UPSA Scores Research Articles

Original research: longitudinal evaluation of cognitively demanding daily function using performance-based functional assessment highlights heterogeneous trajectories in cognitive and functional abilities in people with Parkinson's disease.

Longitudinal assessment of functional abilities in Parkinson's disease (PD) is needed to determine the efficacy of cognitive interventions in providing meaningful improvements in daily life. Additionally, subtle changes in instrumental activities of daily living may precede a clinical diagnosis of dementia and could aid earlier detection of and intervention for cognitive decline. The primary goal was to validate the longitudinal application of the University of California San Diego Performance-Based Skills Assessment (UPSA). An exploratory secondary goal was to determine whether UPSA may identify individuals at higher risk of cognitive decline in PD. Seventy participants with PD completed the UPSA with at least one follow-up visit. Linear mixed effects modeling was used to identify associations between baseline UPSA score and cognitive composite score (CCS) over time. Descriptive analysis of four heterogeneous cognitive and functional trajectory groups and individual case examples was performed. Baseline UPSA score predicted CCS at each timepoint for functionally impaired and unimpaired groups (p < 0.01) but did not predict the rate change in CCS over time (p = 0.83). Participants displayed heterogenous trajectories in both UPSA and CCS during the follow-up period. Most participants maintained both cognitive and functional performance (n = 54), though some displayed cognitive and functional decline (n = 4), cognitive decline with functional maintenance (n = 4), and functional decline with cognitive maintenance (n = 8). The UPSA is a valid measure of cognitive functional abilities over time in PD. Given the heterogeneity of functional and cognitive trajectories, this performance-based assessment did not predict cognitive decline with this relatively short follow-up. Further work is needed to understand longitudinal functional assessments in PD-associated cognitive impairment.

M175. BRAIN STRUCTURAL CORRELATES OF FUNCTIONAL CAPACITY IN FIRST-EPISODE PSYCHOSIS

BackgroundImpaired functional capacity is a core feature of schizophrenia and present even in first episode psychosis (FEP) patients. Impairments in daily functioning tend to persist despite antipsychotic therapy but their neural basis is not clear. Previous studies suggest that volume loss in frontal cortex might be an important contributor but findings are inconsistent. We aimed to comprehensively investigate the brain structural correlates of functional capacity in first episode psychosis using MRI and a reliable objective measure of functioning (University of California, San Diego Performance-Based Skills Assessment (UPSA))MethodsIn FEP and a well-matched control group, we measured cortical thickness, gray matter volume, and white matter tract integrity (fractional anisotropy, FA) in specific regions implicated by previous work. Between-group differences in these parameters were assessed first. We then examined correlations between MRI measures and UPSA scores in the FEP group while controlling for negative symptomology and medication use.ResultsThe FEP group had thinner cortex in various frontal regions, fusiform, and insula, and reduced FA in inferior longitudinal fasciculus. In FEP, poorer functioning (UPSA) correlated with reduced superior frontal volume and lower FA in inferior longitudinal fasciculus.DiscussionIn accordance with previous findings, FEP exhibited widespread brain structural differences compared to controls. Importantly, frontal brain volumes and integrity of the inferior longitudinal fasciculus were identified as the structural correlates of functional capacity in FEP, after controlling for other relevant factors. These findings enhance mechanistic understanding of functional capacity deficits in schizophrenia by specifying the underlying neural correlates. In future, this could help inform intervention strategies.

Developing clinical cut-off scores for the university of California San Diego performance-based skills assessment in patients with schizophrenia.

