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Journal ArticleDOI

Development and validation of a geriatric depression screening scale: A preliminary report

01 Jan 1982-Journal of Psychiatric Research (J Psychiatr Res)-Vol. 17, Iss: 1, pp 37-49
TL;DR: A new Geriatric Depression Scale (GDS) designed specifically for rating depression in the elderly was tested for reliability and validity and compared with the Hamilton Rating Scale for Depression (HRS-D) and the Zung Self-Rating Depression Scale(SDS) as discussed by the authors.
About: This article is published in Journal of Psychiatric Research.The article was published on 1982-01-01 and is currently open access. It has received 13014 citations till now. The article focuses on the topics: Geriatric Depression Scale & Hamilton Rating Scale for Depression.

Summary (4 min read)

INTRODUCTION

  • Frontotemporal dementia (FTD) is a group of clinical syndromes associated with the degeneration of frontal and anterior temporal cortical regions (Neary et al., 1998).
  • The diagnosis of PNFA is usually made when other cognitive processes are found to be relatively preserved, with language being the only impaired area, at least during the first two years of the disease (Mesulam, 2003).
  • The alterations were thought to be localized in the left hemisphere, mainly in the pars opercularis of the inferior frontal gyrus (Brodmann area (BA) 44), upper temporal pole (BA 38), basal ganglia (lenticular nucleus), and middle frontal gyrus (BA 8/9) (Friederici & Kotz, 2003).
  • Such patients do not usually complain of memory disturbances other than in the verbal domain; they are not disorientated and their activities of daily living (ADLs) typically remain unaffected; significant personality changes may occur in advanced stages of the disease (Gorno-Tempini et al., 2004; Neary et al., 1998).

Intervention experience

  • It is known that patients with PNFA may benefit from language stimulation, such as that provided by the strategies used in non-progressive language disorders (Berndt, Mitchum & Haendiges, 1996; Greenwald et al., 1995; Kiran & Thompson, 2002; Raymer & Ellsworth, 2002).
  • Because caregivers have to understand, cope with and accept the symptoms (Raymer et al., 2001) this can become a critical problem.
  • This 12-month speech therapy program was administered to a patient with PNFA to determine whether this kind of program would improve the patient’s language processing, general cognition, neuropsychiatric symptoms (NPS), QOL and ADLs and would also benefit his family.

Participant

  • In 2006, JM complained of increasing word-finding difficulties, which evolved into non-fluent discourse.
  • In 2011, JM attended the National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez” (NINN) in Mexico City where exploration was initiated and the necessary studies were performed to determine his general medical condition.
  • In February 2011, magnetic resonance imaging showed reduced cortical and subcortical cerebral and cerebellar volume; the cortical atrophy was predominantly left posterior fronto-insular region.
  • JM started pharmacological treatment, consisting of citalopram and memantine (20 mg each per day).
  • This treatment was continued during the one-year course of the speech therapy that he received at the Dementia Clinic (NINN).

Design

  • At NINN, over a 12-month period (October 2011 to November 2012), JM received weekly speech therapy from a neuropsychologist (PAAC).
  • This therapy stimulated phonological, lexical, and syntactic processing and was used in conjunction with daily homework.
  • Examination of the therapy effects was documented by applying a single-subject pre-post test design.
  • The protocol adheres to the Declaration of Helsinki (2008) and the regulations of the General Clinical Research Health Law of Mexico (1983).

Assessment

  • A battery of tests was administered to JM, which assessed the patient’s language and general cognitive functioning, NPS, QOL, and ADLs.
  • The emotional state, QOL, and burden of the primary caregiver (JM’s daughter) were also assessed through the application of three scales.
  • The same instruments (see Materials section) were used at three stages: pre-intervention assessment (basal: October 2011); at six months of intervention (intermediate: April 2012); and after receiving twelve months of therapy (final: November 2012).
  • Implementation and assessment of the speech therapy were conducted by the first author of this paper (PAAC).

