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OBJECTIVE—To describe a clock drawing task (CLOX) designed to elicit executive impairment and discriminate it from non-executive constructional failure.
SUBJECTS—90 elderly subjects were studied (45 elderly and well persons from the independent living apartments of a continuing care retirement community and 45 patients with probable Alzheimer's disease). The clock drawing performance of elderly patients was compared with that of 62 young adult controls.
METHODS—Subjects received the CLOX, an executive test (EXIT25), and the mini mental state examination (MMSE). The CLOX is divided into an unprompted task that is sensitive to executive control (CLOX1) and a copied version that is not (CLOX2). Between rater reliability (27 subjects) was high for both subtests.
RESULTS—In elderly subjects, CLOX subscores correlated strongly with cognitive severity (CLOX1: r=−0.83 v the EXIT25; CLOX2: r=0.85 v the MMSE). EXIT25 and MMSE scores predicted CLOX1 scores independently of age or education (F(4,82)=50.7, p<0.001; R2=0.71). The EXIT25 accounted for 68% of CLOX1 variance. Only the MMSE significantly contributed to CLOX2 scores (F(4,72)= 57.2,p<0.001; R2=0.74). CLOX subscales discriminated between patients with Alzheimer's disease and elderly controls (83.1% of cases correctly classified; Wilkes' lambda=0.48, p<0.001), and between Alzheimer's disease subgroups with and without constructional impairment (91.9% of cases correctly classified; Wilkes' lambda=0.31, p<0.001).
CONCLUSIONS—The CLOX is an internally consistent measure that is easy to administer and displays good inter-rater reliability. It is strongly associated with cognitive test scores. The pattern of CLOX failures may discriminate clinical dementia subgroups.



Background:

Within the next 30 years, the number of visits older adults will make to emergency departments (EDs) is expected to double from 16 million, or 14% of all visits, to 34 million and comprise nearly a quarter of all visits.

Objective:

The objectives of this study were to determine prevalence rates of cognitive impairment among older adults in the ED and to identify associations, if any, between environmental factors unique to the ED and rates of cognitive impairment.

Methods:

A cross-sectional observational study of adults 65 and older admitted to the ED of a large, urban, tertiary academic health center was conducted between September 2007 and May 2008. Patients were screened for cognitive impairment in orientation, recall and executive function using the Six-Item Screen (SIS) and the CLOX1, clock drawing task. Cognitive impairment among this ED population was assessed and both patient demographics and ED characteristics (crowding, triage time, location of assessment, triage class) were compared through adjusted generalized linear models.

Results:

Forty-two percent (350/829) of elderly patients presented with deficits in orientation and recall as assessed by the SIS. An additional 36% of elderly patients with no impairment in orientation or recall had deficits in executive function as assessed by the CLOX1. In full model adjusted analyses patients were more likely to screen deficits in orientation and recall (SIS) if they were 85 years or older (Relative Risk [RR]=1.63, 95% Confidence Interval [95% CI]=1.3–2.07), black (RR=1.85, 95% CI=1.5–2.4) and male (RR=1.42, 95% CI=1.2–1.7). Only age was significantly associated with executive functioning deficits in the ED screened using the clock drawing task (CLOX1) (75–84 years: RR=1.35, 95% CI= 1.2–1.6; 85+ years: RR=1.69, 95% CI= 1.5–2.0).

Conclusion:

These findings have several implications for patients seen in the ED. The SIS coupled with a clock drawing task (CLOX1) provide a rapid and simple method for assessing and documenting cognition when lengthier assessment tools are not feasible and add to the literature on the use of these tools in the ED. Further research on provider use of these tools and potential implication for quality improvement is needed.

Objectives

We investigated the impact of polymorphisms in key renin angiotensin system genes on the association between angiotensin converting enzyme inhibitors (ACEINH) exposure and global and executive cognitive function in the Health, Aging and Body Composition study.

Design

Cohort study.

