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Among participants with Alzheimer's disease (AD) we estimated the minimal clinically important difference (MCID) in apathy symptom severity on three scales.
Design:
Retrospective anchor- and distribution-based analyses of change in apathy symptom scores.
Setting:
Apathy in Dementia Methylphenidate Trial (ADMET) and ADMET 2 randomized controlled trials conducted at three and ten clinics specialized in dementia care in United States and Canada, respectively.
Participants:
Two hundred and sixty participants (60 ADMET, 200 ADMET 2) with clinically significant apathy in Alzheimer’s disease.
Measurements:
The Clinical Global Impression of Change in Apathy scale was used as the anchor measure and the MCID on the Neuropsychiatric Inventory – Apathy (NPI-A), Dementia Apathy Interview and Rating (DAIR), and Apathy Evaluation Scale-Informant (AES-I) were estimated with linear mixed models across all study visits. The estimated thresholds were evaluated with performance metrics.
Results:
Among the MCID was a decrease of four points (95% CI: −4.0 to −4.8) on the NPI-A, 0.56 points (95% CI: −0.47 to −0.65) on the DAIR, and three points on the AES-I (95% CI: −0.9 to −5.4). Distribution-based analyses were largely consistent with the anchor-based analyses. The MCID across the three measures showed ∼60% accuracy. Sensitivity analyses found that MMSE scores and apathy severity at baseline influenced the estimated MCID.
Conclusions:
MCIDs for apathy on three scales will help evaluate treatment efficacy at the individual level. However, the modest correspondence between MCID and clinical impression of change suggests the need to consider other scales.
Rather than construct lists of many different welfare indicators and give each of them the same weight, I argue that the assessment of animal welfare should be directed at answering two key questions: I) Are the animals healthy? 2) Do they have what they want? Behaviour has a major role in answering both. Behaviour is currently used to help answer the first question through its use in the clinical and pre-clinical assessment of pain, injury and disease, and potentially could have an even greater role, particularly if used in conjunction with new technology. Behaviour is also of crucial importance in gauging what animals want, most obviously in the use of choice and preference tests, but also through other methods that are particularly suitable for on-farm welfare assessment. These include quantitative observations of the spatial distribution of animals and of behavioural ‘indicators’ of what animals want, such as vocalisations.
Identifies the important characteristics of clinical assessment. Describes the various tests that psychologists use. Explains the way psychologists organize information in an intake report. Explains the purpose and limitations of diagnosis. Summarizes the way diagnostic manuals have changed over time. Describes the research evaluating the effectiveness of psychotherapy.
Direct observation in the radiotherapy clinic remains the primary method for the assessment of procedural skills. But with increasing automation and reductions in clinical placement time during the recent pandemic, the role of summative, simulation-based assessment is being revisited. The aim of this article is to share early experiences of using Virtual Environment for Radiotherapy Training (VERT) in the assessment of a palliative, parallel pair, external beam treatment delivery technique in a new pre-registration undergraduate programme.
Methods:
Eight first-year students completed a campus-based individual virtual assessment using virtual patient plans representing metastatic disease in the brain and pelvis and late-stage primary lung tumours. Performance was logged on a 25-item checklist for pre and post-procedure checks and treatment delivery tasks.
Results:
All eight students participated in the assessment with seven students (87·5%) achieving a pass grade at first attempt. The course team observed that participants demonstrated a range of skills and abilities and were able to compare and contrast individual approaches to patient positioning. Specific feed-forward action points were also highlighted as areas for students’ to focus on during their second placement. The project also identified logistical benefits for assessment teams.
Conclusions:
While these experiences are a single snapshot, a VERT simulation-based summative assessment is feasible and identified benefits included controlled observation and structured feedback on individual performance and scheduling pressure reductions for clinical teams. However, more work is needed to determine the psychometric qualities and predictability of performance in more complex techniques.
Clinicians assessing children with autism are sometimes faced with a dilemma, especially if there is a definite or suspected history of abuse or neglect: is this autism or attachment disorder? This is important because the attachment disorders (reactive attachment disorder and disinhibited social engagement disorder) are thought to be caused by abuse or neglect, whereas autism is not. We discuss the Coventry Grid, a clinical tool aiming to aid differentiation between autism and attachment disorders. We examine the small body of empirical studies focusing on this differential diagnosis and find that the Coventry Grid can be regarded as an evidence-based tool. We also discuss preliminary findings regarding a relatively unstructured observational method involving two assessors who engage the child in jokes and playful social dilemmas, which might help clinicians elicit the information required to complete the Coventry Grid.