Materials

  • The neuropsychological assessment battery applied covered general cognitive functioning, with emphasis on the following measures: General cognitive functioning: Mini-Mental State Examination, MMSE (Folstein, Folstein & McHugh, 1975); Neuropsychological Integrated Exploration Program “Test Barcelona”.
  • Auditory Verbal Learning Test, “Test Barcelona” Alfa Version (Peña-Casanova, 2005), also known as Verbal learning.
  • Trail Making Test (Partington & Leiter, 1949); Stroop Color and Word Test (Golden, 1976), also known as Executive functioning.
  • Neuropsychiatric Inventory Questionnaire, NPI-Q (Cummings et al., 1994); Yesavage Geriatric Depression Scale (Yesavage et al., 1982; Baker & Espino, 1997) and Beck Anxiety Inventory (Beck et al., 1988; Robles et al., 2001), also known as Patient neuropsychiatric symptoms.
  • Emotional state of the patient’s primary caregiver: Self-reporting questionnaire (SRQ) (Harding, et al., 1980; Mari & Williams, 1985).

Intervention

  • Based on the pre-intervention testing (see Results section), a program was designed for working on JM’s language deficits, structuring an intervention that combined exercises to stimulate phonological, lexical and syntactic processing (oral and writing).
  • JM, his family, and the speech therapist (PAAC) selected four topics (food, home, body and animals) that all agreed were the most important to JM’s ADLs; for each of these topics, a list consisting of 20 stimuli that would exercise lexical, phonological and syntactic stimulation was developed.
  • To structure the sentences in each list, four verbs (want, eat, take and give) were selected, since according to JM and his family, these were the most frequently used.
  • Over a 12-month period, in addition to attending 50 individual sessions (60 min. each) with PAAC, which were held at the Laboratory of Dementia, JM also did daily homework, which consisted of repeating the exercises performed at the clinic.
  • In the second stage (months 7–12), JM continued with the same sequence of exercises, but the difficulty of the tasks was gradually increased.

Stimulation of articulatory release

  • In all the sessions, exercises focused on improving articulation were performed; strategies to release automated forms of discourse were used.
  • JM was asked to produce automated information (numbers, days of the week, months of the year, songs), reciting sequences in ascending and descending order, changing the rhythm and speed, and combining the visual and verbal stimuli.

Phonological stimulation

  • Strategies consisted in sound analysis of the elements that compose each word, allowing rehabilitation of the conscious relationship within the word and its rhythmicmelodic structure.
  • In every session, after the strengthening pulmonary ventilation exercises, JM carried out articulation fluency exercises for ten minutes.
  • The phonological exercises consisted of the following: pronunciation of each phoneme, either in isolation or within a word; repetition tasks; reading aloud; understanding of rhymes; verification of the number of syllables; phoneme identification at the beginning or end of a word; or phonological selection tasks.

Lexical stimulation

  • When lexical stimulation started, the sessions were divided as follows: strengthening pulmonary ventilation (5 min.), articulation fluency exercises (10 min.), phonological exercises (10 min.) and stimulation of lexical analysis (35 min.).
  • For the lexical analysis, picture-naming tasks were applied, in which JM, working with visual material, named (orally and in writing) and described each stimulus presented.

Syntactic stimulation

  • Following the same session structure as that of the lexical stimulation, after strengthening pulmonary ventilation (5 min.), articulation fluency exercises (5 min.) and phonological exercises (5 min.), each session of syntactic tasks lasted 45 minutes.
  • Examples of these exercises are the following: construction of sentences based on the combination of worked stimulus and change of gender, number and tense of the structural elements.
  • Visual and verbal support was always provided by the therapist.
  • These strategies aimed to improve the patient’s structural analysis of sentences and speech, thereby enabling recovery and the relearning of grammatical and syntactical elements altered by the progress of the disease.

Pre-intervention assessment

  • The basal assessment revealed that the following mental functions of the patient were preserved: orientation; selective attention for visual material; verbal and visual memory; learning; ideational praxis; and visuo-spatial gnosis.
  • Other mental functions, such as selective attention for verbal material and ideo-motor praxis, showed slight alterations, while sustained attention showed a moderate deficit.
  • In language processing, verbal naming, verbal and text comprehension, and semantic fluency were preserved.
  • JM’s scales showed good QOL, a slight deterioration in ADLs (due to language deficits), moderate depression, and low anxiety (Table 1).
  • From the questionnaire completed by the primary caregiver (Table 2), some characteristics of burden, but good QOL, were found (Table 2).

