment.  The conflicts between scales appeared to be largely due to the varying sensitivities of the scales and, to a lesser extent, sociocultural bias.  The conflicts were partially resolved through adjustments of the scale cut points. [PUBLICATION ABSTRACT]

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Horn L, Cohen CI, Teresi JA. The ESAI: A self-administered screening test for cognitive impairment in the elderly. Journal of the American Geriatrics Society, 1989, Vol. 37, pp. 848-855

The Early Assessment Self Inventory (EASI) a rapid self-administered screening test for cognitive impairment in the elderly, was constructed to permit individuals to be assessed in a group or singly without examiner intervention.  This paper-and-pencil device requires a fourth-grade reading level and makes minimal demands on literacy while assessing orientation, recent and remote memory, language, visual-construction, calculation, and attention.  In the present study, EASI was group-administered to 146 elderly persons attending senior centers and completed individually without examiner intervention by 19 outpatients at a memory disorders clinic.  Participants were 60 to 95 years old with 5 to 18 years of education. The EASI demonstrated good internal consistency and test-retest reliability and was significantly correlated with the Mini-Mental State Exam and the Mattis Dementia Rating Scale, both widely used screening instruments.  Neuropsychological measures of memory, attention, and verbal fluency correlated as well with the EASI as with the examiner-administered screening instruments, suggesting that the EASI may provide an efficient method of screening for cognitive impairment.  [PUBLICATION ABSTRACT]

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