This study aimed to obtain University of California San Diego Performance-based Skill Assessment (UPSA) cut-off scores for the purpose of severity classification and to expand the clinical utility of the UPSA for the evaluation of cognitive function in patients with schizophrenia. In total, 191 patients with schizophrenia were recruited. The UPSA, Positive and Negative Symptom Scale (PANSS), Clinical Global Impression-Schizophrenia Scale (CGI-SCH), and Global Assessment Functioning Scale (GAF) were used for the evaluation. The cognitive symptoms item of the CGI-SCH was used as a reference and the subjects were divided into three groups: mild, moderate, and severe. The sensitivity and specificity of the UPSA were analyzed by receiver operating characteristic curves. There were significant differences in the UPSA, CGI-SCH, PANSS, and GAF scores among the groups. In the mild and moderate groups, a UPSA score of 59 was identified as the optimal cut-off score, and a score of 41 was identified as the optimal cut-off score in the moderate and severe groups. Severity can be classified using the UPSA score as follows: ≥ 60 for mild, 41-59 for moderate, and ≤ 40 for severe. The UPSA could be used to assess the degree of daily living dysfunction in patients with schizophrenia.

The effect of anticholinergic burden on cognitive and daily living functions in patients with schizophrenia.

This study aimed to explore the association between medication-associated anticholinergic burden and cognitive and daily living functions in patients with schizophrenia. Sixty patients with schizophrenia were recruited. We used the Anticholinergic Drug Scale (ADS) for evaluating medication-associated anticholinergic burden. The MATRICS Consensus Cognitive Battery (MCCB) and the University of California San Diego Performance-based Skills Assessment (UPSA) were used for evaluating cognitive and daily living functions. To assess clinical symptoms, psychiatrists conducted interviews using the Positive and Negative Syndrome Scale and the Calgary Depression Scale for Schizophrenia. Subjects were divided into low (n = 31) and high (n = 29) anticholinergic burden based on ADS scores of 3 or more. The "high ADS" group had poorer cognitive (composite MCCB score, p < 0.001) and daily living functions (total UPSA score, p = 0.001) than the "low ADS" group. Medication-associated anticholinergic burden was negatively correlated with cognitive functions (composite MCCB score, r = -0.512, p < 0.001) and daily living functions (total UPSA score, r = -0.355, p = 0.005). A regression analysis showed that anticholinergic burden significantly explained the decline in cognitive functions (composite MCCB score, R2 = 0.262, p < 0.001) and daily living functions (total UPSA score, R2 = 0.126, p = 0.005). Explanatory power was reduced after a covariate adjustment, but the effects of the composite MCCB score (p = 0.013) and of the transportation domain score of the UPSA (p = 0.048) remained significant. Our analysis shows that anticholinergic burden reduces cognitive and daily living functions in patients with schizophrenia. A drug strategy with minimal anticholinergic burden may be helpful to patients if it does not adversely affect clinical symptoms.

Cost per successfully treated patient for vortioxetine versus duloxetine in adults with major depressive disorder: an analysis of the complete symptoms of depression and functional outcome

Objective: To determine the cost-effectiveness of vortioxetine vs duloxetine in adults with moderate-to-severe major depressive disorder (MDD) in Norway using a definition of a successfully treated patient (STP) that incorporates improvement in both mood symptoms and functional capacity.Methods: Using the population of patients who completed the 8-week CONNECT study, the cost-effectiveness of vortioxetine (n = 168) (10–20 mg/day) vs duloxetine (n = 176) (60 mg/day) was investigated for the treatment of adults in Norway with moderate-to-severe MDD and self-reported cognitive dysfunction over an 8-week treatment period. Cost-effectiveness was assessed in terms of cost per STP, defined as improvement in mood symptoms (≥50% decrease from baseline in Montgomery-Åsberg Depression Rating Scale total score) and change in UCSD [University of California San Diego] performance-based skills assessment [UPSA] score of ≥7. The base case analysis utilized pharmacy retail price (apotek utsalgspris (AUP)) for branded vortioxetine (Brintellix) and branded duloxetine (Cymbalta).Results: After 8 weeks of antidepressant therapy, there were more STPs with vortioxetine than with duloxetine (27.4% vs 22.5%, respectively). The mean number needed to treat for each STP was 3.6 for vortioxetine and 4.4 for duloxetine, resulting in a lower mean cost per STP for vortioxetine (NOK [Norwegian Kroner] 3264) than for duloxetine (NOK 3310) and an incremental cost per STP of NOK 3051. The use of a more challenging change in the UPSA score from baseline (≥9) resulted in a mean cost per STP of NOK 3822 for vortioxetine compared with NOK 3983 for duloxetine and an incremental cost per STP of NOK 3181.Conclusions: Vortioxetine may be a cost-effective alternative to duloxetine, owing to its superior ability to improve functional capacity. The dual-response STP concept introduced here represents a more comprehensive analysis of the cost-effectiveness of antidepressants.

