The Survey for Memory, Attention, and Reaction Time (SMART): Development and Validation of a Brief Web-Based Measure of Cognition for Older Adults.

INTRODUCTION: Brief, Web-based, and self-administered cognitive assessments hold promise for early detection of cognitive decline in individuals at risk for dementia. The current study describes the design, implementation, and convergent validity of a fWeb-based cognitive assessment tool, the Survey for Memory, Attention, and Reaction Time (SMART), for older adults. METHODS: A community-dwelling sample of older adults (n = 69) was included, classified as cognitively intact (n = 44) or diagnosed with mild cognitive impairment (MCI, n = 25). Participants completed the SMART at home using their computer, tablet, or other Internet-connected device. The SMART consists of 4 face-valid cognitive tasks available in the public domain assessing visual memory, attention/processing speed, and executive functioning. Participants also completed a battery of standardized neuropsychological tests, a cognitive screener, and a daily function questionnaire. Primary SMART outcome measures consisted of subtest completion time (CT); secondary meta-metrics included outcomes indirectly assessed or calculated within the SMART (e.g., click count, total CT, time to complete practice items, and time of day the test was completed). RESULTS: Regarding validity, total SMART CT, which includes time to complete test items, practice items, and directions, had the strongest relationship with global cognition (ß = -0.47, p < 0.01). Test item CT was significantly greater for the MCI group (F = 5.20, p = 0.026). Of the SMART tasks, the executive functioning subtests had the strongest relationship with cognitive status as compared to the attention/processing speed and visual memory subtests. The primary outcome measures demonstrated fair to excellent test-retest reliability (intraclass correlation coefficient = 0.50-0.76). CONCLUSIONS: This study provides preliminary evidence for the use of the SMART protocol as a feasible, reliable, and valid assessment method to monitor cognitive performance in cognitively intact and MCI older adults.

Subtle Changes in Medication-taking Are Associated With Incident Mild Cognitive Impairment.

INTRODUCTION: Medication-taking is a routine instrumental activity of daily living affected by mild cognitive impairment (MCI) but difficult to measure with clinical tools. This prospective longitudinal study examined in-home medication-taking and transition from normative aging to MCI. METHODS: Daily, weekly, and monthly medication-taking metrics derived from an instrumented pillbox were examined in 64 healthy cognitively intact older adults (Mage=85.5 y) followed for a mean of 2.3 years; 9 transitioned to MCI during study follow-up. RESULTS: In the time up to and after MCI diagnosis, incident MCI participants opened their pillbox later in the day (by 19 min/mo; ß=0.46, P<0.001) and had increased day-to-day variability in the first pillbox opening over time (by 4 min/mo) as compared with stable cognitively intact participants (ß=4.0, P=0.003). DISCUSSION: Individuals who transitioned to MCI opened their pillboxes later in the day and were more variable in their medication-taking habits. These differences increased in the time up to and after diagnosis of MCI. Unobtrusive medication-taking monitoring is an ecologically valid approach for identifying early activity of daily living changes that signal transition to MCI.

Blast concussion and posttraumatic stress as predictors of postcombat neuropsychological functioning in OEF/OIF/OND veterans.

OBJECTIVES: Many combat veterans exhibit cognitive limitations of uncertain origin. In this study, we examined factors that predict cognitive functioning by considering effects of blast-related concussion (BRC), non-blast-related concussion (NBRC), and posttraumatic stress disorder (PTSD) symptoms. Analyses specifically tested whether (a) BRC and NBRC were distinct in their prediction of cognitive performance; (b) a dose-response relationship existed between recurrent concussion (BRC and NBRC) and cognitive impairment; and (c) PTSD symptoms mediated the relationship between BRC and cognitive performance. METHOD: Two hundred eighty veterans with combat zone deployment histories completed semistructured clinical interviews to define BRC and NBRC histories, current and past mental health disorders, and dimensional ratings of PTSD symptomatology. Participants were also administered a number of neuropsychological measures to appraise cognitive functioning. RESULTS: A structural equation model (SEM) suggested that BRC and NBRC were not distinct in their prediction of cognitive performance, and there was no evidence that recurrent concussion (blast or nonblast) was directly associated with cognitive performance. BRC was significantly associated with PTSD symptoms (r = .24), PTSD symptoms were significantly associated with cognitive performance in the SEM (r = -.27), and PTSD symptoms significantly mediated the link between BRC and cognitive performance (p = .03). CONCLUSIONS: These results suggest that concussion history fails to directly contribute to cognitive performance, regardless of mechanism (blast or nonblast) and recurrence. BRC is nonetheless unique in its contribution to PTSD and PTSD-related cognitive deficits. Results support interventions specific to PTSD management in the interest of promoting neuropsychological functioning among war veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Mental Health Diagnoses in Veterans Referred for Outpatient Geriatric Psychiatric Care at a Veterans Affairs Medical Center.

