Vulnerable patients going to court: a psychiatrist's guide to special measures.

There have been significant changes to how vulnerable people are treated in the court system, including the introduction of special measures to support people both as witness and as accused. This paper summarises the use of special measures and their application to people with mental health diagnoses or cognitive impairment.

Associations Between Original and a Reduced Frontal Systems Behavior Scale (FrSBe), Cognition, and Activities of Daily Living in a Large Neurologic Sample.

A recent confirmatory factor analysis (CFA) on the Frontal Systems Behavior Scale (FrSBe) indicated that the basic structure of the FrSBe subscales held after removal of 8 weak items. In a replication of previous studies using the original FrSBe, the present study explored associations between a reduced version of the FrSBe, cognition, and activities of daily living (ADLs) in a large mixed outpatient neurologic sample. Consistent with previous findings with the original FrSBe, significant associations existed between reduced FrSBe scores and the Mattis Dementia Rating Scale-Second Edition. Additionally, after controlling for age, gender, and education, reduced FrSBe Apathy was associated with basic ADLs, and reduced FrSBe Disinhibition was associated with instrumental ADLs. These results offer replication in a larger sample of previous findings and statistical support for a reduced FrSBe beyond CFA results alone.

Feasibility of use of probabilistic reversal learning and serial reaction time tasks in clinical trials of Parkinson's disease.

INTRODUCTION: The aim of this study was to investigate the feasibility of using two computer-administered neuropsychological tasks in a clinical trial involving participants with Parkinson's disease without dementia. The tasks, probabilistic reversal learning (PRL) and serial reaction time (SRT), target dorsolateral prefrontal cortex (SRT) and ventral striatal-orbitofrontal (PRL) functioning respectively. METHODS: Participants were 53 adults with idiopathic Parkinson's disease who completed both the SRT and PRL tasks at baseline in a clinical trial. Repeated measures were examined only for the placebo group (n = 20). RESULTS: No participants were removed from analyses due to inability to complete the tasks, and most had fewer than 10% of trials culled due to slow reaction times. Response accuracy on PRL was 81.98% and 66.65% for the two stages of the task respectively. Disease duration was associated with SRT relearning. Disease duration and stage were associated with initial learning on PRL, and there was a trend towards disease stage predicting greater errors on PRL. Among participants in the placebo group, practice effects were seen on PRL (Phase 1 errors) and SRT (relearning). CONCLUSIONS: These results provide initial evidence for the clinical feasibility of computerized PRL and SRT tasks in clinical trials in Parkinson's disease.

Utility of the cognitive difficulties scale and association with objective test performance.

Subjective memory complaints (SMCs) are commonly noted in memory disorder clinic patients. The present study sought to examine the presence of SMCs on the Cognitive Difficulties Scale (CDS) in older adults and to examine the relationship between CDS scores and current cognitive ability. Participants were 50 adults diagnosed with possible/probable Alzheimer's disease (AD), 100 with amnestic mild cognitive impairment (MCI) and 84 cognitively healthy controls (HCs). Participants completed a neuropsychological evaluation and the self- and informant-reported CDS. Results indicated that greater self-reported SMCs were noted in the group with MCI ; however, self-reported CDS scores were associated with cognition in HCs only. Informant-reported CDS scores were predictive of cognitive ability in the diagnosis of MCI but not AD, indicating the importance of obtaining caregiver report in the evaluation of memory disorders. As AD is a neurodegenerative disorder, SMCs lose value in determining degree of cognitive impairment as disease stage increases.

The contribution of apathy and increased learning trials to risky decision-making in Parkinson's disease.

Impairments in executive functioning are commonly found in Parkinson's disease (PD); however, the research into risky decision making has been mixed. The present study sought to investigate three potential hypotheses: difficulty learning the task probabilities, levodopa equivalent dose (LED), and the presence of apathy. Twenty-four individuals with idiopathic PD and 13 healthy controls completed the Frontal Systems Behavior Scale to assess current apathy, the Iowa Gambling Task, and the Balloon Analog Risk Task (BART). Results indicated that individuals with PD selected more from Deck B, a disadvantageous deck. However, with an additional set of trials, participants with PD and apathy selected more from the most risky deck (Deck A). Apathy was not related to the BART, and LED was not related to either task. Results indicate that apathy is associated with decision-making in PD, and providing additional learning trials can improve decision-making in PD without apathy.

Confirmatory factor analysis of the Frontal Systems Behavior Scale (FrSBe).

