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1.  Robust norms for selected neuropsychological tests in older adults 
The current study provided longitudinal robust norms for individuals age 70 years and older for several neuropsychological tests. We compared baseline neuropsychological test performance in three groups free of dementia at baseline: a robust normative sample free of dementia for at least two post-follow-up assessments, an incident dementia sample which developed new onset dementia during the follow-up and a Lost to Follow-up (LTF) sample. ANCOVAs showed that the robust sample performed better on all neuropsychological tests compared to the incident dementia and LTF samples. These findings support the argument that individuals in transition to developing dementia may reduce the mean, increase the variability and therefore underestimate cognitive performance in normal aging. We suggest that longitudinal robust norms may help mitigate the limitations inherent in cross-sectional normative samples.
doi:10.1016/j.acn.2008.05.004
PMCID: PMC2610426  PMID: 18572380
Aging; Norms; Dementia; Attrition
2.  Robust norms for selected neuropsychological tests in older adults 
Abstract
The current study provided longitudinal robust norms for individuals age 70 years and older for several neuropsychological tests. We compared baseline neuropsychological test performance in three groups free of dementia at baseline: a robust normative sample free of dementia for at least two post-follow-up assessments, an incident dementia sample which developed new onset dementia during the follow-up and a lost to follow-up (LTF) sample. ANCOVAs showed that the robust sample performed better on all neuropsychological tests compared to the incident dementia and LTF samples. These findings support the argument that individuals in transition to developing dementia may reduce the mean, increase the variability and therefore underestimate cognitive performance in normal aging. We suggest that longitudinal robust norms may help mitigate the limitations inherent in cross-sectional normative samples.
doi:10.1016/j.acn.2008.05.004
PMCID: PMC2610426  PMID: 18572380
Aging; Norms; Dementia; Attrition
3.  Profiles of Cognitive Functioning in a Population-Based Sample of Centenarians Using Factor Mixture Analysis 
Experimental aging research  2013;39(2):125-144.
Background/Study Context
The goal of the study was to identify and characterize latent profiles (clusters) of cognitive functioning in centenarians and the psychometric properties of cognitive measures within them.
Methods
Data were collected from cross-sectional, population-based sample of 244 centenarians (aged 98-108, 15.8% men, 20.5% African-American, 38.0% community-dwelling) from 44 counties in Northern Georgia participating in the Georgia Centenarian Study (2001-2009). Measures included the Mini-Mental State Examination (MMSE), Severe Impairment Battery (SIB), Wechsler Adult Intelligence Scale-III, Similarities sub-test (WAIS), Finger Tapping, Behavioral Dyscontrol Scale (BDS), Controlled Oral Word Association Test (COWAT), and Fuld Object Memory Evaluation (FOME). The Global Deterioration Rating Scale (GDRS) was used to independently evaluate criterion-related validity for distinguishing cognitively normal and impaired groups. Relevant covariates included directly assessed functional status for basic and instrumental activities of daily living (DAFS), race, gender, educational attainment, Geriatric Depression Scale Short Form (GDS), and vision and hearing problems.
Results
Results suggest two distinct classes of cognitive performance in this centenarian sample. Approximately one-third of the centenarians show a pattern of markedly lower cognitive performance on most measures. Group membership is independently well-predicted (AUC=.83) by GDRS scores (sensitivity 67.7%, specificity 82.4%). Membership in the lower cognitive performance group was more likely for individuals who were older, African Americans, had more depressive symptoms, lower plasma folate, carriers of the APOE ε4 allele, facility residents, and individuals who died in the two years following interview.
Conclusions
In a population expected to have high prevalence of dementia, latent subtypes can be distinguished via factor mixture analysis that provide normative values for cognitive functioning. The present study allows estimates for normative cognitive performance in this age group.
doi:10.1080/0361073X.2013.761869
PMCID: PMC3579538  PMID: 23421635
4.  Fetal Growth and Risk of Stillbirth: A Population-Based Case–Control Study 
PLoS Medicine  2014;11(4):e1001633.
Radek Bukowski and colleagues conducted a case control study in 59 US hospitals to determine the relationship between fetal growth and stillbirth, and find that both restrictive and excessive growth could play a role.
Please see later in the article for the Editors' Summary
Background
Stillbirth is strongly related to impaired fetal growth. However, the relationship between fetal growth and stillbirth is difficult to determine because of uncertainty in the timing of death and confounding characteristics affecting normal fetal growth.
Methods and Findings
We conducted a population-based case–control study of all stillbirths and a representative sample of live births in 59 hospitals in five geographic areas in the US. Fetal growth abnormalities were categorized as small for gestational age (SGA) (<10th percentile) or large for gestational age (LGA) (>90th percentile) at death (stillbirth) or delivery (live birth) using population, ultrasound, and individualized norms. Gestational age at death was determined using an algorithm that considered the time-of-death interval, postmortem examination, and reliability of the gestational age estimate. Data were weighted to account for the sampling design and differential participation rates in various subgroups. Among 527 singleton stillbirths and 1,821 singleton live births studied, stillbirth was associated with SGA based on population, ultrasound, and individualized norms (odds ratio [OR] [95% CI]: 3.0 [2.2 to 4.0]; 4.7 [3.7 to 5.9]; 4.6 [3.6 to 5.9], respectively). LGA was also associated with increased risk of stillbirth using ultrasound and individualized norms (OR [95% CI]: 3.5 [2.4 to 5.0]; 2.3 [1.7 to 3.1], respectively), but not population norms (OR [95% CI]: 0.6 [0.4 to 1.0]). The associations were stronger with more severe SGA and LGA (<5th and >95th percentile). Analyses adjusted for stillbirth risk factors, subset analyses excluding potential confounders, and analyses in preterm and term pregnancies showed similar patterns of association. In this study 70% of cases and 63% of controls agreed to participate. Analysis weights accounted for differences between consenting and non-consenting women. Some of the characteristics used for individualized fetal growth estimates were missing and were replaced with reference values. However, a sensitivity analysis using individualized norms based on the subset of stillbirths and live births with non-missing variables showed similar findings.
Conclusions
Stillbirth is associated with both growth restriction and excessive fetal growth. These findings suggest that, contrary to current practices and recommendations, stillbirth prevention strategies should focus on both severe SGA and severe LGA pregnancies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Pregnancy is usually a happy time, when the parents-to-be anticipate the arrival of a new baby. But, sadly, about 20% of pregnancies end in miscarriage—the early loss of a fetus (developing baby) that is unable to survive independently. Other pregnancies end in stillbirth—fetal death after 20 weeks of pregnancy (in the US; after 24 weeks in the UK). Stillbirths, like miscarriages, are common. In the US, for example, one in every 160 pregnancies ends in stillbirth. How women discover that their unborn baby has died varies. Some women simply know something is wrong and go to hospital to have their fears confirmed. Others find out when a routine check-up detects no fetal heartbeat. Most women give birth naturally after their baby has died, but if the mother's health is at risk, labor may be induced. Common causes of stillbirth include birth defects and infections. Risk factors for stillbirth include being overweight and smoking during pregnancy.
Why Was This Study Done?
