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    Heart failure is independently associated with white matter lesions: insights from the population-based LIFE-Adult Study
    (John Wiley and Sons Ltd on behalf of European Society of Cardiology, 2021-02) Stegmann T; Chu ML; Witte VA; Villringer A; Kumral D; Riedel-Heller SG; Roehr S; Hagendorff A; Laufs U; Loeffler M; Wachter R; Zeynalova S
    Aims White matter lesions (WML) are common structural alterations in the white matter of the brain and their prevalence increases with age. They are associated with cerebral ischaemia and cognitive dysfunction. Patients with heart failure (HF) are at risk for cognitive decline. We hypothesized that the presence and duration of HF are associated with WML. Methods and results The LIFE-Adult Study is a population-based study of 10 000 residents of Leipzig, Germany. WML were quantitated in 2490 participants who additionally underwent cerebral MRI using the Fazekas score. Mean age was 64 years, and 46% were female; 2156 (86.6%) subjects had Fazekas score of 0–1, and 334 (13.4%) had Fazekas score of 2–3. Thirty participants had a medical history of HF, 1019 had hypertension, and 51 had a history of stroke. Median left ventricular ejection fraction of the participants with HF was 57% (interquartile ranges 54–62). Age, troponin T, NT-proBNP, body mass index, history of acute myocardial infarction, stroke, HF, and diabetes were positively associated with WML in univariate analysis. On multivariate analysis, age, hypertension, stroke, and HF were independently associated with WML. The odd's ratio for the association of WML (Fazekas 2–3) with HF was 2.8 (95% CI 1.2–6.5; P = 0.019). WML increased with longer duration of HF (P = 0.036 for trend). Conclusions In addition to age, hypertension, and stroke, the prevalence and duration of HF are independently associated with WML. This observation sets the stage to investigate the prognostic value of WML in HF and the impact of HF therapies on WML.
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    Neuropsychological assessment of cognitive functioning in individuals with expressive disabilities in addition to traumatic brain injuries : a dissertation presented in partial fulfilment of the requirements of the degree of Doctor of Philosophy in Psychology at Massey University
    (Massey University, 2000) Babbage, Duncan Ross
    This research programme focussed on individuals who have severe physical and sensory disabilities that interfere with standard neuropsychological assessment. Current assessment guidelines when working with people who have such disabilities were examined, which revealed that while various suggestions have been made, much work is required to empirically evaluate the most appropriate procedures for conducting such assessments. The current research was an attempt to further examine these issues. The first study, a retrospective review of a cohort of individuals referred for neuropsychological assessment after traumatic brain injury, was conducted to determine the focus population for the research. Based on this review, the research was limited to individuals who (in addition to traumatic brain injuries) had severe expressive disabilities. That meant they were unable to speak, write, draw, or manipulate test materials-the common modalities for making responses in neuropsychological assessment of cognitive functioning. This review also examined the types of adaptations to standard measures that were required in order to assess such individuals. The research questions related to whether a comprehensive assessment across the domains of cognitive functioning could be undertaken with people in this group. Therefore, comprehensive cognitive assessment had to be defined. The next study therefore examined the issue of what constitutes a comprehensive neuropsychological assessment of cognitive functioning, by evaluating the domains into which researchers divided cognition in their journal articles. All articles published in four neuropsychology journals over a 12-month period were reviewed. Based on this information, a formulation of the domains of cognitive functioning was developed. In the third study was a survey of neuropsychological practitioners, in which a case vignette of an individual which severe expressive disabilities was presented. Respondents were asked to discuss the assessment strategies they would use in such a case. In addition, the survey examined whether clinicians divided the assessment of cognitive functioning into the same domains identified in the earlier journal review. The case vignette discussions provided suggestions regarding assessment strategies for people with expressive disabilities. The survey provided support for the earlier formulation of the domains of cognitive functioning developed from the research review. This formulation was used, therefore, in selecting the domains to be assessed in the final clinical phase of the research. Based on these studies, a group of measures was selected and adapted that would be suitable for the assessment of cognitive functioning in individuals with expressive disabilities. These measures covered a broad range of cognitive domains allowing for as comprehensive an assessment as possible, while not requiring an examinee to speak, write, draw, or manipulate test materials. Rather, an examinee was required only to select from multiple-choice answers by pointing, or in some cases to spell out answers on an alphabet board. These measures were administered to three groups of participants: individuals with expressive disabilities in addition to traumatic brain