Setting

Community-based

Participants

3,075 participants: mean age: 73.6 years, 58% Caucasian, 52% women, 15% on ACEINH, 8 years of follow-up.

Measurements

The phenotypes were longitudinal change in Executive Clock Draw test-1 (CLOX1), the Digit Symbol Substitution test, and the Modified Mini Mental Status Examination. The genetic polymorphisms included the angiotensin converting enzyme insertion deletion (ACEID) in the angiotensin converting enzyme gene and the M235T and 6AG polymorphisms in the angiotensinogen gene (AGT).

Results

The 6AG and M235T polymorphisms in AGT had significant interaction with ACEINH exposure on the longitudinal change in CLOX1 scores in Caucasian participants (p=0.01 for both polymorphisms) independent of blood pressure levels. Specifically, ACEINH exposure was protective against CLOX1 score decline in carriers of the AA genotype of the 6AG and the CC genotype of the M235T (p-value for the ACEINH vs non-ACEINH groups =0.01 for 6AG and 0.005 for M235T) but not the other genotypes. These associations were not significant with other cognitive tests, with ACEID, or in African Americans.

Conclusion

ACEINH may provide a protective effect on executive function in Caucasians with AGT polymorphisms known to be associated with increased renin angiotensin system activity. If confirmed in a pharmacogenetic trial, ACEINH may have additional cognitive protection in a select group of elderly individuals.

Individuals with MCI declined in performance over 6 months in the Clock-drawing (Clox 1) and the WAIS Digit Span tests, but not in the Dementia Rating Scale (DRS). Individual performance on Clox 1 and Digit Span did not correlate after 6 months. Performance on the Digit Span Test also did not correlate with the DRS, but performance on Clox 1 correlated with the DRS. Performance in Clox 1 was, therefore, not a predictor of performance in the Digit Span Test. These findings support the use of a test battery containing the Digit Span test to detect and track cognitive decline in MCI.

Objective

Convergent validation of the Kohlman Evaluation of Living Skills (KELS) to screen older adults’ capacity for safe and independent living.

Design

Cross-sectional study correlating KELS with components of a Comprehensive Geriatric Assessment.

Setting

Participants’ homes

Participants

200 community-dwelling older adults aged ≥65 including 100 referred by adult protective services (APS) and 100 ambulatory patients matched on age, race, gender, and socio-economic status.

Interventions

In-home comprehensive assessment

Main Outcome Measures

Kohlman Evaluation of Living Skills (KELS), Geriatric Depression Scale (GDS), Physical Performance Test (mPPT), Mini-mental state examination (MMSE), Knee Extensor Break Test, Executive test (EXIT25), CLOX 1 & 2, and an 8-foot walk test.

Results

Older adults with abnormal KELS scores performed significantly worse on all tests except for the Knee Extensor Break Test. Accordingly, among the entire group, the KELS correlated with measures of executive function (EXIT25, r = .705, p <.001; CLOX 1, r = −.629 p<.001), cognitive function (MMSE, r=−.508, p<.001), affect (GDS, r= .318, p<.001) and physical function (mPPT, r= −.472, p<.001) but did not correlate with the Knee Extensor Break Test (r = −.068, p = .456). Among those referred by APS the KELS failed to correlate with only the 8-foot walk test (r = .175, p = .153) and GDS (r = .080, p = .450).

Conclusions

This study demonstrated the convergent validity of KELS with a battery of cognitive, affective, executive, and functional measures often used to determine older adults’ ability to live safely and independently in the community. KELS may be a valid and pragmatic alternative to screen for the capacity to live safely and independently among older adults.