Stillbirths are often associated with having a “small for gestational age” (SGA) fetus. Gestation is the period during which a baby develops in its mother's womb. Gestational age is estimated from the date of the woman's last menstrual period and/or from ultrasound scans. An SGA fetus is lighter than expected for its age based on observed distributions (norms) of fetal weights for gestational age. Although stillbirth is clearly associated with impaired fetal growth, the exact relationship between fetal growth and stillbirth remains unclear for two reasons. First, studies investigating this relationship have used gestational age at delivery rather than gestational age at death as an estimate of fetal age, which overestimates the gestational age of stillbirths and leads to errors in estimates of the proportions of SGA and “large for gestational age” (LGA) stillbirths. Second, many characteristics that affect normal fetal growth are also associated with the risk of stillbirth, and this has not been allowed for in previous studies. In this population-based case–control study, the researchers investigate the fetal growth abnormalities associated with stillbirth using a new approach to estimate gestational age and accounting for the effect of characteristics that affect both fetal growth and stillbirth. A population-based case–control study compares the characteristics of patients with a condition in a population with those of unaffected people in the same population.
What Did the Researchers Do and Find?
The researchers investigated all the stillbirths and a sample of live births that occurred over 2.5 years at 59 hospitals in five US regions. They used a formula developed by the Stillbirth Collaborative Research Network to calculate the gestational age at death of the stillbirths. They categorized fetuses as SGA if they had a weight for gestational age within the bottom 10% (below the 10th percentile) of the population and as LGA if they had a weight for gestational age above the 90th percentile at death (stillbirth) or delivery (live birth) using population, ultrasound, and individualized norms of fetal weight for gestational age. Population norms incorporate weights for gestational age from normal pregnancies and from pregnancies complicated by growth abnormalities, whereas the other two norms include weights for gestational age from normal pregnancies only. Having an SGA fetus was associated with a 3- to 4-fold increased risk of stillbirth compared to having a fetus with “appropriate” weight for gestational age based on all three norms. LGA was associated with an increased risk of stillbirth based on the ultrasound and individualized norms but not the population norms. Being more severely SGA or LGA (below the 5th percentile or above the 95th percentile) was associated with an increased risk of stillbirth.
What Do These Findings Mean?
These findings indicate that, when the time of death is accounted for and norms for weight for gestational age only from uncomplicated pregnancies are used, stillbirth is associated with both restricted and excessive fetal growth. Overall, abnormal fetal growth was identified in 25% of stillbirths using population norms and in about 50% of stillbirths using ultrasound or individualized norms. Although the accuracy of these findings is likely to be affected by aspects of the study design, these findings suggest that, contrary to current practices, strategies designed to prevent stillbirth should focus on identifying both severely SGA and severely LGA fetuses and should use norms for the calculation of weight for gestational age based on normal pregnancies only. Such an approach has the potential to identify almost half of the pregnancies likely to result in stillbirth.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001633.
The March of Dimes, a nonprofit organization for pregnancy and baby health, provides information on stillbirth
Tommy's, a UK nonprofit organization that funds research into stillbirth, premature birth, and miscarriage and provides information for parents-to-be, also provides information on stillbirth (including personal stories)
The UK National Health Service Choices website provides information about stillbirth (including a video about dealing with grief after a stillbirth)
MedlinePlus provides links to other resources about stillbirth (in English and Spanish)
Information about the Stillbirth Collaborative Research Network is available
doi:10.1371/journal.pmed.1001633
PMCID: PMC3995658  PMID: 24755550
5.  Robust and Conventional Neuropsychological Norms: Diagnosis and Prediction of Age-Related Cognitive Decline 
Neuropsychology  2008;22(4):469-484.
The aim of the study was to compare the performance of Robust and Conventional neuropsychological norms in predicting clinical decline among healthy adults and in mild cognitive impairment (MCI). The authors developed Robust baseline cross sectional and longitudinal change norms from 113 healthy participants retaining a normal diagnosis for at least 4 years. Baseline Conventional norms were separately created for 256 similar healthy participants without follow-up. Conventional and Robust norms were tested in an independent cohort of longitudinally studied healthy (n = 223), MCI (n = 136), and Alzheimer’s disease (AD, n = 162) participants; 84 healthy participants declined to MCI or AD (NL→DEC), and 44 MCI declined to AD (MCI→AD). Compared to Conventional norms, baseline Robust norms correctly identified a higher proportion of NL→DEC with impairment in delayed memory and attention-language domains. Both norms predicted decline from MCI→AD. Change norms for delayed memory and attention-language significantly incremented baseline classification accuracies. These findings indicate that Robust norms improve identification of healthy individuals who will decline and may be useful for selecting at-risk participants for research studies and early interventions.
doi:10.1037/0894-4105.22.4.469
PMCID: PMC2661242  PMID: 18590359
cognition; longitudinal; normative data; decline from normal; mild cognitive impairment
6.  Conventional And Robust Quantitative Gait Norms In Community Dwelling Older Adults 
Objectives
While gait is widely used to assess health status in older adults, normative data is lacking. Our objective was to develop and compare norms for widely used gait parameters in adults age 70 and older using cross-sectional (conventional) and longitudinal (robust) approaches accounting for important confounders such as disease effects on gait.
Design
Cohort study
Setting
General community
Participants
Community-dwelling older adults (age>70, N=824) without dementia or disability
Measurements
Eight quantitative gait parameters measured using an instrumented walkway.
Results
Of the 824 subjects (conventional normal; CN sample), 304 were included in a ‘robust normal’ (RN) sample after excluding those with either prevalent or incident clinical gait abnormalities developing within one year of the baseline assessment to account for disease effects on gait performance. Descriptively, the RN sample showed better performance on all selected gait variables compared to the CN sample. For instance, mean gait velocity (± standard deviation) was 105.9±17.9 cm/sec in the RN sample compared to 93.3±23.2 cm/sec in the overall CN sample. Applying a one standard deviation below the mean (70.1 cm/sec) derived from CN sample to define slow gait, 15.9% (131) in overall cohort were classified as abnormal whereas the RN cut-off (88.0 cm/sec) classified 39.7% (327) in the overall cohort as abnormal.
Conclusion
Our findings suggest that cross-sectional conventional norms may under-estimate gait performance in aging. Longitudinal robust norms provide more accurate estimates of normal gait performance and thus may improve early detection of gait disorders in older adults.
doi:10.1111/j.1532-5415.2010.02962.x
PMCID: PMC2955162  PMID: 20646103
gait; reference values; elderly
7.  Alzheimer's disease pattern of brain atrophy predicts cognitive decline in Parkinson's disease 
Brain  2011;135(1):170-180.
