London Psychogeriatric Rating Scale Research Articles

Changes in Type of Foodservice and Dining Room Environment Preferentially Benefit Institutionalized Seniors with Low Body Mass Indexes

Objective To compare energy intakes in seniors with cognitive impairment residing in long-term care and receiving meals by bulk (cafeteria style with waitress service) vs traditional tray delivery systems and determine subject characteristics that identify responsiveness to type of foodservice provided. Design and subjects/setting Usual energy intakes were compared in subjects residing in cognitive impairment units in either the old (tray delivery, n=23) or new (bulk delivery, n=26) nursing home at Baycrest, a teaching facility associated with University of Toronto Medical School. Intervention Changes to foodservice and physical environment (from institutional to more home-like environment). Main outcome measures Twenty-one consecutive day investigator-weighed energy and macronutrient intakes and behavioral function (London Psychogeriatric Rating Scale). Statistical analyses performed Analysis of variance determined mean differences in intake and regression analyses identified predictors of sensitivity to type of food delivery systems. Results Higher 24-hour total ( P<0.001) and dinner ( P<0.001) energy intakes in subjects receiving bulk compared to tray delivery were predominantly associated with greater carbohydrate intakes ( P<0.001). Higher energy, carbohydrate, and protein, but not fat intakes, with bulk delivery were more apparent in individuals with lower body mass indexes (BMIs) (food delivery by BMI interaction, all P values <0.05). Conclusions High-risk, cognitively impaired individuals with low BMI benefited the most from the changed foodservice and physical environment, whereas individuals with higher BMIs did not show substantive changes in intake. Bulk foodservice and a home-like dining environment optimize energy intake in individuals at high risk for malnutrition, particularly those with low BMIs and cognitive impairment.

Energy‐Containing Nutritional Supplements Can Affect Usual Energy Intake Postsupplementation in Institutionalized Seniors with Probable Alzheimer's Disease

To determine whether increases in caloric intake associated with consumption of a mid-morning nutritional supplement for 3 weeks were maintained in the week after stopping the supplement and to investigate the effects of body mass index (BMI) and cognitive and behavioral measures on this response. Secondary analysis of a previously published randomized, crossover, nonblinded clinical trial. A fully accredited geriatric care facility affiliated with the University of Toronto. Thirty institutionalized seniors with probable Alzheimer's disease (AD) who ate independently. Investigator-weighed food intake, body weight, cognitive (Severe Impairment Battery; Global Deterioration Scale) and behavioral (Neuropsychiatric Inventory--Nursing Home version; London Psychogeriatric Rating Scale) assessments. Individuals who responded successfully to supplementation as indicated by increases in daily energy intake were likely to maintain 58.8% of that increase postsupplementation, although stopping the supplement was associated with decreased habitual energy intake in low-BMI individuals who reduced their daily intakes during supplementation in response to the extra calories. Cognitive/behavioral tests were not reliable predictors of postsupplement intake. Institutionalized seniors with probable AD are likely to alter their usual energy intakes to maintain changes resulting from 3 weeks of supplementation. This effect may allow for rotating supplementation schedules in nursing homes that could reduce staff burden, but only for those individuals who are most likely to respond favorably. These data indicate that nutritional supplements and diet plans should be carefully prescribed in low-BMI individuals to limit variability in total energy provided and thus prevent lower-than-normal intake.

A Randomized, Crossover Trial of High-Carbohydrate Foods in Nursing Home Residents With Alzheimer's Disease: Associations Among Intervention Response, Body Mass Index, and Behavioral and Cognitive Function