Who Will Benefit from Computerized Cognitive Remediation Therapy? Evidence from a Multisite Randomized Controlled Study in Schizophrenia

Background: Computerized Cognitive Remediation Therapy (CCRT) is generally effective for the cognitive deficits of schizophrenia. However, there is much uncertainty about what factors mediate or moderate effectiveness and are therefore important to personalize treatment and boost its effects. Methods: In a multisite, single-blind, randomized clinical trial, 311 Chinese inpatients with a diagnosis of schizophrenia were recruited and randomized to receive CCRT (n = 196) or active control (n = 115) for 12 weeks with 4-5 sessions per week. All participants were assessed at baseline, post-treatment and 3-month follow-up. The main outcome was cognition (MATRICS Consensus Cognitive Battery total score, MCCB), and secondary outcomes included clinical symptoms (PANSS) and functional outcomes (UPSA, NOSIE and self-esteem). Findings: There was a significant benefit in the primary outcome (MCCB total score) in favour of CCRT (F (1, 258) = 5.62; p = 0.02; effect size was 0.27, 95% CI, 0.04-0.49). Wisconsin Card Sort Test change scores mediated a positive effect on functional capacity (UPSA score) solely in the context of CCRT. Both younger and older participants showed cognitive improvements but on different tests. Younger participants showed improvement in Symbol Coding Test, while older participants showed in Spatial Span Test. On the MSCEIT only the older age group showed benefits at post-treatment. In addition, the effect of cognitive remediation on MCCB total score was negatively correlated with the baseline level of MCCB total score. Participants with an MCCB baseline total score around 31 seem to derive the most cognitive benefits. Interpretation: CCRT can improve the general cognitive function of schizophrenia. The changes in cognitive outcomes also contributed to improvements in functional outcomes either directly or solely in the context of CCRT. Age and the basic cognitive level of the participants seem to affect the cognitive benefits from CCRT. Clinical Trial Number: This trial is registered with Chinese Clinical Trials.gov, identifier ChiCTR-TRC-08000249. Funding Statement: This study was partially supported by National Natural Science Foundation of China (No.31671145); Beijing Municipal Science & Technology Commission grant (Z141107002514016; D0906001000091; D101107047810005); Beijing Municipal Administration of Hospitals Clinical Medicine Development of special funding (XMLX201609; zy201409); Beijing Natural Science Foundation grant (No.7162087). Professor Wykes acknowledges the support of the NIHR Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and her NIHR Senior Investigator award. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: All participants provided written informed consent, and the protocol was approved by the Beijing Huilongguan Hospital Ethics Committee (2006-3).

Vortioxetine improves symptomatic and functional outcomes in major depressive disorder: A novel dual outcome measure in depressive disorders

