Patient perception of care received by students at the Jackson Free Clinic.

INTRODUCTION: Little has been done to examine the role of student-run free clinics in patient care. In this study we examine patient perceptions of care provided by medical students in comparison to that provided by licensed physicians. Care providers were judged on perceived exam thoroughness, trust, and overall patient satisfaction. METHODS: Patients were asked to complete a 37 question survey after being examined by either medical students or by a physician. RESULTS: Differences between physicians and students were not observed for perceived thoroughness, trust, or overall satisfaction scores. Patients who reported never being married gave lower satisfaction scores (p = 0.024); however, all patients reported being satisfied with their care. CONCLUSIONS: Patients are satisfied with the care they received at the Jackson Free Clinic regardless of the provider's level of training. Patients did not report students to be less thorough in their exams than physicians. Furthermore, patients reported equal trust in students and physicians.

Diagnostic validity of age and education corrections for the Mini-Mental State Examination in older African Americans.

OBJECTIVES: To investigate whether demographic (age and education) adjustments for the Mini-Mental State Examination (MMSE) attenuate mean score discrepancies between African-American and Caucasian adults and whether demographically adjusted MMSE scores improve the diagnostic classification accuracy of dementia in African-American adults over unadjusted MMSE scores. DESIGN: Cross-sectional study. SETTING: Community-dwelling adults participating in the Mayo Clinic Alzheimer's Disease Patient Registry and Alzheimer's Disease Research Center. PARTICIPANTS: Three thousand two hundred fifty-four adults (2,819 Caucasian, 435 African American) aged 60 and older. MEASUREMENTS: MMSE score at study entry. RESULTS: African-American adults had significantly lower unadjusted MMSE scores (23.0 ± 7.4) than Caucasian adults (25.3 ± 5.4). This discrepancy persisted despite adjustment of MMSE scores for age and years of education using established regression weights or newly derived weights. Controlling for dementia severity at baseline and adjusting MMSE scores for age and quality of education attenuated this discrepancy. In African-American adults, an age- and education-adjusted MMSE cut score of 23/24 provided optimal dementia classification accuracy, but this represented only a modest improvement over an unadjusted MMSE cut score of 22/23. The posterior probability of dementia in African-American adults is presented for various unadjusted MMSE cut scores and prevalence rates of dementia. CONCLUSION: Age, dementia severity at study entry, and quality of educational experience are important explanatory factors in understanding the existing discrepancies in MMSE performance between Caucasian and African-American adults. These findings support the use of unadjusted MMSE scores when screening older African Americans for dementia, with an unadjusted MMSE cut score of 22/23 yielding optimal classification accuracy.

Diagnostic accuracy of percent retention scores on RBANS verbal memory subtests for the diagnosis of Alzheimer's disease and mild cognitive impairment.

Previous research has supported the use of percent retention scores in the neuropsychological assessment of memory, and many widely used memory measures provide for the calculation and normative comparison of these scores. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), an increasingly utilized assessment tool for cognitive impairment, provides normative data on delayed memory total raw scores only. The current study was aimed at determining the diagnostic accuracy of a novel percent retention score calculated from RBANS verbal memory subtests (delayed recall minus last learning trial) when distinguishing between normal controls, individuals diagnosed with Mild Cognitive Impairment, and individuals diagnosed with Alzheimer's disease. Results revealed excellent diagnostic accuracy of the RBANS percent retention scores when discriminating between the three groups. Findings suggest that RBANS percent retention scores provide excellent diagnostic accuracy offering supplementary information to clinicians and researchers alike.

Identifying functional impairment with scores from the repeatable battery for the assessment of neuropsychological status (RBANS).

OBJECTIVE: To examine the link between RBANS scores and functional impairment. Functional status was evaluated through informant report using the clinical dementia rating (CDR) scale. METHODS: Archival data were reviewed from records of 99 patients in a memory disorder clinic (MDC) research database. Consensus-based diagnoses were Alzheimer's disease (AD; n = 48), mild cognitive impairment (MCI; n = 48), AD with vascular components; (n = 2) and dementia due to psychiatric conditions (n = 1). RESULTS: The RBANS language index score was significantly related to CDR domain scores of community affairs (p < .01), home and hobbies (p < .01), personal care (p < .05), memory (p < 0.01), and judgment (p < 0.01). RBANS immediate memory index scores were significantly related to (p < 0.05) the CDR Memory and judgment and problem solving domains. Based on these findings, follow-up regressions were conducted. Semantic fluency was significantly related to CDR memory (p < 0.01), judgment (p < 0.05), community affairs (p < 0.05), home/hobbies (p < 0.05), and personal care (p < 0.05) functional domains. Picture naming was significantly related to the CDR personal care domain (p < 0.05). List learning was significantly related to CDR memory functional domain (p < 0.01) and judgment (p < 0.05). Lastly, story memory was significantly related to the CDR judgment domain (p < 0.05). CONCLUSIONS: The RBANS may be an indicator of functional impairment as well as a neuropsychological testing tool. The use of the RBANS could reduce the amount of testing that is administered to the patient, or can provide a way to compare other measurements of functional impairment to assess accuracy of findings.

Utility of the RBANS in detecting cognitive impairment associated with Alzheimer's disease: sensitivity, specificity, and positive and negative predictive powers.

Although initially developed as a brief dementia battery, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) has not yet demonstrated its sensitivity, specificity, and positive and negative predictive powers in detecting cognitive impairment in patients with Alzheimer's disease (AD). Therefore, the current study examined the clinical utility of the RBANS by comparing two age-, education-, and gender-matched groups: patients with AD (n=69) and comparators (n=69). Significant differences (p<0.001) were observed on the RBANS Total score, all 5 Indexes, and all 12 subtests, with patients performing worse than the comparison participants. An optimal balance between sensitivity and specificity on RBANS scores was obtained when cutoffs of one and one and a half standard deviations below the mean of the comparison sample were implemented. Areas under the Receiver Operating Characteristic curves for all RBANS Indexes were impressive though Immediate and Delayed Memory Indexes were excellent (0.96 and 0.98, respectively). Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.

Citalopram in the treatment of dysthymic disorder.

This study aimed to provide preliminary data on the tolerability and effectiveness of citalopram for patients with dysthymic disorder. Twenty-one adult subjects meeting DSM-IV criteria for dysthymic disorder were enrolled in this 12-week open-label study, of whom 15 had pure dysthymia (e.g. no major depression in the past 2 years). Citalopram was initiated at 20 mg/day, and increased to a maximum of 60 mg/day. Response was defined as 50% or greater drop in score on the Hamilton Depression Rating Scale (HDRS) and a Clinical Global Impressions-I score of 1 ('very much improved') or 2 ('much improved'). Of these 15 pure dysthymic disorder subjects, all completed the trial, and 11 (73.3%) were treatment responders. All paired sample t-tests were highly significant, demonstrating significant average improvement on all measures of symptomatology and functioning. Scores on the 24-item HDRS decreased from 22.3+/-4.3 at baseline to 9.1+/-7.8 at week 12 [t(14)=6.1, P<0.001]. In addition, improvement was noted in self-reported measures of temperament and social functioning. The average final dose of citalopram was 39 mg/day. Side-effects were reported by nine of 15 subjects (60%), most frequently gastrointestinal symptoms (n=5), dry mouth (n=5) and sexual side-effects (n=3). These findings suggest the effectiveness and tolerability of citalopram in treating dysthymic disorder. Double-blind prospective studies are needed comparing citalopram both to placebo and to other medications, assessing both initial and sustained response to treatment.