Impairment Items Research Articles

The Use of Clinical Experience to Stage the Severity of Functional Impairments in Alzheimer's Disease

Experienced clinicians from Germany and the United States rated the stage of Alzheimer's disease at which each of 44 manifestations of cognitive, behavioural, or functional impairment is considered most clinically relevant. The resulting data were subjected to three methods of metric scale analysis with the dual objective of examining international consistency and elucidating internationally-based clinical understanding of the chronology of increasing functional impairment in Alzheimer's disease. Preliminary examination of the data resulted in elimination of 6 judges for inconsistent performance. The remaining 28, approximately equally divided between Germany and the US, provided acceptably consistent results that were the basis for establishing metric distances between the 44 impairment items based on a combination of equal appearing intervals, principal components, and paired comparison scaling methods. The resulting ordering and associated scale values for the 44 items provide a consistent description of the course of functional impairments in Alzheimer's disease as seen by experienced clinicians in the two countries.

The New York Teacher Rating Scale for Disruptive and Antisocial Behavior

A teacher rating scale designed to reflect current diagnostic descriptors of oppositional defiant disorder and conduct disorder was developed and standardized. Teacher ratings were obtained for 1,258 1st-through 10th-grade children from two school districts in New York and for 81 clinically referred children with conduct disorder. Three factors relevant to oppositional defiant disorder and conduct disorder were generated: defiance, physical aggression, and delinquent aggression. A fourth factor reflects peer problems. Internal consistency, test-retest reliability, and interrater reliability are documented using a population and a conduct disorder sample. The validity of the factors is supported by the factors' ability to discriminate between children in the general population and those with conduct disorders, by correlations with global impairment items, and by expected sex differences. The scale has utility for assessing symptoms of conduct disorder in school settings.

Positive/negative symptomatology and experimental measures of attention in schizophrenic patients.

In a search for an external validation of the negative syndrome construct and the attentional impairment item on Andreasen's scale, 49 unmedicated schizophrenic patients were administered the Span of Apprehension Test and a Continuous Performance Test with two levels of difficulty. This schizophrenic sample performed significantly more poorly on the attentional tests than a comparable group of 27 healthy control subjects. Depending on the difficulty of the test we found a number of significant correlations between the SANS composite score and the pertaining attentional impairment item on the one hand and experimental indices of attentional functioning on the other hand, which might corroborate the psychopathological assumptions. The implications of these results for further attempts to validate clinical concepts of the positive/negative dichotomy by experimental means will be discussed.

Progressive spastic paraparesis associated with human T-cell leukemia virus type I (HTLV-I).

Patients with progressive spastic paraparesis (PSP), commonly middle-aged women, are distributed throughout the country of Chile. During the three years from 1987 to 1990, we collected 83 cases of PSP from among 225 patients with various neurological diseases. The clinical picture was of a bilateral pyramidal syndrome, with sensory deficits in only 15.5% of the cases, and a slow illness progression in the majority of them. In patients with PSP, antibody to human T-cell leukemia virus type I (HTLV-I) was analyzed by enzyme linked immunosorbent assay (ELISA) and confirmed by western blot analysis. Forty-five (54.2%) patients were anti-HTLV-I antibody positive in cerebrospinal fluid (CSF) and peripheral blood. Among them, 2 patients had leukemia/lymphoma and one had Sjögren syndrome. In the laboratory study of seropositive PSP, mononuclear pleocytosis was found in 35.7%; there was an abnormal increase of the IgG index in 66.6% and an increase in CD2 in blood and CSF, and CD4 in blood. A delayed latency of somatosensory evoked potentials was observed in 90.9%. The neuropsychological study revealed a WAIS with a mean verbal IQ of 80.7 and a mean performance IQ of 84.8. The most impaired items were digit symbol and digit span. Seven subjects (18.9%) with anti-HTLV-I antibody were found among 37 relatives from 19 anti-HTLV-I positive cases of PSP.

Memory for the temporal order of events in patients with frontal lobe lesions and amnesic patients

Patients with frontal lobe lesions, amnesic patients with Korsakoff's syndrome, other (non-Korsakoff) amnesic patients, and control subjects were given tests of memory for temporal order. In the first experiment, subjects were presented with a list of 15 words and then asked to reproduce the list order from a random array of the words. In the second experiment, they were asked to arrange in chronological order a random display of 15 factual events that occurred between 1941 and 1985. In both experiments, patients with frontal lobe lesions were impaired in placing the items in the correct temporal order, despite normal item memory (i.e. normal recall and recognition memory for the words and facts). The two groups of amnesic patients exhibited impaired memory for temporal order as well as impaired item memory. Patients with Korsakoff's syndrome exhibited poorer temporal order memory than the other amnesic patients, despite similar levels of item memory. These findings demonstrate that patients with frontal lobe lesions have difficulty organizing information temporally. Patients with Korsakoff's syndrome, who have both diencephalic and frontal damage, have memory impairment together with a disproportionate deficit in memory for temporal order.

Ratings of impairment and functional status in prediction of mortality.

Little attention has been given to selecting a set of variables that define the dimensions of health or illness as a totality. This could have utility, particularly in the field of aging, for better assessment of the person's residual capacity and proper selection of treatments or services. Generally, scales are assembled to measure discrete areas of physical, mental, and social functioning without regard to any overlap between scales or items in the over-all association with some dependent variable. Reducing these to the ones that uniquely contribute to outcome is a desirable research goal. Even within the area of physical health, there are dimensions such as impairment and disability (functional status). Impairment is usually defined as organic pathology judged by a physician, whereas disability or functional status can be determined through observation of the person's self-care ability in such areas as eating, dressing, toileting, bathing, and ambulation. However, some people who are quite impaired continue to function at rather high levels and some nor so organically impaired may exhibit poor functional states. Most medical research has relied on measurement of functional status (since these ratings are based on more objective observation) rather than on estimates of degree of impairment to organ systems. Yet, there seems to be justification for both types of assessment. The purpose of this study was to determine the relationship between these two areas in the prediction of mortality. Males (n = 714) averaging 67 yr. were rated by their physicians in the hospital on a 13-item impairment scale (1) and by a ward nurse on a 16-item functional status scale (2), just before their transfer to community nursing homes. Follow-up 6 mo. later showed that 221 patients (31%) had died. Both stepwise multiple regression and stepdown discriminant function analyses were used to identify the predictors in terms of unique contribution and accuracy in classification. Scales were first analysed separately and then all 29 items were combined. Although 8 functional items discriminated between living and dead at a univariate level. only 5 uniquely predicted mortality. All 16 functional scores had an accuracy in classification of 68%. Five of the 13 impairment items were statistically significant at a univariate level and also contributed significantly as predictors. All 13 impairment items had an accuracy in classification of 74%. Using the combined 29 items, 6 variables (4 impairment and 2 function) emerged as accounting significantly for 80% of the predictable variance in mortality and achieving an accuracy in classification of 77%. At the .O1 level, vascular, respiratory, and neurological impairment and need for assistance with earing were identified. Degree of mental depression and impairment ratings on hepatic system were associated with mortality (P < .05). Our data suggest that combining selected functional status ratings with estimates of impairment led to better classification of clinical condition and predictors of outcome.