BackgroundWith symptomatic remission and functional recovery as the overarching therapeutic objectives of antidepressant therapy, composite endpoint measures that conjointly consider both aspects of treatment are needed. This analysis evaluated the combined effect of vortioxetine on depressive symptoms and functional capacity in adults with MDD. MethodsNCT01564862, a multinational, double-blind, placebo-controlled, duloxetine-referenced study, conducted between April 2012 and February 2014, in 602 adult outpatients (18–65 years) with moderate-to-severe MDD (Montgomery-Åsberg Depression Rating Scale (MADRS) ≥ 26), a major depressive episode of ≥ 3 months’ duration, and self-reported cognitive symptoms were randomized to once-daily vortioxetine (10 or 20mg), duloxetine (60mg), or placebo for 8 weeks. Assessments included the University of California San Diego Performance-based Skills Assessment (UPSA) and the MADRS. Two versions of UPSA were utilized; UPSA ‒Validation of Intermediate Measures and UPSA Brief form. An aligned UPSA-B (communication and finance items) was examined for sensitivity analysis. Efficacy was analyzed versus placebo according to the dual response (change from baseline in UPSA ≥ 7 and ≥ 9 and reduction in MADRS total score from baseline ≥ 50%). ResultsSignificantly more vortioxetine-treated patients were classified as dual responders for change in MADRS total score and UPSA score of ≥ 7 (clinically important difference [CID]) (27.4% vs 14.5%; P = 0.004), and change above CID (≥ 9) (23.4% vs 13.9%; P = 0.025). Duloxetine did not differ significantly from placebo for these dual response criteria. Sensitivity analysis using the aligned UPSA-B confirmed these results for vortioxetine. LimitationsAn exploratory analysis of a new dual outcome measure in patients with MDD. ConclusionsVortioxetine, but not duloxetine, demonstrated a robust combined effect on depressive symptoms and functional capacity in patients with MDD. Trial registrationClinicalTrials.gov identifier: NCT01564862; European Clinical Trials Database [EudraCT] Number 2011–005298-22.

Usefulness of the University of California San Diego Performance-Based Skills Assessment for the evaluation of cognitive function and activities of daily living function in patients with cognitive impairment

ABSTRACTObjectives: To assess the usefulness of the University of California San Diego Performance-Based Skills Assessment (UPSA) as a new diagnostic method and tool for the assessment of cognitive function and activities of daily living function in patients with cognitive impairment.Method: In total, 35 patients with cognitive impairment and 35 healthy controls were recruited for this study. The Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), and Global Deterioration Scale (GDS) were used for the evaluation of cognitive function, while the Barthel Activities of Daily Living Index (BADL), Instrumental Activities of Daily Living Index (IADL), and UPSA were used for the evaluation of activities of daily living function.Results: UPSA scores were significantly lower in patients with cognitive impairment than in controls. The UPSA total score was significantly correlated with MMSE, CDR, GDS, and IADL scores. With regard to the detection of cognitive impairment, UPSA exhibited a greater determination power (R2 = 0.593) compared with BADL (R2 = 0.149) and IADL (R2 = 0.423) and higher sensitivity and specificity compared with IADL.Conclusion: Our results suggest that UPSA is a useful tool for the evaluation of cognitive function and activities of daily living function in patients with cognitive impairment.

UPSA-M: Feasibility and initial validity of a mobile application of the UCSD Performance-Based Skills Assessment

ObjectiveThis study aimed to develop and validate a tablet mobile application version of the UCSD Performance-Based Skills Assessment (UPSA-M), a widely used test for assessing functional capacity in schizophrenia and other neurocognitively impaired patient populations. MethodsThe UPSA-M was developed for an iPad platform. Twenty-one middle-aged and older adults with schizophrenia and 13 healthy comparison (HC) participants completed a brief iPad tutorial, followed by the UPSA-M (full version, which includes all components of Brief UPSA-M) and a computer usage questionnaire. During a separate visit, patients with schizophrenia and HC participants completed the Brief UPSA (UPSA-B), and patients with schizophrenia completed a symptom inventory and brief neuropsychological screening battery. ResultsThe UPSA-M was feasible for use among middle aged and older adults with schizophrenia with no prior history of tablet usage. The UPSA-M was able to differentiate between schizophrenia and HC participants 80% of the time, and this differential ability increased to 87% with the UPSA-M Brief. Traditional UPSA scores, UPSA-B scores, and neuropsychological performance were related to UPSA-M scores, whereas symptoms of psychopathology, experience with tablet technology, or difficulties operating the device were not significantly associated with UPSA-M. ConclusionsThe UPSA-M performed just as well as the standard-of-practice version. These preliminary results indicate that the UPSA-M Brief has greater sensitivity than the full version of the UPSA-M, and carries the advantage of a shorter administration time. Overall, the UPSA-M appears to be a promising mobile tool to assess functional capacity.