Research suggests overlap in brain regions undergoing neurodegeneration in Parkinson's and Alzheimer's disease. To assess the clinical significance of this, we applied a validated Alzheimer's disease-spatial pattern of brain atrophy to patients with Parkinson's disease with a range of cognitive abilities to determine its association with cognitive performance and decline. At baseline, 84 subjects received structural magnetic resonance imaging brain scans and completed the Dementia Rating Scale-2, and new robust and expanded Dementia Rating Scale-2 norms were applied to cognitively classify participants. Fifty-nine non-demented subjects were assessed annually with the Dementia Rating Scale-2 for two additional years. Magnetic resonance imaging scans were quantified using both a region of interest approach and voxel-based morphometry analysis, and a method for quantifying the presence of an Alzheimer's disease spatial pattern of brain atrophy was applied to each scan. In multivariate models, higher Alzheimer's disease pattern of atrophy score was associated with worse global cognitive performance (β = −0.31, P = 0.007), including in non-demented patients (β = −0.28, P = 0.05). In linear mixed model analyses, higher baseline Alzheimer's disease pattern of atrophy score predicted long-term global cognitive decline in non-demented patients [F(1, 110) = 9.72, P = 0.002], remarkably even in those with normal cognition at baseline [F(1, 80) = 4.71, P = 0.03]. In contrast, in cross-sectional and longitudinal analyses there was no association between region of interest brain volumes and cognitive performance in patients with Parkinson's disease with normal cognition. These findings support involvement of the hippocampus and parietal–temporal cortex with cognitive impairment and long-term decline in Parkinson's disease. In addition, an Alzheimer's disease pattern of brain atrophy may be a preclinical biomarker of cognitive decline in Parkinson's disease.
doi:10.1093/brain/awr277
PMCID: PMC3316476  PMID: 22108576
Alzheimer's disease; dementia; mild cognitive impairment; Parkinson's disease; neurodegeneration
8.  Normative Data in Women Age 85 and Older: Verbal Fluency, Digit Span, and the CVLT-II Short Form 
The Clinical neuropsychologist  2012;26(1):18-30.
Individuals age 85 years and above (i.e., the oldest old) represent the fastest growing segment of the U.S. population and are at increased risk of developing dementia. This represents an important challenge for the clinical neuropsychologist, as the extant normative data on neuropsychological measures remains relatively limited for this age group. Therefore, the aim of the present study was to characterize the performance effects of age and education in a large, well-characterized sample of women between the ages of 85 and 95 years on the CVLT-II Short Form (Delis et al., 2000), verbal fluency tasks, and the WAIS-III Digit Span Test (Wechsler, 1997). In order to minimize the likelihood that women with an incipient neurodegenerative process were included in the final normative sample, we applied regression-based change scores to identify and exclude women who evidenced a statistically significant decline on a global cognitive screening measure over a 20 year interval. The results of our analysis indicate varying influence of age and education on these measures and we provide tables with descriptive statistics stratified by both age and education. Findings from the present normative study are discussed within the context of “robust” longitudinal normative data.
doi:10.1080/13854046.2011.639310
PMCID: PMC3927723  PMID: 22224509
oldest old; normative data; CVLT
9.  The Framingham Heart Study Clock Drawing Performance: Normative Data from the Offspring Cohort 
Experimental aging research  2013;39(1):80-108.
Background/Study Context
While the Clock Drawing Test (CDT) is a popular tool used to assess cognitive function, limited normative data on CDT performance exists. The objective of the current study was to provide normative data on an expanded version of previous CDT scoring protocols from a large community-based sample of middle to older adults (aged 43 to 91) from the Framingham Heart Study.
Methods
The CDT was administered to 1476 Framingham Heart Study Offspring Cohort participants using a scoring protocol that assigned error scores to drawn features. Total error scores were computed, as well as for subscales pertaining to outline, numeral placement, time-setting, center, and “other.”
Results
Higher levels of education were significantly associated with fewer errors for time-setting (Command: p<.001; Copy: p=.003), numerals (Command: p<.001) and “other” (Command: p<.001) subscales. Older age was significantly associated with more errors for time-setting (Command: p<.001; Copy: p=.003), numeral (Command: p<.001) and “other” (Command: p<.001) subscales. Significant differences were also found between education groups on the Command condition for all but the oldest age group (75+).
Conclusion
Results provide normative data on CDT performance within a community-based cohort. Errors appear to be more prevalent in older compared with younger individuals, and may be less prevalent in individuals who completed at least some college compared with those who did not. Future studies are needed to determine whether this expanded scoring system allows detection of preclinical symptoms of future risk for dementia.
doi:10.1080/0361073X.2013.741996
PMCID: PMC3612583  PMID: 23316738
Clock Drawing Test; Normal aging; Scoring methods; Neuropsychological tests; Dementia; Cognitive screening
10.  Age and education effects and norms on a cognitive test battery from a population-based cohort: The Monongahela –Youghiogheny Healthy Aging Team (MYHAT) 
Aging & mental health  2010;14(1):100-107.
Objectives
Performance on cognitive tests can be affected by age, education, and also selection bias. We examined the distribution of scores on a several cognitive screening tests by age and educational levels in a population-based cohort.
Method
An age-stratified random sample of individuals aged 65+ years was drawn from the electoral rolls of an urban U.S. community. Those obtaining age and education-corrected scores ≥ 21/30 on the Mini-Mental State Examination were designated as cognitively normal or only mildly impaired, and underwent a full assessment including a battery of neuropsychological tests. Participants were also rated on the Clinical Dementia Rating scale. The distribution of neuropsychological test scores within demographic strata, among those receiving a CDR of 0 (no dementia), are reported here as cognitive test norms. After combining individual test scores into cognitive domain composite scores, multiple linear regression models were used to examine associations of cognitive test performance with age, and education.
Results
In this cognitively normal sample of older adults, younger age and higher education were associated with better performance in all cognitive domains. Age and education together explained 22% of the variation of memory, and less of executive function, language, attention, and visuospatial function.
Conclusion
Older age and lesser education are differentially associated with worse neuropsychological test performance in cognitively normal older adults representative of the community at large. The distribution of scores in these participants can serve as population-based norms for these tests, and be especially useful to clinicians and researchers assessing older adults outside specialty clinic settings.
doi:10.1080/13607860903071014
PMCID: PMC2828360  PMID: 20155526
Neuropsychological tests; epidemiology; normative; community
11.  Predictive Validity of Demographically-Adjusted Normative Standards for the HIV Dementia Scale 
The aim of the current study was to develop and validate demographically-adjusted normative standards for the HIV Dementia Scale (HDS). Given the association between demographic variables and the HDS summary score, demographically-adjusted normative standards may enhance the classification accuracy of the HDS. Demographically-adjusted normative standards were derived from a sample of 182 seronegative healthy participants and were subsequently applied to a sample of 135 HIV-1 seropositive individuals with multidisciplinary case conference diagnoses of HIV-1-associated neurocognitive disorders (e.g., HIV-1-associated dementia and Minor-Cognitive/Motor Disorder) in proportions consistent with published epidemiologic reports. In the normative sample, age and education (and their interaction) emerged as the only demographic factors significantly associated with the HDS. In comparison to the traditional HDS cut score (raw score total ≤10), use of the demographically-adjusted normative standards significantly improved the sensitivity (from 17.2% to 70.7%, respectively) and overall classification accuracy (increasing the odds ratio from 3 to approximately 6) of the HDS for identifying participants with HIV-1-associated neurocognitive disorders. The application of demographically-adjusted normative standards on the HDS improves the clinical applicability and accuracy of this cognitive screening measure in the detection of HIV-1-associated neurocognitive disorders.
doi:10.1080/13803390701233865
PMCID: PMC3659773  PMID: 17852582
Human immunodeficiency virus; Screening Tests; Dementia; Neuropsychological Assessment
12.  Age-expanded normative data for the Ruff 2&7 Selective Attention Test: Evaluating cognition in older male 
The Clinical neuropsychologist  2012;26(5):751-768.