Post-intervention assessment

  • Comparison of the pre- and post-intervention neuropsychological assessments and scores, summarized in Figure 1 and Tables 1 and 2, suggests that JM’s general cognitive abilities before the onset of language therapy were in the average and high ranges.
  • Phonological fluency per minute improved from seven to ten elements.
  • No burden was reported, but there was a decrease in the final Zarit score.
  • In summary, while some aspects of cognitive functioning remained intact, especially in orientation, verbal naming, praxis and memory, there was a slight improvement in verbal fluency and rhythm, but a gradual decline in arithmetic problem solving.
  • Informally, members of JM’s family reported that he was participating more in social life and losing his fear of starting a conversation with relatives or strangers; they associated this behavior to better QOL for JM and family members.

DISCUSSION

  • Cognitive rehabilitation and speech therapy were initially developed to treat patients with non-progressive brain diseases; however, they can also be applied to people with progressive neurodegenerative diseases such as FTD and other dementias.
  • For neurodegenerative diseases, the effectiveness of the intervention would also have to be assessed differently, because the cognitive performance of the patient is not stable, and so the benefits are related to a delay in, or slowing of, deterioration.
  • The present study shows that a program of speech therapy, specifically adapted to the patient diagnosed with PNFA can improve articulation, repetition, fluency, and expressive language content, and also has a positive impact on other cognitive processes of the patient.
  • Therefore, an explanation of the success of the patient’s treatment may be that performing exercises that stimulate language can activate various cortical regions.
  • Thus, the combination of speech therapy strategies used in this study may have had the capacity to stimulate a wider range of impaired and/or preserved cognitive functions of the patient, thereby allowing maintenance and/or stabilization of the patient’s general cognitive functioning.

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Citations
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01 Jan 2009
TL;DR: Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients and Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients.
Abstract: OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

3,716 citations

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TL;DR: High-intensity resistance exercise training is a feasible and effective means of counteracting muscle weakness and physical frailty in very elderly people, in contrast to multi-nutrient supplementation without concomitant exercise, which does not reduce muscle weakness orPhysical frailty.
Abstract: Background Although disuse of skeletal muscle and undernutrition are often cited as potentially reversible causes of frailty in elderly people, the efficacy of interventions targeted specifically at these deficits has not been carefully studied. Methods We conducted a randomized, placebo-controlled trial comparing progressive resistance exercise training, multinutrient supplementation, both interventions, and neither in 100 frail nursing home residents over a 10-week period. Results The mean (±SE) age of the 63 women and 37 men enrolled in the study was 87.1 ±0.6 years (range, 72 to 98); 94 percent of the subjects completed the study. Muscle strength increased by 113 ±8 percent in the subjects who underwent exercise training, as compared with 3 ±9 percent in the nonexercising subjects (P<0.001). Gait velocity increased by 11.8 ±3.8 percent in the exercisers but declined by 1.0 ±3.8 percent in the nonexercisers (P = 0.02). Stair-climbing power also improved in the exercisers as compared with the nonexercis...

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Dan G. Blazer1
TL;DR: The extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective is presented and the current therapies prescribed for depressed elders, ranging from medications to group therapy are presented.
Abstract: Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.

2,034 citations

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TL;DR: After 20 years follow-up of newly diagnosed patients with Parkinson's disease (PD), 100 of 136 (74%) have died and 17 people with dementia had postmortems, while others had mixed neuropathology.
Abstract: After 20 years follow-up of newly diagnosed patients with Parkinson's disease (PD), 100 of 136 (74%) have died. The mortality rate fell in the first 3 years of treatment, then rose compared to the general population, the standardized mortality ratio from 15 to 20 years reaching 3.1. Drug induced dyskinesia and end of dose failure were experienced by most patients, but the main current problems relate to the non-levodopa responsive features of the disease. Dementia is present in 83% of 20-year survivors. Dementia correlates with increasing age and probably reflects an interplay of multiple pathologies. Seventeen people with dementia had postmortems. Eight had diffuse Lewy bodies as the only cause of dementia, while others had mixed neuropathology. Only one person lives independently and 48% are in nursing homes. Excessive daytime sleepiness is noted in 70%, falls have occurred in 87%, freezing in 81%, fractures in 35%, symptomatic postural hypotension in 48%, urinary incontinence in 71%, moderate dysarthria in 81%, choking in 48%, and hallucinations in 74%. The challenge is to understand the cellular mechanisms underlying the diverse features of advanced PD that go far beyond a lack of dopamine.

