Reliability and validity of the Spanish version of the IDEAL Schedule for assessing care needs in dementia: Cross-sectional, multicenter study.

OBJECTIVE: The IDEAL Schedule was developed for staging "care needs" in patients with dementia. We here aim to validate the Spanish version, further test its psychometric properties and explore a latent construct for "care needs". METHODS: A multicenter study was done in 8 dementia care facilities across Spain. Patients referred with a reliable ICD-10 diagnosis of dementia (n = 151) were assessed with the IDEAL Schedule by pairs of raters. Inter-rater reliability (intra-class correlation [ICC] coefficients), internal consistency (Cronbach's alpha), and factor analysis were calculated. Convergent validity for individual items was tested against validated Spanish versions of international instruments. RESULTS: Pilot testing with numerical scales supported the feasibility, face, and content validity of the schedule. The psychometric coefficients were good/clinically acceptable: inter-rater reliability (mean ICC = 0.861; 85% of the ICCs > 0.8), internal consistency (global alpha coefficient = 0.74 in 5 nuclear items), and concurrent validity (global score against the Clinical Dementia Rating schedule, r = 0.63; coefficients for individual items ranging from 0.40 to 0.84, all statistically significant, p < 0.05). Internal consistency was low for the "nonprofessional care" and "social support" dimensions. Factor analysis supported a unidimensional solution, suggesting a latent "care needs" construct. CONCLUSION: The Spanish version of the IDEAL Schedule confirms the main psychometric properties of the original version and documents for the first time the convergent validity of individual items. Factor analysis identified a latent construct consistent with the concept "care needs" although 2 dimensions need further psychometric research.

Mortality in Mild Cognitive Impairment Diagnosed with DSM-5 Criteria and with Petersen's Criteria: A 17-Year Follow-Up in a Community Study.

OBJECTIVE: To explore the possibility that the mortality risk of mild cognitive impairment (MCI) as diagnosed using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria (DSM-5-MCI) will be higher than using Petersen's criteria (P-MCI) and to report the population-attributable fraction (PAF) of mortality due to MCI. METHODS: A representative community sample of 4,803 individuals aged 55 or more years was interviewed and then followed for 17 years. Standardized instruments were used in the assessment, including the Geriatric Mental State-AGECAT, and research psychiatrists diagnosed P-MCI and DSM-5-MCI cases following operationalized criteria. Mortality information was obtained from the official population registry. Kaplan-Meier age-adjusted survival curves were built for the MCI diagnostic groups, and Cox proportional hazards regression models were used to calculate the hazard ratio of death in participants with MCI relative to those without. We also estimated the PAF of mortality due to specific MCI diagnostic groups. RESULTS: Compared with noncases, the mortality rate ratio was approximately double in DSM-5-MCI individuals (2.3) than in P-MCI individuals (1.2). In the multivariate statistical analysis, a significant association between each diagnostic category and mortality was observed but was only maintained in the final model in DSM-5-MCI cases (hazard ratio: 1.24). The PAF of mortality due to MCI was approximately 1% in both MCI categories. CONCLUSION: The mortality risk in comparison with noncases was higher in DSM-5-MCI than in P-MCI. The PAF of mortality in DSM-5-MCI individuals was ~ 1% over a 17-year period.

Innovative methods in teaching psychiatry to medical students

Background and Objectives: To test the conjecture that the innovative method to teach psychosomatic psychiatry previously reported will be confirmed as beneficial in the training of medical students in the field of general psychiatry. Methods: The emphasis in this course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. The results of an intensive clerkship on bedside teaching are also studied. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of five academic courses are presented in this report. Results: External experts consulted assured that the content of the course was adequate. Eight hundred and thirty eight medical students have completed the learning course in the study period, and 418 (one of the two groups) completed the evaluation with the MTQQ. Most items related to the students' satisfaction were rated "high" or "very high", including the items asking about the usefulness of the course for physicians, the quality of the teaching methods and the bedside teaching. In relation to innovation, the discussion of clinical cases in small groups was also very satisfactory and the "enhancement of a researcher's mind" was rated "high" or "very high" by 1/3rd of medical students. The utility of the yearly evaluation of the quality of teaching methods was supported by results showing that items scored not favourably in the initial evaluation were considerably improved in the follow-up evaluations, when modifications in the method were introduced. Conclusions: Good performance and high satisfaction of medical students was documented in a course on general psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject (AU)

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Depression and incident Alzheimer disease: the impact of disease severity.