Mental fatigue, ‘brain fog’, and difficulties maintaining engagement are commonly reported issues in a range of neurological and psychiatric conditions. Traditional sustained attention tasks commonly measure this capacity as the ability to detect target stimuli based on sensory features in the auditory or visual domains. However, with this approach, discrete target stimuli may exogenously capture attention to aid detection, thereby masking deficits in the ability to endogenously sustain attention over time.
Methods:
To address this, we developed the Continuous Temporal Expectancy Task (CTET) where individuals continuously monitor a stream of patterned stimuli alternating at a fixed temporal interval (690 ms) and detect an infrequently occurring target stimulus defined by a prolonged temporal duration (1020 ms or longer). As such, sensory properties of target and non-target stimuli are perceptually identical and differ only in temporal duration. Using the CTET, we assessed stroke survivors with unilateral right hemisphere damage (N = 14), a cohort in which sustained attention deficits have been extensively reported.
Results:
Stroke survivors had overall lower target detection accuracy compared with neurologically healthy age-matched older controls (N = 18). Critically, stroke survivors performance was characterised by significantly steeper within-block performance decrements, which occurred within short temporal windows (˜3 ½ min), and were restored by the break periods between blocks.
Conclusions:
These findings suggest that continuous temporal monitoring taxes sustained attention processes to capture clinical deficits in this capacity over time, and outline a precise measure of the endogenous processes hypothesised to underpin sustained attention deficits following right hemisphere stroke.
Efficient and organized assessment of addiction is essential for research, treatment planning, and referral to specialized services. The goal of this chapter is to provide basic concepts and examples of formalized assessment for substance and nonsubstance (behavioral) addictions including: alcohol and other drug use, food/eating, gambling, exercise, sex/love, and internet use. Measures of reliability and validity are discussed for each measure presented and include examples of self-report measures, interviews, screening instruments and diagnostic tools. The chapter also relates assessment measures to the criteria for diagnosis using the Diagnostic and Statistical Manual of Mental Disorders where appropriate. Current gaps in research on the conceptualization and operationalization of addiction are discussed in relation to the development, testing and effectiveness of assessment tools for substance and behavioral addictions.
This introductory chapter provides an overview of the structure and content of The Cambridge Handbook of Clinical Assessment and Diagnosis. Cross-cutting themes from the chapters are considered within the context of elements of a good clinical psychological assessment. More specifically, the various parts of clinical assessment, including referral, sources of information, differential diagnosis, clinical formulation, and report writing, along with considerations for noncredible reporting and cultural considerations, are discussed. For each component of a clinical assessment, reference to more detailed information in specific chapters is provided. This chapter ends with a call for future developments in clinical psychological assessment, with an emphasis on various technological advances to further bring assessment practices into the twenty-first century.
There is emerging evidence that cognitive behavioral therapy (CBT) can be effective for treating anxiety and depression in people living with dementia (PLWD). Discriminating between thoughts and feelings is a critical element of CBT and also of relevance to emotional understanding more generally. The aim of the present study was the structured adaptation and preliminary validation of an existing measure of thought–feeling discrimination for use in PLWD.
Methods/Design:
The Behavior Thought Feeling Questionnaire (BTFQ) was adapted via expert and service-user consultation for use in PLWD. One hundred two PLWD and 77 people aged over 65 years who did not have measurable cognitive impairments completed the adapted measure along with two measures of emotional recognition and reasoning. The factor structure of this measure was examined and the measure reduced.
Results:
Factor analysis suggested a two-factor solution with thought and feeling items loading on separate factors. The behavior items were not included in scoring due to high cross-loading and ceiling effects, leaving a 14-item measure with two subscales. Thus, an adapted measure was created (named the BTFQ-D), which showed moderate convergent validity in the PLWD but not the older adult sample. Both thought and feeling subscales showed good internal consistency.
Conclusions:
The BTFQ-D showed preliminary validity as a measure of thought–feeling discrimination in PLWD. It may have utility in measuring readiness for CBT as part of clinical assessment. Further validation is required.