INTRODUCTION: Nearly half of the U.S. veterans are over 65 years of age. Older veterans are at higher risk for mental health (MH) conditions, which are associated with increased mortality and health care costs. Given the deficit of specialty-trained geriatric providers, we are conducting a Quality Improvement initiative to improve MH services for older veterans at Minneapolis Veterans Affairs Health Care System. Our first step is to understand the demographic and diagnostic characteristics of veterans referred for geriatric MH specialty treatment. MATERIALS AND METHOD: We conducted a retrospective chart review of demographics and psychiatric diagnoses in veterans seen for outpatient geriatric MH intake between May 1, 2011 and April 30, 2016. We used chi-square and Spearman's rho tests to examine age, diagnoses, and service-time era variables. RESULTS: 1,059 veterans were evaluated, average age of 73.5 years. Depressive (47%), neurocognitive (42%), and anxiety disorders (22%) were the most common MH conditions. Vietnam veterans showed higher prevalence of depressive (56%), post-traumatic stress (11%), and alcohol use (10%) disorders. World War II veterans showed higher prevalence of neurocognitive disorders (71%). Neurocognitive disorder prevalence was significantly correlated with age. CONCLUSIONS: Prevalence and comorbidity of major MH conditions is high in veterans referred for geriatric MH services. Future work will examine challenges faced by non-specialty providers in caring for older veterans, with the goal of developing targeted educational and clinical interventions to better address aging veterans' MH needs.

Steeper aging-related declines in cognitive control processes among adults with bipolar disorders.

BACKGROUND: Little is known about the specificity of executive functioning (EF) decline in older adults with bipolar disorders (OABD), or the impact of bipolar disorders (BD) on the timing and slope of age-related declines in EF processes implicated in both BD etiology and normative aging-cognitive control (CC). This cross-sectional study investigated age-related CC decline in BD. METHODS: Participants were 43 adults with BD (M age = 61.5, SD = 15.8; 86% male) and 45 Controls (M age = 65.2, SD = 12.2; 98% male). Two-way ANOVAs examined the effects of median-age-split and diagnostic groups on cognitive processes with established BD deficits-CC processes (mental flexibility and response inhibition), verbal learning, and verbal fluency. RESULTS: The median-split-age-by-diagnostic-group interaction was significant for mental flexibility; OABD performed significantly worse than younger adults with BD and younger and older Controls. Exploratory multivariate adaptive regression spline characterized non-linear nature of aging-slope changes in mental flexibility for each diagnostic group, yielding an inflection point at older age and steeper subsequent decline in OABD versus Controls. LIMITATIONS: This study is limited by a small sample (particularly for select neuropsychological measures) of mostly Caucasian men and BD diagnoses based on clinical interview and medical records review. CONCLUSIONS: Compared to healthy older adults, OABD showed steeper age-related decline in mental flexibility-select EF processes that depend on the integrity of the CC system. Preliminary evidence links CC integrity to daily functioning in OABD; accelerated aging decline in CC may pose a mechanism for high risk of functional impairment and dementia in OABD.

Cognitive-behavioral group treatment for driving-related anger, aggression, and risky driving in combat veterans: a pilot study.

The present study examined the preliminary effects of an 8-session group cognitive-behavioral treatment (CBT) designed to reduce driving-related anger, aggression, and risky driving behaviors in veterans. Participants (N = 9) with self-reported aggressive and risky driving problems completed self-report measures at pretreatment, posttreatment, and 1-month follow-up. Of those completing the treatment, 89% demonstrated reliable change in driving-related aggression and 67% evidenced reliable change in driving-related anger. Similar changes were found for secondary treatment targets.

Neuropsychological outcomes of U.S. Veterans with report of remote blast-related concussion and current psychopathology.

This study explored whether remote blast-related MTBI and/or current Axis I psychopathology contribute to neuropsychological outcomes among OEF/OIF veterans with varied combat histories. OEF/OIF veterans underwent structured interviews to evaluate history of blast-related MTBI and psychopathology and were assigned to MTBI (n = 18), Axis I (n = 24), Co-morbid MTBI/Axis I (n = 34), or post-deployment control (n = 28) groups. A main effect for Axis I diagnosis on overall neuropsychological performance was identified (F(3,100) = 4.81; p = .004), with large effect sizes noted for the Axis I only (d = .98) and Co-morbid MTBI/Axis I (d = .95) groups relative to the control group. The latter groups demonstrated primary limitations on measures of learning/memory and processing speed. The MTBI only group demonstrated performances that were not significantly different from the remaining three groups. These findings suggest that a remote history of blast-related MTBI does not contribute to objective cognitive impairment in the late stage of injury. Impairments, when present, are subtle and most likely attributable to PTSD and other psychological conditions. Implications for clinical neuropsychologists and future research are discussed. (JINS, 2012, 18, 1-11).

Malingering intellectual disability: the value of available measures and methods.

Atkins v. Virginia (2002) is a case that has changed the landscape in relation to the assessment of malingering in a legal context. This landmark decision abolished the death penalty for defendants found to have intellectual disability (ID; formally known as mental retardation), but limitations in our assessment techniques lead to questions regarding the veracity of ID claims. In fact, Justice Scalia noted with clarity that concerns exist regarding the ability of individuals to feign ID and to do so successfully. At the time of writing, little empirical research has been completed, but that which exists demonstrates an overall lack of validity for traditional measures of cognitive malingering for use with this population. This manuscript provides an overview of the utility of many of the traditional measures of malingering for use with an ID population and serves as a call for research in this very important area.