OBJECTIVES: To test the hypothesis that clinically significant depression (particularly severe depression) increases the risk of Alzheimer's disease (AD). METHODS: A longitudinal, three-wave epidemiologic study was implemented in a sample of individuals aged 55 years and older (n = 4,803) followed up at 2.5 years and 4.5 years. This was a population-based cohort drawn from the Zaragoza Dementia and Depression (ZARADEMP) Project, in Zaragoza, Spain. Participants included individuals cognitively intact at baseline (n = 3,864). The main outcome measures were depression as assessed by using the diagnostic interview Geriatric Mental State- Automated Geriatric Examination for Computer Assisted Taxonomy package; and AD diagnosed by a panel of research psychiatrists according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The Fine and Gray multivariate regression model was used in the analysis, accounting for mortality. RESULTS: At baseline, clinically significant depression was diagnosed in 452 participants (11.7%); of these, 16.4% had severe depression. Seventy incident cases of AD were found at follow-up. Compared with nondepressed individuals, the incidence rate of AD was significantly higher in the severely depressed subjects (incidence rate ratio: 3.59 [95% confidence interval: 1.30-9.94]). A consistent, significant association was observed between severe depression at baseline and incident AD in the multivariate model (hazard ratio: 4.30 [95% CI: 1.39-13.33]). Untreated depression was associated with incident AD in the unadjusted model; however, in the final model, this association was attenuated and nonsignificant. CONCLUSIONS: Severe depression increases the risk of AD, even after controlling for the competing risk of death.

A proposal of basic guidelines for training in psychosomatic and liaison psychiatry in Spanish psychiatry training programs

Background and Objectives: The Psychosomatic and Liaison Psychiatry is an emerging psychiatric subspecialty. This article is intended to summarize the philosophy supporting training programmes in Spain, and the recommended training guidelines. Methods: Review of the literature and teaching experience. Results: The increasing complexity of diagnosis and treatment, and the demand by patients and providers of resources for higher and more efficient quality of care, make skills training a key tool for achieving these goals. The human being is biology, feelings, thoughts, experiences and thus individuality when sick. Understanding all this is the core on which to base our competencies in this exciting crossroads between psychiatry and other medical specialties. We propose a set of competencies to achieve, and point learning spaces and evaluation mechanisms. Conclusions: Based on accumulated experiences in Spain, and the review of European and international literature, it is possible to summarize a realistic set of norms and directions for training in Psychosomatic and Liaison Psychiatry in residency programmes (AU)

Usefulness of 2 questions about age and year of birth in the case-finding of dementia.

OBJECTIVE: To test the hypothesis that the efficacy of 2 simple questions commonly used in clinical practice, asking the age and year of birth of individuals, will be satisfactory to rule out cases of dementia. DESIGN: Population-based, longitudinal, prospective study focused on the incidence of dementia. In the baseline, a 2-phase procedure for identifying cases and noncases of dementia was implemented. SETTING: Zaragoza, Spain. PARTICIPANTS: Individuals 65 years or older without previous diagnoses of dementia (n = 3613) drawn from the population-based random sample of the ZARADEMP project. MEASUREMENTS: Standardized instruments were used, including the Geriatric Mental State (GMS) and the History and Aetiological Schedule (HAS); cases were diagnosed according to DSM-IV criteria ("reference standard"). The simple cognitive test used in this study consists of the following 2 compulsory questions: "How old are you?" and "What year were you born?" RESULTS: The test was well accepted by the participants and took less than 30 seconds to complete. Compared with the "reference standard," validity coefficients for incorrect answers in both questions were as follows: sensitivity 61.2%, specificity 97.8%, positive predictive value 44.4%, negative predictive value 98.9%. CONCLUSIONS: This ultra-short test has very good specificity and negative predictive power. Its use to rule out cases of dementia might be generalized, as it has the best efficiency reported to date.