The Ruff 2&7 Selective Attention Test’s (RSAT) current scoring data are relatively limited for older adults because persons over the age of 70 years were not included in the normative sample. Prior evidence suggests that changes in attention skills, such as those evaluated by the RSAT, may distinguish normal cognitive aging from pathologic cognitive decline. Thus, normative data for older individuals on this measure increases its utility in diagnosing Mild Cognitive Impairment (MCI) and dementia, and enhance its potential use in clinical and research settings. Data from 415 male volunteers (mean age = 69.5 ± 5.7 years) in the PREADViSE clinical trial were used in the current investigation. Analysis of covariance (ANCOVA) shows statistically significant effects of age, race, and education on RSAT Speed measures. Results indicate that age-expanded norms will provide a more accurate reflection of the typical performance of older individuals on the RSAT.
doi:10.1080/13854046.2012.690451
PMCID: PMC3734957  PMID: 22651854
13.  Prevalence, Distribution, and Impact of Mild Cognitive Impairment in Latin America, China, and India: A 10/66 Population-Based Study 
PLoS Medicine  2012;9(2):e1001170.
A set of cross-sectional surveys carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India reveal the prevalence and between-country variation in mild cognitive impairment at a population level.
Background
Rapid demographic ageing is a growing public health issue in many low- and middle-income countries (LAMICs). Mild cognitive impairment (MCI) is a construct frequently used to define groups of people who may be at risk of developing dementia, crucial for targeting preventative interventions. However, little is known about the prevalence or impact of MCI in LAMIC settings.
Methods and Findings
Data were analysed from cross-sectional surveys established by the 10/66 Dementia Research Group and carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India on 15,376 individuals aged 65+ without dementia. Standardised assessments of mental and physical health, and cognitive function were carried out including informant interviews. An algorithm was developed to define Mayo Clinic amnestic MCI (aMCI). Disability (12-item World Health Organization disability assessment schedule [WHODAS]) and informant-reported neuropsychiatric symptoms (neuropsychiatric inventory [NPI-Q]) were measured. After adjustment, aMCI was associated with disability, anxiety, apathy, and irritability (but not depression); between-country heterogeneity in these associations was only significant for disability. The crude prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Country differences changed little (range 0.6%–4.6%) after standardization for age, gender, and education level. In pooled estimates, aMCI was modestly associated with male gender and fewer assets but was not associated with age or education. There was no significant between-country variation in these demographic associations.
Conclusions
An algorithm-derived diagnosis of aMCI showed few sociodemographic associations but was consistently associated with higher disability and neuropsychiatric symptoms in addition to showing substantial variation in prevalence across LAMIC populations. Longitudinal data are needed to confirm findings—in particular, to investigate the predictive validity of aMCI in these settings and risk/protective factors for progression to dementia; however, the large number affected has important implications in these rapidly ageing settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Currently, more than 35 million people worldwide have dementia, a group of brain disorders characterized by an irreversible decline in memory, problem solving, communication, and other “cognitive” functions. Dementia, the commonest form of which is Alzheimer's disease, mainly affects older people and, because more people than ever are living to a ripe old age, experts estimate that, by 2050, more than 115 million people will have dementia. At present, there is no cure for dementia although drugs can be used to manage some of the symptoms. Risk factors for dementia include physical inactivity, infrequent participation in mentally or socially stimulating activities, and common vascular risk factors such as high blood pressure, diabetes, and smoking. In addition, some studies have reported that mild cognitive impairment (MCI) is associated with an increased risk of dementia. MCI can be seen as an intermediate state between normal cognitive aging (becoming increasingly forgetful) and dementia although many people with MCI never develop dementia, and some types of MCI can be static or self-limiting. Individuals with MCI have cognitive problems that are more severe than those normally seen in people of a similar age but they have no other symptoms of dementia and are able to look after themselves. The best studied form of MCI—amnestic MCI (aMCI)—is characterized by memory problems such as misplacing things and forgetting appointments.
Why Was This Study Done?
Much of the expected increase in dementia will occur in low and middle income countries (LAMICs) because these countries have rapidly aging populations. Given that aMCI is frequently used to define groups of people who may be at risk of developing dementia, it would be useful to know what proportion of community-dwelling older adults in LAMICs have aMCI (the prevalence of aMCI). Such information might help governments plan their future health care and social support needs. In this cross-sectional, population-based study, the researchers estimate the prevalence of aMCI in eight LAMICs using data collected by the 10/66 Dementia Research Group. They also investigate the association of aMCI with sociodemographic factors (for example, age, gender, and education), disability, and neuropsychiatric symptoms such as anxiety, apathy, irritability, and depression. A cross-sectional study collects data on a population at a single time point; the 10/66 Dementia Research Group is building an evidence base to inform the development and implementation of policies for improving the health and social welfare of older people in LAMICs, particularly people with dementia.
What Did the Researchers Do and Find?
In cross-sectional surveys carried out in six Latin American LAMICS, China, and India, more than 15,000 elderly individuals without dementia completed standardized assessments of their mental and physical health and their cognitive function. Interviews with relatives and carers provided further details about the participant's cognitive decline and about neuropsychiatric symptoms. The researchers developed an algorithm (set of formulae) that used the data collected in these surveys to diagnose aMCI in the study participants. Finally, they used statistical methods to analyze the prevalence, distribution, and impact of aMCI in the eight LAMICs. The researchers report that aMCI was associated with disability, anxiety, apathy, and irritability but not with depression and that the prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Other analyses show that, considered across all eight countries, aMCI was modestly associated with being male (men had a slightly higher prevalence of aMCI than women) and with having fewer assets but was not associated with age or education.
What Do These Findings Mean?
These findings suggest that aMCI, as diagnosed using the algorithm developed by the researchers, is consistently associated with higher disability and with neuropsychiatric symptoms in the LAMICs studied but not with most sociodemographic factors. Because prevalidated and standardized measurements were applied consistently in all the countries and a common algorithm was used to define aMCI, these findings also suggest that the prevalence of aMCI varies markedly among LAMIC populations and is similar to or slightly lower than the prevalence most often reported for European and North American populations. Although longitudinal studies are now needed to investigate the extent to which aMCI can be used as risk marker for further cognitive decline and dementia in these settings, the large absolute numbers of older people with aMCI in LAMICs revealed here potentially has important implications for health care and social service planning in these rapidly aging and populous regions of the world.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001170.