The aim of the study is to improve patient safety by identifying factors influencing gatekeeping decisions by crisis resolution and home treatment teams. A theoretical sampling method was used to recruit clinicians. Semi-structured interviews to elicit various aspects of clinical decision-making were carried out. The transcripts were thematically analysed using a grounded theory approach.
Results
Patient needs (safety and treatment) was the primary driver behind decisions. The research also revealed that information gathered was processed using heuristics. We identified five key themes (anxiety, weighting, agenda, resource and experience), which were constructed into an acronym ‘AWARE’.
Clinical implications
AWARE provides a framework to make explicit drivers for decision-making that are often implicit. Incorporating these drivers into reflective practice will help staff be more mindful of undue influences and result in improved clinical decisions.
The aim of the present study was to evaluate the association between depression and SSRI monotherapy and frailty both baseline and prospectively in older adults.
Design:
Prospective cohort study, 12-month follow-up.
Setting:
Geriatric outpatient clinic in São Paulo, Brazil.
Participants:
A total of 811 elderly adults aged 60 or older.
Measurements:
Depression was diagnosed as follows: (1) a diagnosis of major depression disorder (MDD) according to DSM-5; or (2) an incomplete diagnosis of MDD, referred to as minor or subsyndromic depression, plus Geriatric Depression Scale 15-itens ≥ 6 points, and social or functional impairment secondary to depressive symptoms and observed by relatives. Frailty evaluation was performed through the FRAIL questionnaire, which is a self-rated scale. Trained investigators blinded to the baseline assessment conducted telephone calls to evaluate frailty after 12-month follow-up. The association between depression and the use of SSRI with frailty was estimated through a generalized estimating equation adjusted for age, gender, total drugs, and number of comorbidities.
Results:
Depression with SSRI use was associated with frailty at baseline (OR 2.82, 95% CI = 1.69–4.69) and after 12 months (OR 2.75, 95% CI = 1.84–4.11). Additionally, depression with SSRI monotherapy was also associated with FRAIL subdomains Physical Performance (OR 1.99, 95% CI = 1.29–3.07) and Health Status (OR 4.64, 95% CI = 2.11–10.21). SSRI use, without significant depressive symptoms, was associated with subdomain Health Status (OR 1.52, 95% CI = 1.04–2.23).
Conclusion:
It appears that depression with SSRI is associated to frailty, and this association cannot be explained only by antidepressant use.
Cognitive markers of early Alzheimer's disease (AD) should be sensitive and specific to memory impairments that are not associated with healthy cognitive aging. In the present study, we investigated the effect of healthy cognitive aging on two proposed cognitive markers of AD: the Free and Cued Selective Reminding Task with Immediate Recall (FCSRT-IR) and a temporary visual memory binding (TMB) task.
Method:
Free recall and the cost of holding bound information in visual memory were compared between 24 younger and 24 older participants in a mixed, fully counterbalanced experiment.
Results:
A significant effect of age was observed on free recall in the FCSRT-IR only and not on the cost of binding in the TMB task.
Conclusions:
Of these two cognitive markers, the TMB task is more likely to be specific to memory impairments that are independent of age.
Despite the high risk of falling for people with severe mental illness, there is limited falls research in mental health settings. Therefore, the objective of this observational cohort study was to conduct a focused post-fall review of fall episodes within aged acute inpatient mental health units at one of Australia's largest publicly funded mental health organizations.
Methods:
A post-fall reporting tool was developed to collect intrinsic and extrinsic fall risk factors among three aged acute mental health inpatient units over an 18-month period. Descriptive and inferential analyses were conducted to describe fall risk factors and predictors of fall risk.
Results:
There were a total of 115 falls, of which the tool was used for 93 (80.9%) episodes. Falls occurred most often in consumer's bedroom/bathroom and were unwitnessed. Intrinsic risk factors were most often attributed to postural drop and losing balance during walking. However, that was in contrast to consumer's who self-reported feeling dizzy as the reason of the fall.
Conclusions:
Based on the cohort, future falls could be reduced by targeting those aged above 82 years, or with a diagnosis of dementia. Recurrent falls during admission could be reduced by targeting those with psychotic illness and males with a diagnosis of dementia. A clearer dialogue among consumers and clinical staff reporting about fall episodes may support future remedial interventions and inform programs to reduce fall risk and assist the challenge of describing unwitnessed falls in aged acute inpatient mental health settings.