Despite recognition that weight loss is a problem in elderly persons with probable Alzheimer's disease (AD), increasing their food intake remains a challenge. To effectively enhance intake, interventions must work with individuals' changing needs and intake patterns. Previously, the authors reported greater food consumption at breakfast, a high-carbohydrate meal, compared with dinner, and shifts toward carbohydrate preference at dinner in those with increased behavioral difficulties, low body mass index, or both. Thirty-four nursing home residents with probable AD who ate independently participated in a randomized, crossover, nonblinded study of two nutrition interventions. The intervention described here included replacing 12 nonconsecutive "traditional" dinners with meals high in carbohydrate but comparable to traditional dinners in protein. Measures included weighed food intake, body weight, cognitive function (as assessed using the Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (as assessed using the Neuropsychiatric Inventory-Nursing Home Version), and behavioral function (as assessed using the London Psychogeriatric Rating Scale). Group mean dinner and 24-hour energy intake increased during the intervention phase compared with baseline, protein intake was unaffected, and carbohydrate intake increased. Increased dinner intake, attributable to intervention foods, was achieved in 20 of 32 of participants who completed the study and was associated with increased carbohydrate preference, poorer memory, and increased aberrant motor behavior. Those with low body mass indices were the most resistant to the intervention. Providing a high-carbohydrate meal for dinner increases food intake in seniors at later stages of the disease who are experiencing cognitive and behavioral difficulties, possibly as a result of a shift in preference for high-carbohydrate foods.

Behavioral Disturbances, Not Cognitive Deterioration, Are Associated With Altered Food Selection in Seniors With Alzheimer's Disease

We previously reported alterations in circadian patterns of food intake that are associated with measures of functional and cognitive deterioration in seniors with probable Alzheimer's disease (AD). This study further explored disturbed eating patterns in AD, focusing on alterations in macronutrient (protein, carbohydrate, and fat) selection, and their association with measures of functional and behavioral losses. Forty-nine days of food intake collections were conducted on 32 residents (26 females, 6 males; age = 88.4 +/- 4.1 years; body mass index = 24.1 +/- 4.0 kg/m(2)) with probable AD residing at a nursing home (a fully accredited geriatric teaching facility affiliated with the University of Toronto's Medical School). All residents ate their meals independently. The relationships between patterns of habitual food consumption and measures of cognitive function (Severe Impairment Battery), behavioral disturbances (Neuropsychiatric Inventory-Nursing Home Version) and behavioral function (London Psychogeriatric Rating Scale) were examined, cross-sectionally. Consistent with our previous studies, breakfast intakes were not predicted by any of the measures of behavioral, cognitive, or functional deterioration, although those residents with greater functional deterioration, especially disengagement, attained lower 24-hour energy intakes. The presence of "psychomotor disturbances," including irritability, agitation, and disinhibition, were strongly associated with shifts in eating patterns toward carbohydrate and away from protein, placing individuals with these conditions at increased risk for inadequate protein intakes. Between-individual differences in intake patterns could not be explained by the use of either anorexic or orexigenic medications. Behavioral, not cognitive, deterioration is associated with appetite modifications that increase risk of poor protein intake, perhaps indicating a common monoaminergic involvement.

Shift in diurnal feeding patterns in nursing home residents with Alzheimer's disease.

Individuals with Alzheimer's disease (AD) are highly susceptible to weight loss and malnutrition, which, to date, have not been associated with decreased food consumption. The current study examined food intake patterns and how they change in relation to body mass index (BMI), behavioral function, and cognitive status in institutionalized seniors with AD. Twenty-one consecutive days of investigator-weighed food intake collections were conducted on 25 subjects with likely AD residing at a home for the aged. All subjects maintained the ability to self-feed. Eighty-eight percent of participants did not meet targeted energy needs, including an estimated 37% prevalence of protein inadequacy. Subjects with increased behavioral difficulties, based on the London Psychogeriatric Rating Scale, had reduced meal-related intakes that were highly associated with decreased energy consumption at dinner. With behavioral changes, particularly increased mental disorganization and confusion, there was a shift in circadian eating patterns such that the greatest proportion of daily energy was consumed at breakfast. Individuals with low BMIs tended to be those with more behavioral difficulties, such that BMI was also associated with the shift in overall eating patterns. Changes in behavioral function in seniors with AD result in a circadian shift in intake patterns with the preponderance of calories consumed at breakfast in those with increased behavioral difficulties. This shift in eating patterns associates both with poor overall intake and poor BMI.