Alzheimer's Disease International is the international federation of Alzheimer associations around the world; it provides links to individual associations, information about dementia, and links to three World Alzheimer Reports; information about the 10/66 Dementia Research Group is also available on this web site
The Alzheimer's Society provides information for patients and carers about dementia, including information on MCI and personal stories about living with dementia
The Alzheimer's Association also provides information for patients and carers about dementia and about MCI, and personal stories about dementia
A BBC radio program that includes an interview with a man with MCI is available
MedlinePlus provides links to further resources about MCI and dementia (in English and Spanish)
doi:10.1371/journal.pmed.1001170
PMCID: PMC3274506  PMID: 22346736
14.  Metabolic Cost of Daily Activities and Effect of Mobility Impairment in Older Adults 
Journal of the American Geriatrics Society  2011;59(11):10.1111/j.1532-5415.2011.03655.x.
OBJECTIVES
There is a shortage of information on metabolic costs of daily physical activities in older adults and the effect of having mobility impairments. The primary purpose of this study was to evaluate metabolic equivalent (MET) values on common daily tasks in men and women aged > 70 years compared to normative criteria. A secondary purpose was to determine the effect of having mobility impairments.
DESIGN
Cross-sectional observational study.
SETTING
University based research clinic
PARTICIPANTS
Forty-five participants aged 70 to 90 years of age (mean: 76.3 ± 5.1) volunteered to complete 17 daily activities, each lasting 10 minutes.
MEASUREMENTS
Oxygen consumption (VO2 = ml•kg−1•min−1) was measured through a mask by a portable gas analyzer and MET values were calculated as measured VO2/3.5 ml•kg−1•min−1. Values were compared to both normative values and between participants with and without mobility impairments.
RESULTS
Compared to the established normative criteria, measured METs were different in 14 of 17 tasks performed. Compared to measured METs, normative values underestimated walking leisurely (0.87 ± 0.12 METs) walking briskly (0.87 ± 0.12 METs ), and bed making (1.07 ± 0.10 METs ), but overestimated gardening (1.46 ± 0.12 METs) and climbing stairs (0.73 ± 0.18). Participants with impairments had significantly lower METs while gardening, vacuuming/sweeping, stair climbing, and walking briskly. However, when METs were adjusted for performance speed the metabolic costs were 16–27% higher for those with mobility impairments.
CONCLUSION
Compared to normative values, metabolic costs of daily activities are substantially different in older adults and having mobility impairments increases this metabolic cost. These results may have implications for practitioners to appropriately prescribe daily physical activities for healthy and mobility impaired older adults.
doi:10.1111/j.1532-5415.2011.03655.x
PMCID: PMC3874461  PMID: 22091979
Energy expenditure; Aging; Disability; Metabolic Efficiency
15.  HIV-associated neurocognitive disorders (HAND) in a South Asian population - contextual application of the 2007 criteria 
BMJ Open  2012;2(1):e000662.
Objectives
To estimate the prevalence of HIV-associated neurocognitive disorders (HAND) among HIV patients in a multiethnic South Asian population, describe the pattern of neurocognitive impairment in HAND and the factors associated with HAND.
Design
A cross-sectional survey of HIV-positive outpatients and inpatients.
Setting
The sole referral centre for HIV/AIDS treatment in Singapore.
Participants
Inclusion criteria were HIV positive, age between 21 and 80 years old and at least 3 years of education. Exclusion criteria included concomitant delirium, serious systemic disease or major psychiatric illness. 265 patients did not meet criteria or declined to participate. The final sample size was 132.
Outcome measures
The primary outcome measure was cognitive impairment based on performance on the Montreal Cognitive Assessment, International HIV Dementia Scale and Instrumental Activities of Daily Living. The secondary outcome measure was the classification of impairment based on the 2007 updated research nosology for HAND.
Results
The prevalence of HAND was 22.7% of which 70% (15.9% of total) were asymptomatic neurocognitive impairment, 23.3% (5.3% of total) were mild neurocognitive disorder and 6.7% (1.5% of total) were HIV-associated dementia. Increasing age (OR 1.104, 95% CI 1.054 to 1.155, p<0.001), less education (OR 0.78, 95% CI 0.69 to 0.89, p<0.001) and low baseline CD4 count (OR 0.15, 95% CI 0.03 to 0.74, p=0.019) were associated with HAND. Delayed recall, language and abstract thinking were the domains most commonly affected, but impairment in visuospatial ability (RC 3.013, 95% CI 1.954 to 4.073, p<0.001) and attention (RC 2.205, 95% CI 1.043 to 3.367, p<0.001) were most strongly associated with HAND.
Conclusion
HAND is common among HIV patients in a South Asian sample, most of whom are asymptomatic. Older patients with less education and severe illness at diagnosis are at highest risk of HAND. Delayed recall is most commonly affected, but visuospatial dysfunction is most strongly associated with prevalent HAND.
Article summary
Article focus
What is the prevalence of HIV-associated neurocognitive disorders (HAND) in South Asia?
What are the demographic and clinical characteristics of South Asian individuals with HAND?
Key messages
The estimated prevalence of HAND in South Asia is high.
Older patients with less education and more severe HIV illness at diagnosis are at highest risk for HAND.
Early diagnosis of HIV and access to care and treatment is essential.
Strengths and limitations of this study
The article's strengths are it is the first study on HAND in a representative multiethnic South Asian population and it used a method of detection that is applicable to local clinical practice.
The limitations are the small sample size and non-comparability with other HAND studies due to different methods used in detection of HAND cases.
Another major limitation is the lack of published local normative data on the tools used.
doi:10.1136/bmjopen-2011-000662
PMCID: PMC3282293  PMID: 22331389
16.  Evidence for Added Value of Baseline Testing in Computer-Based Cognitive Assessment 
Journal of Athletic Training  2013;48(4):499-505.
Context:
Large-scale baseline cognitive assessment for individuals at risk for concussion is a common part of the protocol for concussion-surveillance programs, particularly in sports. Baseline cognitive testing is also being conducted in US military service members before deployment. Recently, the incremental validity of large-scale baseline cognitive assessment has been questioned.
Objective:
To examine the added value of baseline cognitive testing in computer-based neuropsychological assessment by comparing 2 methods of classifying atypical performance in a presumed healthy sample.
Design:
Cross-sectional study.
Setting:
Military base.
Patients or Other Participants:
Military service members who took the Automated Neuropsychological Assessment Matrix (ANAM) before and after deployment (n = 8002).
Main Outcome Measure(s):
Rates of atypical performance in this healthy, active-duty sample were determined first by comparing postdeployment scores with a military normative database and then with each individual's personal baseline performance using a reliable change index.
Results:
Overall rates of atypical performance were comparable across these 2 methods. However, these methods were highly discordant in terms of which individuals were classified as atypical. When norm-referenced methods were used, 2.6% of individuals classified as normal actually demonstrated declines from baseline. Further, 65.7% of individuals classified as atypical using norm-referenced scores showed no change from baseline (ie, potential false-positive findings).
Conclusions:
Knowing an individual's baseline performance is important for minimizing potential false-positive errors and reducing the risks and stresses of misdiagnosis.
doi:10.4085/1062-6050-48.3.11
PMCID: PMC3716479  PMID: 23724773
Automated Neuropsychological Assessment Metrics; computerized neuropsychological testing; concussions; mild traumatic brain injuries; military athletes
17.  Physical functioning in pediatric survivors of childhood posterior fossa brain tumors 
Neuro-Oncology  2013;16(1):147-155.