The Frontal Systems Behavior Scale (FrSBe) is a 46-item questionnaire that measures behaviors associated with frontal subcortical deficits (apathy, disinhibition, and executive dysfunction) in adult neurologic populations. Based on findings from a previous exploratory factor analysis on the scale, the current study used confirmatory factor analysis to explore and potentially improve on the measurement model fit of current FrSBe scores. Model fit indices and reliabilities (measured using internal consistency reliability) were compared in the original and in several alternative models. The original scale demonstrated a generally good fitting model, although the best fitting model (referred to as the reduced model) removed eight items from the original measure and modestly improved model fit over the original FrSBe. Strong reliability was found in both versions. Results from the current study provide a critical first step in a potential FrSBe scale revision.

The ethics of using placebo medication in a non-capacitous patient.

BACKGROUND: The use of placebo has long been controversial. Whilst evidence accumulates regarding it's beneficial and safe effects, ethical issues around the eroding of patient autonomy and accusations of deception stop most doctors prescribing inert placebo substances. CASE STUDY: This paper presents a case of a non-capacitous patient who was prescribed placebo medication, as a 'best interest' decision under the Mental Capacity Act 2005. Good and safe effect was achieved in treating the patient's anxiety. This paper argues that in the non-capacitous patient, the principles of beneficence and justice may outweigh those of autonomy and, therefore, prescription of placebo medication should be more widely considered for this significant group of patients.

Use of the telephone-administered Minnesota Cognitive Acuity Screen to detect mild cognitive impairment.

This study determined the sensitivity and specificity of the telephone-administered Minnesota Cognitive Acuity Screen (MCAS) to distinguish mild cognitive impairment (MCI) from healthy controls (HCs) and from Alzheimer's disease (AD). A total of 100 individuals with MCI, 50 individuals with possible/probable AD, and 50 HCs were screened to exclude medical and psychiatric conditions affecting cognition. In-office evaluation included neuropsychological testing, neurologic examination, and neurodiagnostic work-up. Participants with AD obtained significantly lower MCAS total scores than participants with MCI, who in turn performed worse than the HC group. Sensitivity was 86% and specificity was 78% for distinguishing between MCI and HC. Sensitivity was 86% and specificity was 77% for discriminating between MCI and AD. Sensitivity was 91% and specificity was 78% for discriminating between impaired groups (MCI and AD) and HCs. Results suggest that the MCAS successfully discriminates MCI from HC and AD and has potential as an effective telephone-administered screening tool for memory disorders.

Computerized maze navigation and on-road performance by drivers with dementia.

This study examined the ability of computerized maze test performance to predict the road test performance of cognitively impaired and normal older drivers. The authors examined 133 older drivers, including 65 with probable Alzheimer disease, 23 with possible Alzheimer disease, and 45 control subjects without cognitive impairment. Subjects completed 5 computerized maze tasks employing a touch screen and pointer as well as a battery of standard neuropsychological tests. Parameters measured for mazes included errors, planning time, drawing time, and total time. Within 2 weeks, subjects were examined by a professional driving instructor on a standardized road test modeled after the Washington University Road Test. Road test total score was significantly correlated with total time across the 5 mazes. This maze score was significant for both Alzheimer disease subjects and control subjects. One maze in particular, requiring less than 2 minutes to complete, was highly correlated with driving performance. For the standard neuropsychological tests, highest correlations were seen with Trail Making A (TrailsA) and the Hopkins Verbal Learning Tests Trial 1 (HVLT1). Multiple regression models for road test score using stepwise subtraction of maze and neuropsychological test variables revealed significant independent contributions for total maze time, HVLT1, and TrailsA for the entire group; total maze time and HVLT1 for Alzheimer disease subjects; and TrailsA for normal subjects. As a visual analog of driving, a brief computerized test of maze navigation time compares well to standard neuropsychological tests of psychomotor speed, scanning, attention, and working memory as a predictor of driving performance by persons with early Alzheimer disease and normal elders. Measurement of maze task performance appears to be useful in the assessment of older drivers at risk for hazardous driving.

Boston naming performance distinguishes between Lewy body and Alzheimer's dementias.

