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Objective To present challenges in assessment of applied cognition and the results of differential item functioning (DIF) analyses used to inform the development of a computerized adaptive test (CAT). Design Measurement evaluation cohort study. DIF analyses of 107 items were conducted across educational, age, and sex groups. DIF hypotheses informed the evaluation of the results. Setting Hospital-based rehabilitation from a single hospital system. Participants A total of 2216 hospitalized patients (N=2216). Interventions Not applicable. Main Outcome Measures Applied cognition item pool from multiple sources. Results Many items were hypothesized to show DIF, particularly for age. Information was moderately high in the lower (cognitive disability) tail of the distribution, but some items were not informative. Reliability estimates were high (>0.89) across all studied groups, regardless of estimation method. There were 35 items with DIF of high magnitude and 19 with accompanying supportive hypotheses. Conclusions A key clinical tool in inpatient rehabilitation medicine is assessment of applied functional cognitive ability to inform patient-centered rehabilitation strategies to improve function. This was the first study to evaluate measurement equivalence of the applied cognition item pool across large samples of hospitalized patients. Although about one-third of the item pool evidenced DIF or low discrimination, results supported placement of most items into the bank and its use across groups differing in education, age, and sex. Six items were classified with salient DIF, defined as consistent DIF of high magnitude and or impact, with confirmatory directional DIF hypotheses, generated by content experts. These were recommended for adjustment or removal from the bank; 4 were deleted from the bank and 2 had lowered CAT exposure (administration frequency) rates. Many items hypothesized to show DIF contained content measuring constructs other than applied cognition such as physical frailty, perceptual difficulties, or skills reflective of greater educational attainment. Challenges in measurement of this construct are discussed.

Objective To assess differential item functioning (DIF) in an item pool measuring the mobility of hospitalized patients across educational, age, and sex groups. Design Measurement evaluation cohort study. Content experts generated DIF hypotheses to guide the interpretation. The graded response item response theory (IRT) model was used. Primary DIF tests were Wald statistics; sensitivity analyses were conducted using the IRT ordinal logistic regression procedure. Magnitude and impact were evaluated by examining group differences in expected item and scale score functions. Setting Hospital-based rehabilitation. Participants Hospitalized patients (N=2216). Interventions Not applicable. Main Outcome Measures A total of 111 self-reported mobility items. Results Two linking items among those used to set the metric across forms evidenced DIF for sex and age: “difficulty climbing stairs step-over-step without a handrail (alternating feet)” and “difficulty climbing 3-5 steps without a handrail.” Conditional on the mobility state, the items were more difficult for women and older people (aged ≥65y). An additional 18 items were identified with DIF. Items with both high DIF magnitude and hypotheses related to age were difficulty “crossing road at a 4-lane traffic light with curbs,” “jumping/landing on one leg,” “strenuous activities,” and “descending 3-5 steps with no handrail.” Although DIF of higher magnitude was observed for several items, the scale-level effect was relatively small and the exposure rate for the most problematic items was low (0.35, 0.27, and 0.20). Conclusions This was the first study to evaluate measurement equivalence of the hospital-based rehabilitation mobility item bank. Although 20 items evidenced high magnitude DIF, 5 of which were related to stairs, the scale-level effect was minimal; however, it is recommended that such items be avoided in the development of short-form measures. No items with salient DIF were removed from calibrations, supporting the use of the item bank across groups differing in education, age, and sex. The bank may thus be useful to assist clinical assessment and decision-making regarding risk for specific mobility restrictions at discharge as well as identifying mobility-related functions targeted for postdischarge interventions. Additionally, with the goal of avoiding long and burdensome assessments for patients and clinical staff, these results could be informative for those using the item bank to construct short forms.

Objective: To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans. Design: This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics. Setting: A large (2000-bed) Midwestern Medical Center. Participants: The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495). Intervention: Not applicable. Main Outcome Measures: Not applicable. Results: The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization. Conclusions: The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

Purpose This was a Phase II pilot study of a problem-solving treatment (PST) to address subsyndromal depression in residents of long-term care facilities. Our goal was to demonstrate PST implementation feasibility and to identify PST’s potential for reducing depressive symptoms in this geriatric health care setting. Methods Eligible participants were randomized to receive a PST treatment (six 1-hour sessions) or a social contact comparison (6 “friendly” visits) after an initial baseline assessment. Follow-up assessments occurred 7 weeks later (after treatment) and 2 months posttreatment. The basic analytic approach was based on an intention-to-treat analysis. Findings We enrolled 21 elderly subjects in the PST group and 16 elderly subjects in the social contact comparison group. The PST group experienced a decline in depression scores compared with the social contact group. Although not statistically significant (likely due to the small sample size), PST was associated with decreased depressive symptom scores for those who were able to complete the intervention. Implementation proved to be difficult in terms of study recruitment and intervention acceptance and adherence. Implications These study findings point to the potential benefits of an integrated mental health component in long-term care, involving rehabilitation professionals who are already working with the older adults in both postacute/short-stay and long-stay settings.