Background
Survival rates for children diagnosed with posterior fossa brain tumors (PFBTs) have improved significantly over the past several decades, and long-term functioning assessments have become priorities. These evaluations have occurred frequently in adults but only rarely in children. This study describes a cross-sectional assessment of physical functioning in pediatric survivors of PFBTs using the Bruininks-Osteretsky Test of Motor Performance, Second Edition (BOT-2).
Methods
Primary analyses compared BOT-2 scores to normative data using 1-sample t tests for each gross motor subscale (Bilateral Coordination, Balance, Running Speed/Agility, Strength) and motor-area composite (Body Coordination and Strength and Agility). Second, the cohort was stratified by diagnostic or treatment variables. Group differences and groups vs norms were evaluated using independent 2-sample and 1-sample t tests, respectively. Primary analyses compared BOT-2 scores with normative data using 1-sample t tests for each gross motor subscale (Bilateral Coordinationcoordination, Balance, Running Speed/Agility, Strength) and motor-area composite (Body Coordination and Strength and Agility). Second, the cohort was stratified by diagnostic or treatment variables. Group differences and groups vs norms were evaluated using independent 2-sample and 1-sample t tests, respectively.
Results
Mean age of 30 participants was 11.4 years (range, 4.9y–18.2y), and mean time from diagnosis was 6.1 years (range, 1.1y–16.7y). Cerebellar astrocytoma (43.3%) and medulloblastoma (40%) were the most common diagnoses. As a group, significantly decreased functioning, compared with norms, was observed in Balance (P < .001) and Running Speed/Agility (P = .005). Specifically in Balance, 21 (70%) participants performed below or well-below average. Participants with a non-astrocytoma performed significantly lower than norms in all areas, independent of age at diagnosis. Survivors with tumors infiltrating the vermis demonstrated significantly lower Body Coordination than norms (P < .001).
Conclusions
Pediatric survivors of PFBTs demonstrated decreased physical functioning, most notably in Balance. These data underscore the need for further research and implementation of physical activity programs aimed specifically at approaches to minimize physical limitations.
doi:10.1093/neuonc/not138
PMCID: PMC3870837  PMID: 24305707
cancer survivor; disability; long-term outcome; pediatric; physical function; posterior fossa brain tumor
18.  LIVER TRANSPLANT RECIPIENTS: INDIVIDUAL, SOCIAL, AND ENVIRONMENTAL RESOURCES 
CONTEXT
Patient characteristics are important in the liver transplant (LTX) population because of proven associations between individual and environmental factors, treatment adherence, and health outcomes in general medical and other transplant (txp) populations.
OBJECTIVE
The objective of this report is to determine generalizability of the sample to other LTX populations and to establish reliability of measures used to assess individual and environmental resources.
DESIGN
This is a cross sectional analysis of baseline data in a longitudinal study of adherence and health outcomes.
PARTICIPANTS, SETTING
Ninety first-time adult LTX recipients at the University of Pittsburgh Medical Center completed assessments of socio-demographic, health history, psychosocial and environmental factors shortly after surgery; adherence and health outcomes are tracked throughout the study.
RESULTS
The UPMC cohort is older, less racially diverse, and contains more living donors than the national sample. Our sample is generally comparable to the UPMC cohort on pre-txp socio-demographic and clinical characteristics.
Comparable reliability/internal consistency on psychological measures is demonstrated between our sample and most published norms. The mean scores on all coping scales in our sample are higher than normative. Our subjects indicated a more negative perception of family environment and perceived relationships with their primary caregiver more positively than the normative group.
CONCLUSION
The generalizability of our sample to the parent population and reliability of individual and environmental measures reported here will enable us to examine relationships and predictive capability of patient and contextual resources on treatment adherence and health outcomes among liver transplant recipients.
PMCID: PMC2858345  PMID: 20397349
liver; transplant; psycho-social; socio-demographic
19.  The Alzheimer’s Disease Centers’ Uniform Data Set (UDS): The Neuropsychological Test Battery 
The neuropsychological test battery from the Uniform Data Set (UDS) of the Alzheimer’s Disease Centers (ADC) program of the National Institute on Aging (NIA) consists of brief measures of attention, processing speed, executive function, episodic memory and language. This paper describes development of the battery and preliminary data from the initial UDS evaluation of 3,268 clinically cognitively normal men and women collected over the first 24 months of utilization. The subjects represent a sample of community-dwelling, individuals who volunteer for studies of cognitive aging. Subjects were considered “clinically cognitively normal” based on clinical assessment, including the Clinical Dementia Rating scale and the Functional Assessment Questionnaire. The results demonstrate performance on tests sensitive to cognitive aging and to the early stages of Alzheimer disease (AD) in a relatively well-educated sample. Regression models investigating the impact of age, education, and gender on test scores indicate that these variables will need to be incorporated in subsequent normative studies. Future plans include: 1) determining the psychometric properties of the battery; 2) establishing normative data, including norms for different ethnic minority groups; and 3) conducting longitudinal studies on cognitively normal subjects, individuals with mild cognitive impairment, and individuals with AD and other forms of dementia.
doi:10.1097/WAD.0b013e318191c7dd
PMCID: PMC2743984  PMID: 19474567
20.  Semantic memory activation in individuals at risk for developing Alzheimer disease 
Neurology  2009;73(8):612-620.
Objective:
To determine whether whole-brain, event-related fMRI can distinguish healthy older adults with known Alzheimer disease (AD) risk factors (family history, APOE ɛ4) from controls using a semantic memory task involving discrimination of famous from unfamiliar names.
Methods:
Sixty-nine cognitively asymptomatic adults were divided into 3 groups (n = 23 each) based on AD risk: 1) no family history, no ɛ4 allele (control [CON]); 2) family history, no ɛ4 allele (FH); and 3) family history and ɛ4 allele (FH+ɛ4). Separate hemodynamic response functions were extracted for famous and unfamiliar names using deconvolution analysis (correct trials only).
Results:
Cognitively intact older adults with AD risk factors (FH and FH+ɛ4) exhibited greater activation in recognizing famous relative to unfamiliar names than a group without risk factors (CON), especially in the bilateral posterior cingulate/precuneus, bilateral temporoparietal junction, and bilateral prefrontal cortex. The increased activation was more apparent in the FH+ɛ4 than in the FH group. Unlike the 2 at-risk groups, the control group demonstrated greater activation for unfamiliar than familiar names, predominately in the supplementary motor area, bilateral precentral, left inferior frontal, right insula, precuneus, and angular gyrus. These results could not be attributed to differences in demographic variables, cerebral atrophy, episodic memory performance, global cognitive functioning, activities of daily living, or depression.
Conclusions:
Results demonstrate that a low-effort, high-accuracy semantic memory activation task is sensitive to Alzheimer disease risk factors in a dose-related manner. This increased activation in at-risk individuals may reflect a compensatory brain response to support task performance in otherwise asymptomatic older adults.