1,754 citations

References
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Journal ArticleDOI
TL;DR: A simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely.

76,181 citations

01 Jan 2002
TL;DR: The Mini-Mental State (MMS) as mentioned in this paper is a simplified version of the standard WAIS with eleven questions and requires only 5-10 min to administer, and is therefore practical to use serially and routinely.
Abstract: EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.

70,887 citations

Journal ArticleDOI
TL;DR: In this paper, a general formula (α) of which a special case is the Kuder-Richardson coefficient of equivalence is shown to be the mean of all split-half coefficients resulting from different splittings of a test, therefore an estimate of the correlation between two random samples of items from a universe of items like those in the test.
Abstract: A general formula (α) of which a special case is the Kuder-Richardson coefficient of equivalence is shown to be the mean of all split-half coefficients resulting from different splittings of a test. α is therefore an estimate of the correlation between two random samples of items from a universe of items like those in the test. α is found to be an appropriate index of equivalence and, except for very short tests, of the first-factor concentration in the test. Tests divisible into distinct subtests should be so divided before using the formula. The index $$\bar r_{ij} $$ , derived from α, is shown to be an index of inter-item homogeneity. Comparison is made to the Guttman and Loevinger approaches. Parallel split coefficients are shown to be unnecessary for tests of common types. In designing tests, maximum interpretability of scores is obtained by increasing the first-factor concentration in any separately-scored subtest and avoiding substantial group-factor clusters within a subtest. Scalability is not a requisite.

37,235 citations

Journal ArticleDOI
TL;DR: The present scale has been devised for use only on patients already diagnosed as suffering from affective disorder of depressive type, used for quantifying the results of an interview, and its value depends entirely on the skill of the interviewer in eliciting the necessary information.
Abstract: Types of Rating Scale The value of this one, and its limitations, can best be considered against its background, so it is useful to consider the limitations of the various rating scales extant. They can be classified into four groups, the first of which has been devised for use on normal subjects. Patients suffering from mental disorders score very highly on some of the variables and these high scores serve as a measure of their illness. Such scales can be very useful, but have two defects: many symptoms are not found in normal persons; and less obviously, but more important, there is a qualitative difference between symptoms of mental illness and normal variations of behaviour. The difference between the two is not a philosophical problem but a biological one. There is always a loss of function in illness, with impaired efficiency. Self-rating scales are popular because they are easy to administer. Aside from the notorious unreliability of self-assessment, such scales are of little use for semiliterate patients and are no use for seriously ill patients who are unable to deal with them. Many rating scales for behaviour have been devised for assessing the social adjustment of patients and their behaviour in the hospital ward. They are very useful for their purpose but give little or no information about symptoms. Finally, a number of scales have been devised specifically for rating symptoms of mental illness. They cover the whole range of symptoms, but such all-inclusiveness has its disadvantages. In the first place, it is extremely difficult to differentiate some symptoms, e.g., apathy, retardation, stupor. These three look alike, but they are quite different and appear in different settings. Other symptoms are difficult to define, except in terms of their settings, e.g., mild agitation and derealization. A more serious difficulty lies in the fallacy of naming. For example, the term "delusions" covers schizophrenic, depressive, hypochrondriacal, and paranoid delusions. They are all quite different and should be clearly distinguished. Another difficulty may be summarized by saying that the weights given to symptoms should not be linear. Thus, in schizophrenia, the amount of anxiety is of no importance, whereas in anxiety states it is fundamental. Again, a schizophrenic patient who has delusions is not necessarily worse than one who has not, but a depressive patient who has, is much worse. Finally, although rating scales are not used for making a diagnosis, they should have some relation to it. Thus the schizophrenic patients should have a high score on schizophrenia and comparatively small scores on other syndromes. In practice, this does not occur. The present scale has been devised for use only on patients already diagnosed as suffering from affective disorder of depressive type. It is used for quantifying the results of an interview, and its value depends entirely on the skill of the interviewer in eliciting the necessary information. The interviewer may, and should, use all information available to help him with his interview and in making the final assessment. The scale has undergone a number of changes since it was first tried out, and although there is room for further improvement, it will be found efficient and simple in use. It has been found to be of great practical value in assessing results of treatment.