Introduction: Understanding factors that influence laboratory test ordering in emergency departments (EDs) can help to improve current laboratory test ordering practices. The aim of this study is to compare patterns and influences in laboratory test ordering between emergency physicians and nurses at two ED sites, Halifax Infirmary (HI) and Dartmouth General (DG). Methods: A mixed-methods approach involving administrative data and telephone interviews was employed. Data from 211,279 patients at HI and DG EDs were analyzed. Chi-square analysis and binary logistic regression were used to determine significant factors influencing whether a test was ordered, as well as significant factors predicting likelihood of a nurse or a physician ordering a test. All significant associations had a p-value of <0.0001. Interviews were conducted (n=25) with doctors and nurses in order to explore areas of potential influence in a clinician’s decision-making process, and discuss what makes decision making difficult or inconsistent in the ED. These interviews were analyzed according to the Theoretical Domains Framework. The interviews were coded by two individuals using a consensus methodology in order to ensure accuracy of coding. Results: Overall, laboratory tests were more likely to be ordered at DG than at HI (OR=1.52, 95% CI: [1.48, 1.55]). Laboratory tests were more likely to be ordered by nurses at DG than at HI (OR=1.58, 95% CI: [1.54, 1.62]). Laboratory tests were more likely to be ordered if the ED was not busy, if the patient was over 65, had a high acuity, had a long stay in the ED, required consults, or was admitted to hospital. Doctors were more likely to order a laboratory test in patients over 65, requiring consults or hospital admission, whereas nurses were more likely to order laboratory tests in patients with high acuity or long stays in the ED. Data from the interviews suggested differing influences on decision making between nurses and doctors, especially in the areas of social influence and knowledge. Conclusion: Currently, there is limited research that investigates behaviour of both emergency physicians and nurses. By determining barriers that are most amenable to behaviour change in emergency physicians and nurses, findings from this work may be used to update practice guidelines, ensuring more consistency and efficiency in laboratory test ordering in the ED.
Literature indicates that people's experiences of receiving a diagnosis of dementia can have a lasting impact on well-being. Psychiatrists frequently lead in communicating a diagnosis but little is known about the factors that could contribute to potential disparities between actual and best practice with regard to diagnostic disclosure. A clearer understanding of psychiatrists’ subjective experiences of disclosure is therefore needed to improve adherence to best practice guidelines and ensure that diagnostic disclosure facilitates living well with dementia.
Methods:
This study utilized qualitative methodology. Semi-structured interviews conducted with 11 psychiatrists were analyzed using Interpretive Phenomenological Analysis (IPA).
Results:
Three superordinate and nine subordinate themes emerged from the data analysis. These included the following: (i) “The levels of well-being” (Continuing with life, Keeping a sense of who they are, Acceptance of the self), (ii) “Living well is a process” (Disclosure can set the scene for well-being, Positive but realistic messages, Whose role it is to support well-being?), and (iii) Ideal care versus real care (Supporting well-being is not prioritized, There isn't time, The fragmentation of care).
Conclusions:
Findings indicate that psychiatrists frame well-being in dementia as a multi-faceted biopsychosocial construct but that certain nihilistic attitudes may affect how well-being is integrated into diagnostic communication. Such attitudes were linked with the perceived threat of dementia and limitations of post-diagnostic care. Behaviors used to manage the negative affect associated with ethical and clinical tensions triggered by attempts to facilitate well-being at the point of diagnosis, and their impact on adherence to best practice disclosure, are discussed.