Susceptibility of current adaptive behavior measures to feigned deficits.

The current study examined the susceptibility of the Adaptive Behavior Assessment System-2nd edition (ABAS-II; Harrison & Oakland, 2003) and the Scales of Independent Behavior-Revised (S1B-R; Bruininks, Woodcock, Weatherman, & Hill, 1996) to the feigning of adaptive functioning deficits. Using four different instruction sets, the authors evaluated whether the provision of diagnostic information (a form of coaching) improved participants' ability to simulate adaptive deficits commensurate with a diagnosis of mental retardation. The authors found that the ABAS-II was quite vulnerable to believable manipulation by raters, while the SIB-R was not. In fact, exaggeration on the SIB-R was easily detected regardless of the information provided. Implications regarding the use of these measures in Atkins mental retardation evaluations are discussed.

Effects of a community toxic release on the psychological status of children.

This study sought to determine the emotional effects of a major community toxic release on children in the exposed community while controlling for the potential effects of response bias. Controlling for the response bias inherent in litigated contexts is an advance over previous studies of toxic exposure in children. A randomly selected representative sample of Exposed children (n = 31) was compared to a matched Control group (n = 28) from a nearby, unexposed community. Symptoms and complaints were assessed via interview with the children and their guardians, surveys and checklists, and well-established psychological instruments. Even when biased responding was controlled the Exposed children experienced more psychological distress, more physical symptoms, and greater general concern over their physical functioning than the Controls. The Exposed children also reported some concern about their future health and cancer risk but usually only if asked. Limitations and future research directions are discussed.

Classification accuracy of the test of memory malingering in traumatic brain injury: results of a known-groups analysis.

This study used a known-groups design to determine the classification accuracy of the Test of Memory Malingering (Tombaugh, 1996, 1997) in detecting cognitive malingering in traumatic brain injury (TBI). Forty-one of 161 TBI patients met Slick, Sherman, and Iverson (1999) criteria for Malingered Neurocognitive Dysfunction. Twenty-two no-incentive memory disorder patients were also included. The original cutoffs (<45) for Trial 2 and Retention demonstrated excellent specificity (less than a 5% false positive error rate) and impressive sensitivity (greater than 45%). However, these cutoffs are actually conservative in the context of mild TBI. Over 90% of the non-MND mild TBI sample scored 48 or higher on the Retention Trial and none scored less than 46 while 60% of the MND patients claiming mild TBI were detected at those levels. Trial 1 also demonstrated excellent classification accuracy. Application of these data to clinical practice is discussed.

Detection of feigned tactile sensory loss using a forced-choice test of tactile discrimination and other measures of tactile sensation.

OBJECTIVE: Intentional exaggeration of disability is a risk in work injuries but is hard to reliably detect clinically. This study examined the accuracy of tactile sensory threshold and forced-choice discrimination measures in detecting feigned sensory loss. METHODS: Participants (n = 80) were randomly assigned to one of four sensory loss groups: (1) none; (2) partial; (3) full; or (4) feigned. Sensory data were collected for the upper extremities. RESULTS: Tactile thresholds greater than 0.5 g, discriminability less than 0.50, or forced-choice scores less than 90% were associated with a very low probability of false-positive errors. CONCLUSIONS: Below-chance scores are definitive evidence that the sensory loss is intentionally feigned. Scores beyond cut-offs should raise the clinician's suspicion of malingering if there is no physical basis for sensory loss.

Agreement between the abbreviated and standard portland digit recognition test.

This study sought to determine the classification agreement between the standard and abbreviated forms of the Portland Digit Recognition Test (PDRT), a well-established symptom validity test. PDRTs (N=200: 100 traumatic brain injury, 100 chronic pain) were randomly selected from case manager and attorney referrals for psychological assessment. Only three cases were misclassified and agreement was as high as 99.5%. This study demonstrated that when using the abbreviated PDRT there is little risk of false negative errors.

Psychological evaluation of the emotional effects of a community toxic exposure.

OBJECTIVE: We sought to assess the emotional effects of a major community toxic release while controlling the potential effects of response bias associated with litigation. METHODS: Participants included 152 exposed adult litigants and a matched unexposed comparison group (n = 76). Psychological assessment methods included: (1) Minnesota Multiphasic Personality Inventory-2; (2) Symptom Checklist-90-Revised; and (3) Impact of Event Scale-Revised. RESULTS: Ten to 40% of the exposed group demonstrated emotional distress (compared with a 5% comparison baseline) depending on indicator and cutoff score used. CONCLUSIONS: The psychological consequences of a community toxic exposure were present even when exaggeration was carefully controlled. Accounting for exaggeration in the assessment of subjective psychological complaints provides a more accurate view of the subjective emotional state of persons who have experienced toxic exposure thereby facilitating appropriate clinical management of their mental health needs.