In 288 men and women from general population in a cross-sectional survey, all neuropsychological tests were negatively associated with age; memory and executive function were also positively related with education. The hypertensives (HT) were less efficient than the normotensives (NT) in the test of memory with interference at 10 sec (MI-10) (−33%, P = 0.03), clock drawing test (CLOX) (−28%, P < 0.01), and mini-mental state examination (MMSE) (−6%, P = 0.02). Lower MMSE, MI-10, and CLOX were predicted by higher systolic (odds ratio, OR, 0.97, P = 0.02; OR 0.98, P < 0.005; OR 0.95, P < 0.001) and higher pulse blood pressure (BP) (OR 0.97, P = 0.02; OR 0.97, P < 0.01; and 0.95, P < 0.0001). The cognitive reserve index (CRI) was 6% lower in the HT (P = 0.03) and was predicted by higher pulse BP (OR 0.82, P < 0.001). The BP vectors of lower MMSE, MI-10, and CLOX were directed towards higher values of systolic and diastolic BP, that of low CRI towards higher systolic and lower diastolic. The label of hypertension and higher values of systolic or pulse BP are associated to worse memory and executive functions. Higher diastolic BP, although insufficient to impair cognition, strengthens this association. CRI is predicted by higher systolic BP associated to lower diastolic BP.

The Clock Drawing Test (CDT) is a common neuropsychological measure sensitive to cognitive changes and functional skills (e.g., driving test performance) among older adults. However, normative data have not been adequately developed. We report the distribution of CDT scores using three common scoring systems (Mendez, Ala, and Underwood, 1992; Freund, Gravenstein, Ferris, Burke, & Shaheen, 2005; and Cahn, Salmon, Monsch, Butters, Wiederholt, & Corey-Bloom, 1996), among 207 cognitively normal elderly. The systems were well correlated, took little time to use, and had high inter-rater reliability. We found statistically significant differences in CDT scores based on age and WRAT-3 Reading score, a marker of education quality. We present means, standard deviations, and t- and z-scores based on these subgroups. We found that “normal” CDT performance includes a wider distribution of scores than previously reported. Our results may serve as useful comparisons for clinicians wishing to know whether their patients perform in the general range of cognitively normal elderly.

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.

Background

The Clock-in-the-Box is a rapid (2 minute) cognitive screening tool. The purpose of this study was a) to compare the Clock-in-the-Box with the Mini-Mental State Exam (MMSE) and neuropsychological tests, b) to determine Clock-in-the-Box score normative values by age and education group, and c) to determine if the Clock-in-the-Box score is associated with measures of physical function.

Methods

Community-dwelling older participants in the Boston-area were recruited for a prospective, longitudinal study in which they completed a variety of cognitive and functional assessments.

Results

At baseline, participants (n=798; mean age (±SD)=78.2 (±5.5) years; 14 (±3) mean years of education) completed in-home assessments of cognition – the Clock-in-the-Box and MMSE; measures of independent function - Activities of Daily Living and Instrumental Activities of Daily Living; and measures of physical function - Short Physical Performance Battery. Mean MMSE score was 27.1 (±1.6; range 0–30 – 0 worst) and mean Clock-in-the-Box was 6.2 (±1.6; range 0–8 – 0 worst). Performance on the Clock-in-the-Box was correlated (Spearman) with the MMSE (r=0.49, p<.001) and neuropsychological measures (r=0.37–0.50; p<.001). Higher Clock-in-the-Box score was significantly associated with no difficulty in Activities of Daily Living (χ2=39.6, p=<.001) and Instrumental Activities of Daily Living (χ2=35.5, p=<.001). Additionally, higher Clock-in-the-Box scores were associated with higher scores on the Short Physical Performance Battery (F=5.4, p<.001).

Conclusion

The Clock-in-the-Box is a brief cognitive screening test that is correlated with the MMSE, neuropsychological tests, and measures of independent and physical function in community-dwelling older adults.