An Abilities Assessment Instrument for Elderly Persons With Cognitive Impairment: Psychometric Properties and Clinical Utility

In this article the psychometric properties of an Abilities Assessment Instrument (AAI), developed to assess the self-care, social, interactional and interpretive abilities of older people with cognitive impairment (CI) related to dementia, are described. The sample consisted of 112 institutionalized older men with CI and 60 institutionalized older men without CI. The psychometric evaluation of the AAI indicated that: (a) it is reliable in terms of test-retest (Pearson's r range .93-.99), interrater (Pearson's r range .95- .99), and internal consistency evaluations (Cronbach's alpha .90-.98), as well as through confirmatory factor analysis; and (b) that it is valid with respect to content validity (CVI 87.3%), concurrent validity (Pearson's r correlations ranging from -.67-.80 on the London Psychogeriatric Rating Scale [LPRS], and from -.76-.85 on the Functional Assessment Stages Scale [FAST]), and construct validity with significant differences between subjects with and without CI (t values ranging from 5.13-9.30). The AAI is a reliable and valid instrument that can be used to provide assessment data.

A brief neuropsychological battery for the differential diagnosis of probable alzheimer's disease

Abstract The purpose of this study was to develop a brief battery of tests to distinguish patients with Alzheimer's disease (AD) from normal controls and from patients with other dementias (OD). The sample included 35 AD patients and 35 OD patients (matched on mental status) and a normal control group (n = 108). All participants underwent a neuropsychological assessment and were rated on the London Psychogeriatric Rating Scale (LPRS). Logistic regression analyses (with backward stepping) accurately classified 94% of the normal controls and demented patients with a delayed recall test. The same test and the Disengagement Scale of the LPRS accurately classified 74% of the AD and OD patients. These findings were replicated with a second random assortment of AD and OD subjects matched again on mental status. These results indicate that if the purpose of the assessment is to distinguish AD from other dementias, these two tests may be most useful.

On the Clinical Value of the London Psychogeriatric Rating Scale

The London Psychogeriatric Rating Scale (LPRS) was administered to 76 probable Alzheimer's patients, 59 patients with dementia unrelated to Alzheimer's, 102 neurologically normal subjects, and 27 patients with symptoms of both Alzheimer's and dementia of other etiologies. By examining the relationships among the four subscales of the LPRS and conducting factor analyses, it was demonstrated that the four subscales were not measuring different phenomena. The internal consistency of the full 36-item scale was high (Cronbach's Alpha = 0.96) indicating the total LPRS score provided a reliable global index of behavioral function. The total LPRS scores correlated with the independently administered Goldfarb Mental Status Examination scores (r = -0.79). The LPRS differentiated between the normals and the combined demented groups and between inpatients and outpatients. The LPRS continues to have clinical value for functional assessments in a non-intrusive manner. The LPRS may be particularly useful in situations where direct assessment of mental status is not practical.

An Exploratory Use of the Symptoms Checklist‐90 in a Mixed Geriatric Study Group

There are currently no self-rating scales of general psychopathology in the older population. Such scales can be used to screen patients who may then be referred on for psychiatric assessment. The validity of the Symptoms Checklist-90 (SCL-90), a self-rating scale of general psychopathology widely used in the nongeriatric adult population, was explored in 44 older subjects. It was compared with the Sandoz Clinical Assessment Geriatric (SCAG) scale and a measure of functional disability, the London Psychogeriatric Rating Scale (LPRS). Caregivers to all subjects also rated the degree of difficulty experienced with their care on a four-point scale. Thirty of the subjects attended a geriatric day hospital, and the remaining 14 were waiting to go into long-term care facilities. Symptoms Checklist-90 was not significantly different between the two groups of subjects (day hospital and preinstitutional) after Bonferroni corrections, though SCAG scale and LPRS were (P less than .01 for both). Although SCL-90 was correlated significantly with the SCAG scale (r = .46), it was not significantly correlated with the LPRS. It showed good internal consistency but poor face validity and an inability to differentiate between levels of difficulty for the caregiver. It is concluded that the use of SCL-90 in older people may be limited because of the lack of sensitivity to functional disability and care difficulty. This nevertheless needs to be further explored, perhaps with some modification of the scale for older people.