Investigation of the Montreal Cognitive Assessment (MoCA) as a cognitive screener in severe mental illness

This study examined the Montreal Cognitive Assessment (MoCA) as a neurocognitive screener and its relationship with functional outcomes in a sample of outpatients diagnosed with severe mental illness (SMI). The MoCA, Brief Assessment of Cognition in Schizophrenia (BACS), UCSD Performance-Based Skills Assessment Test-2 (UPSA-2), and Global Assessment of Functioning (GAF) were administered to 28 SMI patients and 18 non-psychiatric controls. Patients obtained significantly lower scores on the MoCA, BACS, UPSA-2, and GAF compared to non-patients. The cutoff score <26 of the MoCA resulted in favorable sensitivity (89%) but lower specificity (61%) in classification of SMI patients. The MoCA was significantly correlated with UPSA scores but not GAF scores, whereas the BACS was not significantly correlated with UPSA or GAF scores. When entered into hierarchical regression analyses, the MoCA accounted for significant variance in UPSA scores above variance accounted for by the BACS. Both the MoCA and the BACS contributed unique variance in GAF scores. Overall, the MoCA demonstrated high sensitivity as a cognitive screener in SMI. Moreover, MoCA scores were related to performance-based measures of functional capacity.

Depression, deficits in functional capacity, and impaired glycemic control in urban African Americans with type 2 diabetes

BackgroundEffective depression treatment does not reliably reduce glycosylated hemoglobin (HbA1c) in depressed patients with type 2 diabetes, possibly in part due to deficits in functional capacity, i.e. performance of certain everyday living skills, essential for effective diabetes self-management. We sought to determine: a) the magnitude of deficits in functional capacity among urban, African American (AA) patients with type 2 diabetes, and b) whether these deficits were associated with poorer glycemic control. MethodsAt their initial visit to an inner-city diabetes clinic, 172 AA patients with type 2 diabetes were assessed with a variety of instruments, including the Mini International Neuropsychiatric Interview (MINI) and the UCSD Performance Skills Assessment-Brief (UPSA-B). They then entered a comprehensive diabetes management intervention, whose success was indexed by HbA1c levels at up to four reassessments over a one-year period. A mixed-effects model repeated-measures method was used to predict HbA1c. ResultsThe prevalence of depression was 19%; the mean UPSA-B score was 81 ± 17. After multivariate adjustment, increased HbA1c levels over time were predicted by the presence of major depression (B = .911, p = .002) and decreasing (worse) scores on the UPSA-B (B = −.016, p = .027), respectively. Further adjustment for increasing the dosage of oral or insulin during the treatment eliminated the association between the UPSA score and HbA1c level (B = −.010, p = .115). ConclusionsDepression, as well as deficits in functional capacity, predicted reduced effectiveness of a diabetes self-management intervention. Future studies will determine whether interventions targeted at both improve glycemic control.

Neurocognition, functional capacity, and functional outcomes: The cost of inexperience