Elder abuse in long-term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.The design was a prospective cluster randomized trial with randomization at the unit level.A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p0.001), significantly increased recognition of R-REM (p0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long-term care facilities.

The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60 years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12 months. The secondary outcomes are blood pressure control at 12 months; changes in levels of physical activity; body mass index; and number of daily servings of fruits and vegetables from baseline to 12 months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.

Objectives The aim was to conduct a comparative effectiveness research study to estimate the effects on falls, negative affect and behavior, and the associated societal costs of implementing evidence-based education and best practice programs in nursing homes (NHs). Design A quasi-experimental design, a variant of a cluster randomized trial of implementation research examining transfer of research findings into practice, was used to compare outcomes among three groups of residents in 15 nursing homes per group. Methods Forty-five NHs participated in one of three conditions: (1) standard training, (2) training and implementation modules provided to facility staff, or (3) staff training and implementation modules augmented by surveyor training. After application of exclusion and matching criteria, nursing homes were selected at random within three regions of New York State. Outcomes were assessed using medical records and the Minimum Data Set (MDS). Results The main finding was of a significant reduction of between 5 and 12 annual falls in a typical nursing home. While both intervention groups resulted in fall reduction, the larger and significant reduction occurred in the group without surveyor training. A significant reduction in negative affect associated with training staff and surveyors was observed. Net cost savings from fall prevention was estimated. Conclusions A low cost intervention targeting dissemination of evidence-based best practices in nursing homes can result in the potential for fall reduction, and cost savings.

Objective To evaluate differences between rural older adults with diabetes reporting the presence or absence of food insecurity with respect to meal planning, preparation, shopping, obesity, and glycemic control after receiving nutrition counseling through telemedicine. Methods Food insecurity data were obtained by telephone survey (n = 74). Group differences for continuous variables were measured by t tests; categorical variables by Pearson chi-square tests. Results Participants reporting mild food insecurity (23%) had higher body mass index (35.5 ± 7.1 kg/m 2 vs 30.5 ± 6.0 kg/m 2 , P = .01) and lower household incomes ( P = .03) and were more likely to consider cost of ingredients in food preparation compared to food-secure participants ( P = .03). Most purchased fresh produce (97%) and considered the dietitian's advice when purchasing food. Both groups report similar adherence to dietitians' advice and had similar glycemic control. Conclusions and Implications Strategies to address higher levels of obesity associated with food insecurity are needed.

Objective We present results of a feasibility test of a sequential treatment strategy using continuation phase cognitive-behavioral therapy (CBT) to prevent relapse in youths with major depressive disorder (MDD) who have responded to acute phase pharmacotherapy. Method: Forty-six youths (ages 11-18 years) who had responded to 12 weeks of treatment with fluoxetine were randomized to receive either 6 months of continued antidepressant medication management (MM) or antidepressant MM plus relapse prevention CBT (MM+CBT). Primary outcome was time to relapse, defined as a Childhood Depression Rating Scale-Revised score of 40 or higher and 2 weeks of symptom worsening or clinical deterioration warranting alteration of treatment to prevent full relapse. Results Cox proportional hazards regression, adjusting for depression severity at randomization and for the hazard of relapsing by age across the trial, revealed that participants in the MM treatment group had a significantly greater risk for relapse than those in the MM+CBT treatment group (hazard ratio=8.80; 95% confidence interval 1.01-76.89; X 2 = 3.86, p = .049) during 6 months of continuation treatment. In addition, patient satisfaction was significantly higher in the MM+CBT group. No differences were found between the two treatment groups on attrition rate, serious adverse events, and overall global functioning. Conclusions These preliminary results suggest that continuation phase CBT reduces the risk for relapse by eightfold compared with pharmacotherapy responders who received antidepressant medication alone during the 6-month continuation phase. J. Am. Acad. Child Adolesc. Psychiatry, 2008;47(12): 1395–1404.

Objective The authors examined the multivariate relationships between depression recognition by staff members and characteristics of nursing home residents. Methods Analyses used a simple random sample of 270 residents, drawn from six randomly selected nursing homes, who were evaluated by psychiatrists for depression and depressive symptomatology. Results African Americans were generally seen by psychiatrists as having less depressive symptomatology than residents from other ethnic groups. The data suggest that nurse aides, perhaps because they see residents more often or because they are less influenced by demographic characteristics, may be the most valid source of information about residents' depression. In contrast, after partialing out the degree of depression severity, nurses tended to overrecognize depression among African-American residents. Social workers underrecognized depression among residents with cognitive impairment and/or Parkinson disease and among women, and overrecognized depression among African Americans. Conclusion The results underline the need for more training in depression recognition, particularly in distinguishing social from clinical phenomena and in distinguishing symptoms of dementia from those of depression. Equally important is further investigation of the potential biases associated with diagnosis and recognition of depression among African Americans.