Deficits in learning, memory, and executive functions are common cognitive sequelae of Parkinson's disease with dementia (PDD) and Alzheimer's disease (AD); however, the pattern of deficits within these populations is distinct. Hierarchical regression was used to investigate the contribution of two measures with executive function properties (Verbal Fluency and CLOX) on list-learning performance (CVLT-II total words learned) in a sample of 25 PDD patients and 25 matched AD patients. Executive measures were predictive of list learning in the PDD group after the contribution of overall cognition and contextual verbal learning was accounted for, whereas in the AD group the addition of executive measures did not add to prediction of variance in CVLT-II learning. These findings suggest that deficits in executive functions play a vital role in learning impairments in patients with PDD; however, for AD patients, learning difficulties appear relatively independent of executive dysfunction.

This multi-center study examined prevalence of cognitive and academic delays in children following liver transplant (LT). 144 patients ages 5–7 and 2 years post-LT were recruited through the SPLIT consortium and administered the Wechsler Preschool and Primary Scale of Intelligence, 3rd Edition (WPPSI-III), the Bracken Basic Concept Scale, Revised (BBCS-R), and the Wide Range Achievement Test, 4th edition (WRAT-4). Parents and teachers completed the Behavior Rating Inventory of Executive Function (BRIEF). Participants performed significantly below test norms on intelligence quotient (IQ) and achievement measures (Mean WPPSI-III Full Scale IQ = 94.7± 13.5; WRAT-4 Reading = 92.7± 17.2; WRAT-4 Math = 93.1± 15.4; p<0001). 26% of patients (14% expected) had “mild to moderate” IQ delays (Full Scale IQ=71–85) and 4% (2% expected) had “serious” delays (Full Scale IQ ≤70; p<0.0001). Reading and/or math scores were weaker than IQ in 25%, suggesting learning disability, compared to 7% expected by CDC(1) statistics (p<0.0001). Executive deficits were noted on the BRIEF, especially by teacher report (Global Executive Composite = 58; p<0.001). Results suggest a higher prevalence of cognitive and academic delays and learning problems in pediatric LT recipients compared to the normal population.

The primary goal of this study was to establish the stability of the Wide Range Achievement Test (WRAT-3) Reading score across two annual assessments of aging individuals. Participants were classified as controls (n = 200), mild cognitive impairment (MCI; n = 137), or possible or probable Alzheimer’s disease (AD; n = 41). Test–retest stability was acceptable to high for all diagnostic groups. The descriptive classification (e.g., “average”) remained consistent for only 74% of participants. Results indicated that WRAT-3 Reading scores are appropriate for use with older adults, though the use of categorical descriptors to describe premorbid ability based on these scores is not supported.

DNA oxidative stress has been suggested as an important pathogenic mechanism in cognitive impairment and dementia. With baseline data collected from 2004 to 2008, the authors examined whether urinary 8-hydroxy-2-deoxyguanosine (8-OHdG), a biomarker of global DNA oxidation, was associated with cognitive function in a sample of 1,003 Puerto Rican adults, aged 45–75 years, living in Boston, Massachusetts, and the surrounding area. Cognitive function was measured by using a battery of 7 tests: the Mini-Mental State Examination, word list learning, digit span, clock drawing and figure copying, Stroop, and verbal fluency tests. The primary outcome was a global cognitive score, averaging standardized scores across all cognitive tests. A higher 8-OHdG concentration was significantly associated with lower global cognitive scores, after adjustment for age, education, status of the gene for apolipoprotein E (APOE), and other covariates (Ptrend = 0.01). The difference in the global score, comparing participants in the 2 extreme 8-OHdG quartiles, was −0.11 (95% confidence interval: −0.20, −0.02), which was equivalent to accelerating cognitive aging by about 4 years, as observed in this population. Prospective studies are needed to elucidate whether elevated urinary 8-OHdG concentrations can predict the rate of cognitive decline and incident dementia.

Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and perinatally HIV-exposed but uninfected (seroreverters; HIV-negative). Participants included 340 youths (206 HIV-positive, 134 HIV-negative), 9–16 years old, and their caregivers. Youths completed the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive youths scored lower than the seroreverters (M = 83.8 versus 87.6, t = 2.21, p = 0.028) on the PPVT-III and on the WRAT-3 (M = 88.2 versus 93.8, t = 2.69, p = 0.008). Among the HIV-positive youths, neither CD4+ cell count, HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication had lower WRAT-3 scores than youths not taking medication (M = 95.03 versus 86.89, t = 2.38, p = 0.018). HIV status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demographic variables. Many youths had been retained in school and attended special education classes. Findings highlight poor language ability among youths infected with and affected by HIV, and the importance of educational interventions that address this emerging need.

Background

Little is known regarding the normative levels of leisure activities among the oldest old and the factors that explain the age-associated decline in these activities.

Methods

The sample included 303 cognitively intact community-dwelling elderly persons with no disability in Activities of Daily Living (ADL) and minimal dependency in Instrumental ADL (IADL) in Shiga prefecture, Japan. We examined (i) the nature and frequency of leisure activities, comparing the oldest old versus younger age groups; (ii) factors that explain the age-associated differences in frequencies of engagement in these activities; and (iii) domain-specific cognitive functions associated with these activities, using three summary index scores: physical and nonphysical hobby indexes and social activity index.

Results

The oldest old (85 years old or older) showed significantly lower frequency scores in all activity indexes, compared with the youngest old (age 65–74 years). Gait speed or overall mobility consistently explained the age-associated reduction in levels of activities among the oldest old, whereas vision or hearing impairment and depressive symptoms explained only the decline in social activity. Frequency of engagement in nonphysical hobbies was significantly associated with all cognitive domains examined.

Conclusions

Knowing the factors that explain age-associated decline in leisure activities can help in planning strategies for maintaining activity levels among elderly persons.

OBJECTIVES

There is increasing evidence that depressive symptoms are associated with the development of cognitive impairment and dementia in late life. We sought to examine whether depression increased the risk of incident cognitive impairment in a longitudinal study of older women.

DESIGN

observational study, up to 6 examinations spanning up to 9 years.

SETTING

university-based Division of Geriatric Medicine

PARTICIPANTS

community-based sample of 436 older, non-demented women

MEASUREMENTS

Participants were followed with regular medical and neuropsychiatric evaluations. Cognitive assessment included episodic immediate and delayed memory, psychomotor speed, and executive functioning. Participants were characterized as having incident impairment on a cognitive test when scores fell below the tenth percentile on age-adjusted norms. Baseline depressive symptoms were measured using the Geriatric Depression Scale (GDS) (30-item). Discrete-time Cox Proportional hazards regression with generalized linear models were used to determine whether baseline risk factors predicted incident impairment on each cognitive test, defined as performance below the tenth percentile on age-adjusted norms.

RESULTS

Baseline GDS was highly associated with incident impairment on all cognitive tests (p <.03). These associations were unaffected by vascular conditions except diabetes, which was associated with incident impairment in delayed recall and psychomotor speed.

CONCLUSIONS

These data suggest that depression may be risk factors for cognitive decline, and thus a potential target for diagnostic and therapeutic interventions.

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.

Background

Functional impairment in community-dwelling older adults is common and is associated with poor outcomes. Our goal was to compare the contribution of impairment in executive function or global cognitive function to predicting functional decline and mortality.

Methods

We studied 7717 elderly women enrolled in a prospective study (mean age 73.3 years) and identified women with poor baseline executive function (score > 1 standard deviation [SD] below the mean on the Trail Making Test B (Trails B; n = 957, 12.4%), poor global cognitive function (score > 1 SD below the mean on a modified Mini-Mental State Examination [mMMSE], n = 387, 5.0%), impairment in both (n = 249, 3.2%), or no impairment (n = 6124, 79.4%). We compared level of functional difficulty (Activities of Daily Living [ADLs] and Instrumental ADLs [IADLs]) at baseline and at 6-year follow-up and survival at follow-up. We also determined if the association was independent of age, education, depression, medical comorbidities, and baseline functional ability.