GLOSSARY
= Alzheimer disease;
= Analysis of Functional NeuroImages;
= analysis of variance;
= area under the curve;
= Brodmann area;
= blood oxygen level–dependent;
= control;
= Dementia Rating Scale 2;
= Diagnostic and Statistical Manual of Mental Disorders, 4th edition;
= episodic memory;
= family history;
= field of view;
= functional region of interest;
= hemodynamic response function;
= mild cognitive impairment;
= Mayo Older Americans Normative Studies;
= magnetic resonance;
= medial temporal lobe;
= not significant;
= Rey Auditory–Verbal Learning Test;
= semantic memory;
= supplementary motor area;
= spoiled gradient-recalled at steady state;
= echo time;
= repetition time;
= voxel-based morphometry.
doi:10.1212/WNL.0b013e3181b389ad
PMCID: PMC2731619  PMID: 19704080
21.  Effects of Varying Diagnostic Criteria on Prevalence of Mild Cognitive Impairment in a Community Based Sample 
Mild cognitive impairment (MCI) is proposed to be a prodrome to dementia in some older adults. However, the presentation of MCI in the community can differ substantially from clinic-based samples. The aim of the current study is to demonstrate the effects of different operational definitions of MCI on prevalence estimates in community-dwelling older adults. A consecutive series of 200 participants aged 65 and over from the Adult Changes in Thought (ACT) community-based cohort were approached to undergo comprehensive neuropsychological and medical evaluation; 159 were included in the final analyses. Nondemented subjects were categorized using various diagnostic criteria for MCI. In a novel approach, neuropsychological test scores were evaluated using an individualized benchmark as a point of test comparison, as well as traditional methods that entail comparison to age-based normative data. Diagnostic criteria were further subdivided by severity of impairment (1.0 vs. 1.5 standard deviations [sd] below the benchmark) and extent of impairment (based on a single test or an average of tests within a cognitive domain). MCI prevalence rates in the sample were highly dependent on these diagnostic factors, and varied from 11% to 92% of the sample. Older groups tended to show higher prevalence rates, although this was not the case across all diagnostic schemes. The use of an individualized benchmark, less severe impairment cutoff, and impairment on only a single test all produced higher rates of MCI. Longitudinal follow-up will determine whether varying diagnostic criteria improves sensitivity and specificity of the MCI diagnosis as a predictor for dementia.
doi:10.3233/JAD-2011-101821
PMCID: PMC3146555  PMID: 21368379
Age related memory disorders; aging; cognition; Alzheimer's disease; dementia; diagnosis; epidemiology; individual differences; neuropsychological tests; prevalence; normative
22.  Cognitive Change Checklist (3CL): Psychometric Characteristicsin Community Dwelling Older Adults 
Objective
To extend the psychometric study of the Cognitive Change Checklist (3CL) by examining the reliability, factor structure, and external correlates of 3CL informant and self-report ratings in community dwelling adults. We also conducted ROC analyses examining rating scores from this normative sample with those of clinical samples.
Design
Scale reliability and validity study.
Setting
Community sites.
Participants
Six hundred and seventy-nine older adults.
Results
The pattern of scale relationships within and across versions, and the failure to find associations with age and education, were consistent with findings in clinic samples reported previously. Factor analysis replicated the four-factor structure of the informant ratings. All informant version scales significantly discriminated amnestic Mild Cognitive Impairment (MCI) cases and patients with mild dementia from normals.
Conclusion
These findings provide support for the use of the checklist as a clinical tool to facilitate identification of cases of MCI and early dementia.
doi:10.1097/JGP.0b013e3182702c31
PMCID: PMC3508163  PMID: 23032479
rating scales; informant; activities of daily living; cognition; aging; cognitive decline; mild cognitive impairment; dementia
23.  First Diagnosis and Management of Incontinence in Older People with and without Dementia in Primary Care: A Cohort Study Using The Health Improvement Network Primary Care Database 
PLoS Medicine  2013;10(8):e1001505.
Robert Grant and colleagues used the British THIN primary care database to determine rates of first diagnosis of urinary and faecal incontinence among people aged 60–89 with dementia compared with those without dementia, and the use of medication or indwelling catheters for urinary incontinence in those with and without dementia.
Please see later in the article for the Editors' Summary
Background
Dementia is one of the most disabling and burdensome diseases. Incontinence in people with dementia is distressing, adds to carer burden, and influences decisions to relocate people to care homes. Successful and safe management of incontinence in people with dementia presents additional challenges. The aim of this study was to investigate the rates of first diagnosis in primary care of urinary and faecal incontinence among people aged 60–89 with dementia, and the use of medication or indwelling catheters for urinary incontinence.
Methods and Findings
We extracted data on 54,816 people aged 60–89 with dementia and an age-gender stratified sample of 205,795 people without dementia from 2001 to 2010 from The Health Improvement Network (THIN), a United Kingdom primary care database. THIN includes data on patients and primary care consultations but does not identify care home residents. Rate ratios were adjusted for age, sex, and co-morbidity using multilevel Poisson regression.
The rates of first diagnosis per 1,000 person-years at risk (95% confidence interval) for urinary incontinence in the dementia cohort, among men and women, respectively, were 42.3 (40.9–43.8) and 33.5 (32.6–34.5). In the non-dementia cohort, the rates were 19.8 (19.4–20.3) and 18.6 (18.2–18.9). The rates of first diagnosis for faecal incontinence in the dementia cohort were 11.1 (10.4–11.9) and 10.1 (9.6–10.6). In the non-dementia cohort, the rates were 3.1 (2.9–3.3) and 3.6 (3.5–3.8).
The adjusted rate ratio for first diagnosis of urinary incontinence was 3.2 (2.7–3.7) in men and 2.7 (2.3–3.2) in women, and for faecal incontinence was 6.0 (5.1–7.0) in men and 4.5 (3.8–5.2) in women. The adjusted rate ratio for pharmacological treatment of urinary incontinence was 2.2 (1.4–3.7) for both genders, and for indwelling urinary catheters was 1.6 (1.3–1.9) in men and 2.3 (1.9–2.8) in women.
Conclusions
Compared with those without a dementia diagnosis, those with a dementia diagnosis have approximately three times the rate of diagnosis of urinary incontinence, and more than four times the rate of faecal incontinence, in UK primary care. The clinical management of urinary incontinence in people with dementia with medication and particularly the increased use of catheters is concerning and requires further investigation.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Globally, more than 35 million people have dementia, brain disorders that are characterized by an irreversible decline in cognitive functions such as language and memory. Alzheimer's disease and other forms of dementia mainly affect older people and, because people are living longer than ever, experts estimate that by 2050 more than 115 million people will have dementia. The earliest sign of dementia is usually increasing forgetfulness but, as the disease progresses, people gradually lose their ability to deal with normal daily activities such as dressing, they may become anxious or aggressive, and they may lose control of their bladder (urinary incontinence), bowels (bowel or fecal incontinence), and other physical functions. As a result, people with dementia require increasing amounts of care as the disease progresses. Relatives and other unpaid carers provide much of this care—two-thirds of people with dementia are cared for at home. However, many people with dementia end their days in a care or nursing home.
Why Was This Study Done?