injuries, individuals with traumatic brain injury alone, and a healthy normative group. To examine the psychometric properties of these measures, a group of comparison measures, administered in their standard formats, was also included in the protocol. These tests were selected to measure the same constructs as the adapted measures, and were used to provide a benchmark against which performance on the new measures could be evaluated. As these comparison measures were administered in standard format, they could only be administered to the non-disabled participants. To evaluate further the adapted measures, some participants were seen for follow-up assessments two to four weeks after their initial assessments, and the adapted measures were re-administered. Internal consistency and test-retest reliability of the measures were investigated, and concurrent, construct and discriminant validity were also examined. The measures in this protocol were generally found to be reliable and valid neuropsychological assessment instruments and the results provided support for the types of adaptations trialed in this research. The performances of individuals with expressive disabilities were examined closely, which indicated that people with these disabilities were able to manage the task requirements of the adapted tests and that the tests were generally of appropriate difficulty. Qualitative aspects of conducting assessments with people with expressive disabilities were also discussed. Based on the performance of individuals in the normative group, preliminary norms were presented as both standard scores and percentile scores. These data were presented so that clinicians using the adapted measures described in this research could compare examinees to a reference group. However, the adaptations could not be considered fully standardised measures and the limitations of both the tests and the norms were discussed. The final section reviewed the aims that were outlined at the beginning of this research programme. Each of the 20 objectives of the research were met. The research provided clinically relevant information about working with people with severe expressive disabilities, was conducted in an ethical manner, which considered carefully the specific needs of participants, particularly those with severe disabilities, and did so in a manner that maintained scientific rigour and objectivity.
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    Brief cognitive screening instruments and the clinical utility of three screens in a New Zealand clinical geriatric setting : a thesis presented in partial fulfilment of the requirements for the degree of Doctorate in Clinical Psychology at Massey University, Wellington, New Zealand
    (Massey University, 2012) Strauss, Heide-Marie
    Cognitive impairment (CI) is a serious concern for an aging global population, and its impact is not only felt within the family unit but also society at large. The current thesis involved two studies – an online survey about the use and role of screening instruments in New Zealand, and an evaluation of the clinical utility of three screens used in a clinical geriatric setting. The survey found that the Mini Mental Status Examination (MMSE) was the most frequently used screen, followed by the Clock Drawing Test (CDT), Addenbrooke‘s Cognitive Examination-Revised (ACE-R), Verbal Fluency (FAS), Three Word Recall (3WR), and Trail-making Test (TMT). The opinions of the survey respondents confirmed international publications suggesting that the MMSE does not fulfil the requirements of current assessment and/or screening practices. The survey further suggested that the ACE-R showed promise as an appropriate alternative to the MMSE due to its continuity from the MMSE, and because it appears to meet clinician requirements for brief screening instruments. The second study evaluated the clinical utility of the ACE-R, MMSE and the Modified Mini Mental State (3MS) within a larger assessment approach. It found that all three screens successfully differentiated between milder forms of CI and dementia; however, predictive ability for milder CI could not be determined. The ACE-R outperformed both the 3MS and MMSE in terms of predictive ability for dementia, with the 3MS showing marginally higher predictive ability than the MMSE. The study suggested that the 3MS‘s incremental validity did not justify its inclusion in a routine assessment process. Optimal sensitivity and specificity ratios – providing the best balance between sensitivity and specificity – were obtained with different cut-off scores than those recommended by the screens‘ original publications. This may have been due to the screens‘ authors seeking ratios that favoured sensitivity at the cost of specificity. However, in the data set from a clinical geriatric setting, used for this current study, the focus was on limiting both false-negatives and false-positives. While the MMSE showed adequate sensitivity and specificity, its known cultural and socio-economic bias makes it inappropriate for widespread use. The predictive ability (and incremental validity) of the ACE-R, coupled with the fact that it is cost-effective, relatively brief and covers all the recommended cognitive domains suggest that it is a suitable substitute for the MMSE in clinical geriatric service settings. Further research is however required to assess any potential biases inherent in the ACE-R. It is recommended that all initial assessments with CI patients include a mood screen due to their high comorbidity and the increased scope of treatment options available when a mood component underlies cognitive complaints.