Results

At baseline, women with Trails B impairment only or impairment on both tests reported the highest proportion of ADL and IADL dependence compared to the other groups. At the 6-year follow-up after adjusting for age, education, medical comorbidities, depression, and baseline ADL or IADL, women with only Trails B impairment were 1.3 times more likely to develop an incident ADL dependence (adjusted odds ratio [OR] = 1.34; 95% confidence interval [CI], 1.07–1.69) and 1.5 times more likely to develop a worsening of ADL dependence (adjusted OR = 1.48; 95% CI, 1.16–1.89) when compared to women with no impairment on either test. In addition, women with only Trails B impairment had a 1.5-fold increased risk of mortality (adjusted hazard ratio [HR] = 1.48; 95% CI, 1.21–1.81). In contrast, women with impairment on only mMMSE were not at increased risk to develop incident ADL or IADL dependence, a worsening of ADL or IADL dependence, or mortality.

Conclusion

Compared to women with no impairment, women with executive function impairment had significantly worse ADL and IADL function cross-sectionally and over 6 years. Individuals with executive dysfunction also had increased risk of mortality. These results suggest that screening of executive function can help to identify women who are at risk for functional decline and decreased survival.

The authors aim to study subjective ratings of clock drawing test by clinicians and determine interrater reliability and diagnostic accuracy. The clock drawing test has been advocated over the Mini-Mental State Examination as an office screening test for dementia, but use of the clock drawing test by neurologists and dementia specialist clinicians has not been validated. The authors conducted a study of clock drawing test scoring by dementia specialists. The authors randomly assigned 25 clocks from each of six predetermined groups based on consensus diagnosis (cognitive comparison subjects, subjects with a memory complaint but with normal neuropsychological testing, subjects with probable and possible mild cognitive impairment, and subjects with possible and probable Alzheimer’s disease) to dementia specialists for blinded scoring using a binary yes/no impairment system and a 0–10 scale as subjectively determined by each individual clinician rater. The authors collapsed the six groups into three (comparison subjects, mild cognitive impairment patients, and Alzheimer’s disease patients) and analyzed interrater reliability, sensitivity, and specificity for consensus diagnosis of mild cognitive impairment, and Alzheimer’s disease. The authors found excellent interrater reliability, sensitivity, and specificity for predicting consensus diagnosis. The 0–10 clock drawing test rating scale was more predictive of consensus diagnosis than the binary impairment scale. Based on the five clinicians’ average dichotomous rating, the clinicians differentiated comparison and Alzheimer’s disease participants with a sensitivity of 0.75 and a specificity of 0.81. For three of the four comparisons, a cutoff score of two or greater resulted in the maximization of sensitivity and specificity for differentiating diagnostic groups. A cutoff score of four or greater maximized sensitivity (0.54) and specificity (0.74) for differentiating Alzheimer’s disease from mild cognitive impairment. Based on rating systems, clock drawing test scoring by dementia clinicians had excellent interrater reliability and sensitivity for differentiating the mild Alzheimer’s disease subjects from comparison subjects. When utilizing a binary rating scale for the clock drawing test in the absence of clinical information, dementia specialist clinicians at the Boston Medical Center were moderately sensitive and highly specific in separating mild cognitive impairment from healthy comparison subjects. These dementia clinicians were also highly sensitive and less specific in differentiating mild cognitive impairment from Alzheimer’s disease.

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.

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.

Clock drawing is a quick, easy to remember test that is well received by patients. It is a good screening test for Alzheimer's disease in the outpatient setting. We evaluated its usefulness compared with the standard Mini Mental State Examination (MMSE) in elderly acute medical and surgical hospital admissions. Within 48 hours of admission, 117 patients over 70 years old were administered the MMSE and asked to draw a clock. Using the MMSE as the standard, clock drawing had a sensitivity of 77% and a specificity of 87%. Patients with discrepant scores were then further evaluated. The findings suggest that normal clock drawing ability reasonably excludes cognitive impairment or other causes of an abnormal MMSE in elderly acute medical and surgical hospital admissions, where cognitive impairment is common and frequently missed.