Incontinence in people with dementia is distressing for the person with dementia and for their carers and often influences decisions to move individuals into care homes. However, little is known about the diagnosis and treatment of urinary and/or fecal incontinence among people with dementia living at home. This information is needed to help policymakers commission the services required for this section of society and insurers recognize the needs such patients have, as well as helping to raise clinicians' awareness of the issue. In this cohort study (an investigation that compares outcomes in groups of people with different characteristics), the researchers use data routinely collected from general practices (primary care) in the UK to determine the rate of first diagnosis of urinary and fecal incontinence in elderly patients with and without dementia and to find out whether a diagnosis of dementia affects the rate of use of drugs or of indwelling urinary catheters (tubes inserted into the bladder to drain urine from the body) for the treatment of urinary incontinence.
What Did the Researchers Do and Find?
The researchers extracted data collected between 2001 and 2010 on incontinence for nearly 55,000 people aged 60–89 with a diagnosis of dementia (the dementia cohort) and for more than 200,000 individuals without a diagnosis of dementia (the non-dementia cohort) from The Health Improvement Network (THIN) primary care database, which includes anonymized consultation records from nearly 500 UK general practices. In the dementia cohort, the rates of first diagnosis of urinary incontinence were 42.3 and 33.5 per 1,000 person-years at risk among men and women, respectively. In the non-dementia cohort, the corresponding rates were 19.8 and 18.6. The rates of first diagnosis of fecal incontinence were 11.1 and 10.1 in the dementia cohort, and 3.1 and 3.6 in the non-dementia cohort among men and women, respectively. After adjusting for age, sex and other diseases, the adjusted rate ratio for the first diagnosis of urinary incontinence in people with dementia compared to people without dementia was 3.2 in men and 2.7 in women; for fecal incontinence, it was 6.0 in men and 4.5 in women; the adjusted rate ratio was 2.2 for both men and women for drug treatment of urinary incontinence and 1.6 in men and 2.3 in women for use of indwelling urinary catheters.
What Do These Findings Mean?
These findings indicate that, in primary care in the UK, dementia is associated with a three-fold higher rate of diagnosis of urinary incontinence and a greater than four-fold higher rate of diagnosis of fecal incontinence. Moreover, the authors suggest that some aspects of clinical management of urinary continence vary between people with and without dementia. In particular, the use of indwelling urinary catheters appears to be more common among people with dementia than among people without dementia, increasing the risk of infection. Thus, health care practitioners providing care for people with dementia may be prioritizing ease of management over risk avoidance, a possibility that requires further investigation. Although the accuracy of these findings is limited by certain aspects of the study design (for example, the THIN database does not identify which patients are living in care homes), they nevertheless suggest that policymakers and insurers involved in planning and providing services for people with dementia living at home need to provide high levels of help with incontinence, including the provision of advice and support for carers.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001505.
The UK not-for-profit organization Alzheimers Society provides information for patients and carers about dementia, including information on coping with incontinence and personal stories about living with dementia
The US not-for-profit organization Alzheimers Association also provides information for patients and carers about dementia and about incontinence, and personal stories about dementia
The UK National Health Service Choices website provides information (including personal stories) about dementia, urinary incontinence, and bowel incontinence
MedlinePlus provides links to further resources about dementia, urinary incontinence and fecal incontinence (in English and Spanish)
The International Continence Society and the International Consultation on Urological Diseases provide independent advice on products to manage incontinence
More information about the THIN database is available
doi:10.1371/journal.pmed.1001505
PMCID: PMC3754889  PMID: 24015113
24.  Effects of age, gender, education and race on two tests of language ability in community-based older adults 
International psychogeriatrics / IPA  2009;21(6):1051-1062.
Background
Neuropsychological tests, including tests of language ability, are frequently used to differentiate normal from pathological cognitive aging. However, language can be particularly difficult to assess in a standardized manner in cross-cultural studies and in patients from different educational and cultural backgrounds. This study examined the effects of age, gender, education and race on performance of two language tests, the animal fluency task (AFT) and the Indiana University Token Test (IUTT). We report population-based normative data on these tests from two combined ethnically divergent, cognitively normal, representative population samples of older adults.
Methods
Participants aged ≥65 years from the Monongahela-Youghiogheny Healthy Aging Team (MYHAT) and from the Indianapolis Study of Health and Aging (ISHA) were selected based on (1) a Clinical Dementia Rating (CDR) score of 0; (2) non-missing baseline language test data; and (3) race self-reported as African American or white. The combined sample (n=1885) was 28.1 % African American. Multivariate ordinal logistic regression was used to model the effects of demographic characteristics on test scores.
Results
On both language tests, better performance was significantly associated with higher education, younger age, and white race. On the IUTT, better performance was also associated with female gender. We found no significant interactions between age and sex, and between race and education.
Conclusions
Age and education are more potent variables than are race and gender influencing performance on these language tests. Demographically-stratified normative tables for these measures can be used to guide test interpretation and aid clinical diagnosis of impaired cognition.
doi:10.1017/S1041610209990214
PMCID: PMC2783556  PMID: 19586563
neuropsychological tests; norms; cognitive aging; verbal fluency; token test
25.  Broad Spectrum Assessment of Psychopathology and Adaptive Functioning with the Older Adult Behavior Checklist: A Validation and Diagnostic Discrimination Study 
Objective
Self-administered by spouses and other collateral informants, the nationally normed Older Adult Behavior Checklist (OABCL) provides standardized data on diverse aspects of older adult psychopathology and adaptive functioning. We tested the validity of the Older Adult Behavior Checklist (OABCL) scale scores in terms of associations with diagnoses of dementia of the Alzheimer’s type (DAT) and mood disorders (MD) and with 9 measures of psychopathology, cognitive performance, and adaptive functioning.
Method
Informants completed OABCLs for 727 60- to 97-year-olds recruited from a memory disorders clinic, geriatric psychiatry clinic, and community–dwelling seniors. OABCL scale scores were tested for associations with DAT and MD diagnoses, as well as with scores on the Neuropsychiatric Inventory, Mini-Mental State Exam (MMSE), Clock Drawing Test, Alzheimer’s Disease Assessment Scale, Geriatric Depression Scale, Clinical Dementia Rating, Dementia Severity Rating Scale, Trail Making Test Part A, and Instrumental Activities of Daily Living.
Results
OABCL scales had medium to large correlations with the 9 other indices of functioning and significantly augmented MMSE discrimination between patients with DAT vs. MD. OABCL scales also discriminated significantly between patients diagnosed with DAT vs. MD and both these groups vs. nonclinical subjects.
Conclusions
Multiple OABCL scales had medium to large associations with diverse indices of functioning based on other kinds of data. The nationally normed OABCL provides new ways to integrate informant and self-report data to improve assessment of older adults. Specifically, the OABCL can provide discrimination between those who qualify for diagnoses of DAT vs. MD vs. neither diagnosis.
doi:10.1002/gps.2459
PMCID: PMC2957545  PMID: 20054835
Older Adult Behavior Checklist; Mini-Mental State Exam; Dementia of the Alzheimer’s Type; Mood Disorders; Neuropsychiatric Inventory

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