Assessment by relatives of elderly patients with psychiatric illness.

Participation of relatives to provide clinical information on psychiatric patients is frequently under-utilized resulting in valuable data being bypassed. In an attempt to formalise the gathering of data from relatives we used the Geriatric Evaluation by Relatives Rating Instrument (GERRI), a 49-statement questionnaire in which the relative rates the patient's behaviour in terms of frequency of occurrence, The information obtained from relatives was then compared with that obtained from other forms of patient-assessment—the London Psychogeriatric Rating Scale completed by nursing staff, the Minimental State Screening Test and the Visual Analogue Scale for Depression completed by the patient, and the Activities of Daily Living Instrument completed by the occupational therapist. These instruments were chosen as being valid and reliable procedures with which to compare the GERRI. Subjects were 100 patients aged 65 yr. and over who were admitted consecutively to a psychogeriatric unit in a large psychiatric hospital. Significant correlations between relatives' assessment of cognitive and social function and those completed by the patients and other staff were noted. The relatives' assessment of the patients' mood, however, did not correlate with the patients' self-assessment of mood, suggesting that depression in the elderly may be “masked.”

Prediction of Discharge from a Psychogeriatric Unit: (Development and Evaluation of the LPRS Prognosis Index)

Data based on the 36-item London Psychogeriatric Rating Scale was statistically analysed in order to select a small number of questions which would discriminate well between those psychogeriatric inpatients who were likely to be discharged in the following six months and those who were not. A very brief Prognosis Index was developed utilizing the five best discriminating items of the LPRS. The content of these indicated that patients who could communicate coherently, made friends and did not threaten others were those most likely to leave hospital. The predictive accuracy of the index was assessed for the inpatient populations of a 136-bed psychogeriatric unit at three different points in time. The index was found to correctly predict whether or not patients would be discharged within six months in 78–85% of all cases. Correct prediction was generally seen to increase with time. Predictive accuracy reached as high as 96% (25/26) in the sample of acute ward patients examined after eighteen months. Since discharge was seen to be dependent on the availability of appropriate placements, the predictive accuracy of the Prognosis Index might be seen as surprisingly high. The simplicity and predictive accuracy of the items utilized and the fact that administration and scoring of the index can be done in less than five minutes without cooperation on the part of the patient suggest that the Prognosis Index is a useful measure. The results also emphasize the importance of personal relationships in determining discharge from hospital.

Development and Application of the Extended Scale for Dementia

As part of an interdisciplinary study of organic dementia, a psychologic test for assessing the degree of dementia--the Extended Scale for Dementia--was developed through the expansion and rescoring of the original Mattis Dementia Scale. Statistical analyses of the 23 test items resulted in a scoring scheme which includes the "weighting" of items for scoring purposes. The test was successfully administered to 90 subjects from 6 hospitals in the London (Ontario) region. With use of the Extended Scale, it was possible to discriminate between dementia and non-dementia groups of psychogeriatric inpatients and to correlate the findings closely with those of another measure of the degree of dementia, viz, the London Psychogeriatric Rating Scale (Ment.). Dementia patients who were retested after 6-month and 12-month intervals showed a significant decline in scores. No significant scoring differences were noted between males and females or between Alzheimer dementia and multi-infarct dementia.

Clinical value of the London Psychogeriatric Rating Scale.

The London Psychogeriatric Rating Scale (LPRS) was developed in answer to the demand for a reliable psychometric rating scale suited to a psychogeriatric population. All inpatients on a Psychogeriatric Unit (approximately 140 at any specific time) were rated with the LPRS every third month for an 18-month period. The 4 components of the total score include a measure of mental status originally derived by factor analysis. Predictive validity has been established in terms of various clinically relevant areas including the following: a) ward placement; b) outcome (continued hospitalization, discharge, or death); c) diagnosis (by scoring levels and progress patterns across time); and d) ability of the patient to function in, or benefit from, a particular treatment program. The scale has been used successfully to assess a given patient's progress quantitatively and globally over a long period.