Although naming impairment is common among persons with dementia, little is known about how specific error types on naming tasks may differ between dementias. Recent research has suggested that persons with dementia with Lewy bodies (DLB) have more visuospatial/visuoperceptual dysfunction than those with Alzheimer's disease (AD), which may impact their ability to correctly perceive and name objects. Our retrospective study evaluated the presence and frequency of error types among patients with DLB and AD on the Boston Naming Test (BNT). Errors on the BNT were classified into five types (i.e., visuoperceptual, semantic, phonemic, no response, and other), and performance was compared among 31 probable DLB patients and 31 probable AD patients matched for age, gender, education, and overall dementia severity. AD patients' overall performance on the BNT was significantly worse than DLB patients (p<.05). In terms of error types, DLB patients made significantly more visuoperceptual errors (p<.05) while AD patients made significantly more semantic errors (p<.001). Logistic regression revealed that the number of visuoperceptual and semantic errors significantly predicted group membership (p<.005), with an accuracy of up to 85%. Results suggest that error analysis of BNT responses may be useful in distinguishing between patients with DLB and AD.

Factor structure of patient and caregiver ratings on the dementia quality of life instrument.

Preliminary evidence suggests that quality of life reports from patients diagnosed with mild cognitive impairment (MCI) and mild Alzheimer's disease (AD) are as reliable and valid as data provided by caregivers. To date, no studies compared the factor structure of data provided by caregivers and patients. Factor analyses are important to conduct because they are an indicator of validity. This study compared the factor structure of patient and caregiver reports on the Dementia Quality of Life scale (DQoL). Participants (N=67) were patients diagnosed with amnestic MCI or mild AD and their caregivers. Principal axis factor analyses were run separately on patient and caregiver report data. The three-factor solutions for patient and caregiver data were nearly identical. Three factors corresponding to positive affect, negative affect, and aesthetics emerged reliably from analyses. Thus, data from patients demonstrated a factor structure that was highly consistent with caregiver report data and conformed to meaningful psychological constructs.

A comparison of fatigue measures in Parkinson's disease.

Fatigue is a common problem in Parkinson's disease (PD). The Parkinson's Fatigue Scale (PFS) designed for measurement of fatigue in PD has not been validated in the US. The objective of this study was to validate the PFS by comparing it to the Fatigue Severity Scale (FSS). Fifty PD patients and 16 controls completed PFS, FSS and semi-structured interview. FSS and PFS were strongly correlated with one another and had high internal consistency, indicating that both are reliable scales. PD patients and healthy controls differed significantly on both measures. PD patients endorsed significantly more fatigue. The PFS is a reliable, valid fatigue measure.

The Frontal Systems Behavior Scale discriminates frontotemporal dementia from Alzheimer's disease.

Frontotemporal dementia (FTD) is characterized by pronounced changes in affect, self-regulation, and social conduct. These behaviors can predate significant cognitive changes and can be the most disabling aspect of FTD, yet there are few scales designed to assess such changes. The Frontal Systems Behavior Scale (FrSBe) is a 46-item behavior rating scale that is intended to measure behavior associated with damage to the frontal systems of the brain, with subscales measuring Apathy, Disinhibition, and Executive Dysfunction. Thirty-four FTD patients and 34 matched patients with dementia of the Alzheimer's type (DAT) were compared on the FrSBe in the present study. Both groups displayed increases in apathy and dysexecutive behaviors after the onset of dementia, but the FTD group exhibited significantly greater change in disinhibition. A discriminant analysis with just two scores from the FrSBe and a memory test correctly classified 81% of the patients into diagnostic group.

Insight and cognitive impairment: effects on quality-of-life reports from mild cognitive impairment and Alzheimer's disease patients.

This study follows previous work to determine the effect of patient insight and cognitive impairment on the reliability and validity of self-reported quality of life (QOL) from patients diagnosed with Alzheimer's disease (AD) and mild cognitive impairment (MCI). AD and MCI patients (N = 68) and their caregivers participated. Patients with impaired insight provided QOL ratings that were less reliable than those provided by patients with better insight. Patient-caregiver agreement for. QOL reports was used as an index of validity. Neither better insight nor lesser cognitive impairment suggested better agreement. Thus, even when patient insight is intact, patient reports are unlikely to agree with caregiver reports. Patient and caregiver reports about patient QOL may represent 2 unique, yet potentially valid, perspectives.

Deep brain stimulation surgery for Parkinson's disease: the role of neuropsychological assessment.

Neuropsychological assessment has two primary roles in the DBS process. First, assessment of cognitive and emotional functioning ensures that only appropriate candidates undergo this surgical procedure. Patients with dementia, cognitive performance suggestive of an additional neuropathological process, or significant psychiatric impairments should not undergo DBS. Second, neuropsychological assessment is essential to determine the cognitive and emotional outcomes following surgery. At the present time, a disruption in verbal fluency is the only consistent cognitive decline associated with DBS. While worsening of depression and the development of symptoms of mania are potential side effects from DBS, more studies find that DBS is associated with improvements in emotional functioning. Based on the growing understanding of the risk factors and potential side effects to DBS, neuropsychological assessment is necessary to ensure that patients selected to undergo this surgical intervention will likely have positive cognitive and emotional outcomes, in addition to the expected benefits in motor functioning.