Introduction: TIAs precede about 30% of strokes, with 4-10% having a stroke within 90 days of their TIA. In patients with a TIA due to symptomatic carotid disease, diagnosis and treatment within 2 weeks has been shown to have much better outcomes, while delay beyond 12 weeks no longer reduces subsequent stroke risk. The objective of this study was to determine the clinical findings associated with symptomatic critical disease following an ED visit for TIA to indicate patients requiring prompt carotid imaging. Methods: We performed a prospective Canadian multicenter cohort study, at 13 academic sites, of ED patients with TIA or non-disabling stroke from 2006-2014. Treating ED physicians indicate clinical features on standardized data collection forms. Symptomatic carotid disease was carotid stenosis 50-99%, or carotid dissection, adjudicated by stroke neurology to be the etiology of the index event. Patients were followed by medical review and telephone up to 90 days. Univariate analysis was conducted for clinical features associated with patients who were eventually found to have symptomatic carotid disease as a cause for their TIA. Results: The cohort included 305 patients with and 5,277 without symptomatic carotid disease. Positive predictors of symptomatic carotid disease included older age (74.0 yrs vs 68.0 yrs p<0.0001), male sex (62.9% vs 47.9%; p<0.0001), history of weakness (63.3% vs 41.4%; p<0.0001), language disturbance (52.1% vs 40.0%; p<0.0001), weakness on physical exam (25.5% vs 17.1%; p=0.0002), history of hypertension (74.8% vs 59.5%; p<0.0001), and known history of carotid stenosis (18.9% vs 3.1%; p<0.0001). Negative predictors of symptomatic carotid disease included first ever TIA (56.8% vs 68.8%; p<0.0001), history of altered sensation (39.4% vs 45.8%; p=0.0322), lightheadedness (13.0% vs 22.4%; p=0.0002), and vertigo (3.6% vs 12.7%; p<0.0001). Conclusion: TIA patients with older age, male sex, weakness, language disturbance or history of carotid stenosis need to be promptly imaged to assess for symptomatic carotid disease.
Although rates of anxiety tend to decrease across late life, rates of anxiety increase among a subset of older adults, those with mild cognitive impairment (MCI) or dementia. Our understanding of anxiety in dementia is limited, in part, by a lack of anxiety measures designed for use with this population. This study sought to address limitations of the literature by developing a new measure of anxiety for cognitively impaired individuals, the anxiety in cognitive impairment and dementia (ACID) Scales, which includes both proxy (ACID-PR) and self-report (ACID-SR) versions.
Methods:
The ACID-SR and ACID-PR were administered to 45 residents, aged 60 years and older, of three long-term care (LTC) facilities, and 38 professional caregivers at these facilities. Other measures of anxiety, and measures of depression, functional ability, cognition, and general physical and mental health were also administered.
Results:
Initial evaluation of its psychometric properties revealed adequate to good internal consistency for the ACID-PR and ACID-SR. Evidence for convergent validity of measures obtained with the ACID-SR and ACID-PR was demonstrated by moderate-to-strong associations with measures of worry, depressive symptoms, and general mental health. Discriminant validity of measures obtained with the ACID-SR and ACID-PR was demonstrated by weak correlations with measures of cognition, functional ability, and general physical well-being.
Conclusions:
The preliminary results suggest that the ACID-SR and ACID-PR can obtain reliable and valid measures of anxiety among individuals with cognitive impairment. Given the subjective nature of anxiety, it may be prudent to collect self-report of anxiety symptoms even among those with moderate cognitive impairment.
Cortical thickness measurement offers an index of brain development processes. In healthy individuals, cortical thickness is reduced with increasing age and is related to cognitive decline. Cortical thinning has been reported in schizophrenia. Whether cortical thickness changes differently over time in patients and its impact on outcome remain unanswered.
Method
Data were examined from 109 patients and 76 healthy controls drawn from the Santander Longitudinal Study of first-episode schizophrenia for whom adequate structural magnetic resonance imaging (MRI) data were available (n = 555 scans). Clinical and cognitive assessments and MRIs were acquired at three regular time points during a 3-year follow-up period. We investigated likely progressive cortical thickness changes in schizophrenia during the first 3 years after initiating antipsychotic treatment. The effects of cortical thickness changes on cognitive and clinical variables were also examined along with the impact of potential confounding factors.
Results
There were significant diagnoses × scan time interaction main effects for total cortical thickness (F1,309.1 = 4.60, p = 0.033) and frontal cortical thickness (F1,310.6 = 5.30, p = 0.022), reflecting a lesser thinning over time in patients. Clinical and cognitive outcome was not associated with progressive cortical changes during the early years of the illness.
Conclusions
Cortical thickness abnormalities do not unswervingly progress, at least throughout the first years of the illness. Previous studies have suggested that modifiable factors may partly account for cortical thickness abnormalities. Therefore, the importance of implementing practical actions that may modify those factors and improve them over the course of the illness should be highlighted.