Abstract

Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and perinatally HIV-exposed but uninfected (seroreverters; HIV-negative). Participants included 340 youths (206 HIV-positive, 134 HIV-negative), 9–16 years old, and their caregivers. Youths completed the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive youths scored lower than the seroreverters (M = 83.8 versus 87.6, t = 2.21, p = 0.028) on the PPVT-III and on the WRAT-3 (M = 88.2 versus 93.8, t = 2.69, p = 0.008). Among the HIV-positive youths, neither CD4+ cell count, HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication had lower WRAT-3 scores than youths not taking medication (M = 95.03 versus 86.89, t = 2.38, p = 0.018). HIV status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demographic variables. Many youths had been retained in school and attended special education classes. Findings highlight poor language ability among youths infected with and affected by HIV, and the importance of educational interventions that address this emerging need.

OBJECTIVES

To examine the independent association between heart rate variability (HRV), a marker of cardiac autonomic function, and cognitive impairment.

DESIGN

Cross-sectional analysis of baseline data from Women’s Health and Aging Study I.

SETTING

Urban community in Baltimore, Maryland.

PARTICIPANTS

A subset of 311 physically disabled, community-dwelling women aged 65 and older whose HRV data were obtained.

MEASUREMENTS

Reduced HRV was defined as the lowest quartile of each of several HRV measures exploring time and frequency domains and compared with the remaining three quartiles. Cognitive impairment was defined as a Mini-Mental State Examination score less than 24. Multiple logistic regression was used to model the independent relationship between reduced HRV and prevalent cognitive impairment.

RESULTS

The age-, education-, and race-adjusted prevalence of cognitive impairment was higher in those with reduced HRV than in those with nonreduced HRV. After adjusting for relevant demographic and clinical characteristics, participants with reduced HRV were significantly more likely than those with nonreduced HRV to have cognitive impairment; these findings were consistent across different HRV indices. In particular, reduced high-frequency power, indicative of decreased parasympathetic activity, was associated with 6.7 times greater odds of cognitive impairment (95% confidence interval = 2.27–20.0).

CONCLUSION

Cardiac autonomic dysfunction, particularly decreased parasympathetic activity, was independently associated with cognitive impairment in older disabled women in the community. This finding may improve understanding of the pathophysiological basis of cognitive impairment. The potential role of HRV as a cause or consequence of cognitive impairment needs to be elucidated in future studies.

OBJECTIVE

To determine the accuracy of the Mini-Mental State Examination combined with the Verbal Fluency Test and Clock Drawing Test for the identification of patients with mild cognitive impairment and Alzheimer’s disease (AD).

METHOD

These tests were used to evaluate cognitive function in 247 older adults. Subjects were divided into three groups according to their cognitive state: mild cognitive impairment (n=83), AD (n=81), cognitively unimpaired controls (n=83), based on clinical and neuropsychological data. The diagnostic accuracy of each test for discriminating between these diagnostic groups (mild cognitive impairment or AD vs. controls) was examined with the aid of Receiver Operating Characteristic (ROC) curves. Additionally, we evaluated the benefit of the combination of tests on diagnostic accuracy.

RESULTS

Although they were accurate enough for the identification of Alzheimer’s disease, neither test alone proved adequate for the correct separation of patients with mild cognitive impairment from healthy subjects. Combining these tests did not improve diagnostic accuracy, as compared to the Mini-Mental State Examination alone, in the identification of patients with mild cognitive impairment or Alzheimer’s disease.

CONCLUSIONS

The present data do not warrant the combined use of the Mini-Mental State Examination, the Verbal Fluency Test and the Clock Drawing Test as a sufficient diagnostic schedule in screening for mild cognitive impairment. The present data do not support the notion that the combination of test scores is better that the use of Mini-Mental State Examination scores alone in the screening for Alzheimer’s disease.