The management of behavioural and psychiatric symptoms in delirium.

Delirium is a common and usually reversible syndrome occurring during a period of physical illness. It is most common in children and the elderly. The primary treatment of delirium focuses on the underlying cause, but behavioural and psychiatric symptoms are sometimes of sufficient severity to treat. If behavioural and environmental interventions are ineffective, psychotropic medication may be needed. This paper reviews the drugs commonly used in the management of behavioural and psychiatric symptoms in delirium, and suggests the need for further trials.

Neuropsychological deficits associated with driving performance in Parkinson's and Alzheimer's disease.

Neuropsychological and motor deficits in Parkinson's disease that may contribute to driving impairment were examined in a cohort study comparing patients with Parkinson's disease (PD) to patients with Alzheimer's disease (AD) and to healthy elderly controls. Nondemented individuals with Parkinson's disease [Hoehn & Yahr (H&Y) stage I-III], patients with Alzheimer's disease [Clinical Demetia Rating scale (CDR) range 0-1], and elderly controls, who were actively driving, completed a neuropsychological battery and a standardized road test administered by a professional driving instructor. On-road driving ability was rated on number of driving errors and a global rating of safe, marginal, or unsafe. Overall, Alzheimer's patients were more impaired drivers than Parkinson's patients. Parkinson's patients distinguished themselves from other drivers by a head-turning deficiency. Drivers with neuropsychological impairment were more likely to be unsafe drivers in both disease groups compared to controls. Compared to controls, unsafe drivers with Alzheimer's disease were impaired across all neuropsychological measures except finger tapping. Driving performance in Parkinson's patients was related to disease severity (H&Y), neuropsychological measures [Rey Osterreith Complex Figure (ROCF), Trails B, Hopkins Verbal List Learning Test (HVLT)-delay], and specific motor symptoms (axial rigidity, postural instability), but not to the Unified Parkinson Disease Rating Scale (UPDRS) motor score. Multifactorial measures (ROCF, Trails B) were useful in distinguishing safe from unsafe drivers in both patient groups.

A review of rating scales for measuring behavior change due to frontal systems damage.

OBJECTIVE: To perform a critical review of scales designed to measure frontal behavior change. BACKGROUND: Changes in cognition due to frontal disease or damage have been well described, but noncognitive changes in behavior are often more deleterious functionally for frontal patients. METHOD: The review concentrates on five behavior rating scales: the Behavior Rating Inventory of Executive Functions (BRIEF), the Dysexecutive Questionnaire (DEX), the Frontal Behavior Inventory (FBI), the Frontal Systems Behavior Scale (FrSBe), the Iowa Rating Scales of Personality Change (IRSPC), and the Neuropsychiatric Inventory (NPI). Other scales purporting to measure specific aspects of frontal functioning, but having less research support, are described briefly. RESULTS AND CONCLUSIONS: The BRIEF and FrSBe have good reliability and large-scale norms. No norms are available for the other scales. The FrSBe and IRSPC have been shown to be valid in discriminating frontal from nonfrontal lesioned patients, but this has not been shown in the other scales. The FBI and NPI require trained raters, whereas the FrSBe, IRSPC, and BRIEF are administered to patients and/or family informants directly. The NPI and FBI are sensitive to certain changes in behavior attributed to frontal systems disruption but have been used primarily in dementia.

Validity of informant reports about AD and MCI patients' memory.

Efficient, valid, and economical methods are needed to measure memory in elderly patients who are participants in clinical trials for the prevention or treatment of dementia. Data provided by knowledgeable informants are an ideal means of assessment, but factors that may limit the validity of informant-report data are not known. This study investigated the living status, relationship type, and educational history of informants and determined the impact of these factors on the validity of informant-report data about patients (N = 62) diagnosed with Alzheimer disease or mild cognitive impairment. Validity of informant-reported memory was indicated by the correlation between the reports and patients' performance on a neuropsychological memory test. Results indicated that informants who lived with patients provided more accurate reports of the patients' memory than informants who did not live with the patient. Spouses were more accurate than other relationship types, although relationship type was confounded with living status. Patient education and neuropsychiatric symptoms were not significantly associated with informant accuracy. Results of this study will aid in selecting informants who can provide the most accurate data about memory disorder patients and will aid in the development of protocols for clinical trials for dementia prevention and treatment.