The teaching of liaison psychiatry.

OBJECTIVE: To document performance and satisfaction of medical students in a short course on liaison psychiatry. METHODS: The emphasis in this optional course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of four academic courses are presented in this report. RESULTS: External experts consulted assured that the content of the course was adequate. It has been completed by more than 200 medical students, and high marks have been obtained by most. Above average scores (AA, "high" or "very high") were given by substantial proportions of students in most items, related to the "relevance" of the subject, the "usefulness of the clinical cases" or the "enhancement of student-teacher interaction". Compared to the first academic course, students' satisfaction has improved. "Enhancement of a researcher's mind" was rated AA by 61.1% of students in the last academic course, and "global satisfaction" by 88.8%. CONCLUSIONS: Good performance and high satisfaction of medical students was documented in a course on liaison psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject.

Depression in the elderly community: I. Prevalence by different diagnostic criteria and clinical profile

Background and Objectives: Depression is one of the most intriguing disorders in the elderly. We conjecture that prevalence of depression in the community vary according to the diagnostic criteria used. Furthermore, we anticipate that important proportions of depression go untreated or inadequately treated in a Southern European city. Metodology: This report is part of the Zaragoza Study (or ZARADEMP 0), an epidemiological project to document psychiatric morbidity in a representative sample of the elderly. A two - phase design was completed in a sample of n= 1080 elderly (65+ years).Standardized instruments were used, and the Geratric Mental State (GMS) was the main instrument. Cases of depression were diagnosed with three different sets of diagnostic criteria: AGECAT syndrome, AGECAT diagnosis and DSM - IV criteria. Descriptive statistics were used. Results: In support of the working hypothesis, the prevalence of depression tended to be lower when stringent diagnostic criteria were used. It was 7.0 % with AGECAT syndrome,5.7% with AGECAT diagnosis among the cases, 4.8% with DSM - IV criteria. Anxiety, co - morbid syndromes were frequent among the cases (45.5%) and 18.2% of them had co - morbid AGECAT organic syndromes. Differential psychopathological profiles are observed between cases of major and minor depression. Undertreament or inadequate treatment was very frequent, and only 54.5% of major depression cases were onantidepressants. Conclusions: The prevalence of depression in the elderly varies according to diagnostic criteria used, and does not increase with age. Co-morbid anxiety and “organic” syndromes are common, and only half the major depressive cases were on antidepressants (AU)

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Depression in the elderly community: II. Outcome in a 4.5 years follow-up

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Background and Objectives: In this study, we test to what extent negative outcomes of depression reported in different countries may be confirmed in a Southern European population. Methods: This is a follow-up (mean 4.5 years) of the elderly sample interviewed in the baseline of the Zaragoza Study (or ZARADEMP 0). The general methodology is described in the previous paper. The same two-phase procedure completed at baseline was also implemented at follow-up and the same standardized instruments were used. Cases of depression at follow-up were diagnosed with AGECAT criteria. Operational criteria were also used for definition of both “incident case of depression” and “chronic case of depression”. Results: Six hundred and sixty three elderly (61.4%) were reassessed at follow-up, and216 died in the follow-up period. A negative outcome of both, major and minor depression was observed. Taken together, the pessimistic outcome (death, chronicity or conversion to other psychiatric diagnosis) was observed in 70.5% of cases of depression, but only in30.8% of “non-cases”, the differences being statistically significant (Z = 6.7; p < 0.001).Similarly, a high proportion of subcases of depression had a negative prognosis (48.5%),the differences with “non-cases” also being statistically significant (Z = 2.7; p < 0.005). Incidence rate of depression was 14.4 (95% C.I.: 11.0-18.6) the rate being significantly higher in women when compared to men. Conclusions: This is the first report of a negative outcome of depression in a representative sample of the elderly in a Southern European city. Subcases of depression also had a negative outcome. The clinical significance in AGECAT cases of depression is emphasized (AU)

Prevalence of “organic brain syndrome” in a Southern European population in two different time periods. The ZARADEMP Project