BackgroundNeurocognitive impairments are the strongest predictor of functional deficits in schizophrenia, but adaptive (i.e., functional) capacity, typically measured with performance-based assessments, yields an objective index of current abilities, whereas real-world functional performance relies on observations of community activity. However, limited experiences in the community may limit the acquisition, retention, or expression of these skills. MethodsWe examined the frequency of engagement in behaviors that are assessed in the current “gold standard” in person functional capacity assessment. The UCSD Performance-Based Skills Assessment (i.e., UPSA) examines skills associated with recreational engagement, handling money, scheduling appointments, and navigating public transportation. We used neurocognition, experience, and UPSA performance as predictors of the relationships among cognition and real-world functioning variables. ResultsNeurocognition was a significant correlate of UPSA scores regardless of whether it was forced into the model before or after prior experience, whereas experience was only a significant predictor of UPSA scores when entered before neurocognition. Further, functional capacity, neurocognition, and experience were significant predictors of real-world outcomes and experience remained a significant predictor regardless of the order it was entered into the model. ConclusionsThe amount of current experience with functional tasks is not a rate-limiter of the relationships between neurocognition and functional capacity but does account for some previously unexplained variance in the functional capacity–everyday functioning relationship. These findings underscore the importance of neurocognitive deficits as they relate to functional capacity in schizophrenia, and suggest an incremental functional cost of limited experience with independent living.

Performance-Based Measures of Everyday Function in Mild Cognitive Impairment

The view that everyday function is preserved in mild cognitive impairment may be problematic. The objectives of this study were to determine the magnitude of impairment in everyday function in patients with mild cognitive impairment and Alzheimer's disease using a novel sensitive performance-based measure (the UCSD Performance-Based Skills Assessment; UPSA), contrast it with use of an informant-based measure (the Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory; ADCS-ADL), and model the relationship between cognitive measures and the performance-based measure. Fifty cognitively normal elders, 26 patients who met criteria for amnestic mild cognitive impairment, and 22 patients who suffered from mild to moderate Alzheimer's disease were assessed on the UPSA, the ADCS-ADL, and a battery of neurocognitive tests. Patients with mild cognitive impairment had significant impairments on the UPSA but not on the ADCS-ADL. The magnitude of the effect size between the cognitively healthy and the mild cognitive impairment group for the UPSA was large (d=0.86). A strong and significant relationship was observed between cognitive performances in speed (R(2)=0.37), episodic memory (R(2)=0.10), and semantic processing (R(2)=0.03) and UPSA score using multiple regression models. The psychometric properties of the UPSA were acceptable, as were its sensitivity and specificity in contrasts between cognitively normal elders and patients with mild cognitive impairment and between the latter group and patients with Alzheimer's disease. These findings indicate that performance-based measures of function may be a sensitive tool in studies of Alzheimer's disease and mild cognitive impairment and suggest the need for a reconceptualization of the relationship between cognition and function in mild cognitive impairment so that they can be usefully aligned.

Correlations of functional capacity and neuropsychological performance in older patients with schizophrenia: Evidence for specificity of relationships?

Background Neuropsychological (NP) performance is a consistent correlate of everyday functioning in schizophrenia, but it is unclear whether relationships between individual NP ability areas and domains of everyday functioning are general or specific. Assessments of real-world everyday functioning may be influenced by environmental and social factors (e.g., social security, disability status, opportunities and restrictions in living situations). This study examined the specificity of the relationships between different NP abilities and performance-based measures of social and living skills. Methods 181 ambulatory older (age> 50) patients with schizophrenia were examined with NP tests measuring episodic and working memory, executive functioning, verbal fluency, and processing speed. All subjects performed tasks examining social (Social Skills Performance Assessment: SSPA) and everyday living (UCSD Performance Based Skills Assessment: UPSA) skills. Results Using canonical analysis, the NP variables were used to predict the functional capacity measures. The analysis found that 37% of the variance in the functional capacity and NP measures was shared, X 2 (54) = 106.29, p < .001. Two canonical roots described the cognitive variables and the roots were differentially associated with everyday living and social skills. The root loading on processing speed, episodic memory, and executive functions were associated with UPSA scores, while the root loading on working and episodic memory and verbal fluency were associated most strongly with social competence. Implications Social and everyday living skills deficits in patients with schizophrenia may reflect generally independent domains of functional outcome, linked through cognitive performance. The data suggest that somewhat different cognitive processes are associated with these two domains of functional capacity, although there appears to be some overlap, which may be due to the nature of the NP tests employed.