Objective An instrument to measure menu board literacy (MBL) was developed to capture children's understanding of menu board nutrition information, including abbreviations, serving sizes and calorie ranges, and self-efficacy for using this information. Methods A list of 55 potential items (47 MBL and 8 self-efficacy) was generated. Content validity was established by 29 registered dietitians. Cognitive interviews were conducted with 24 black and Hispanic fourth- and fifth-grade students to assess comprehension and readability. The researchers assessed reliability in 2 fourth- and fifth-grade convenience samples (n = 32 and 141, respectively) of similarly representative students. Results The final instrument included 20 MBL and 7 self-efficacy items. Internal consistency estimates at both pretest and posttest for the first sample were 0.88 for the MBL scale and 0.80 for the self-efficacy scale. Results for the larger sample were similar. Conclusions and Implications This instrument could be used for assessing MBL and self-efficacy among fourth- and fifth-grade children. The MBL scale provides researchers and practitioners with a tool to measure the role of nutrition literacy and numeracy in point-of-purchase dietary decisions of children, with the potential for use with low-literacy adults as well.

Proliferation of arterial smooth muscle cells (aSMC) is a key component of atherogenesis. A sample of 225 volunteers, aged 21-65 years, was exposed to "frustration," "harassment," or "relaxation," after completing the 50-item Hostility subscale of the Minnesota Multiphasic Personality Inventory (MMPI). Whole blood was measured before and after exposure for platelet-derived growth factor (PDGF), and sera were evaluated for total and HDL cholesterol concentrations and PDGF-independent mitogenic activity (SMA). Blood pressure and pulse rate were also evaluated. Analyses of SMA (i.e., serum independent of PDGF) revealed an increase in mitogenic effect for cultured human aSMC when hostility was treated as a dichotomous modifier. Among high-hostility subjects, surprisingly, those in the relaxed group and those with a lower educational level were found to have a significant mitogen response; no significant effects were observed for the low-hostility groups. The data suggest that endogenous stresses may occur in high-hostility individuals when "relaxed," to influence proliferation of arterial smooth muscle cells, as a contribution to atherogenesis. In individuals with lower educational levels and higher hostility scores, lifestyle changes may play a role.

The North Manhattan Aging Project registry, using both Reporting and Survey Components, identifies dementia cases among Latino, African-American, and non-Latino white sociocultural groups (9,349 persons 65 years of age or older) in contiguous census tracts. During a 2-year prevalence period of the reporting component, 1,592 persons were reported to the Registry and screened with five widely used brief cognitive measures; 844 were evaluated in a "clinical core," and 452 met research criteria for dementia, covering all subtypes, according to DSM-III-R criteria. Thirteen different case definitions for dementia were applied to the sociocultural groups at three levels of educational achievement, examining for associations with rates of dementia cases and controlling for age. The following findings were robust across case definitions: sociocultural membership was not associated, but lower education was associated, with increased rates of recorded dementia; however, the patterns of the association with education varied across sociocultural groups.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)

A multivariate approach incorporating both biological and psychosocial factors was used in a cross-sectional study of schizophrenic inpatients and outpatients selected to represent opposite ends of the outcome spectrum. Twenty-six RDC-diagnosed chronic schizophrenic patients hospitalized continuously for 18 months or longer, and 26 patients with a history of at least three years of community tenure without rehospitalization were matched for sex, age, ethnicity, SES and chronicity, and assessed on a structured family interview (Social Behavior Assessment Schedule), neuropsychological test battery, Brief Psychiatric Rating Scale and Premorbid Asociality Scale. Stepwise discriminant function analysis was performed; family ratings of patients' problem behaviors was the most powerful discriminator between the two groups and a composite measure of neuropsychological functioning ranked second. Other significant discriminators were BPRS scores, availability of social support to the family and age of onset. Family ratings of patient behavior were related to ratings of family burden and to BPRS scores. Further research is needed to understand the complex interactions between the diverse sets of social, clinical and neurobiological factors that determine long-term outcome in schizophrenia.

In varied cultural frameworks men and women in old age have shown distinct differences in their ability to engage in social interaction. This article examines the sex differences in social interaction among 133 inner-city elderly living in SRO hotels. Contrary to earlier reports of inner-city elderly women, there was no evidence of pervasive isolation and longitudinal data indicated that SRO women had dynamic networks that allowed for the replacement of lost contacts with new ones. In comparing the sexes there were similarities in the various social network dimensions and the use of these networks to fulfill needs and cope with physical illness. Moreover, the similarities in life histories between the sexes would suggest that as women's life-styles in the general population come to approximate those of men, the social interactions of aging men and women may more closely resemble each other.