29,488 citations

Frequently Asked Questions (18)
Q1. What contributions have the authors mentioned in the paper "Positive impact of speech therapy in progressive non-fluent aphasia" ?

The aim of this paper is to analyze the effects of intensive speech therapy intervention in a case of progressive non-fluent aphasia ( PNFA ). 

For future research in this area, the implementation of such a speech therapy program with a group of patients having different educational levels is worth considering in order to determine whether such a program would be beneficial to a wider range of PNFA patients. 

The left posterior parietal cortex could be part of the temporo-parietal-frontal network, a system that acts as an interface between auditory and articulatory processes (Ackermann & Rieker, 2004; Loevenbruck et al., 2005). 

Because the generation of fluent speech requires planning in order to convey the intentions of the speaker, language processing involves a large number of cortical and subcortical structures. 

In every session, after the strengthening pulmonary ventilation exercises, JM carried out articulation fluency exercises for ten minutes. 

Fluency deficits have usually been associated with atrophy in the posterior inferior and middle frontal gyrus, whereas grammatical processing is associated with more widespread atrophy, including other regions of the inferior frontal gyrus and supramarginal gyrus (Rogalski et al., 2011). 

For the implementation of the neuropsychological test battery, three sessions of 60 minutes each, one per week, were required in each of the three instances of assess-ment. 

The basal assessment revealed that the following mental functions of the patient were preserved: orientation; selective attention for visual material; verbal and visualmemory; learning; ideational praxis; and visuo-spatial gnosis. 

One limitation of the present work is its single-case design, which makes it impossible to generalize the results to other PNFA patients; another limitation that may bias or influence the results is the patient’s educational level, as it may be associated with cognitive reserve, a factor that plays an important role in preventing, or slowing, the neurodegenerative process (Stern, 2002). 

The temporal lobe is frequently involved in language syntax processes and the decoding and recovery of complex linguistic long-term memory materials (Mandonnet et al., 2007). 

The characteristics of the aforementioned interventions show the need for and importance of the design, implementation, and dissemination of systematic speech therapy programs for PNFA patients, that are not only ecologically valid and can be replicated, but that can also be used to assess the benefit, maintenance, and/or generalization of the intervention. 

Other mental functions, such as selective attention for verbal material and ideo-motor praxis, showed slight alterations, while sustained attention showed a moderate deficit. 

in addition to the use of functional magnetic resonance imaging or other functional neuroimaging studies (such as single photon emission computed tomography (SPECT) or positron emission tomography (PET)), can be used to identify possible changes in brain activation patterns over time resulting from speech therapy. 

These strategies aimed to improve the patient’s structural analysis of sentences and speech, thereby enabling recovery and the relearning of grammatical and syntactical elements altered by the progress of the disease. 

After six and twelve months of therapy, JM’s family reported maintenance and even improvement of cognitive functioning (IQCODE), preserved ADLs (Barthel scale and PFAQ), no presence of neuropsychiatric symptoms, and good QOL. 

From reports on prognosis in PNFA (Rogers & Alarcon, 1999; Hodges et al., 2003), the median survival is 6.8 years; therefore, a rapid progression of the disease is expected. 

When lexical stimulation started, the sessions were divided as follows: strengthening pulmonary ventilation (5 min.), articulation fluency exercises (10 min.), phonological exercises (10 min.) and stimulation of lexical analysis (35 min.). 

It is important to note the improvement in the mood of the patient, who reported absence of depression and less anxiety after the intervention.