To avoid costly evaluation of healthy individuals, efficient methods of screening for incident dementia must combine adequate sensitivity and high specificity. Two-stage screening may offer improvements over single-stage methods. We therefore investigated a two-stage screening protocol for incident dementia among 3,308 elderly.
We administered the Modified Mini-Mental-State (3MS) or, rarely, Jorm's IQCODE, to a validation sample of 441 high-risk respondents. Informants then completed the Dementia Questionnaire (DQ). Finally, all 441 sample members underwent physical, neurologic, and neuropsychologic assessment. We studied the sensitivity and specificity of the 3MS/IQCODE and DQ using Receiver-Operating Characteristic analyses.
A 3MS cut point of 82/83 (of 100) yielded sensitivity and specificity of 91.5 and 90.1%. With 3MS scores of < or =82, a DQ cut point of 2/3 (of five) yielded conditional sensitivity and specificity of 90.2 and 55.3%. Combining these instruments yielded sensitivity and specificity of 82.5 and 95.6%. Age stratification and use of longitudinal decline score criteria did not materially improve these figures.
The improved specificity of the two-stage approach offers economies that are attractive, particularly if sensitivity can be enhanced, for example, by examination of a high-risk validation sample.
"Such findings have resulted in the use of scale adjustments for factors such as age, education, and race. However, age-adjusted scores may not improve predictive value (e.g., Hayden et al., 2003; Lindeboom, Launer, Schmand, Hooyer, & Jonker, 1996), and the use of race and education adjustments for cognitive screening measures and neuropsychological tests used to detect dementia has been debated (Berkman, 1986; Kittner et al., 1986; Stern et al., 1992). The use of adjustments has been questioned on the grounds that education cannot be studied as a risk factor if it is already adjusted in diagnostic tests (Heun, Papassotiropoulos, & Jennssen, 1998; Kittner et al.). "
[Show abstract][Hide abstract] ABSTRACT: A randomized controlled trial examined whether the diagnostic process for Alzheimer's disease and other dementias may be influenced by knowledge of the patient's education and/or self-reported race. Four conditions were implemented: diagnostic team knows (a) race and education, (b) education only, (c) race only, or (d) neither. Diagnosis and clinical staging was established at baseline, at Wave 2, and for a random sample of Wave 3 respondents by a consensus panel. At study end, a longitudinal, "gold standard" diagnosis was made for patients with follow-up data (71%). Group differences in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis were estimated using logistic regression and generalized estimating equations. Sensitivity and specificity were examined for baseline diagnosis in relation to the gold standard, longitudinal diagnosis. Despite equivalent status on all measured variables across waves, members of the "knows race only" group were less likely than those of other groups to receive a diagnosis of dementia. At final diagnosis, 19% of the "knows race only" group was diagnosed with dementia versus 38% to 40% in the other 3 conditions (p = .038). Examination of sensitivities and specificities of baseline diagnosis in relation to the gold standard diagnosis showed a nonsignificant trend for lower sensitivities in the knowing race conditions (0.3846), as contrasted with knowing education only (0.480) or neither (0.600). The finding that knowledge of race may influence the diagnostic process in some unknown way is timely, given the recent State-of-the-Science conference on Alzheimer's disease prevention, the authors of which called for information about and standardization of the diagnostic process. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
"A 3MS score from 0 to 100 was calculated from the exam. A cutoff score of 86/87 was determined by other studies to be sensitive to early stage dementia and mild cognitive impairment (Khachaturian, Gallo, and Breitner 2000; Hayden et al. 2003). Those scoring 86 or less on the 3MS underwent further clinical evaluation including in depth neuropsychological assessment employing methods used in other similar studies of dementia (Tschanz et al. 2000)). "
[Show abstract][Hide abstract] ABSTRACT: Susceptibility genes for Alzheimer's disease are proving to be highly challenging to detect and verify. Population heterogeneity may be a significant confounding factor contributing to this difficulty. To increase the power for disease susceptibility gene detection, we conducted a genome-wide genetic linkage screen using individuals from the relatively isolated, genetically homogeneous, Amish population. Our genome linkage analysis used a 407-microsatellite-marker map (average density 7 cM) to search for autosomal genes linked to dementia in five Amish families from four Midwestern U.S. counties. Our highest two-point lod score (3.01) was observed at marker D4S1548 on chromosome 4q31. Five other regions (10q22, 3q28, 11p13, 4q28, 19p13) also demonstrated suggestive linkage with markers having two-point lod scores >2.0. While two of these regions are novel (4q31 and 11p13), the other regions lie close to regions identified in previous genome scans in other populations. Our results identify regions of the genome that may harbor genes involved in a subset of dementia patients, in particular the North American Amish community.
American Journal of Medical Genetics Part B Neuropsychiatric Genetics 03/2006; 141B(2):160-6. DOI:10.1002/ajmg.b.30257 · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Depressive disorders are common among opiate abusers and are associated with detrimental behavioral effects. However, there is little precedent for offering active drug users complex treatments for depression.
To determine whether combined psychotherapy and pharmacotherapy treatment reduces reported depressive symptoms compared with an assessment-only condition among out-of-treatment drug injectors.
Randomized controlled trial.
Research office located at an academic medical center.
Active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with symptoms persisting for at least 3 months, or major depression plus dysthymia, and a Modified Hamilton Rating Scale for Depression (HAM-D) score greater than 13.
Combined psychotherapy (8 sessions of cognitive behavior therapy) plus pharmacotherapy (citalopram).
Modified HAM-D scale scores at the end of 3 months of combined treatment.
The 109 study subjects were 64% male and had a mean age of 36.7 years and a mean baseline HAM-D score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and major depression plus dysthymia (17%). In the intent-to-treat analysis, participants in treatment averaged 2.11 HAM-D points greater improvement than control subjects (P=.08), and 26.1% of combined treatment patients (n=53) compared with 12.5% of control patients (n=56) were in remission (P=.047). Nearly 40% of fully adherent subjects (receiving >75% of either psychotherapy or pharmacotherapy) were in remission at follow-up (odds ratio, 3.6; P=.04).
Combined treatment for depression is significantly superior to a control condition (assessment only) in proportion of patients in remission, but not in HAM-D improvement among drug injectors. Full adherence to treatment is associated with the largest treatment effects. Our findings demonstrate that active drug users with dual diagnoses are able to participate in conventional treatment.
Archives of General Psychiatry 03/2004; 61(2):152-9. DOI:10.1001/archpsyc.61.2.152 · 14.48 Impact Factor
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