Background: Comparative studies of dementia in different time periods are quite limited in the international literature, but might be useful to test environmental hypotheses. The aim of this study is to compare the prevalence of “organic brain syndrome”, as a measure of dementia, in the elderly living in the same community in two different time periods and using the same methods. Methods: Representative samples of the elderly in the Zaragoza Study or ZARADEMP0 (n= 1,080), completed the past decade, and now in Wave I of the ZARADEMP Project or ZARADEMP I (n= 4,803) were interviewed. The Geriatric Mental State (GMS) was the main case-finding instrument and the results were analysed using the AGECAT diagnostic package to generate diagnoses. Results: Adjusted, total prevalence of “organic brain syndrome” in individuals aged 65years and older has not varied from the previous decade. It was 8.4% in ZARADEMP I ,and 7.4% in ZARADEMP 0 (prevalence ratio, PR = 0.83; CI 0.65-1.07). Adjusted prevalence among men was lower in ZARADEMP I (3.6%) when compared to ZARADEMP 0(5.5%), although the differences do not reach statistically significance (PR= 0.65; CI 0.41-1.05). However, in support of the working hypothesis, the differences were more marked, and we consider they reach statistically significant proportions in the age group 80-84years.Conclusions: The prevalence of “organic brain syndrome” has not increased from the previous decade. On the contrary, the prevalence tends to be lower in men, and the differences reach statistical significance in the age group 80-84 years. New analysis using diagnostic criteria of dementia in the same sample are required to confirm these findings (AU)

The ZARADEMP Project on the incidence, prevalence and risk factors of dementia (and depression) in the elderly community: I. The context and the objectives

Background and Objectives: The public health dimension of the problem ofdementia and depression in the elderly population is well documented, but epidemiologicaldata are generally considered to be insufficient and, at times, contradictory. This paperidentifies relevant research areas for the ZARADEMP Project, which follows the ZaragozaStudy (or ZARADEMP 0) and is part of both EURODEM and EURODEP Studies.Methods: Review of the literature. Hypotheses emerging in previous studies of thisresearch group.Results: The following relevant objectives to study in relation to dementia (and depression)have been identified: a) potential variations over time in the prevalence rate; b) provisionof reliable estimations of incidence rates, specific for age and gender; c) data aboutthe course and natural history of so called “mild cognitive deficit”; d) association betweenhypothesized risk factors and cases of dementia (and depression) and its most frequentsubtypes; and e) testing of hypotheses related to the overlap between dementia and depressionand, specifically, to what extent depression has an increased risk for DAT. Otherobjectives of the study are also reviewed, in particular the cross-cultural comparison offindings in Zaragoza and in other European cities incorporated in both EURODEM andEURODEP Studies. The importance of maintaining good, contemporary methodologicalstandards is emphasized.Conclusions: A number of relevant research areas in the epidemiology of both dementiaand depression in the elderly have been identified. Case-control studies based on incidentcases of dementia of the Alzheimer’s type (DAT) to adequately assess risk factorsseem particularly timely (AU)

The ZARADEMP Project on the incidence, prevalence and risk factors of dementia (and depression) in the elderly community: II. Methods and first results

Background: There is a pressing need to identify environmental risk factorsof dementia and depression in the elderly.Aims: To describe the methods and first results of the ZARADEMP Project, the firstpsychiatric study to document risk factors in incident cases of dementia (and depression)in a Southern European elderly population.Method: A three-wave (baseline and two follow-up waves) epidemiological study toidentify incident cases of dementia (and depression) was completed in a representativesample population. Valid Spanish versions of case-finding instruments, including theGeriatric Mental State (GMS) were administered by standardized researchers. The incidentcases, diagnosed by a panel of psychiatrists using DSM-IV criteria, will be includedin a case-control study.Results: Response rate was acceptable (63.6% in Wave I, 87’2% in Wave II and 85’8%in Wave III), and 4,803 individuals completed Wave I. Diagnostic agreement was achievedin 91.4% of probable cases presented to the panel, and a total of 146 incident cases ofdementia were identified.Conclusions: We feel confident that modern epidemiological requirements have beenfulfilled and the statistical power in the calculations of risk will be acceptable (AU)